Eastern Mediterranean Health Journal [2017; Vol.23, Issue 12]

Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 23 / No. 12 December/Décembre 12 ددع / نوشرعلاو ثلاثلا دلجلما لولأا نوناك/برمسيد2017 Contents V o lu m e 2 3 N u m b er 1 2 D ecem b er 2 0 1 7 A sound understanding of the context in which health systems must operate is essential in order to formulate effective policy-making, which can only be realized through the very best research evidence available, and is a priority for the many critical situations present in the Eastern Mediterranean Region. Editorial Improving evidence informed policy-making for health in the Eastern Mediterranean Region .......................... 793 Research articles Independent prescription of medicines and diagnostic test advice by final year medical students in Punjab .................................................................................................................................................................... 795 Challenges impeding integration of oral health into primary health care .............................................................802 Caractérisation génétique du sous-groupe Maculipennis (Diptera : Culicidae) au Maroc : un outil fondamental pour lutter contre le paludisme ................................................................................................................................809 Assessment of the quality of life in patients on haemodialysis in Iraq ....................................................................815 Trend and seroprevalence of Epstein–Barr virus in Bahrain: 2001–2015 ..................................................................821 Investigation of breastfeeding training based on BASNEF model on the intensity of postpartum blues .............830 Changes in dietary habits and physical activity and status of metabolic syndrome among expatriates in Saudi Arabia ........................................................................................................................................................... 836 Réflexions éthiques sur le principe de l’autonomie du patient .............................................................................. 845 ايروس في رركتلما مدلا لقن ضىرم ىدل يئابلا سيويرفلا دبكلا باهتلا ّدض ميعطتلا ةيلعاف مييقت .......................................................850 Commentary The forgotten history of pre-modern epidemiology: contribution of Ibn An-Nafis in the Islamic golden era .... 854 WHO events addressing public health priorities Redesigning the integrated approach to child health in line with the United Nations Sustainable Development Goals .................................................................................................................................................. 858 Cover 23-12.indd 5-7 2/26/2018 7:37:37 AM EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con- cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col- laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser-vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collabora- teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/ EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). © World Health Organization (WHO) 2017. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Disclaimer. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. If authors are staff members of the World Health Organization, the authors alone are responsible for the views expressed in this publication and do not necessarily represent the decisions, policy or views of the World Health Organization. ISSN 1020-3397 تاسايسلا ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه يرغو ثاحبلأا جئاتنو ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تايلكلاو ،ةيحصلا نهلما ءاضعأ لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا .هجراخو ميلقلإا فى ةحصلاب ينمتهلما طسوتلما قشرل ةيحصلا ةلجلما Correspondence Editor-in-chief Eastern Mediterranean Health Journal 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: emrgoemhj@who.int طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ايبيل . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . نميلا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . 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 . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne Somalie . Soudan . Tunisie . Yémen Subscriptions and Permissions Publications of the World Health Organization can be obtained from Knowledge Sharing and Production, World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 2670 2535, fax: +202 2670 2492; email: emrgoksp@who.int). Requests for permission to reproduce, in part or in whole, or to translate publications of WHO Regional Office for the Eastern Mediterranean – whether for sale or for noncommercial distribution – should be addressed to WHO Regional Office for the Eastern Mediterranean, at the above address; email: emrgoegp@who.int. Cover 23-12.indd 8-10 2/26/2018 7:37:37 AM Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 23 No. 12 12 ددع نوشرعلاو ثلاثلا دلجلما• 2017 • Editorial Improving evidence informed policy-making for health in the Eastern Mediterranean Region Arash Rashidian, Ahmed Mandil and Jaouad Mahjour ............................................................................................................................................................................................................... 793 Research articles Independent prescription of medicines and diagnostic test advice by final year medical students in Punjab Kashif Aziz, Hafiz M. Aeymon and Saba Batool............................................................................................................................................................................................................................ 795 Challenges impeding integration of oral health into primary health care Zahra Ghorbani, Mina Pakkhesal, Shahnam Arshi, Mohammad J. Eghbal, Marzieh Deghatipour, Marc Tennant and H. Malekafzali Ardakani ................................... 802 Caractérisation génétique du sous-groupe Maculipennis (Diptera : Culicidae) au Maroc : un outil fondamental pour lutter contre le paludisme Bouchra Trari et Mohamed Dakki ....................................................................................................................................................................................................................................................... 809 Assessment of the quality of life in patients on haemodialysis in Iraq Safauldeen A. Alhajim .............................................................................................................................................................................................................................................................................. 815 Trend and seroprevalence of Epstein–Barr virus in Bahrain: 2001–2015 Eman Farid and Mohammed Al-Biltagi ............................................................................................................................................................................................................................................. 821 Investigation of breastfeeding training based on BASNEF model on the intensity of postpartum blues Marzieh Akbarzadeh, Sima Kiani Rad, Marzieh Moattari and Najaf Zare ........................................................................................................................................................................ 830 Changes in dietary habits and physical activity and status of metabolic syndrome among expatriates in Saudi Arabia Rasmieh A. Alzeidan, Fatemeh Rabiee, Ahmed A. Mandil, Ahmad S. Hersi and Anhar A. Ullah ................................................................................................................................. 836 Réflexions éthiques sur le principe de l’autonomie du patient Marianne Bracconi, Christian Hervé et Philippe Pirnay ............................................................................................................................................................................................................... 845 ايروس في رركتلما مدلا لقن ضىرم ىدل يئابلا سيويرفلا دبكلا باهتلا ّدض ميعطتلا ةيلعاف مييقت معنم ةزوف ،لاّبلحا ءافو ،يجزاي دادو ........................................................................................................................................................................................................................................................ 850 Commentary The forgotten history of pre-modern epidemiology: contribution of Ibn An-Nafis in the Islamic golden era Ghazi Kayali ................................................................................................................................................................................................................................................................................................ 854 WHO events addressing public health priorities Redesigning the integrated approach to child health in line with the United Nations Sustainable Development Goals .......................................... 858 Book 23-12.indb 791 3/4/2018 11:44:20 AM Jaouad Mahjour, Editor-in-Chief Arash Rashidian, Executive Editor Ahmed Mandil, Deputy Executive Editor Phillip Dingwall, Managing Editor Editorial Board Zulfiqar Bhutta Mahmoud Fahmy Fathalla Rita Giacaman Ahmed Mandil Ziad Memish Arash Rashidian Sameen Siddiqi Huda Zurayk International Advisory Panel Mansour M. Al-Nozha Fereidoun Azizi Rafik Boukhris Majid Ezzati Hans V. Hogerzeil Mohamed A. Ghoneim Alan Lopez Hossein Malekafzali El-Sheikh Mahgoub Hooman Momen Sania Nishtar Hikmat Shaarbaf Salman Rawaf Editorial assistants Nadia Abu-Saleh, Suhaib Al Asbahi (graphics), Diana Tawadros (graphics) Editorial support Guy Penet (French editor) Eva Abdin, Fiona Curlet, Cathel Kerr, Marie-France Roux (Technical editors) Manar Abdel-Rahman, Ahmed Bahnassy, Abbas Rahimiforoushani (Statistics editors) Administration Yasmeen Sedky, Iman Fawzy, Dalya Mostafa Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt Cover photograph: © World Health Organization Book 23-12.indb 792 3/4/2018 11:44:20 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 793 Editorial Improving evidence informed policy-making for health in the Eastern Mediterranean Region Arash Rashidian 1, Ahmed Mandil 1 and Jaouad Mahjour 2 1Department of Information, Evidence and Research; WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to: Arash Rashidian: rashidiana@who.int). 2Acting Regional Director, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt https://doi.org/10.26719/2017.23.10.793 Health policies should be based on a sound understanding of the problems, issues and context in which they oper- ate, for which they require reliable data and information for action (1,2). The policies should also be informed by the best available research evidence (3), which also helps in better capturing the problem, understanding existing trends and patterns, and setting reasonable objectives that can be achieved using effective interventions. More impor- tantly, research can provide evidence of comparative effectiveness of alter- native interventions for a given public health issue; the costs and feasibility of implementing each intervention; and efficiency of the proposed interventions (policies) in comparison with alterna- tive interventions. These arguments apply whether we are considering na- tional policies or focusing on policies developed or advocated through inter- national organizations, including the World Health Organization (WHO) (4,5). In the Eastern Mediterranean Region (EMR), three parallel streams have shaped, and continue to shape, use of research evidence in health policies. First, there has been a growing interest in the use of research evidence in health policies. The increasing demand for research evidence has followed national discourse in many countries, where public policies – including health policies – are increasingly assessed in a critical way (6-9). In recent years, health concerns are prominently featured in political debates and national discourse in several countries. This level of scrutiny had made it important for the politicians to demonstrate how they develop prudent policies, and the effects of such policies on health outcomes. Also, increasing population demand for health services and aging populations have resulted in increasing health care costs, resulting in closer scrutiny of health policies. Moreover, such conditions have also meant that ministries of health are having more success in putting ‘health’ on the agenda of policy-makers outside the health sector. With increasing focus on social determinants of health, and now the Social Development Goals as a global agenda (10), health is more featured in the political discussions and hence, further demand to support health policy decisions with research evidence. The second stream is related to availability, validity and relevance of research evidence for health policy- making. Different assessments have demonstrated a considerable increase in the number of research outputs from the countries of the region. While this trend started from a handful of countries in the last decade, it has affected more countries in the Region (11). This is important as this may partially alleviate a major concern related to use of research evidence in decision-making. The policy-makers’ concern has traditionally related to the fact that most research evidence presented to them actually originated from high-income countries beyond the Region, which have a different set of priorities, challenges and decision-making processes. Hence, policy-makers perceived research evidence presented to them as irrelevant to their context (12). With more research originating from the Region, this picture is about to change. At the same time, regional output on research is challenged from two fronts. Over the last decade, five countries of the Region produced 80% of regional research output in terms of peer-reviewed publications. More noteworthy, the three leading universities of the Region published over 10% of the total papers published in indexed journals (11). The other relevant challenge is related to the quality of research from the Region, and its attention to public health issues (13). In both fronts, there has been some progress, but there remain important limitations. The third stream is related to the institutional capacity of the ministries of health (and other related public institutions) in retrieving, assessing and using research evidence. While there are many more ‘decision-oriented’ research studies being published every year (e.g. systematic reviews), systematically using such evidence in decision-making processes requires a level of institutional capacity and technical expertise that many ministries of health may lack. Also, technical expertise on its own may not be sufficient for the expectations and processes of decision-making. Over the years, WHO has advocated different structural approaches and technical solutions for further use of research evidence in formulating key decisions. Health Technology Assessment programmes, and national plans for adoption or development of clinical Book 23-12.indb 793 3/4/2018 11:44:20 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 794 References 1. Alwan A, Ali M, Aly E, Badr A, Doctor H, Mandil A, et al. Strengthening national health information systems: challenges and response. East Mediterr Health J. 2016 02 1;22(11):840–50. https://doi.org/10.26719/2016.22.11.840 PMID:28177115 2. Eastern Mediterranean Region Framework for health information systems and core indicators for monitoring health situation and health system performance. Cairo: WHO Regional Office for the Eastern Mediterranean; 2017. 3. World Health Organization. The WHO strategy on research for health. Geneva: World Health Organization; 2012. 4. World Health Report 2013. Research for universal health coverage. Geneva: World Health Organization; 2013 (http:// www.who.int/whr/2013/report/en/ ). 5. Rashidian A. Policy and programme evaluation: principles and objectives. East Mediterr Health J. 2017 02 21;23(1):3–4. https:// doi.org/10.26719/2017.23.1.3 PMID:28244054 6. Haq Z, Hafeez A, Zafar S, Ghaffar A. Dynamics of evidence- informed health policy making in Pakistan. Health Policy Plan. 2017 Dec 1;32(10):1449–56. https://doi.org/10.1093/heapol/ czx128 PMID:29045672 7. Al Mawali AHN, Al Qasmi AM, Al Sabahi SMS, Idikula J, Elaty MAA, Morsi M, et al. Oman Vision 2050 for Health Research: A Strategic Plan for the Future Based on the Past and Present Experience. Oman Med J. 2017 Mar;32(2):86–96. https://doi. org/10.5001/omj.2017.18 PMID:28439378 8. Imani-Nasab MH, Seyedin H, Yazdizadeh B, Majdzadeh R. A qualitative assessment of the evidence utilization for health policy-making on the basis of SUPPORT tools in a developing country. Int J Health Policy Manag. 2017 01 8;6(8):457–65. https://doi.org/10.15171/ijhpm.2016.158 PMID:28812845 9. El-Jardali F, Lavis JN, Ataya N, Jamal D, Ammar W, Raouf S. Use of health systems evidence by policymakers in eastern Mediterranean countries: views, practices, and contextual influences. BMC Health Serv Res. 2012 07 16;12(1):200. https:// doi.org/10.1186/1472-6963-12-200 PMID:22799440 10. World Health Organization. Health in 2015: from MDGs to SDGs. Geneva: World Health Organization; 2015 (http:// www.who.int/gho/publications/mdgs-sdgs/en/). 11. Tadmouri GO, Mandil A, Rashidian A. Development of an Eastern Mediterranean Region search strategy for biomedical citations indexed in PubMed. East Mediterr Health J. 2017 11 19;23(9):619–29. https://doi.org/10.26719/2017.23.9.619 PMID:29178119 12. Yousefi-Nooraie R, Rashidian A, Nedjat S, Majdzadeh R, Mortaz-Hedjri S, Etemadi A, et al. Promoting development and use of systematic reviews in a developing country. J Eval Clin Pract. 2009 Dec;15(6):1029–34. https://doi.org/10.1111/j.1365- 2753.2009.01184.x PMID:20367702 13. Rashidian A, Jahanmehr N, Jabbour S, Zaidi S, Soleimani F, Bigdeli M. Bibliographic review of research publications on access to and use of medicines in low-income and middle- income countries in the Eastern Mediterranean Region: identifying the research gaps. BMJ Open 2013;3:10 e003332. https://doi.org/10.1136/bmjopen-2013-003332. 14. World Health Organization. WHO handbook for guideline development. 2nd ed. Geneva: World Health Organization; 2014. 15. World Health Organization. 2015 Global Survey on Health Technology Assessment by National Authorities. Main findings. Geneva: World Health Organization; 2015. 16. World Health ORanization. SURE guides for preparing and using evidence-based policy briefs. Version 2.1. Geneva: World Health Organization; 2011 (http://www.who.int/ evidence/sure/guides/en/). public health guidelines are among these (14). So far the progress on both fronts has been limited in the Region, as few countries have established such mechanisms at the national level (15). WHO also advocates development of policy briefs for key policy decisions (16). Policy briefs can improve the transparency of decision-making in health, as well as bringing forward benefits and challenges that might be faced if policy-makers adopt one course of action instead of others. In summary, there is a strong political will in the EMR to enhance use of research evidence in decision- making. This was demonstrated in the Eastern Mediterranean Regional Committee Resolution EM/RC64/R.1 (Islamabad, Pakistan; October 2017)1, in which ministers of health commit- ted themselves to “take necessary ac- tion towards conducting public health research that is directed towards the requirements of health services and that addresses people’s health needs; and build national capacity to use evi- dence from health research in national policy-making for health”. The Member States also requested WHO to “estab- lish regional mechanisms to support the bridging of gaps between relevant research institutions and policy-makers and the translation of research evidence into health policy statements, and support the establishment of national mechanisms.” To materialize these commitments, systematic programmes are required to identify the priority health topics, establish research evidence review pro- cesses, and develop decision-making approaches that require the considera- tion of research evidence. While these may sound difficult to a country with limited past experience or with complex decision-making processes, in practice there might be effective approaches that work for different scenarios with differ- ent levels of capacity within the coun- tries. WHO is committed to supporting countries in their objective of improving health-related policies, and ultimately improving health outcomes, through evidence informed policy-making. 1 Regional Committee for the Eastern Mediterranean. Sixty-fourth Session RC1/64 (http://applications.emro.who.int/docs/RC_ technical_papers_20094_1_2017_en.pdf?ua=1). Book 23-12.indb 794 3/4/2018 11:44:20 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 795 1Aga Khan University Hospital, Karachi, Pakistan (Correspondence to: K. Aziz: kashif.aziz@aku.edu); 2Nishter Hospital, Multan, Pakistan; 3Allied Hospital, Faisalabad, Pakistan. Received: 16/06/16; accepted: 22/01/17 Independent prescription of medicines and diagnostic test advice by final year medical students in Punjab Kashif Aziz 1, Hafiz M. Aeymon 2 and Saba Batool 3 Prescription indépendante de médicaments et recommandation de tests diagnostiques par des étudiants en dernière année de médecine au Pendjab RÉSUMÉ La vente de médicaments n’est pas rigoureusement contrôlée au Pakistan. Ainsi, les étudiants en médecine commencent à prescrire des médicaments et à recommander des tests diagnostiques avant l’obtention de leur diplôme. La présente étude transversale a examiné la fréquence de la prescription indépendante de médicaments auprès de 180 étudiants en dernière année de médecine sélectionnés de façon aléatoire et stratifiée dans trois écoles de médecine publiques au Pendjab. Les données ont été obtenues au moyen d’un questionnaire auto-administré. Cent douze étudiants avaient prescrit des médicaments de façon indépendante et sans aucun contrôle ; 38 avaient procédé à un examen physique en amont de la prescription ; 74 avaient recommandé des tests diagnostiques et 49 avaient interprété lesdits tests de façon indépendante. Quarante-quatre étudiants avaient administré des médicaments injectables et un tiers de ces médicaments avaient été administrés sans consultation des dates de péremption. Les anti-inflammatoires non stéroïdiens (92 %) et les antibiotiques (73 %) étaient les médicaments le plus souvent prescrits. Un hémogramme complet, une radiographie pulmonaire et des rapports urinaires détaillés étaient les examens le plus souvent recommandés. Cent vingt-sept participants étaient d’avis que les étudiants en médecine ne devraient pas prescrire de médicaments. Il existait une relation significative entre le sexe, le revenu du foyer et les pratiques de prescription. De nombreux étudiants en dernière année de médecine avaient prescrit des médicaments et recommandé des tests diagnostiques avant l’obtention de leur diplôme. ءاـقلت نـم ةـيبطلا تاـيلكلا في ةـيئاهنلا ةنـسلا باـط بـناج نـم ةيصيخـشتلا تاـيلحتلا نأـشب ةروـشلما مـيدقتو ةـيودلأا فـصو باـجنبلا مـيلقإ في مهـسفنأ لوتب ابص ،نميأ دممح ظفاح ،زيزع فشاك تاـيلتح نأـشب ةروـشلما مـيدقتو ةـيودلأا فـصو في ةـيبطلا تاـيلكلا باـط أدـبي ،لياـتلابو .ناتـسكاب في ةـمراصلا ةـبقارملل ةـيودلأا عـيب عـضيخ لا :ةـصالخا ةراـتمخو تاـقبطل ةـفنصم ةـعومجلم تاذـلا ءاـقلت نـم ةـيودلأا فـصو رـتاوت في قـيقحتلا لىإ ةـيعطقلما ةـساردلا هذـه تدـمعو .مـهجرتخ لـبق ةيصيخـشت ًاـبلاط 112 نأ نـبتف .ًاـيتاذ رادـم نايبتـسا قـيرط نـع تاـنايبلا عـجم مـتو .باـجنبلا مـيلقإ في ةـماع بـط تاـيلك ثاـث باـط نـم ًاـبلاط 180 نـم ًايئاوـشع نأـشب ةروـشم اوـمدق نأو قبـس ًاـبلاط 74و ؛ةـيودلأا فـصو لـبق ًاـيندب ًاـصحف اورـجأ ًاـبلاط 38و ؛ةـبقارم يأ نود مهـسفنأ ءاـقلت نـم ةـيودأ اوـفصو نأو قبـس ةـعلاطم نود اـهثلث ،ةـيودأ نـقحب اوـماق نأو قبـس ًاـبلاط 44 نأ ّنـبتو .مهـسفنأ ءاـقلت نـم ةيصيخـشت صوـحف يرـسفتب اوـماق ًاـبلاط 49و ؛ةيصيخـشت تاـيلتح رـثكأ تلمـشو .)% 73( ةـيويلحا تاداـضلماو )% 92( باـهتلال ةداـضلما ةيدويرتـسالا ةـيودلأا ةـفوصولما ةـيودلأا رـثكأ تـنمضتو .ناـيسرلا ءاـهتنا خـيرات مـهداقتعا نـع ًاكراـشم 127 برـعأو .ةـيليصفتلا لوـبلا لـيلتح رـيراقتو ةينيـسلا ةعـشلأاو لـماكلا مدـلا اـياخ ددـع لـيلتح اـبه حـصنلا مـت يـتلا صوـحفلا نأ ّنـبتو .ةـيودلأا فـصو تاـسراممو ةسرلأا لـخدو سـنلجا عوـن نـب ةـللاد تاذ ةـقاع دوـجو ّنـبتو .ةـيودأ اوـفصي لاأ يـغبني بـطلا تاـيلك ةـبلط نأـب .جرـختلا لـبق ةيصيخـشت تاـيلتح نأـشب ةروـشلما اوـمدق وأ ةـيودأ فـصو مـله قبـس ةـيبطلا تاـيلكلا في ةيرـخلأا ةنـسلا باـط نـم يرـثك ABSTRACT Sale of medicines is not rigorously controlled in Pakistan. Therefore, medical students start prescribing drugs and advising diagnostic tests before they graduate. This cross-sectional study investigated the frequency of independent medical prescription by 180 stratified, randomly selected final year medical students from 3 public medical colleges in Punjab, Pakistan. Data were obtained by self-administered questionnaire. One hundred and twelve students had prescribed medicines independently without any supervision; 38 had performed a physical examination before prescribing; and 74 had advised and 49 interpreted diagnostic tests independently. Forty-four students had administered injectable drugs and one third of these were administered without seeing expiry dates. The most frequently prescribed drugs were nonsteroidal anti- inflammatory drugs (92%) and antibiotics (73%). The most frequently advised tests were complete blood cell count, chest X-ray and urine detailed reports. One hundred and twenty-seven participants thought that medical students should not prescribe drugs. There was a significant relationship between gender and household income and prescription practices. Many final year medical students had prescribed drugs and advised diagnostic tests before graduation. https://doi.org/10.26719/2017.23.12.795 Book 23-12.indb 795 3/4/2018 11:44:20 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 796 Introduction Prescription of drugs is regulated world- wide and only physicians are allowed to prescribe. Unfortunately, in develop- ing countries, there are other channels from which drugs can be acquired. In Pakistan, there is a statutory law called The Allopathic System (Prevention of Misuse) Rule 1968 that defines who can prescribe drugs, but informal drug distribution channels are still prevalent (1). After graduation medical students must undergo 1 year supervised train- ing. This training period is termed a house job/internship. After this year of supervised training doctors are certi- fied in Pakistan. The law requires that each prescription must be signed by a medical practitioner and their registra- tion number must be mentioned on the prescription (2). Some pharmacists in Pakistan dis- pense drugs even without asking for a prescription. Many pharmacists and allied healthcare workers like nurses and dispensers treat illnesses on their own and prescribe drugs (3,4). Due to this culture, medical students in Paki- stan also start prescribing drugs before graduation (4). It can expose patients to unwanted drugs, create drug resistance, and even contagious diseases can re- main undetectable if a person has been taking medication for symptomatic relief without proper evaluation (2). Many studies have been done on self-medication among medical and nonmedical students. However, inde- pendent prescription practices of medi- cal students are an unexplored area. Such practices cannot thrive in developed countries because of strict pharmacy regulations. However, in developing countries like Pakistan such practices can prevail due to loose legislation (5). Only one study has investigated the pre- scription practices of medical students in one city in Pakistan, which showed that medical students began prescribing before graduation (6). To explore this issue further and establish the factors leading to such practices, we studied final year medical students at 3 medical colleges in Punjab Province, Pakistan. We postulated that medical students start prescribing drugs after they have studied pharmacology in the 3rd year of their MBBS degree. Methods Study population This was a cross-sectional study from June 2013 to June 2014. In 2013 there were 12 registered public sector medical colleges in Punjab. Three of these, Quaid E. Azam Medical College (QMC), Bahawalpur, Nishter Medical College (NMC), Multan, and Punjab Medical College (PMC), Faisalabad, were randomly selected. We selected final year medical students who had already studied pharmacology and pathology. There was no previous refer- ence study for sample size estimation. Therefore, to calculate the sample size, a pilot study was done on 30 randomly se- lected medical students who were asked about independent drug prescription. Twenty-four of them had prescribed in- dependently. We used these pilot study data (80% prescription rate) to estimate sample size, taking 5% as margin of er- ror and 95% confidence interval and 600 was our population under study. Sample size came out to be 175 and we decided to study 180 students. There were 600 final year medical students in all 3 medical colleges, thus, we decided to take 30% of these. Weighted samples were taken from each medical college according to enrolment. We selected 30% of the enrolled final year medical students from each institute. Overall ratio of male to female students was 2:3. A stratified random sampling technique was used and stratification was based on gender. Random numbers were gener- ated using Microsoft Excel version 10. One hundred and seventy-two of 180 students agreed to participate. The sole exclusion criterion was non-Pakistani nationality but no students met this criterion. Among the 172 students, 109 (63%) were female and 63 (37%) were male; 47 were from PMC, 69 from NMC and 56 from QMC. Data collection Data were collected through a self- reported questionnaire that was devel- oped by the authors for an unpublished pilot study. Initially, 5 medical students were interviewed on prescription and diagnostic test advice practices, and the questionnaire was developed after con- tent analysis of these interviews. Then, the aforementioned medical students were given the questionnaire and inter- nal consistency was evaluated. Test– retest reliability was also checked by again administering the questionnaire after 20 days. After this pilot study, the questionnaire was finalized for inclusion in the present study. The questionnaire included general demographic data (age, gender, rural or urban residence and monthly income). Urban areas were defined according to the Pakistan National Statistical Of- fice. Large cities of Lahore, Gujranwala, Faisalabad, Rawalpindi, Multan, Sialkot, Sargodha, Bahawalpur, district head- quarters and tehsil headquarters were classified as urban areas. All remaining areas were classified as rural. Monthly income was recorded in Pakistani Ru- pees and classified into 4 groups: < 10 000, 10 000–25 000, 25 000–50 000 and > 50 000. Drugs were categorized into the following groups: analgesics, antibiotics, diuretics, vitamin supple- ments, steroids, antipyretics, sleeping pills, antiemetics, contraceptives, ho- meopathic medicines, antihistamines, H2 blockers and proton pump in- hibitors. The following diagnostic tests were studied: X-rays, sputum culture, computed tomography, pregnancy tests, blood cultures, complete blood count, lipid profile, magnetic resonance imaging, renal function tests, urine detailed reports, electrocardiograms, Book 23-12.indb 796 3/4/2018 11:44:21 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 797 ultrasonography and liver function tests. If the participants had prescribed other than the above-mentioned drugs/tests, they were asked to name them. We asked the students about the number of times annually that each drug was prescribed. Seven structured questions were asked to inquire about attitude and perception of medical students toward prescription practices. Data analysis Data were doubled entered in and ana- lysed by SPSS version 17. Descriptive analyses were performed. Data were stratified based on gender of partici- pant, their household income and their residence. The χ2 test was applied for significance, and P < 0.05 was taken as significant. The pilot study data were not included in the final analysis. Ethics Informed consent was obtained from each participant before administering the questionnaire. Confidentiality was maintained. Ethical approval was ob- tained from each institute. Results Demographic details of the participants are shown in Table 1. One hundred and twelve (65%) students prescribed drugs independently without any super- vision from a certified medical practi- tioner. Prescription rates at the different medical colleges are shown in Table 2. Twenty-two students prescribed volun- tarily, 74 were asked for a prescription and 16 prescribed as a result of family expectations. When we asked about the rationale behind independent prescrip- tion, 44 (40%) students did not give any reason and 28 (25%) said that they prescribed because, in their opinion, the patient’s condition was trivial and did not need any expert opinion. Six of 112 (5%) students prescribed as part of first aid advice and then referred the patient to a hospital. Among the 112 students who had prescribed, 14 (13%) had prescribed on only 1 occasion, 47 (42%) had prescribed twice a year, 39 (35%) had prescribed once monthly and 5 (4%) had prescribed every week. Forty-five (26%) students had admin- istered injectable drugs in response to a patient’s request (Table 2), and 30 of these students did not see the expiry dates of the drug preparations. Anal- gesics and antibiotics were the most frequently prescribed drugs (Table 3). Seventy-four (43%) students ad- vised diagnostic tests independently (details of tests are shown in Table 4), and 44 did not perform any physi- cal examination before advising tests. Fifty (29%) students had interpreted the diagnostic tests independently and informed their patients that the results were normal. The most common tests interpreted were complete blood count, urine detailed report, lipid profile, chest X-ray and liver function test in descend- ing order. We asked several questions to deter- mine the attitude of the students toward independent medication. Forty-three (25%) thought that medical students can prescribe medication; 108 (62%) thought that medical students could ad- vise diagnostic tests; 36 (21%) thought it right that medical students could treat patients if certified medical practitioners were not available; 144 (84%) knew about antibiotic resistance; 92 (53%) did not know about the dangers of self-medication; 140 (81%) thought it better for lay people to consult a medi- cal student instead of self-medicating themselves; and 78 (45%) thought if a medical student refused to prescribe medication to lay people on their re- quest, they would be considered an incompetent doctor. There was no significant differ- ence in prescription rates among the 3 medical colleges (P = 0.077). Male students were significantly more likely to prescribe independently than female students were (P = 0.001). There was no significant relationship between students’ rural/urban residence and prescription practices (P = 0.444). Stu- dents with low monthly household in- come (< 10 000 Pakistani Rupees) had significantly higher prescription rates (P = 0.03). There was also a significant relationship between student house- hold income and diagnostic test advice (P = 0.008): the higher the student’s household income, the fewer tests were advised (Table 5). Post-stratification analysis revealed that there was a significant association of gender with the perception that medical students could prescribe after passing pharmacology (P = 0.03) Fe- male students thought that just passing pharmacology did not qualify a student to prescribe medication. There was sig- nificant association between gender and perception that medical students should diagnose a disease in the absence of a certified doctor (P = 0.004). Male students were more inclined toward diagnosis of disease by students in the absence of a certified doctor. There was a significant association of residence with perception of disease diagnosis in the absence of a certified doctor (P = 0.01). Urban students thought that they should not diagnose a disease in the absence of a certified doctor. There was no significant association between monthly income of students and their attitude toward medical prescription. Discussion Our study was a multicentre cross-sec- tional study on unique topic on the fre- quency of drug prescription by medical students before graduation. We found that many students (112; 65%) were involved in this practice. About half of the students were unable to specify a reason for this practice. When asked about frequency of annual prescription, most of the students had prescribed only once or twice a year and only 4% of them were prescribing almost weekly. It was found that male students and Book 23-12.indb 797 3/4/2018 11:44:21 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 798 students from low-income households were more likely to prescribe. There has been much research on self-medication but research on inde- pendent prescription by medical stu- dents has not been done. Prescription by medical students is more dangerous than self-medication because of the po- tential dangers. This can result in anti- biotic resistance, masking of diagnoses, unnecessary exposure to medication and incorrect diagnoses. The study of Zafar et al. investigated independent prescription by medical and nonmedical students in Karachi (6). Our study differed in that we stud- ied only medical students and only in their final year. We studied 3 different medical colleges that were ~200 km apart. Zafar et al. found that 53% of med- ical students had prescribed, while our finding was 65%. The most frequently prescribed medications were the same in both studies: antibiotics, antiallergics, antipyretics and analgesics. Prescription by medical students is prevalent in Pakistan because of loose regulation. Pharmacies dispense medi- cation without prescription. A study by Hussain et al. in Sindh Province evalu- ated 371 community pharmacies and none of them completely followed all the regulations established by the Phar- macy Act 1967 (5). A survey by Haseeb and Bilal in rural Karachi revealed that 85% of participants were using informal ways of taking medication (7). The most common reasons evaluated were cost of consultation (90.3%) and availability of transport (81.0%) from rural areas to healthcare facilities (8). Prescription by medical students is more dangerous than self-medication because patients are consulting students rather than qualified practitioners. One reason for such practice is economics. Certified doctors cost a lot of money, while seek- ing help from a neighbouring medical student comes free of charge. Similar practices have been documented in Kerala, India, where interns who are supposed to work under supervision, run independent practices to make ex- tra money. (9). Apart from the ethical questions, there is a need to evaluate whether fi- nal year medical students have enough knowledge to prescribe safely. This question was addressed by a Nigerian study (10). Thirty-one final year stu- dents were interviewed and it was found that they all needed training to prescribe safely. Another study in the United Table 1 Demographic details Total, n (%) QMC n (%) PMC n (%) NMC n (%) Participants 172 56 47 69 Gender Male 63 (37) 25 (45) 17 (36) 21 (30) Female 109 (63) 31 (55) 30 (64) 48 (70) Mean age (SD), yr 22.5 (0.9) 22.5 (0.85) 22.5 (0.9) 22.6 (1.1) Residence Rural 28 (16) 10 (18) 7 (15) 11(16) Urban 144 (84) 46 (82) 40 (85) 58 (84) Household income, Pakistani Rupees < 10 000 12 (7) 5 (8) 5 (11) 2 (3) 10 000–25 000 30 (17) 5 (8) 8 (17) 17 (25) 25 000–50 000 62 (36) 21 (38) 22 (46) 19 (27) > 50 000 68 (40) 25 (46) 12 (26) 31 (45) NMC = Nishter Medical College; PMC = Punjab Medical College; QMC = Quaid E Azam Medical College; SD = standard deviation. Table 2 Study results Variable Cumulative result (total 172) n (%) QMC (total 56) n (%) PMC (total 47) n (%) NMC (total 69) n (%) Prescribed medicine All students 112 (65) 40 (71) 34 (72) 38 (55) Male students 51 21 15 15 Female students 61 19 19 23 Advised diagnostic tests All students 74 (43) 26 (46) 19 (40) 29 (42) Interpreted diagnostic tests All students 50 (29) 14 (25) 16 (34) 20 (29) Administered injections All students 45 (26) 19 (34) 10 (21) 16 (23) NMC = Nishter Medical College; PMC = Punjab Medical College; QMC = Quaid E. Azam Medical College. Book 23-12.indb 798 3/4/2018 11:44:21 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 799 Kingdom investigated the readiness of graduating students to prescribe safely (11). Many students felt underprepared to take responsibility for safe prescrip- tion. Therefore, a mandatory internship year or foundation year is necessary. A similar but more plausible concept in the United States of America (USA) is student-run health clinics, where medi- cal students care for underprivileged patients who are poor and uninsured. This improves medical students’ clini- cal experience and provides a medical service to a neglected stratum of society. One important factor is that the clinics Table 3 Medicines prescribed by studentsa Medicine Cumulative result (112 prescribed) n (%) QMC (40 prescribed) n (%) PMC (34 prescribed) n (%) NMC (38 prescribed) n (%) Analgesics 104 (92) 38 (95) 31 (91) 35 (89) Antibiotics 83 (73) 29 (72) 28 (82) 26 (66) Multi vitamins 44 (39) 14 (35) 12 (35) 18 (46) Steroids 5 (4) 2 (5) 0 3 (7.7) Antipyretics 70 (62) 27 (67) 21 (61) 22 (56) Anxiolytics 18 (16) 5 (12) 3 (9) 10 (25) Antiemetics 34 (30) 11 (27) 11 (32) 12 (30) Contraceptives 4 (3) 3 (7.5) 0 1 (2) Antihistamines 58 (51) 25 (62.5) 15 (44) 18 (46) H2 receptor blockers 18 (16) 6 (15) 7 (20) 5 (12.8) Proton pump inhibitors 29 (26) 5(12.5) 13(38) 11(28) Diuretics 3 (2) 0 1 (3) 2 (5) Other 6 (4) 1 (2.5) 2 (6) 2 (5) aPercentages are calculated among the students who prescribed medicines. NMC = Nishter Medical College; PMC = Punjab Medical College; QMC = Quaid E. Azam Medical College. Table 4 Diagnostic tests advised by studentsa Diagnostic test Cumulative result (74 students advised tests) n (%) QMC (26 students advised tests) n (%) PMC (19 students advised tests) n (%) NMC (30 students advised tests) n (%) X-ray 46 (61) 18 (69) 10 (52) 18 (60) Sputum test 13 (17) 5 (19) 4 (21) 4 (13) CT scan 10 (13) 3 (11) 2 (10) 5 (16) Pregnancy test 11 (12) 4 (15) 4 (4.8) 3 (10) Culture sensitivity 1 (1) 0 1 (5.3) 0 Complete blood count 49 (65) 18 (69) 12 (63) 19 (63) Lipid profile 20 (26) 3 (11) 9 (47) 8 (26) MRI 7 (9) 3 (11) 2 (10) 2 (6.7) Renal function tests 14 (18) 4 (11) 6 (31) 4 (13) Urine detailed report 34 (45) 14 (15) 7 (36) 13 (43) Electrocardiogram 15(20) 7 (26) 5 (26) 3 (10) Ultrasonography 29 (38) 9 (34) 10 (52) 10 (33) Liver function tests 21 (28) 7 (26) 8 (42) 6 (20) Other 8 (10) 1 (3) 4 (21) 3 (10) aPercentages are calculated among the students who advised diagnostic tests. CT = computed tomography; MRI = magnetic resonance imaging; NMC = Nishter Medical College; PMC = Punjab Medical College; QMC = Quaid E. Azam Medical College. Book 23-12.indb 799 3/4/2018 11:44:21 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 800 are managed by a certified physician who shadows all medical students working in the clinic, which provides a safety net against any inadvertent medi- cal errors. It is reported that the quality of services provided by such clinics has not been rigorously studied (12). When we asked the medical stu- dents about the reason for prescrib- ing, 16% revealed peer pressure and family expectation. There is a need to educate the population about the risk of prescription by medical students. They should counsel their family members to have a proper check-up by a certified doctor. Twenty-five percent of medi- cal students prescribed because they thought that the patient’s condition was not serious enough to refer to a doctor. However, as shown in previous stud- ies11, medical students are not capable of identifying subtle clinical signs and they can miss a diagnosis. Thirty percent of the students in our study, who had administered inject- able drugs, did not confirm the expiry date. Medical students should be taught about safe pharmacy practices and there is lack of such training in medical schools. Medication errors should be included in the curriculum. In our study, medical students not only prescribed drugs but also advised diagnostic tests and interpreted the results. Advice for a diagnostic test is a complicated task. Medical students are not capable of choosing the appropriate test. Before giving appropriate diagnos- tic advice there is a need to take a proper history and perform a physical exami- nation (13). In our study, 73 students advised diagnostic tests but 44 of them did not perform a physical examination. A study by McGregor et al. also revealed that medical students are not capable of accurate clinical decision-making (14). The same applies to interpretation of test results. Half of medical students who interpreted test results had not undertaken physical examinations. We hypothesized that prescription practice of medical students from rural areas would differ from that of urban ar- eas but there were no significant differ- ences. There is a need to implement the same model as the clinics led by medical students in the USA. The population in Pakistan is unable to afford health care, therefore, such student-led clinics could resolve this issue but they should be shadowed by certified medical prac- titioners. Such clinics have also been studied in Australia, with favourable outcomes (15). Our post-stratification analyses revealed that male medical students prescribed more as compared to female students. Female students thought that medical students were not capable of prescribing medication after passing pharmacology. Gender and safety of doctors are controversial, with studies having conflicting results. A meta-anal- ysis of 32 reports in 2015 revealed that male doctors had ~2.5 times the odds of being subject to medicolegal action than female doctors had. Female doc- tors seem to take less risk and therefore are less prone to medicolegal action (16). Antibiotic resistance is on rise and much research is being done to curb this issue (17). Our study showed that an- tibiotics are among the most common drug prescribed, but alarmingly only 1 of the 112 students advised a culture and sensitivity test. Medical students are not equipped to guide adequate antibiotic therapy (18). We found that 81% of all students who participated in our study thought that it was right to consult a medical stu- dent instead of self-medication. There is a need to correct this misconception. Universities should include the harm of independent prescription and self- medication in their curricula. Medical students should be advised to counsel people who approach them for a pre- scription instead of entertaining them. In a country like Pakistan, where per capita income is low, it is tempt- ing to adopt cheap illegal pathways to take medication. Although there is government legislation, and drug inspectors are there to oversee drug distribution channels, drugs can still be availed without a prescription from a certified doctor (1). There is a need for a strict monitoring system to eradicate Table 5 Prescription practices cross tabulation Prescribed medicines P Yes No College PMC 39 13 0.077 NMC 38 31 QMC 40 16 Gender Male 51 12 0.001 Female 61 48 Residence Rural 20 8 0.444 Urban 92 52 Monthly income, Pakistani Rupees < 10 000 11 1 0.03 10 000–25 000 24 6 25 000–50 000 thousands 37 25 > 50 000 40 28 NMC = Nishter Medical College; PMC = Punjab Medical College; QMC = Quaid E. Azam Medical College. Book 23-12.indb 800 3/4/2018 11:44:21 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 801 this issue. Pharmacies should be reg- istered and should not be allowed to sell medication without prescriptions. There are free hospitals established by the government throughout Paki- stan that provide free medication but they are under-resourced. Free quality healthcare provision can also stop this problem. There were several limitations to this study. We only included public sec- tor medical colleges. There are many private sector medical colleges in Paki- stan and students at these institutions should be investigated to establish any difference from the public sector. We assumed that final year medical students would prescribe more than nonmedical students. A comparative study should be done to see whether there is any dif- ference in prescribing practice between first and final year medical students. Another limitation was that we only studied 1 province. The study should be replicated nationwide. We did not study the patient perspective on this issue. Another study could be done to determine whether patients would pre- fer to consult a nearby medical student or a certified doctor and the reasons for such health-seeking behaviour. In conclusion, many undergraduate medical students prescribe medica- tion and advise diagnostic tests. Public health scientists should further investi- gate the causes of this issue and a holistic References 1. Allopathic system (prevention of misuse) (West Pakistan) rules, 1968 (http://www.pmdc.org.pk/LinkClick.aspx?fileticket=cyh 4G9XLyPs%3d&tabid=292&mid=850, accessed 31 May 2017). 2. Hu J, Wang Z. Non-prescribed antibiotic use and general prac- titioner service utilisation among Chinese migrants in Australia. Aust J Prim Health. 2015;22(5):434–9. PMID:26328599 3. Chang FR, Trivedi PK. Economics of self-medication: the- ory and evidence. Health Econ. 2003 Sep;12(9):721–39. PMID:12950092 4. Tomson G, Sterky G. Self-prescribing by way of pharma- cies in three Asian developing countries. Lancet. 1986 Sep 13;2(8507):620–2. PMID:2875329 5. Gurwitz JH. Serious adverse drug effects–seeing the trees through the forest. N Engl J Med. 2006 Mar 30;354(13):1413–5. PMID:16510740 6. Zafar SN, Syed R, Waqar S, Irani F, Saleem S. Prescription of medicines by medical students of Karachi, Pakistan: A crosssectional study. BMC Public Health. 2008 May19;8:162. PMID:18485246 7. Hussain A, Ibrahim MI, Baber ZU. Compliance with legal requirements at community pharmacies: a cross sectional study from Pakistan. Int J Pharm Pract. 2012 Jun;20(3):183–90. PMID:22554161 8. Afridi MI, Rasool G, Tabassum R, Shaheen M. Siddiqullah, Shujauddin M. Prevalence and pattern of self-medication in Karachi: a community survey. Pak J Med Sci. 2015 Sep– Oct;31(5):1241–5. PMID:26649022 9. Pakistan Medical & Dental Council, Higher Education Com- mission Islamabad. Curriculum of M.B.B.S. (http://www. pmdc.org.pk/LinkClick.aspx?fileticket=EKfBIOSDTkE%3d&tab id=292&mid=849, accessed 1 June 2017). 10. Haseeb A, Bilal M. Prevalence of using non prescribed medica- tions in economically deprived rural population of Pakistan. Arch Public Health. 2016 Jan 22;74:1. PMID:26807216 11. Sreejit EM. MBBS doctors working as quacks: private practice by interns in Kerala medical colleges. Indian J Med Ethics. 2009 Jan–Mar;6(1):38–9. PMID:19241955 12. Oshikoya KA, Bello JA, Ayorinde EO. Prescribing knowledge and skills of final year medical students in Nigeria. Indian J Pharmacol. 2008 Nov;40(6):251–5. PMID:21279180 13. Han WH, Maxwell SR. Are medical students adequately trained to prescribe at the point of graduation? Views of first year foundation doctors. Scott Med J. 2006 Nov;51(4):27–32. PMID:17137145 14. Simpson SA, Long JA. Medical student-run health clinics: im- portant contributors to patient care and medical education. J Gen Intern Med. 2007 Mar;22(3):352–6. PMID:17356967 15. Noguchi Y, Matsui K, Imura H, Kiyota M, Fukui T. Quantita- tive evaluation of the diagnostic thinking process in medi- cal students. J Gen Intern Med. 2002 Nov;17(11):839–44. PMID:12406355 16. McGregor CA, Paton C, Thomson C, Chandratilake M, Scott H. Preparing medical students for clinical decision making: a pilot study exploring how students make decisions and the perceived impact of a clinical decision making teaching inter- vention. Med Teach. 2012;34(7):e508–17. PMID:22452752 17. Foucault C, Brouqui P. How to fight antimicrobial resist- ance. FEMS Immunol Med Microbiol. 2007 Mar;49(2):173–83. PMID:17181560 18. Ibia E, Sheridan M, Schwartz R. Knowledge of the princi- ples of judicious antibiotic use for upper respiratory infec- tions: a survey of senior medical students. South Med J. 2005 Sep;98(9):889–95. PMID:16217981 approach is needed to resolve it. Further research is needed to investigate this issue in other developing countries to see a global perspective. This practice can be transformed in a positive way by creating clinics led by medical students that are shadowed by physicians. Acknowledgements We are grateful to the students who participated in the study and their in- stitutions. Funding: None. Competing interests: None declared. Book 23-12.indb 801 3/4/2018 11:44:21 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 802 1Preventive Dentistry Research Center, Research Institute of Dental Sciences, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran. 2Community Oral Health Department, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to: M. Pakkhesal: m_pakkhesal@yahoo.com). 3Department of Public Health Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran. 4Dental Research Center, Iranian Center for Endodontic Research, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran. 5School of Anatomy, Physiology and Human Biology, University of Western Australia, Perth, WA, Australia. 6Epidemiology and Biostatistics Department, School of Public Health, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. Received: 05/10/16; accepted: 23/01/17 Challenges impeding integration of oral health into primary health care Zahra Ghorbani 1,2, Mina Pakkhesal 2, Shahnam Arshi 3, Mohammad J. Eghbal 4, Marzieh Deghatipour 2, Marc Tennant 5 and H. Malekafzali Ardakani 6 Les obstacles à l’intégration de la santé bucco-dentaire aux soins de santé primaires RÉSUMÉ Les services de soins de santé primaires en République islamique d’Iran sont parvenus avec succès à traiter le nombre élevé de cas de maladies transmissibles. Néanmoins, il semblerait qu’ils soient moins performants dans la prise en charge des maladies bucco-dentaires de la mère et de l’enfant. La présente étude avait pour objectif d’examiner les obstacles à l’intégration de la santé bucco-dentaire aux services de soins de santé primaires. Il s’agissait d’une étude de recherche qualitative comprenant des groupes de discussion et des entretiens. Cinq groupes de discussion ont été tenus. Il réunissaient des sages-femmes, des médecins de famille, des agents de soins de santé primaires en milieu rural, des dentistes suppléants, et des dentistes en santé publique. Des entretiens individuels ont également été organisés avec des experts membres du corps enseignant des domaines concernés, des gestionnaires en charge de la planification et de la coordination et des responsables politiques. D’autre part, des entretiens approfondis ont été menés auprès de femmes enceintes dans quatre établissements de soins de santé primaires. Des cassettes audio ont été retranscrites à la suite de chaque session, et une analyse thématique qualitative a été menée sur les données recueillies. L’analyse des données a fait ressortir quatre types de problèmes principaux liés à des facteurs d’ordre environnemental et organisationnel, et concernant la formation des praticiens et les programmes scolaires. La présente étude permet une compréhension plus détaillée des obstacles à l’intégration des services de santé bucco-dentaires aux soins de santé primaires. ةيلولأا ةيحصلا ةياعرلا في مفلا ةحص جامدإ قوعت يتلا تايدحتلا نياكدرا ليضفأ كلام نسح ،تنانيت كرام ،روب يتقد هيضرم ،لابقإ رفعج دممح ،شيرع مانهش ،لاصخكاب انيم ،نيابرق ةرهز ودـبت اـنهأ لاإ ،ةيراـسلا ضارـملأا تايوتـسم عاـفترلا يدـصتلا في ةيماـسلإا نارـيإ ةـيروهجم في ةـيلولأا ةـيحصلا ةـياعرلا تاـمدخ تـحجن :ةـصالخا جاـمدإ في ةـمئاقلا تاكـشلما في رـظنلا في ةـساردلا هذـه نـم فدـلها لـّثتمو .لاـفطلأاو تاـهملأا فوـفص في مـفلا ضارـمأ عـم لـماعتلا ىـع ةردـق لـقأ تاـشقانم سـخم تدـقعف .تاـباقمو ةـيعاجم تاـشقانم نـم فـلأتت ةـينيك ةـيثحب ةـسرادك تءاـجو .ةـيلولأا ةـيحصلا ةـياعرلا في مـفلا ةـحص تاـمدخ ةـحصلا لاـمج في نانـسأ ءاـبطأو ،فـيرلا في ةـيحصلا ةـياعرلا مـيدقت لاـمج في نـلماعو ،ةـيسرلأا ةـيحصلا ةـياعرلا لاـمج في نـسراممو ،تاـباق عـم ةـيعاجم تدـقُعو ،رارـق عاـنصو نـفراع نـيريدمو ةـطبترم تلااـمج في سـيردتلا ةـئيه ءاـضعأ نـم ءارـخ عـم ةـيدرف تاـباقم تـمِّظُن ،كـلذ ىـع ًاـضفو .ةـماعلا يـعيضاوم لـيلتح ىرـجأو ،ةـسلج لك دـعب ةـيتوصلا تايجـستلا غـيرفت مـتو .ةـماعلا ةـحصلا ةـياعرل زـكارم ةـعبرأ في لـماوح ءاـسن عـم ةـقّمعم تاـباقم ةـيميلعتلاو ةـيئيبلا ةـيمجارلا لـماوعلا :يـهو ،تاـيدحتلاب قـلعتت ةيـسيئر عـيضاوم ةـعبرأ نـع تاـنايبلا لـيلتح رفـسأو .ةـعمجلما تاـنايبلا نأـشب يـفيك .ةـيلولأا ةـيحصلا ةـياعرلا في مـفلا ةـحص تاـمدخ جاـمدإ هـجاوت يـتلا تاـيدحتلل حـضوأ اـهف ةـساردلا هذـه رـفوتو .ةيـسردلماو ةـيميظنتلاو ABSTRACT The primary healthcare (PHC) services in the Islamic Republic of Iran have succeeded in addressing high levels of communicable diseases; however, they seem less able to deal with maternal and paediatric oral diseases. The aim of this study was to examine problems in integrating oral health services into PHC. This was a qualitative research study comprising focus group discussions and interviews. Five focus-group discussions were held with midwives, family healthcare practitioners, rural PHC workers, duty-service dentists, and public health dentists. Also, individual interviews were organized with experts of faculty members in related fields, informant managers and policy makers, and in-depth interviews were done with pregnant women in four PHC centres. Audiotapes were transcribed following each session, and then a qualitative thematic analysis was carried out on gathered data. Data analysis resulted in 4 main themes relating to the challenges: environmental, educational, organizational and school-based programme factors. This study provides a clearer understanding of the challenges of integrating oral health services into PHC. https://doi.org/10.26719/2017.23.12.802 Book 23-12.indb 802 3/4/2018 11:44:21 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 803 Introduction Oral health is a critical component of overall health and well-being; yet, oral disease remains a silent epidemic (1). Many children in developed and devel- oping countries, especially those from deprived areas, are affected by dental caries and suffer from pain and infection associated with their teeth and gums (2). The prevalence of caries increases with age, especially in high-risk chil- dren with limited access to oral health services (3). Furthermore, dental caries in deciduous dentition predicts later caries experience in adulthood (4). So, it seems that prevention and early initia- tion of dental care, especially provided in a primary healthcare (PHC) setting, can lead to improved oral health out- comes and are both cost saving and effective (5–7). Pregnancy represents a unique and sensitive period of maternal oral health, and due to changes in hormonal levels, pregnant women are more susceptible to oral diseases. Possible adverse preg- nancy outcomes, including low birth weight, preterm birth, pre-eclampsia and miscarriages have been reported as consequences of oral diseases. It is also widely accepted that poor maternal oral health is a predictor of early child- hood caries, and education of pregnant women can effectively prevent early childhood caries (1). A majority of babies, young children and pregnant women do not undertake regular dental visits; instead, they fre- quently visit PHC providers for routine check-ups. These check-ups provide an opportunity to integrate oral health pro- motion into the practices of nondental staff in public health centres. Sharing the responsibility for child oral health care with PHC creates opportunities for interprofessional efforts to target this at-risk population (8,9). Structured PHC in the Islamic Re- public of Iran was established in the 1970s, and integration of oral health care into the nationwide PHC network followed in 1997 (10). Oral health was integrated into the monitoring pro- grammes for maternal and child care through which the responsibility for oral health education, primary screen- ing and referral to the dentist was as- signed to the PHC workers, including midwives, family health physicians and rural healthcare workers. About 60% of PHC centres have an oral healthcare unit with a dentist who is in charge of ba- sic services, such as restoration, scaling and extraction, mainly for target groups consisting of children aged < 12 years, pregnant women and nursing mothers (9). The PHC services in the Islamic Republic of Iran have clearly succeeded in addressing high levels of communi- cable diseases and maternal and infant mortality, but have been less effective in dealing with maternal and paediatric oral diseases. The aim of this study was to explore the considerable challenges of integrating oral health promotion into PHC in Iran. Methods Study design The present study used a qualitative research design consisting of 3 sources of data: focus group discussions, in- dividual interviews with experts, and semistructured interviews with preg- nant women. Focus group discussions and interviews Five focus groups were held with mid- wives, family healthcare practitioners, rural PHC workers, duty-service den- tists and public health dentists. Each focus group consisted of 10 participants and lasted 2–2.5 hours. Purposive sam- pling was used to select the members of each focus group, since researchers needed to consider who could best ad- dress the research questions. A modera- tor asked the participants to think about the various challenges with which they dealt in the integration of oral health care into PHC services. The focus groups provided detailed explanations and examples of positive and negative experiences and views regarding oral healthcare integration into PHC. Semistructured interviews were conducted with a convenience sample of 27 pregnant women seeking regular maternal care in 4 selected PHC cen- tres. A purposive sampling method was initially used for selection of 4 PHC centres with high levels of provision of maternal and paediatric services located in 2 deprived regions of Tehran Prov- ince. Women were eligible for inclusion in the study if they were aged ≥ 20 years; were in 2nd or 3rd trimester of preg- nancy; and were willing to participate in the interview. They were asked whether they received any examination, service or education regarding oral health in their last maternal visit, and what oral health care did they expect to receive via PHC. The average length of each in- terview was 20 minutes. The interviews were transcribed individually and the sampling continued until data satura- tion was reached. Semistructured and individual in- terviews were also conducted with 10 experts lasting for 45 minutes to 2 hours. The sample included experts from 3 groups consisting of faculty members in related fields, informed managers and policy makers in the Iranian health system using purposive sampling. The participants were asked whether they were aware of the history of the integra- tion of oral health into PHC, and if they thought the programme was successful, and if not, what were the causes. The interview guide for each group was developed from our literature re- view and after discussions among the team members; these were then piloted with an expert and a pregnant woman. Some questions were reworded to make them clearer and some subques- tions were added to the interview guide as a result of the piloting. Three authors (MP, ZG and MD) conducted the Book 23-12.indb 803 3/4/2018 11:44:22 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 804 interviews and focus group discussions between July 2015 and February 2016. Data analysis Thematic analysis was used to analyse and organize the collected data. First, 2 researchers (MP and MD) read and re- read the text transcription of each focus group discussion and interview, inde- pendently, to identify units of meaning related to the subject. Then, all of the units of meaning were categorized into initial themes. After matching the initial themes through informal discussion, the research team categorized the initial themes into overarching themes that were labelled as an inductive or bottom- up approach. The proposed labels for the main themes were discussed and achieved through consensus. The principal investigator (ZG) resolved any disagreement between the research team by discussion and made the final decision. The robustness of the data should be acknowledged because the research team attempted to maximize the va- lidity of the study in 3 main ways: 1) they attempted to take control of their own perspectives and expectations; 2) the transcripts were independently analysed by 2 members of the research team, and any disagreements were dis- cussed by the team; and 3) to cover all the viewpoints about the topic, we tried to cover all the potential stakeholders. We attempted to contact all partici- pants who had been involved in plan- ning and/or provision of oral health services delivered in PHC centres. The different stakeholders were selected to provide a wide range of views in the oral health services that are delivered in PHC centres, based on their perspec- tives. It also allowed us to compare and recognize the different perspectives of different stakeholders in this regard. Ethical issues This study was approved by the 27th Research Ethics Committee of the Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences (number: IR.SBMU.RIDS. REC.1395.188). The participants were clarified about the aims of the study and verbal consent was obtained for participation. It was confirmed that par- ticipation in the study was completely voluntary, respecting the confidentiality of the data. Results Study participants The characteristics of the 5 focus group members (n = 50), and experts (n = 10) participating in the study are shown in Table 1. The educational background of the experts was dental sciences (n = 6), medical/health sciences (n = 3) and nursing care (n = 1). Mean age (standard deviation) of the 27 pregnant women participating in the interviews was 28.6 (5.8) years, ranging from 20 to 40 years. Most of the pregnant women had finished high school (41%) and were in the 2nd trimester (63%), experiencing their 2nd pregnancy (52%). Analysis of the data from the focus groups and interviews gave rise to 21 subthemes; later classified into 4 main themes in line with the methods (Table 2) related to environmental, educational, organizational and school- based programme factors. Educational factors Many PHC providers believed that pro- viding preventive oral health services was not their responsibility. Specifically, midwives thought that they were not sufficiently qualified to assess oral health nor to ask specific questions about it. However, most of them expressed interest and willingness to complete appropriate training programmes. Some dentists stated that they feared the legal consequences of po- tential complaints about their practice, and therefore avoided performing procedures on pregnant women. They expressed that they were not provided with clear protocols for managing some dental problems during pregnancy, and most of them were not covered by re- sponsibility insurance. The pregnant women’s insufficient knowledge and demand for oral health care were other challenges in this study. The pregnant women felt that poor oral health was a normal outcome of pregnancy and there was no need to consult a dentist. Environmental factors According to focus group participants, nowadays, people go where they obtain good services. They usually go to the clinics that have advanced technology instead of to dispensaries where there are limited equipment and facilities. Some focus group participants also reported that the physical infrastructure and available equipment, such as mod- ern dental chairs, instruments and ma- terials, were not suitable to provide oral health education and dental screening. Organizational factors PHC providers consistently talked about time limitation as a key barrier to providing oral health education and dental examination. They were involved in the provision of vaccination and child and maternal care, leading to crowded clinic waiting areas. One midwife complained about insufficient human resources and high workload. Another reported that some mothers failed to arrive on time for appointments, for various reasons, especially early in the morning, therefore, there was often overcrowding in the middle of the day. She reported that because of these time and human resource constraints, they were unable to counsel mothers regard- ing oral health. Many of the focus group partici- pants noted that using paper record- keeping instead of integrated electronic records wasted a lot of time in the ma- jority of PHC centres. The existing salary-based payment system for all PHC providers did not provide incen- tives to improve their performance. Book 23-12.indb 804 3/4/2018 11:44:22 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 805 Inadequate advocacy was another chal- lenge noted by some experts, and that powerful community individuals (such as religious leaders and local govern- ment managers) were not involved in developing and disseminating health programmes. School-based programme factors Most focus group participants and ex- perts reported inadequate support for school-based oral health programmes. They also believed that parents and school staff were not involved in developing school-based oral health programmes and therefore not commit- ted to achieving the programme goals. Some focus group participants were dissatisfied with inadequate physical space in the schools for implementation of oral health programmes. Discussion This study used a qualitative research design to understand the challenges that impede integration of oral health programmes into PHC. Qualitative methods seem to be an appropriate design for exploring complex phenom- ena about which little is known (11,12). This study revealed 4 main themes relating to the challenges of integration of oral health into PHC: educational, environmental, organizational and school-based factors. With regard to educational factors and in agreement with our findings, many studies have shown that insuffi- cient knowledge and inappropriate per- ception among pregnant women about oral health are common causes of the decrease in dental care demand during pregnancy (13–15). Also, the majority of pregnant women believe that dental treatment during pregnancy might have a negative effect on pregnancy outcome (16). Many pregnant women still be- lieve in the folk myth of “a tooth for a child”, which suggests an association between childbearing and loss of teeth, and they perceive that gingival bleed- ing does not indicate inflammatory disease that requires professional help (17). Mothers are unaware that vertical transmission of cariogenic microbes contributes to the development of den- tal caries in children (17,18). They are also unaware about the importance of cleaning deciduous teeth, proper feed- ing practices, and the important role of early-onset regular dental visits for their children (19). Furthermore, the insufficient knowledge of PHC workers about oral health has been highlighted in studies from other countries (20–24). As a result, oral health is often neglected by maternal-care providers during pre- natal care, and is only discussed when initiated by pregnant women (21). The need for community-based education of dental students is also noted in the literature (25). With regard to the prob- lem of unclear guidelines for dentists about treatment of pregnant women, evidence-based guidelines have been developed with a focus on tracking oral health services, screening, and triaging prenatal patients for oral health risks to the mother, fetus and baby (26). Such guidelines need to be reviewed and customized according to the local and structural situations of each country. On the topic of environmental fac- tors, the need for increasing financial investment and human resources to de- velop primary oral health care has been mentioned as an integral part of PHC (27). The time limitations for PHC pro- viders to provide oral health education and screening have also been identified as a challenging barrier (8,24). With regard to organizational factors, insufficient interprofessional collaboration has been considered Table 1 Characteristics of focus group members and experts participating in the study Variables Focus groups Interviews Rural primary healthcare workers Midwives Family healthcare practitioners Duty- service dentists Public health dentists Experts Sex Female 6 10 10 8 7 3 Male 4 0 0 2 3 7 Age (yr) 20–30 2 3 2 10 0 0 31–40 5 5 6 0 2 0 ≥ 41 3 2 2 0 8 10 Length of practice (yr) < 10 4 4 3 10 1 1 10–20 3 3 4 0 2 4 20–30 3 3 3 0 7 5 Total 10 10 10 10 10 10 Book 23-12.indb 805 3/4/2018 11:44:22 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 806 elsewhere (19) and has led to genera- tion of a model to educate dental and medical practitioners about these fac- tors. The model involves a system of referral for comprehensive clinical care of pregnant women, and an educa- tional guide for women about their oral health and that of their children. Such programmes can help meet interpro- fessional accreditation standards and encourage implementation of practice guidelines (28). Similar to our findings, a lack of provider capacity, training and expe- rience for operating in the context of cross-disciplinary or integrated settings is another challenge considered in the literature (22,23). It is also suggested that integration of the PHC approach into the dental curriculum is crucial for training a competent workforce (29). Given this situation, there is a need to provide the current and future PHC and dental workforce with the skills needed to practice integrated oral health services (23,30). The limitations of time and human resources for PHC providers are another organizational challenge that has been addressed to some extent by using lay health workers as the main facilitators of oral health programmes in some contexts (8). In relation to school-based factors, the Ottawa Charter for Health Promo- tion notes that schools can provide a supportive environment for promoting child health. The survey of Jurgensen and Petersen has demonstrated the important role of oral health educa- tion in promoting oral health among school-aged children (31). The main factors identified as barriers for suc- cessful implementation of school-based oral health programmes were: financial constraints; inadequate capacity and availability of human resources; lack of collaboration at local level; inadequate policy framework; lack of high-level leadership and governance; poor atti- tude, support and awareness among school health team, parents and the local community leaders; and failure to provide quality services (31). This study tried to gather the views of all potential stakeholders involved in planning, providing and receiving integrated oral health services. Despite the small number of participants in each group, the sample size was appropriate considering the qualitative methodo- logical approach, which emphasized the purposeful selection of information- rich cases that provided in-depth data. We selected participants according to their experience of oral health care pro- vided as PHC services and their ability to express their perspectives. However, the most recent improvements in man- agement and planning in the Iranian Ministry of Health have addressed to some extent some of the barriers found in this study. For instance, electronic health records have been recently used in PHC centres, facilitating time management among workers. Also, the renovation of dental offices in PHC settings has been emphasized in the past Table 2 Recognized main themes and subthemes related to challenges in oral health integration into PHC Main themes Subthemes Educational factors Insufficient women’s attitudes and perceptions regarding oral health and dental care during pregnancy (FG 1,2,3,4,5, IPW) Insufficient PHC providers’ knowledge about oral health care (FG 1,2,3) Imperfect curriculum for undergraduate dental students to work with other areas of PHC (FG 2,3, IE) Unclear guidelines for dentists for treatment of pregnant women (FG 4,5, IE) Environmental factors Inappropriate facilities (FG 2,3,4,5) Inadequate physical clinic space (FG 2,3,4,5, IPW) Improper clinic waiting area (FG 2,3, IPW) Unstuitable equipment (FG 2,3,4,5) Organizational factors Insufficient interprofessional collaboration (IE) Little involvement of community leaders in developing and disseminating health programmes (IE) Insufficient human resources and high workload in PHC centres (FG 2,3, 5, IE) Insufficient time for provision of preventive services and oral health education (FG 1,2,3,4,5) Salary-based payment system with no financial incentives to motivate health workers (FG 2,3,4,5, IE) School-based programme factors Inadequate collaboration among healthcare workers and school staff (FG 1,2,3,5) Uncommitted school staff and parents with the programme goals (FG 1,2,3,5, IE) Imperfect relationship between dental staff and students (FG 2,5) Inadequate physical space in schools for oral health programmes (FG 1,2,3,4,5) Unspecified places to refer high-risk students to appropriate services (IE) Unhealthy nutrition of school children at school (FG 1,2,3,4,5, IE) Insufficient number of health counsellors in schools (FG 2,3,4,5) Inadequate coverage of oral health topics in school curriculum (IE) FG 1= focus group with rural primary healthcare workers; FG 2 = focus groups with midwives; FG 3 = focus group with family healthcare practitioners; FG 4 = focus group with duty-service dentists; FG 5 = focus group with public health dentists; IE = interview with experts; IPW = interview with pregnant women. Book 23-12.indb 806 3/4/2018 11:44:22 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 807 year, which could potentially improve dental care services (32). We should also acknowledge that all the findings might not be generalized to other coun- tries because of the distinct culture and structure of the healthcare system in the Islamic Republic of Iran. However, some of the findings will be helpful for other countries to consider developing their own integrated oral healthcare systems. Our findings will serve as an initial step towards establishing evidence- based interventions and identifying potential gaps to guide future efforts. The next step will be identification and prioritization of solutions related to the barriers to integration of oral health care into the PHC system. The experi- ences from other countries can be used in this regard. For instance, the Brazil- ian unified PHC system is suggested to benefit from a mixed approach, by focusing on social factors (upstream) and simultaneously preventing modifi- able risk factors at the individual level (downstream), to tackle the serious obstacles to achieving universal access to integrated oral health services (33). In conclusion, since administrative and clinical leadership support can be critical to the success of integrative ap- proaches, this study provides a better understanding of the challenges around integrating oral health services into PHC, including environmental, educa- tional, organizational and school-based programme factors. Acknowledgements This study was supported by Preventive Dentistry Research Center, Research Institute of Dental Sciences, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Re- public of Iran. We would like to thank the Vice Chancellor in Health Affairs of Shahid Beheshti University of Medical Sciences, Dr. Bastani, Dr. Taheri, Dr. Ghanbari, Dr. Ehdaeivand, Dr. Shahza- deh Fazeli and Dr. Khoshnevisan who were involved at different stages of this research. Finally, we express our grati- tude to the people who participated in focus group discussions and individual interviews with midwives, family health- care practitioners, rural PHC workers, dentists, experts, and pregnant women for sharing their experiences and views regarding oral healthcare integration into PHC. Funding: None. Competing interests: None declared. References 1. Vamos CA, Thompson EL, Avendano M, Daley EM, Quinonez RB, Boggess K. Oral health promotion interventions during pregnancy: a systematic review. Community Dent Oral Epide- miol. 2015 Oct;43(5):385–96. PMID:25959402 2. De Grauwe A, Aps J, Martens L. Early childhood caries (ECC): what’s in a name? Eur J Paediatr Dent. 2004 Jun;5(2):62–70. 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Al Habashneh R, Guthmiller JM, Levy S, Johnson GK, Squier C, Dawson DV et al. Factors related to utilization of dental servic- es during pregnancy. J Clin Periodontol. 2005 Jul;32(7):815–21. PMID:15966891 14. Hullah E, Turok Y, Nauta M, Yoong W. Self-reported oral hygiene habits, dental attendance and attitudes to dentist- ry during pregnancy in a sample of immigrant women in North London. Arch Gynecol Obstet. 2008 May;277(5):405–9. PMID:17940783 15. Bamanikar S, Kee LK. Knowledge, attitude and practice of oral and dental healthcare in pregnant women. Oman Med J. 2013 Jul;28(4):288–91. PMID:23904926 16. Dinas K, Achyropoulos V, Hatzipantelis E, Mavromatidis G, Zepiridis L, Theodoridis T et al. Pregnancy and oral health: utilisation of dental services during pregnancy in northern Greece. Acta Obstet Gynecol Scand. 2007;86(8):938–44. PMID:17653878 17. Keirse MJ, Plutzer K. Women’s attitudes to and perceptions of oral health and dental care during pregnancy. J Perinat Med. 2010;38(1):3–8. PMID:20047523 18. Mohebbi SZ, Virtanen JI, Vahid-Golpayegani M, Vehkalahti MM. A cluster randomised trial of effectiveness of educational intervention in primary health care on early childhood caries. Caries Res. 2009;43(2):110–8. PMID:19321988 Book 23-12.indb 807 3/4/2018 11:44:22 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 808 19. Ramos-Gomez FJ. A model for community-based pediatric oral heath: implementation of an infant oral care program. Int J Dent. 2014;2014:156821. PMID:24587803 20. Wooten KT, Lee J, Jared H, Boggess K, Wilder RS. Nurse practi- tioners’ and certified nurse midwives’ knowledge, opinions and practice behaviors regarding periodontal disease and adverse pregnancy outcomes. J Dent Hyg. 2011 Spring;85(2):122–31. PMID:21619740 21. George A, Shamim S, Johnson M, Dahlen H, Ajwani S, Bhole S, et al. How do dental and prenatal care practitioners perceive dental care during pregnancy? Current evidence and implica- tions. Birth. 2012 Sep;39(3):238–47. PMID:23281906 22. Rabiei S, Mohebbi SZ, Patja K, Virtanen JI. Physicians’ knowl- edge of and adherence to improving oral health. BMC Public Health. 2012 Oct 9;12:855. PMID:23046660 23. Sandhya MP, Shanthi M, Fareed N, Sudhir KM, Kumar RK. Ef- fectiveness of oral health education among primary health care workers at the primary health center in Nellore district, Andhra Pradesh. J Indian Assoc Public Health Dent. 2014;12(2):74–9. 24. Rozier G, Sutton BK, Bawden JW, Haupt K, Slade GD, King RS. Prevention of early childhood caries in North Carolina medical practices: implications for research and practice. J Dent Educ. 2003 Aug;67(8):876–85. PMID:12959161 25. Mofidi M, Strauss R, Pitner LL, Sandler ES. Dental students’ reflections on their community-based experiences: the use of critical incidents. J Dent Educ. 2003 May;67(5):515–23. PMID:12809186 26. Stevens J. Lida H, Ingersoll G. Implementing an oral health pro- gram in a group prenatal practice. J Obstet Gynecol Neonatal Nurs. 2007 Nov–Dec;36(6):581–91. PMID:17973702 27. Honkala E. Primary oral health care. Med Princ Pract. 2014;23(Suppl 1):17–23. PMID:24503932 28. Jackson JT, Quninonez RB, Kerns AK, Boggess K, Chuang A, Eidson RS, et al. Implementing a prenatal oral health program through interprofessional collaboration. J Dent Educ. 2015 Mar;79(3):241–8. PMID:25729017 29. Mumghamba EG. Integrating a primary oral health care ap- proach in the dental curriculum: a Tanzanian experience. Med Princ Pract. 2014;23(Suppl 1):69–77. PMID:24246734 30. Norwood CW, Maxey HL, Randolph C, Gano L, Koch- har K. Administrative challenges to the integration of oral health with primary care: a SWOT analysis of health care ex- ecutives at federally qualified health centers. J Ambul Care Manage. 2016 May 23; [Epub ahead of print] PMID:27218701 31. Jürgensen N, Petersen PE. Promoting oral health of chil- dren through schools – results from a WHO global survey 2012. Community Dent Health. 2013 Dec;30(4):204–18. PMID:24575523 32. Moradi-Lakeh M, Vossogh-Moghaddam A. Health sector evolution plan in Iran; equity and sustainability concerns. Int J Health Policy Manag. 2015 Aug 31;4:637–40. PMID:26673172 33. Nascimento AC, Moysés ST, Werneck RI, Moysés SJ. Oral health in the context of primary care in Brazil. Int Dent J. 2013 Oct;63(5):237–43. PMID:24074017 Book 23-12.indb 808 3/4/2018 11:44:22 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 809 1Unité de Recherche et Développement, Institut Supérieur des Professions infirmières et Techniques de Santé, Rabat (Maroc) (Correspondance à adresser à : btrari@hotmail.com). 2Laboratoire de Zoologie et Biologie Générale, Faculté des Sciences, Université Mohamed V, Rabat (Maroc). 3Département de Zoologie et Écologie animale, Institut Scientifique, Université Mohamed V, Rabat (Maroc). Reçu : 14/06/15 ; accepté : 6/03/17 Caractérisation génétique du sous-groupe Maculipennis (Diptera : Culicidae) au Maroc : un outil fondamental pour lutter contre le paludisme Bouchra Trari 1, 2 et Mohamed Dakki 3 Genetic characterization of the Anopheles maculipennis complex (Diptera: Culicidae) in Morocco: a fundamental tool for malaria control ABSTRACT The Anopheles maculipennis complex has been implicated in the transmission of malaria, which was endemic in Morocco until 2010. Climate change, intensification of international travel and the permanent presence of the vector increase the risk of malaria re-emergence. Using polymerase chain reaction assay (PCR), this study attempts to identify the possible presence of the Maculipennis complex in several areas of Morocco, based on the concept of risk. Eighty-six mosquito specimens were analyzed using PCR amplification of the ITS2 (Internal Transcribed Spacer 2) sequence of ribosomal DNA. The ITS2 sequences of the mosquitoes were compared to those of the 7 species of the Maculipennis complex available in GenBank. The results obtained confirm the presence of Anopheles labranchiae. In order to enable technology transfer, DNA extraction and amplification steps are presented for the first time in detail, given the fact that the technique is still unknown to several Moroccan peripheral laboratories. ايرالما ةحفاكلم ةيساسأ ةادأ :برغلما في )تايضوعبلا ةليصف( حانلجا تاعقبم ةيرمزل ينيلجا فيصوتلا يكاد دممح ،يرارطا ىشرب في ًاببـس ةـليوط ةرـفل تـلظو ،حاـنلجا تاـعقبم ةيرـمز ءاـضعأ ىدـحإ )Anopheles labranchiae Falleroni 1926) ةـضوعب دـعت :ةـصالخا دوجوو ليودـلا رفـسلا ديازتو خاـنلما يرـغت لـماوع يدؤـتو .2010 ماـع ىـتح برـغلما في تـنطوت يـتلا ،ةطيـشنلا ةروـصتلما اـيرالما ىودـع لاـقتنا ةيرـمزل نـيرخآ ءاـضعأ دوـجو ةـيناكمإ دـيدتح لىإ ةـساردلا هذـه فدـتهو .روـهظلل اـيرالما ةدوـع رـطامخ ةداـيز لىإ ةـمئاد ةروـصب ىودـعلا لـقان عوـنل ًاـقفو تيرـتخا يـتلاو ،قـطانم ةدـع في عـّمجلما ضوـعبلا نـب )PCR) ليـسلستلا زايرـميلوبلا لـعافت مادختـساب ،برـغلما في حاـنلجا تاـعقبم ضـملحا ةلـسلسل ليـسلستلا زايرـميلوبلا لـعافت مـيخضت مادختـساب ضوـعبلا نـم ةـنيع 86 لـيلتح مـتو .ةـحصلا ةرازو هـتددح ابـسح رـطاخلما جـئاتنلا دـكؤتو .تاـنيلجا كـنب في ةـحاتلما حاـنلجا تاـعقبم ةيرـمز نـم عاوـنأ 7 لـساسب ضوـعبلل ITS2 حاـسفم لـساس تـنروقو .ITS2 يـبيرلا لىولأا ةرـملل تـحيتأ ،اـيجولونكتلا لـقن باـب نـمو .برـغلما في ةيرـمزلا هذـله دـيحولا لـثملما اـهرابتعاب ةـيكناربالا ةـليفونلأا دوـجو ةاقتـسلما .ةـيبرغلما تارـتخلما نـم ددـع ىدـل ةـفورعم يرـغ لازـت لا ةـقيرطلا هذـه نإ ثـيح ،هـميخضتو يووـنلا ضـملحا صاختـسا تاءارـجإ RÉSUMÉ Le complexe maculipennis a été incriminé dans la transmission du paludisme, endémique au Maroc jusqu'en 2010. Le réchauffement climatique, l'intensification des voyages internationaux et la présence des vecteurs constituent un risque de réémergence de la maladie. L'étude a tenté d'identifier par PCR (Polymerase Chain Reaction), le complexe maculipennis dans plusieurs régions du Maroc, choisies en se basant sur la notion de risque. Quatre-vingt six (86) spécimens de moustiques ont été analysés en utilisant l'amplification par PCR de la séquence ITS2 (Internal Transcribed Spacer) de l'ADN ribosomique. Les séquences ITS2 des moustiques ont été comparées à celles des 7 espèces du groupe Maculipennis, disponibles dans GenBank. Les résultats obtenus confirment la présence d'An. labranchiae Falleroni, 1926. Aussi, dans un souci de transfert de technologie,les étapes d'extraction d'ADN et d'amplification sont exposées pour la première fois, en détail, étant donné que la PCR reste encore inconnue dans plusieurs laboratoires périphériques marocains. https://doi.org/10.26719/2017.23.12.809 Book 23-12.indb 809 3/4/2018 11:44:22 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 810 Introduction La lutte antivectorielle reste le principal moyen de réduire la transmission du parasite responsable du paludisme, mais son succès repose en grande partie sur une bonne connaissance du vecteur. L a p l u p a r t d e s v e c t e u r s d e Plasmodium appartiennent à des complexes d’espèces (1), groupes ou sous-groupes, dont les membres sont morphologiquement identiques mais génétiquement distincts (espèces jumel les) et peuvent présenter d e s d i ff é r e n c e s é c o l o g i q u e s e t comportementales qui se répercutent souvent au niveau épidémiologique. Depuis la mise au point des techniques de biologie moléculaire (2), l ’ é t u d e d u p o l y m o r p h i s m e d e s p o p u l a t i o n s a n o p h é l i e n n e s p a r PCR (Polymerase Chain Reaction – réaction de polymérisation en chaîne) n’a pas cessé de prouver s o n e ffi c a c i t é p o u r l ’ é t u d e d e s populations de vecteurs, aussi bien en région afrotropicale (complexe Anopheles gambiae) (3 ,4) qu’en région paléarctique (sous-groupe Maculipennis) pour les régions qui nous intéressent (5), pour devenir actuellement une technique de routine dans la plupart des laboratoires d’entomologie médicale à travers le monde. Au Maroc, où le dernier cas de paludisme autochtone à Plasmodium vivax a été enregistré en 2004 (6) et l’élimination a été certifiée par l’Organisation mondiale de la Santé en 2010 (7), la transmission était essentiellement due à An. labranchiae Falleroni, 1926, membre du sous- groupe Maculipennis. Celui-ci a été le premier « complexe d’espèces » à avoir été découvert parmi les moustiques (8 ,9). L’identification morphologique précise des membres de ce sous-groupe reposait sur l’ornementation des œufs (10). Ces derniers présentent toutefois une importante variabilité au sein d’une même espèce, voire d’une même descendance, ce qui parfois peut rendre l’identification impossible. Il en est de même pour l’analyse morphologique des stades larvaires, nymphaux et imaginaux (10 ,11). La « variété » An. sicaulti , décrite au Maroc près de Rabat par Roubaud (12), illustre bien la confusion qui peut avoir lieu à propos de ce sous-groupe (13- 16). Depuis le travail de White qui reconnaissait neuf espèces (16), de nombreux changements ont été opérés et concernent aussi bien l’appellation du sous-groupe Maculipennis (complexe, groupe, sous-groupe) que le nombre et le statut des espèces qui le composent. À l’heure actuelle, et selon la dernière classification (17 ,18), dix espèces du sous-groupe Maculipennis sont officiellement reconnues : An. artemievi, An. atroparvus, An. daciae, An. labranchiae, An. maculipennis , An. martinius , An. melanoon, An. messeae, An. persiensis et An. sacharovi. Au Maroc, la nécessité d’étudier la structure génétique des populations naturelles des membres du sous- groupe Maculipennis a déjà été soulignée (19). Des études génétiques récentes montrent la présence d’An. labranchiae comme seul représentant du sous-groupe Maculipennis (20,21). Cependant, dans le contexte actuel des changements climatiques et de l’adaptation de nouvelles espèces, la présence éventuelle d’autres espèces n’est pas à exclure, puisque certaines espèces du sous-groupe Maculipennis sont déjà signalées dans les pays voisins. Il s’agit de la présence d’An. sacharovi en Algérie (22) et d’An. atroparvus en Espagne (23). Cette dernière espèce est très fréquente dans les rizières et les zones irriguées (1) et figure parmi les plus importants vecteurs de Plasmodium susceptibles d’étendre leur aire de distribution géographique (24). Il a été prouvé que les stratégies d’aménagement de l’environnement t e l l e s q u e l ’ i r r i g a t i o n p e u v e n t augmenter le risque de transmission de Plasmodium (25). Le principal objectif de ce travail est l’identification précise du sous- groupe Maculipennis au Maroc, au sein de trois régions représentatives des situations épidémiologiques du paludisme dans le pays telles que définies par le ministère de la Santé, en vue d’y rechercher la présence d’autres représentants susceptibles de transmettre le Plasmodium. Aussi, étant donné que la technique PCR est encore inconnue dans la plupart des laboratoires périphériques qui assurent la surveillance entomologique dans le cadre du programme de lutte antipaludique, les étapes de la PCR sont exposées en détail, dans un souci de transfert de technologie. Méthodes Choix de la zone d’étude T e n a n t c o m p t e d u r i s q u e d e transmission du Plasmodium, le choix des sites étudiés a été effectué en fonction de la classification établie par le ministère de la Santé (26) et permettant de distinguer trois zones : haut risque, risque potentiel et faible risque. Cette stratification repose sur les données é p i d é m i o l o g i q u e s ( n o t i fi c a t i o n r é c e n t e d e c a s d e p a l u d i s m e autochtone), mais aussi sur les notions de réceptivité (abondance des gîtes anophéliens, présence e t d e n s i t é d u v e c t e u r ) e t d e v u l n é r a b i l i t é ( m o u v e m e n t d e s populations en relation avec les régions ou les pays à risque) qui sont les deux critères de base pour définir le « potentiel paludogène » d'une région. Pour ce faire, nous nous sommes basés sur les données des foyers récents et anciens (27), sur la répartition anophélienne déjà connue du sous- groupe Maculipennis (28) ainsi que sur les informations obtenues sur les zones de migration de population Book 23-12.indb 810 3/4/2018 11:44:22 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 811 et d’aménagement hydroagricole à r i s q u e ( 2 9 ) . T r o i s c h a n t i e r s géographiques correspondant à 12 provinces ont alors été retenus dans ce travail (Figure 1). 1) Région nord • Zone à haut risque de paludisme : province de Chefchaouen1 • Zone à risque potentiel de paludisme : provinces de Larache et Khémisset • Zone à faible risque de paludisme : provinces de Meknès, Oujda, Rabat et Tétouan 2) Région centre • Zone à haut risque de paludisme : province de Khouribga • Zone à risque potentiel de paludisme : province de Settat • Zone à faible risque de paludisme : province de Marrakech 1 Bien que la région de Chefchaouen soit évaluée par certains auteurs comme une zone à faible risque de paludisme (30), cette province continue, selon les critères établis par le ministère de la Santé (26), d’être une zone où le risque demeure relativement élevé. 3) Région sud • Zone à risque potentiel de paludisme : province d’Ouarzazate • Zone à faible risque de paludisme : province de Tiznit Échantillonnage des moustiques Les anophèles ont été prélevés lors de campagnes d’échantillonnage (larves et adultes) réalisées entre février 2004 et septembre 2005. Pour la région de Rabat, les prélèvements ont eu lieu entre décembre 2003 et septembre 2004. Les prélèvements larvaires, de type semi- quantitatif, ont été effectués à l’aide d’un filet Langeron et le nombre de coups de filet a été variable selon la superficie du gîte. Les adultes ont été capturés manuellement au repos, à l’intérieur des habitations humaines ou des abris pour animaux, à l’aide d’aspirateurs à bouche. Identification morphologique et conservation des anophèles Les moustiques récoltés ont été identifiés sur la base de critères m o r p h o l o g i q u e s ( 3 1 ) , p u i s l e s spécimens triés du sous-groupe Maculipennis ont été conservés pour une identification plus précise à l’aide d’outils de biologie moléculaire. Chaque spécimen adulte a été sectionné en deux parties, conservées séparément, l’une comprenant l’abdomen ainsi que les pattes et les ailes du moustique servant pour les analyses PCR2 et l’autre le reste du corps (tête et thorax) pour des tests ELISA (Enzyme Linked Immunosorbent Assay) repas de sang. Les larves ont été conservées dans de l’alcool à 70° et les adultes ont été gardés en présence d’un dessicateur (gel de silice). Extraction de l’ADN Pour les larves d’anophèles, chaque spécimen entier a été individuellement broyé dans 200 µL de CTAB 2 % (Cetyl Trimethyl Ammonium Bromide – bromure d’hexadécyltriméthyl ammonium) préalablement préparé et conservé à température ambiante. Après cinq minutes au bain-marie à 65 °C, ce broyat a été mélangé par inversion avec 200 µL de chloroforme puis centrifugé pendant cinq minutes à 12 000 tr/ min, à température ambiante (25 °C). La phase supérieure a été prélevée et mise dans un autre tube, puis 200 µL d’isopropanol ont été ajoutés à ce surnageant ; le tout a été bien mélangé par inversion avant d’être centrifugé pendant 15 minutes à 12 000 tr/min, à température ambiante. Par la suite, l’isopropanol a été éliminé et égoutté, puis remplacé par de l’éthanol à 70 % et le nouveau mélange a été centrifugé pendant cinq minutes à 12 000 tr/ min, à température ambiante. Après élimination de l’éthanol, le culot ainsi obtenu a été séché pendant cinq 2 Les manipulations de biologie moléculaire ont eu lieu au Laboratoire de Lutte contre les Insectes Nuisibles (LIN), Institut de Recherche pour le Développement (IRD), Montpellier (France). Figure 1 Localisation des sites étudiés Book 23-12.indb 811 3/4/2018 11:44:22 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 812 minutes au SpeedVac®, repris dans 20 µL d’eau stérile et enfin gardé toute la nuit à température ambiante avant d’être dilué au 1/50e pour être analysé par PCR. Pour les adultes, la PCR a été réalisée sans extraction d’ADN préalable mais directement sur les pattes de moustiques (technique d’usage au Laboratoire de Lutte contre les Insectes Nuisibles [LIN] de Montpellier, non publiée). Amplification PCR La région ITS2 (Internal Transcribed Spacer 2) de l’ADN ribosomal a été amplifiée par PCR, en utilisant les amorces décrites par Proft et al. (5). Les conditions de PCR ainsi que le programme d’amplification de l’ADN se sont déroulés conformément aux protocoles d’usage au LIN de Montpellier. Pour les anophèles adultes, une patte issue de chaque spécimen a été directement uti l isée pour l’amplification de l’ADN. Concernant les larves, la PCR a été pratiquée sur l’ADN préalablement obtenu par extraction à partir du moustique entier et dilué au 1/50e. Ainsi, au total, 86 spécimens (larves et adultes) p r o v e n a n t d e h u i t p r o v i n c e s différentes (Tableau 1) ont pu être analysés en trois séries de PCR : une première et une deuxième série pour les adultes (18 et 24 échantillons), et une troisième série pour les larves (44 échantillons). Résultats Parmi les neuf espèces anophéliennes signalées au Maroc (28, 32), six ont pu être identifiées durant cette étude ; d’après les critères morphologiques, elles appartiennent aux sous-genres Anopheles (An.) et Cellia (Cel.). Il s’agit de : An. (An.) labranchiae (huit provinces), An. (Cel.) sergentii et An. (Cel.) cinereus (quatre provinces), puis An. (An.) algeriensis, An. (An.) marteri et An. (An.) ziemanni (deux provinces) (Tableau 2). Les trois autres espèces, An. (An.) claviger, An. (Cel.) dthali et An. (Cel.) multicolor n’ont pas été trouvées dans nos échantillonnages. Aucun spécimen du sous-groupe Maculipennis n’a été capturé au niveau des provinces de Marrakech, Ouarzazate, Tiznit et Oujda. Les résultats des trois séries de PCR des 86 spécimens d’anophèles analysés, obtenus par électrophorèse sur un gel d’agarose à 4 %, montrent que les séquences ITS2 de 72 anophèles correspondent bien à celle d'An. Labranchiae ; deux ont dû être confirmés par séquençage, 14 spécimens étaient négatifs et n’ont pu être amplifiés. Discussion La caractérisation génétique du sous- groupe Maculipennis par PCR dans les sites étudiés montre bien qu’il n’est représenté que par une seule espèce, An. labranchiae ; c’est l’espèce anophélienne la plus fréquente. Ces résultats confirment les recherches précédentes (20,21) sur ce sous-groupe au Maroc. Toutefois, étant donné la rareté de ces études, il serait intéressant de poursuivre les enquêtes en considérant de nouvelles régions, en particulier les rizières, biotopes typiques ayant par le passé favorisé la transmission de l’agent pathogène du paludisme au Maroc (33, Tableau 1 Taille, provenance et identification des échantillons analysés Origine des moustiques Date du prélèvement Stade Nombre de spécimens analysés Espèces identifiées An. labranchiae Négatifs Chefchaouen septembre 2004 adulte 9 6 3 Larache mars 2005 adulte 12 8 4 Khémisset octobre 2004 octobre 2004 mars 2005 adulte larve larve 4 15 7 2 15 7 2 0 0 Meknès mai 2005 juin 2005 juin 2005 larve larve adulte 2 5 4 2 5 4 0 0 0 Rabat février 2004 larve 8 8 0 Tétouan juin 2005 adulte 11 5 6 Khouribga avril 2005 larve 5 5 0 Settat avril 2005 mai 2005 mai 2005 adulte adulte larve 1 1 2 0 0 2 1 1 0 Book 23-12.indb 812 3/4/2018 11:44:23 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 813 34) ainsi qu'en Espagne si bien que le roi de Valencia avait interdit la culture du riz (35). En effet, les modifications de l’environnement telles que l’irrigation, s’ajoutant au nombre recrudescent de cas de paludisme importé au Maroc (6) ainsi qu’aux changements climatiques actuels favorables à la transmission de l’agent pathogène du paludisme, sont susceptibles d’influencer son épidémiologie . Des mesures de surveil lance de l ’ importation de nouveaux vecteurs sont essentielles pour préparer des opérations de lutte antivectorielle adaptées et éviter le risque de reprise de la transmission et la réémergence du paludisme. Remerciements Nous remercions M. Abdelaziz Agoumi, ancien Chef du Département de Parasitologie, Faculté de médecine et de pharmacie de Rabat (Maroc), de nous avoir permis de prendre en charge le projet SGS04/67, M. Didier Fontenille et Mme Cécile Brengues du Laboratoire de Lutte contre les Insectes Nuisibles (LIN), Institut de Recherche pour le Développement , Montpellier (France) pour l’accueil au LIN et pour l’aide dans la réalisation des manipulations de biologie moléculaire, Mme Btissam Ameur, M. Tachfine, M. Bouhrara et M. Nachi du Service de Lutte antivectorielle, Direction de l’Épidémiologie et de Lutte contre les Maladies, Ministère de la Santé, Rabat (Maroc) pour leur collaboration concernant la capture des moustiques adultes. Financement : Organisation mondiale de la Santé (projet SGS04/67). Intérêts concurrents : aucun déclaré. Références 1. Mouchet J, Carnevale P, Coosemans M, Julvez J, Manguin S, Richard-Lenoble D et al. Biodiversité du paludisme dans le monde. Montrouge: John Libbey Eurotext; 2004. 428 p. 2. Saiki RK, Gelfand DH, Stoffel S, Scharf SJ, Higuchi R, Horn GT, et al. Primer-directed enzymatic amplification of DNA with a thermostable DNA polymerase. Science. 1988 Jan 29;239(4839):487–91 .doi : 10.1126/science.2448875 PMID:2448875 3. Fontenille D, Faye O, Konate L, Sy N, Collins FH. Comparaison des techniques PCR et cytogénétiques pour la détermination des membres du complexe Anopheles gambiae au Sénégal. Ann Parasitol Hum Comp. 1993;68(5-6):239–40.doi:10.1051/ parasite/1993685239. 4. Fontenille D, Diatta M, Konate L, Lochouarn L, Lemasson JJ, Diagne N et al. Intérêt de l’utilisation des outils de biologie moléculaire dans l’étude de la transmission du paludisme : l’exemple des programmes conduits au Sénégal. Med Trop.1995;55:52S–5S. 5. Proft J, Maier WA, Kampen H. Identification of six sibling species of the Anopheles maculipennis complex (Diptera: Culicidae) by a polymerase chain reaction assay. Parasitol Res. 1999 Oct;85(10):837–43.doi: 10.1007/s004360050642 PMID:10494811 6. Trari B, Carnevale P. De la préélimination à l’élimination du paludisme au Maroc. Quels risques pour l’avenir ? Bull Soc Pathol Exot. 2011 Oct;104(4):291–5. doi:10.1007/s13149-011- 0156-2. 7. Eliminating malaria: learning from the past, looking ahead. Progress & impact series, n. 8 (October 2011). Geneva: World Health Organization; 2011. 84 p. 8. Falleroni D. Fauna anofelica italiana e suo “habitat” (paludi, risaie, canali). Metodi di lotta contra la malaria. Riv Malariol. 1926;5(5-6):553–93. 9. Van Thiel PH. Sur l’origine des variations de taille de l’Anopheles maculipennis dans les Pays-Bas. Bull Soc Pathol Exot. 1927;20:366–90. Tableau 2 Faune anophélienne des sites étudiés Espèce Province An. labranchiae An. sergentii An. cinereus An. algeriensis An. marteri An. ziemanni Chefchaouen + + + + + Khémisset + Larache + Meknès + Oujda + Rabat + Tétouan + + + + Khouribga + + + Marrakech Settat + + Tiznit + + + Ouarzazate Book 23-12.indb 813 3/4/2018 11:44:23 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 814 10. Guy Y, Salières A, Boesiger E. Contribution à l’étude du « complexe maculipennis » (Diptera-Culicidae-Anophelinae). Mise au point en 1975. Ann Biol. 1976;15(5-6):227–82. 11. Deruaz D, Deruaz J, Pichot J. Correspondence analysis of larval chaetotaxy in the « Anopheles maculipennis complex » (Diptera, Culicidae). Ann Parasitol Hum Comp. 1991;66(4):166– 72. doi:10.1051/parasite/1991664166. 12. Roubaud E. Variété nouvelle de l’A. maculipennis au Maroc, A. maculipennis sicaulti (n.var.). Bull Soc Pathol Exot. 1935;28:107– 11. 13. Gaud J. Notes biogéographiques sur les Culicidés du Maroc. Arch Inst Pasteur Maroc. 1953;4:443–90. 14. Senevet G, Andarelli L, Sergent E. Les Anophèles de l'Afrique du Nord et du bassin méditerranéen. Encyclopédie entomologique. Série A,33. Paris: P. Lechevalier;1956. 280 p. 15. Stone A, Knight KL, Starcke H. A synoptic catalog of the mosquitoes of the world (Diptera, Culicidae). The Thomas Say Foundation (Series),v. 6. Washington: Entomological Society of America;1959 (Supplements 1961 & 1963).358 p. 16. White GB. Systematic reappraisal of the Anopheles maculipennis Complex. Mosq Syst. 1978;10(1):13–44 (http:// www.biodiversitylibrary.org/content/part/JAMCA/MS_V10_ N1_P013-44.pdf) 17. Harbach RE. Mosquito Taxonomic Inventory. Anopheles classification (Updated 15 March 2017). http://mosquito- taxonomic-inventory.info/sites/mosquito-taxonomic- inventory.info/files/Anopheles%20classification_48.pdf (consulté le 11 juin 2017). 18. 18. Linton Y. Systematics of the Holarctic maculipennis complex. Systematics Symposium: 70th Annual Meeting of the American Mosquito Control Association, Savannah, Georgia, USA, 22-26 February 2004. 19. Trari B. Culicidae (Diptera): Catalogue raisonné des peuplements du Maroc et études typologiques de quelques gîtes du Gharb et de leurs communautés larvaires [Thèse]. Rabat: Université Mohamed V, Faculté des Sciences;1991. 20. Faraj C, Adlaoui E, Saaf N, Romi R, Boccolini D, Di Luca M et al. Note sur le complexe Anopheles maculipennis au Maroc. Bull Soc Pathol Exot. 2004;97(4):293–4 (http://www.pathexo.fr/ documents/articles-bull/T97-4-2648-2p.pdf). 21. Laboudi M, Faraj C, Sadak A, Harrat Z, Boubidi SC, Harbach RE, et al. DNA barcodes confirm the presence of a single member of the Anopheles maculipennis group in Morocco and Algeria: An. sicaulti is conspecific with An. labranchiae. Acta Trop. 2011 Apr;118(1):6–13. doi: 10.1016/j.actatropica.2010.12.006 PMID:21172298 22. Boudemagh N, Bendali-Saoudi F, Soltani N. Inventory of Culicidae (Diptera: Nematocera) in the region of Collo (North- East Algeria). Ann Biol Res. 2013;4(2):94–9. 23. Bueno-Marí R, Jiménez-Peydró R. Anophelism in a Former Malaria Area of Northeastern Spain. J Arthropod Borne Dis. 2013;7(2):147–53. PMCID:PMC3875881 24. Sinka ME, Bangs MJ, Manguin S, Coetzee M, Mbogo CM, Hemingway J, et al. The dominant Anopheles vectors of human malaria in Africa, Europe and the Middle East: occurrence data, distribution maps and bionomic précis. Parasit Vectors. 2010 Dec;3:117. doi: 10.1186/1756-3305-3-117 PMCID:PMC3016360 25. Ghebreyesus TA, Haile M, Witten KH, Getachew A, Yohannes AM, Yohannes M, et al. Incidence of malaria among children living near dams in northern Ethiopia: community based incidence survey. BMJ. 1999 Sep 11;319(7211):663–6. doi: 10.1136/bmj.319.7211.663 PMCID:PMC28216 26. Stratégie d’élimination du paludisme au Maroc : plan et éléments d’évaluation. Rabat: Ministère de la Santé du Royaume du Maroc; 2001.41 p. 27. Données épidémiologiques des maladies sous surveillance. Bulletin épidémiologique1966-2004.Rabat: Ministère de la Santé du Royaume du Maroc, Direction de l’Épidémiologie et de Lutte contre les Maladies. 28. Trari B, Harbach RE, Himmi O, Dakki MA, Agoumi A. An inventory of the mosquitoes of Morocco. I. Genus Anopheles (Diptera: Culicidae). Eur Mosq Bull. 2004;18:1–19. 29. Fenêtres sur le territoire marocain. Rabat: Ministère de l’Aménagement du Territoire, de l’Urbanisme, de l’Habitat et de l’Environnement du Royaume du Maroc, Direction de l’aménagement du territoire; 2002.147 p. 30. Faraj C, Adlaoui E, Ouahabi S, Rhajaoui M, Fontenille D, Lyagoubi M. Entomological investigations in the region of the last malaria focus in Morocco. Acta Trop. 2009;109(1):70–3. doi: 10.1016/j.actatropica.2008.09.021 PMID:18992211 31. Bruhnes J, Rhaim A. Geoffroy B, Angel G, Hervy JP. Les moustiques de l’Afrique méditerranéenne. Logiciel d’identification et d’enseignement. Montpellier: Institut de Recherche pour le Développement (IRD) / Institut Pasteur de Tunis (IPT) CD-Rom (Collection Didactiques); 2000. 32. Trari B, Dakki M, Harbach RE. An updated checklist of the Culicidae (Diptera) of Morocco, with notes on species of historical and current medical importance. J Vect Ecol. 2017 Jun;42(1):94-104.doi :10.1111/jvec.12243 33. Gaud J, Mechali D, Delrieu J. Riziculture et paludisme au Maroc. Bull Inst Hyg Maroc (NS). 1949;9(3-4):181–90. 34. Houel G. La lutte antipaludique dans les zones rizicoles du Maroc. Bull Inst Hyg Maroc (NS). 1954;14(1-2):43–90. 35. Rico-Avelló y Rico C. Aportación española a la historia del paludismo. Rev Sanid Hig Publica. 1947;21:483-733. Book 23-12.indb 814 3/4/2018 11:44:23 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 815 1Department of Medicine, College of Medicine, University of Basra, Basra, Iraq (Correspondence to: Safauldeen A. Alhajim: safauldinhachim@ yahoo.com). Received: 28/12/15; accepted: 19/02/17 Assessment of the quality of life in patients on haemodialysis in Iraq Safauldeen A. Alhajim 1 Évaluation de la qualité de vie des patients sous hémodialyse en Iraq RÉSUMÉ L’existence d’une maladie rénale chronique nécessite la mise en place d’une thérapie de remplacement rénal à vie, ce qui peut grandement impacter la qualité de vie des patients. La présente étude transversale avait pour objectif d’évaluer la qualité de vie des patients sous hémodialyse, ainsi que les facteurs de détérioration de la qualité de vie, à l’unité de dialyse de l’hôpital général de Bassora. Au total, 104 patients atteints de maladie rénale en phase terminale et sous hémodialyse ont été inclus à l’étude. Les données ont été collectées à l’aide du questionnaire d’évaluation de la qualité de vie de l’Organisation mondiale de la Santé. Des données socio- démographiques et cliniques ont également été recueillies. Sur les 104 patients, 57 % étaient des hommes, 73 % étaient âgés de plus de 45 ans, 87 % étaient issus de milieux socio-économiques moyen et faible, 70 % étaient sous dialyse depuis plus d’un an, 74 % disposaient d’un abord vasculaire de type fistule artério-veineuse, 34 % souffraient de diabète et 48 % avaient contracté le virus de l'hépatite. Tous les domaines de la qualité de vie (santé physique, psychologique, relations sociales et environnement) étaient affectés, le domaine physique étant celui le plus impacté. Un âge plus avancé, un statut socio-économique inférieur, une durée prolongée de la dialyse, un abord vasculaire par cathéter central, le fait d’être diabétique et d’avoir une sérologie positive au virus de l'hépatite étaient associés de façon significative à une diminution de la qualité de vie (p < 0,05). قارعلا في يولكلا ليسغلا ضىرلم ةايلحا ةدوج مييقت مجالحا نيدلا ءافص ةدوـج ىـع ًاـغلاب ًايرـثأت رـثؤي نأ هنأـش نـم وـه اـمو ،ةاـيلحا ىدـم ةـيولكلا ةضاعتـسلااب ًاـجاع ةـنمزلما ىكـلا ضارـمأ بـلطتت :ةـصالخا رـثؤت يـتلا لـماوعلاو ،يوـلكلا ليـسغلا ضىرـلم ةبـسنلاب ةاـيلحا ةدوـج مـييقت في ةـيعطقلما ةـساردلا هذـه نـم ضرـغلا لـثتمو.ضىرلما ةاـيح في يوــ لك ضرــ م نــ م نوــ ناعي صاخــ شأ 104 ةــ عوممج اــ م ةــ ساردلا تلمــ شو .ماــ علا ةرــ بلا ىفــ شتسمب ىكــ لا ليــ سغ ةدــ حو في ،اــ هيلع تاـنايب عـيمتج مـتو .ةاـيلحا ةدوـلج ةـيلماعلا ةـحصلا ةـمظنم نايبتـسا مادختـساب تاـنايبلا تـعجمو .ًاـيولك ًايـسغ نوـقلتيو ةيرـخلأا هـلحارم ،ةنـس 45 نـم رـكلأا ةـيرمعلا ةـئفلا في % 73و ،روـكذلا نـم % 57 ءاـج ،ضىرـم 104 مـهددع غـلابلا ضىرـلما نـمو .ةـيريسرو ةيناكـس-ةيعاتجا ةرطـسق اوـقلت % 74و ،ةنـس نـم رـثكلأ ىكـلل ًايـسغ يـقلت مـله قبـس % 70و ،ضـفخنم وأ طـسوتم يداـصتقا يـعاتجا عـضو نـم % 87و نـبتو .يدـبكلا باـهتللاا سويرـفب نـباصم اوـناك % 48و ،يركـسلا ءادـب نـباصم اوـناك % 34و ،يدـيرولا نياـيشرلا روـسانلا جاـعل ةـيديرو تـطبتراو .ًاـغلاب ًارـثأت نيدـبلا لاـجلما رـثأت اـك ؛)ةـئيبلاو ةـيعاتجلاا تاـقاعلاو ةيـسفنلاو ةـيندبلا ةـحصلا( ةاـيلحا ةدوـج تلااـمج عـيجم رـثأت ةـباصلإاو ةـيزكرلما ةـيديرولا ةرطـسقلاو ىكـلا ليـسغب جاـعلا ةرـف لوـطو يداـصتقلااو يـعاتجلاا عـضولا ضاـفخناو رـمعلا مدـقت لـماوع .)p<0.05( ةاـيلحا ةدوـج ضاـفخناب ةـللاد اذ ًاـطابترا يدـبكلا باـهتللااب ةـباصلإاو يركـسلاب ABSTRACT Chronic kidney disease requires life-long renal replacement therapy, which can greatly impair the quality of life (QOL) of patients. This cross-sectional study aimed to assess the QOL of patients on haemodialysis, and the factors affecting it, at the dialysis unit of Basra General Hospital. A total of 104 patients with end-stage renal disease on haemodialysis were included. Data were collected using the World Health Organization QOL questionnaire. Sociodemographic and clinical data were also collected. Of the 104 patients, 57% were male, 73% were older than 45 years, 87% were of middle and low socioeconomic status, 70% had been on dialysis for more than 1 year, 74% had arteriovenous fistula vascular access, 34% had diabetes and 48% were positive for hepatitis virus. All domains of QOL (physical health, psychological, social relationships and environment) were affected; the physical domain was the most severely affected. Older age, lower socioeconomic status, longer duration of dialysis, central line vascular access, having diabetes and positive hepatitis serology were significantly associated with lower QOL (P < 0.05). https://doi.org/10.26719/2017.23.12.815 Book 23-12.indb 815 3/4/2018 11:44:23 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 816 Introduction Chronic kidney disease affects 5-10% of the world’s population; it is associated with poor quality of life (QOL) and im- poses a high economic burden (1–3). This is particularly true in the develop- ing world where resources are limited (4). The global prevalence of end-stage renal disease, which is associated with considerable morbidity and mortality, has increased in the past 2 decades. The treatment option at this stage is renal replacement therapy, which includes dialysis and kidney transplant (1,2). According to various studies, the cost of dialysis is between US$ 3 000 and 4 000 per month, and it is a lifelong treatment. It is very difficult for the average patient to afford dialysis and it is important to ensure good QOL while on such expensive treatment (3). The World Health Organization (WHO) has defined QOL as “an in- dividual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns” (4). Many studies have evaluated QOL with ge- neric as well as disease-specific instru- ments (5). The assessment of QOL is an essential element of health care evaluation and helps suggest suitable measures to be taken to increase the QOL of patients with end-stage renal disease. Haemodialysis is not a cure for chronic kidney disease but helps to prolong and improve a patient’s life (6). However, patients on haemodi- alysis often experience complications such as cardiovascular disease which decrease their QOL. Furthermore, co- morbidities, such as anaemia, diabetes mellitus, hypertension, dyslipidaemia and thyroid disorders, greatly impair the QOL of patients on haemodialysis, negatively affecting their physical, social, financial and psychological well-being (7). Studies show that because of lack of awareness, patients often do not come for timely dialysis until severe co- morbidities develop (8). Several studies have shown that regular pre-dialysis attendance helps to provide the patient with proper education and thereby achieve better QOL (9). These findings were supported by the study of Lii et al. who concluded that patients who received psychosocial interventions showed better QOL (10). Improvement in the QOL has become the major treatment goal in end-stage renal disease patients (8). Therefore, the aim of this study was to evaluate the QOL of patients on hae- modialysis in the dialysis unit of Basra General Hospital, Iraq. Methods Study design and setting This was a cross-sectional study carried out at the dialysis unit of Basra General Hospital. This unit serves about 200 pa- tients, providing an average of 3 dialysis sessions per week for each patient, free of charge. Study sample The sample was drawn from patients registered at the unit. The inclusion criteria were patients aged over 18 years who were diagnosed with end-stage re- nal disease and had completed at least 3 months on haemodialysis. Patients who declined to answer the questionnaire, those who had voluntarily withdrawn from dialysis, those with severe illness or psychosis, and pregnant and lactating women were excluded. Data collection Data were collected from April to October 2013 using a data collection form. It included information on: so- ciodemographic characteristics, prin- cipal diagnosis, co-morbid conditions (diabetes, hypertension and diabetes and other co-morbidities, such as poly- cystic kidney disease and systemic lupus erythematosus), type of vascular access [arteriovenous fistula (AV-fistula) or central line], duration of haemodialysis, and hepatitis serology status (hepatitis B and/or C positive, hepatitis B and C negative). Data were collected by interview during the dialysis session. It took about 30 minutes for each patient. The inter- view questionnaire was tested on a small sample to assess any errors and bias that could occur in explaining questions and to avoid suggestions by the interviewer. Patients were divided into 3 sub- groups according to the duration of dialysis: group I were on dialysis for < 1 year, group II for 1-3 years and group III for > 3 years. Socioeconomic status of participating patients was categorized as upper, middle, and lower socioeconom- ic status based on income, educational level and type of employment (11). To assess the quality of life we adapted the WHOQOL-BREF as- sessment questionnaire (short form of WHO-100), which has been used worldwide (4). This questionnaire has 26 items, which assess 4 main domains: physical health, psychological health, social relationships and environment of the patient. After recording all necessary items, a raw score is calculated for each facet and each domain. Both facet and domain are scored through simple sum- mation of each item in that scale. Each question contributes equally to the facet score and each facet contributes equally to the domain score. Since each facet has 4 items with response value of 1 to 5, the raw score for any facet has a mini- mum value of 4 and a maximum value of 20. The next step involves transforming each raw scale score to a 0-100 scale using the formula below: Transformed scale = x 100(Actual raw score —lowest possible raw score) possible raw scrore range Book 23-12.indb 816 3/4/2018 11:44:23 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 817 where the actual raw score is the value reached by summation, the lowest possible raw score is the lowest possible value that could be reached by summa- tion (this value would be 4 for all facets), and the possible raw score range is the difference between the maximum pos- sible raw score and the lowest possible raw score, i.e. 20–4 = 16 for all facets. This transformation converts the lowest and highest possible scores to zero and 100, respectively. Statistical analysis Data obtained from the WHOQOL- BREF questionnaire were analysed using SPSS, version 20.0. Descriptive analysis was done using mean and standard deviation (SD), and number and percentage of each value. The chi- squared test was used to compare the effect of different variables on QOL scores A P-value less than 0.05 was con- sidered statistically significant. Ethical considerations The study was approved by the ethics committee in Basra Medical College. Written informed consent was obtained from all the participants. Results A total of 104 patients met the inclusion criteria and were included in the study. Of these, 59 (57%) were male. The mean age of the patients was 49.7 (SD 13.1) years. With regard to duration of dialysis, 31 (30%) patients were on di- alysis for < 1 year, 40 (38%) for 1-3 years and 33 (32%) for > 3 years. Most pa- tients, 77 (74%), had AV-fistula access and 27 (26%) had central line access. Out of the 104 patients, 35 (34%) had diabetes, 23 (22%) had hypertension and diabetes, while the remaining 46 (44%) had other co-morbidities such as polycystic kidney disease and systemic lupus erythematosus. With regard to socioeconomic status of the participat- ing patients, 13 (13%) were categorized as upper socioeconomic status, 44 (42%) as middle and 47 (45%) as lower socioeconomic status. Regarding the hepatitis serology status, 50 (48%) pa- tients were positive for hepatitis virus and 54 (52%) were negative. The overall QOL of patients on haemodialysis was greatly impaired: the mean (SD) score was 39.1 (16.1). The QOL of 58 (56%) patients was greatly affected (score < 50), while 46 (44%) patients were mildly affected (score ≥ 50). Table 1 shows effect of the studied variables on the QOL of the patients. There was no significant effect of the pa- tient’s gender on the QOL (P = 0.969). However, older age (P = 0.004), longer duration of dialysis (P = 0.001), having central line vascular access (P = 0.002), having diabetes and hypertension, or di- abetes co-morbidity (P = 0.001), lower socioeconomic status (P = 0.003), and positive hepatitis serology (P = 0.0001) all negatively affected QOL (Table 1). The transformed scores of the 4 main domains of QOL were: physical (34%), psychological (40%), environ- mental (48%) and social (53%). Discussion This study found that the quality of life of patients on haemodialysis was significantly impaired. A similar effect on QOL was observed in other studies (12,13). Common complications of dialysis, such as strict dietary restrictions, reduce social and recreational activities. Medi- cal complications, economic pressure, marital disputes, sexual dysfunction, emotional stress and anxiety result in further pressure on patients and their caregivers that impair their QOL. Moreover, daily activities are also af- fected by renal failure, including sleep- ing, eating, working and planning a daily schedule, and these can become a challenge for patients and their fami- lies. Many permanent changes in family roles and expectations are needed for patients with end-stage renal disease, which can also increase the stress level and decrease QOL (14). In addition, caregivers also face many difficulties, such as changes in sleep patterns, health and social activities (15). In addition, patients have to spend at least 3 days a week on dialysis, often accompanied by their caregivers, which imposes limita- tions on social life and creates a feeling of dependency on the dialysis centre. So, both patients and caregivers have to make many modifications to their life styles (16). The present study showed that the physical domain of QOL was the most affected, followed by psychologi- cal, environmental and social domains. Similar results have been reported in other studies (17,18). According to various studies, male patients with end-stage renal disease outnumber female patients. This may be because of the smoking and alcohol habits of men, which might aggravate renal failure (8,19). However, in the present study, there was no significant ef- fect of gender on QOL, which is similar to a study from Egypt (20). Older patient age was negatively associated with QOL in our study, mainly in the physical domain. This finding is in line with several studies that showed similar results (21–24). The negative effect of the disease process on the physical activity of patients, such as a decrease in haematocrit, and muscu- loskeletal and neurological problems may contribute to this finding. Because of a physiological decline from ageing, the elderly experience a gradual and progressive reduction in their functional capacity. This may limit their daily ac- tivities and result in worse QOL for dimensions associated with physical health (25). The duration of dialysis adversely affects QOL in dialysis patients and was significantly associated with lower QOL in the patients in the present Book 23-12.indb 817 3/4/2018 11:44:23 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 818 study. QOL was better in patients with a haemodialysis duration of less than 1 year compared with patients with a dialysis duration 1-3 years, and both groups had a better QOL than those on dialysis for more than 3 years. Initially, when patients start dialysis, they may think that their kidneys will recover and dialysis will be stopped, but with the passage of time when they maintain their life on dialysis, their worries in- crease and impair their QOL. A similar observation has been made in another study in which QOL remained constant during the first year of dialysis (26). AV-fistula is considered the best form of vascular access for those who have end-stage renal disease and receive haemodialysis. The clinical practice guidelines for vascular access of the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative recommend early placement and use of an AV-fistula in at least 50% of inci- dent patients on haemodialysis (27). Referral of pre-dialysis patients to neph- rologists is usually late and a temporary access catheter is used as the primary access for dialysis. A study in Pakistan reported late referral in 100% of dialysis patients and temporary access catheter was used for dialysis in these patients (28). Failure of AV-fistula in dialysis patients also contributes to the use of central lines. When catheters are used as the primary access for dialysis, they affect not only QOL but also morbidity because they are a continuous source of infection in the body. Furthermore, the inconvenient site of central lines may make daily activities like bathing and sleeping more difficult, and they may be socially embarrassing and cosmetically unaccepted (21). In this study, central line access for haemodialysis adversely affected the QOL of the patients. The main cause of end-stage renal disease in this study was diabetes mel- litus, which is similar to other national and international studies (28,29). In the present study, the QOL of diabetic patients on dialysis was poor compared with patients without diabetes. Diabetes affects multiple organs in the body; it affects the eyes causing vision prob- lems, and leads to cardiac problems, kidney failure, cerebrovascular events and peripheral vascular disease, which may result in amputation and impaired QOL. All these problems limit daily Table 1 Effect of the studied variables on the quality of life of patients (n = 104) Variable Quality of life P-value Badly affected Mildly affected No. (%) No. (%) Sex 0.969 Male 33 (56) 26 (44) Female 25 (56) 20 (44) Age (years) 0.004 18-45 9 (32) 19 (68) ˃ 45 49 (64) 27 (36) Duration of dialysis (years) 0.001 ˂ 1 9 (29) 22 (71) 1-3 25 (62) 15 (38) ˃ 3 24 (73) 9 (27) Vascular access 0.002 Arteriovenous fistula 36 (47) 41 (53) Central line 22 (81) 5 (19) Co-morbidities 0.001 Diabetes 22 (63) 13 (37) Diabetes and hypertension 19 (83) 4 (17) Other 17 (37) 29 (63) Socioeconomic status 0.003 Upper 2 (15) 11 (85) Middle 18 (41) 26 (59) Lower 40 (85) 7 (15) Hepatitis serology 0.0001 Negative 11 (20) 43 (80) Positive 47 (94) 3 (6) Book 23-12.indb 818 3/4/2018 11:44:24 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 819 activities and work capacity, lead to de- pendence on anti-diabetes drugs and disturbed sleep because of pain which affects physical health. A similar pattern of poor QOL has been reported in other studies (30,31). Furthermore, in the present study, QOL was markedly affected in patients with concomitant diabetes and hypertension compared with patients with diabetes alone be- cause of the additional complications imposed by hypertension. Socioeconomic status was also significantly associated with QOL in the present study; those of lower socio- economic status had a lower QOL. The findings of other studies, which found that employed patients had a better QOL than unemployed patients, sup- port this finding (12,22). Demographic factors such as unemployment, low ed- ucation and low socioeconomic status can impair QOL (32). This is because financial independence may improve QOL in working patient to some extent. Also, daily activity and work capacity may help to improve QOL (12). Hold- ing down a job certainly has a positive influence on the perception that an individual has a role in society and it contributes to improved self-esteem, which is an important aspect of QOL (24). Higher education also raises the QOL according to a study from Italy (33), and can raise awareness of chronic diseases and help patients acquire better coping skills (24). The QOL in haemodialysis patients with positive hepatitis serology was sig- nificantly impaired which may be due to multiple factors such as social isolation, sexual deprivation and the development of clinical features and complications of hepatitis itself (24). The main limitation of our study was the relatively small patient sample. We studied the correlation of QOL with dialysis-related factors and there is a need for further study of health- related domains of QOL in a much larger sample of patients with end-stage renal disease. The QOL questionnaire was completed when patients came for dialysis, where they may feel more secure and friendly to dialysis staff, which may affects their how they are feeling and hence their responses when interviewed. Conclusion The results of the present study provide evidence that the QOL of the haemodi- alysis patients is significantly impaired. Gender had no significant effect on QOL. Increasing age, longer duration of dialysis, diabetes and hypertension, central venous catheter as a vascular access for dialysis, lower socioeconomic status, and positive hepatitis serology were all statistically significant factors that adversely affected QOL. Some of these factors are modifiable, so we should aim for better diabetes and hypertension control, encourage the use of AV-fistula rather than central catheter, and improve infection control for hepatitis viruses. Acknowledgement I would like to acknowledge Dr Safaa A. Hneid for his help in the collection of the data for this study. 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Costs and quality of life effects of the first year of renal replace- ment therapy in one Finnish treatment centre. J Med Econ. 2009 Jun;12(2):136-40. https://doi.org/10.3111/13696990903119530 PMID:19566482 27. KDOQI Clinical practice guideline for hemodialysis adequacy: 2015 update. Am J Kidney Dis. 2015 Nov;66(5):884-930. https://doi.org/10.1053/j.ajkd.2015.07.015 PMID:26498416 28. Anees M, Mumtaz A, Nazir M, Ibrahim M, Rizwan SM, Kausar T. Referral pattern fof hemodialysis patients to neph- rologists. J Coll Physicians Surg Pak. 2007 Nov;17(11):671-4. PMID:18070574 29. United States Renal Data System. USRDS 2007 Annual Data Report. Bethesda (MD): National Institute of Diabetes and Di- gestive and Kidney Diseases, National Institutes of Health, US Department of Health and Human Services; 2007. 30. Gumprecht J, Zelobowska K, Gosek K, Zywiec J, Adamski M, Grzeszczak W. Quality of life among diabetic and non- diabetic patients on maintenance haemodialysis. Exp Clin Endocrinol Diabetes. 2010 Mar;118(3):205-8. https://doi. org/10.1055/s-0029-1192023 PMID:19226477 31. Sørensen VR, Mathiesen ER, Watt T, Bjorner JB, Andersen MV, Feldt-Rasmussen B. Diabetic patients treated with di- alysis: complications and quality of life. Diabetologia. 2007 Nov;50(11):2254-62. https://doi.org/10.1007/s00125-007- 0810-1 PMID:17876568 32. Kalender B, Ozdemir AC, Dervisoglu E, Ozdemir O. Quality of life in chronic kidney disease: effects of treatment modal- ity, depression, malnutrition and inflammation. Int J Clin Pract. 2007 Apr;61(4):569-76. https://doi.org/10.1111/j.1742- 1241.2006.01251.x PMID:17263698 33. Mingardi G, Cornalba L, Cortinovis E, Ruggiata R, Mosconi P, Apolone G; DIA-QOL Group. Health-related quality of life in dialysis patients. A report from an Italian study using the SF-36 Health Survey. Nephrol Dial Transplant. 1999 Jun;14(6):1503- 10. https://doi.org/10.1093/ndt/14.6.1503 PMID:10383015 Book 23-12.indb 820 3/4/2018 11:44:24 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 821 1Immunology Section, Saylmaniya Medical Center, Manama, Kingdom of Bahrain. 2Arabian Gulf University, Manama, Kingdom of Bahrain. 3Paediatrics Department, Faculty of Medicine, Tanta University, Tanta, Egypt (Correspondence to: Mohammed Al-Biltagi: mbelrem@hotmail.com). Received: 25/04/16; accepted: 19/02/17 Trend and seroprevalence of Epstein–Barr virus in Bahrain: 2001–2015 Eman Farid 1,2 and Mohammed Al-Biltagi 2,3 Tendance et séroprévalence du virus d’Epstein Barr à Bahreïn (2001–2015) RÉSUMÉ À Bahreïn, il n'existe aucune information épidémiologique adéquate sur le taux d’infection par le virus Epstein Barr (EBV). Or, des données dans ce domaine pourraient permettre de mettre au point des mesures de protection contre les infections par EBV. La présente étude avait ainsi pour objectif d’examiner la tendance de l’infection par EBV à Bahreïn sur une période de 15 ans (2001-2015). Les résultats sérologiques de 10 560 patients ayant une infection par EBV suspecte ont été évalués. Les échantillons prélevés au centre médical de Salmaniya entre 2001 et 2015 ont été inclus. La présence ou l’absence des anticorps IgG de l’antigène de la capside virale de l’EBV, IgM de la capside virale, et IgG dirigés contre l’antigène nucléaire de l’EBV (EBNA) a été enregistrée. Sur les 10 560 échantillons, 10 333 étaient utilisables. Sur ce nombre, 86,1 % étaient séropositifs, et montraient une tendance à la hausse des cas d’infection par EBV sur la période couverte par l’étude. Une primo-infection à EBV a été trouvée pour 7,4 % des échantillons, et sur ce chiffre, 47,3 % des sujets avaient entre 5 et 19 ans. La réactivation de l’EBV a été observée dans 11 % des échantillons séropositifs. Sur ce nombre, 50 % des sujets avaient 25 ans ou plus. Le patient séropositif le plus jeune était âgé de 11 mois. L’EBV est une infection courante à Bahreïn. La plupart des infections ont lieu entre l’âge d’un et cinq ans, tandis que les cas de réactivation de l’infection apparaissent après l’âge de 25 ans. La surveillance en série de l'infection par EBV est requise à Bahreïn. Des mesures de protection contre cet type d'iinfection devraient être mises en place. 2015-2011 :نيرحبلا في راب - نيابشتبإ سويرفل ليصلما راشتنلااو ماعلا هاتجلاا يجاتلبلا دممح ،ديرف نايإ يرــبادت دادــعإ في دعاــست نأ انهأــش نــم يــتلا ،EBV سويرــفب ةــباصلإا لدــعم نــع ةــيفاكلا ةــيئابولا تاــمولعلما لىإ نــيرحبلا رــقتفت : ةــصالخا لاــخ نــيرحبلا في سويرــفلا ىودــعل ماــعلا هاــتجلاا ّيــقت في ةــساردلا هذــه نــم فدــلها لــثمتي ،كــلذلو .سويرــفلاب ىودــعلا نــم ةــياحلل تــجردأو .EBV سويرــف ىودــعب مــهتباصإ لــمتيح ًاــضيرم 56010 هــعوممج اــلم ةــيلصلما جــئاتنلا مــييقت ىرــج .2015-2001 ،ًاــماع 15 ةرــف تادضتــسلم G يــعانلما نــلويبوللجا باــيغ وأ دوــجو لجــسو .2015-2001 ةرــفلا لاــخ يــبطلا ةينالــسلا عوــممج في ةذوــخألما تاــنيعلا ةــيوونلا تادضتــسملل G يــعانلما نــلويبوللجا دادــضأو ،سويرــفلا تاــصيفُق تادضتــسلم M يــعانلما نــلويبوللجاو ،EBV سويرــفلا تاــصيفُق لــصملل ةــيبايجلإا تاــنيعلا ةبــسن تــغلبو .ةــنيع 33310 مادختــسال ةــلباقلا تاــنيعلا ددــع غــلب ،ةــنيع 56010 لــصأ نــم .EBV سويرــفلل ؛لـصملل ةـيبايجلإا تاـنيعلا نـم % 7.4 في سويرـفلاب ةـيلوأ ىودـع دوـجو ّنـبتو .ةـساردلا ةرـف لاـخ EBV سويرـفب ىودـعلل دـيازتم هاـتجا عـم % 86.1 رـغصلأا ةـيرمعلا ةـئفلا في % 50 اـهنم ؛لـصملل ةـيبايجلإا تاـنيعلا نـم % 11 في سويرـفلا ةدوـع ّنـبتو .ةنـس 19و 5 نـب اـم ةـيرمعلا ةـئفلا في % 47.3 اـهنم تلااــ ح مــ ظعم ثدــ تحو .نــ يرحبلا في ةعئاــ ش EBV سويرــ ف ىودــ عب ةــ باصلإا نإ .ًارهــ ش 11 لــ صملل بياــ يجإ ضــ يرم رــ غصأ رــ مع غــ لبو .ةنــ س 25 نــ م .25 نـس دـعب ىودـعلا ةدوـع تلااـح مـظعم ثدـتح نـح في تاونـس 5و ةنـس نـب اـم ةـيرمعلا ةـئفلا في ةـيلولأا ىودـعلا ABSTRACT In Bahrain, adequate epidemiological information is lacking concerning the rate of EBV infection, which could be helpful in order to develop measures to protect against EBV infections. The aim of this study, was to investigate the trend of EBV infection in Bahrain over a 15-year period, 2001–2015. The EBV serological results of 10 560 patients with possible EBV infection were evaluated. Samples taken at the Salmaniya Medical Complex during 2001–2015 were included. The presence or absence of EBV viral capsid antigen (VCA) IgG, VCA IgM and EBV nuclear antigen (EBNA) IgG antibodies was recorded. Of the 10 560 samples, 10 333 were usable; of these, 86.1% were seropositive with an increasing trend of EBV infection over the study period. Primary EBV infection was found in 7.4% of the seropositive samples; of these, 47.3% were between 5 and 19 years. EBV reactivation was found in 11% of the seropositive samples; of these, 50% were > 25 years of age. The youngest seropositive patient was 11 months old. EBV is a common viral infection in Bahrain. Most primary infections occur between 1 and 5 years while most reactivation infections occur after the age of 25 years. Serial surveillance of EBV infection is needed in Bahrain. Measures to protect against EBV infections should be implemented. https://doi.org/10.26719/2017.23.12.821 Book 23-12.indb 821 3/4/2018 11:44:24 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 822 Introduction E p s t e i n - B a r r v i r u s ( E B V ) i s a B-lymphotropic human herpesvirus which is widespread in the world. It can cause long-term immune damage and has lifelong latency in the infected host. It is the etiologic agent for a number of autoimmune diseases and malignancies (1). EBV is a globally prevalent virus and over 90% of the world’s population is infected with the virus in adulthood. Upon infection, the individual remains a lifelong carrier of the virus and remains without serious overt consequences in most cases. However, in some individuals, the virus is implicated in the development of malignancy (2). The rate and timing of primary infections with EBV differ from one country to another. For instance, most children in the developing world are infected during childhood, in contrast to most developed countries where most primary infections occur at a later age, often in adolescence (3). The timing of primary infection is important as it affects the host differently depending on when it is acquired. For example, acquisition of primary EBV infection in preadolescents is generally mild. However, acquisition in infancy is a risk factor for later malignancy. The infection in infants and children is usually less severe than that of adults (4). The clinical presentation of EBV infection is challenging as it may be asymptomatic or indistinguishable from other mild, short-lived infections. Therefore, it is important to use the best diagnostic tests with a high degree of confidence (5). Several serological tests can be used for diagnosing EBV infections, such as indirect fluorescent antibody, rapid monospot tests (for heterophile antibodies), and enzyme immune assay for detection of early antigens, the viral capsid antigens (VCA) and the EBV nuclear antigen (EBNA). Full automation of EBV serological diagnosis is important for routine diagnostic laboratories (6). The use of only 3 parameters (VCA IgG, VCA IgM and EBNA IgG) can distinguish acute and past infections in immunocompetent people. The presence of VCA IgG and VCA IgM in the absence of EBNA IgG indicates acute infection, while the presence of VCA IgG and EBNA IgG in the absence of VCA IgM is typical of past infection. However, some cases may have different profiles that can create diagnostic doubts, such as the presence of VCA IgG in the absence of VCA IgM and EBNA IgG, the simultaneous presence of VCA IgG, VCA IgM and EBNA IgG, and the presence of EBNA IgG in the absence of VCA IgG and IgM. In such circumstances, in addition to following up patients to assess any changes in the antibody profile, it is also useful to perform other laboratory tests (7). Baseline information of EBV infection in healthy populations is helpful in order to develop measures to protect against EBV infections. In Bahrain, adequate epidemiological information about the rate of EBV infection is lacking. The aim of this study, therefore, was to investigate the trend of EBV infection in Bahrain over a 15-year period, 2001-2015. Methods This study was a retrospective analysis of the national data of both paediatric and adult patients that had been evaluated for the presence of EBV infection for various reasons in a major tertiary care hospital in Bahrain during the 15-year period 2001-2015. The study included a total of 10 560 patients aged between 3 months and 91 years who were referred to the Salmaniya Medical Complex (SMC) Laboratory with suspected EBV infection. On all cases and the type of EBV infections over the past 15 years were retrospectively collected from the Laboratory Information System data and entered in a Microsoft Excel database. The data were analysed separately for the trend in EBV seropositive and seronegative status. Seropositive results were further categorized into primary EBV infection, previous infection and reactivation infections according VCA IgM and VCA IgG positivity, and the presence or absence of serum EBVNA IgG. Serum EBVNA IgG and VCA IgG < 18 U/mL were considered negative, and ≥ 22 U/ mL were considered positive. VCA IgM was considered negative if < 36 U/m and positive if ≥ 44 U/mL. Borderline results were considered equivocal and, according to laboratory procedure, they are repeated after 1 week. Samples were considered seronegative (no previous exposure) when serum EBVNA IgG, VCA IgG and VCA IgM were negative (Figure 1). Positive VCA IgM only, or positive VCA IgM and VCA IgG with negative EBNA IgG were considered acute primary EBV infection. Positive VCA IgM and positive EBNA IgG with or without positive VCA IgG was considered EBV reactivation (8,9). Patients with haemolysed samples or with equivocal results were not included in the data analysis. Inconclusive results (could not be classified according to Table 1) were also excluded. EBV VCA IgG, VCA IgM and EBNA IgG antibodies were measured by an advanced third-generation immunoassay system using an Immulite 2000 machine (Siemens Healthcare GmbH, Germany). The sex and nationality of the patients were recorded, and they were divided into 6 age groups: < 5 years, 5–10 years, 11–15 years, 16–20 years, 21–25 years and > 25 years. The data were analysed separately for the trend in the seroprevalence over the past 15 years using TexaSoft, WINKS SDA software 2007, 6th edition (Cedar Hill, Texas, USA). Mean differences between subgroups were tested by the Book 23-12.indb 822 3/4/2018 11:44:24 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 823 Student t-test. Comparison between ratios was done using the z-score test. P < 0.05 was considered statistically significant. Ethical considerations The study was approved by the Ethics Committee of the Salmaniya Medical Center and the Secondary Health Care Research Subcommittee of the Ministry of Health, Bahrain, and was conducted in accordance with the Helsinki Declaration. No consent was obtained as it was a retrospective analysis of laboratory data which were anonymized. Results The study included 10 560 blood samples taken over a period of 15 years; 90 samples were rejected because of haemolysis or insufficient sample to test, and 137 samples gave equivocal results. From the remaining 10 333 valid samples, 13.9% were negative for EBV, while 6.4% showed primary EBV infection, 9.4% showed reactivation of EBV infection, and 70.3% showed previous infection with EBV. Primary EBV infection represented 40.3% and EBV reactivation occurred in 59.7% of the active infections. Figure 2 shows the trend of EBV infection over the 15-year period. The number of screened samples increased and consequently the number of the samples with previous infections increased from the year 2010 onwards. However, the numbers of samples without infection, with primary EBV infections or with reactivation of EBV infection over the study period did not increase to the same degree. Primary EBV infection was more common in males (M:F ratio = 1.86), while EBV infection reactivation was slightly more common in females (M:F Table 1 Epstein–Barr virus (EBV) profile in all tested patients, 2001–2015 Year People screened EBV negative Primary infection Past infection Reactivation No. No. (%) No. (%) No. (%) No. (%) 2001 375 38 (10.1) 38 (10.1) 220 (58.7) 79 (21.1) 2002 350 34 (9.7) 30 (8.6) 216 (61.7) 70 (20.0) 2003 355 43 (12.1) 30 (8.5) 213 (60.0) 69 (19.4) 2004 409 46 (11.2) 39 (9.5) 243 (59.4) 81 (19.8) 2005 450 55 (12.2) 23 (5.1) 322 (71.5) 50 (11.1) 2006 577 99 (17.2) 45 (7.8) 314 (54.4) 119 (20.6) 2007 560 128 (22.9) 53 (9.5) 286 (51.0) 93 (16.6) 2008 554 139 (25.1) 45 (8.1) 290 (52.3) 80 (14.4) 2009 568 157 (27.6) 48 (8.5) 297 (52.3) 66 (11.6) 2010 572 135 (23.6) 59 (10.3) 322 (56.3) 56 (9.8) 2011 904 93 (10.3) 45 (5.1) 727 (80.4) 38 (4.2) 2012 1 153 109 (9.4) 40 (3.5) 964 (83.6) 40 (3.5) 2013 1 133 98 (8.6) 49 (4.3) 939 (82.9) 47 (4.1) 2014 1 324 153 (11.6) 67 (5.1) 1053 (79.5) 51 (3.9) 2015 1 054 110 (10.4) 53 (5.0) 856 (81.2) 35 (3.3) Total 10 338 1437 (13.9) 664 (6.4) 7262 (70.2) 974 (9.4) Figure 1 Interpretation of Epstein–Barr virus (EBV) antibody serology (VCA: viral capsid antigens; EBNA: EBV nuclear antigen) Book 23-12.indb 823 3/4/2018 11:44:25 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 824 ratio = 0.96). The majority of patients with both primary EBV infection and reactivation EBV infection were Bahraini, 87.8% and 81.6% respectively. The age trends for primary and reactivation EBV infections are shown in Tables 2 and 3 and Figures 3 and 4. Overall, primary EBV infection was most prevalent in age groups < 5 years Table 2 Trend in primary Epstein-Barr virus infection from 2001 to 2015 according to age group, male: female ratio and nationality Year Total Age group (years) M:F Bahraini nationality < 5 5- 11- 16- 21- > 25 No. No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) % 2001 38 12 (31.6) 13 (34.2) 4 (10.5) 2 (5.3) 2 (5.3) 5 (13.2) 2.1 90.0 2002 30 5 (16.7) 17 (56.6) 4 (13.3) 1 (3.3) 1 (3.3) 2 (6.7) 2 90.0 2003 30 8 (26.7) 9 (30.0) 4 (13.3) 3 (10) 3 (10) 3 (10) 1.5 90.0 2004 39 18 (46.2) 14 (35.9) 4 (10.3) 1 (2.6) 1 (2.6) 1 (2.6) 3.3 97.4 2005 23 5 (21.7) 10 (43.5) 2 (8.7) 0 2 (8.7) 4 (17.4) 2.3 82.6 2006 45 19 (42.2) 15 (33.3) 3 (6.7) 2 (4.4) 2 (4.4) 4 (8.9) 2.2 95.5 2007 53 21 (39.6) 15 (28.4) 4 (7.5) 4 (7.5) 1 (1.9) 8 (15.1) 1.4 83.0 2008 45 10 (22.2) 21 (46.7) 5 (11.1) 4 (8.9) 2 (4.4) 3 (6.7) 1.9 86.0 2009 48 10 (20.8) 24 (50) 4 (8.3) 3 (6.2) 2 (4.2) 5 (10.4) 1.7 86.0 2010 59 15 (25.4) 30 (50.8) 6 (10.2) 3 (5.1) 3 (5.1) 2 (3.4) 1.6 87.0 2011 45 0 31 (68.9) 8 (17.8) 2 (4.4) 1 (2.2) 3 (6.7) 1.42 84.7 2012 40 0 22 (55) 4 (10) 5 (12.5) 2 (5.0) 7 (17.5) 2.33 80.0 2013 49 6 (12.2) 36 (73.4) 4 (8.2) 1 (2.0) 2 (4.1) 0 1.33 94.0 2014 67 8 (11.9) 42 (62.7) 7 (10.4) 4 (6.0) 5 (7.4) 1 (1.5) 1.91 94.0 2015 53 24 (45.3) 21 (39.6) 5 (9.4) 2 (3.8) 0 1 (1.9) 1.79 77.4 Mean 44.3 10.7 (24.2) 21.3 (47.3) 4.5 (10.4) 2.5 (5.5) 1.9 (4.6) 3.3 (6.2) 1.9 87.8 0 200 400 600 800 1000 1200 1400 N o. o f c as es Total screened Negative for EBV infection Primary infection Past infection Reactivation Figure 2 Trend of Epstein-Barr virus (EBV) infections in Bahrain: 2001-2015 Book 23-12.indb 824 3/4/2018 11:44:25 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 825 and 5–10 years (24.4% and 48.6% respectively), while reactivation EBV infection was most prevalent in the age group > 25 years (45.3%) followed by the age group 5–10 years (15.9%). The youngest recorded case with primary infection was an 11-month-old Bahraini boy. About 54% of cases with primary EBV infections occurred after 2008 (P < 0.01). Reactivation of EBV infection in the age group between 5 and 10 years was associated with the presence of vitamin D deficiency [75 cases (48.4%, P < 0.01)], chemotherapy use [21 cases (13.5%, P < 0.001)], steroid use [12 cases (7.7%, P > 0.05)], and previous hospitalization due to respiratory tract infection (15 cases (9.7%), P < 0.01]. Malaria was present in 3 boys (1.9%) a few months before reactivation of EBV. Reactivation of EBV infection in the age group over 25 years was associated with steroid use [95 cases (19.8%, P < 0.01)], and previous infection (134 cases (27.8%, P <0.001)]. Table 4 shows a comparison of primary and reactivation EBV infections with regard to sociodemographic and clinical data. Significantly more pregnant women had reactivation of EBV infection than primary infection (P < 0.001). In addition, a significantly higher percentage of patients with EBV reactivation had chronic diseases, such as chronic renal diseases, diabetes mellitus, malignancy, autoimmune diseases and chronic infections (tuberculosis, cytomegalovirus co- infection and HIV) than patients with primary infection. As regards clinical presentation, significantly more patients with primary infection presented with lymphadenopathy, pharyngitis, organomegaly and prolonged fever than patients with reactivation of EBV infection. On the other hand, abdominal pain was significantly less common in primary infection than in reactivation of EBV infection. The duration of EBV infection-related hospitalization was Table 3 Trend in reactivation of Epstein-Barr virus infection from 2001 to 2015 according to age group, male: female ratio and nationality Year Total Age group (years) M:F Bahraini nationality < 5 5-10 11-15 16-20 21-25 > 25 No. No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) 2001 79 4 (5.1) 10 (12.7) 4 (5.1) 8 (10.1) 11 (13.9) 42 (53.2) 0.58 84.0 2002 70 3 (4.3) 5 (7.1) 0 6 (8.6) 7 (10) 49 (70) 0.46 83.0 2003 69 1 (1.4) 11 (15.9) 5 (7.2) 5 (7.2) 8 (11.6) 39 (56.5) 0.73 90.0 2004 81 8 (9.9) 9 (11.1) 4 (4.9) 9 (11.1) 12 (14.8) 39 (48.1) 0.95 80.4 2005 50 2 (4) 1 (2) 4 (8.0) 5 (10) 3 (6) 35 (70) 0.92 88 2006 119 3 (2.5) 17 (14.3) 4 (3.4) 16 (13.4) 20 (16.8) 59 (49.6) 1.05 78.1 2007 93 9 (9.7) 12 (12.9) 5 (5.4) 6 (6.5) 14 (15) 47 (50.5) 1.16 81.7 2008 80 4 (5) 11 (13.8) 4 (5) 7 (8.8) 19 (23.8) 35 (43.8) 1.2 75.0 2009 66 5 (7.6) 13 (19.7) 5 (7.6) 4 (6.1) 10 (15.1) 29 (43.9) 1.2 82.0 2010 56 7 (12.5) 11 (19.6) 4 (7.1) 3 (5.4) 6 (10.7) 25 (44.6) 0.9 84.0 2011 38 0 10 (26.3) 2 (5.3) 7 (18.4) 2 (5.3) 17 (44.7) 1.45 68.4 2012 40 0 12 (30) 7 (17.5) 4 (10) 2 (5) 15 (37.5) 1.35 77.5 2013 47 5 (10.6) 16 (34) 5 (10.6) 1 (2.2) 2 (4.3) 18 (38.3) 1.14 93.6 2014 51 7 (13.7) 13 (25.5) 5 (9.8) 1 (2) 8 (15.7) 17 (33.3) 0.76 78.4 2015 35 8 (22.9) 4 (11.4) 3 (8.6) 1 (2.9) 4 (11.4) 15 (42.9) 0.67 80.0 Mean 65 4.4 (6.8) 10.3 (15.8) 4.1 (6.3) 5.5 (8.5) 8.5 (13.1) 32.1 (49.3) 0.97 81.6 Figure 3 Age distribution of patients with primary Epstein-Barr virus infection 24% 48% 10% 6%5% 7% < 5 yrs 5-10 yrs > 10-15 > 15-20 yrs > 20-25 yrs > 25 yrs Book 23-12.indb 825 3/4/2018 11:44:26 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 826 significantly longer in patients with primary infection than those with EBV reactivation. Discussion Primary EBV infection is often asymptomatic but may result in lifelong infection, the course of which depends on the host immune system. In some cases, primary infection can result in infectious mononucleosis (10). In our study, 86% of the tested patients were positive for EBV infection. There was a striking increase in the rate of primary infection in children between 5 and 10 years over the 15-year duration of the study together with a relative increase in the primary infection rate among males than females. The prevalence and age distribution of this latent virus infection varies in different populations. In our study, the trend of primary EBV infection in Bahrain increased, especially during the period 2010 to 2015. This was also observed in Taiwan where the prevalence of primary EBV infection increased with a seropositive rate > 50% at the age of 2 years, > 80% at the age of 5–9 years and > 90% at age 10 years and above (11). This is in contrast with the situation in the United States of America (USA), where the EBV antibody prevalence declined in individuals aged 6-19 years from 2003/2004 to 2009/2010, mainly because of a decrease among non-Hispanic white participants (12). The increased trend of primary EBV infection in Bahrain could just be due to the increase in population numbers and hence increased the numbers of patients. In addition, the ratio of Bahraini to non-Bahraini people dropped from an average of 89% each year in the first 9 years to an average of 86% in the following 6 years, which indicates a relative increase in the number of expatriates, which could be a reason. The reasons behind the increase in primary EBV infection in Bahrain need be addressed. A Malaysian study in 1987 showed that all the children had acquired primary infection by the age of 8 years (13). This EBV infection in early life explained the absence of infectious mononucleosis in the Malaysian population (13). A study in Espírito Santo, Brazil showed a higher prevalence of EBV antibodies in children and adolescents, with more frequent infections occurring at a younger age in children from families of low socioeconomic status (14). Another study in the Islamic Republic of Iran between 2007 and 2011 showed that 91.5% of primary EBV infections occurred by the age of 10 years compared with 72.4% in our study (15). However, a study in the USA found that about 50% of primary EBV infection in American children occurred between 6 and 8 years of age (12). The study was concerned with antibody prevalence in Americans aged 6–19 years from 2003 to 2010. It showed a decreased prevalence in the age group 6–12 years with a higher prevalence in those aged 12–19 years, which supported the need for EBV vaccination before 12 years of age (12). Our study showed a higher incidence of primary EBV infection in males than in females. A Brazilian study reported a higher incidence of EBV-associated childhood Burkitt lymphoma in male children than female children in south- eastern Brazil (16). However, in our study the number of females with EBV reactivation infection was greater than with primary infection. This increase in reactivation infection among females may be due to increased silent primary EBV infections among females. EBV tends to establish latency in the host as with other herpes viruses. Primary infection leads to transitional viraemia, followed by a strong T-cell adaptive immune response, which keeps the infection latent in immunocompetent individuals (17). The higher rate of EBV infection among Bahrainis than non-Bahrainis could be related to the relative increase in the number of the Bahraini citizens and the easier access of Bahrainis to government medical facilities than non- Bahrainis. However, a study conducted in the USA showed different prevalence rates in different races; the prevalence of primary EBV infection was more common in non-Hispanic black children (74%), followed by Asian children (62%), then multiracial children (54%), Hispanics (50%), and non-Hispanic white children (26%). This marked ethnicity variability of EBV prevalence could be explained by differences in demographic and socioeconomic status of families, including education and health care availability (18). However, socioeconomic position and factors related to lifestyle explain only a part of the large ethnic differences in EBV seroprevalence (19). Unknown triggers can cause reactivation of EBV infection due to stimulation of latently infected B cells. The virus can re-infect new B cells and 7% 16% 6% 9% 13% 49% < 5 yrs 5-10 yrs > 10-15 > 15-20 yrs > 20-25 yrs > 25 yrs Figure 4 Age distribution of patients with reactivation Epstein-Barr virus infection Book 23-12.indb 826 3/4/2018 11:44:27 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 827 Table 4 Comparison of primary and reactivation Epstein–Barr virus (EBV) infection over 15 years (2001 to 2015) according to sociodemographic and clinical data Variable Primary EBV infection (n = 664) Reactivation of EBV infection (n = 974) P-value (z -test) No. (%) No. (%) Age (years) < 5 161 (24.2) 66 (6.8) < 0.0001 5–10 320 (48.2) 155 (15.9) < 0.0001 11–15 68 (10.2) 61 (6.3) < 0.01 16–20 37 (5.57) 83 (8.5) < 0.05 21–25 29 (4.3) 128 (13.1) < 0.0001 > 25 49 (7.4) 481 (49.3) < 0.0001 Sex Male 435 (65.5) 481(49.4) < 0.0001 Female 229 (34.5) 493 (50.6) < 0.0001 Nationality Bahraini 583 (87.8) 796 (81.6) < 0.001 Non-Bahraini 81 (12.2) 178 (18.3) < 0.001 Pregnant women 20 (3.0) 69 (7.1) <0.001 History of chronic renal diseases 13 (2.0) 68 (7.0) <0.0001 History of diabetes mellitus 20 (3.0) 107 (11.0) <0.001 History of malignancy 7 (1.1) 49 (5.0) <0.0001 Associated chronic infection Tuberculosis 20 (3.0) 68 (7.0) < 0.001 Cytomegalovirus 73 (11.0) 263 (27.0) < 0.001 HIV 4 (0.6) 36 (3.7) < 0.001 Autoimmune diseases 13 (2) 64 (6.6) < 0.001 Clinical presentation Fever 611 (92.0) 828 (84.9) < 0.001 Duration of fever (weeks) > 1 230 (37.6) 300 (36.2) 0.3 < 1 381 (62.4) 528 (63.8) 0.4 Mean (SD) 7.2 (3.4) 6.4 (3.5) < 0.0001 Abdominal pain 299 (45.0) 536 (55.0) < 0.0001 Rash 126 (19.0) 69 (17.1) 0.3 Pharyngitis 598 (90.0) 819 (84.0) < 0.001 Lymphadenopathy 358 (53.9) 224 (23.0) < 0.0001 Organomegaly 212 (31.9) 243 (24.9) < 0.01 Laboratory data Erythrocyte sedimentation rate > 20 mm in first hour 412 (62.0) 624 (64.0) 0.4 C-reactive protein > 6 (mg/L) 359 (54.1) 692 (71.0) < 0.0001 White blood cell count (109/L) [mean (SD)] 12.4 (7.9) 10.1 (4.7) < 0.0001 Haemoglobin (g/L) [mean (SD)] 11.0 (1.2) 11.9 (3.7) < 0.0001 Platelet count (109/L) [mean (SD)] 256.7 (135.4) 294.5 (151.7) < 0.0001 Rate of hospitalization 64 (9.6) 44 (4.5) <0.0001 Duration of hospitalization, if any (weeks) > 1 30 (4.5) 20 (2.1) < 0.01 < 1 34 (5.1) 24 (2.5) < 0.01 Mean duration (SD) 7.1 (3.5) 5.2 (2.1) < 0.0001 SD = standard deviation. Book 23-12.indb 827 3/4/2018 11:44:27 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 828 epithelial cells, becoming a source of viral transmission initiating reactivated EBV infection (10). In our study, reactivation was reported in 9.4% of the total sample and 11.0% of the positive samples compared with 6.4% and 7.4% respectively with primary EBV infections. Of the 1634 active infections, 40.3% were primary EBV infection and 59.7% were EBV reactivation. The most common age group for reactivation was over 25 years followed by the ages 5-10 years. In the 5-10 years age group, vitamin D deficiency was found in nearly half of the cases. Vitamin D deficiency may increase the risk of certain viral infections, while it has been shown to have some direct antiviral effects (20). Chemotherapy use was associated with EBV reactivation in 13.5% of those aged 5-10 years. Certain chemotherapeutic drugs, including gemcitabine, doxorubicin, cis-platinum and 5-fluorouracil, have been reported to induce the lytic form of EBV infection in latently infected host cells and hence EBV reactivation (21). At the same time, the use of steroids was associated with EBV reactivation in 7.7% of cases of reactivation. Steroids are a common cause of EBV reactivation from latency, possibly directly by promoting viral replication or alternatively by down- regulating the ability of the memory T-cell response to control the latent virus (22). Previous hospitalization due to respiratory tract infection was reported in 9.7% of reactivation cases. Hospitalization itself is a form of stress, which in turn could stimulate reactivation of herpesviruses including EBV (23). A strong relation was found in a study between cytomegalovirus super-infection and EBV reactivation leading the authors to suggest that cytomegalovirus might be an important co-factor in EBV pathogenesis, especially in immunocompromised patients (24). There were 3 cases of malaria infection preceding reactivation of EBV in our study. Malaria infection profoundly affects the B cell compartment, inducing polyclonal activation and hypergammaglobul i nae mia . The cystein-rich inter-domain region 1alpha (CIDR1alpha) of the Plasmodium falciparum membrane protein 1 acts as a polyclonal B cell activator that preferentially activates the memory compartment, where EBV is known to persist (25). At the same time, about 50% of the EBV reactivation occurred after the age of 25 years with nearly equal male to female ratio. In a study by Nystad and Myrmel, 42% of 43 patients with suspected primary EBV infection had late primary infection, while 49% had high-avidity IgG-antibodies, indicating an IgM response due to reactivation, which agrees with our results (4). EBV reactivation essentially occurs in clinical situations associated with chronic immunosuppression secondary to systemic disease, viral superinfection or specific treatments, as in the case of organ or bone marrow transplantation (26). The importance of determining the epidemiological status of EBV infection in the country is to estimate the magnitude of the problem and to help to decide the need for an EBV vaccine. A vaccine against EBV would help to prevent primary EBV infection and consequently EBV- related malignancies. Such a vaccine is still in clinical trials and must be given early in life before the peak of seroconversion (as in our study) before the age of 5 years. It would also be useful in seronegative organ transplant recipients and those developing severe infectious mononucleosis, such as the male offspring of X-linked proliferative syndrome carriers (27). Our study had some limitations. Being a retrospective study is a major limitation with inferior level of evidence compared with prospective studies. The absence of available clinical data constitutes a clear limitation when attempting to compare our results with the results of similar studies. Clinical data are important to relate the EBV infection positivity with clinical severity. At the same time, the difference between the methods used in our study compared with other studies made it difficult to compare results. We also did not correlate EBV prevalence with HLA typing and did not correlate EBV reactivation with the EBV viral DNA load. HLA typing could help to stratify the patients at risk of infection and even complications of EBV infection. High EBV viral loads are strongly associated with current or impending lymphoproliferative disorder. Conclusion EBV is a common viral infection in the hospital setting in Bahrain, occurring in childhood as early as 1 year of age with a high seroprevalence. The majority of primary infections occur in the age range 1-5 years while most reactivation infections occur after the age of 25 years. The effect of these epidemiological findings on the prevalence of certain diseases in Bahrain, mainly infectious mononucleosis, Burkitt lymphoma, Hodgkin disease, nasopharyngeal carcinoma and B-cell lymphoma, needs to be explored. Funding: None. Competing interests: None declared. Book 23-12.indb 828 3/4/2018 11:44:27 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 829 1. Goncharova EV, Senyuta NB, Smirnova KV, Shcherbak LN, Gurtsevich VE. [Epstein-Barr virus (EBV) in Russia: infection of the population and analysis of the LMP1 gene variants in patients with EBV-associated pathologies and healthy individuals]. Vopr Virusol. 2015;60(2):11-7 [In Russian]. PMID:26182651 2. Chijioke O1, Azzi T, Nadal D, Münz C. Innate immune responses against Epstein Barr virus infection. J Leukoc Biol. 2013 Dec;94(6):1185-90. doi: 10.1189/jlb.0313173. PMID: 23812328 3. Jayasooriya S, de Silva TI, Njie-jobe J, Sanyang C, Leese AM, Bell AI, et al. Early virological and immunological events in asymptomatic Epstein-Barr virus infection in African children. PLoS Pathog. 2015 Mar 27;11(3):e1004746. doi: 10.1371/journal. ppat.1004746. eCollection 2015. PMID: 25816224 4. Nystad TW, Myrmel H. Prevalence of primary versus reactivated Epstein-Barr virus infection in patients with VCA IgG-, VCA IgM- and EBNA-1-antibodies and suspected infectious mononucleosis. J Clin Virol. 2007 Apr;38(4):292-7. 10.1016/j. jcv.2007.01.006 PMID:17336144 5. Pariente M, Bartolomé J, Lorente S, Crespo MD. Distribución por edad de los patrones serológicos de infección por el virus de Epstein-Barr: revisión de resultados de un laboratorio de diagnóstico [Age distribution of serological profiles of Epstein-Barr virus infection: review of results from a diagnostic laboratory]. Enferm Infecc Microbiol Clin. 2007 Feb;25(2):108- 10. PMID:17288908 6. Koidl C, Riedl R, Schweighofer B, Fett S, Bozic M, Marth E. Performance of new enzyme-linked fluorescent assays for detection of Epstein-Barr virus specific antibodies in routine diagnostics. Wien Klin Wochenschr. 2011 Apr;123(7-8):230-4. 10.1007/s00508-011-1561-z PMID:21451951 7. De Paschale M, Clerici.P. Serological diagnosis of Epstein-Barr virus infection: Problems and solutions. World J Virol. 2012 Feb 12;1(1):31-43. doi: 10.5501/wjv.v1.i1.31. PMID: 24175209 8. De Paschale M, Clerici P. Serological diagnosis of Epstein-Barr virus infection: Problems and solutions. World J Virol. 2012 Feb 12;1(1):31-43. 10.5501/wjv.v1.i1.31 PMID:24175209 9. De Paschale M, Agrappi C, Manco MT, Mirri P, Viganò EF, Clerici P. Seroepidemiology of EBV and interpretation of the “isolated VCA IgG” pattern. J Med Virol. 2009 Feb;81(2):325-31. 10.1002/jmv.21373 PMID:19107979 10. Odumade OA, Hogquist KA, Balfour HH Jr. Progress and problems in understanding and managing primary Epstein-Barr virus infections. Clin Microbiol Rev. 2011 Jan;24(1):193-209. 10.1128/CMR.00044-10 PMID:21233512 11. Chen C-Y, Shen J-H, Huang Y-C. P294 seroepidemiology of Epstein–Barr virus and herpes simplex virus-1 in Taiwan. Int J Antimicrob Ag, 2013; June; 42:S135·10.1016/S0924- 8579(13)70535-1 12. Balfour HH Jr, Sifakis F, Sliman JA, Knight JA, Schmeling DO, Thomas W. Age-specific prevalence of Epstein-Barr virus infection among individuals aged 6-19 years in the United States and factors affecting its acquisition. J Infect Dis. 2013 Oct 15;208(8):1286-93. 10.1093/infdis/jit321 PMID:23868878 13. Yadav MS, Malliga N, Ablashi DV. Development of immunity to Epstein-Barr virus in Malaysian children. Microbiologica. 1987 Jan;10(1):29-35. PMID:3033449 14. Figueira-Silva CM, Pereira FE. Prevalence of Epstein-Barr virus antibodies in healthy children and adolescents in Vitória, State of Espírito Santo, Brazil. Rev Soc Bras Med Trop. 2004 Sep- Oct;37(5):409-12. PMID:15361959 15. Moeini M, Ziyaeyan M, Asaei S, Behzadi MA. The incidence of epstein-barr virus primary infection among suspected patients referred to namazi hospital of shiraz, iran. Jundishapur J Microbiol. 2015 Apr 18;8(4):e16109. doi: 10.5812/ jjm.8(4)2015.16109. eCollection 2015. PMID: 26034534 16. Hassan R, Klumb CE, Felisbino FE, Guiretti DM, White LR, Stefanoff CG, et al. Clinical and demographic characteristics of Epstein-Barr virus-associated childhood Burkitt’s lymphoma in Southeastern Brazil: epidemiological insights from an intermediate risk region. Haematologica. 2008 May;93(5):780- 3. 10.3324/haematol.12424 PMID:18367488 17. Petrova M, Kamburov V. Epstein-Barr virus: silent companion or causative agent of chronic liver disease? World J Gastroenterol. 2010 Sep 7;16(33):4130-4. 10.3748/wjg.v16. i33.4130 PMID:20806428 18. Condon LM, Cederberg LE, Rabinovitch MD, Liebo RV, Go JC, Delaney AS, et al. Age-specific prevalence of Epstein-Barr virus infection among Minnesota children: effects of race/ethnicity and family environment. Clin Infect Dis. 2014 Aug 15;59(4):501- 8. 10.1093/cid/ciu342 PMID:24820696 19. Jansen MA, van den Heuvel D, Bouthoorn SH, Jaddoe VW, Hooijkaas H, Raat H, et al. Determinants of Ethnic Differences in Cytomegalovirus, Epstein-Barr Virus, and Herpes Simplex Virus Type 1 Seroprevalence in Childhood. J Pediatr. 2016 Mar;170:126-34.e1-6. doi: 10.1016/j.jpeds.2015.11.014. PMID: 26707579 20. Beard JA, Bearden A, Striker R. Vitamin D and the anti-viral state. J Clin Virol. 2011 Mar;50(3):194-200. 10.1016/j.jcv.2010.12.006 PMID:21242105 21. Feng WH, Cohen JI, Fischer S, Li L, Sneller M, Goldbach- Mansky R, et al. Reactivation of latent Epstein-Barr virus by methotrexate: a potential contributor to methotrexate- associated lymphomas. J Natl Cancer Inst. 2004 Nov 17;96(22):1691-702. 10.1093/jnci/djh313 PMID:15547182 22. Cacopardo B1, Nunnari G, Mughini MT, Tosto S, Benanti F, Nigro L. Fatal hepatitis during Epstein-Barr virus reactivation. Eur Rev Med Pharmacol Sci. 2003 Jul-Aug;7(4):107-9. PMID: 15068233 23. Coskun O, Sener K, Kilic S, Erdem H, Yaman H, Besirbellioglu AB, et al. Stress-related Epstein-Barr virus reactivation. Clin Exp Med. 2010 Mar;10(1):15-20. 10.1007/s10238-009-0063-z PMID:19779966 24. Loutfy SA, Abo-Shadi MA, Fawzy M, El-Wakil M, Metwally SA, Moneer MM, et al. Epstein-Barr virus and cytomegalovirus infections and their clinical relevance in Egyptian leukemic pediatric patients. Virol J. 2017 Mar 6;14(1):46. doi: 10.1186/ s12985-017-0715-7. PMID: 28264674 25. Chêne A, Donati D, Guerreiro-Cacais AO, Levitsky V, Chen Q, Falk KI, et al. A molecular link between malaria and Epstein-Barr virus reactivation. PLoS Pathog. 2007 Jun;3(6):e80. 10.1371/ journal.ppat.0030080 PMID:17559303 26. Keymeulen B, Candon S, Fafi-Kremer S, Ziegler A, Leruez-Ville M, Mathieu C, et al. Transient Epstein-Barr virus reactivation in CD3 monoclonal antibody-treated patients. Blood. 2010 Feb 11;115(6):1145-55. 10.1182/blood-2009-02-204875 PMID:20007541 27. Cohen JI, Mocarski ES, Raab-Traub N, Corey L, Nabel GJ. The need and challenges for development of an Epstein-Barr virus vaccine. Vaccine. 2013 Apr 18;31 Suppl 2:B194-6. 10.1016/j. vaccine.2012.09.041 PMID:23598481 References Book 23-12.indb 829 3/4/2018 11:44:27 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 830 1Maternal–fetal Medicine Research Centre, Department of Midwifery, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran (Correspondence to: A. Marzieh: akbarzadm@sums.ac.ir); 2Research Centre for Health Sciences, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran; 3Community Based Psychiatric Care Research Center, School of Nursing & Midwifery, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran; 4Department of Biostatistics, Infertility Research Centre, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran Received: 02/07/15; accepted: 23/01/17 Investigation of breastfeeding training based on BASNEF model on the intensity of postpartum blues Marzieh Akbarzadeh 1, Sima Kiani Rad 2, Marzieh Moattari 3 and Najaf Zare 4 ةيسافنلا ةبآكلا ةدش لىع - فنساب جذومن لىإ ًادانتسا - ةيعيبطلا ةعاضرلا لىع بيردتلا رثأ ّصقت عراز فجن ،يرطعم هيضرم ،دار نيايك ايس ،هداز ركا هيضرم هبـش ةـساردلا هذـه تدـمعو .ةـيعيبطلا ةـعاضرلا عاـطقناو ةدلاوـلا دـعب اـم باـئتكا ثودـلح رـطلخا لـماوع رـكأ دـحأ ةيـسافنلا ةـبآكلا لـثتم :ةـصالخا ةلصفنم ةـيفيقثت تاـسلج عـبرأ تدـقُعو .ةيـسافنلا ةـبآكلا ةدـش ىـع فنـساب جذوـمن لىإ ًادانتـسا - ةـيعيبطلا ةـعاضرلا ىـع بـيردتلا رـثأ يـقت لىإ ةـيبيرجتلا مـت ،عـضولا دـعبو .ةداـيعلا في ةـينيتور ةـياعر ةـطباضلا ةـعومجلما تـّقلتو .نـهجاوزأو نـتهاوحمو نـتهاهمأو لـماوح ءاـسنل - فنـساب جذوـمن لىإ ًادانتـسا - نـب ةيرـبك تاـفاتخا دوـجو ّنـبتو .باـئتكال تياذـلا فـينصتلل جـنوز ساـيقم مادختـساب اـهوحن نـتهاهاتجاو ةيـسافنلا ةـبآكلاب ءاـسنلا تاـمولعم مـييقت ةبآكلا ةـجرد طـسوتم ءاج اـك .ةـينيكمتلا لـماوعلاو تاـهاتجلااو ةيكولـسلا تاـجرخملل تاـهملأا مـييقتو ةـفرعلما تاـجرد طـسوتم ثـيح نـم تاـعومجلما تامولعم ىـع بيايجإ رـثأ هـل فنـساب حذوـمن ىـع مـئاقلا بـيردتلا نأ ّنـبت ،ًاـماتخ .ةـطباضلا ةـعومجلماب ةـنراقم ةـيبيرجتلا ةـعومجلما في يرـثكب لـقأ ةيـسافنلا .اـهتيلاعفو ةـقيرطلا هذـه ةـيقوثوم ىدـم دـيدحتل تاـساردلا نـم دـيزم ءارـجإ نـعتيو .باـئتكلاا ةدـش لياـتلابو نـتهاهاتجاو تاـهملأا ABSTRACT Postpartum blues is a major risk factor for the incidence of postpartum depression and disruption of breastfeeding. This semi-experimental study investigated the effect of breastfeeding training based on the BASNEF model on severity of postpartum blues in 2012. Four educational sessions based on the BASNEF model were held separately for pregnant women and their mothers, mothers-in-law and spouses. The control group received routine care at the clinic. After delivery, women’s knowledge of and attitude towards postpartum blues were evaluated using the Zung Self- Rating Depression Scale. There were significant differences between the groups regarding mean scores of knowledge, mothers’ evaluation of behaviour outcomes, attitude, and enabling factors. Also, the mean score for postpartum blues was significantly lower in the intervention group compared to the control group. In conclusion, training based on the BASNEF model had a positive effect on maternal knowledge and attitude and, consequently, the intensity of postpartum blues. Further studies are required to determine the reliability and effectiveness of this method. https://doi.org/10.26719/2017.23.12.830 Étude de l'impact d’une formation sur l’allaitement reposant sur le modèle BASNEF en matière d’intensité du baby blues RÉSUMÉ Le baby blues constitue un facteur de risque majeur pour l’incidence de la dépression postpartum et de l’arrêt de l’allaitement au sein. La présente étude semi-expérimentale menée en 2012 avait pour objectif d’examiner l’influence d’une formation sur l’allaitement reposant sur le modèle BASNEF (modèle d’évaluation des croyances, des attitudes, des normes subjectives et des facteurs favorables) en matière de gravité du baby blues. Quatre sessions éducatives reposant sur le modèle BASNEF ont été organisées séparément pour les femmes enceintes et leurs mères, leurs belles-mères et leurs époux. Le groupe témoin a bénéficié de soins de routine à la clinique. Après l’accouchement, les connaissances et l’attitude des femmes en matière de baby blues ont été évaluées sur la base de l’échelle d'autoévaluation de la dépression de Zung. Des différences significatives ont été observées entre les groupes concernant les scores moyens portant sur les connaissances, l’évaluation des conséquences comportementales par les mères, leur attitude et les facteurs favorables. De même, le score moyen pour le baby blues était significativement moins élevé dans le groupe d’intervention que dans le groupe témoin. En conclusion, on peut dire que la formation reposant sur le modèle BASNEF a eu une influence positive sur les connaissances, les attitudes, et par conséquent l’intensité du baby blues des mères. D’autres études sont nécessaires afin de déterminer la fiabilité et l’efficacité de cette méthode. Book 23-12.indb 830 3/4/2018 11:44:27 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 831 Introduction Exclusive breastfeeding in the first 6 months of life has been recommended by many organizations, such as World Health Organization (WHO) and American College of Obstetricians and Gynecologists (1). Many factors affect the decision to start and continue breastfeeding. Continuation of breastfeeding can be encouraged by cultural, social and po- litical factors, mass media, accessibility of health services, social and health staff support (2), traditions, local beliefs and familial factors (3). Different educational programmes have been considered to increase ma- ternal interest and ability in breastfeed- ing. To achieve successful behavioural change, the healthcare team should be aware of the effective factors in behav- iour formation. The BASNEF model is one of the comprehensive models used for identification of individuals changing behaviour (4). This model focuses on the effect of knowledge, at- titude and personal skills on behaviour change and is appropriate for use in developing countries. The BASNEF model comprises beliefs, attitude, sub- jective norms and enabling factors (5). Generally, individuals change their be- haviour if they believe that it has health and economic benefits. A combination of attitudes towards the behaviour and subjective norms results in deciding upon behaviour change (behavioural intention). In this way, the messages affecting the individual’s knowledge and how they influence behavioural change are determined. Overall, this approach aims at identification of the factors that enable behavioural change (6). Postpartum blues is a transient phe- nomenon involving mood changes that may occur within the first few days after delivery. This phenomenon is accom- panied by unstable mood fluctuating between happiness and sadness, exces- sive sensitivity, crying without reason, restlessness, weakness in concentration, anxiety, irritability and anger (7). On average, 50% (15.3–85%) of mothers experience postpartum blues in the 1st week after delivery (8). However, lack of diagnostic criteria and different research methods have led to different preva- lence rates of postpartum blues (9). The postpartum period has the greatest probability for incidence of mood dis- orders, such as sadness, depression and psychosis, which have negative effects on women’s physical and mental health, and consequently, their quality of life (10,11). There is evidence of a significant de- crease in postpartum depression up to 3 months after birth among women who exclusively breastfeed their infants for ≥ 3 months (12). In contrast, mothers who do not begin or continue breast- feeding are more prone to depression after delivery. Also, mothers who experi- ence depression after delivery are less interested in beginning and continuing with breastfeeding. Postpartum depres- sion may occur following disruption of breastfeeding (13). Nonpharmaco- logical methods are among the most effective ways of coping with stress and depression. Breastfeeding may improve the quality of the maternal–infant rela- tionship, develop safe attachment at the beginning of infancy, and provide a basis for reducing maternal stress. Therefore, the present study aimed to determine the effect of breastfeeding training based on the BASNEF model on postpartum blues in women referred to gynaecology clinics affiliated to Shiraz University of Medical Sciences, Islamic Republic of Iran in 2012. Methods Study population This semi-experimental study investi- gated the effect of breastfeeding training based on the BASNEF model on the se- verity of postpartum blues in 2012. The study population included pregnant women referred to gynaecology clinics of the selected hospitals affiliated to Shi- raz University of Medical Sciences. The inclusion criteria were: primiparity, no complications, gestational age 36–41 weeks, age 18–35 years, at least sec- ondary school education, no serious physical or mental disorders during the study, living in Shiraz, intending to breastfeed their infants, and willingness to participate in the study. A sample size of 100 was determined based on previous results (α = 0.05, β = 0.2, P = 0.8). One hundred pregnant women were selected by purposive sampling and randomly divided into a control (n = 50) and an intervention (n = 50) group using a table of random numbers. Interventions After selection of the mothers and completion of the demographic ques- tionnaires, 4 educational intervention sessions of 90 minutes based on the BASNEF model were held for the mothers once weekly. These sessions included the advantages of breastfeed- ing; correct breastfeeding technique; role of breastfeeding in maternal health; effect of breast milk on improvement of children’s physical and mental health; signs of sufficiency of milk such as in- fant weight gain, frequency of urination, sleeping comfortably after breastfeed- ing; milking and storage techniques; consultation with mothers and their acquaintances regarding breastfeeding; and effect of continuation of exclusive breastfeeding on children’s develop- mental–physical indexes. These ses- sions were presented through lectures, group discussion, role play, educational pictures, question and answer sessions, pamphlets and DVDs. An educational pamphlet and a CD were also given to the mothers. In addition, 3 educational sessions were held separately for 20 mothers, 14 mothers-in-law and 19 husbands. Both groups completed the BASNEF questionnaire before and immediately, 1 month and 3 months after the intervention. The mothers Book 23-12.indb 831 3/4/2018 11:44:27 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 832 also completed the Zung Self-Rating Depression Scale after the intervention. Three months after giving birth, mothers were invited by telephone to the nearest clinic for evaluation of BAS- NEF model parameters. If mothers did not attend on time, they were invited a second time by telephone. BASNEF questionnaire The reliability and validity of the BAS- NEF questionnaire have been con- firmed previously (14), and Cronbach’s α coefficients were the basis of the present study. In order to determine the reliability of the questionnaire, a pilot study was conducted on 20 individuals and Cronbach’s α coefficients of 0.81, 0.9, 0.78, 0.82 and 0.91 were obtained for beliefs, attitudes, subjective norms and enabling factors, respectively. The BASNEF questionnaire was completed by both groups before and immediately, 1 month and 3 months after the inter- ventions. Zung Self-Rating Depression Scale The Zung Self-Rating Depression Scale was published in 1965 and its reliabil- ity and validity have been confirmed in various studies worldwide (15,16). This scale consists of 20 items measuring different aspects of depression, scored from 1 to 4. In the present study, women were required to mark the sentences that best described their feelings during the previous 2 weeks. The scores increased from left to right for positive feelings, but from right to left for negative ones. Scores < 50, 50–59, 60–69, and > 70 represented normal mood without psy- chopathology, mild to average depres- sion, average to severe depression, and severe depression, respectively (17). The reliability of this scale was assessed by Khanjani et al. in the Islamic Repub- lic of Iran using a test–retest method with a 15-day interval and a value of 0.92 was obtained (18), which was the basis of the current study. The Zhung Self-Rating Depression Scale was given to mothers in the last training session and the first postpartum visit. Data analysis All data analyses were performed using SPSS version 16 statistical software and analysed using independent t tests. The significance level of α was 0.05. Ethical considerations This research project was approved by the local Ethics Committee of Shiraz University of Medical Sciences (Proposal No. 91-4605) and written informed consent was obtained from all the participants. Results The mean age of the mothers was 23.86 (standard deviation 4.30) years in the intervention group and 24.4 (4.18) years in the control group. The age range for the 2 groups was 18–34 years. Before the intervention, no significant differ- ence was found between the 2 groups regarding age (P = 0.786), education Table 1 Comparison of mean scores of knowledge, evaluation of behavioural outcomes, attitude towards behaviour, enabling factors before and immediately and 1 and 3 months after educational intervention Variables Groups Before intervention After intervention After intervention 1 month later 1 month later 3 months later Mean (SD) Mean (SD) Mean (SD) Knowledge Intervention 58.1 (14.4) 97.2 (4.3) 97.2 (4.3) 94.1 (5.1) 94.1 (5.1) 91.8 (6.5) P < 0.001 < 0.001 < 0.001 Control 55.7 (14.4) 61.1 (14.0) 61.1 (14) 58.1 (14.3) 58.1 (14.3) 57.4 (14.7) P 0.063 0.09 0.16 Evaluation of behavioural outcomes Intervention 64.8 (22) 97.2 (8.1) 97.2 (8.1) 88.4 (21) 88.4 (21) 90 (21.5) P < 0.001 0.004 0.399 Control 63.6 (13.2) 64.4 (13.6) 64.4 (13.6) 62.8 (22.5) 62.8 (22.5) 80.4 (24.4) P 0.159 0.598 < 0.001 Attitude towards the behaviour Intervention 3.1 (0.4) 3.3 (0.4) 3.3 (0.4) 3.3 (0.3) 3.3 (0.3) 3.3 (0.3) P < 0.001 0.380 0.5 Control 3.1 (0.42) 3.09 (0.4) 3.1(0.4) 3.1 (0.4) 3.1 (0.3) 3.04 (0.3) P 0.827 0.601 0.04 Enabling Factors Intervention 31.2 (23.3) 96.3 (7.5) 96.3 (7.5) 94 (8.7) 94 (8.7) 95.2 (8.0) P < 0.001 0.018 0.159 Control 30.9 (21) 35.6 (20.6) 35. 6 (20.6) 39.1 (19.8) 39.1 (19.8) 41 (20.4) P 0.019 0.003 0.013 Book 23-12.indb 832 3/4/2018 11:44:27 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 833 level (P = 0.852), and occupation (P = 0.952). There was no significant difference in the control group’s mean scores of knowledge immediately, 1 month and 3 months after intervention (Table 1). For mean scores of evaluation of behaviour outcomes in the intervention group, there was a significant difference before and immediately after interven- tion, immediately and 1 month after intervention, and 1 and 3 months after intervention (Table 1). In the control group, there was only a significant dif- ference between 1 and 3 months after intervention. The mean scores of attitude in the intervention group were significantly different before and immediately after intervention (Table 1). However, no significant difference was found imme- diately and 1 month after intervention, and 1 and 3 months after intervention. In the control group, there was only a significant difference between 1 and 3 months after intervention. The mean scores of enabling factors in the intervention group were signifi- cantly different before and immediately after intervention, and immediately and 1 month after intervention (Table 1). However, there was no significant dif- ference between 1 and 3 months after intervention. In contrast, the control group’s mean scores of enabling factors were significantly different before and immediately after intervention, imme- diately and 1 month after intervention, and 1 and 3 months after intervention. The mean score of postpartum blues was significantly lower in the interven- tion group [31.36 (7.98)] compared to the control group [37.61 (12.15)] after intervention (t = 3.005, P = 0.004). Discussion The results of the present study demon- strated a significant difference between the intervention and control groups regarding the mean score of knowl- edge about breastfeeding immediately after intervention. This implied the ef- fectiveness of educational interven- tion based on the BASNEF model on increasing maternal knowledge, which is consistent with other studies using the BASNEF model (19). Also, the results immediately, 1 month and 3 months after intervention indicated that the dif- ference remained significant over time. Similarly, Matvienko et al. showed that a 6-month educational intervention improved the participants’ knowledge level and prevented them from weight gain (20). The study also showed a significant difference between the intervention and control groups with respect to the change in knowledge. An- other study was performed on maternal knowledge and attitude towards breast- feeding in Isfahan, Islamic Republic of Iran in 2008, which showed that the in- tervention and control groups differed significantly regarding knowledge but not attitude (21). However, our current results were not in agreement with those obtained by Young et al. in a study of health education (22). Those two stud- ies indicated no significant difference between the intervention and control groups with regards to knowledge and attitude. The difference between those and our studies might have been due to the lack of any related models or theories in the design and execution of the educational programme, as well as to the cultural and time differences between the studies. In our study, the intervention group’s attitude towards breastfeeding improved and continued in the follow- up period. Generally, attitude is not fixed and positive experiences can direct the individuals toward maintenance and improvement of positive attitudes (23). However, Charkazi et al. reported no significant change in attitude (21). It should be noted that training is not suf- ficient for changing individual attitudes. One appropriate method for changing attitude is expressing one’s opinions and watching others’ reactions. . In the current study, the mean score of the intervention group’s evaluation of behaviour outcomes immediately, 1 month and 3 months after intervention showed that the differences remained significant over time. This result was similar to that of another study conduct- ed on breastfeeding using the BASNEF model (14). Our findings revealed a significant difference between the 2 groups regard- ing the mean score of enabling factors. This might have resulted from acces- sibility of the enabling factors, such as pamphlets, educational materials and CDs, the researcher’s phone number and electric breast pumps (24). In a pre- vious study by Shakespeare et al., moth- ers mentioned lack of access to health staff as a major problem in continuation of breastfeeding (25). Furthermore, Laveist et al. proposed that the enabling factors were more important than cul- tural and behavioural differences for changing behaviour (26). Similarly, a study in England demonstrated that husbands’ support, acceptance of breastfeeding as a social norm, friends’ support, and taking part in educational classes before and after delivery were among the key factors for beginning and continuation of breastfeeding (27). Therefore, it is suggested that individu- als who are in close contact with the mothers, such as grandmothers, sisters and husbands, can pass on their experi- ences and encourage breastfeeding. In the present study, the control group’s mean score for enabling factors was also significantly different before and after intervention, which indicates the effectiveness of the healthcare staff in provision of training. Moreland and Coombs also emphasized the role of family physicians and the healthcare team in the success of breastfeeding (28). We revealed no significant differ- ence between the intervention group’s mean scores for subjective norms Book 23-12.indb 833 3/4/2018 11:44:28 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 834 regarding husbands, mothers-in-law and friends before and after inter- vention, but there was a significant difference in the subjective norms re- garding the mothers and healthcare staff. However, no significant difference was found in the control group in this regard. Bertini et al. stated that subjec- tive norms, including the viewpoints of husbands, friends and healthcare per- sonnel were effective in beginning and continuing breastfeeding (27). One other study also demonstrated that the husbands’ support and proper attitude towards breastfeeding were effective in breastfeeding premature infants (29). Moreover, a study in England showed that conflict between one’s personal expectations and social norms led to social, physical and emotional isola- tion in the mothers who intended to start breastfeeding their infants (30). Similarly, studies in Tanzania indicated that the individuals around the mother could play an active role in supporting the mother and her decision for breast- feeding (31). Studies in developed countries have demonstrated a positive correlation between paternal support and increase in breastfeeding. Studies in the United States of America on the effectiveness of intervention and mental health education based on the BASNEF model have also revealed an increase in the intervention group’s knowledge, attitude and behavioural intention (32). The present study showed a signifi- cant difference between the 2 groups with regard to postpartum blues. A previous study indicated that initiation of breastfeeding was accompanied by a decrease in postpartum depression in multiparous women (33). Watkins et al. reported that women who had not breastfed their infants were more likely to experience depression within 2 months after delivery (34). There is evidence that the hypo- thalamic–pituitary–adrenal (HPA) axis shows a weak response to stress in breastfeeding women. The function of this axis and cortisol response are associated with progress of depression after delivery. Thus, breastfeeding re- duces the response to stress and tension, eventually decreasing the incidence of postpartum depression. Hormones may also play a role in the relationship between breastfeeding and mental func- tion. For instance, oxytocin has shown antidepressive and anxiolytic effects in human and animal models. Prolactin may play a role in the relationship be- tween breastfeeding and depression (33). One study assessed the correla- tion between postpartum blues and ma- ternal emotional status before delivery, readiness for delivery, and social sup- port after delivery. Among the 131 study participants, 18.3% experienced depres- sion throughout pregnancy, 61.8% ex- perienced postpartum blues, and 8.4% experienced postpartum depression. In that study, postpartum blues was negatively correlated to husbands’ and social support, but positively related to emotional status during pregnancy. However, no significant association was found between readiness for delivery and postpartum blues (35). One of the limitations of the present study was the lack of an appropriate location for holding the training classes, which was to some extent eliminated by group training, reviewing the content in each session, and role playing. One other limitation was utilization of a question- naire for evaluation of the participants’ real attitudes, which was somehow controlled by coding the questionnaires to maintain the participants’ privacy. Moreover, not having access to the re- sults of related studies on breastfeeding and the BASNEF model caused us to compare our results to those of studies using this model in other areas. Hence, further studies are required to achieve more comparable results. In conclusion, we showed the ef- fectiveness of training based on the BASNEF model in increasing maternal knowledge and attitude, encouraging them towards breastfeeding and reduc- ing postpartum blues. Considering the importance of breastfeeding in maternal and infant health and the effectiveness of this model, it is recommended to replace routine training in gynaecology clinics. Acknowledgements The present study was extracted from research project 91-4605. The authors would like to thank Shiraz University of Medical Sciences, the Center for Devel- opment of Clinical Research of Nema- zee Hospital, Shiraz and Dr. Nasrin Shokrpour for editorial assistance. Funding: The study was financially supported by the Research Center for Health Sciences, Shiraz University of Medical Sciences. Competing interests: None declared. References 1. McDonald SD, Pullenayegum E, Chapman B, Vera C, Giglia L, Fusch C, et al. Prevalence and predictors of exclusive breastfeeding at hospital discharge. Obstet Gynecol. 2012 Jun;119(6):1171–9. PMID:22617582 2. Spiby H, McCormick F, Wallace L, Renfrew MJ, D’Souza L, Dy- son L. A systematic review of education and evidence-based practice interventions with health professionals and breast feeding counsellors on duration of breast feeding. Midwifery. 2009 Feb;25(1):50–61. PMID:17418464 3. Hizel S, Ceyhun G, Tanzer F, Sanli C. Traditional belief as for- gotten influencing factors on breast-feeding performance in turkey. 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Black/white differences in prenatal care utilization: an assessment of predisposing and enabling factors. Health Service Res. 1995 Apr;30(1):43–58. PMID:7721584 27. Bertini G, Perugi S, Dani C, Pezzati M, Tronchin M, Rubaltelli FF. Maternal education and the incidence and duration of breast feeding: A prospective study. J Pediatr Gastroenterol Nutr. 2003 Oct;37(4):447–52. PMID:14508215 28. Moreland J, Coombs J. Promotion and supporting breast-feed- ing. Am Fam Physician. 2000 Apr 1;61(7):2093–100 (http:// www.aafp.org/afp/2000/0401/p2093.html). 29. Sweet L, Darbyshire P. Fathers and breast feeding very-low- birthweight preterm babies. Midwifery. 2009 Oct;25(5):540– 53. PMID:18191313 30. Mahon-Daly P, Andrews GJ. Liminality and breastfeeding: women negotiating space and two bodies. Health Place. 2002 Jun;8(2):61–76. PMID:11943579 31. Omer-Salim A, Persson LL, Olsson P. Whom can I rely on? Mothers’ approaches to support for feeding: An interview study in suburban Dar es Salaam, Tanzania. Midwifery. 2007 Jun;23(2):172–83. PMID:17049695 32. Casper ES. The theory of planned behavior applied to continu- ing education for mental health professionals. Psychiatr Serv. 2007 Oct;58(10):1324–9. PMID:17914010 33. Mezzacappa ES, Endicott J. Parity mediates the association between infant feeding method and maternal depressive symptoms in the postpartum. Arch Womens Ment Health. 2007;10(6):259–66. PMID:18040595 34. Watkins S, Meltzer-Brody S, Zolnoun D, Stuebe A. Early breast- feeding experiences and postpartum depression. Obstet Gy- necol. 2011 Aug;118(2 Pt 1):214–21. PMID:21734617 35. Jung MH, Kim JI. A study on the relationship among pre- natal emotional status, preparation for delivery, postpar- tum social support and postpartum blues. Korean J Women Health Nurs. 2005 Mar;11(1):38–45 (https://kjwhn.org/search. php?where=aview&id=10.4069/kjwhn.2005.11.1.38&code=01 02KJWHN&vmode=PUBREADER). Book 23-12.indb 835 3/4/2018 11:44:28 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 836 1Cardiac Sciences Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia (Correspondence to: R.A. Alzeidan: ras_zeidan@hotmail. com). 2School of Health Sciences, Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, United Kingdom. 3Department of Epidemiology, High Institute of Public Health, Alexandria University, Alexandria, Egypt; WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt. Received: 15/11/16; accepted: 11/12/17 Changes in dietary habits and physical activity and status of metabolic syndrome among expatriates in Saudi Arabia Rasmieh A. Alzeidan 1, Fatemeh Rabiee 2, Ahmed A. Mandil 3, Ahmad S. Hersi 1and Anhar A. Ullah 1 ةيدوعسلا ةيبرعلا ةكلملما في نيدفاولا ينب يئاذغلا ليثمتلا ةمزاتم ةلاحو نيدبلا طاشنلاو ةيئاذغلا تاداعلا في تايرغتلا للهارانهأ ،سيره دحمأ ،ليدنم دحمأ ،عيبر ةمطاف ،ناديزلا ةيمسر ةـيئاعولا ةـيبلقلا رـطلخا لـماوع ثـيح نـم مـهسرأو نـيدفاولا نـفظولما ىـع ةيدوعـسلا ةـيبرعلا ةـكلملما في ةـشيعلما يرـثأت مـييقت لىإ اـنفده دـق : ةـصالخا ،ًادرـف 1437 ىـع ةـيعطقم ةـسارد تـيرجأ. يـئاذغلا لـيثمتلا ةـمزاتم فيو هذـه رـطلخا لـماوع في تا ُّيرـغتلا نـب ةـقاعلا ةـساردو ،اـله نـضرعلما ةيكولـسلا تاوـطلخا نايبتـسا نوـثحابلا مدختـساو. ةيدوعـسلا ةـيبرعلا ةـكلملما ،ضاـيرلا ةـنيدم ،دوعـس كـللما ةـعماج نـم ،ةنـس 18 يواـسي وأ نـم رـكأ مـهرمع ةـيئاعولا ةـيبلقلا رـطلخا لـماوع لوـح كراـشم لك ىـع نـترم ةلئـسلأا حرـطل ةـيلماعلا ةـحصلا ةـمظنلم )STEPS( ةيراـسلا يرـغ ضارـملأا دـ ُّصرل ةـييجردتلا 40.9 مـهرمع طـسوتم غـلب. ليـصلأا مـهدلب في ةاـيلحا ىـع ءوـضلا طيلـستل )2( ؛ةيدوعـسلا ةـيبرعلا ةـكلملما في مهـشيع ةرـف نـع يرـبعتلل )1) :ةيكولـسلا 1049 في نيدـبلا لوـملخا ،)% 11( ًاصخـش 156 في غـبتلا مادختـسا: لياـتلا وـحنلا ىـع ةيكولـسلا ةـيئاعولا ةـيبلقلا رـطلخا لـماوع راـشتنا ناكو. ةنـس )11.7 ±) نوـميقلما لـلق دـقو .)% 26( ًاصخـش 378 في يـئاذغلا لـيثمتلا ةـمزاتم ،)% 88( ًاصخـش 1264 في تاورـلخاو هـكاوفلا لواـنت ضاـفخنا ،)% 73( اًصخـش ناك دـقل .ةـعيسرلا تاـبجولا كاهتـسا في ةيرـبك ةداـيز اـًضيأ كاـنه ناكو ،تاورـلخاو ةـهكافلا لواـنتو نيدـبلا طاـشنلا نـم ةيدوعـسلا ةـيبرعلا ةـكلملما في ةـيئاصحإ ةـللاد اذ طاـبترا كاـنه نـكي لم ،كـلذ عـمو. ةيكولـسلا ةـيئاعولا ةـيبلقلا رـطلخا لـماوع ليـع ةيرـبك تايرـثأت ةيدوعـسلا ةـيبرعلا ةـكلملما في شـيعلل .يـئاذغلا لـيثمتلا ةـمزاتم ةـلاحو نيدـبلا طاـشنلاو تاورـلخاو ةـهكافلا لواـنت في تا ُّيرـغتلا نـب ABSTRACT The aim of this paper is to assess the impact of living in Saudi Arabia on expatriate employees and their families’ behavioural cardiovascular risk factors (BCVRFs), and to examine the association between changes in BCVRFs and metabolic syndrome (MetS). A cross-sectional study was conducted on 1437 individuals, aged ≥ 18 years, from King Saud University in Riyadh, Saudi Arabia. We used the World Health Organization STEPS questionnaire to ask every participant questions about BCVRFs twice: (1) to reflect their period of living in Saudi Arabia and (2) to shed light upon life in their country of origin. Their mean age was 40.9 (11.7) years. The prevalence of BCVRFs was as follows: tobacco use in 156 (11%), physical inactivity in 1049 (73%) low intake of fruit and vegetables in 1264 (88%) and MetS in 378 (26%). Residing in Saudi Arabia had reduced physical activity and intake of fruit and vegetables. There was also a significant increase in the fast food consumption. In conclusion, living in Saudi Arabia had a significant negative effect on BCVRFs. However, there was no statistically significant association between changes in fruit and vegetable intake and physical activity and MetS status, except that intake of fast food was lower among participants with MetS. https://doi.org/10.26719/2017.23.12.836 Changements concernant les habitudes alimentaires et l’activité physique, et situation du syndrome métabolique parmi les expatriés vivant en Arabie saoudite La présente étude avait pour objectif d’évaluer l’impact de la vie en Arabie saoudite sur les employés expatriés, ainsi que les facteurs de risque cardio-vasculaire comportementaux de leurs familles, et d’examiner l’association entre les changements en termes de facteurs de risque de ce type et le syndrome métabolique. Une étude transversale a été menée auprès de 1437 individus âgés de 18 ans et plus à l’Université Roi Saoud de Riyad, en Arabie saoudite. Nous avons utilisé le questionnaire STEPS de l’Organisation mondiale de la Santé afin d’interroger chaque participant à deux reprises au sujet des facteurs de risque cardio-vasculaire comportementaux afin de refléter leurs comportements durant leur séjour en Arabie saoudite et d’apporter un éclairage sur leur habitudes de vie dans leur pays d’origine. L’âge moyen était 40,9 ans (ET 11,7). La prévalence des facteurs de risque cardio-vasculaire comportementaux était la suivante : tabagisme pour 156 individus (11 %), sédentarité pour 1049 (73 %), faible consommation de fruits et légumes pour 1264 d’entre eux (88 %) et présence de syndrome métabolique chez 378 des participants (26 %). Le fait de résider en Arabie saoudite avait réduit l’activité physique et la consommation de fruits et légumes. On observait également une augmentation significative de la consommation de fast food. Le fait de vivre en Arabie saoudite avait un impact négatif significatif sur les facteurs de risque cardio-vasculaire comportementaux. Néanmoins, il n’y avait pas d’association statistiquement significative entre les changements dans la consommation de fruits et légumes, l’activité physique et le syndrome métabolique, excepté que la consommation de fruits et légumes était plus faible chez les participants porteurs de syndrome métabolique. Book 23-12.indb 836 3/4/2018 11:44:28 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 837 Introduction The Gulf Cooperation Council (GCC) countries, which came into existence in 1981, include Bahrain, Saudi Arabia, Kuwait, Oman, Qatar and the United Arab Emirates (1). Following oil discovery in the Gulf region during the 1950s, these countries including Saudi Arabia lacked human resources, particularly in health professions. They have therefore attracted professionals from all over the world seeking opportunities for employment and a better standard of living (2). For this reason, the Saudi Arabian population profile has changed and, like other GCC countries, enjoys a wide variety of expatriates from diverse ethnic backgrounds. The Annual Statistical Report from the Saudi Ministry of Health indicates that 33% of the total inhabitants (30 770 375) in 2014 were expatriates. In Riyadh, where the present study took place, the expatriates represented 38% of the total population (3). Also, an official statistical report form King Saud University (KSU) showed that expatriates constituted 23% of the total university employees1. Th e p o l i c i e s o f m o s t h o s t c o u n t r i e s , i n c l u d i n g t h e G C C , require all expatriates to undergo medical screening, and people who have health issues are usually denied entry (4). Overall, new expatriates have good health status, however, it is perceived that the health of expatriates progressively deteriorates with their duration of stay in a new host country. Such deterioration may be attributed to cultural differences, psychosocial and socioeconomic changes, as well as lifestyle changes (including dietary habits and physical activity) with migration, which may have negative impacts on health (5). 1 Kingdom of Saudi Arabia Statistical Report received via email (dfpa_es@ ksu.edu.sa). Accessed May 2015. Worldwide, 6% (3.2 million) of deaths each year are attributed to physical inactivity, where physical inactivity is considered to be the fourth most frequent cause of adult death (6). In wealthy GCC countries, particularly in Saudi Arabia, rapid socioeconomic transition and vast urbanization have led to a predominantly sedentary lifestyle among the population. Consequently, physical inactivity has become a major public health concern in this region as well as in some other countries. Prevalence of physical inactivity varies among the countries of the Eastern Mediterranean, with the highest level in Saudi Arabia (96%) and the lowest in the Syrian Arab Republic (31%) (7). Globally , 2 .8% (1.7 mil l ion) of deaths are attributable to low consumption of fruit and vegetables (8). However, the worldwide consumption of fruit and vegetables is still below the recommended intake of ≥ 5 five servings per day (9). Likewise, in Saudi Arabia, a recent report shows that only 3% of the population consumed the recommended daily portions of fruit and vegetables (10). Substantial evidence worldwide demonstrates the phenomenon of acculturation, which has been simply defined as the gradual adoption of the host country’s cultural patterns, including attitudes, values, customs, beliefs and behaviours by the migrants (11, 12). Furthermore, one of the well- established migration effects is dietary acculturation, where the minority groups adopt the dietary practice of their host countries (12). In addition, acculturation influences the physical activity of migrants (13). The present study estimated t h e p r e v a l e n c e o f b e h a v i o u r a l cardiovascular risk factors (BCVRFs), including unhealthy diet and physical inactivity, among expatriate employees and their families at KSU, to assess the possible impact of living in Saudi Arabia on expatriates’ BCVRFs, and the association between the changes in BCVRFs and metabolic syndrome (MetS). Methods Study design This was a cross-sectional study conducted on KSU employees and their families over 9 months from 8 July, 2013 to 30 April, 2014. The current investigation was a substudy of a larger study (n= 4500 subjects) and focused only on non-Saudi employees and their families (n=1437). The details of the larger study and participants’ recruitment procedure are described elsewhere (14). We used a modified version of the World Health Organization (WHO) STEPS questionnaire (15), version 2.1 (both Arabic and English forms). This questionnaire uses sequential steps, starting with a questionnaire (Step I), followed by physical measurements ( S t e p I I ) a n d b i o c h e m i c a l measurements (Step III). All participants personally reported their sociodemographic information, such as age, sex, country of origin, marital status, educational level, job title, and length of residence in Saudi Arabia. Body weight and height and waist and hip circumferences were measured for all participants, as described previously (14). Questions about lifestyle behaviour, including diet, physical activity and tobacco use, were asked twice: (1) to describe their current behaviour and (2) to report their behavioural habits before moving to Saudi Arabia. The biochemical measurements in this study included: glycosylated haemoglobin (HbA1C), high-density lipoprotein–cholesterol (HDL-C), low-density lipoprotein– cholesterol (LDL-C), total cholesterol ( T C ) a n d t r i g l y c e r i d e ( T G ) . Participants were instructed to fast for ≥ 12 hours before they were subjected to blood testing. Book 23-12.indb 837 3/4/2018 11:44:28 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 838 MetS Using the National Cholesterol Education Programme classification (16,17), participants were identified as having MetS if they had ≥ 3 of the fol lowing 5 factors: (1) abdominal obesity measured by waist circumference; participants were considered to have abdominal obesity if waist circumference was ≥ 102 cm for men and ≥ 88 cm for women; (2) raised triglyceride ≥ 1.7 mmol/l ; (3) reduced HDL, ≤ 1.03 mmol/l for men and ≤ 1.29 mmol/l for women; (4) raised fasting plasma glucose (≥ 5.6 mmol/l) or under treatment for and/ or previously diagnosed with diabetes; and (5) hypertension (systolic blood pressure ≥ 130 mmHg and/or diastolic blood pressure ≥ 85 mmHg or under treatment for hypertension). Statistical analysis Categorical data were summarized as absolute numbers and percentages. Numerical data were summarized with means and standard deviations (SDs). Categorical variables were compared using the χ2 test or Fisher’s exact test, and continuous variables were compared using independent sample t test or Mann–Whitney U test. To compare the dietary habits and physical activity patterns of participants before and after residing in Saudi Arabia, we used a paired sample t test. To study the association of duration of stay, gender and MetS with changes of dietary habits and physical activity patterns, a calculation was done using the mean difference, and a comparison between different groups was conducted using an independent sample t test or Mann–Whitney U test. For testing the marginal homogeneity between tobacco use before and after residing in Saudi Arabia, the McNemar test was used, and the results presented as text. All analyses were performed using SAS/STAT version 9.2 (SAS Institute Inc., Cary, NC, USA). A 2-sided P value < 0.05 was considered statistically significant. To compare changes in lifestyle behaviour, a 5-year cutoff point was used as it reflected the median length of residence in Saudi Arabia. Ethical standards This study was conducted according to the principles expressed in the Declaration of Helsinki. Furthermore, it was reviewed and approved by the Institutional Review Board of KSU, College of Medicine; approval letter number is 13-372. In addition, written informed consent was obtained from each participant prior to participation in the study. Results Sociodemographic characteristics of the studied population There were 1437 expatriates in our study; 1091 (75.9%) were non-Saudi Arabs, 37 (2.57%) were from different nationalities, and 309 (21.5%) were South Asians. The mean age of participants was 40.9 (SD 11.7) years, and more details about sociodemographic characteristics are shown in Table 1. Prevalence of BCVRFs One hundred and fifty-six (11%) of the participants were current tobacco users; 1049 (73%) were physically inactive; and women were more physically inactive than men were (Table 1). Moreover, 1264 (88%) of the participants were reported to have low intake of fruit and vegetables and women had a significantly higher rate of low fruit and vegetable consumption compared to men (P < 001). Three hundred and seventy-eight (26%) of the expatriates had MetS, but not statistically significant difference was observed between genders (P=0.08). Effect of living in Saudi Arabia on BCVRFs Tobacco use There was a low rate of current daily tobacco use (n = 156; 11%). The prevalence before and after residing in Saudi Arabia (using McNemar test) was 16% (n = 134) and 15.4% (n = 129) for men and 2.8% (n = 17) and 3.1% (n = 18) for women, respectively. Although this indicates that living in Saudi Arabia had a small effect on the pattern of tobacco use (higher in men and lower in women), the changes were not statistically significant. Dietary intake Table 2 presents the mean and SD of number of days of eating fruit and vegetables, as well as the number of servings per day before and after residing in Saudi Arabia. There were significant differences in both measures before and after coming to live in Saudi Arabia (P < 0.001 for both comparisons). However, these differences, particularly reduced fruit consumption, were significantly higher among women and individuals who had resided > 5 years in Saudi Arabia compared to their counterparts (P < 0.001 and P = 0.001, respectively) (Table 3). In contrast, the consumption of fast food increased significantly almost threefold during living in Saudi Arabia (P < 0.001) (Table 2). This increased consumption was significantly higher among men than women (P < 0.001), and among newcomers (< 5 years residence) compared to those with longer length of stay (P < 0.001) (Table 3). Physical activity Physical activity patterns in all domains, such as travel to work, traveling to/ from places or recreational activities were affected negatively by living in Saudi Arabia. Thus, the number of days and duration of physical activity were decreased noticeably during residence in Saudi Arabia (Table 2). This decrease was significantly higher in the first 5 Book 23-12.indb 838 3/4/2018 11:44:29 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 839 years of living in Saudi Arabia than in later years for both domains of physical activity (work and sport), whereas not statistically significant changes were reported between the lengths of stay and type of traveling (Table 4). A significant reduction in physical activity in both work and recreational domains was higher in men than in women. Association between food consumption and MetS The intake of fruit and vegetables remained low in both groups, with or without MetS, and there was no association between MetS and low intake of fruit and vegetables. However, consumption of fast food was significantly lower among people with MetS (P = 0.001) (Table 3). Furthermore, MetS was not associated with physical activity pattern changes in all domains. Discussion Our findings indicate that non-Saudi participants demonstrated significant negative effects on BCVRFs after their arrival in Saudi Arabia; namely, high rate of physical inactivity, high consumption of fast food and low consumption of fruit and vegetables. The expatriates’ low consumption of fruit and vegetables is comparable with the Saudi participants in the larger study (14), as well as country-wide population findings (18), and agrees with other studies worldwide (19). Also noteworthy, in recent decades, GCC nations have been influenced by a global trend towards high consumption of fast food, which is thought to have the following attributes: fast food is often quick, delicious, appealing to all age groups and affordable to a l l s o c i o e c o n o m i c c l a s s e s ( 2 0 ) . Moreover, within Saudi Arabia, fast food is generally available and easily accessible throughout the year through a wide variety of global fast food chains, especially in food courts of modern shopping malls (21). This could also Table 1 Sociodemographic characteristics of expatriate population and prevalence of behavioural risk factors and MetS (n = 1437) Sociodemographic characteristics Total Men n (%) 840 (58%) Women n (%) 597(42%) P Age (yr); mean (SD) 40.9 (11.7) 41.9 (11.7) 39.1 (11.5) < 0.001 Educational level; n (%) Higher education (college and above) 1265 (88) 798(63) 467 (37) < 0.001 Essential educationa 168 (12) 42 (25) 126 (75) <0.001 Illiterate 4 (0.3) 0 4 (100) 0.005 Participant status in KSU; n (%) Employee 969 (67) 773 (80) 196 (20) < 0.001 Family member 468 (33) 67 (14) 401 (86) < 0.001 Occupation; n (%) Faculty staff 555 (37) 452 (81) 103 (19) < 0.001 Healthcare provider 96 (7) 39 (41) 57 (59) < 0.001 Technician 16 (1) 14 (88) 2 (13) < 0.001 Administrative 24 (2) 14 (58) 10 (42) < 0.001 Other KSU employee 278 (19) 254 (91) 24 (9) < 0.001 Marital status; n (%) Single 106 (7) 54 (51) 52(49) 0.01 Married 1321(92) 784 (59) 537(41) 0.01 Widowed / divorced 10 (1) 2 (20) 8 (80) 0.01 Behavioural risk factors; n (%) Tobacco use 156 (11) 134 (16) 22 (3) < 0.001 Physical inactivity 1049 (73) 539 (64) 510 (84) < 0.001 Low fruit/vegetable intake 1264 (88) 731 (87) 533 (89) 0.11 MetS according to NCEP-ATP III criteria; n (%) Total 378 (26) 233 (28) 145 (24) 0.08 aEssential education indicated completion of any school: elementary, preparatory or high school. KSU = King Saud University; MetS = metabolic syndrome; NCEP-ATP III = National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III); SD = standard deviation. Book 23-12.indb 839 3/4/2018 11:44:29 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 840 explain our reported significant increase in fast food intake by expatriates during their residence in Saudi Arabia, which resembles that in the larger study (14) and the findings of prior Saudi and GCC studies (22, 23). Moreover, previous studies have indicated that men consume more fast food than women do (24, 25), which is in accordance with the findings of our study. One reason for this could be the greater number of social activities for men (26). Substantial evidence worldwide supports the results of the present study concerning the changes in dietary pattern among expatriates living in Saudi Arabia. This transition in nutritional habits and consumption is usually associated with dietary acculturation when the migrants adopt the dietary practices of the host country (11, 12, 27). Saudi Arabia, like other GCC countries, has witnessed vast change in wealth and subsequent urbanization over the past few decades. This led to a sedentary lifestyle, in part due to increased use of motorized commuting, as well as changes to the nature of the work environment and facilities that require less physical activity (28). A significant decline was observed in the physical activity of expatriate employees and their families in this study during their residence in Saudi Arabia. Such changes were more marked during the first 5 years of residence. Moreover, these results are in line with findings from other Saudi and regional studies (18, 28, 29). The significant changes in physical activity levels were reported by male participants, which indicates that expatriate men were more physically active than women in their homeland (30). Nevertheless, overall women from the larger study (14) as well as expatriate Table 2 Dietary and physical activity patterns among expatriates before and after residing in Saudi Arabia (n = 1437) Question Before living in Saudi Arabia After living in Saudi Arabia Mean difference P Dietary pattern, mean (SD) In a typical week, on how many days do you eat fruit? 4.59 (2.14) 4.81 (2.06) 0.22 < 0.001* How many servings of fruit do you eat a day? 1.95 (1.18) 1.92 (1.13) 0.03 < 0.001* In a typical week, on how many days do you eat vegetables? 5.17 (1.96) 5.10 (1.98) 0.07 < 0.001* How many servings of vegetables do you eat a day? 2.34 (1.35) 2.32 (1.32) 0.02 < 0.001* How many fast food meals per week do you eat that were not prepared at home? 1.27 (2.35) 3.42 (5.40) −2.14 < 0.001* Physical activities Work In a typical week, how many days do you do vigorous-intensity activities as part of your work? 0.50 (1.45) 0.30 (1.05) 0.20 < 0.001* How much time do you spend doing vigorous-intensity activities at work on a typical day? (min) 18.27 (57.07) 11.16 (42.10) 7.37 < 0.001* In a typical week, how many days do you do moderate-intensity activities as part of your work? 3.50 (2.82) 3.03 (2.62) 0.47 < 0.001* How much time do you spend doing moderate-intensity activities at work on a typical day? (min) 75.49 (87.69) 54.36 (70.61) 21.13 < 0.001 Travel to and from places In a typical week, on how many days do you do walk or cycle for ≥ 10 min continuously to get to/from places? 5.08 (2.72) 3.51 (2.92) 1.57 < 0.001* How much time do you spend walking or cycling for travel on a typical day? (min) 78.28 (74.87) 36.95 (43.78) 44.33 < 0.001* Recreational activities In a typical week, on how many days do you do vigorous-intensity sports, fitness or recreational (leisure) activities? 0.83 (1.68) 0.57 (1.38) 0.26 < 0.001 How much time do you spend doing vigorous-intensity sports, fitness or recreational activities on a typical day? (min) 23.04 (52.18) 13.59 (33.68) 9.11 < 0.001 In a typical week, on how many days do you do moderate-intensity sports, fitness or recreational activities? 2.07 (2.59) 1.53 (2.18) 0.54 < 0.001* How much time do you spend doing moderate-intensity sports, fitness or recreational activities on a typical day? (min) 33.94 (50.15) 21.92 (33.85) 12.021 < 0.001* *Tests were done using Mann–Whitney U test. SD = standard deviation. Book 23-12.indb 840 3/4/2018 11:44:29 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 841 women in this study all reported higher rates of physical inactivity compared to men, and this finding is strongly consistent with previous reports from Saudi Arabia and the region (18, 28, 29). Reasons behind this phenomenon among women could be due to the prevailing conservative social norms and restrictions on outdoor exercise for women in Saudi Arabia. Another possible contributing factor to such high rates of physical inactivity among all participants after living in Saudi Arabia is the hot arid climate in the Gulf Region, which is present for a substantial part of the year and restricts outdoor activities (31). In addition, Saudi Arabia has a scarcity of sidewalks, parks and facilities, which is not conducive for walking and sporting activities (32). We observed that there was no association between the negative changes in physical activity pattern or consumption of fruit and vegetables and MetS status. However, there was an inverse correlation between fast food intake and MetS status. The only explanation is that participants with MetS were more aware of the negative effects of fast food on their health, hence participants with MetS reported less consumption (33). This study is one of the few to explore the possible effects of living in Saudi Arabia on BCVRFs of expatriate employees and their families. It represents a comprehensive survey of BCVRFs using a standardized WHO STEPwise approach; furthermore, data were collected by well-trained research assistants under close supervision. Nevertheless, the l imitations of this study include the following. First, the answers to questions about behavioural risk factors, such as dietary habits, physical inactivity and tobacco use were self-reported. In addition, relying on memories about past behaviour could have led to over- or under-reporting. Second, the results cannot be generalized to the entire expatriate population in Saudi Arabia as the sample was not randomly selected. Finally, due to its cross-sectional design, the study does not allow us to assess whether MetS was prevalent or not before entering Saudi Arabia. Despite the above limitations, this was a comprehensive survey and the findings are expected to inform public health policy and practice, to take further steps towards best interventions for changing adverse behavioural patterns in KSU, including among the expatriate population. Conclusions and recommendations Our study indicated a high prevalence of BCVRFs among the study population. Non-Saudi participants showed a higher rate of physical inactivity, higher consumption of fast food and lower Table 3 Association of dietary pattern changes with gender and length of stay in Saudi Arabia (n = 1437) Length of stay in Saudi Arabia Covariate < 5 yr, n = 634 ≥ 5 yr, n = 803 P Fruit/vegetable intake, mean (SD) Number of days eating fruit 0.39 (1.79) 0.09 (1.74) 0.001* Number of fruit servings/day change 0.08 (0.88) −0.11 (0.95) < 0.001 Number of days of ate Vegetables change −0.05 (1.54) −0.09 (1.29) 0.639* Number of Vegetable servings change −0.03 (0.93) −0.02 (0.82) 0.345* Fast food change 3.26 (6.66) 1.27 (3.84) < 0.001 Gender Male, n = 840 Female, n = 597 P Number of days eating fruit 0.43 (1.92) −0.07 (1.48) < 0.001* Number of fruit servings/day change 0.06 (0.93) −0.14 (0.91) < 0.001* Number of days of ate Vegetables change −0.06 (1.59) −0.09 (1.11) 0.698 Number of Vegetable servings change −0.02 (0.85) −0.04 (0.89) 0.334* Fast food change 3.32 (6.52) 0.49 (2.2) < 0.001* MetS NCEP_ATPIII criteria Normal, n = 1059 MetS, n = 378 P Number of days eating fruit 0.23 (1.84) 0.22 (1.56) 0.933 Number of fruit servings/day change 0.0 (0.93) −0.09 (0.9) 0.097* Number of days of ate Vegetables change −0.07 (1.47) −0.09 (1.22) 0.886* Number of Vegetable servings change −0.01 (0.87) −0.08 (0.88) 0.369* Fast food change 2.42 (5.63) 1.36 (4.43) 0.001 *Tests performed by Mann–Whitney U test. MetS = metabolic syndrome; NCEP-ATP III = National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III); SD = standard deviation. Book 23-12.indb 841 3/4/2018 11:44:29 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 842 Acknowledgements We would like to thank all heads of concerned departments for their support and approval and to the research assistants for their help with data collection. Special thanks are directed to the participants of the study, without whom, this work would not have been possible. The funder had no role in study design, data collection, data analysis, decision or writing up of the manuscript. Funding: King Abdulaziz City for Science and Technology (KACST), research grant number MS 34-5. Competing interests: None declared. wellness among the university staff and their dependents. This should be done through the following. (1) A behavioural intervention programme focusing on promoting and sustaining a healthy diet and active lifestyle at the university level could prevent and reduce the burden of diet-related diseases. (2) Such a high rate of behavioural risk factors is enough to justify both population- and high- risk-based public health intervention programmes and health promotion activities to prevent further increases, and to manage future cardiovascular disease burden at both university and national levels. consumption of fruit and vegetables after their arrival in Saudi Arabia. Living in Saudi Arabia had a different impact on gender. Among women a significant reduction was reported in physical activity and intake of fruit and vegetables, while men reported greater fast food consumption. There was no association between the changes in physical activity or intake of fruit and vegetables and MetS, except that the intake of fast food was lower among participants with MetS. Based on the findings of our study, we recommend building an effective public health strategy to prevent cardiovascular events, and to improve cardiovascular Table 4 Association of physical activity changes with gender and length of stay in Saudi Arabia (n = 1437) Covariate 0–5 yr, n = 634 ≥ 5 yr, n = 803 P Work Number of days of vigorous activity change −0.28 (1.11) −0.14 (1.04) < 0.001* Time consumed in vigorous change (in minutes) −9.32 (46.54) −5.85 (39.7) 0.012* Number of days of moderate activity change −0.67 (1.77) −0.31 (1.65) < 0.001* Time consumed in moderate change ( in minutes) −25.66 (60.2) −16.92 (65.0) 0.001* Travel to and from places Number of days of Walk change −1.64 (2.78) −1.55 (2.74) 0.573* Time consumed in Walk change ( in minutes) −41.5 (65.95) −41.94 (70.81) 0.246 Recreational activities Number of days of sport vigorous change −0.3 (1.53) −0.23 (1.44) 0.248 Time consumed in of sport vigorous change ( in minutes) −10.74 (44.76) −7.84 (48.14) 0.337* Number of days of sport moderate change −0.62 (2.34) −0.48 (2.18) 0.248 Time consumed in sport moderate change (in minutes) −13.07 (43.07) −10.83 (43.95) 0.337 Male, n = 840 Female, n = 597 P Work Number of days of vigorous activity change −0.25 (1.18) −0.14 (0.9) <0.001* Time consumed in vigorous change(in minutes) −8.96 (43.83) −5.1 (41.37) 0.001* Number of days of moderate activity change −0.57 (1.69) −0.32 (1.73) 0.001* Time consumed in moderate change (in minutes) −22.57 (58.95) −18.25 (8.44) 0.203 Travel to and from places Number of days of Walk change −0.77 (2.12) −2.75 (3.12) < 0.001* Time consumed in Walk change (in minutes) −43.42 (61.83) −39.42 (77.26) 0.05* Recreational activities Number of days of sport vigorous change −0.29 (1.55) −0.23 (1.39) 0.34* Time consumed in of sport vigorous change (in minutes) −12.39 (56.25) −4.51 (27.68) 0.011 Number of days of sport moderate change −0.52 (2.25) −0.57 (2.25) 0.689* Time consumed in sport moderate change (in minutes) −10.93 (43.01) −13.07 (44.35) 0.703* Values are presented as mean (standard deviation). *Tested by Mann–Whitney U test Book 23-12.indb 842 3/4/2018 11:44:29 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 843 References 1. 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National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cho- lesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002 Dec 17;106(25):3143–421. PMID:12485966 17. Grundy SM, Cleeman JI, Merz CN, Brewer HB Jr, Clark LT, Hun- ninghake DB, et al.; National Heart, Lung, and Blood Institute; American College of Cardiology Foundation; American Heart Association. Implications of recent clinical trials for the Na- tional Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004 Jul 13;110(2):227–39. https:// doi.org/10.1161/01.CIR.0000133317.49796.0E PMID:15249516 18. Amin TT, Al Sultan AI, Mostafa OA, Darwish AA, Al-Nabo- li MR. Profile of non-communicable disease risk factors among employees at a Saudi university. Asian Pac J Cancer Prev. 2014;15(18):7897–907. https://doi.org/10.7314/AP- JCP.2014.15.18.7897 PMID:25292084 19. Goulão B, Santos O, Carmo I. The impact of migration on body weight: a review. Cad Saude Publica. 2015 Feb;31(2):229–45. https://doi.org/10.1590/0102-311X00211913 PMID:25760158 20. DeMaria AN. Of fast food and franchises. J Am Coll Car- diol. 2003 Apr 2;41(7):1227–8. https://doi.org/10.1016/S0735- 1097(03)00294-8 PMID:12679226 21. Mahfouz AA, Abdelmoneim I, Khan MY, Daffalla AA, Diab MM, Al-Gelban KS, et al. Obesity and related behaviors among adolescent school boys in Abha City, Southwestern KSA. J Trop Pediatr. 2008 Apr;54(2):120–4. https://doi.org/10.1093/ tropej/fmm089 PMID:18039676 22. ALFaris NA, Al-Tamimi JZ, Al-Jobair MO, Al-Shwaiyat NM. Trends of fast food consumption among adolescent and young adult Saudi girls living in Riyadh. Food Nutr Res. 2015 03 18;59(1):26488. https://doi.org/10.3402/fnr.v59.26488 PMID:25792229 23. bin Zaal AA, Musaiger AO, D’Souza R. Dietary habits associated with obesity among adolescents in Dubai, United Arab Emir- ates. Nutr Hosp. 2009 Jul-Aug;24(4):437–44. PMID:19721923 24. Moore LV, Diez Roux AV, Nettleton JA, Jacobs DR, Franco M. Fast-food consumption, diet quality, and neighborhood expo- sure to fast food: the multi-ethnic study of atherosclerosis. Am J Epidemiol. 2009 Jul 1;170(1):29–36. https://doi.org/10.1093/ aje/kwp090 PMID:19429879 25. Anderson B, Rafferty AP, Lyon-Callo S, Fussman C, Imes G. Fast- food consumption and obesity among Michigan adults. Prev Chronic Dis. 2011 Jul;8(4):A71. PMID:21672395 26. Maccoby EE. Gender and relationships. A developmental account. Am Psychol. 1990 Apr;45(4):513–20. https://doi. org/10.1037/0003-066X.45.4.513 PMID:2186679 27. Nakamura Y, Ueshima H, Okuda N, Miura K, Kita Y, Okamura T, et al.; INTERLIPID Research Group. Relation of dietary and lifestyle traits to difference in serum leptin of Japanese in Japan and Hawaii: the INTERLIPID study. Nutr Metab Cardiovasc Dis. 2012 Jan;22(1):14–22. https://doi.org/10.1016/j.num- ecd.2010.03.004 PMID:20678905 28. Mabry RM, Reeves MM, Eakin EG, Owen N. Evidence of physical activity participation among men and women in the countries of the Gulf cooperation council: a review. Obes Rev. 2010 Jun;11(6):457–64. https://doi.org/10.1111/j.1467- 789X.2009.00655.x PMID:19793376 29. Al-Zalabani AH, Al-hamdan NA, Saeed AA. The prevalence of physical activity and its socioeconomic correlates in King- dom of KSA: a cross-sectional population-based national survey. J Taibah Univ Med Sci. 2015;10(2):208–15. https://doi. org/10.1016/j.jtumed.2014.11.001 30. Pengpid S, Peltzer K, Kassean HK, Tsala Tsala JP, Sychare- un V, Müller-Riemenschneider F. Physical inactivity and associated factors among university students in 23 low-, mid- dle- and high-income countries. Int J Public Health. 2015 Book 23-12.indb 843 3/4/2018 11:44:29 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 844 Jul;60(5):539–49. https://doi.org/10.1007/s00038-015-0680- 0 PMID:25926342 31. Serour M, Alqhenaei H, Al-Saqabi S, Mustafa AR, Ben-Nakhi A. Cultural factors and patients’ adherence to lifestyle measures. Br J Gen Pract. 2007 Apr;57(537):291–5. PMID:17394732 32. Al-Nakeeb Y, Lyons M, Collins P, Al-Nuaim A, Al-Hazzaa H, Duncan MJ, et al. Obesity, physical activity and sedentary behavior amongst British and Saudi youth: a cross-cultural study. Int J Environ Res Public Health. 2012 Apr;9(4):1490–506. https://doi.org/10.3390/ijerph9041490 PMID:22690207 33. Hosseinpour-Niazi S, Mirmiran P, Mirzaei S, Azizi F. Cereal, fruit and vegetable fibre intake and the risk of the metabolic syndrome: a prospective study in the Tehran Lipid and Glucose Study. J Hum Nutr Diet. 2015 Jun;28(3):236–45. https://doi. org/10.1111/jhn.12242 PMID:24890325 Book 23-12.indb 844 3/4/2018 11:44:29 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 845 1Laboratoire d'éthique médicale et de médecine légale, Unité de recherche EA 4569, Faculté de médecine, Université Paris Descartes, Paris (France). 2Département de Santé publique, Faculté de chirurgie dentaire, Université Paris Descartes, Montrouge (France). 3Service d’odontologie, Hôpital Albert-Chenevier, Groupe hospitalier Henri-Mondor, Assistance publique-Hôpitaux de Paris, Créteil (France). 4 Expert en éthique auprès de l’Observatoire mondial d’éthique de l’UNESCO (Correspondance à adresser à Dr Philippe Pirnay : drphp1@orange.fr). Reçu : 23/04/15 ; accepté: 7/03/17 Réflexions éthiques sur le principe de l’autonomie du patient Marianne Bracconi, 1,2,3 Christian Hervé 1 et Philippe Pirnay 1,2,3,4 Ethical reflections on the principle of patient autonomy ABSTRACT In a world open to the movement of people, medical ethics is today associated with the area of loyal behavior of the practitioner and oriented in the patient's interest and accountability of each. The universal vision of respect for the dignity of the sick person progresses. Yet, many behaviours are sometimes illegitimate, but not in principle legally reprehensible. One of the main principles marking the observance of patient consent is based on the autonomy given to the patient to decide for himself what appears to be adapted to his or her care. The patient must be the one who makes the final decision on issues concerning them and doctors must act to respect it. Therefore, they must accept that the patient has a different value system. ضيرلما ةيلاقتسا أدبم لىع ةيقاخلأا تاساكعنلاا يانيرب بيليف ،فييره نايتسيرك ،نيوكارب نايرام هدـيري اـلم هـّجولماو ةلءاـسلماب طـبترلما بـيبطلا كولـسب موـيلا ةـيبطلا تاـيقاخلأا طـبترت ،صاخـشلأا لـّقنت ىـع حـتفنم ٍلماـع في : ةـصالخا نأ نود ةـ ّيعشرلا تاّيكولـ سلا ضـ عب ًاـ نايحأ ىـ قبت ضـ يرلما صخـ شلا ةـ مارك مارـ حلا يـ لماعلا موـ هفلما رّوـ طت نـ م مـ غرلا ىـ عو ،ضـ يرلما هـسفنب هرارـق ذاـّتخا في ةّيلاقتـسلاا هـئاطعإ ىـع يـنبم ضـيرلما ةـقفاوم مارـحا في ةيـساسلأا ئداـبلما دـحأ نإ .ةـينوناق تاـعبت لىإ ًاـيئّدبم يـفت مارـحا ّلاإ بـيبطلا ىـع اـمو هـينعت يـتلا روـملأا في يـئاهنلا رارـقلا ذاـّتخا ةـّيرح ضـيرملل نوـكي نأ كـلذ مـّتيحو. هـجاعل ًاـئام هارـي اـلم .ةـفلتمخ مـيق ضـيرملل نوـكت نأ لـبقي نأ هـيلع كـلذل. رارـقلا اذـه RÉSUMÉ Dans un monde ouvert à la circulation des personnes, on associe aujourd’hui à l’éthique médicale le domaine du comportement loyal du praticien, orienté dans l’intérêt du patient et la responsabilisation de chacun. La vision universelle du respect de la dignité de la personne souffrante progresse. Pourtant, bien des comportements restent parfois illégitimes sans être, en principe, répréhensibles juridiquement. L’un des principes essentiels marquant le respect du consentement du patient repose sur l’autonomie laissée au patient de décider pour lui-même ce qui lui semble être adapté à ses soins. Le patient doit alors être celui qui prend la décision finale sur les questions le concernant. Le soignant doit agir pour la respecter. C’est pourquoi il doit accepter que le patient puisse avoir un système de valeurs différent. https://doi.org/10.26719/2017.23.12.845 Book 23-12.indb 845 3/4/2018 11:44:29 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 846 Introduction Si le Code d'Hammourabi (1752 av. J.-C.) décline les premières dispositions concernant la responsabil ité du m é d e c i n , H i p p o c r a t e r e s t e l e précurseur des principes de l’éthique médicale. La relation médecin-malade était alors vue comme une rencontre entre une conscience et une confiance. Actuellement, il s’agit de la rencontre de deux confiances. L’éthique renforce ce lien et permet d’apprécier et de distinguer le bien du mal, c’est-à-dire le soin du praticien qui sera bénéfique pour son patient de celui qui sera nocif, par un questionnement, une réflexion sur le comportement de la personne (Tableau 1). Or, ni les questions d’éthique appliquée ni celles de l’éthique théorique ne peuvent être traitées par le simple renvoi au droit positif d’une région ou d’un pays, car les lois en vigueur peuvent fort bien être condamnables d’un point de vue éthique. La détermination de ce qui est juste d’un point vue éthique ne se résume donc pas à la détermination de ce qui est en accord avec la loi. Inversement, bien des comportements sont illégitimes, bien qu’ils ne soient en principe pas répréhensibles juridiquement. Aussi, la recherche d’une éthique à portée universelle est une préoccupation que partagent aujourd’hui de nombreuses institutions régionales, nationales ou internationales, et en premier, l ’ O r g a n i s a t i o n m o n d i a l e d e l a Santé (OMS) et l’Organisation des Nations Unies pour l’éducation, la science et la culture (UNESCO). L’autonomie comme principe éthique L’autonomie du patient est reconnue partout dans le monde de la part des soignants comme une valeur. Ce principe d’autonomie émerge de deux philosophies qui s’opposent. Selon Rameix, le système anglo-saxon associe la notion d’autonomie d’un individu à une liberté individuelle et admet un fonctionnement sociétal basé sur la négociation et la contractualisation (1). Les pays issus du droit romain ont adopté l’idée que l’autonomie s’exprime législativement, de façon universelle. Ainsi l’autonomie individuelle une fois exprimée se soumet à la volonté générale. Aujourd’hui, le patient doit être celui qui prend la décision finale sur les questions qui le concernent. Il s’agit du respect pour chacun de disposer soi- même de sa santé et de choisir les options qui correspondent à ses souhaits, ses valeurs ou ses projets de vie. Le respect de l’autonomie est la norme qui prescrit de respecter les capacités de prise de décision des personnes autonomes, en connaissance de cause. C’est donc la capacité d’une personne à choisir son praticien, à maîtriser sa volonté à consentir ou non à un traitement, à suivre ou non les recommandations ou les conseils du soignant. Elle présuppose la capacité de juger, de prévoir, de choisir et la liberté de pouvoir agir, accepter ou refuser en fonction de son jugement éclairé (2). Elle sous-tend le droit du patient à l’autodétermination. Comme telle, l’autonomie s’oppose au paternalisme médical, lequel a été au cœur d’un type traditionnel de relation entre le prestataire de soins et son patient consistant pour le soignant à se substituer à son patient dans la prise de décision au motif que le praticien agirait pour le bien de son patient. L e p r é a l a b l e a u r e s p e c t d e l'autonomie est d'offrir au patient u n e i n f o r m a t i o n q u i s o i t d e qualité (complète, loyale, approximative et en des termes intelligibles) et de recueillir un consentement éclairé avant, pendant et après les soins à chaque fois qu'une intervention ou un soin devait être proposé(e)/prodigué(e). Ceci doit respecter la décision du patient même si celle-ci allait à l'encontre de l'avis du praticien (par exemple, en cas de refus d’une sédation profonde d’un patient en fin de vie alors que le praticien est enclin à la lui proposer) ou de la loi, lorsque celle-ci ne peut pas être mise en application. La France exige depuis le 2 février 2016 la désignation d’une personne de confiance ou le recueil de directives anticipées permettant de connaître la volonté d’un patient qui ne serait plus en état de donner son avis. Cependant, la mise en application s ’avère extrêmement complexe , voire impossible dans de nombreux services hospitaliers qui doivent malgré tout rester à l’écoute du patient et respecter sa volonté. Néanmoins, lorsque le patient se présente dans un état comateux, la désignation de cette personne de confiance ou le respect des Tableau 1 Différences entre éthique et morale La morale L’éthique A une connotation religieuse Est plutôt de nature laïque Elle comporte une notion de contrôle imposée de l’extérieur. Elle comporte une notion d’autocontrôle. Elle part de l’intérieur de la personne. Elle nous interpelle, crée des obligations. Elle nous fait réfléchir et nous responsabilise. Book 23-12.indb 846 3/4/2018 11:44:30 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 847 directives anticipées du patient permet de respecter son avis. En cela, le principe d’autonomie rejoint celui du respect de la dignité humaine. La personne humaine est considérée dès le XVIIIe siècle comme étant la valeur suprême par Locke « […] un état dans lequel, sans demander de permission à personne, et sans dépendre de la volonté d'aucun autre homme, ils peuvent faire ce qu'il leur plaît, et disposer de ce qu'ils possèdent et de leurs personnes » (3) et Rousseau « Hommes, soyez humains, c’est votre premier devoir » […] « je lui veux donner un rang qu'il ne puisse perdre, un rang qui l'honore dans tous les temps ; je veux l'élever à l'état d'homme » (4), de sorte que Kant énonce en conséquence la théorie de la dignité inhérente à chaque être humain : « L'humanité elle-même est une dignité ; en effet, l'homme ne peut être utilisé par aucun homme (ni par autrui, ni par lui-même) simplement comme un moyen, mais toujours être traité en même temps comme une fin, et c'est en cela que consiste précisément sa dignité », « l’autonomie est donc un principe de la dignité de la nature humaine et de toute nature raisonnable » (5,6). La philosophie moderne propose une acception laïque de la dignité humaine, qu’elle associe progressivement à l’idée de droits de l’homme. L’un des principes de base de l’éthique de Kant – traiter autrui toujours en même temps comme une fin, jamais simplement comme un moyen (impératif catégorique) – a été admis par la philosophie morale et la politique moderne comme le fondement de la conception des droits de l’homme ; c’est, de ce point de vue, un principe fondateur. Ainsi, de grandes déclarations de droits et de libertés essentiels des personnes y font depuis expressément référence : la Déclaration universelle des droits de l’homme des Nations Unies du 10 décembre 1948, la Déclaration américaine des droits et devoirs de l’homme du 30 avril 1948 suivie par des textes aussi célèbres que l’Acte final de la Conférence sur la sécurité et la coopération en Europe signé à Helsinki le 1er août 1975, la Déclaration puis la Convention des Nations Unies sur les droits de l’enfant ou même la Déclaration des droits et libertés fondamentaux adoptée par le Parlement européen le 12 avril 1989. On en déduit plusieurs principes : la dignité de l’être humain est intangible ; elle représente le fondement de l’ordre politique et de la paix sociale ; elle doit être protégée par l’État et enfin, rien ne peut motiver son abaissement. Pour atteindre cet objectif , la reconnaissance de la dignité d’une personne présuppose un respect actif de ses droits de l’homme, de son estime de soi et de son autonomie. Mais l’autonomie n’est pas seulement un droit, c’est aussi une responsabilité partagée, un choix issu d’une décision mutuelle, car le patient n’est autonome que pour prendre des décisions responsables, c’est-à-dire éclairées, légitimes et raisonnables. Le praticien doit rester maître de son choix thérapeutique. Aussi, le patient peut refuser l’option proposée par le prestataire de soins, mais il ne peut pas prétendre à un traitement inutile, contre-indiqué ou pouvant parfois être dangereux (en chirurgie plastique, par exemple), ou qui ne tiendrait pas compte des normes médicales du moment et des soins disponibles (2). La seule personne qui soit à même de décider pour le patient est le patient lui-même et il n’est pas dans les prérogatives du praticien d’imposer sa propre échelle de valeurs. Le partenariat soignant/soigné découlant d’une relation de confiance basée sur une information juste, compréhensible par le soigné et vérifiée comme telle en reste le garant. Aussi, les patients gardent le droit de refuser un traitement mais ils ne peuvent pas réclamer n’importe quel traitement. Du point de vue de l’exercice médical, cette primauté de l’autonomie signifie donc que savoir mieux que le sujet n’implique pas l’existence d’un droit d’autorité du praticien sur le patient. Selon Machat, l’interprétation de la notion « d’autonomie » dans le contexte médical est également d é p e n d a n t e d e l a p h i l o s o p h i e adoptée (7). Dans un système libéral anglo-saxon, l’autonomie du patient sera interprétée comme purement individualiste, tout sera contrat entre patient et praticien. Les responsabilités seront parfaitement identifiées avant, pendant et après la réalisation du contrat. Dans un système universaliste, où l’idée d’un État protecteur domine, l’autonomie individuelle se verra limitée par celle législativement exprimée (7). De ce fait, si l’autonomie joue un rôle majeur dans certaines sociétés parce qu’elle implique une affirmation de soi, en contrepartie, l’individu est surchargé de responsabilités et d’épreuves qu’il ne connaissait pas auparavant. Elle participe aussi à l’affaiblissement du lien social (8). C’est pourquoi d’autres approches, telles que la solidarité, la responsabilité, l’autonomie intriquée, représentent la réalité de l’autonomie dans beaucoup d’autres sociétés. Reste deux questions en suspens… Comment s'assurer de la valeur de l'autonomie ? L’autonomie de décision du patient s’appuie sur la qualité de l’information et la pertinence des recommandations données par le soignant. Elle tient c o m p t e d e t o u t e s l e s s o u r c e s d’information du patient. Car l’ouverture au monde par les médias, l’élévation du degré de formation des populations, l’augmentation des niveaux de vie font que des situations autrefois admises sont de moins en moins supportées (9). L’autonomie doit ainsi amener le patient à décider non pas de ce qui est souhaitable, hypothétique, irréaliste, irrationnel, mais de « ce » qui est parfaitement établi comme l’option Book 23-12.indb 847 3/4/2018 11:44:30 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 848 thérapeutique adaptée au patient. Les convictions et des sensibilités personnelles de chaque patient ne doivent intervenir qu’après. En ce sens, il faut respecter la liberté individuelle de conscience tant qu’elle ne s’approprie pas la liberté d’autrui et être conscient que, dans la rencontre de deux libertés (liberté du soignant à proposer les options thérapeutiques et liberté du patient à choisir ses soins), le praticien ne peut vouloir faire toujours le bien d’une personne contre son gré au nom d’une solidarité humaine (10). Aussi, en privilégiant l’éducation permanente de son patient au cours des soins, le praticien contribue à compléter l’autonomie de décision de son patient en compétence. Quelle limite accorder à l’autonomie ? L’autonomie n’est pleine et entière que si le patient a été clairement et loyalement informé et s’il a la capacité et la liberté à consentir à des soins justes. L’autonomie reste donc toujours encadrée par l’information d’une part et le consentement d’autre part (Figure 1). Mais l’obligation du praticien de respecter la volonté du malade trouve sa limite dans l’obligation qu’il a aussi de protéger la vie et la santé de l’individu. Il doit aussi tenir compte de la communauté car la notion de choix fondé sur l’intérêt du groupe est la base de l’équité. La santé publique est importante. L’autonomie d’un individu s’arrête là où commence celle des autres. Aussi, si nous sommes obligés de respecter le libre arbitre et les valeurs des autres, nous n’avons pas le droit de mettre en danger la santé d’autrui, l’environnement, l’économie, etc. Ainsi, la société devrait prendre en compte prioritairement l’intérêt général avant le malade présentant, par exemple, une pathologie transmissible source d'épidémie. En ce sens, les règles de prévention et de traitement de cette épidémie pourraient donc s’appliquer aux dépens du choix personnel du malade. Les libertés de choix du praticien, de la chambre à l’hôpital, de circulation ou de visite des malades, etc., seraient réduites au regard de la prise en charge de l’épidémie. On passerait d’un droit aux soins à une obligation de soins. Pour les mêmes raisons, un patient dangereux souffrant d’une maladie mentale et adoptant un comportement à risque pourrait se voir refuser ses choix s’il mettait la vie ou la sécurité d’autrui en jeu. Comment respecter l'autonomie du patient qui n'a pas/plus ses capacités de discernement, le laissant inapte à consentir ou en cas d’urgence vitale ? En l’absence d’une personne de confiance, d’une déclaration anticipée de volonté, d’un tuteur, etc., le choix du praticien, de l’équipe soignante aidée par l’avis d’un comité d’éthique pluridisciplinaire doit alors guider la décision médicale. C e s s i t u a t i o n s p r o u v e n t l a complexité du respect de l’autonomie du patient et obligent les équipes médicales à s’adapter au cas par cas en menant une réflexion éthique qui tient compte du respect de la dignité du malade dans la fidélité aux valeurs qui fondent la médecine. Les pays de la Méditerranée orientale Pour une large part de la population de ces régions, la religion représente l’une des composantes de la réflexion, mais la réflexion éthique partage des valeurs communes en Occident comme ailleurs. Selon Chaoui et Legros, dans un monde ouvert à la circulation des personnes, médecins ou malades, des biens médicaux et pharmaceutiques, des idées et des modèles de gestion, les pays du Maghreb central ont essayé de conduire leurs systèmes de santé dans de nouvelles directions en modifiant les rapports entre public et privé et en tentant de répondre avec des moyens limités à une demande de soins plus massive et surtout renouvelée (11). Pour Boustany, on peut distinguer d’une part, l’Algérie et le Maroc où le statut personnel codifié met en forme un droit musulman traditionnel, et d’autre part, l’Égypte, la Syrie et le Liban qui sont des pays de pluralisme des statuts personnels (12). En Égypte et en Syrie, le droit musulman bénéficie d’une certaine prééminence ; toutefois, les juridictions communautaires doivent respecter la procédure des juridictions civiles. La Constitution libanaise fait une obligation à l’État de respecter cette Figure 1 La pyramide de l’éthique des soins Book 23-12.indb 848 3/4/2018 11:44:30 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 849 autonomie. Le contexte libanais ne spécifie pas particulièrement la réflexion éthique et limite souvent sa possibilité de progression législative. En Tunisie , les avis récents d u C o m i t é N a t i o n a l d ' É t h i q u e Médicale (CNEM) vont tous dans le sens de l'état de l'art et du respect de l’autonomie du patient (13). Le Ministère de la Santé publique tunisien a publié deux décisions en 2009 et en 2012 (14). La première a instauré une charte du patient garantissant le respect de la dignité du patient (y compris son autonomie), le respect de la décision de refuser les soins et l'obligation du praticien de délivrer une information et de collecter le consentement du patient qui remplissent toutes les trois les conditions préalables au respect de l'autonomie du patient. La deuxième décision, intégrée dans la charte, a rappelé l'obligation à tout médecin de délivrer une information et a prévu un modèle de recueil du consentement valable pour le secteur public et le secteur privé ; cette dernière décision fut d'ailleurs fortement influencée par la loi française sur les droits du malade du 4 mars 2002. D'un autre côté, le respect de l'autonomie ainsi que l'information et le consentement font partie des notions qui ont été rajoutées aux syllabus des quatre facultés de médecine tunisiennes depuis 2006. Conclusion Dans la mesure où la plupart des patients se sentent dépendants des médecins, il semble donc essentiel que ces derniers respectent l’autonomie des patients ; il convient de délimiter un espace discrétionnaire à l’intérieur duquel les patients prennent leurs propres décisions quand il s’agit de leur propre dignité (15). Cela peut tenir compte aussi des valeurs religieuses. Mais, pour Huriet, auteur de la première loi éthique en France, « il n'y a pas d'éthique universelle, car des références culturelles , sociales , spirituelles , historiques, interviennent dans les choix éthiques. L’expérience que j’ai acquise comme membre du Comité International de Bioéthique de l’Unesco me l’a maintes fois confirmé. Mais des principes éthiques fondamentaux sont universellement admis : l'autonomie de la personne, à travers le consentement, la bienfaisance et la non-malfaisance, à travers le rapport bénéfice/ risque, et l'équité et la justice, c'est-à-dire l'accès aux soins. » (16). Financement : aucun. Intérêts concurrents : aucun déclaré. Références 1. Rameix S. Fondements philosophiques de l’éthique médicale. Paris: Ellipses; 1996. pp. 91–9. 2. Pirnay P. Responsabilités et exigences éthiques à l'égard du chirurgien-dentiste. In: Tardivo D, Camilleri F, eds. Prévention et gestion du risque contentieux en odontologie. Paris: Éditions CdP; 2015. pp. 51-8. 3. Locke J. Two Treatises of Government. London: Awnsham Churchill; 1690. Traité du gouvernement civil. Paris : Garnier- Flammarion, Deuxième édition corrigée, Collection Texte intégral (traduction de Davuk Mazel);1992. p.17 4. Rousseau JJ. Émile ou de l’éducation. Paris: Garnier- Flammarion; 1966. p. 92. 5. Kant E. Fondements de la métaphysique des mœurs (1785). Paris: Vrin; 1968. p. 140 6. Kant E. Fondements de la métaphysique des mœurs. Paris: LGF/Livre de Poche, Classiques de la philosophie (trad. de l’allemand par V. Delbos), no 4622; 1993. p.115. 7. Machat E. Principe d’autonomie et soins dentaires. In: Pirnay P, ed. L’éthique en médecine bucco-dentaire. Paris: Espace ID; 2012. pp.109-12. 8. Ehrenberg A. Faire société à travers l ’autonomie. Recherche & formation. 2014;76(2):107-18. doi: 10.4000/ rechercheformation.2256 9. Chaoui F, Legros M. Le Maghreb face aux nouveaux enjeux mondiaux - Les systèmes de santé en Algérie, au Maroc et en Tunisie : des transitions inachevées. Note de l’Ifri. IFRI (Institut français des relations internationales); 2013 (https://www.ifri.org/sites/default/files/atoms/files/ notedelifriocpchaouilegros.pdf, consulté le 15 mai 2017). 10. Comité Consultatif National d’Éthique pour les Sciences de la Vie et de la Santé. Refus de traitement et autonomie de la personne. Avis n° 87 du 14/04/2005. (http://www. ccne-ethique.fr/sites/default/files/publications/avis087.pdf, consulté le 17 mai 2017). 11. Chaoui F, Legros M. Les systèmes de santé en Algérie, Maroc et Tunisie - Défis nationaux et enjeux partagés. Les Notes IPEMED (Institut de Prospective Économique du Monde Méditerranéen), Études et Analyses. IPEMED. 2012;13 (http://www.ipemed.coop/adminIpemed/media/fich_ article/1336128563_LesNotesIPEMED_13_Sante_avril2012.pdf, consulté le 17 mai 2017). 12. Boustany FN. Bioéthique dans le monde arabe. Étude analytique et régulations. J Med Liban. 2011;59(1):7–11. 13. République Tunisienne, Ministère de la Santé publique. Comité National d’Éthique Médicale (http://www.comiteethique.rns. tn/). 14. République Tunisienne, Ministère de la Santé publique. Charte du patient (http://www.santetunisie.rns.tn/images/ charteresume.pdf http://www.santetunisie.rns.tn/images/ articles/chartepatient.pdf, consulté le 6 juin 2017). 15. Organisation des Nations Unies pour l’éducation, la science et la culture (UNESCO). Cours de base de bioéthique, Section 1: Syllabus. Programme d’éducation en éthique; 2008 (http:// unesdoc.unesco.org/images/0016/001636/163613f.pdf, consulté le 18 mai 2017). 16. Huriet C. Préface. In: Pirnay P, ed. L’éthique médicale en chirurgie dentaire : principes et applications. Espace ID; 2016. p. 4. Book 23-12.indb 849 3/4/2018 11:44:30 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 850 Evaluation of vaccination efficiency against HBV among Syrian multitransfused patients ABSTRACT This cross-sectional study estimates HBV prevalence and evaluates vaccination efficiency among multitransfused patients. 159 patients with various hemoglobinopathies were tested for HBsAg, anti-HBs, and anti-HBc, using enzyme-linked immunosorbent assay (ELISA). The serological results were then compared with the relevant documentation in medical records. Seropositivity of HBV was detected in 1/8 of recruited patients. Serological immunity was found in only half of patients, while the other half were either infected or non-immune. The vaccination against HBV appeared inefficient in almost half of vaccinated patients and was not documented in the medical records of 1/6 of patients. Thus, multitransfused patients are at risk of acquiring hepatitis B infection. Applying prophylactic vaccination, documenting vaccine doses, and monitoring immune response are highly recommended. 159 في لصلما رتخا .رركتلما مدلا لقن ضىرم ىدل ميعطتلا ةيلعاف مييقتو ،يئابلا يدبكلا باهتللاا سويرف راشتنا ةيعطقلما ةساردلا هذه ردقت :ةصالخا تنروق مث ، ELISA لاعتساب كلذو يئابلا يدبكلا باهتللاا سويرفل ةداضلما ماسجلأا دوجول ،ةينيبولجوميلها ضارملأا فلتمخ نم نوناعي ًاضيرم .ةساردلا في نكرشلما ضىرلما نمث في يئابلا دبكلا باهتلا سويرفل لصلما ةيبايجإ فِشُتكاو .ةيبطلا تاجسلا في ةلصلا تاذ قئاثولا عم ةيلصلما جئاتنلا يرغ يئابلا دبكلا باهتلا دض ميعطتلا نأ ودبيو .نصمح يرغ وأ ًاباصم امإ رخلآا فصنلا ناك نح في ،طقف ضىرلما فصن في ةيلصلما ةعانلما تفشتكاو رركتلما مدلا لقن ضىرم نإف ،مث نمو .ضىرلما سدس في ةيبطلا تاجسلا في ميعطتلا قثوي لمو ،هب اوحقل نيذلا ضىرلما فصن نم برقي ام في لاّعف .ةيعانلما ةباجتسلاا دصرو ،حاقللا تاعرج قيثوتو ،يئاقولا ميعطتلا قيبطتب ةدشب حصنيو .يئابلا دبكلا باهتلا ىودعب ةباصلإا رطلخ نوضرعم Évaluation de l'efficacité de la vaccination contre le VHB chez des patients polytransfusés syriens RÉSUMÉ La présente étude transversale vise à estimer la prévalence du VHB et à évaluer l'efficacité de la vaccination chez les patients polytransfusés ; 159 patients atteints de diverses hémoglobinopathies ont été testés à la recherche d’HBsAg, d’anti-HBs et d’anti-HBc en recourant à la méthode immuno-enzymatiqu (ELISA). Les résultats sérologiques ont ensuite été comparés avec les documents pertinents dans les dossiers médicaux. Une séropositivité au VHB a été détectée chez un patient recruté sur huit. Une immunité sérologique n'a été retrouvée que chez la moitié des patients, tandis que les autres étaient infectés ou non immuns. La vaccination contre le VHB semblait inefficace chez près de la moitié des patients vaccinés, et la vaccination n'a pas été documentée dans les dossiers médicaux d'un patient sur six. Les patients polytransfusés sont donc à risque de contracter une hépatite B. Il est vivement recommandé de pratiquer une vaccination prophylactique, de documenter les doses de vaccin, et d’effectuer le suivi de la réponse immunitaire. 1Biochemistry and Microbiology Department, Faculty of Pharmacy, Damascus University, Damascus, Syrian Arab Republic. (Correspondence to: w_yazagi@yahoo.com). 2Clinical Laboratories Department, Al-Assad Hospital, Damascus University, Damascus, Syrian Arab Republic. Received: 10/03/16; accepted: 30/03/17 .(w_yazagi@yahoo.com) :نيوركللاا ديرلا( ايروس ،قشمد ،قشمد ةعماج ،ةلديصلا ةيلك ،ايجولويبوركيلماو ةيويلحا ءايميكلا مسق 1 .ايروس ،قشمد ،قشمد ةعماج ،دسلأا ىفشتسم ،ةيبطلا تارتخلما مسق2 17/03/30 :لوبقلا ،16/03/10 :ماتسلاا https://doi.org/10.26719/2017.23.12.850 رركتلما مدلا لقن ضىرم ىدل يئابلا سيويرفلا دبكلا باهتلا ّدض ميعطتلا ةيلعاف مييقت ايروس في 1 معنم ةزوف ،2 لاّبح ءافو ،1 يجزاي دادو Book 23-12.indb 850 3/4/2018 11:44:30 AM lanruoJ htlaeH naenarretideM nretsaE 7102 • 21 .oN 32 .loV • JHME elatneiro eénarretidéM al ed étnaS ed euveR aL 158 المقدمة يعتـر نقـل الـدم تداخـًا عاجيـًا هامـًا لـدى مــرضى الاعتــالات الهيموغلوبينيــة، حيــث يحت ــاج ه ــؤلاء الم ــرضى إلى نق ــل ال ــدم المتك ــرر للحفــاظ عــى (بقائهــم عــى قيــد الحيــاة) البقيــا lavivrus وتحســن نمــط الحيــاة (1). تعتــر عــدوى فيروســات التهــاب الكبــد ومنه ــا ف ــيروس الته ــاب الكب ــد البائ ــيVBH م ـن أه ـم مضاعف ـات نق ـل ال ـدم (2)، لاس ـيا في سـوريا حيـث ينتـشر التهـاب الكبـد البائـي انتشـارا ًمتوسـطًا يبلـغ 26.5% (3)، ممـا يزيـد احتاليـة تعـرض مـرضى اعتـالات الخضـاب لاختطـار هـذه العـدوى؛ فقـد ذكـرت العديـد مــن الدراســات أن ارتفــاع نســب انتشــار إيجابي ــة المس ــتضد الس ــطحي لف ــيروس الته ــاب الكب ــد البائ ــي ل ــدى المترع ــن بال ــدم ينعك ــس ارتفاعــًا في نســب الإصابــة لــدى المــرضى المتلقـن للـدم المتكـرر (4،5). وبالت ـالي تكـون الوقايـة لـدى هـذه المجموعـة مـن المـرضى عـى قـدر بالـغ مـن الأهميـة، ويعتـر التمنيـع الفعـال noitazinummi بلقـاح التهـاب الكبـد البائـي قبــل التعــرض للفــيروس الطريقــة الفضــى للوقايــة مــن العــدوى (6) حيــث يــؤدي تطبيق ــه إلى تناق ــص ح ــدوث الع ــدوى الح ــادة منه ــا والمزمن ــة (7). ُأدرج لقــاح التهــاب الكبــد البائــي في بدايــة التســعينيات ضمــن برنامــج التلقيــح الوطن ــي في س ــوريا وفق ــًا لنظ ــام مؤل ــف م ــن ثــاث جرعــات تعطــى بعــد الــولادة وفي الشــهر الثالــث وفي الشــهر الســابع (8،9) حيــث تظهــر أضــداد المســتضد الســطحي الحامي ــة ض ــد المس ــتضد الس ــطحي للف ــيروس عن ــد 09% م ــن الأش ــخاص المؤهل ــن مناعي ــًا tnetepmoconummi بعــد الجرعــات الثــاث (6). يعت ــر عي ــار أض ــداد المس ــتضد الس ــطحي للف ــيروس أع ــى م ــن 01 مي ــلي وح ــدة دولي ــة مــؤشرًا عــى وجــود حمايــة تجــاه العــدوى بفــيروس التهــاب الكبــد البائــي حيــث أن العيـار بـن 001-01 ميـلي وحـدة دوليـة يـدّل عـى اسـتجابة ضعيفـة، أمـا العيـار الأكـر مـن 001مي ــلي وح ــدة دولي ــة ي ــدّل ع ــى اس ــتجابة قويـة (01). ونظـرًا للتعديـات المناعيـة الناتجـة ع ــن ف ــرط حم ــل الحدي ــد ل ــدى م ــرضى نق ــل الـدم المتكـرر، فـإّن ذلـك ُيضعـف اسـتجابتهم للق ــاح (11)، مم ــا ق ــد ينق ــص ق ــدرة اللق ــاح ع ــى تأم ــن الحاي ــة الازم ــة له ــم م ــن ع ــدوى ف ـيروس الته ـاب الكب ـد البائ ـي. هدف ـت ه ـذه الدراســة إلى معرفــة انتشــار التهــاب الكبــد البائــي لــدى مــرضى نقــل الــدم المتكــرر وتقييـم نجاعـة التلقيـح في هـذه المجموعـة ذات الخط ــورة العالي ــة. المواد والطرق شــملت دراســتنا المقطعيــة 951 مريضــًا باعت ــال هيموغلوبين ــي م ــن مراجع ــي مرك ــز الثاســيميا الوطنــي ومستشــفى الأطفــال الجامع ــي في مدين ــة دمش ــق ب ــن تشري ــن الأول 2102 وكانــون الأول 3102. خضــع جميــع المـرضى لنقـل الـدم ثـاث مـرات عـى الأقـل قبــل الاعتيــان، وكانــوا غــير موســومن أو مصاب ــن بع ــدوى كبدي ــة مس ــبقة، ولم يراجع ــوا طبي ــب الأس ــنان أو يج ــروا عملي ــات جراحي ــة في الأشــهر الثاثــة الســابقة لاعتيــان. ُأجريــت المقابــات الشــخصية مــع المــرضى أو ذويهــم وروجعــت ســجاتهم للحصــول عــى المعلومــات الشــخصية المتعلقــة بالعم ــر والجن ــس والحال ــة العائلي ــة والمهني ــة، وللحص ــول ع ــى المعلوم ــات الطبي ــة المتعلق ــة بتلقيه ــم لق ــاح الته ــاب الكب ــد البائ ــي. وتبع ــًا للتوثي ـق في الس ـجات الطبي ـة ُصن ـف الم ـرضى إلى مجموعتــن: مجموعــة المــرضى المتلقــن للقــاح وهــم مــن أتمُــوا جرعــات لقــاح التهــاب الكبــد البائــي الثــاث مــع أو دون الجرع ــة الداعم ــة وق ــد وثق ــت جرعاته ــم ع ــى السـجات، ومجموعـة المـرضى الذيـن لم يوثـق في ســجاتهم أنهــم قــد تلقــوا اللقــاح. تــّم الحص ــول ع ــى الموافق ــات المس ــتنيرة م ــن جمي ــع المـرضى أو ذويهـم؛ كـا نالـت الدراسـة موافقـة لجن ــة الأخاقي ــات في كلي ــة الصيدل ــة، جامع ــة دمشــق. ُجم ــع 5 م ــل م ــن ال ــدم المحيط ــي م ــن كل مري ــض للحص ــول ع ــى المص ــل ال ــذي ُحف ــظ في الدرجــة -°08 مئويــة إلى حــن إجــراء اختب ــارات الكش ــف ع ــن الواس ــات المصلي ــة المدروسـة وهـي المسـتضد السـطحي لفـيروس التهــاب الكبــد البائــي، وأضــداد المســتضد السـطحي للفـيروس، وأضـداد المسـتضد اللبـي للفــيروس بتقنيــة مقايســة الامتــزاز المناعــي مالمرتبـط بالإنزيـ -onummI dekniL emyznE yassA tnabroS باس ــتخدام عتائ ــد asileoiB (شركـة tiKoiB، إسـبانيا)، وُحسـبت قيـم الحـد الفاص ــل ffo-tuc بن ــاء ع ــى تعلي ــات الشرك ــة المصنع ــة. ُصن ــف الم ــرضى بن ــاًء ع ــى نتائجه ــم المصليــة إلى مجموعــة المتعرضــن لفــيروس الته ــاب الكب ــد البائ ــي وه ــم الإيجابي ــون تج ــاه المس ــتضد الس ــطحي لف ــيروس الته ــاب الكب ــد البائـي و/أو ضـد المسـتضد اللبـي للفـيروس، ومجموع ــة الممنَّع ــن مصلي ــًا وه ــم الإيجابي ــون تج ــاه أض ــداد المس ــتضد الس ــطحي للف ــيروس وحـده، ومجموعـة غـير الممنعـن مصليـًا وهـم الســلبيون تجــاه جميــع الواســات المصليــة المدروس ــة. ُعــّر عــن البيانــات بنســٍب مئويــٍة مــع حســاب المتوســط والانحــراف المعيــاري، وُحســبت قيمــة نســبة الأرجحيــةsddO oitaR مــن خــال اســتخدام موقــع /clac/gro.clacdem.www//:ptth) php.oitar_sddo( واعتــرت قيمــة 50.0 <P ذات دلالة إحصائية. النتائج ش ــملت مجموع ــة الدراس ــة 88 ذك ــرا ً (55%) و17 أنثــى (54%). تــوزع المــرضى حســب نـوع المـرض إلى 421 مريضـا ًمصاب ـا ً بمـرض الثاســيمّية، و12 مريضــا مصابــا ً بمــرض الثاسـيمية المنجليـة، و7 مـرضى مصابـن بفقـر ال ــدم المنج ــلي، و7 م ــرضى مصاب ــن بالناع ــور. كان متوس ــط عم ــر المش ــاركن 52.9±11.71 عام ــا ً (المج ــال 25-5.1عام ــًا). ت ــوزع الم ــرضى حس ــب نتائجه ــم المصلي ــة إلى 12 )3.31%) مريض ــا ً متعرض ــا ً لف ــيروس التهـاب الكبـد البائـي وكان متوسـط أعارهـم 95.01±67.32 عامـا ً (المجـال 25-6 عامًا)؛ أّم ــا غ ــير المتعّرض ــن لف ــيروس الته ــاب الكب ــد البائــي فتوزعــوا إلى 48 )8.25%) مريضــًا ممنعــا،ً و45 )9.33%) مريضــَا غــير ممنــع مصليــًا وكان متوســط أعارهــم 6.8±1.61 عامــا ً (المجــال 84-5.1 عامــًا). وقــد زاد الاختط ــار بش ــكل يعت ــّد ب ــه إحصائي ــًا ل ــدى الذي ــن ول ــدوا قب ــل ع ــام 3991 م ــا يق ــارب 7 م ــرات ع ــن الذي ــن ول ــدوا بع ــد ع ــام3991 ) 6000.0=P 84.7=RO، الجدول 1). بين ــت مراجع ــة الس ــجات أن 99 مريض ــًا مــن أصــل 951 )26%) ُوّثــق في ســجاتهم MA 13:44:11 8102/4/3 158 bdni.21-32 kooB المجلد الثالث والعشرونالمجلة الصحية لشرق المتوسط العدد الثاني عشر 258 تلقيهـم لقـاح التهـاب الكبـد البائـي بجرعاتـه الثــاث، ولم يحصــل أي منهــم عــى جرعــة داعمـة. تـوزع هـؤلاء المـرضى حسـب نتائجهم المصليــة إلى 31 متعرضــًا لفــيروس التهــاب الكبــد البائــي، و03 غــير ممنعــن مصليــًا، و 65ممنع ــن مصلي ــًا. أم ــا الس ــّتون الباق ــون م ــن 951 مش ــاركًا (83%) لم يوث ــق تلقيه ــم اللق ــاح في السـجات حيـث توزعـوا حسـب نتائجهـم المصليــة إلى 8 متعرضــن، و42 غــير ممنعــن مصلي ــًا، و 82 ممنع ــن مصلي ــًا. المناقشة تش ــير النتائ ــج إلى أّن أكث ــر م ــن ُثُم ــن الم ــرضى المشــاركن في هــذه الدراســة قــد تعرضــوا لع ــدوى الته ــاب الكب ــد البائ ــي، ويرّج ــح أن يع ــود س ــبب انتق ــال الع ــدوى له ــؤلاء الم ــرضى إلى نق ــل ال ــدم بع ــد اس ــتبعادنا ط ــرق انتق ــال فـيروس التهـاب الكبـد البائـي الأخـرى لـدى مجموع ــة الدراس ــة. ق ــد يك ــون ه ــذا الانتق ــال قـد تـم مـن خـال وحـدات دم مقطوفـة مـن مترعـن في مرحلـة النافـذة doirep wodniw، حيـث تمثـل النافـذة المـدة الفاصلـة بـن وجـود الف ــيروس في ال ــدم وظه ــور أح ــد الواس ــات المصلي ــة (21) والت ــي يصع ــب تفاديه ــا رغ ــم الالت ــزام بمعاي ــير منظم ــة الصح ــة العالمي ــة في تح ــري ال ــدم ومش ــتقاته. مــن جهــة أخــرى يشــكل مــرضى الاعتــالات الهيموغلوبينيــة مجموعــة ذات اختطــار عــاٍل لاكتســاب هــذه العــداوى الفيروسـية بسـبب الحاجـة المتكـررة لنقـل الـدم )31)، لذلـك يعتـر التمنيـع الفعـال -inummi noitaz بلقـاح التهـاب الكبـد البائـي الطريقـة الفض ــى لوقايته ــم م ــن الع ــدوى (6). ودلي ــل ذل ــك أن الم ــرضى الأك ــر س ــنًا والذي ــن ول ــدوا قبــل إدخــال لقــاح التهــاب الكبــد البائــي ضمـن برنامـج التلقيـح الوطنـي (عـام 3991) ه ــم في اختط ــار يزي ــد س ــبع م ــرات للإصاب ــة بالعــدوى علــًا أن تطبيــق اللقــاح خّفــض انتش ــار المس ــتضد الس ــطحي لف ــيروس الته ــاب الكبــد البائــي في المجتمــع، وبالتــالي أنقــص الإصابــة لــدى مــرضى نقــل الــدم المتكــرر المتلق ــن للق ــاح ك ــا أش ــارت دراس ــات س ــابقة )41،51). عــى الرغــم مــن أهميــة التلقيــح لــدى ه ــذه المجموع ــة فق ــد بين ــت النتائ ــج المصلي ــة أن الممنّعـن فعـًا لم يشـكلوا أكثـر مـن نصـف المش ــاركن في الدراس ــة، بين ــا كان المش ــاركون الباقــون إمــا مصابــن أو غــير ممنعــن ممــا يزيـد اختطـار تعرضهـم إلى اكتسـاب العـدوى بف ــيروس الته ــاب الكب ــد البائ ــي م ــع كل نق ــل دم يجرون ــه مم ــا يؤك ــد ع ــى ضرورة تلقيحه ــم. مـن جهـة أخـرى وّثقـت السـجات تلقـي اللقـاح لـدى ثلثـي مـرضى دراسـتنا رغـم عـدم نجاعـة التلقيـح لـدى جـزء منهـم وفـق نتائجنـا المصلي ــة الت ــي أثبت ــت أن 4.14% م ــن ه ــؤلاء كانـوا غـير ممنعـن مصليـًا أو تعرضـوا لفـيروس الته ــاب الكب ــد البائ ــي. ويمك ــن تفس ــير ذل ــك بالإصابـة بذريـة فيروسـية تحمـل طفـرات عـى جـن المسـتضد السـطحي S في مناطـق ارتبـاط الأضـداد (61)، أو بضعـف الاسـتجابة المناعيـة أساسـًا لـدى هـؤلاء المـرضى بسـبب فـرط حمـل الحدي ــد النات ــج ع ــن نق ــل ال ــدم المتك ــرر (2)؛ وه ــذا يؤك ــد ع ــى ضرورة مراقب ــة الاس ــتجابة المناعيــة لــدى مجموعــة مــرضى نقــل الــدم المتكـرر مـن خـال متابعـة مسـتويات أضـداد المس ــتضد الس ــطحي للف ــيروس بع ــد التلقي ــح لض ـان وقايته ـم م ـن الع ــدوى (01). أمـا ثلـث المـرضى الذيـن لم توثق سـجاتهم تلقيه ــم اللق ــاح فق ــد أثبت ــت دراس ــتنا المصلي ــة الجدول 1 الصورة المصلية للمرضى المشاركين في الدراسة ونتائج مراجعة السجات الطبية الصورة المصلية الدلالة عدد المرضى (%) تاريخ الولادة توثيق التلقيح في السجات الطبية قبل 3991: 0 1 مريض ملقح بعد 3991: 1 (+) المستضد السطحي لفيروس التهاب الكبد البائي متعرض 1 من 951 )%6.0( )–) ضد المستضد السطحي للفيروس )–) cBH-itna 01 مرضى ملقحن 1 مرضى غير ملقحن قبل 3991: 41 بعد 3991: 2 )–) المستضد السطحي لفيروس التهاب الكبد البائي متعرض 61 من 951 )%1.01( (+) ضد المستضد السطحي للفيروس (+) cBH-itna 2 مريض ملقح 2 مريض غير ملقح قبل 3991: 3 بعد 3991: 1 )–) المستضد السطحي لفيروس التهاب الكبد البائي متعرض 4 من 951 )%5.2( )–) ضد المستضد السطحي للفيروس (+) cBH-itna 65 مريضًا ملقحًا 82 مريضًا غير ملقح قبل 3991: 03 بعد 3991: 45 48 من 951 )%8.25( )–) المستضد السطحي لفيروس التهاب الكبد البائي ممنع (+) ضد المستضد السطحي للفيروس )–) cBH-itna 03 مريضًا ملقحًا 42 مريضًا غير ملقح قبل 3991: 61 بعد 3991: 83 )–) المستضد السطحي لفيروس التهاب الكبد البائي غير ممنع 45 من 951 )%43( )–) ضد المستضد السطحي للفيروس )–) ضد المستضد اللبي للفيروس MA 13:44:11 8102/4/3 258 bdni.21-32 kooB EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 853 دوــ جول ًارــ ظن ًاــ عف نــ عنمم اوــ ناك مــ هفصن نأ اـهدحو سويرـفلل يحطـسلا دضتـسلما دادـضأ ةرـف في حاـقللا مـهيقلت ىـع لدـي اـمم ،مـيهدل دـكؤي اذـهو متهاجـس في كـلذ قـيثوت نود اـم .ضىرـلما ةرـطانم ضرـغب قـيثوتلا ةـيهمأ ىـع تاجاتنتسلاا يــ نطولا حــ يقلتلا جــ مانرل لاــ عفلا قــ يبطتلا نإ باـهتلاب ةـباصلإا راـطتخا ضـيفتخ في مهاـسي تلااــتعلاا ضىرــم ىدــل يــئابلا دــبكلا عــ يجم َحــ يقلت كــ لذ يــ تقيو ،ةــ ينيبولغوميلها تاـعرلجا قـيثوتب مازـتللاا عـم ضىرـلما ءلاؤـه ىدــ ل اــ هتعباتمو ةــ يعانلما ةباجتــ سلاا مــ ييقتو تايوتــسم ةــسياقم لاــخ نــم نــحقللما .سويرــ فلل يحطــ سلا دضتــ سلما دادــ ضأ 1. Soliman HH, Kabbash IA, El-Shanshory MR, Nagy HM, Abdou SH. Evaluation of immune status against hepatitis B in children with thalassemia major in Egypt: A single center study. Journal of microbiology and infectious diseases. 2012; 2(2):44-9. 2. Sharifi Z, Milani S, Shooshtari MM. Study on efficacy of hepatitis B immunization in vaccinated beta thalassemia children in Tehran. Iran J Pediatr. 2010; 20(2):211-5. 3. Karim M, Laham H. Prevalence of viral hepatitis B and C in Syria. Syrian Epidemiological Bulttein. 2008; 2(3):9-11. 4. Ansari SH, Shamsi TS, Khan MT, Perveen K, Farzana T, Erum S et al. Seropositivity of hepatitis C, hepatitis B and HIV in chronically transfused β-thalassaemia major patients. J coll Physicians Surg Pak. 2012; 22(9):610-1. 5. Al-Sheyyab M, Batieha A, El-Khateeb M. The prevalence of hepatitis B, hepatitis C and human immune deficiency virus markers in multi-transfused patients. J Trop Pediatr. 2001; 47(4):239-42. 6. Filippelli M, Lionetti E, Gennaro A, Lanzafame A, Arrigo T, Salpietro C et al. Hepatitis B vaccine by intradermal route in non responder patients: an update. World J Gastroenterol. 2014; 20(30):10383-94. 7. McMahon BJ, Dentinger CM, Bruden D, Zanis C, Peters H, Hurlburt D et al. Antibody levels and protection after hepatitis B vaccine: results of a 22-year follow-up study and response to a booster dose. J Infect Dis. 2009; 200(9):1390-6. 8. ينطولا حيقلتلا جمانرب. Damascus: Ministery of Health; 2015 (http:// www.moh.gov.sy/Default.aspx?tabid=414&language=ar-YE, accessed 04 Sep 2015). 9. Yacoub R, Al Ali R, Moukeh G, Lahdo A, Mouhammad Y, Nasser M. Hepatitis B vaccination status and needlestick injuries among healthcare workers in Syria. J Glob Infect Dis. 2010; 2(1):28-34. 10. Chathuranga LS, Noordeen F, Abeykoon AM. Immune response to hepatitis B vaccine in a group of health care workers in Sri Lanka. Int J Infect Dis. 2013;17(11):1078-9. 11. Froutan-Pishbijari H, Ghofrani H, Mirmomenm S, Kazemi-Asl S, Nassiri-Toosi M, Farahvash MJ et al. Immunogenicity of hepatitis B vaccine in multi-transfused thalassemic patients with and without hepatitis C infection: a comparative study with healthy controls. Med Sci Monit. 2004;10(12): CR679-83. 12. Shyamala V. transfusion transmitted infections in thalassaemics: need for reappraisal of blood screening strategy in India. transfus med. 2014;24(2):79-88. 13. Azarkar Z, Sharifazdeh GHR. Efficacy of HBV vaccination in children with thalassemia major, South Khorasan, Iran. Iran Red Crescent Med J. 2009;14(3):318-20. 14. Mirmomen S, Alavian SM, Hajarizadeh B, Kafaee J, Yektaparast B, Zahedi MJ et al. Epidemiology of hepatitis B, hepatitis C, and human immunodeficiency virus infecions in patients with beta-thalassemia in Iran: a multicenter study. Arch Iran Med. 2006;9(4):319-23. 15. Vidja PJ, Vachhani JH, Sheikh SS, Santwani PM. Blood transfusion transmitted infections in multiple blood transfused patients of beta thalassaemia. Indian J Hematol Blood Transfus. 2011; 27(2):65-9. 16. El-faramawyi AA, El-Rashidy OF, Tawfik PH, Hussein GH. Transfusion transmitted hepatitis: where we do stand now? a one center study in upper Egypt. Hepat Mon. 2012;12(4):286- 91. References عجارلما Book 23-12.indb 853 3/4/2018 11:44:31 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 854 1Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas Health Sciences Center, Houston, Texas. 2Human Link, Hazmieh, Lebanon (Correspondence to: Ghazi Kayali: ghazi@human-link.org). Received: 19/07/16; accepted: 12/02/17 Introduction Hippocrates (around 460−370 BCE) was a Greek physician and philosopher who is considered the father of mod- ern medicine (Figure 1). The history of epidemiology typically starts with Hippocrates in about 400 BCE but then more than 2000 years are skipped until the birth of modern epidemiology in the 17th century CE with the work of John Graunt, followed by William Farr and John Snow in the 19th cen- tury (1). However, between the time of Hippocrates and the 17th century, the Islamic golden age of science occurred (8th−16th century CE) (2). This work attempts to fill this gap of 2000 years by tracing the contribu- tions of Muslim scientists to the field of epidemiology. The epidemiological concepts described by Hippocrates are highlighted followed by a discussion of how his work influenced the work of Muslim scientists, in particular Ibn An- Nafis, who preserved and advanced the field until the European Renaissance. Hippocrates In his book, Of the Epidemics (3), Hip- pocrates introduced several concepts of epidemiology that are considered the fundamentals of modern epidemiol- ogy. His main thesis was that disease causality can be attributed to climate, seasonal variations and location. He noted that habits, regimens and person- al pursuits are all factors associated with disease occurrence. His book included Commentary The forgotten history of pre-modern epidemiology: contribution of Ibn An-Nafis in the Islamic golden era Ghazi Kayali 1,2 a description of the disease prognosis of several patients. Hence, this was the first epidemiology work to present case series, a modern design for observa- tional studies. For most of the cases, he provided information about age, gen- der, place of residence and the seasonal conditions at the time of onset of the illness. After describing the symptoms, Hippocrates described the outcome in terms of morbidity and mortality. He also discussed disease modes of trans- mission and recognized that certain “genetic” predispositions could lead to disease. This was evident when he discussed the case of a feverish woman whose symptoms were brought on by eating grapes and who had a “congenital tendency to phthisis”. Illness of another two cases was attributed to drinking and sexual indulgence. The case of Apol- lonius was clearly a foodborne episode as Hippocrates states that, “Having eaten beef, and drunk unseasonably, he became a little heated at first, and betook himself to bed, and having used large quantities of milk, that of goats and sheep, and both boiled and raw, with a bad diet otherwise, great mischief was occasioned by all these things.” In another book, On Airs, Waters and Places (4), Hippocrates presented the thesis that diseases should be studied in light of the season in which they happen, the quality of the available water and the prevailing environmental conditions. Hippocrates drew a distinction between epidemic and endemic diseases. He explained that a good physician, “as the season and the year advances, he can tell what epidemic diseases will attack the city, either in summer or in winter, and what each individual will be in dan- ger of experiencing from the change of regimen”. Hence, he introduced the concept of endemicity in contrast to epidemic diseases that occur out of the routine. He associates endemicity with the climatic conditions of each region. Another important concept in this book is the association of place, water and food with physical and emotional health. Hippocrates observed that a person’s diet and alcohol consumption were directly associated with disease. He further observed that people with sedentary lifestyles tended to be more obese and those who were obese typi- cally had reproductive health problems. He directly attributed certain diseases to poor water quality. Stagnant waters were directly linked to the occurrence of diarrhoea and dysentery, especially in the summer, while consumption of water with a high mineral content was directly attributed to having kidney problems. Ibn An-Nafis The Muslim-Arab physician Alaa Al- Din Ali Ibn Abi Al-Hazm Al-Qurashi Al-Demashki Al-Masri El-Safii, better known as Ibn An-Nafis, was born in Damascus, Syria in 1210 CE (Figure 1) (5−7). He spent the first half of his life in Damascus where he studied medicine. He then settled in Cairo, Egypt where he practised at its largest hospital at the time, Al-Bimaristan Al-Nasiri (5). He https://doi.org/10.26719/2017.23.12.854 Book 23-12.indb 854 3/4/2018 11:44:31 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 855 lived for 78 years and died in Cairo in 1288 (5). His most influential work was in the field of medicine and he is credited with discovering the pulmo- nary blood circulation (2,6,7). He is also credited with early work in cardiology (8,9). However, his interests extended beyond medicine and included epide- miology, nutrition, Islamic religion and philosophy as evidenced by at least 24 books authored by him. As a scholar, Ibn An-Nafis was influenced by the works of his prede- cessors. He studied the works of Ibn Sina (Avicenna, about 980−1037 CE), Al-Razi (Rhazes, about 865−925 CE), Galen (about 130−199 CE) and Hippocrates (2,5,10). It is worthwhile mentioning here that the vast majority of the works of Hippocrates and Galen were translated into Arabic, especially by the Christian-Arab scholars Hanin Ibn Ishaq, Yuhanna Ibn Al-Batriq and Qusta Ibn Luqa (5). As an epidemi- ologist, Ibn An-Nafis was influenced by Hippocrates and his most relevant work was A commentary on Hippocrates’ “Of the Epidemics”. Ibn An-Nafis also wrote A commentary on Hippocrates’ Aphorisms based on the Aphorisms of Hippocrates where both authors, each in his own book, showed their prowess as early epidemiologists. A commentary on Hippocrates’ "Of the Epidemics" (Sharh Kitab Al-Epidemia) (11) Hippocrates’ book Of the Epidemics was translated into Arabic by Ibn Ishaq, based on which, Ibn An-Nafis wrote his commentary on Of the Epidemics. An ancient Arabic copy of this book dated 1215 AH (1800−1801 CE) is available on microfilm at the Egyptian National Library and Archives in Cairo and was reviewed for this analysis (Figures 2 and 3). Ibn An-Nafis’ book was not a mere translation of the original work by Hippocrates but rather a critical ap- praisal of it. In the first constitution of Hippo- crates’ Of the Epidemics, Hippocrates opens with the phrase: “In Thasus, about the autumn equinox, and under the Pleiades…”. Ibn An-Nafis opened his book by providing an explanation of why Hippocrates specified the location “Thasus” explaining that geographic location and not only climate is impor- tant when studying disease occurrence. Both scholars embraced the notion that imbalances in temperature and humidity were causes of disease, an ac- cepted biological dogma in their times. However, Ibn An-Nafis tries to provide biological plausibility for this notion by giving a potential biological mechanism, according to the accepted biological concepts of the time, through which hu- midity can cause disease. Both scholars described the distribution of disease by Figure 1 Hippocrates (left) and Ibn An-Nafis (right) Book 23-12.indb 855 3/4/2018 11:44:31 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 856 demographic categories, but Ibn An- Nafis explained that people of different ages and genders have different biologi- cal processes and occupational hazards that contribute to the onset of disease. In his analysis of the second consti- tution, Ibn An-Nafis explained the ex- posure−outcome association laid down by Hippocrates. He provided a better definition of the seasons (exposure) using astrological signs, and then cat- egorized outcome under several groups from mild to severe. An example here would be Ibn An-Nafis’ categorization of respiratory illness from mild colds to tuberculosis. In the explanation of the third constitution, the influence of Persian medical practice on Ibn An-Nafis is also evident. He uses the Persian term (bersam/sersam) to explain what Hippocrates meant by phrenitis (an inflammation of the body and mind). In this section, Hippocrates discussed seasonality of disease, changes in the elements, geographic distribution and associated risk factors and Ibn An-Nafis provided examples. A significant portion of Of the Epidemics is dedicated to describing a series of cases of illness. Ibn An-Nafis provided some biological explanations for the disease prognosis for some of those cases. In addition, Ibn An-Nafis used what Hippocrates described to compare and contrasts cases and out- breaks of diseases that he handled. For example, Ibn An-Nafis compares an outbreak of malnutrition in Damascus to that described by Hippocrates. Both scholars clearly describe the location of cases as if drawing an outbreak map as did John Snow hundreds of years later. In addition, Ibn An-Nafis described cases of anthrax, linking incidence to climate and demonstrating that when a person has minor uncovered wounds, there is a risk of infection that typically ends with death. Figure 2 First page of Ibn An-Nafis book A commentary on Hippocrates’ "Of the Epidemics". An ancient Arabic language copy of this book, dated 1215 AH (1800−1801 CE), at the Egyptian National Library and Archives in Cairo was reviewed for this manuscript. Book 23-12.indb 856 3/4/2018 11:44:32 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 857 References 1. Prinicples of epidemiology in public health practice. Atlanta: Centers for Diesease Contriol and Prevention; 2012 (http:// www.cdc.gov/ophss/csels/dsepd/ss1978/lesson1/section2. html, accessed 27 Ocober 2017). 2. West JB. Ibn al-Nafis, the pulmonary circulation, and the Is- lamic Golden Age. J Appl Physiol. 2008; 105(6):1877−80. 3. Hippocrates. Of the epidemics. Kessinger Legacy Reprints. Montana: Kessinger Publishing; 2012. 4. Hippocrates. On airs, waters and places. Kessinger Legacy Re- prints. Montana: Kessinger Publishing; 2009. 5. Abdel Kader M, Zeedan Y. Sharh Fusul Bocrat [A commentary on Hippocrates aphorisms]. Cairo: Al-Dar Al-Masriah Al- Lubnaniah; 1991 [In Arabic]. 6. Akmal M, Zulkifle M, Ansari A. Ibn Nafis − a forgotten genius in the discovery of pulmonary blood circulation. Heart Views. 2010 Mar;11(1):26–30. PMID:21042463 7. Loukas M, Lam R, Tubbs RS, Shoja MM, Apaydin N. Ibn al-Nafis (1210-1288): the first description of the pulmonary circulation. Am Surg. 2008 May;74(5):440–2. PMID:18481505 8. Baharvand-Ahmadi B, Bahmani M, Zargaran A. Ibn Nafis and the early description of the role of coronary arteries in blood supply of the heart. Int J Cardiol. 2016 Feb 1;204:131–2. PMID:26657607 9. Numan MT. Ibn Al Nafis: his seminal contributions to cardiolo- gy. Pediatr Cardiol. 2014 Oct;35(7):1088–90. PMID:25096906 10. Lakhtakia R. A trio of exemplars of medieval Islamic medicine: Al-razi, Avicenna and Ibn Al-Nafis. Sultan Qaboos Univ Med J. 2014 Nov;14(4):e455–9. PMID:25364546 11. Ibn An-Nafis A. Sharh Kitab Al-Epidemia [A commentary on Hippocrates’ Of the epidemics. Cairo: Dar El-Kotob Al-Masri- ah; before 1288 [In Arabic]. A commentary on Hippocrates’ Aphorisms (Sharh Fusul Bocrat) (5) Hippocrates’ Aphorisms was translated by Ibn Ishaq and based on this transla- tion Ibn An-Nafis wrote his commen- tary. Hippocrates discussed the role of seasonality, changes in climate, rain and wind on disease incidence. Ibn An- Nafis attempted to provide biological plausibility to this by explaining how these factors affect different organs. For example, Ibn An-Nafis explained that winds may carry diseases hence dem- onstrating the occurrence of airborne respiratory illness. When discussing the role of location, Ibn An-Nafis explained that different disease patterns occur in different locations due to differences not only in climate but also in the body types of people living in different loca- tions, hence suggesting the role genetics in disease predisposition. Conclusion Modern epidemiology was shaped by the work of 16th century scientists. However, when discussing the history of pre-modern epidemiology, discussing the work of Hippocrates only is a com- mon mistake. Hippocrates remains the father of epidemiology but the field was a scholarly topic for Muslim scientists who excelled during the Islamic golden age between the 8th and 16th centuries Figure 3 Last paragraph of Ibn An-Nafis book A commentary on Hippocrates’ “Of the epidemics”. CE. Influenced by Hippocrates, these scholars, and in particular Ibn An-Nafis, moved the science of epidemiology forward. Hence, their work deserves to be credited. It becomes more plausible since the works of Hippocrates were preserved through their translation to Arabic and through the critical apprais- als of them by Muslim scholars. Renais- sance and modern era scientist then studied the Latin translations of Arabic works which led to the rise of modern epidemiology. Hence, the evolution of epidemiology, similar to other sciences, was a continuum that was contributed to by different civilizations in different eras. Acknowledgements I am grateful to Dr Youssef Ziedan for his guidance. Dr Ziedan is an Egyptian scholar specializing in Arabic and Is- lamic studies. He has directed a number of projects aimed at the delimitation and preservation of Arabic manuscripts. His academic work on documenting the works of Ibn An-Nafis and other Muslim scientists was crucial to the preparation of this manuscript. Funding: None Competing interests: None declared. Book 23-12.indb 857 3/4/2018 11:44:32 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 858 WHO events addressing public health priorities Key lessons learnt over the two decades since the imple- mentation of the Integrated Management of Childhood Ill- ness (IMCI) platform (1) have highlighted difficulties faced by regional governments and partners in engaging the private sector in the implementation of the platform. Currently, there has been a focus on training of health care providers only, while investment in supervision has been inadequate and lim- ited emphasis has been placed on community care. Country level health systems have not been responsive to integrated management of childhood illness implementation needs (1). In order to address these shortcomings, a consultative meeting on redesigning the integrated approach to child health in line with the United Nations Sustainable Develop- ment Goals and other related global initiatives was held in Cairo, Egypt, from 24 to 26 September 2017. A total of 28 participants from ministries of health, the academic com- munity, regional and global experts from the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), attended the meeting (2). This consultative meeting aimed to discuss and agree on future directions and a clear framework for action for newborn, child and adolescent health in the Region. The objectives of the meeting were to analyse the implications of the findings of the IMCI global strategic review in countries of the Region. Thus, determine necessary action to be included in the draft of the proposed regional framework for child and adolescent health and development 2018–2025. In addition, there was a review of the draft regional framework for child and adolescent health and development, taking into account emerging newborn and child health issues, and propose mechanisms of alignment with existing platforms, includ- ing the IMCI; propose concrete guidance on child health programming in humanitarian contexts; and suggest practical steps to operationalize the guidance (2). The inaugural speech of the late Dr Mahmoud Fikri, Regional Director, WHO Regional Office for the Eastern Mediterranean (WHO/EMRO), was presented on his behalf by Dr Maha Eladawy, Director, Health Protection and Promotion (WHO/EMRO). In his opening remarks, Dr Fikri stated that the proposed regional framework for child and adolescent health and development 2018–2025 represented a unique platform to bring together all related programmes and concerned sectors along with United Nations agencies and nongovernmental organizations. In ad- dition, Dr Anirban Chatterjee, Regional Adviser, Health and Nutrition, UNICEF Middle East and North Africa Regional Office (MENARO) reiterated UNICEF’s commitment to advancing the issues of child and adolescent health in coordi- nation with WHO and other partners. Summary of discussions Global and regional overviews of the current status of child and adolescent health were presented by WHO head- quarters and EMRO representatives, respectively, followed by presentations on the outcomes of the WHO global child survival and health strategic review and implications for the Region. To address the highlighted issues during the consulta- tion’s deliberations, participants proposed the following priority actions (2): • advocating for the redesigned package of child health services within the regional framework; • identifying the package of services for children under 5 years to be included in the pre- and in- service training of health providers; • agreeing on the multisectoral scope and roles of stakeholders; • revitalizing/establishing national child health steering committees; • including the IMCI platform as part of country- level mandatory continuous professional devel- opment and care-provider re-licensing; • engaging professional associations in IMCI training courses/evaluation/curricula updates; • including the IMCI platform in national health insurance packages; and • using integrated supervisory checklists at country level. Redesigning the integrated approach to child health in line with the United Nations Sustainable Development Goals1 1 This report is extracted from the Summary report on the Consultative meeting on redesigning the integrated approach to child health in line with the United Nations Sustainable Development Goals and other related global initiatives, Cairo, Egypt, 26–24 September 2017 (http://applications.emro.who.int/docs/IC_Meet_Rep_2017_EN_20198.pdf?ua=1, accessed 18 January 2018). https://doi.org/10.26719/2017.23.12.858 Book 23-12.indb 858 3/4/2018 11:44:32 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شرع نياثلا ددعلا 859 In light of the draft WHO global conceptual framework to redesign child health in line with the United Nations Sus- tainable Development Goals2, participants also discussed the proposed regional framework for child and adolescent health and development 2018–2025, along with regional child and adolescent health goals, targets and milestones with respect to the Sustainable Development Goals, the United Nations Global Strategy for Women’s, Children’s and Adolescent Health 2016–2030, and the Roadmap of WHO’s work for the Eastern Mediterranean Region 2017–2021 (3). Discussions also addressed the current gaps in maternal, newborn, child and adolescent health in humanitarian crisis settings, and the role of the Regional Office in these settings, and concluded that health programme integration is vital in emergency settings (2). The following recommendations were put forward: • an essential package of services should be de- fined for maternal, newborn child and adolescent health, and health kits should be developed for emergency settings; • an inter-agency working group is needed to sup- port partnership and alignment, with an initial global group leading the establishment of re- gional groups; • child and adolescent health indicators must clas- sify information according to age and sex, and this should also be applied to all existing assess- ment tools; • during emergencies, countries should make every attempt to maintain existing health sys- tems, but if this is not possible, then they should simplify the health indicators; and • build upon the successful experience of the nutri- tion cluster in relation to emergency situations, and the WHO Expanded Programme on Immu- nization (4) experience of developing a decision- makers’ tool and programme implementation guidelines. References 1. World Health Organization. Integrated management of child- hood illness (IMCI) (http://www.who.int/maternal_child_ad- olescent/topics/child/imci/en/, accessed 18 January 2018). 2. WHO Regional Office for the Eastern Mediterranean (EMRO). Summary report on the Consultative meeting on redesigning the integrated approach to child health in line with the United Nations Sustainable Development Goals and other related global initiatives. Cairo: EMRO; 2017 (http://applications. emro.who.int/docs/IC_Meet_Rep_2017_EN_20198.pdf?ua=1, accessed 18 January 2018). 3. WHO Regional Office for the Eastern Mediterranean (EMRO. Roadmap of WHO’s work for the Eastern Mediterranean Region. Cairo: EMRO; 2017 (http://apps.who.int/iris/ bitstream/10665/258986/1/EMROPUB_2017_19695_EN.pdf, accessed 18 January 2018). 4. World Health Organization. The expanded programme on immunization. Geneva: World Health Organization; 2013 (http://www.who.int/immunization/programmes_systems/ supply_chain/benefits_of_immunization/en/, accessed 18 January 2018). 2 SDG 3.2: By 20130, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under5- mortality to at least as low as 25 per 1000 live births. Book 23-12.indb 859 3/4/2018 11:44:32 AM EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con- cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col- laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser-vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collabora- teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/ EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). © World Health Organization (WHO) 2017. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Disclaimer. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. If authors are staff members of the World Health Organization, the authors alone are responsible for the views expressed in this publication and do not necessarily represent the decisions, policy or views of the World Health Organization. ISSN 1020-3397 تاسايسلا ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه يرغو ثاحبلأا جئاتنو ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تايلكلاو ،ةيحصلا نهلما ءاضعأ لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا .هجراخو ميلقلإا فى ةحصلاب ينمتهلما طسوتلما قشرل ةيحصلا ةلجلما Correspondence Editor-in-chief Eastern Mediterranean Health Journal 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: emrgoemhj@who.int طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ايبيل . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . نميلا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . 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 . Libye . Jordanie . Koweït . Liban . 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Cover 23-12.indd 8-10 2/26/2018 7:37:37 AM Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 23 / No. 12 December/Décembre 12 ددع / نوشرعلاو ثلاثلا دلجلما لولأا نوناك/برمسيد2017 Contents V o lu m e 2 3 N u m b er 1 2 D ecem b er 2 0 1 7 A sound understanding of the context in which health systems must operate is essential in order to formulate effective policy-making, which can only be realized through the very best research evidence available, and is a priority for the many critical situations present in the Eastern Mediterranean Region. Editorial Improving evidence informed policy-making for health in the Eastern Mediterranean Region .......................... 793 Research articles Independent prescription of medicines and diagnostic test advice by final year medical students in Punjab .................................................................................................................................................................... 795 Challenges impeding integration of oral health into primary health care .............................................................802 Caractérisation génétique du sous-groupe Maculipennis (Diptera : Culicidae) au Maroc : un outil fondamental pour lutter contre le paludisme ................................................................................................................................809 Assessment of the quality of life in patients on haemodialysis in Iraq ....................................................................815 Trend and seroprevalence of Epstein–Barr virus in Bahrain: 2001–2015 ..................................................................821 Investigation of breastfeeding training based on BASNEF model on the intensity of postpartum blues .............830 Changes in dietary habits and physical activity and status of metabolic syndrome among expatriates in Saudi Arabia ........................................................................................................................................................... 836 Réflexions éthiques sur le principe de l’autonomie du patient .............................................................................. 845 ايروس في رركتلما مدلا لقن ضىرم ىدل يئابلا سيويرفلا دبكلا باهتلا ّدض ميعطتلا ةيلعاف مييقت .......................................................850 Commentary The forgotten history of pre-modern epidemiology: contribution of Ibn An-Nafis in the Islamic golden era .... 854 WHO events addressing public health priorities Redesigning the integrated approach to child health in line with the United Nations Sustainable Development Goals .................................................................................................................................................. 858 Cover 23-12.indd 5-7 2/26/2018 7:37:37 AM