Eastern Mediterranean Health Journal [2006; Vol.12, Issue 5]

504 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 ٢٠٠٦ ،٥ ددعلا ،رشع نياثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Adjunct therapy with corticosteroids or paracentesis for treatment of tuberculous pleural effusion A.A. Mansour1 and T.B. Al-Rbeay2 1Department of Medicine, Basra College of Medicine, Basra, Iraq (Correspondence to A.A. Mansour: aambaam@yahoo.com). 2Chest Hospital, Basra, Iraq. Received: 20/09/04; accepted: 22/02/05 ABSTRACT To determine the effect of adjunct therapy, we carried out a prospective cohort study on 190 patients with tuberculous pleural effusion during May 2003–April 2004. Patients were divided into 3 groups. All groups were treated with anti-tuberculosis (TB) drugs for 6 months; in group 2 (n = 46) prednisolone, 30 mg/day for 10 days, was added; group 3 (n = 78) were given paracentesis to remove fluid. Fever and constitutional symptoms disappeared faster in group 2 (P > 0.05). After 10 days, there was a significantly greater reduction in the size of pleural effusion in group 2, but after 6 months the difference was not statistically significant. We found corticosteroids and therapeutic paracentesis are not necessary in the management of TB pleural effusion. Ê·èj¶=¿‚=H>Fr¾×=TØ£¶¹hF¶>EÆ?L=bÈÆJidzÉIedz¶>EÌb¢>j™=͂>£™= Ê£ÉEf¶=KÉ~Ð>Éu(eÇr¿ºÊ·¢l>F¢  „=Í[qØ6e>È?ÀºÌb™=›ÍÉ®>FJi×=ÍÉE=fIÙ=Íi=eb¶=ÅdÂKÈfQî?+ÇÈ>[º2003Á>j[ɾ‘C+¸[ÈfEC2004zf[§E( η¢Ìb¢>j™=͂>£™=M@Iη¢­èf£J¶=190Ê·èj¶=¿‚=H>Fr¾×>EE>r™=Îuf™=Àº*‘CÎ[uf™=¼ëj[î®b®Æ L>ÒªPØM*Ìb[™¸j·¶Ìa>v™=ÍÈÆaÙ>EL>Ò«¶=Åd¤ɖ͂>£ºK“Æ6Í[ɾ>N¶=Í[Ò«¶=>[º?7fÃ[m?%>Âab[¢Æ46 ð>vÈfº$¯ª¹b£’ÁǶÆhɾbȶ=>ÃɶC¬Éuî?b30¨ º+Ìb™½ÇÈ10Í[N¶>N¶=Í[Ò«¶=>[º?Æ7½>[È?%>Âab[¢Æ78ð>v[Èfº$ ¸ Ñ=Çj¶=\áhß¿¶¹hF¶=>ËfQî@ª*Í[Ò«¶=›[²?Í[[[[¢fj[EÍ[ÈÇÉ¿F¶=z=f[¢Ù=ÆÎç»àV[[¶=z=f¢?Ð>«J]= UǶb®Æ Í[ɾ>N¶=%0.05>P*$b£EÆ10bE²?z>«Š= UǶ½>È?›¿[‚=H>Fr[¾×=¼[RU›ð>ÉÑ>r[UC>[ÃEèbßJá£àÈÍQe b£Eð>ÉÑ>rUCÄEèbJá£àÈOÉ}±f«¶=À³ÈÀ³¶Æ(Íɾ>N¶=ÍÒ«¶=6fÃm?*½Æh[¶×Ä[¾?Í[i=eb¶=À[ºÁ>NU>F¶=SJ¿Ji=Æ Ê·èj¶=¿‚=H>Fr¾×=TØ¢›ÊQØ£¶=¹hF¶=Æ?L=bÈÆJidzÉIedz¶=Ð>ì¢Ý*  Corticothérapie adjuvante ou ponction pour le traitement de l’épanchement pleural tuberculeux RÉSUMÉ Afin de déterminer l’effet de la thérapie adjuvante, nous avons réalisé une étude de cohorte prospective chez 190 patients atteints d’épanchement pleural tuberculeux entre mai 2003 et avril 2004. Les patients ont été répartis en trois groupes. Tous les groupes ont été traités par antituberculeux pendant 6 mois ; dans le groupe 2 (n = 46), on a donné en supplément 30 mg/jour de prednisolone pendant 10 jours ; dans le groupe 3 (n = 78), les sujets ont subi une ponction pour drainer le liquide. La fièvre et les symptômes constitutionnels ont disparu plus rapidement dans le groupe 2 (p > 0,05). Après 10 jours, il y avait une réduction significativement plus importante de la dimension de l’épanchement pleural dans le groupe 2, mais après 6 mois, la différence n’était pas statistiquement significative. On constate que les corticoïdes et la ponction évacuatrice ne sont pas nécessaires pour la prise en charge de l’épanchement pleural tuberculeux. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 505 ٢٠٠٦ ،٥ ددعلا ،رشع نياثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction According to World Health Organization (WHO) recommendations, tuberculous pleural effusion is treated according to the category III regimen: 2 months with 3 anti-tuberculosis (TB) drugs followed by 4 months with 2 anti-TB drugs [1]. Adjunct therapy with corticosteroids or pleural fluid aspiration until dryness have been recommended by some research- ers [2–5]. Corticosteroids in conjunction with anti-TB drugs may be appropriate in particular forms of TB such as tuberculous meningitis and pericardial and pleural dis- ease [6]. Cohen and Sahn, however, do not recommended routine use of corticosteroids in tuberculous pleural effusion unless there are acute symptoms such as fever, chest pain or dyspnoea that are disturbing to the patient [7]. It has even been suggested that there is insufficient evidence for the effectiveness of adjunctive corticosteroid treatment in such patients [8]. Drug interac- tion with rifampin should, naturally, be taken into consideration [9]. The aim of this study was to determine the effect of adjunct therapy (corticosteroids and paracentesis) on tuberculous pleural ef- fusion with regard to symptoms, size of the effusion and pleural thickening (scarring). Methods We carried out a prospective cohort study of all patients with TB pleural effusion (all biopsy and biochemically confirmed) in Al-Faiha hospital in Basra, Iraq, from May 2003 to April 2004. The study protocol was explained for all patients and informed consent was taken from them. Patients were recruited in 3 groups: group 1 were enrolled in the first 4 months of the study, group 2 after 4 months and group 3 were enrolled in the last 6 months of the study. For all par- ticipants, the total duration of anti-TB drugs was 6 months. The patients in group 1 (n = 66) were treated with anti-TB drugs only for 6 months, in line with WHO recommenda- tions [1]. Those in group 2 (n = 46) were given the same anti-TB drugs plus corti- costeroids in the form of prednisolone, 30 mg/day for 10 days. The patients in group 3 (n = 78) were treated with the same anti-TB drugs plus ≥ 1 paracentesis on an as-needed basis to remove as much of the fluid as pos- sible until near dryness. All patients were treated in hospital for at least 10 days. Daily records for presence or absence of malaise, anorexia, weakness and night sweating were completed by the doctor using a chart prepared specifically for the purpose. The size of pleural effusion was estimat- ed according to the chest X-ray findings. Opacified hemithorax of ≥ two thirds of the hemithorax was classified as severe grade; if it involved > one third of the hemithorax but < two thirds, it was considered moder- ate grade; if it involved ≤ one third of the hemithorax, it was considered mild grade pleural effusion. A chest X-ray was taken on diagnosis, again after 10 days, and then monthly for the 6 months of treatment. Reduction in pleural effusion was considered to be 50% if the amount of fluid decreased to a lower grade or 25% if there was reduction in the amount of fluid but still within the same grade. The size of residual pleural thickening (scarring) was estimated using the same measurement grades as pleural effusion (≥ two thirds of the hemithorax, > one third but < two thirds, and ≤ one third). The term “obliteration of costophrenic angle” was used when the angle was > 90º. For statistical analysis, the chi-squared test was used as appropriate. P < 0.05 was considered significant throughout the analy- sis. 506 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 ٢٠٠٦ ،٥ ددعلا ،رشع نياثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Results The total number of patients was 190, 185 males and 5 females (2 in group 1, 2 in group 2 and 1 in group 3). Age range was 17–45 years. There were no significant dif- ferences between the 3 groups regarding age, sex or clinical symptoms (Table 1). The time of disappearance of fever and constitutional symptoms (malaise, anorexia, weakness, and night sweating) in the group who were treated with adjunct corticoster- oids was 4 [standard deviation (SD) 3.2] days compared to 1 (SD 1.3) week in the other 2 groups (P > 0.05). Two patients, 1 in the corticosteroid group and the other in group 1, showed paradoxical response to anti-TB drugs with increase in fever and size of pleural effusion that lasted for 1 month. Comparisons between lines of treatment of tuberculous pleural effusion are shown in Table 1. There were no differences between the 3 treatment groups with regard to extent of pleural thickening. After 10 days, there was > 50% reduction in the size of pleural effusion in the group having adjunct cor- ticosteroid treatment (group 2) compared with 25% in the other groups. In all groups, there was progressive reduction of size of pleural effusion up to the third month of treatment. After 6 months there was, how- ever, no statistically significant difference between the 3 groups. Table 1 Comparison of 3 lines of treatment for tuberculous pleural effusion (size of pleural effusion before treatment and pleural thickening at the end of treatment) Variable Treatment Total Anti-TB With steroidb With alonea paracentesisc No. % No. % No. % No. Size of pleural effusion before treatmentd Severe 8 12.1 13 28.3 31 39.7 52 Moderate 23 34.8 18 39.1 13 16.7 54 Mild 35 53.0 15 32.6 34 43.6 84 Pleural thickening after 6 months treatmentd Severe 2 3.0 0 – 2 2.6 4 Moderate 4 6.1 0 – 3 3.8 7 Mild 12 18.2 17e 37.0 11e 14.1 40 Obliteration of costophrenic angle 43 65.2 16e 34.7 59e 75.6 118 Normal chest X-ray 5 7.6 13e 28.3 3e 3.8 21 Total 66 46 78 190 aMean age 30 (standard deviation 12.5) years. bMean age 34 (standard deviation 11.4) years. cMean age 28 (standard deviation 10.6) years. dSevere: ≥ 2/3 of the hemithorax; moderate: > 1/3 but < 2/3; mild: ≤ 1/3. eP-value > 0.05 (compared with anti-TB drugs alone). Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 507 ٢٠٠٦ ،٥ ددعلا ،رشع نياثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما No significant relation was found be- tween size of effusion and later pleural scarring (Table 2). Discussion Corticosteroids have been shown to be ben- eficial in treatment of TB [6,10,11] although in the study of Kalita and Misra no benefit was shown, even in tuberculous meningitis [12]. This is not absolute fact, and adjunc- tive corticosteroid therapy appears to offer significant short-term, but minimal long- term, benefit for patients with TB [11]. In our study, corticosteroids hastened the recovery of constitutional symptoms and led to early reduction in symptoms, but after 6 months there was no difference be- tween the groups. Some researchers are of the opinion that, although benefit has been shown in pleural disease, adjunct therapy is not routinely required unless there are significant systemic symptoms of fever or a particularly large effusion [6]. Though corticosteroids may bring about more rapid resolution of pleural effusion with less pleural scarring, scarring only rarely presents a problem in any event [5,13]. Some even advocate repeated paracentesis as superior to other treatments [5,7]. Similar findings to those in our study were reported in 3 previous studies [3–5], but one of those showed no clinical dif- ferences, even in resolution of symptoms in the corticosteroid group, compared to placebo [5]. There were some limitations in this study. There may have been selection bias for the 3 groups, since there was no real randomization and the groups were divided according to the time they presented to us rather than any other parameter, and the duration of corticosteroid treatment may have been shorter and the dosage lower than in previous studies [3–5]. In conclusion, corticosteroid treatment and therapeutic paracentesis are not neces- sary in the management of tuberculous pleural effusion, and have no effect on extent of residual pleural thickening after 6 months treatment with anti-TB drugs. Table 2 Comparison of size of pleural effusion at presentation and residual pleural thickening after 6 months treatment Residual thickeninga Pleural effusiona Total Mild Moderate Severe No. % No. % No. % No. Severe – 1 1.8 3 5.7 4 Moderate – 3 5.6 4b 7.7 7 Mild 12 14.3 17b 31.5 11b 21.2 40 Obliteration of costophrenic angle 60 71.4 27b 50.0 31b 59.6 118 Normal chest X-ray 12 14.3 6b 11.1 3b 5.8 21 Total 84 54 52 190 aSevere: ≥ 2/3 of the hemithorax; moderate: > 1/3 but < 2/3; mild: ≤ 1/3. bP-value > 0.05. 508 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 ٢٠٠٦ ،٥ ددعلا ،رشع نياثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما References 1. Maher D et al. Treatment of tuberculosis: guidelines for national programmes, 2nd ed. Geneva, World Health Organization, 1997:29. 2. Satya Sri S. Textbook of pulmonary and extrapulmonary tuberculosis, 2nd ed. New Delhi, Interprint, 1995:82–6. 3. Lee C et al. Corticosteroids in the treat- ment of tuberculous pleurisy: a double- blind, placebo-controlled, randomized study. Chest, 1988, 94(6):1256–9. 4. Galarza I et al. Randomised trial of corti- costeroids in the treatment of tuberculous pleurisy. Thorax, 1995, 50(12):1305–7. 5. Wyser C et al. Corticosteroids in the treat- ment of tuberculous pleurisy: a double- blind, placebo-controlled, randomized study. Chest, 1996, 110(2):333–8. 6. Alzeer AH, FitzGerald JM. Corticosteroids and tuberculosis: risks and use as adjunct therapy. Tubercle and lung disease, 1993, 74(1):6–11. 7. Cohen M, Sahn SA. Resolution of pleural effusions. Chest, 2001, 119(5):1547–62. 8. Matchaba PT, Volmink J. Steroids for treating tuberculous pleurisy. Cochrane database of systematic reviews, 2000, 2. 9. Grange JM, Winstanley PA, Davies PDO. Clinically significant drug interactions with antituberculosis agents. Drug safety, 1994, 11(4):242–51. 10. Alarifi A, Nylen ES. Dislodging sacred dogmas in combating systemic stress: the case for steroids. Annals of Saudi medicine, 2000, 20(5,6):358–9. 11. Dooley DP, Carpenter JL, Rademacher S. Adjunctive corticosteroids therapy for tuberculosis: a critical reappraisal of the literature. Clinical infectious diseases, 1997, 25(4):872–87. 12. Kalita J, Misra UK. Effect of methyl pred- nisolone on sensory motor functions in tuberculous meningitis. Neurology India, 2001, 49(3):267–71. 13. Hopewell PC. Tuberculosis and nontu- berculous mycobacterial infections. In: Stein JH, Daly WJ, eds. Internal medi- cine, 2nd ed. Boston, Little, Brown & Co., 1987:1731–48. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 509 Knowledge of tuberculosis among medical professionals and university students in Oman A.A. Al-Jabri,1 A.S.S. Dorvlo,2 S. Al-Rahbi,1 J. Al-Abri1 and S. Al-Adawi1 1Department of Behavioural Medicine, Microbiology and Immunology, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman (Correspondence to S. Al-Adawi: adawi@squ.edu.om). 2Department of Mathematics and Statistics, College of Science, Sultan Qaboos University, Muscat, Oman. Received: 24/02/04; accepted: 14/02/05 ABSTRACT This study in Oman investigated knowledge about tuberculosis among 142 medics (medi- cal students, paramedics) and 133 non-medics (arts and social science students). Knowledge was assessed using a validated questionnaire with 28 statements on general knowledge, risk factors and diagnosis of tuberculosis. As expected, tuberculosis knowledge was significantly higher among medics but there was no significant difference between men and women. Although medics had better knowl- edge in general, some of the technical statements were answered correctly by higher proportions of non-medics. 4 Knowledge of tuberculosis among medical professionals and university Ø{ÆÍÉFì¶=ÀÙ=H>Ee?­e>£º¸j¶=¹ÇUÁ>»à¢›Gì¶=H ËÆb£¶=(Ë£¶=Á>ÃÉQ(Uf¶=Íɺ>i(Ç·ªeÆaÇjI?(ËfE>‚==bF¢Ê·¢  „=Í[qØ6Ïb[¶>ºη¢Á>[»à¢›KÈfQî?¶=Íi=eb¶=Åd[ÂKªçf£I142º[[ëÉFì¶=ÀÈb¢>j™=ÆGì¶=HØ{À Æ133ÍÉFì¶=¦½Ç·£¶=ÍF·{Àº%ÍÉ¢>»JQ×=½Ç·£¶=ÆH=aÛ=ÍF·{¸Nº$¸j¶=¹ÇU­e>£ºÀº*­e>[£™=Kß»ëÉî®Æ Àç»vJÈÍVr¶=±ÇMǺÁ>ÉFJi=½=b^Ji>E28¸j¶=sÉ^nIÆÌeÇì„=¸º=Ç¢Æ(ͺ>£¶=­e>£™=¹ÇUeÆbIÌe>F¢* ²(¤õ®ÇJºÇÂ>»²ÆÁÆa(¼Â¦­e>£ºÀºžÇV·º¸³nEÆfN²?[ÉFì¶=ÀÈb¢>j™=ÆGì¶=HØ{­e>£ºK¾> Ð>j¿¶=ƹ>Qf¶=E±fªµ>¿ÂÁdzÈÁ?*À[ºf[N²?­e>[£º[[ÉFì¶=ÀÈb¢>j[™=ÆG[ì¶=HØ[{Ïb¶Á?¼¦eÆ ¶=Í[F·{À[ºF²¼j®Ïb¶ÍVÉVqL>E>QDEKɟUb®ÍÉ¿¯J¶=L=e>F£¶=x£EÁDª(½>¢¸³nE¼Â¦[¦½Ç[·£ ÍÉFì¶=*    Connaissances concernant la tuberculose chez les professionnels médicaux et les étudiants universitaires à Oman RÉSUMÉ La présente étude réalisée à Oman a examiné les connaissances concernant la tuberculose chez 142 étudiants en médecine et paramédicaux (les « médicaux ») et 133 étudiants de premier cy- cle en lettres et en sciences sociales (les « non-médicaux »). Les connaissances ont été évaluées au moyen d’un questionnaire validé comportant 28 affirmations relatives aux connaissances générales, aux facteurs de risque et au diagnostic de la tuberculose. Comme on pouvait s’y attendre, le niveau des connaissances concernant la tuberculose était significativement plus élevé chez les médicaux mais il n’y avait pas de différence significative entre les hommes et les femmes. Même si les médicaux avaient de meilleures connaissances en général, une réponse correcte a été fournie à certaines affirmations techniques par une plus grande proportion de non-médicaux. 510 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Introduction Globally, tuberculosis (TB) is regarded as one of the highest burden communicable diseases [1]. One-third of the world’s popu- lation is already infected with the TB bacte- rium. By 2020 an estimated 200 million of these people would contract TB and there would be about 35 million deaths among them unless the infection rate is halted [1]. The situation is especially challenging in Asia, the Middle East and Africa [2] where there is a relatively high incidence of TB. As HIV-seropositivity tends to adverse- ly amplify the severity of other immune- compromised conditions such as TB, the real incidence is likely to be even higher. One essential step for adequate contain- ment of TB is to ascertain the understanding in society of its risk factors, mode of trans- mission and diagnosis. It is becoming in- creasingly clear that many problems which were previously thought of as primarily biomedical are in fact more appropriately disentangled by changing individual and social attitudes and behaviour. TB- and HIV-related knowledge, attitudes, beliefs and practices have been examined in differ- ent parts of the world [3,4] and suggest the presence of a pervasive misunderstanding about the disease. TB is thought to be due to “idleness and generative tendency” and in some communities the word for TB is often associated with an insult [4]. TB has been thought to be hereditary, triggered by smok- ing, alcohol, even hard work, as well as ex- posure to cold [4]. Sufferers may hide their condition for fear of desertion, rejection or being blamed for spreading TB [4]. With the onset of the AIDS pandemic, the stigma of HIV has increased the existing stigma surrounding TB [5]. Such negative attitudes also persist among health care professionals. As TB control is essentially a management problem and health care professionals play a vital role, negative opinions among them are likely to have a wide-ranging influence, affecting the personal consequences of in- fection, prevention, care and management of the disease. Education may be one of the principal means for reducing or even halting the spread of TB. As groundwork for embarking on such an undertaking, there is a need to establish the prevailing awareness towards TB. De- spite a few anecdotal observations, attitudes towards TB have been little reported in the Arab world and to our knowledge, there has been no study on psychosocial issues associated with TB from Oman. Increas- ing affluence in the country has resulted in Omanis travelling to high-burden TB countries [6]. Oman also attracts a large labour force from parts of the world known to have epidemics of infectious diseases including TB [7]. The prevalence of TB in Oman has been classified as moderate with an annual risk of TB estimated to be around 1% [8]. The Ministry of Health in Oman has instituted the bacille Calmette–Guérin (BCG) vaccination programme to be uni- versally dispensed to all infants at birth [8]. However, little is known about how TB is perceived by the Omani public. The present study aimed to examine the knowledge about TB by medical profes- sionals (medical students and paramed- ics) and by non-medical students. It was hypothesized that medics who have better health education were likely to have fewer misconceptions about the mode of transmis- sion and other clinical aspects of TB than non-medics. We also postulated according to the “contact hypothesis” that previous exposure to TB would enhance a person’s understanding and form a basis for height- ening essential knowledge towards TB [9]. In a paternalistic society such as Oman, women have traditionally played a domestic role and it is not clear how such division of Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 511 roles would influence TB awareness. Stud- ies carried out in different cultures suggest that there are gender differences in attitudes towards TB [10], and thus another aim of the present study was to examine whether knowledge differs between men and women in Oman. Methods Participants The participants consisted of 2 groups op- erationalized for this study as “medics” and “non-medics”. Medics were medical students and paramedics (nurses and tech- nicians) working in a hospital setting. A random sample of 120 medical students were selected from the pool of medical students at the College of Medicine of Sul- tan Qaboos University: 105 completed the questionnaire. Out of a convenience sample of 50 nurses and technicians at the Sultan Qaboos University Teaching Hospital, 37 agreed to participate. The medical students were selected on the basis of their training in a subject that has an element of micro- biology, and paramedics were those whose work involved contact with patients who were likely to carry some air borne diseases and therefore should have received some training in universal precautions procedures [11]. Non-medics were a convenience sam- ple of 180 various arts and social science students at Sultan Qaboos University, of whom 133 participated. Verbal consent was sought from each participant before a questionnaire was handed out. Most of the subjects filled the questionnaire within the vicinity of the clinics and laboratories at the Sultan Qaboos University Teaching Hospital. The participants were requested not to discuss the questionnaire with others. The students were also informed that their responses would have no influence on their grades or examination performance. The data were collected between April and May 2002. Development of the questionnaire The material for the questionnaire was adapted from the literature that reported on the understanding and attitudes toward infectious diseases [3]. The items of the questionnaire were specifically chosen for their established psychometric properties and their cross-cultural relevance and sen- sitivity. Literature searches resulted in a questionnaire that consisted of 28 differ- ent statements to elicit information on 3 broad areas; 14 items on general knowledge about TB, 5 on statements on risk factors and 9 statements on basic diagnosis of TB to which the respondents could respond “agree”, “disagree” or “don’t know”. An initial sample of 60 health care profession- als and 64 non-health care professionals (as defined above) were used for examining the factor structure and internal consistency and reliability of the assessment measure. The reliability (internal consistency and test–retest stability) has an alpha of 0.88 for the total scores. Only about 27% of the bivariate correlations were significantly dif- ferent from zero at the 5% level; an indica- tion of the lack of a relationship between the variables. Nine factors, out of a possible 28, explained only 60% of the variation. Hence all the variables were retained in the questionnaire. Data analysis The data was entered into the statistical software package SPSS. Cross-tabulations were computed from which odd ratios (OR) and their 95% confidence intervals (CI) were calculated. Tests of equal proportions were carried out using a large-sample test for proportions. 512 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Results Demographic data A total of 275 students, technicians and nurses participated in the study: 43% male and 57% female. The medics comprised 105 medical students (45% pre-clinical and 55% clinical students) and 37 paramedics who were biomedical technicians and nurs- es. The non-medics were 133 students from the colleges of Arts and Social Science. The response rate was 78.6%. The overall mean age of respondents was 22.8 years (range 18–48 years): medics 23.7 years; non-med- ics 21.7 years; medical students 22.2 years and nurses and technicians 28.2 years. The non-medics were significantly older than the students. Overall knowledge about TB For all 28 questions about knowledge of TB, a significantly higher proportion of medics than non-medics gave the correct responses (71% versus 63%). A medic was 1.5 times more likely to give a correct response than a non-medic. There was no sex difference overall. The correct response rate among the student medics was significantly higher than for the technicians and nurses (72% overall versus 69%). General knowledge about TB There were 14 questions on general knowl- edge about TB. Overall, medics and non- medics gave 73% and 67% correct responses to the general statements (Table 1). The medics did better on 5 of the statements, the non-medics did better on 2 statements and there was no significant difference between the 2 groups for 7 statements. Almost all re- spondents believed that Oman is not free of TB; however, they believed the incidence to be low in the country. They knew that close contact with an infected person is harmful: 55% of medics and 38% of non-medics felt uncomfortable in the presence of a TB pa- tient and 72% and 55% believed that keep- ing a TB patient at home carries a high risk of infecting others. The proportion of males and females giv- ing correct responses were not significantly different on 13/14 statements (Table 2). A higher proportion of males agreed that BCG vaccine does not provide 100% protection against TB and close contact with TB pa- tients is harmful but this was not significant (P = 0.06). A higher proportion of females, agreed that simple hygienic precautions such as wearing masks and washing hands should be taken when taking care of TB patients but this was also not significant. A comparison of medical students and paramedics in the medics group indicated that the 2 groups were similar on most of the general knowledge statements (Ta- ble 3). The students scored significantly higher on the statement “Mycobacterium could be dormant for many years and get reactivated” while the paramedics scored significantly higher for “incidence of TB in Oman is high”. Knowledge about risk factors or factors precipitating contracting TB Various issues pertaining to risk factors for contracting TB were explored. Overall, med- ics knew the causes of TB 76% of the time as opposed to only 55% by the non-medics. Both medics and non-medics agreed that poor living conditions are a major contribut- ing factor to the incidence of TB (Table 1). More medics (55%) correctly indicated that drinking raw infected milk could result in contracting TB than did non-medics (41%). High proportions of both groups agreed that TB is an airborne disease. Not surprisingly, a significantly higher proportion of medics (81%) than non-medics (46%) knew that TB is not caused by a virus. The odds of a medics knowing that TB is caused by a Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 513 Ta bl e1 R es po ns e ra te s fo r m ed ic s (m ed ic al s tu de nt s an d pa ra m ed ic s) a nd n on -m ed ic s (a rt s an d so ci al s ci en ce s st ud en ts ) o n kn ow le dg e st at em en ts a bo ut tu be rc ul os is (T B) Va ria bl e % c or re ct re sp on se M ed ic s N on - P- O R (9 5% C I) m ed ic s va lu ea (n = 1 42 ) (n = 1 33 ) Kn ow le dg e fa ct or s A n A ID S pa tie nt c ou ld b e in fe ct ed w ith th e ag en t c au si ng T B ev en if M an to ux te st is n eg at iv e 52 15 0. 00 5. 96 (3 .3 4– 10 .6 4) Tw o- w ee ks tr ea tm en t w ith a nt ib io tic s en su re s cu re o f T B 96 93 0. 34 1. 66 (0 .5 7– 4. 80 ) M yc ob ac te riu m c ou ld b e do rm an t f or m an y ye ar s an d ge t r ea ct iv at ed 81 40 0. 00 6. 46 ( 3. 73 –1 1. 17 ) Pr ot ec tio n ag ai ns t T B ca n be e st ab lis he d by c he m op ro ph yl ax is 48 58 0. 08 0. 66 (0 .4 1– 1. 06 ) Th er e ar e > 30 m ill io n de at hs /y ea r b ec au se o f T B in fe ct io n w or ld w id e 60 79 0. 00 0. 40 (0 .2 3– 0. 68 ) A ll im m ig ra nt s to O m an s ho ul d be s cr ee ne d fo r M yc ob ac te riu m 81 77 0. 43 1. 27 (0 .7 0– 2. 31 ) In ci de nc e of T B in O m an is h ig h 79 87 0. 10 0. 58 (0 .3 0– 1. 11 ) O m an is a c ou nt ry w hi ch is fr ee o f T B 99 95 0. 12 3. 34 (0 .6 6– 16 .8 3) BC G v ac ci ne e ns ur es 1 00 % p ro te ct io n ag ai ns t T B 87 92 0. 17 0. 57 (0 .2 5– 1. 28 ) Cl os e co nt ac t w ith a p at ie nt h av in g TB is h ar m le ss 89 83 0. 20 1. 56 (0 .7 8– 3. 13 ) Si m pl e pr ec au tio ns li ke w ea rin g m as k, w as hi ng h an ds a nd g oo d ve nt ila tio n ar e he lp fu l w hi le ta ki ng c ar e of a T B pa tie nt 83 72 0. 03 1. 92 (1 .0 7– 3. 43 ) I f ee l u nc om fo rt ab le w hi le ta lk in g to a p at ie nt w ith T B 55 38 0. 00 2. 02 (1 .2 4– 3. 29 ) A p at ie nt w ith T B m us t n ot s ha re k itc he n to ol s (p la te s, sp oo ns , g la ss es , e tc .) w ith o th er s 36 50 0. 02 0. 56 (0 .3 5– 0. 92 ) Ke ep in g a pa tie nt w ith T B at h om e ca rr ie s th e ris k of in fe ct in g ot he rs 72 55 0. 00 2. 12 (1 .2 8– 3. 52 ) Ri sk fa ct or s TB is c au se d by a v iru s 81 46 0. 00 4. 96 (2 .8 9– 8. 52 ) Po or li vi ng c on di tio ns , c ro w de dn es s an d re fu ge e ca m ps a re g oo d en vi ro nm en ts fo r t ra ns m is si on o f T B 92 87 0. 17 1. 75 (0 .7 9– 3. 88 H IV e pi de m ic is th e m ai n re as on b eh in d th e ne w o ut br ea ks o f T B w or ld w id e 71 29 0. 00 6. 16 ( 3. 65 –1 0. 39 ) Yo u ca n ge t T B by d rin ki ng ra w m ilk fr om a n in fe ct ed a ni m al 55 41 0. 02 1. 73 (1 .0 7– 2. 79 ) Th e co m m on es t m od e of tr an sm is si on o f T B is th ro ug h in ha la tio n of M . t ub er cu lo si s in a er os ol s an d du st 81 71 0. 05 1. 77 (1 .0 1– 3. 10 ) 514 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 bacterium was 5 times higher than non- medics. In all statements except 2 there was no significant difference in the knowl- edge of the risk factors of TB between men and women (Table 2). Significantly more females knew that “poor living conditions, crowdedness and refugee camps were good environments for the transmission of TB” and “the com- monest mode of transmission of TB is through inhalation of M. tuberculosis in aerosols and dust”. The correct response was high for both sexes on these state- ments. Both medical students and para- medics scored highly on most of the statements on the risk factors (Table 3). Medical students scored significantly higher only on 1 statement: “HIV is the main reason behind the new outbreaks of TB worldwide”. Knowledge about diagnosis of TB Various issues regarding symptoms, signs and diagnosis of TB were com- pared between medics and non-med- ics. A direct comparison of the groups indicated that out of 9 questions, the proportion of respondents giving cor- rect responses was similar on 3 ques- tions. More of the medics knew the correct responses on 9 statements than the non-medics; however the differ- ences were not significant (Table 1). On average 67% and 63% of the medics and non-medics knew some of the ways of diagnosing TB, and 92% of medics and 80% of non-medics knew that dis- seminated TB did not involve meninges and bones. Also 91% and 73% of med- ics and non-medics respectively knew that “TB is not confined only to the respiratory tract”. Most of both groups (89%) agreed that a positive Mantoux Ta bl e1 R es po ns e ra te s fo r m ed ic s (m ed ic al s tu de nt s an d pa ra m ed ic s) a nd n on -m ed ic s (a rt s an d so ci al s ci en ce s st ud en ts ) o n kn ow le dg e st at em en ts a bo ut tu be rc ul os is (T B) ( co nc lu de d) Va ria bl e % c or re ct re sp on se M ed ic s N on - P- O R (9 5% C I) m ed ic s va lu ea (n = 1 42 ) (n = 1 33 ) D ia gn os is fa ct or s A 1 -w ee k dr y co ug h is s ug ge st iv e of T B 67 63 0. 46 1. 20 (0 .7 3– 1. 98 ) Ev er y pa tie nt w ith T B co ug hs o ut b lo od y sp ut um 58 46 0. 04 1. 64 (1 .0 2– 2. 65 ) A p er so n co ul d be in fe ct ed w ith T B bu t s ho w n o cl in ic al s ym pt om s th ro ug ho ut li fe 36 10 0. 00 5. 23 (2 .6 8– 10 .2 0) D is se m in at ed T B do es n ot in vo lv e m en in ge s an d bo ne s 92 80 0. 01 2. 63 (1 .2 7– 5. 46 ) TB is o nl y co nfi ne d to th e re sp ira to ry tr ac t 91 73 0. 00 3. 68 (1 .8 5– 7. 32 ) TB is d ia gn os ed u si ng b lo od s m ea rs 59 61 0. 79 0. 94 (0 .5 8– 1. 52 ) N ig ht fe ve r a nd s w ea tin g ar e sy m pt om s of p at ie nt s w ith T B 67 46 0. 00 2. 44 (1 .4 9– 4. 00 ) A p os iti ve M an to ux te st m ea ns a d efi ni te T B in fe ct io n 89 89 0. 99 1. 01 (0 .4 7– 2. 18 ) A tu be rc ul in te st is e ss en tia l t o di ag no se s us pe ct ed c as es o f T B 39 88 0. 00 0. 09 (0 .0 5– 0. 16 ) O R = od ds ra tio , t he o dd s of a m ed ic al p er so n ge tt in g th e co rr ec t a ns w er v er su s a no n- m ed ic al p er so n. a T w o- si de d P- va lu e fo r t es tin g eq ua lit y of p ro po rt io ns . Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 515 Ta bl e 2 Re sp on se ra te s fo r m al es a nd fe m al es o n kn ow le dg e st at em en ts a bo ut tu be rc ul os is (T B) Va ria bl e % c or re ct re sp on se M al es Fe m al es P- va lu ea O R (9 5% C I) (n = 1 17 ) (n = 1 52 ) Kn ow le dg e fa ct or s A n A ID S pa tie nt c ou ld b e in fe ct ed w ith th e ag en t c au si ng T B ev en if M an to ux te st is n eg at iv e 33 35 0. 72 0. 91 ( 0. 80 –1 0. 71 ) Tw o- w ee ks tr ea tm en t w ith a nt ib io tic s en su re s cu re o f T B 97 93 0. 09 2. 92 (0 .4 5– 1. 20 ) M yc ob ac te riu m c ou ld b e do rm an t f or m an y ye ar s an d ge t r ea ct iv at ed 57 64 0. 22 0. 73 (0 .8 0– 2. 09 Pr ot ec tio n ag ai ns t T B ca n be e st ab lis he d by c he m op ro ph yl ax is 56 50 0. 30 1. 29 (0 .5 7– 1. 61 ) Th er e ar e > 30 m ill io n de at hs /y ea r b ec au se o f T B in fe ct io n w or ld w id e 69 70 0. 86 0. 95 (0 .3 5– 1. 16 ) A ll im m ig ra nt s to O m an s ho ul d be s cr ee ne d fo r M yc ob ac te riu m 75 83 0. 13 0. 63 (0 .9 2– 3. 61 ) In ci de nc e of T B in O m an is h ig h 88 80 0. 08 1. 82 (0 .2 2– 4. 55 ) O m an is a c ou nt ry w hi ch is fr ee o f T B 97 97 1. 00 1. 00 (1 .0 1– 6. 00 ) BC G v ac ci ne e ns ur es 1 00 % p ro te ct io n ag ai ns t T B 94 86 0. 04 2. 46 (0 .9 6– 4. 28 ) Cl os e co nt ac t w ith a p at ie nt h av in g TB is h ar m le ss 91 82 0. 06 2. 03 (0 .3 3– 1. 03 ) Si m pl e pr ec au tio ns li ke w ea rin g m as k, w as hi ng h an ds a nd g oo d ve nt ila tio n ar e he lp fu l w hi le ta ki ng c ar e of a T B pa tie nt 72 82 0. 06 0. 58 (0 .5 3– 1. 41 ) I f ee l u nc om fo rt ab le w hi le ta lk in g to a p at ie nt w ith T B 45 48 0. 56 0. 87 (0 .5 8– 1. 53 ) A p at ie nt w ith T B m us t n ot s ha re k itc he n to ol s (p la te s, sp oo ns , g la ss es , e tc .) w ith o th er s 41 43 0. 81 0. 94 (0 .4 7– 1. 28 ) Ke ep in g a pa tie nt w ith T B at h om e ca rr ie s th e ris k of in fe ct in g ot he rs 60 66 0. 32 0. 78 (1 .2 8– 3. 52 ) Ri sk fa ct or s TB is c au se d by a v iru s 62 66 0. 50 0. 84 (0 .0 7– 0. 45 ) Po or li vi ng c on di tio ns , c ro w de dn es s an d re fu ge e ca m ps a re g oo d en vi ro nm en ts fo r t ra ns m is si on o f T B 81 96 0. 00 0. 17 (0 .4 5– 1. 17 ) H IV e pi de m ic is th e m ai n re as on b eh in d th e ne w o ut br ea ks o f T B w or ld w id e 46 54 0. 19 0. 73 (0 .5 1– 1. 32 ) Yo u ca n ge t T B by d rin ki ng ra w m ilk fr om a n in fe ct ed a ni m al 45 50 0. 42 0. 82 (0 .3 2– 0. 97 ) Th e co m m on es t m od e of tr an sm is si on o f T B is th ro ug h in ha la tio n of M . t ub er cu lo si s in a er os ol s an d du st 70 81 0. 04 0. 55 (0 .8 2– 2. 27 ) 516 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 test meant a definite TB infection. Signifi- cantly more of the non-medics (88%) than the medics (39%) knew that the tuberculin test is not essential to diagnose suspected cases of TB, whereas significantly more medics (67%) than non-medics (46%) knew that night fever and sweating are symptoms of TB. Very low proportions of medics (36%) and non-medics (10%) knew that a person could be infected with TB but show no clinical symptoms throughout life. Overall, there were no significant differ- ences between males and females as regards the diagnosis of TB; 65% of males and 64% of females knew the correct responses to the questions on diagnosis. Out of the 9 questions, there was only 1 question where the females significantly outperformed the males. Significantly more females correctly identified night fever and sweating as symp- toms of TB. Very high proportions of both males and females knew that a positive Mantoux test did not mean a definite TB infection and also that TB was not confined only to the respiratory tract (Table 2). The medical students scored signifi- cantly better than the paramedics on only 1 statement: that night fevers and sweating are symptoms of TB. Both medical students (40%) and paramedics (25%) scored poorly on the diagnosis statement “a person could be infected with TB but show no clinical symptoms throughout life” (Table 3). On all other statements there were no differences. Discussion Despite the triumph of “germ theory” and the enthusiasm for eradication in the past decade, infectious diseases continue to pose a global challenge. There have been no major recent advances in anti-TB drug de- velopment or research efforts that would translate into immediate meaningful reduc- Ta bl e 2 Re sp on se ra te s fo r m al es a nd fe m al es o n kn ow le dg e st at em en ts a bo ut tu be rc ul os is (T B) (c on cl ud ed ) Va ria bl e % c or re ct re sp on se M al es Fe m al es P- va lu ea O R (9 5% C I) (n = 1 17 ) (n = 1 52 ) D ia gn os is fa ct or s A 1 -w ee k dr y co ug h is s ug ge st iv e of T B 69 63 0. 23 1. 36 (0 .8 0– 2. 09 ) Ev er y pa tie nt w ith T B co ug hs o ut b lo od y sp ut um 56 50 0. 30 1. 29 (0 .4 9– 1. 54 ) A p er so n co ul d be in fe ct ed w ith T B bu t s ho w n o cl in ic al s ym pt om s th ro ug ho ut li fe 22 25 0. 63 0. 87 (0 .6 8– 2. 79 ) D is se m in at ed T B do es n ot in vo lv e m en in ge s an d bo ne s 88 85 0. 38 1. 37 (0 .7 4– 2. 65 ) TB is o nl y co nfi ne d to th e re sp ira to ry tr ac t 85 80 0. 30 1. 40 (0 .6 1– 1. 62 ) TB is d ia gn os ed u si ng b lo od s m ea rs 59 60 0. 97 0. 99 (0 .3 0– 0. 81 ) N ig ht fe ve r a nd s w ea tin g ar e sy m pt om s of p at ie nt s w ith T B 47 64 0. 00 0. 49 (0 .5 6– 2. 71 ) A p os iti ve M an to ux te st m ea ns a d efi ni te T B in fe ct io n 90 88 0. 61 1. 23 (1 .0 0– 2. 77 ) A tu be rc ul in te st is e ss en tia l t o di ag no se s us pe ct ed c as es o f T B 69 57 0. 06 1. 67 (0 .5 5– 1. 52 ) O R = od ds ra tio , t he o dd s of a m al e ge tt in g th e co rr ec t a ns w er v er su s a fe m al e. a T w o- si de d P- va lu e fo r t es tin g eq ua lit y of p ro po rt io ns . Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 517 Ta bl e 3 Re sp on se ra te s fo r m ed ic s, co m pa rin g m ed ic al s tu de nt s an d pa ra m ed ic s, on k no w le dg e st at em en ts a bo ut tu be rc ul os is (T B) Va ria bl e % c or re ct re sp on se M ed ic al Pa ra m ed ic s P - O R (9 5% C I) st ud en ts va lu ea (n = 1 05 ) (n = 3 7) Kn ow le dg e fa ct or s A n A ID S pa tie nt c ou ld b e in fe ct ed w ith th e ag en t c au si ng T B ev en if M an to ux te st is n eg at iv e 56 41 0. 11 1. 85 (0 .8 6– 3. 96 ) Tw o- w ee ks tr ea tm en t w ith a nt ib io tic s en su re s cu re o f T B 94 10 0 0. 14 0. 00 – M yc ob ac te riu m c ou ld b e do rm an t f or m an y ye ar s an d ge t r ea ct iv at ed 87 65 0. 00 3. 48 (1 .4 5– 8. 39 ) Pr ot ec tio n ag ai ns t T B ca n be e st ab lis he d by c he m op ro ph yl ax is 43 59 0. 09 0. 52 (0 .2 4– 1. 11 ) Th er e ar e > 30 m ill io n de at hs /y ea r b ec au se o f T B in fe ct io n w or ld w id e 58 68 0. 29 0. 65 (0 .3 0– 1. 44 ) A ll im m ig ra nt s to O m an s ho ul d be s cr ee ne d fo r M yc ob ac te riu m 82 78 0. 60 1. 29 (0 .5 1– 3. 27 ) In ci de nc e of T B in O m an is h ig h 75 92 0. 03 0. 26 (0 .0 7– 0. 93 ) O m an is a c ou nt ry w hi ch is fr ee o f T B 99 97 0. 44 2. 86 ( 0. 17 –4 6. 94 ) BC G v ac ci ne e ns ur es 1 00 % p ro te ct io n ag ai ns t T B 88 86 0. 87 1. 09 (0 .3 6– 3. 31 ) Cl os e co nt ac t w ith a p at ie nt h av in g TB is h ar m le ss 88 89 0. 89 0. 92 (0 .2 8– 3. 05 ) Si m pl e pr ec au tio ns li ke w ea rin g m as k, w as hi ng h an ds a nd g oo d ve nt ila tio n ar e he lp fu l w hi le ta ki ng c ar e of a T B pa tie nt 84 81 0. 72 1. 19 (0 .4 5– 3. 16 ) I f ee l u nc om fo rt ab le w hi le ta lk in g to a p at ie nt w ith T B 59 46 0. 18 1. 67 (0 .7 8– 3. 55 ) A p at ie nt w ith T B m us t n ot s ha re k itc he n to ol s (p la te s, sp oo ns , g la ss es , e tc .) w ith o th er s 38 31 0. 45 1. 36 (0 .6 0– 3. 07 ) Ke ep in g a pa tie nt w ith T B at h om e ca rr ie s th e ris k of in fe ct in g ot he rs 75 64 0. 20 1. 70 (0 .7 5– 3. 82 ) Ri sk fa ct or s TB is c au se d by a v iru s 84 73 0. 15 1. 92 (0 .7 9– 4. 68 ) Po or li vi ng c on di tio ns , c ro w de dn es s an d re fu ge e ca m ps a re g oo d en vi ro nm en ts fo r tr an sm is si on o f T B 91 94 0. 56 0. 63 (0 .1 3– 3. 05 ) H IV e pi de m ic is th e m ai n re as on b eh in d th e ne w o ut br ea ks o f T B w or ld w id e 78 51 0. 00 3. 38 (1 .5 3– 7. 47 ) Yo u ca n ge t T B by d rin ki ng ra w m ilk fr om a n in fe ct ed a ni m al 56 51 0. 61 1. 22 (0 .5 7– 2. 58 ) Th e co m m on es t m od e of tr an sm is si on o f T B is th ro ug h in ha la tio n of M . t ub er cu lo si s in a er os ol s an d du st 82 78 0. 64 1. 25 (0 .4 9– 3. 16 ) 518 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 tion of transmission [12,13]. This means that other cost-effective ways to create a sustainable control of infectious diseases need to be considered to counter and control the rising tide of infectious dis- eases such as TB. As there is a pervasive lack of understanding of various aspects of TB among health practitioners [12], the International Union Against TB and Lung Disease and the World Health Or- ganization have called for campaigns to increase awareness of TB [14], and many countries have made it mandatory for health sciences professionals to acquire training in universal precautions [11]. This study is the first of its type to be conducted in Oman. It was confined to students from the national university in Oman and it suggested that arts and social science students (operationalized as non-medics) do have an adequate knowledge of TB. Overall, 63% know the correct responses to the items on the questionnaire compared with 71% of those who are working as nurses, laboratory technicians or are medical students (operationalized as medics). If close proximity to an event leads to a bet- ter understanding of it [9], medics work- ing with TB would be expected to have significantly better understanding than non-medics. The present study supports this idea, as medical professionals gener- ally scored higher than non-medics on 20 out of 28 statements, although some of the differences were not significant. Globally, TB kills more women than any single cause of maternal mortality [15]. As a result, campaigns to reduce the burden of TB have targeted women. In some parts of the world, women’s move- ments are leading the efforts to control TB [16]. Little is known of the level of knowledge of TB among Omani women. This study compared men and women Ta bl e 3 Re sp on se ra te s fo r m ed ic s, co m pa rin g m ed ic al s tu de nt s an d pa ra m ed ic s, on k no w le dg e st at em en ts a bo ut tu be rc ul os is (T B) (c on cl ud ed ) Va ria bl e % c or re ct re sp on se M ed ic al Pa ra m ed ic s P - O R (9 5% C I) st ud en ts va lu ea (n = 1 05 ) (n = 3 7) D ia gn os is fa ct or s A 1 -w ee k dr y co ug h is s ug ge st iv e of T B 69 62 0. 43 1. 37 (0 .6 3– 3. 00 ) Ev er y pa tie nt w ith T B co ug hs o ut b lo od y sp ut um 57 62 0. 59 0. 81 (0 .3 8– 1. 75 ) A p er so n co ul d be in fe ct ed w ith T B bu t s ho w n o cl in ic al s ym pt om s th ro ug ho ut li fe 40 25 0. 11 2. 00 (0 .8 6– 4. 68 ) D is se m in at ed T B do es n ot in vo lv e m en in ge s an d bo ne s 93 86 0. 20 2. 19 (0 .6 5– 7. 37 ) TB is o nl y co nfi ne d to th e re sp ira to ry tr ac t 90 92 0. 80 0. 84 (0 .2 2– 3. 23 ) TB is d ia gn os ed u si ng b lo od s m ea rs 57 64 0. 49 0. 76 (0 .3 5– 1. 66 ) N ig ht fe ve r a nd s w ea tin g ar e sy m pt om s of p at ie nt s w ith T B 72 54 0. 04 2. 20 (1 .0 1– 4. 78 ) A p os iti ve M an to ux te st m ea ns a d efi ni te T B in fe ct io n 88 91 0. 62 0. 72 (0 .1 9– 2. 71 ) A tu be rc ul in te st is e ss en tia l t o di ag no se s us pe ct ed c as es o f T B 37 43 0. 50 0. 77 (0 .3 6– 1. 65 ) O R = od ds ra tio , t he o dd s of a m ed ic al s tu de nt g et tin g th e co rr ec t a ns w er v er su s a pa ra m ed ic (n ur se a nd te ch ni ci an s) . a T w o- si de d P- va lu e fo r t es tin g eq ua lit y of p ro po rt io ns . Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 519 and found, in general, that knowledge of TB was similar. Such a finding is not surpris- ing since recent modernization has helped to equalize access to education in Oman. However, it is not clear whether this finding can be generalized to the rest of the country since the present sample consisted only of educated women attending university. More studies are needed to explore the effect of education and sex on awareness towards health-related matters. The third aim of the present study was to assess whether awareness varies between medical students and their paramedical counterparts who are nurses and biomedi- cal laboratory technicians. On the whole, medical students showed more accurate knowledge than paramedics. This is not sur- prising, as medical students were likely to have recently acquired knowledge about TB via their microbiology studies. It is possible that paramedics, being older, would have had their education when TB was viewed as a “conquered” illness. Previous studies have generally dem- onstrated that both health care personnel and the general public do harbour nega- tive attitudes toward people with TB and generally showed lack of knowledge [17]. Nonetheless, there are a few studies that have compared differences in the awareness of TB. At face value, the students appear to have a reasonable understanding of TB. On the other hand, the results of the present study are surprising because the gap in the knowledge of the 2 groups, “expert” and “non-expert”, is very small. It is important to consider the limitations of the present findings. It is possible that “ceiling” or “floor” effects might have re- sulted in the small difference between the 2 groups, medics and non-medics. However, assessment of the individual items did not suggest that questions were either too easy or too hard for the 2 groups. For example, it would be expected that only experts would know that a positive Mantoux test does not mean a presence of TB infection. However, a high proportion of the non-medics knew the correct response to statements that only experts would be expected to know. For example, a higher proportion of non-medics (88%) knew that the tuberculin test is not essential to diagnose suspected cases of TB as opposed to only 39% of the medics. This study suggested that non-health- care professionals do have an adequate knowledge of TB. It is possible that this knowledge was obtained from the many readily available information sources on infectious diseases in Oman. However, the knowledge gap between medical and non- medical groups was low, which suggests that another possible limitation to the study is that the questionnaire did not discriminate between factual knowledge and correct guesses. Another confounding factor of the present study is the heterogeneity of partici- pants. The medics group comprised those working in a medical setting and included medical students and other paramedics. Such a diverse group might limit the ability to generalize the findings. However, there is a cultural rationale for the grouping, as in the Arab world the general public regards anybody working in the health sector as a “doctor”, irrespective of his or her train- ing. This study has operationalized various health professionals or prospective health practitioners as medics in view of the fact that these individuals are potential health care providers in the eyes of the community [18]. Similarly, the rationale for choosing a cohort of students needs to be justified. The Sultan Qaboos University, the only state university in the country, draws students from all regions and sub-cultural group- ings in Oman. This group of young adults 520 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 reflects the population structure of Oman since 70% of the Omani population is aged under 20 years [19]. Epidemiological sur- veys from other parts of the world suggest that this age group is more conducive to health promotion campaigns and the young in a population are effective transmitters of health messages [20]. TB predominantly affects a similar age group. In addition, such a cohort constitutes a cadre of the new gen- eration to have grown up during a 2-decade period of immense development in Oman. Conclusion If non-experts could be used as a reference for comparison, then this study lends sup- port to the view that health care profession- als in Oman have a good basic awareness of TB. However, item-by-item analysis suggests that the gap in the knowledge of TB is small between medic and non-medics. This would suggest that more awareness education is needed in Oman. Although the country has a moderate annual incidence rate of TB, health education is the first line of defence in an era of proliferating and treatment-resistant infectious diseases. Acknowledgements The data for this project was part of the baseline survey for the impact evaluation of health promotion initiatives for infectious disease, Sultan Qaboos University (Grant No. IG/MED/MICR/01/01; 20). References 1. Raviglione MC. The TB epidemic from 1992 to 2002. Tuberculosis, 2002, 83:4– 14. 2. Doline PJ, Raviglione MC, Kochi A. Glo- bal tuberculosis incidence and mortality during 1990–2000. Bulletin of the World Health Organization, 1994, 72:213–20. 3. Jeffe DB et al. Does clinical experience affect medical students’ knowledge, at- titudes, and compliance with universal precautions? Infection control and hospi- tal epidemiology, 1998, 19:767–71. 4. Webster C. Tuberculosis. In: Seale C, Pattison S, Davey B, eds. Medical knowl- edge: doubt and certainty. Buckingham, Open University Press, 2001:54–85. 5. Godfrey-Faussett P, Ayles H. Can we con- trol tuberculosis in high HIV prevalence settings? Tuberculosis, 2003, 83:68–76. 6. Elshafie SS, Rafay AM. Chlorampheni- col-resistant typhoid fever: an emerging problem in Oman. Scandinavian journal of infectious diseases, 1992, 24:819–20. 7. Singh J et al. Epidemiology of endemic viral hepatitis in an urban area of India: a retrospective community study in Alwar. Bulletin of the World Health Organization, 1997, 75:463–68. 8. Scrimgeour EM. Scope of infectious and tropical diseases in the Middle East. Acta tropica, 2001, 80:117–8. 9. Al-Adawi S et al. Perception of and at- titude towards mental illness in Oman. International journal of social psychiatry, 2002, 48:305–17. 10. Long NH et al. Fear and social isolation as consequences of tuberculosis in Vietnam: a gender analysis. Health policy, 2001, 58:69–81. 11. Diekema DJ et al. Universal precautions training of preclinical students: impact on knowledge, attitudes, and compliance. Preventive medicine, 1995, 24:580–85. 12. Mullan Z. New class of drugs provides hope for future of tuberculosis treatment. Lancet, 2000, 355:2223. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 521 13. Young DB. Ten years of research progress and what’s to come. Tuberculosis, 2003, 83:77–81. 14. Broekmans JF et al. European frame- work for tuberculosis control and elimi- nation in countries with a low incidence. Recommendations of the World Health Organization (WHO), International Union Against Tuberculosis and Lung Disease (IUATLD) and Royal Netherlands Tu- berculosis Association (KNCV) Working Group. European journal of respiratory diseases, 2002, 19:765–75. 15. TB advocacy—a practical guide 1999. Geneva, World Health Organization, 1998 (WHO/TB/98.239). 16. Singla N et al. Survey of knowledge, attitudes and practices for tuberculosis among general practitioners in Delhi, In- dia. 1. International journal of tuberculosis and lung disease, 1998, 2:384–9. 17. Kilicaslan Z et al. Evaluation of under- graduate training on tuberculosis at Istan- bul Medical School. International journal of tuberculosis and lung disease, 2003, 7:159–64. 18. Underwood H, Underwood Z. New spells for old: expectations and realities of West- ern medicine in a remote society in Yem- en, Arabia. In: Stanley NF, Joske RA, eds. Changing diseases patterns and human behavior. London, Academic Press, 1980. 271–97. 19. United Nations Children’s Fund. The state of the world’s children 1997. Oxford, Ox- ford University Press, 1997. 20. Orrett FA, Shurland SM. Knowledge and awareness of tuberculosis among pre- university students in Trinidad. Journal of community health, 2001, 26:479–85. Virtual Health Sciences Library Databases that can be accessed on the WHO Eastern Mediterranean Region (EMR) Virtual Health Sciences Library (http://www.emro.who. int/HIS/VHSL/Index.htm) include the Index Medicus for the Region, the Arabic Medical Library, the Union Catalogue of Health Sciences Journals in the EMR, WHO-CEHA Library Database and WHO-CEHA Environmental Health Articles Database. Users can also pull up lists of medical sites sorted by subject, e.g. alternative and complementary medicine, consumer information, epidemiology and heath statistics and telemedicine (http://www.emro. who.int/HIS/VHSL/ConsumerInformation.htm). 522 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Clinical characteristics of pulmonary tuberculosis in adult Pakistani patients with co-existing diabetes mellitus A. Jabbar,1 S.F. Hussain1 and A.A. Khan1 1Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan (Correspondence to A. Jabbar: abdul.jabbar@akunet.org). ABSTRACT A review was made of the records of all patients with pulmonary tuberculosis and diabetes mellitus admitted over a 5-year period to a teaching hospital in Karachi, Pakistan. Among 42 358 pa- tients, the total number with both tuberculosis and diabetes was 173. The prevalence of tuberculosis in diabetic patients was 10-times higher than in non-diabetic patients and prevalence increased with dura- tion of diabetes. The lower lung field was most frequently involved, followed by the upper and middle. Bilateral involvement was seen in half and an associated pleural effusion in one-third of the patients. Cavitating lesions were seen in 32% of men and 15% of women. 6 Clinical characteristics of pulmonary tuberculosis in adult Pakistani patients [ëɾ>Jj²>F¶=§¶>F¶=Ïb¶Ëfõ³j¶>E°ª=f[J™=ËÇÑf¶=¸j·¶ÍÈfÈfj¶=G¾=ǂ= Á>]kɾ?­e>¢(jUz>ɪbÉi(e>F‚=bF¢  „=Í[qØ6Ê[»É·£J¶=ΫnJj™==Ç·]a?ÀšËfõ³j¶=ÆËÇÑf¶=¸j¶=Îufº¤É–LØRj¶Í£Q=fºÁÇNU>F¶=ÏfQ? Ìf[Jª¹Ø](Á>Jj²>E(ÊnI=f²›5L=Ç¿i*EÀºľ?=bQǪ42 358µ>[¿ÂÁ>²(ð>vÈfº173ú¸ [³Eð>E>r[º Èf³j¶=E¸j¶=e>nJ¾=¹b£ºÁ>²Æ(ð>£ºËf³j¶=Ƹj¶=Àº[[¦Ïb[¶Ä[É·¢Ç[Â>[º­>£[u?Ìfn¢¹a>£È Ëf³j¶>EÍE>qÝ=Ìbºa>Èag>Ea=ahÈe>nJ¾×=¹b£ºÁ>²Æ([Èf³j¶=*Ç[JÑf[¶=À[ºÊ·«j[¶=¼j¯¶=Á>²b®Æ œiÇJ™=ÆËÇ·£¶=¼j¯¶=ÅÇ·JÈðÍE>qCfN²Ù=*¤[ºK¯ª=fIÆ(Îuf™=¬r¾›G¾>‚=ÍÉÑ>¿ML>E>qCLbÂÇm>»² =O·M›¿QH>Fr¾=›­Çó¶=LbÂÇmÆ(Îuf™32!›Æ¹>Qf¶=Àº15!Ð>j¿¶=Àº*  Caractéristiques cliniques de la tuberculose pulmonaire chez des patients adultes pakistanais présentant une comorbidité de diabète sucré RÉSUMÉ On a procédé à un examen des dossiers de tous les patients atteints de tuberculose pul- monaire et de diabète sucré qui ont été admis dans un hôpital universitaire de Karachi (Pakistan) sur une période de 5 ans. Sur les 42 358 patients, le nombre total de patients atteints à la fois de tubercu- lose et de diabète s’élevait à 173. La prévalence de la tuberculose chez les patients diabétiques était 10 fois plus élevée que chez les patients non diabétiques et la prévalence augmentait avec la durée du diabète. Le champ pulmonaire inférieur était le plus fréquemment atteint, suivi par le champ supérieur et moyen. On a noté une atteinte bilatérale chez la moitié des patients et un épanchement pleural associé chez un tiers des patients. Des lésions cavitaires ont été observées chez 32 % des hommes et 15 % des femmes. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 523 Introduction Pulmonary tuberculosis (TB) and diabet tes mellitus (DM) may coexist frequently, particularly in a population at high risk of acquiring TB. DM has been reported to modify the clinical features of TB. Comt parative studies of TB in diabetics have provided conflicting results. In a recent study from Mexico, diabetic patients were older, had more lower lung field lesions and had more multiple cavities [1]. In a Turkish study, DM did not affect the pret senting features of pulmonary TB and was only associated with more lower lung field disease in females and in older patients [2]. Another study from Saudi Arabia showed similar symptoms, radiographic distribution and cavitary disease in diabetic and nont diabetic patients with pulmonary TB [3]. Pulmonary TB may adversely affect glycaemic control. TB infection has been shown to produce glucose intolerance that improves or normalizes with antitTB treatt ment [4]. This association is not specific to TB but is seen in other respiratory infections such as pneumonia [5]. Asian patients from the Indian subcontinent have a higher incit dence of insulin resistance and associated complications [6]. There is little information on whether DM affects the presentation, radiographic manifestations and clinical course of pulmonary TB for Asian patients from the Indian subcontinent. The aims of this study were to detert mine whether DM alters the clinical and radiographic manifestations of pulmonary TB in Pakistani patients and to compare the prevalence of TB in hospitalized patients with and without DM. Methods The study was a retrospective descriptive study conducted at The Aga Khan Univert sity Hospital, a 450tbed teaching hospital in Karachi, Pakistan. The medical records were reviewed for all adult patients (aged 14 years and above) with a diagnosis of both pulmonary TB and DM, admitted from Jant uary 1992 to December 1996. Information about demographic data, clinical features, laboratory investigations and outcome of treatment were recorded. Patients with diabetes were included if they had a previous history of DM and were receiving antitdiabetic therapy at the time of hospital admission or were later found to have 2 or more fasting blood glucose levels greater than 140 mg/dL and started on antit diabetic treatment. An aget and sextmatched group of nontdiabetic patients, who were hospitalized during the same time period, were used as the control group to estimate the prevalence of TB in nontdiabetics. The diagnosis of TB was based on a post itive culture or histopathology, a suggestive serosal fluid report or typical radiographic findings with high clinical probability of TB. The data on radiographic findings were collected using the posterior–anterior roentt genograms obtained at the time of diagnot sis. In compliance with the usual clinical approach, the upper, mid and lower zones were defined by theoretical horizontal lines passing at the level of the anterior ends of the second and fourth ribs, respectively. Statistical analysis (including prevat lence rates) was performed using Epi-Info statistical software, version 6.0. Student’s tttest or chitsquared test were performed where applicable. Results A total of 42 358 patients were admitted to The Aga Khan University Hospital, between 1992 and 1996. The number of patients dist charged with a diagnosis of DM was 1458 524 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 and with a diagnosis of TB was 691. The total number of patients with both TB and DM were 173. The prevalence of TB in diabetic patients was 173/1458 (11.9%) and in nontdiabetic patients was 691/40 900 (1.7%) (P < 0.5). Data on 93 of the 173 patients (56 males, 37 females) with both TB and DM was availt able for analysis. The clinical characteristics of these patients are presented in Table 1. The majority of the patients (82%) were 40–70 years of age, with only 6% below 40 years and 12% above 70 years of age. The prevalence of TB increased progressively with the duration of DM (Table 1). The highest prevalence was in those with DM of more than 10 years duration. Most of the patients (80%) required oral hypoglyt caemic agents and hence were classified as type 2 diabetics; about 9% required insulin and the remainder were diettcontrolled. Fever was the commonest presenting symptom of TB in this group, being high grade (> 38 ºC) in 55% of patients and of more than 3tmonths duration in 10% of patients. Positive auscultatory findings on chest examination were found in 84%, with bronchial breathing in 13%. We found 43.0% of lower lobe, 20.3% upper lobe and only 15.0% middle lobe involvement on clinical examination. Chest radiograph findings are presented in Table 2 for the 77 patients for whom chest Xtrays were available (some Xtrays were unavailable for analysis as patients had been allowed to take the films). The lower lung fields were most frequently involved, followed by the upper and middle fields. Cavitating lesions were significantly more common in males (32%) than in fet males (15%). Erythrocyte sedimentation Table 1 Clinical characteristics of pulmonary tuberculosis (TB) patients with diabetes mellitus (n = 93) Characteristic Value Patient characteristics Male: female ratio 3:2 Mean (range) age (years) 46.1 (20–90) Mean (range) duration of diabetes (years) 13.8 (1–17) No. % Duration of diabetes (years) < 2 6 7 2–5 14 15 5–10 26 28 >10 47 51 Family history of tuberculosis Yes 10 11 Presenting symptoms of TB Fever 67 72 Cough 61 66 Dyspnoea 22 24 Haemoptysis 17 18 Weight loss 8 9 Table 2 Chest radiograph findings in pulmonary tuberculosis patients with diabetes mellitus (n = 77) Variable No. % Side affected Right 31 40 Left 10 13 Bilateral 36 47 Lung field affected Upper only 12 18 Middle only 10 15 Lower only 24 36 Upper and middle 9 13 Upper, middle and lower 1 1 Upper and lower 5 7 Middle and lower 6 9 Associated features Effusion 25 32 Cavity 20 26 Hilar lymphadenopathy 4 5 Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 525 rate (ESR) was checked in 61 patients and was < 100 mm/h in only 13 patients. Pleural biopsy was performed in 13/25 patients with pleural effusion and was diagnostic in 11 patients. The number of patients who died was 10 overall, giving a mortality rate in these 93 patients with DM and TB of 11%. Mortalt ity was not influenced by the radiographic appearance. A high ESR (> 50 mm/h) was associated with a better outcome. The mean ESR for patients who died was 46 mm/h compared with 76 mm/h for patients who were cured. The outcome of antitTB therapy was better in type 1 DM, when compared with type 2 DM with early clearance of bacilli and improvement in cavities: after 6 months 5/9 (56%) patients with type 1 DM showed clearance of bacilli compared with 32/84 (40%) patients with type 2 DM. Discussion Our study describes the characteristics of pulmonary TB in Pakistani adult diabetics with a diagnosis of both TB and DM. In our hospitalized patients, TB prevalence was 11.9% in patients with DM, 10ttimes more common than in those without DM. In a large cohort of Korean diabetic patients (over 8000) the relative risk of developt ing bacteriological confirmed pulmonary TB was 5 times higher in diabetics than in matched controls [6]. In a random sample of 100 Indian diabetic patients, TB was diagnosed by a positive sputum result in 6% and by radiological examination in 27% [7]. In a 1–7 year followtup study of 1250 African diabetic patients, 5.4% developed pulmonary TB [8]. The prevalence was higher in those with a lower body mass index, in type 1 DM compared with type 2 DM and in those whose diabetes was poorly controlled. The majority of our patients who develt oped TB were middletaged (30–60 years), similar to other studies. In the Indian study, a majority of patients were above 40 years of age [7]. In both the Korean [6] and Japanese [9] studies, the prevalence was particularly high in the age groups 40–50 years compared to the other age groups. In our study, the prevalence of TB increased progressively with duration of diabetes. The highest prevalence was seen in those who had been diagnosed with DM for more than 10 years. Comparative studies of type 1 DM and type 2 DM have shown that the prevat lence of type 1 DM was 8ttimes higher in TB patients than in the general population, whereas the prevalence of type 2 DM was similar [10]. TB patients with type 1 DM have a more acute course of TB, rapid progression, and formation of extensive let sions with multiple cavities [11]. There was early clearance of bacilli and improvement in cavities in type 1 DM compared with type 2 DM. The reason for increased susceptibility of diabetics to TB may be multifactorial. Alveolar macrophages play a critical role in eliminating mycobacterial infection in collaboration with lymphocytes. Alveolar macrophages have been found to be less act tivated in TB patients complicated with DM which may contribute to increased susceptit bility [12]. In a study of 64 TB patients with DM a higher depression of cellular immut nity was evidenced by fewer T lymphocytes and their decreased capacity for blasttcell transformation than those with TB alone [13]. Differences in cytokine production have also been observed. Interferon (IFN)t gamma production by CD4+ Ttcell was reduced in patients with TB but those with poor diabetic control produced significantly less IFNtgamma than did patients with good diabetic control. In a longitudinal study, IFNtgamma production returned to normal 526 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 by 6 months in patients with TB alone and in well controlled diabetic TB patients but remained suppressed in poorly controlled diabetic TB patients [8]. Changes in pulmot nary vasculature and alveolar oxygen prest sure may also be contributory. Histological features of disseminated microangiopathy were observed in the lung preparations of 47 patients with destructive TB and DM [14]. The presence of DM does not seem to modify the presenting symptoms of pult monary TB [2,3]. Fever with cough and sputum remain the common presenting features. Tuberculin reaction was found to be similar [2]. Data on bacteriological results are variable. Some studies showed no difference in bacteriology results, bacilli negative conversion rate or TB relapse rate in diabetic patients [14]. Other studies have shown that in diabetic patients the proport tion of smear positive cases was higher, the culturetnegative conversion period was longer [15], relapse rates were higher [16] and TB relapses were frequently associated with resistant strains [14]. In a case–control study from New York the relative risk of multitdrug resistant TB was found to be 8.6 (confidence interval, 3.1 to 23.6) in the diabetic group compared with the control group [17]. In patients with pulmonary TB, the most common underlying disease was DM [15]. In an innertcity cohort, presence of underlying illness (DM, chronic obstruct tive pulmonary disease, renal failure) and immunosuppression were important predict tors of survival for patients with pulmonary TB [18]. Upper zone involvement and presence of cavitations are typical features of active pulmonary TB. In patients with DM and other systemic diseases, chest radiograph changes may be atypical. In our study, lower lung field involvement was the most frequent change, with upper and middle changes less common. Bilateral changes were present in half of the patients and an associated effusion was present in onet third. In a comparative study of pulmonary TB patients with and without DM, being a diabetic was found to be the most important factor determining lower lung field lesions [1]. In a second study, lower lung field TB was only seen in older diabetic patients (above 40 years) and female sex [2]. Other studies have, however, failed to show any differences in localization of TB lesions [3,19]. Cavitation was seen in only 26% of our patients. A higher rate of multiple cavitation has been reported in many studt ies [1,2,19] but not in others [3]. Among diabetics, patients with type 1 diabetes were found to have more extensive lesions with multiple cavities [11]. In conclusion, pulmonary TB may occur more often among patients with diabetics than those without, mostly between 40 and 70 years of age. Fever and cough are the common presenting symptoms. Lower lung field and bilateral or multitlobar involvet ment is common. An associated effusion may be present. The mortality rate was 10% but was not associated with a particular radiographic appearance. References 1. Perez-Guzman C et al. Atypical radio- logical images of pulmonary tuberculosis in 192 diabetic patients: a comparative study. International journal of tuberculosis and lung disease, 2001, 5(5):455–61. 2. Bacakoglu F et al. Pulmonary tubercu- losis in patients with diabetes mellitus. Respiration, 2001, 68(6):595–600. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 527 3. Al Wabel AH et al. Symptomatology and chest roentgenographic changes of pulmonary tuberculosis among diabet- ics. East African medical journal, 1997, 74(2):62–4. 4. Jawad F et al. Glucose intolerance in pulmonary tuberculosis. Journal of the Pakistan Medical Association, 1995, 45(9):237–8. 5. Basoglu OK et al. The oral glucose tol- erance test in patients with respiratory infections. Monaldi archives for chest diseases, 1999, 54(4):307–10. 6. Kim HJ et al. Ambulatory treatment of multidrug-resistant pulmonary tuberculo- sis patients at a chest clinic. International journal of tuberculosis and lung diseases, 2001, 5(12):1129–36. 7. Ezung T et al. Pulmonary tuberculosis and diabetes mellitus––a study. Journal of the Indian Medical Association, 2002, 100(6):376–9. 8. Tsukaguchi K et al. [Longitudinal assess- ment of IFN-gamma production in patients with pulmonary tuberculosis complicated with diabetes mellitus]. Kekkaku, 2002, 77(5):409–13 [in Japanese]. 9. Yamagishi F et al. [Prevalence of coexist- ing diabetes mellitus among patients with active pulmonary tuberculosis]. Kekkaku, 1996, 71(10):569–72 [in Japanese]. 10. Chukanova VP et al. [Epidemiological and immunogenetic analysis of tubercu- losis and diabetes mellitus association]. Problemy tuberkuleza, 2000, 4:11–4 [in Russian]. 11. Kossii I et al. [Pulmonary tuberculosis in patients with different types of diabetes mellitus]. Problemy tuberkuleza, 2002, 5:21–4 [in Russian]. 12. Wang CH et al. Hypodense alveolar mac- rophages in patients with diabetes mel- litus and active pulmonary tuberculosis. Tuberculosis and lung diseases, 1999, 79(4):235–42. 13. Karachunskii MA, Komliakova EG, Pos- pelov LE. [Specific features of pulmonary tuberculosis course in patients with insu- lin-dependent diabetes mellitus in relation to a varying HLA phenotype]. Problemy tuberkuleza, 1997, 5:23–5 [in Russian]. 14. Kameda K, Kawabata S. [The chemo- therapy of pulmonary tuberculosis com- plicated by diabetes mellitus]. Kekkaku, 1986, 61(8):413–23 [in Japanese]. 15. Tamura M et al. [A study on relation be- tween active pulmonary tuberculosis and underlying diseases]. Kekkaku, 2001, 76(9):619–24 [in Japanese]. 16. Wada M. [The effectiveness of pyra- zinamide-containing six-month short course chemotherapy]. Kekkaku, 2000, 75(11):665–73 [in Japanese]. 17. Bashar M et al. Increased incidence of multidrug-resistant tuberculosis in diabet- ic patients on the Bellevue Chest Service, 1987 to 1997. Chest, 2001, 120(5):1514– 9. 18. Oursler KK et al. Survival of patients with pulmonary tuberculosis: clinical and molecular epidemiologic factors. Clinical infectious diseases, 2002, 34(6):752–9. 19. Ikezoe J et al. CT appearance of pulmo- nary tuberculosis in diabetic and immuno- compromised patients: comparison with patients who had no underlying disease. American journal of roentgenology, 1992, 159(6):1175–9. 528 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Seroprevalence of hepatitis B in Nahavand, Islamic Republic of Iran A.H.M. Alizadeh,1 M. Ranjbar,2 S. Ansari,1 A. MirArab,2 S.M. Alavian,3 K. Mohammad,4 P. Adibi,5 GhH. Sadri,2 F. Keramat,2 A. Ardalan,1 M.Arabi1, S. Gharekhani,2 A. Ataei,2 GhR. Amraei,2 M. Hosseinzadeh,2 S. Hatami2 and M. Zali1 1Research Centre of Gastroenterology and Liver Diseases, Shaheed Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to A.H.M. Alizadeh: ahmaliver@yahoo.com). 2Hamedan University of Medical Sciences, Hamedan, Islamic Republic of Iran. 3Baghiataleh University of Medical Sciences, Tehran, Islamic Republic of Iran. 4Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 5Isfahan University of Medical Sciences, Isfahan, Islamic Republic of Iran. Received: 19/05/04; accepted: 11/01/05 ABSTRACT We determined the seroprevalence of hepatitis B in Nahavand in a sample of 1824 subjects > 5 years in 2002. Face-to-face interviews were conducted and blood samples taken. The association between risk factor and hepatitis B was assessed using logistic regression. The prevalence of HBsAg positive cases was 2.3%, and HBcAb and HBsAb were isolated in 7.8% and 11.6% of the participants respectively; 11.9% were positive for both HBcAb and HBsAb. History of surgery and imprisonment were the major risk factors for infection with odds ratios of 2.14 (95% CI: 1.22–3.05) and 3.57 (95% CI: 1.68–5.4) respectively. 20 Seroprevalence of hepatitis B in Nahavand, Islamic Republic of Iran, 2002 (ÍɺØiÝ=Á=fÈCÍÈeÇÖ(b¾Æ>þ›ÊÑ>F¶=bF³¶=H>ÃJ¶×Ê·r™=e>nJ¾×=¹b£º2002 º²?(Ëe>r¾?Â>m(ˆe=f[Jɺ(Åa=hÉ·¢b»†´¿mǺ?Á>»ÉE(b»†¼ž>²(Á>ÈÇ·¢bÈÖºbÉi(Hf¢ Ø[¦(ÊÈ>[ì¢Ê[·¢(ʾ>[]Åe>[®Â>m(ÊE=f¢?Ëbú(Á×ae?Ê·¢(Kº=f²>FÈfª(Ëebqj†ئ([Èa? ʶ=g>ueb»†(ʓ>UbÉ£i(Åa=gjUb»†(ÊÈ=fº=>ufº  „=Í[qØ6¶=H>[[ÃJ¶×Ê·r[™=e>[nJ¾×=¹b[£ºbÈbVJEÁÇ[NU>F¶=½>[®K»[uÍ[[¿ëÉ¢›b[[¾Æ>þ›ÊÑ>[F¶=b[[F³ 1824½>¢›Íjº>„=Ài±Çªð>r^m2002*¼Ã¿[º½aL>[¿É¢Ld[]?>[»²¼Ã£ºÍÉr^mL=Ð>¯¶KÈfQî?Æ* jÉQÇ·¶=­èÇVJ¶=½=b^Ji>EÊÑ>F¶=bF³¶=H>ÃJ¶=EÆe>ìJ]×=¸º=Ç¢EœE=¶=¼É[ɯIÆ*¹b[£ºÁ?b[QÆÆ ÍÉE>‹Ý=L×>ƒ=e>nJ¾=bF³¶=H>ÃJ¶=bvJj™GÇÂ2.3!Ïb[¶ÊÑ>[F¶=b[F³¶=H>[ÃJ¶×·¶=bv¶=a=f«Ji=Æ7 11.6!Ïb¶ÊVìj¶=bv¶=Ɛ²e>n™=Àº7.8*!Á>²Æ11.9ÊVìj[¶=ÀáÈçbv[¶=س¶[ÉE>‹C²e>n™=Àº ·¶=Æ*=Ç¢¼[Â?¸[ëN“ÁÇRj[¶=›b[Q=ÇJ¶=Æ?Í[ÉU=fQÍÉ·»¢Ð=fQCͯE>iÁ?ÀçÉFIÆÍFj[¿EÏÆb[£¶=e>[ìJ]=¸[º ÍÉVQe?2.14%95!ͯN¶=Ìf[Jª1.22–3.05$Æ‘ÆÚ¶3.5%95!ͯN¶=Ìf[Jª1.68–5.4$ÍÉÑ>¿N·¶*  Séroprévalence de l’hépatite B à Nahavand (République islamique d’Iran) RÉSUMÉ Nous avons déterminé la séroprévalence de l’hépatite B à Nahavand dans un échantillon de 1824 sujets âgés de plus de 5 ans en 2002. Des entretiens face à face ont été menés et des pré- lèvements sanguins ont été effectués. L’association entre le facteur de risque et l’hépatite B a été évaluée au moyen de la régression logistique. La prévalence des cas Ag HBs positifs était de 2,3 % ; des anticorps anti-HBc et des anticorps anti-HBs ont été isolés chez 7,8 % et 11,6 % des participants respectivement ; 11,9 % étaient positifs à la fois pour les anticorps anti-HBc et les anticorps anti-HBs. Des antécédents de chirurgie et d’emprisonnement étaient les principaux facteurs de risque d’infection, avec un odds ratio de 2,14 (IC 95 % : 1,22 - 3,05) et 3,57 % (IC 95 % : 1,68 - 5,4) respectivement. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 529 Introduction The prevalence of hepatitis B worldwide is 5%, which makes it one of the most preval lent infectious diseases. It is estimated that 400 million people in the world are carriers of hepatitis B virus (HBV) with 75% to 80% living in Asia and Eastern Europe [1]. Middle East countries have an intermediate prevalence with 2%–7% infection in the general population and a 20%–60% lifetime risk of infection. Chronic hepatitis B acl counts for about 1 million deaths each year and is a major risk factor for cirrhosis and hepatocellular carcinoma [1,2]. In an epidemiological study in the Islaml ic Republic of Iran, hepatitis B prevalence has been reported to be as low as 1.07% in Shiraz to as high as 8.96% (in Toicerkan). The prevalence in provinces ranges from 1.7% in Fars to 5% in SistanlolBaluchestan. In Tehran 3.6% of men and 1.6% of women were reported to be hepatitis B surface antigen (HBsAg) positive [3]. The main route of HBV transmission, like hepatitis C virus (HCV) and human iml munodeficiency virus (HIV) is via blood and blood products. In hyperendemic regions in the world vertical transmission from mother to newborn infant and horizontal transmisl sion among children play an important role in intralfamilial transmission of HBV [4–6]. In North America and Western Europe, however, the main route of transmission is intimate sexual contact [1]. Needlelstick injuries in health personnel, haemodialyl sis, shared needles in drug abusers, dental surgery, receiving blood or blood products, blood letting, ear and nose piercing pracl tices, tattooing, and contact with body fluid or mucosa of HBV carriers (e.g. workers in clinical laboratories) have been associated with increased risk of transmission [1]. In the Islamic Republic of Iran, 46% of patients with hepatocellular carcinoma and 51% of those with cirrhosis are reported to be HBsAg positive [7]. HBV is also recogl nized as the most frequent cause (70%–80%) of chronic hepatitis in the country. Of all measures to control the disease in the Islamic Republic of Iran, vaccination of all newborns from 1993 onwards has been the most significant. In order to devise any further measures to control this disease more exact epidemiological information is required. There has been no definitive study about prevalence of hepatitis B in the city of Nal havand in Hamedan province in the western part of the Islamic republic of Iran. Therel fore, in this study, we aimed to determine the prevalence of hepatitis B in Nahavand and its associated risk factors. Methods This crosslsectional study was conducted during a 2lmonth period (February–March 2003) on people aged 6 years and over in the city of Nahavand (72 000 population). We used lot quality assurance sampling (LQAS) to select individuals from the genl eral population of Nahavand. Of the 6 urban areas from the health administrative system map in Nahavand, 5 (amounting to over 61 000 people) were included in the study and 1824 participants were recruited through systematic random sampling (apl proximately 365 participants in each area as a stratum) [8]. The area excluded covered mostly suburban populations. Based on data extracted from the 1999 census registry, the number of potential candidates and their contact address and phone numbers were determined by the family health official of each health care centre. A questionnaire including demographic and socioeconomic data and risk factors of hepatitis B was developed by gastroenteroll 530 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 ogists and epidemiologists at the Research Centre. After taking the approval of health authorities of the city and the city council, training of data collection teams and direcl tors of health care centres was held to train them on conducting the interview, filling the questionnaire and blood sampling. The selected participants were contacted and interviewed at their homes. If the chol sen family was not available due to change of address, refusal or some other reason, another family was selected to replace them using the same sampling procedure. Every participant signed an informed consent form before the interview. For those bel tween 5 and 15 years the consent form was signed by one of the parents. The blood samples and completed questionnaires were gathered at the end of each day. The serum samples were sent to the Research Centre in Tehran to be assessed for hepatitis B serologic markers. The virologic markers of hepatitis B were measured. HBsAg detection was carried out with a DiaSorin kit (No. 0370790/1A) (DiaSorin, Saluggia, Italy) through sandl wiched enzymellinked immunosorbent assay (ELISA). Levels of antibodies to hepatitis B surface antigen (HBsAb) and hepatitis B core antigen (HBcAb) were measured by DiaSorin kit (No. 9230320/ A) through sandwiched nonlcompetitive ELISA and DiaSorin kit (No. 8540480/1B) through competitive ELISA respectively. Hepatitis Be antigen (HBeAg) detection was carried out with a DiaSorin kit (No. 3120128) through sandwiched nonlcoml petitive ELISA. HBsAb titres over 10 U/mL were considered positive. All data were analysed with SPSS, verl sion 11. Bivariate and multivariate associal tions of seropositivity (as binary dependent variable) with other independent variables were examined by logistic regression modl el, and odds ratios (OR) and correspondl ing 95% confidence intervals (CI) were calculated. Results Of all the selected individuals, 85 (4.6%) did not participate due to change of address or refusal, and were replaced by others who were eligible. The total number of parl ticipants over 5 years in the chosen families was 7682. As regards sex, 1025 (56.2%) of the participants were male and 799 (43.8%) were female. Mean age (standard deviation) was 34.8 (SD 19.6) years, range 6–93 years. The age distribution of the participants is shown in Figure 1. The most frequent age group was 15–20 years. The age distribul tion of our sample was compared with that of the Health Surveillance Study carried out in April 1998 to March 1999 by the Nal tional Centre for Medical Research for the whole country [7] (Figure 2). As regards demographic data, 1005 (55.1%) of the participants were married. The mean size of households was 4.8 (SD 1.9) members, range 1–13 members. The mean number of members over 5 years of age per family was 4.2 (SD 1.9). The frequency distribution of hepatitis B serological markers in the study participants is shown in Table 1. Of the 1824 particil pants, 42 (2.3%) were positive for HBsAg. Only 2 of these 42 (4.8%) were aware of having hepatitis B before the results of blood sample tests were revealed. Of the 42 HBsAg positive participants, 4 (9.5%) were also HBeAg positive, indicating wild type condition in these subjects. Among the sample, 13 (7.8%) were positive for HBcAb and 211 (11.6%) were positive for HBsAb; 217 (11.9%) were positive for both HBsAb and HBcAb. Age frequency distribution of particil pants with hepatitis B showed that the frel Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 531 quency of the disease increased with age with age groups of 55–59 years and 80–84 years having the highest rates of the disease. The disease was not observed in 5–9lyearl old participants (Figure 3). Logistic regression analysis was used to find the risk factors most strongly associl ated with the disease (Table 2). History of surgery and imprisonment had the greatest risk with OR of 2.14 and 3.57 respectively. Figure 1 Age distribution of the participants of the Nahavand study (n = 1824) Figure 2 Age distribution of the participants compared with that of the Health Surveillance Study [7] % 532 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Of all the participants, 5 had thalassael mia major, 6 had renal failure and were unl dergoing haemodialysis, 2 had haemophilia and 16 had diabetes. However, of these, only 1 diabetic patient had hepatitis B. Being affected with these diseases was not considered in the regression analysis of risk factors to allow a more exact calculation of attributable risk. Figure 4 shows the proportion of study participants positive for HBsAb according to age group. In the 5–9 years age group, only 33.6% of the subjects had an acceptl able level of HBsAb. The proportion of individuals with adequate HBsAb levels increased with age. Figure 5 shows the proportion of parl ticipants positive for HBcAb according to Table 1 Frequency distribution of hepatitis B serologic markers among the participants of the Nahavand study by demographic variables (n = 1824) Positive for Positive for Positive for Positive for HBsAg isolated isolated HBcAb & HBcAb HBsAb HBsAb No. (%) 42 (2.3) 143 (7.8) 212 (11.6) 217 (11.9) % male 54.8 44.1 41.5 53.9 Mean age (SD) (years) 40.2 (18) 55.2 (16) 37.3 (22) 52.8 (17) % married 66.7 71.3 51.4 80.2 SD = standard deviation. Figure 3 Distribution of HBsAg positive cases among participants according to age group Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 533 Table 2 Logistic regression analysis of risk factors for hepatitis B in the study sample Variable ββ coefficient Odds ratio Confidence P-value interval Sex 0.53 1.71 0.820–2.950 0.1 Age 0.022 1.022 0.900–1.040 0.01 Blood transfusion 0.656 1.92 0.870–3.040 0.399 Tattoo 0.55 1.74 0.930–2.100 0.99 Cupping –0.28 0.75 0.490–1.510 0.57 Outpatient surgery 0.231 1.26 0.750–1.690 0.54 Smoking –0.57 0.56 0.300–1.020 0.311 High-risk job –0.435 0.013 0.003–0.027 0.74 History of jaundice –0.07 0.92 0.840–1.120 0.94 History of hospitalization –1.74 0.17 0.006–0.032 0.01 Surgery 1.27 3.57 1.680–5.400 0.062 History of imprisonment 0.76 2.14 1.220–3.050 0.32 History of liver disease in family 0.53 1.71 0.970–2.360 0.21 Figure 4 Proportion of subjects positive for HBsAb according to age group 534 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 age group. This group represents those who were still affected by the disease. The prol portion of participants positive for HBcAb increased with age. Standardized morbidity rate (SMR) for hepatitis B was 1.3 (95% CI: 0.81–1.53). Discussion A comparison of age frequency distribution of the sample and that of National Health Surveillance [7] showed no significant difl ference which suggests the sample was repl resentative of the respective society. The prevalence of HBsAg among our sample in Nahavand was 2.3%. Comparl ing this with national norms of hepatitis B prevalence [7] showed that the standardized morbidity rate (SMR) was 1.3 (95% CI: 0.81–1.53). Based on the calculated SMR and respective CI, there was no significant difference between the prevalence of hepal titis B in Nahavand and national norms. In a study in 1989 in Hamedan province, 4930 people (1649 men and 3281 women) were tested for hepatitis B risk factors and markers and 3.49% were found HBsAg positive [9]. Of those with HBsAg, 13.8% were also HBcAg positive. The lowest prevalence was observed in children and young adults under 19 years and in those over 60 years. There was no difference between men and women. This study sugl gested that horizontal transmission of the disease may be the major form of transmisl sion in children and young adults [9]. In our study, the frequency of HBeAg positive cases was 9.5%, clearly lower than that reported by other studies [10,11]. In a study on 11 455 blood donor medical records at a blood transfusion organization of Hamedan in 1995–1996, 1.9% of donors were HBsAg positive [10]. The highest rates (8.69%) were reported from Toicerl kan and the lowest from Gharveh (1.3%) and Hamedan (1.36%). The lowest rate Figure 5 Proportion of subjects positive for HBcAb according to age group Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 535 (0.96%) was observed in 58–68 years age group. In another study of 104 236 blood donor records in Hamedan in 1981–1993 (12 years), the overall HBsAg prevalence was 2.96%. Of the HBsAg positive cases, 164 were examined for HBeAg and HBeAb with 82.3% HBeAb positive, 11% HBeAg positive and 6.7% positive for both markers. The disease was most prevalent in farmers, with Nahavand having the highest rate in Hamedan province [11]. In a recent study in Khorasan province, hepatitis B prevalence was 3.6% [12]. In other countries variable prevalence rates of hepatitis B have been reported [13–16]. A study in Bangkok reported a prevalence of 4.6% for HBsAg positive cases with 20% also being positive for HBeAg [14]. Croatia has less than 2% of HBsAg carriers in the general population [15] and a study in Pakistan revealed 2.56% of individuals in the general population were positive for HBsAg [16]. Our results show that there were no cases of hepatitis B in the 5–9 years age group. This suggests that the national vaccil nation programme has reduced the hepatitis B prevalence, so improving the coverage of vaccination seems necessary. The fact that the rate of HBsAg positive cases increased with age, suggests the critical role of horil zontal transmission. The results of our study show a lower prevalence for hepatitis B in Nahavand than previously reported [10,11]. It is important to note that in the previous studies, the prevalence of hepatitis B was assessed in blood donors who may not be represental tive of the community. However, in our study the sample was representative of the community. HBsAb was isolated in 11.6% of our participants, which is likely to be the result of hepatitis B vaccination. A study in 1989 found HBsAb and HBcAb prevalence rates in Hamedan of 18.09% and 5.13% respecl tively [9], which are different from our results. The differences could be due to the different times of these studies, different locations and differences in compliance with vaccination. As regards vaccination status, 44% of the participants reported previous vaccil nation and 30% were not aware of their vaccination status. HBV vaccination of all newborns began 10 years before our study. So, the subjects under 10 years old must have received HBV vaccine through the national immunization programme. Given the 95% coverage of hepatitis B vaccination and 33.6% prevalence of isolated HBsAb in the 5–9 years age group, the antibody response in children seems inconsistent. A booster dose of hepatitis B vaccine should, therefore, be carefully evaluated. A number of studies have reported antibody response rates. Goldenberg et al. reported a lack of response in up to 14% of adults [17]. In another study on 1–3lyearlold Turkish chill dren, 96.7% had an antibody titre of more than 10 U/mL [18]. In our study, 11.9% of the participants were positive for both HBcAb and HBsAb. In a study carried out on 1000 blood donors in Brazil in 2003, 120 had HBcAb; 10 (8.3%) of whom also had HBsAg [19]. All the individuals with HBcAb were positive for HBV DNA, confirmed by polymerase chain reaction (PCR); 2 had HBsAb [19]. In a German study, HBcAb and HBsAb were detected in 1.5% of HBsAglnegative cases; HBV DNA was confirmed by PCR [20]. In another study of Chinese blood donors, no cases of HBV DNA were detected in individuals positive for HBsAb and HBcAb [21]. In a study on 9006 Swiss women, 1.2% had HBcAb and 5.1% had both HBcAb and HBsAb [22]. This is lower than our results. A history of imprisonment and surgery had the highest attributable risks for hepatil 536 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 tis B infection. In the study on blood donors of Hamedan, a history of surgery had the greatest risk (OR = 3.11) for hepatitis B [10]. The risk factors identified in our study are similar to studies carried out in other countries [23]. Nahavand can be classified intermedil ate in terms of HBsAg prevalence in its population. Given the result of this study, public health education and vaccination programmes should be continued progresl sively. We recommend further investigal tion into the relation between surgery and increased risk of hepatitis B to find effective intervention for reducing the risk of hepatil tis B transmission. References 1. Nair S, Perillo RP. Hepatitis B and D. In: Zakim D, Boyer TD, eds. Hepatol- ogy, 4th ed. Philadelphia, WB Saunders, 2003:959–1016. 2. Alter M. Epidemiology of hepatitis B infec- tion in the Western Pacific and South-East Asia. Gut, 1976, 38(suppl. 2):S18–23. 3. Zali MR et al. Epidemiology of hepatitis B in the Islamic Republic of Iran. East- ern Mediterranean health journal, 1996, 2(2):290–8. 4. Joshi N, Yr NK, Kumar B. Age-related seroprevalence of antibodies to hepatitis A virus in Hyderabad, India. Tropical gas- troenterology, 2000, 21(2):63–5. 5. Werner GT, Frosner GG, Fresenius K. Prevalence of serological hepatitis A and B markers in a rural area of northern Za- ire. American journal of tropical medicine and hygiene, 1985, 34:620–4. 6. Lionis C et al. Prevalence of hepatitis A, B and C markers in school children of a rural area of Crete, Greece. European journal of epidemiology, 1997, 13:417–20. 7. Iran’s health and disease surveillance report, 2001. Tehran, National Medical Research Centre, 2001 [In Farsi]. 8. Levy PS, Lemeshow S. Selected topics in sample design and estimation meth- odology. In: Levy PS, Lemeshow S, eds. Sampling of population: Methods and ap- plications, 3rd ed. New York, John Wiley & Sons, 1999:427–30. 9. Amini S et al. Seroepidemiology of hepati- tis B, delta and human immunodeficiency virus infections in Hamadan province, Iran: a population-based study. Journal of tropical medicine and hygiene, 1993, 96(5):277–87. 10. Saboori Ghanad M, Ghasemi G. [Fre- quency distribution of HBsAg in Hamedan province blood donors, February to De- cember 1995.] Journal of Hamedan Uni- versity of Medical Sciences and Health Services, 1997, 4(2):76–81 [In Farsi]. 11. Mojtahedzadeh SM et al. [Prevalence of HBsAg and VDRL positive cases in Hamedan province blood donors.] Jour- nal of research in medicine, Shaheed Beheshti University of Medical Sciences, 1995, (3,4):74 [In Farsi]. 12. Farhat A, Khademi G, Mazouman SJ. The prevalence of hepatitis B carrier state in Khorasan province of Iran. Saudi medical journal, 2003, 24(5):549–51. 13. Hernandez MT et al. Hepatitis B prev- alence in young women living in low- income areas: the population-based San Francisco Bay area’s Young Women’s Survey. Sexually transmitted diseases, 2000, 27(9):539–44. 14. Luksamijarulkul P, Maneesri P, Kittigul L. Hepatitis B seroprevalence and risk factors among school-age children in a low socioeconomic community, Bangkok. Asia-Pacific journal of public health, 1995, 8(3):158–61. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 537 15. Lesnikar V. Epidemiology of hepatitis B and C in Croatia. Acta medica Croatica, 2005, 59(5):377–81. 16. Khokhar N, Gill ML, Malik GJ. General se- roprevalence of hepatitis C and hepatitis B virus infections in population. Journal of the College of Physicians and Sur- geons—Pakistan, 2004, 14(9):534–6. 17. Goldenberg R et al. Antibody titers to hep- atitis B surface antigen among vaccinated emergency physicians: three years’ expe- rience with a wellness booth. Annals of emergency medicine, 1999, 33(2):156–9. 18. Karaoglu L et al. Evaluation of the immune response to hepatitis B vaccination in chil- dren aged 1–3 years in Malatya, Turkey. New microbiologica, 2003, 26(4):311–9. 19. Arraes LC et al. The biological meaning of anti-HBC positive result in blood donors: relation to HBV-DNA and to other sero- logical markers. Revista do Instituto de Medicina Tropical de São Paulo, 2003, 45(3):137–40. 20. Hennig H et al. Frequency and load of hepatitis B virus DNA in first-time blood donors with antibodies to hepatitis B core antigen. Blood, 2002, 100(7):2637–41. 21. Ren F, Li H, Zhao H. Studies on hepatitis B virus infection in blood donors with positive anti-HBc and negative HBsAg. Zhonghua Yu Fang Yi Xue Za ZhiI, 1998, 32(1):7–9. 22. Bart PA et al. Seroprevalence of HBV (anti-HBc, HBsAg and anti-HBs) and HDV infections among 9006 women at deliv- ery. Liver, 1996, 16(2):110–6. 23. Beier FJ. Risk of endangering patients by hepatitis B infected surgeons: monitoring the health of medical personnel in hos- pitals must be evaluated. Gesundheits- wesen, 2000, 62(2):64–70. World Health Statistics 2006 World Health Statistics 2006 presents the most recent statistics since 1997 of 50 health indicators for WHO’s 192 Member States. This sec- ond edition of World Health Statistics includes an expanded set of sta- tistics, with a particular focus on equity between and within countries. It also introduces a section with 10 highlights in global health statistics for the past year. Further information is available at: http://www.who. int/whosis/en/. The document can be downloaded from: http://www. who.int/whosis/whostat2006/en/index.html or a hard copy ordered from WHO Press at: http://bookorders.who.int. 538 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Connaissances sur les virus des hépatites B et C et le VIH chez des donneurs de sang à Casablanca H. Boutayeb,1 A. Aamoum1 et N. Benchemsi1 1Centre régional de Transfusion sanguine (Maroc) (Correspondance à adresser à H. Boutayeb : drboutayebh@yahoo.fr ; khairhouda@caramail.com). Reçu : 26/12/04 ; accepté : 04/04/05 RÉSUMÉ Une enquête a été réalisée au niveau du Centre régional de Transfusion sanguine de Cas sablanca de février à mai 2002 auprès de 1750 donneurs de sang. Un questionnaire a été soumis à chaque donneur de sang. Son objectif était d’évaluer les connaissances sur les modes de transmission des virus des hépatites B et C et de l’immunodéficience humaine. Les modes de transmission du VIH semblent mieux connus que ceux de l’hépatite B avec respectivement 85 % et 60 % de réponses justes. Les modes de transmission du virus de l’hépatite C sont les moins bien connus avec 54 % de réponses exactes, et ce même au sein des groupes informés comme le personnel paramédical et les étudiants en médecine. Des efforts doivent être faits en matière d’information sur les modes de transmission des virus des hépatites B et C pour une meilleure prévention. Knowledge about hepatitis B and C viruses and HIV among blood donors in Casablanca ABSTRACT A survey was conducted in the Casablanca Regional Blood Transfusion Centre from Febs ruary to May 2002. A questionnaire was given to 1750 blood donors from different groups of society to asses the knowledge of the public about hepatitis B and C and human immunodeficiency viruses. The responses indicated that the mechanism of HIV transmission was well known to the public: 85% gave correct answers. Hepatitis B and hepatitis C viruses were less well understood: 60% and 54% gave correct answers respectively. Our study suggests that the public needs to be better informed about hepatitis B and C virus transmission. 1 bF³¶=H>ÃJ¶=áÊßiƪ¹ÇU½b¶>E¢J™=­e>£º%%ÊE$$Æ%%Êi$$Ð>vÉF¶=e=b¶=› ÊjÀEÍjÉ«¾(½Ç»¢?¬Éì·¶=bF¢(GëÉ{ÇEÏb  „=Í[qØ6>F[mÀ[ºÌb[™=¹Ø]Ð>vÉF¶=e=b¶=›ʻɷ®Ý=½b¶=¸¯¾h²fº›XjºËfQî?+e>[È?‘Cf[È=ª+ÇÈ>[º 2002*Ji=Ð>ì¢CÆÇV¿¶Á>ÉF1750¹Ç[UeÇ[û‚=­e>[£º¼É[[ɯIÍßÉá§àE¤»J=L>Òª¬·J‡Àº½b¶>Eð>¢ëÇìJº bF³¶=H>ÃJ¶=%%ÊE$$Æ%%Êi$$Ëfn[F¶=Ê¢>¿™=gßÇߣ¶=L>iƪÆ*eÇ[û‚=Í[ªf£ºÎ[·¢Í[ºçb¯™=L>[E>QÝ=K[õ¶aÆ gbÈÝ=lƪÍÈ=fiL>ɶBE6Îì¢?b¯ª85!ÍVÉVqL>E>QC*>º?b[F³¶=H>[ÃJ¶=áÊßiÆ«EÍÈ=eb¶=¹b£º%%Ê[E$$ Æ%%Êi$$Á>²OÉU¸[®?Çê60!b[F³¶=H>[ÃJ¶=lÆ[ªÀ[¢L>[E>QÝ=Àº%%Ê[E$$Æ54!À[¢L>[E>QÝ=À[º bF³¶=H>ÃJ¶=lƪ%%Êi$$ÍVÉVq*b[F³¶=áÊ[ßiƪÍÈ=fj[EeÇ[û‚=Í[É¢ÇIÍ[É»Â?Î[·¢Í[i=eb¶=ÅdÂè¹bIÆ  %%ÊE$$Æ%%Êi$$¸vª?¸³nE*    Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 539 Introduction Les hépatites B et C, ainsi que le SIDA, constituent un nouvel enjeu de santé publiq que de par l’importance du nombre des perq sonnes contaminées, la gravité des formes évolutives de l’infection et le coût élevé de la prise en charge des patients. En effet, on estime à 2 milliards le nombre de personnes infectées par le virus de l’hépatite B (VHB), dont plus de 350 millions deviennent des porteurs chroniques, et à 170 millions le nombre de porteurs chroniques du virus de l’hépatite C (VHC) avec 3 à 4 millions de nouveaux cas infectés chaque année [1,2]. Par ailleurs, d’après le rapport du Programme commun des Nations Unies sur le VIH/SIDA et de l’Organisation mondiale de la Santé en 2004, 39,4 millions de perq sonnes vivent aujourd’hui avec le virus de l’immunodéficience humaine (VIH) [3]. Au Maroc, les taux élevés d’analphaq bétisation et de pauvreté représentent une des causes majeures de l’augmentation de l’incidence de ces affections du fait de l’ignorance des modes de transmission et de prévention de ces virus par la population marocaine. Ainsi, et selon les données du Centre régional de Transfusion sanguine de Casablanca (CRTS), l’incidence des hépatiq tes B et C et du SIDA était respectivement de 2,4 % , 0,54 % et 0,06 % en 2002. Ce travail se propose d’évaluer l’état des connaissances de la population marocaine de différents niveaux d’instruction concerq nant les causes, les modes de transmission, les manifestations cliniques ainsi que les moyens thérapeutiques et préventifs de ces affections afin de cerner la nécessité d’informer, et si besoin est, le type d’inforq mation à donner. Méthodes L’enquête a été réalisée au Centre régional de Transfusion sanguine de Casablanca de février à mai 2002. Un questionnaire a été distribué lors des collectes mobiles de sang ou dans la salle de prélèvement du CRTS à 2000 donneurs de sang. Le choix de la taille de l’échantillon étudié a été basé sur le désir d’inclure des groupes de niveaux d’instruction différents et de taille statistiquement interprétable. Un questionnaire a été établi par les méq decins du CRTS. Il teste les connaissances concernant les modes de transmission des virus des hépatites B et C et du VIH, et les possibilités de prévention et de traitement de ces maladies. Il a été tiré en 2000 exemq plaires. Mille questionnaires ont été rédigés en arabe et 1000 en français. Les questions étaient courtes et simples sous forme de questions à choix multiples. Les réponses ont également été rédigées en arabe et en français, sur une feuille à part, et ont été distribuées à chaque participant après qu’il ait répondu au questionnaire, l’objectif étant également de donner une information si nécessaire. Les formulaires ont été distribués à 2000 personnes par un médecin ou un assisq tant social lors des collectes de sang. Pour le groupe des lycéens dont l’âge ne permettait pas un don de sang, le questionnaire a été distribué dans les classes. Pour les sujets analphabètes, le formulaire a été lu et rempli par un médecin ; pour les autres, il a été remis et rempli avant le don de sang par chaque donneur de sang. L’analyse des questionnaires a été faite par le médecin responsable de l’enquête. 540 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Résultats Après étude des 2000 questionnaires, seuls 1750 ont pu être exploités, avec un taux de compliance de 87,5 %. L’âge moyen était de 27 ans pour tous les groupes confondus, avec des extrêmes allant de 16 à 38,5 ans (Tableau 1). Après analyse des dossiers, les particiq pants ont été répartis en 8 groupes selon leur niveau d’instruction et/ou leur profession. • Groupe 1 : lycéens du lycée Moulay Abdellah de Casablanca (n = 100) • Groupe 2 : étudiants en 1re année à la faculté de médecine de Casablanca (n = 200) • Groupe 3 : étudiants en 5e année à la faculté de médecine de Casablanca (n = 150) • Groupe 4 : étudiants des différentes faq cultés de droit, d’économie et des scienq cesqtechniques de l’université Hassan II de Casablanca (n = 450) • Groupe 5 : ouvriers (n = 100) • Groupe 6 : cadres (n = 100) • Groupe 7 : techniciens de laboratoire et infirmiers du Centre hospitalier univerq sitaire Ibn Rochd de Casablanca (n = 100) • Groupe 8 : donneurs de sang, volontaiq res ou parents de malades, se présentant au CRTS de Casablanca (n = 550). Sur les 7 questions posées sur les moq des de transmission du VIH, 85 % des réponses étaient exactes. Les transmissions sexuelle et maternoqfœtale de la maladie étaient connues de la majorité des groupes. La notion de contamination par piqûre de moustique, dans les toilettes publiques ou en buvant dans le verre d’une personne contaminée existait chez 14 % des partiq cipants, dont 24 % étaient des étudiants en première année de médecine, 7 % des étudiants en cinquième année et 10 % du personnel de santé (Tableau 2). Les moyens de prévention étaient connus et la nécessité d’isoler le malade était notée chez 83 % des lycéens, 10 % des étudiants en médecine en 5e année et 15 % du personnel paramédical (Tableau 2). L’absence de vaccin efficace était connue de 79 % des participants. Sur les 7 questions posées sur les modes de transmission du VHB, on a noté 64 % de réponses justes. La transmission sexuelle de la maladie était connue de 23 à 52 % des donneurs de sang ne faisant pas partie du corps médical contre 60 à 84 % du perq sonnel médical (Tableau 3). Soixanteqdeux pour cent (62 %) des étudiants en 1re année de médecine, 70 % des lycéens et 30 % des étudiants en 5e année de médecine pensaient que l’hépatite B se transmettait par les mains sales, la salive ou l’eau du robinet (Tableau 3). Tableau 1 Âge moyen et sexe Groupes 1 2 3 4 5 6 7 8 Âge moyen (ans) 16 18,5 23,5 21 38,5 36,3 35 32 Sexe féminin (%) 70 80 72 53 20,7 33,3 77 19 Groupes 1 : lycéens ; 2 : étudiants en 1re année de médecine ; 3 : étudiants en 5e année de médecine ; 4 : étudiants de différentes facultés ; 5 : ouvriers ; 6 : cadres ; 7 : personnel paramédical ; 8 : donneurs de sang vus au CRTS de Casablanca. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 541 Ta bl ea u 2 Ét at d es c on na is sa nc es s ur le V IH : co nt am in at io n, s ig ne s cl in iq ue s, pr év en tio n Ite m G ro up es 1 (n = 1 00 ) 2 (n = 2 00 ) 3 (n = 1 50 ) 4 (n = 4 50 ) 5 (n = 1 00 ) 6 (n = 1 00 ) 7 (n = 1 00 ) 8 (n = 5 50 ) N br e % N br e % N br e % N br e % N br e % N br e % N br e % N br e % Co nt am in at io n en b uv an t da ns le v er re d ’u ne pe rs on ne c on ta m in ée , da ns le s to ile tt es pu bl iq ue s ou p ar p iq ûr e de m ou st iq ue 27 27 48 24 11 7 90 20 25 25 16 16 10 10 99 18 Co nt am in at io n lo rs d ’u n ra pp or t s ex ue l 86 86 19 2 96 13 9 93 40 5 90 90 90 92 92 96 96 47 8 87 Tr an sm is si on d e la m èr e à so n no uv ea us né 73 73 19 2 96 13 9 93 38 7 86 69 69 70 70 91 91 26 9 49 Co nn ai ss an ce d ’a u m oi ns 2 si gn es c lin iq ue s 49 49 19 6 98 13 5 90 31 5 70 50 50 47 47 85 85 25 3 46 L’i nf ec tio n pa r l e VI H p eu t ex is te r s an s do nn er d e si gn es 73 73 18 4 92 13 0 87 37 3 83 52 52 75 75 79 79 33 0 60 M od es d e pr ot ec tio n Éd uc at io n 46 46 20 0 10 0 13 5 90 33 7 75 65 65 70 70 87 87 24 7 45 Pr és er va tif 83 83 20 0 10 0 13 5 90 32 4 72 81 81 72 72 89 89 33 5 61 N on sr éu til is at io n du m at ér ie l à u sa ge u ni qu e 83 83 18 0 90 13 5 90 33 7 75 64 64 72 72 87 87 24 2 44 Is ol em en t d u m al ad e 83 83 44 22 15 10 85 19 40 40 15 15 15 15 13 2 24 In ex is te nc e de tr ai te m en t effi ca ce 52 52 20 0 10 0 14 8 99 36 9 82 78 78 81 81 85 85 37 9 36 8 In ex is te nc e de v ac ci n 75 75 19 2 96 15 0 10 0 35 5 79 70 70 85 85 90 90 69 67 G ro up es 1 : ly cé en s ; 2 : ét ud ia nt s en 1 re a nn ée d e m éd ec in e ; 3 : ét ud ia nt s en 5 e a nn ée d e m éd ec in e ; 4 : ét ud ia nt s de d iff ér en te s fa cu lté s ; 5 : ou vr ie rs ; 6 : c ad re s ; 7 : pe rs on ne l p ar am éd ic al ; 8 : d on ne ur s de s an g vu s au C RT S de C as ab la nc a. 542 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Ta bl ea u 3 Ét at d es c on na is sa nc es s ur le v iru s de l’ hé pa tit e B : c on ta m in at io n, s ig ne s cl in iq ue s, pr év en tio n Ite m G ro up es 1 (n = 1 00 ) 2 (n = 2 00 ) 3 (n = 1 50 ) 4 (n = 4 50 ) 5 (n = 1 00 ) 6 (n = 1 00 ) 7 (n = 1 00 ) 8 (n = 5 50 ) N br e % N br e % N br e % N br e % N br e % N br e % N br e % N br e % Co nt am in at io n pa r l e sa ng 67 67 19 6 98 14 4 96 29 7 66 53 53 75 75 95 95 39 0 71 Co nt am in at io n pa r l es ra pp or ts s ex ue ls 52 52 16 2 81 12 6 84 20 7 46 23 23 37 37 60 60 13 2 24 Co nt am in at io n pa r l es m ai ns s al es , l a sa liv e, l’e au d u ro bi ne t 70 70 12 4 62 45 30 17 1 38 35 35 23 23 23 23 14 3 26 Co nn ai ss an ce d ’a u m oi ns 2 si gn es c lin iq ue s 90 90 20 0 10 0 15 0 10 0 28 3 63 40 40 75 75 45 45 13 7 2 L’i nf ec tio n pa r l e VH B pe ut ex is te r s an s do nn er d e si gn es 65 65 16 0 80 15 0 10 0 25 6 57 48 48 77 77 83 83 34 1 62 M od es d e pr ot ec tio n Pr és er va tif 45 45 17 2 86 14 4 96 19 3 43 23 23 38 38 53 53 82 15 Se rin gu es à u sa ge un iq ue , e n év ita nt d e pa rt ag er le s ra so irs 45 45 17 2 86 14 4 96 18 9 42 33 33 49 49 73 73 24 2 44 Ex is te nc e d’ un v ac ci n 55 55 14 4 72 12 0 80 23 8 79 70 70 73 73 85 85 41 8 76 G ro up es 1 : ly cé en s ; 2 : ét ud ia nt s en 1 re a nn ée d e m éd ec in e ; 3 : ét ud ia nt s en 5 e a nn ée d e m éd ec in e ; 4 : ét ud ia nt s de d iff ér en te s fa cu lté s ; 5 : ou vr ie rs ; 6 : c ad re s ; 7 : pe rs on ne l p ar am éd ic al ; 8 : d on ne ur s de s an g vu s au C RT S de C as ab la nc a. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 543 Les signes cliniques de la maladie étaient connus des jeunes (groupes 1, 2, 3) et ignorés de plus de 60 % du personnel paramédical (Tableau 3). La possibilité de recourir à une vacciq nation pour se protéger de l’hépatite B était connue de 68,7 % des participants, dont 55 % étaient des lycéens et étudiants des facultés de droit et 80 % des étudiants en 5e année (Tableau 3). Sur les 6 questions posées sur les modes de transmission du VHC, on a observé 55 % de réponses exactes. Pour 75 % des étudiants en 5e année de médecine, le VHC était un virus sexuellement transmissible (Tableau 4). Les autres modes de transmisq sion de ce virus étaient bien connus de ces derniers (Tableau 4). Les taux de réponses justes chez les cadres et les ouvriers étaient similaires : 25 % d’entre eux savaient que la contamination pouvait se faire par les instruments du dentiste et 33 % par l’inq termédiaire de la brosse à dents (Tableau 4). Douze pour cent (12 %) des étudiants en première année de médecine et 10 % des étudiants en 5e année ne savaient pas que le VHC se transmettait par la brosse à dents, les seringues mal stérilisées et les instruments dentaires mal stérilisés. À la question d’absence de vaccin contre le VHC, seul le groupe représentant le perq sonnel de santé a répondu correctement, avec 75 % de réponses justes (Tableau 4). Les autres groupes, notamment les étudiants en médecine, ignoraient dans 80 % des cas l’inexistence de ce vaccin. Hormis 80 % des étudiants en 5e année et 68 % du personnel paramédical, les donq neurs de sang des autres groupes ignoraient pour la plupart l’existence d’un traitement. Discussion Le virus responsable du SIDA semble le mieux connu du public. En effet, une enq quête faite à Nancy révèle que les modes de transmission du VIH sont les mieux connus, avec 92,5 % de réponses justes [4]. Une autre étude réalisée au Yémen montre que la population générale a de bonnes connaissances générales sur le VIH/SIDA [5]. Cette étude révèle un taux de réponses justes de 85 %. Cependant, certaines idées fausses persistent, telles que la contamination par piqûre de moustique (14 % Casablanca vs 68 % Yémen), en buvant dans le verre d’une personne contaminée (14 % Casablanca vs 41 % Yémen) ou la nécessité d’isoler le maq lade (14 % Casablanca vs 65 % Yémen) [5]. L’analyse des résultats par groupe montre que ces fausses idées sont plus importantes dans la population générale comparée au personnel de santé. Ainsi, 83 % des lyq céens pensent que l’isolement du malade est un moyen de protection contre le SIDA contre 10 % des étudiants en 5e année de médecine et 15 % du personnel paramédical (p < 0,0001). L’information doit être maintenue dans ce domaine, essentiellement chez les perq sonnes non informées et chez les groupes à risque. En effet, des études réalisées chez des prisonniers [6,7], des chauffeurs de bus longues distances, etc. [8] ont montré la présence de lacunes concernant les connaisq sances sur le SIDA. Il est vrai que le SIDA a été vulgarisé par les médias. Mais la psychose de 1985 a disparu et actuellement le SIDA est consiq déré comme la maladie des autres [9]. Entre 1994 et 1998, en France, on observe une diminution du sentiment de crainte associé aux maladies infectieuses, notamment aux hépatites et particulièrement au SIDA. En 1998, 69 % des Franciliens déclaraient craindre peu le SIDA contre 59 % en 1994 [9]. La sensibilisation du public et l’éduq cation sanitaire des groupes à risque sont 544 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Ta bl ea u 4 Ét at d es c on na is sa nc es s ur le v iru s de l’ hé pa tit e C : c on ta m in at io n, s ig ne s cl in iq ue s, pr év en tio n Ite m G ro up es 1 (n = 1 00 ) 2 (n = 2 00 ) 3 (n = 1 50 ) 4 (n = 4 50 ) 5 (n = 1 00 ) 6 (n = 1 00 ) 7 (n = 1 00 ) 8 (n = 5 50 ) N br e % N br e % N br e % N br e % N br e % N br e % N br e % N br e % Co nt am in at io n pa r l es ra pp or ts s ex ue ls 32 32 16 4 82 11 2 75 18 0 40 16 16 38 38 34 34 19 2 35 Co nt am in at io n pa r l a br os se à d en ts 57 57 17 6 88 13 5 90 26 1 58 33 33 33 33 87 87 17 0 31 Co nt am in at io n pa r l es se rin gu es m al st ér ili sé es 57 57 17 6 88 13 5 90 21 6 48 33 33 49 49 91 91 23 6 43 Co nt am in at io n pa r l es in st ru m en ts d u de nt is te m al s té ril is és 57 57 17 6 80 13 5 90 15 3 34 26 26 25 25 79 79 15 9 29 L’i nf ec tio n pa r l e VH C pe ut e xi st er s an s do nn er d e si gn es 60 60 15 6 78 12 0 80 25 2 56 47 47 65 65 90 90 25 8 47 In ex is te nc e de v ac ci n co nt re le V H C 40 40 52 26 30 20 22 5 50 25 25 37 37 75 75 12 1 22 Pr ot ec tio n pa r l e re sp ec t d es rè gl es de s té ril is at io n 60 60 19 6 98 13 5 90 25 6 57 48 48 65 65 90 90 22 0 40 In ex is te nc e de tr ai te m en t e ffi ca ce 46 46 12 0 60 30 20 16 2 36 36 36 40 40 32 32 30 8 56 Le ri sq ue p er si st e m al gr é le s m es ur es pr év en tiv es 57 57 13 6 68 13 0 87 20 2 45 30 30 43 43 51 51 12 6 23 G ro up es 1 : ly cé en s ; 2 : ét ud ia nt s en 1 re a nn ée d e m éd ec in e ; 3 : ét ud ia nt s en 5 e a nn ée d e m éd ec in e ; 4 : ét ud ia nt s de d iff ér en te s fa cu lté s ; 5 : ou vr ie rs ; 6 : c ad re s ; 7 : pe rs on ne l p ar am éd ic al ; 8 : d on ne ur s de s an g vu s au C RT S de C as ab la nc a. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 545 recommandées pour faciliter la mise en place de moyens d’intervention, combattre les préjugés et assurer les prestations aux personnes atteintes. En ce qui concerne les modes de transq mission du VHB, les résultats de cette enq quête sont comparables à ceux de l’étude de Nancy (64 % de réponses exactes vs 77 %) [4]. Cependant, 65 % des Français connaisq saient le risque de transmission sexuelle de la maladie contre seuls 34,5 % des particiq pants marocains (en excluant les étudiants en médecine et le personnel de santé) [4]. Une enquête réalisée à Karachi a montré que la transmission sexuelle de la maladie était connue de 34,6 % des hommes et de 48,7 % des femmes interrogés [10]. Par ailleurs, certaines idées fausses perq sistent, même chez les étudiants en 5e année de médecine, qui pensent dans 30 % des cas que la transmission du virus peut se faire par les mains sales ou l’eau du robinet. La possibilité de recourir à une vacciq nation contre l’hépatite B est connue de 68,7 % des marocains de cette enquête contre 78 % des Français, 67,6 % des hommes et 80,9 % des femmes à Karachi [4,10]. Seuls 55 % des lycéens marocains et 80 % des étudiants en 5e année de médecine connaissent l’existence du vaccin alors que ce dernier fait partie intégrante du proq gramme national de vaccination de l’enfant depuis juillet 1999. Ainsi, une information sur les modes de prévention et la vaccination s’avère nécesq saire, et ce d’autant plus que l’incidence de la maladie chez les donneurs de sang est esq timée à 2,4 % à Casablanca (année 2002). Les modes de transmission du VHC restent les moins bien connus aussi bien au niveau de cette étude que de celle de Nancy (55 % de réponses justes vs 63 %) [4]. Soixanteqquinze pour cent (75 %) des étudiants en 5e année de médecine croient que le VHC se transmet par voie sexuelle. Or l’hépatite C fait partie du programme d’enseignement de 4e année de médecine. Ces fausses réponses sont très probablement dues à des confusions entre les différents virus B et C. Selon une étude rurale réalisée en Égypq te pour la prévention de l’hépatite C, seuls 39 % des infirmiers et 70 % des médecins savaient que les seringues mal stérilisées pouvaient être à l’origine d’une contaq mination. Mais les médecins ont donné plus que les infirmiers de fausses réponses concernant le mode de transmission et les moyens de prévention de l’hépatite C, avec au moins une mauvaise réponse chez 27 % des infirmiers contre 41 % des médecins [11]. À Casablanca, 91 % du personnel de santé sait que la contamination peut se faire par les seringues mal stérilisées. Il semble, à première vue, que le personnel médical au Maroc soit plus informé qu’en Égypte. En fait, le questionnaire de l’étude de Casablanca, donnant des réponses à choix multiples, est beaucoup plus suggestif que le questionnaire à réponses ouvertes proposé dans l’étude égyptienne ; ainsi les résultats de l’étude faite à Casablanca sont biaisés. Soixante pour cent (60 %) des Français savent qu’il n’existe pas de vaccin pour se protéger de l’hépatite C contre seuls 23 % des participants marocains et 38,9 % des hommes et 30,4 % des femmes à Karachi [4,10]. Par ailleurs, des études ont montré le rôle important joué par les représentations culturelles et les idées reçues fausses dans l’attitude des patients infectés par le virus de l’hépatite C face à la maladie [12]. Ainsi, il est important de faire une inq formation sur les modes de transmission de l’hépatite C qui a une incidence de 0,54 % chez les donneurs de sang marocains en 2002. 546 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 La forte prévalence de ces maladies virales, notée au Maroc sur les chiffres rapq portés par le Centre national de Transfusion sanguine, et la gravité de l’évolution des hépatites B et C ont conduit le ministère de la Santé à rendre obligatoire la vaccination contre l’hépatite B. Mais d’autres mesures préventives restent indispensables. Ainsi, il a été décidé de mener une campagne d’inq formation sur les modes de transmission des hépatites B et C et du SIDA et d’inciter à l’utilisation de seringues à usage unique, les seringues étant les sources principales de contamination du fait de leur réutilisaq tion. L’accompagnement médiatique de ces mesures est indispensable car il perq met l’amélioration des connaissances de la population et sa sensibilisation. En effet, actuellement une campagne médiatique concernant les modes de transmission et attitudes visqàqvis du SIDA est diffusée à la radioqtélévision marocaine. Par ailleurs, le ministère de la Santé a décidé de renforcer le système de surveillance des hépatites à travers la réactivation de la déclaration obligatoire (Discours de Monsieur Thami El Khiari, Ministre de la Santé. Présentation de la stratégie nationale de lutte contre les hépatites, Rabat, le 20 février 2002). Conclusion Cette étude permet de disposer « d’un état des lieux » des connaissances de la poq pulation. Des efforts doivent être faits en matière d’information de la population sur les modes de transmission des hépatites B et C et du SIDA. Au terme de cette inforq mation, un nouveau questionnaire identique ou mieux, sous forme de questions ouvertes, permettra d’évaluer l’impact de celleqci. L’impact pourra également être évalué sur le pourcentage de contamination des donq neurs de sang. Ainsi, en Égypte la campaq gne d’information qui a suivi l’enquête a permis une diminution remarquable du taux de contamination de la population par le virus de l’hépatite C [11]. Références 1 Hépatite B. Genève, Organisation mons diale de la Santé, 2000 (Aidesmémoire N° 204) (http://www.who.int/mediacentre/ factsheets/fs204/fr, consulté le 17 avril 2006). 2 Hépat i te C . Genève , Organisat ion mondiale de la Santé, 2000 (Aidesmés moire N° 164) (http://www.who.int/medias centre/factsheets/fs164/fr, consulté le 17 avril 2006). 3 Rapport sur l ’épidémie mondiale de SIDA 2004. 4e Rapport mondial. Genève, ONUSIDA, 2004. (http://www.unaids.org/ bangkok2004/GAR2004_pdf_fr/UNAIDSs GlobalReport2004_fr.pdf, consulté le 17 avril 2006). 4 Boyer L et al. Prévention des risques de transmission VIH, VHB, VHC : Année 2000, quel message pour quel public ? Médecine et maladies infectieuses, 2000, 50(6). 5 AlsSerouri AW et al. Knowledge, attitudes and beliefs about HIV/AIDS in Sana’a, Yemen. Eastern Mediterranean health journal, 2002, 8(6):706–15. 6 Nakhaee F.H. Prisoners knowledge of HIV/AIDS and its prevention in Kerman, Islamic Republic of Iran. Eastern Medis terranean health journal, 2002, 8(6):725– 31. 7 Delorme C et al. Connaissances, croyans ces et attitudes des détenus face au Sida : Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 547 une enquête au centre pénitentiaire de Marseille. Revue d’épidémiologie et de Santé publique, 1999, 47(3):229–38. 8 Abdelmoneim I et al. Knowledge and ats titudes towards AIDS among Saudi and nonsSaudi bus drivers. Eastern Mediterras nean health journal, 2002, 8(6):716–24. 9 Halfen S et al. Hépatites B et C : Aspects épidémiologiques et prévention en Îlesde France. Bulletin de santé, 2001, 4. 10 Khuwaja AK, Qureshi R, Fatmi Z. Knowleds ge about hepatitis B and C among pas tients attending family medicine clinics in Karachi. Eastern Mediterranean health journal, 2002, 8(6):787–93. 11 El Katcha S et al. Education for health providers in the prevention of the transs mission of hepatitis C virus: a case study in rural Egypt. Promotion and education, 2002, 9(1):16–21. 12 Castera L et al. Études des représens tations culturelles et des idées reçues concernant l’hépatite C chez des pas tients suivis dans un pôle de référence. Gastroentérologie clinique et biologique, 2003, 27(HS1):8319–20. Bibliothèque et réseaux d’information à l’appui des connaissances La Bibliothèque de l’OMS et les réseaux d’information à l’appui des connaissances (LNK) (http://www.who.int/library/index.fr.shtml) ofs frent des services complets de bibliothèque et d’information sur les documents produits et publiés par l’OMS sous forme imprimée ou sous toute autre forme. De plus, ces services donnent accès aux ress sources documentaires mondiales sur la santé et le développement. Nos utilisateurs preferentiels sont: le personnel du Siège de l’OMS, le personnel des régions et des bureaux des pays, les agents de santé des Etats Membres, les ministères de la santé et autres administras tions publiques, les organismes internationaux, le système des Nas tions Unies et les missions diplomatiques. Les programmes conçus par la bibliothèque de l’OMS aident les régions et pays en développes ment à être autonomes pour la fourniture de services documentaires destinés au secteur de la santé. Les collections abritées par la bibliothèque incluent : La Collection permanente OMS : Littérature consacrée à la Santé Publique : Journeaux et bases de données : La Collection Historique : • • • • 548 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Albendazole versus metronidazole in the treatment of patients with giardiasis in the Islamic Republic of Iran A.Alizadeh,1 M. Ranjbar,2 K.M.Kashani,3 M.M. Taheri4 and M. Bodaghi4 1Research Centre for Gastroenterology and Liver Disease, Shaheed Beheshti University of Medical Sciences and Health Services, Tehran, Islamic Republic of Iran (Correspondence to A. Alizadeh: ahmaliver@yahoo.com). 2Department of Infectious Disease; 3Department of Community Medicine; 4Hamadan University of Medical Sciences and Health Services, Hamadan, Islamic Republic of Iran. Received: 02/03/04; accepted: 30/11/04 ABSTRACT We examined the therapeutic effects of albendazole compared to metronidazole in 120 patients with giardiasis in Hamdan. Patients were randomized to receive albendazole (400 mg, once daily for 5 days) or metronidazole (250 mg, 3 times a day for 5 days). Demographic data of the patients, results of stool exa amination for Giardia trophozoites before and after treatment, and drug sideaeffects were recorded. After treatment 6 (10.0%) of the albendazole group had trophozoites compared with 14 (23.3%) of metronidazole group (P < 0.05). Patients in the albendazole group had fewer sideaeffects while 43.3% of the metronidazole group experienced a metallic taste and 35.0% experienced loss of appetite. Albendazole is an easy, safe and effective treatment for giardiasis. 2 lbendazole versus metroindazole in the treatment of patients with giardiasis L>Èae>ɂ=Ð=bEE>r™=͂>£º›¹Æg=bɾÆf[J™=ƹÆg=b¿ÉF¶Ù=E;e>¯º ÍɺØiÝ=Á=fÈCÍÈeÇÖ› ʦ=bEͺÇr£º(ËfÂ>{b»†(ʾ>m>²ʾ>ºÆfj](ˆe=ɺ(Åa=hÉ·¢º?  „=Í[qØ6NU>F¶=½>®¹Æg=bɾÆf[[J™=¤[ºÍ[¾e>¯™>E¹Æg=b[¿ÉF¶Ú¶ÍÉQØ£¶=L=M@J¶=¼É[ɯJEÍi=eb¶=ÅdÂe>{C›ÁÇ Ïb¶120Á=b»ÂÍ¿Èbº›L>Èae>ɂ=Ð=bEÎuf™=Àº*¹Æg=b¿ÉF¶Ù=Êù¯ ·J¶ð>ÉÑ=Çn¢zf™=¼ëjî®Æ%¹b£’400¨º Ìb™ÌbU=ÆÌfº5½>È?$¹Æg=bɾÆf[J™=Êù¯ ·J¶Æ?(%¹b£’250Ìb[™ð>[ɺÇÈL=f[ºPØM(¨º5½>[È?*$¸ÉRj[IÆ ¸[F®(Í[Èae>ɂ=Ê[·É«{Ì>[ÉUÌeÆaÀ[ºœÉn[¿¶=eÆb¶=ËëfVJ¶g=¶=sVªSÑ>J¾Æ(Îuf»·¶Íɪ=f§•b¶=L>É죙= Í[ÈÆaÚ¶Í[ÉF¾>‚=L=M@[J¶=´¶d²Æ(>Âb£EÆ͂>£™=*=Ç[ò¯ ·IÀÈd[¶=Î[uf™=Í[ÒªÀ[ºÍJ[iÁ?Í[‚>£™=b[£EÀçÉ[FIÆ ¹Æg=b¿ÉF¶Ù=%ÍFj¾10$!¤º;e>¯™>E(Ê·É«ì·¶œÉn¿¶=eÇì¶=¼ÃÈb¶Á>²14ð>vÈfº%ÍFj¾23.3$!¶=ÍÒ«¶=Àº ¹Æg=bɾÆf[J™=KÉì¢î?%0.05<P*$ξ>[¢[U›(¹Æg=b[¿ÉF¶Ù=ÍÒªÏb¶¸®?ÍÉF¾>QL=M@IKŸUǶÆ43.3! Æ(ʾb£º±=dºÀº¹Æg=bɾÆf[J™>E‚>£™=ÍÒªÀºξ>¢35!½>£ì·¶ÍÉÃn¶=s¯¾Àº¼Ã¿º*Íi=eb¶=KRJ¿Ji=Æ L>Èae>R·¶¹>磪ÆÁǺ@ºÆ¸ÃiTØ¢¹Æg=b¿ÉF¶Ù=Á?*  Comparaison entre albendazole et métronidazole dans le traitement des patients atteints de giardiase en République islamique d’Iran RÉSUMÉ Nous avons examiné les effets thérapeutiques de l’albendazole par rapport au métronidazole chez 120 patients atteints de giardiase à Hamdan. Les patients ont été randomisés pour recevoir de l’albendazole (400 mg une fois par jour pendant 5 jours) ou du métronidazole (250 mg 3 fois par jour pendant 5 jours). Les données démographiques des patients, les résultats de l’examen coprologique à la recherche de trophozoïtes de Giardia avant et après le traitement, et les effets secondaires des médicaments ont été notés. Après le traitement, 6 patients (10,0 %) du groupe albendazole avaient des trophozoïtes contre 14 (23,3 %) dans le groupe métronidazole (p < 0,05). Les patients du groupe albendazole avaient moins d’effets secondaires tana dis que 43,3 % des patients du groupe métronidazole ressentaient un goût métallique et 35,0 % présentaient une perte d’appétit. L’albendazole constitue un traitement facile, sûr et efficace pour la giardiase. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 549 Introduction Giardia lamblia, also known as Giardia duodenalis or Giardia intestinalis, is one of the most common intestinal parasites worldw wide and is a frequent cause of diarrhoeal illness [1–4]. It is estimated that about 300 million people annually are affected with the parasite all around the world [3] and it is an important cause of morbidity in the developing world [5]. G. lamblia causes both epidemic and sporadic disease and is an important cause of waterborne and foodw borne diarrhoea, daywcare centre outbreaks, and diarrhoea in international travellers [1]. Waterborne, foodborne and direct contact are 3 important patterns of potential transw mission of the pathogen [5]. The infection may be asymptomatic or present with a vaw riety of symptoms such as diarrhoea, weight loss, abdominal cramps and failure to thrive [1]. The incubation period is 1 to 2 weeks following ingestion and the acute stage of the disease lasts from 3 to 4 days but can go on for much longer [6]. Severe symptoms of diarrhoea and sickness can be persistent and even lifewthreatening in immunocomw promized individuals, infants and in the aged, although the disease is selfwlimiting in the majority of patients [3]. Diagnosis of infection is by stool examination, which may also eliminate other possible infectious agents [2]. Many drugs, including metronidazole and albendazole, are used for the treatment of the disease. For the treatment of giardiaw sis, metronidazole is the drug of choice [7] but in cases of resistance, drugs such albenw dazole have been said to be effective [1]. Review of the literature shows that there have been few clinical trials to compare alw bendazole with other effective antiwgiardial drugs [2,4,8]. As albendazole is an available and safe antiprotozoal medicine in the Isw lamic Republic of Iran and perhaps in other parts of the world, we conducted a clinical trial in order to assess the antiwgiardial efw fects compared to metronidazole. Methods The study was conducted in Hamadan, a city in the northwwest of the Islamic Repubw lic of Iran over a period of 1 year (2001). Cases were selected from among patients attending 4 prewdefined private outpatient clinics in 4 different parts of the city. Due to difficulty in coordination, patients of mediw cal centres of the health administration netw work were not entered in the study. Based on biostatistical calculations (alpha level of 0.05 and beta level of 0.2), the sample size needed was calculated to be 120 docuw mented cases of the disease. Before starting the study one number was assigned for each case. All the numbers were assigned in 2 groups (60 cases in each) at random and a physician was assigned to give the needed numbers to the clinics. The physician was also responsible for following up the cases. Referral with acute symptoms of giardiasis and a positive stool examination report for trophozoites of the pathogen were considw ered as the inclusion criteria. One parasiw tologist who was blinded to the treatment received was responsible for detecting the trophozoites in the samples and checked all iodinewstained wet stool preparations before and after treatment. The first group received the standard treatment with albendazole (400 mg daily as a single dose for 5 days) and the second group received metronidazole (250 mg 3 times a day for 5 days). Patients received the specified dosages daily and they were asked whether they had taken the complete dose of the drugs. A week after starting the treatw ment, stool examination to detect trophow zoites of G. lamblia was performed 3 times 550 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 in 3 consecutive days for all the patients. Response to treatment was determined as negative stool examination for trophozoites and cysts. Those who continued to be posiw tive for trophozoites and/or cysts despite completing the course of treatment were considered nonwresponders. Demographic data, the results of stool examination for Giardia trophozoites before and after treatw ment, and any sideweffects experienced were recorded. All the cases signed an informed consent form before starting treatment. For cases under 16 years, one of the parents signed the consent form. The Ethics Committee of Hamadan University of Medical Sciences approved the study. We used protocolwbased analysis instead of intentionwtowtreat analysis because, acw cording to the primary design of the trial, patients who refused to participate in the study were replaced by new patients to reach the desired number of cases in each group. However, in the followwup period we sought the reasons why the patients refused to participate. Although protocolwbased analysis tends to bias the interpretation of the results, concerning the main cause of the patients’ dropwout, it was possible to get similar results by using each kind of analyw sis. Descriptive statistics for both groups were reported. Using the chiwsquared and independent Student twtests, statistical analw ysis of the data was performed with SPSS, version 9.01. The level of significance was set at P < 0.05. Results The mean and standard deviation (SD) of the patients' age was 22.3 (SD 11) years (range 2–53 years). Table 1 shows the charw acteristics of patients in the 2 groups. Male to female ratio was 61:59. Mean (SD) of duration of the symptoms in the first group Table 1 Characteristics of patients in the groups receiving albendazole and metronidazole in the treatment of giardiasis Characteristic Albendazole Metronidazole group (n = 60) group (n = 60) Mean age (SD) (years) 21.3 (8.9) 22.9 (12.1) Male/female 30/30 31/29 Mean duration of symptoms (SD) (days) 3.4 (0.6) 4.2 (0.7) Educationa Illiterate (No.) 4 5 Educated (No.) 44 32 Highly educated (No.) 12 13 Quit treatment 15 9 Response to treatment All patients, No. (%) 54/60 (90.0) 46/60 (76.7) Male, No. (%) 26/30 (86.7) 22/31 (71.0) Female, No. (%) 28/30 (93.3) 24/29 (82.8) SD = standard deviation. aIlliterate: no schooling/not able to read or write; educated: able to read or write up to highaschool diploma; highly educated: attended university. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 551 was 3.4 (0.6) days and in the second it was 4.2 (0.7) days. Independent Student t-test showed a significant difference between the 2 groups in terms of duration of the sympw toms (P < 0.01). None of patients in the 2 groups had a history of immune deficiency or disabling disease. As regards compliance, 15 patients from the albendazole group and 9 patients from the metronidazole group failed to complete the course of medication. In followwup of these patients, we found it was due to difficulty in revisiting the clinic, not to continuation of symptoms or sidew effects of the drugs. After the whole course of treatment, 6 patients in the albendazole group were found still to have trophozoites in the stool while 14 (23.3%) in the metronidazole group still had the pathogen, giving a significant difference in nonwresponder rate between the 2 groups (P < 0.05). The difference in response rate between the 2 groups was staw tistically significant (Yates corrected χ2, P < 0.05). There was no significant difference between males and females in response of treatment of each group. Table 2 shows the sideweffects of the treatment with the 2 drugs. Metallic taste, vertigo and loss of appetite were significantly higher in the paw tients who had taken metronidazole. Tranw sient abdominal pain was only observed in the albendazole group. Participants taking metronidazole reported more sideweffects than those taking albendazole, metallic taste being the commonest sideweffect (43.3%), followed by loss of appetite (35.0%). Discussion In human giardiasis, therapeutic failure is occurring more and more frequently due to low compliance with drug therapy, rew infestation or parasite resistance to metrow nidazole and/or the nitroimidazolewrelated compounds like tinidazole [9]; hence examw ining alternative treatments is always valuaw ble. In this study we found that albendazole was more effective than metronidazole in the treatment of acute giardial infection. As all the cases were followed for a fairly acceptable period (1 week) after the start of treatment and no significant sideweffects of the drugs were documented, prescription of albendazole not only in cases of drug rew sistance but also as an alternative firstwline therapy is advised. Nevertheless, it must be considered that it could increase the risk of Table 2 Frequency of sideaeffects of metronidazole and albendazole in the treatment of patients with giardiasis Sideaeffect Metronidazole Albendazole Pavalue (n = 60) (n = 60) No. % No. % Metallic taste 26 43.3 – – < 0.0001 Vertigo 14 23.3 4 6.6 0.01 Nausea/vomiting 11 18.3 12 2.0 NS Loss of appetite 21 35.0 – – < 0.0001 Urticaria 2 3.3 – – NS Transient abdominal pain – – 11 18.3 < 0.0001 NS = not significant. 552 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 developing resistance to albendazole. The lack of sensitivity in the diagnostic test apw plied in this study [10] cannot be considered a serious limitation as the probability of obw taining a false negative result was the same for both groups. Review of the literature shows that some controversy exists about the efficacy of albendazole compared to metronidazole in the treatment of giardial infection. As metw ronidazole is a wellwestablished antigiardial medicine and has generally remained the firstwline chemotherapeutic agent against this microorganism [7], we sought data indicating the therapeutic effects of albenw dazole rather than metronidazole on giarw diasis. In most studies, albendazole was as good as metronidazole or better [8,11–19]: only a few studies reported that albendazole was inferior to metronidazole in treatment of giardiasis. Chan Del Pino et al. indicated that albendazole is as effective as furazow lidone, tinidazole and secnidazole but faster at eradicating the G. lamblia in children and is better tolerated than metronidazole [11]. In a study performed in France, the researchers found that in some cases of metronidazole resistance, albendazole was an effective drug [12]. After performing a randomized clinical trial, Pengsaa et al. indicated that albendazole appeared to be safe and produced a moderate cure rate for G. intestinalis infection when a 3wday antiwhelminthic regimen was given [13]. Reynoldson et al. examined the efficacy of albendazole at a dose rate of 400 mg daily for 5 days on eradicating giardial and hookworm infections and concluded that the drug was highly effective in reducing hookworm egg numbers and both Giardia antigen and cysts [16]. In a randomized trial RomerowCabello et al. concluded that alw bendazole and metronidazole were equally effective in a 5wday treatment period, but some undesirable sideweffects may occur with metronidazole [17]. Albendazole has been proved to be effective in in vitro setw tings and asserted to be the most effecw tive antihelminthic benzimidazole [18]. In a clinical trial in children in the Islamic Republic of Iran, Sadjjadi, Alborzi and Mostovfi showed that mebendazole was as effective as metronidazole with fewer sideweffects [19]. In a systematic review done by Zaat Mank and Assendelft it was shown that most of the clinical trials on drug therapy for giardiasis had some methodological flaws; a single dose of tinidazole appeared to give the highest clinical cure rate for giardiasis with relatively few adverse sideweffects [20]. It has been reported that albendazole was inferior to other known antigiardial drugs [21]. However the study was conducted as an open pilot trial in travw ellers returning from the tropics, while we used a randomized clinical trial with precise monitoring of patients. The results of the current study show that albendazole is a safe and effective drug in the treatment of giardiasis and provide further evidence of the usefulness of this drug. However, this will not put an end to the controversies surrounding the treatment of giardiasis. Hence, new evidence about the efficacy of antigiardial medicines is needed. In the future, studies should be designed to better evaluate albendazole in comparison with other new medicines. In addition, we need studies with larger numbers of cases and clinical trials in children and immunew compromised patients, especially patients with humoral abnormalities. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 553 References 1. Lundgren RG Jr et al. Intestinal parasita ism in the United States. The American journal of tropical medicine and hygiene, 1994, 50(6):705–13. 2. Vesy CJ, Peterson WL. Review article: the management of giardiasis. Alimena tary pharmacology & therapeutics, 1999, 13(7): 843–50. 3. Lane S, Lloyd D. Current trends in rea search into the waterborne parasite Giaa rdia. Critical reviews in microbiology, 2002, 28(2): 123–47. 4. Nash TE et al. Treatment of patients with refractory giardiasis. Clinical infectious diseases, 2001, 33(1):22–8. 5. Curtale F et al. Anaemia and intestinal parasitic infections among school age children in Behera Governorate, Egypt Behera Survey Team. Journal of tropical pediatrics, 1998, 44:323. 6. Adam RD. The biology of Giardia spp. Microbiological reviews, 1991, 55(4):706– 32. 7. Hill DR. Giardia lamblia. In: Mandell GL, Bennett IE, Dolin R, eds. Principles and practice of infectious diseases, 5th ed. Philadelphia, Churchill Livingstone, 2000. 8. Hall A, Nahar Q. Albendazole as a treata ment for infections with Giardia duodenaa lis in children in Bangladesh. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1993, 87(1):84–6. 9. Hill DR Nash TE. Intestinal flagellate and ciliate infections. In: Guerrant RL, Walker DH, Weller PF, eds. Tropical infectious diseases: principles, pathogens, & praca tice. Philadelphia, Churchill Livingstone, 1999. 10. Christopher D, Huston CD, Guerrant RL. Intestinal protozoa. In: Feldman M, Friedman LS, Sleisenger MH eds. Gasa trointestinal and liver disease. Pathoa physiology/diagnosis/management, 7th ed. Philadelphia, WB Saunders, 2002. 11. Chan Del Pino M, Cueva Cornejo L, Troyes Rivera L. Comparación de Albena dazol con nitrofuranos y nitroimidazoles en el tratamiento de giardiasis en niños [Comparative study of albendazole vera sus nitrofurazones and nitroimidazoles in the treatment of giardiasis in children.] Revista de gastroenterología del Perú, 1999, 19(2):95–108. 12. Lemee V et al. Metronidazole and albena dazole susceptibility of 11 clinical isolates of Giardia duodenalis from France. Joura nal of antimicrobial chemotherapy, 2000, 46:819–21. 13. Pengsaa K et al. Albendazole treatment for Giardia intestinalis infections in school children. Southeast Asian journal of tropia cal medicine and public health, 1999, 30(1):78–83. 14. Misra PK et al. A comparative clinical trial of albendazole versus metronidazole in children with giardiasis. Indian pediatrics, 1995, 32(7):779–82. 15. Dutta AK et al. A randomised multi centre study to compare the safety and efficacy of albendazole and metronidazole in the treatment of giardiasis in children. Ina dian journal of pediatrics, 1994, 61 (6): 689–93. 16. Reynoldson JA et al. Efficacy of albendaa zole against Giardia and hookworm in a remote Aboriginal community in the north of Western Australia. Acta tropica, 1998, 71(1):27–44. 17. RomeroaCabello R et al. Estudio aleatorio para comparar seguridad y eficacia de albendazol y metronidazol en el tratamia ento de giardiasis en niños. [Randomized study comparing the safety and efficacy 554 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 of albendazole and metronidazole in the treatment of giardiasis in children.] Rea vista latinoamericana de microbiologia, 1995, 37(4):315–23. 18. Edlind TD, Hang TL, Chakraborty PR. Aca tivity of the anthelmintic benzimidazoles against Giardia lamblia in vitro. Journal of infectious diseases, 1990, 162:1408– 1411. 19. Sadjjadi SM, Alborzi AW, Mostovfi H. Comparative clinical trial of mebendazole and metronidazole in giardiasis of chila dren. Journal of tropical pediatrics, 2001, 47(3):176–8. 20. Zaat JO, Mank T, Assendelft WJ. Drugs for treating giardiasis. The Cochrane database of systematic reviews, 1998, I ssue 3 . Art . No. : CD000217. DOI : 10.1002/14651858. 21. Kollaritsch R, Jeschko E, Wiedermann G. Albendazole is highly effective against cutaneous larva migrans but not against Giardia infection: results of an open pilot trial in travellers returning from the tropa ics. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1993, 87:689. Micronutrient Forum first international meeting Consequences and Control of Micronutrient Deficiencies: science, policy, and programs—defining the issues. Istanbul, Turkey, 16–18 April 2007. For information contact the Micronutrient Forum Secretariat, Washinga ton, DC, United States of America (tel: 202a659a9024; fax: 202a659a 3617; eamail: mnforum@ilsi.org) Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 555 Frequency of Giardia lamblia among children in Dohuk, northern Iraq A.T. Al-Saeed1 and S.H. Issa1 1Department of Microbiology, College of Medicine, University of Dohuk, Dohuk, Iraq (Correspondence to A.T. Al-Saeed: safa_adel97@yahoo.com). Received: 13/04/03; accepted: 24/08/04 ABSTRACT Out of 1261 stool specimens collected from children in Dohuk city, northern Iraq, the preva- lence of Giardia lamblia infection was 38.5%. The highest rate of infection was in orphan care centres (48.1%) and the lowest in the paediatric hospital (31.3%). The age group 10–12 years had the highest rate (81.2%) and 7–9 years the lowest (22.9%); boys had a higher rate than girls. Some infected sam- ples (70/486) showed double or triple infections and G. lamblia was combined with Hymenolepis nana, Blastocystis hominis, Entamoeba histolytica and Iodamoeba buetschlii. 16 Frequency of Giardia Lamblia among children in Dohuk, north Iraq ±=f£¶=¹>›(µÇÂaÍ¿Èbº›¹>«{Ù=EÍÉ·FºØ¶=ÍÈae>ɂ=e>nJ¾=Íi=ea {¹a>¢ÎjÉ¢jUÁ=gÇi(bÉ£j¶=G¶>  „=Í[qØ6sVª1261O[ÉU(±=f£¶=¹>(µÇÂaÍ¿Èbº›¹>«{Ù=ÀºLd]î?¶=g=¶=L>¿ëÉ¢Àºð>Qcǔ Í[É·FºØ¶=Í[Èae>ɂ>EÍE>qÝ=e>[nJ¾=¹b[£º¨·E38.5*!½>[JÈÙ=Í[È>¢eeÆa›ÏÆb[£¶=L×b£ºη¢?K§·Eb®Æ %48.1$!b£™=ξa?ƹ>[«{Ù=L>[É«nJjº›L×%31.3*$!Í[[Èf»£¶=Í[[Ò«¶=›Í[E>qÞ¶Í[Fj¾η¢?KŸUÇ¶Æ %10)12ð>º>¢$¹äb£’%81.2$!ÍÈf»£¶=ÍÒ«¶=›ÍFj¾ξa?Æ(%7)9½=Ç¢?$¹äb[£’%22.9$!L×b[£ºK[¾>²Æ( P>¾Ý=Àºη¢?eDzd¶=ÍE>qC*ÍE>r[™=L>[¿É£¶=x[£ELf[Þ?b®Æ%486+70$ahºÏÆb[¢C(Í[ÉMØMÆ?Í[QÆ ÍFɺßaÇàɶ=Æ(Sj¿·¶Ͷ>ƒ=ͶäÇVJ™=Æ(ÍÈfnF¶=ÍÉjɳ¶=Í»¢J™=Æ(ͺh¯¶=Í«mf>EÍEÇVrºÍÉ·FºØ¶=ÍÈae>ɂ=K¾>² ÍÉ·nIÇF¶=*  Fréquence de Giardia lamblia chez des enfants à Dohuk (Iraq septentrional) RÉSUMÉ Dans les 1261 échantillons de selles prélevés chez des enfants de la ville de Dohuk (Iraq septentrional), la prévalence de l’infection à Giardia lamblia était de 38,5 %. Le taux d’infection le plus élevé se trouvait dans les centres d’accueil pour orphelins (48,1 %) et le plus faible à l’hôpital pédiatri- que (31,3 %). Le groupe d’âge des 10-12 ans avait le taux le plus élevé (81,2 %) et celui des 7-9 ans le plus faible (22,9 %) ; le taux était plus élevé chez les garçons que chez les filles. Certains échantillons infectés (70/486) présentaient une double ou une triple infection et G. lamblia était associé à Hymeno- lepis nana, Blastocystis hominis, Entamoeba histolytica et Iodamoeba buetschlii. 556 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Introduction Giardia lamblia is a protozoan parasite which has worldwide distribution and is common in warm and moist climates throughout the world. Giardiasis is an imp portant unresolved health problem in dep veloping countries, as it is related to poor sanitation and management of supplied water, a problem that is exacerbated by the absence of a simple reliable diagnostic test [1]. The prevalence of G. lamblia ranges from 2%–7% in industrialized countries and 20%–60% in developing countries [2]. The majority of infections are probably asymptomatic but some are associated with subacute or chronic diarrhoea and intestinal irritation [3], which contribute to malabp sorption and nutritional deficiency especialp ly in children [4,5]. Giardiasis is transmitted by the faecal–oral route and direct personptopperp son spread. In most cases it is associated with contaminated drinking water but also occasionally by recreational activity in still water [6,7]. G. lamblia is more common in children but all age groups are affected in epidemic areas [8]. Infants under 1 year old are less likely to be infected than the older children [9]. It is particularly common in children’s institutions such as day care centres, primary schools and big families [10,11]. Several surveys of intestinal parasitosis in Iraq have shown a high incidence of giardiasis among children [12,13]. The present study was conducted because little information is available about G. lamblia infection among children in northern Iraq. The aim of this study in Dohuk city was directed to determine the frequency of G. lamblia in different age groups of children, the incidence of G. lamblia throughout the year and the association of G. lamblia with other intestinal parasites. Methods This study was conducted from 1 October 2001 to 31 July 2002 on children living in Dohuk city. Sample Stool samples were collected from boys and girls aged 3 months to 12 years attending day care centres, kindergartens, primary schools and the local paediatric hospital. With the assistance of the children’s parents and supervisors of centres, a fresh stool specimen was collected from each child into a disposable plastic container. The stool samples were taken immediately to the laboratory of the Microbiology Departp ment at the University of Dohuk College of Medicine for examination. Those with negative results had 2 other samples taken at different times for examination. Laboratory methods The stool samples were examined with the naked eye for colour, consistency and the presence of any adult helminths. They were then examined microscopically by direct and concentration methods for presence of Giardia trophozoite and cyst stages and for detection of other parasites stages. The concentration method used in this study was the zinc sulphate floatation method [14]. Two types of direct wet film preparation were done for each sample at the same time, 1 slide by using normal saline 0.85% for detecting the motility of trophozoites and Lugol’s iodine 5% slide for demonstrating structures [14]. Data about age, sex and residence were recorded for each child on a special form, together with the stool examination results (type of stool, direct and concentration test results), stage of Giardia lamblia and asp sociated parasites. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 557 The results were analysed statistically using the Fptest. Results A total of 1261 stool samples were collected and examined: 833 samples were from children in schools and care centres (451 attending primary schools, 261 attending kindergartens, 94 day attending care centres and 27 attending orphan care centres) and 428 samples were from children presenting at the paediatric hospital with a complaint of gastroenteritis. The total infection rate with G. lamblia among the examined samples was 38.5% (standard error range 38.49%–38.51%). The distribution of G. lamblia according to the children’s institute and schools is summarized in Table 1. The highest rates of giardiasis were from the orphan care centres (48.1%) and kindergartens (45.6%), whereas the rates were lower in the primary schools, day care centres and the paediatric hospital) (41.2%, 36.2% and 31.3% respecp tively). The statistical analysis revealed a highly significant difference in infection rate between primary schools and other children’s institutes (P < 0.01). The rate of infection varied across difp ferent age groups of children (Table 2). The age group 10–12 years showed the highest rate of infection (81.1%), and the lowest rate was in children 7–9 years (22.9%). There was a highly significant difference among different age groups (P < 0.01). The infection rate was higher among boys (41.6%) than girls (35.6%). The distribution of G. lamblia according to the months of the year is shown in Table 3. Although more samples were collected in the summer months, the rate of G. lamblia infection as a proportion of the number of stools examined was lowest in June (28.4%). Fewer sample were collected in the colder months but the highest infection rate of samples was in December (49.2%) followed by November (44.8%), April (43.5%) and May (43.4%). The difference in the rates of infection during the months was significant (P < 0.05). Overall, 70 out of 486 infected samp ples showed double and triple infections with other intestinal parasites combined with G. lamblia (Table 4). G. lamblia was combined with Hymenolepis nana (46.4%), with Blastocystis hominis (39.4%) and each of Entamoeba histolytica and Iodamoeba Table 1 Distribution of Giardia lamblia infection among children attending different institutions in Dohuk city Institution (number) Age group No. of No. % (years) samples positive positive examined Primary school (18) 6–8 451 186 41.2 Kindergarten school (3) 3–6 261 119 45.6 Day care centre (2) < 1–3 94 34 36.2 Orphan care centre (2) < 1–12 27 13 48.1 Paediatric hospital (1) < 1–12 428 134 31.3 Total < 1–12 1261 486 38.5 χ2 = 17.6, df = 4, P < 0.01. 558 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 buetschlii (7.1%). These results indicated that the infection with G. lamblia was usup ally more associated with the intestinal cestode H. nana. As triple infections, G. lamblia was combined with H. nana and B. hominis in 61.9% of samples, and combined with H. nana and Ent. coli in 38.1%. Discussion The infection rate with G. lamblia in stool samples from children in Dohuk city was very high (38.5%). The narrow standard erp ror range in the samples is due to the large number of samples analysed. The rate of infection in the present study is similar to other studies in Iraq [12,15–17]. The results are also in agreement with studp ies in other parts of the world [4,18,19]. This high rate of infection among children could be related to a number of factors such as poor health hygiene and toilet training, overcrowding, low education of children, low socioeconomic status and climatic conp ditions [20]. Giardia lamblia was isolated from stool samples of children in all primary schools but the highest rate of infection was reported from children in a primary school which is located in a low socioeconomic area (Serheldan region). Another important factor which affects the rate of giardiasis is the presence of asymptomatic patients in the community who can be considered as the main source of infection through continuously excreting the cysts stages with their stools [21]. Most of the cases in this study were infected with cysts. Regarding the lifepcycle of these parap sites, those carrier patients act as a source of infection by continuously excreting the cyst stage with their stool [22]. Although carp rier persons are asymptomatic, the infection may be converted to acute infection through excystation of cysts inside the intestine rep sulting in the main complaints of giardiasis such as abdominal pain, steatorrhoea and loss of weight [23]. Table 2 Distribution of Giardia lamblia infection among children in Dohuk city according to age and sex Variable No. of No. % samples positive positive examined Age (years) < 1 235 60 25.5 1–3 235 118 50.2 4–6 389 157 40.4 7–9 301 69 22.9 10–12 101 82 81.2 χ2 = 141.3, df = 4, P < 0.01 Sex Male 618 257 41.6 Female 643 229 35.6 χ2 = 4.7, df = 1, P < 0.05 Total 1261 486 38.5 Table 3 Distribution of Giardia lamblia infection among children in Dohuk city according to months of the study 2001–02 Month No. of No. % samples positive positive examined October 40 16 40.0 November 67 30 44.8 December 65 32 49.2 January 102 40 39.2 February 86 30 34.9 March 91 38 41.8 April 184 80 43.5 May 198 86 43.4 June 211 60 28.4 July 217 74 34.1 Total 1261 486 38.5 χ2 = 20.0, df = 9, P < 0.05. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 559 The higher rate of infection with G. lamblia among children in orphan care centres, kindergartens and primary schools might be related to bad personal hygiene or overcrowding. On the other hand, the lower rate of infection among children in day care centres and the hospital might be an indicap tion of good care taken by the supervisors of these centres [24]. Regarding the results of G. lamblia inp fection among different age groups, the < 1 year old group had a low rate of infection, perhaps because parents are responsible for their hygiene [25]. The infection rate was highest in the age group 10–12 years. This may be because this group of children are fully independent in toilet use and are more involved in outdoor activities which might lead to Giardia transmission [26]. The present results are similar to studies of intestinal parasitosis in Saudi Arabia and Senegal [27,28]. Higher numbers of samples were colp lected during the summer months when the maximum temperature in Dohuk is about 40–45 ºC. Cold weather kills the infective cysts [29,30]. The unfavourable temperap ture of G. lamblia cyst is less than 5 ºC and the cysts usually die at more than 62 ºC [31]. In Dohuk city the temperature in winter is 0 ºC or less to 5 ºC [32]. Other behavioural factors could be involved, for example there is greater consumption of drinks and food, e.g. ice cream, in summer which may be sources of infection [33]. The present study revealed that the inp testinal cestode H. nana was the most comp mon intestinal parasite associated with G. lamblia infection. Although other studies have demonstrated the same results [34], there was no clear reason for this assop ciation. However, it may be related to the infective stage of both parasites being rep sistant to various environmental conditions and remaining viable for a long time [35]. The other important pathogenic intestinal parasites recorded were B. hominis and Ent. histolytica. Table 4 Distribution of other intestinal parasites associated with Giardia lamblia infection among children in Dohuk city Organism No. of % samples positive infected Double infections G. lamblia + Hymenolepis nana 13 46.4 G. lamblia + Blastocystis hominis 11 39.4 G. lamblia + Entamoeba histolytica 2 7.1 G. lamblia + Iodamoeba buetschlii 2 7.1 Triple infections G. lamblia + Blastocystis hominis + Hymenolepis nana 26 61.9 G. lamblia + Hymenolepis nana + Entamoeba coli 16 38.1 Total 70 100.0 560 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 References 1. Addiss DG et al. Evaluation of a commer- cially available enzyme-linked immuno- sorbent assay for Giardia lamblia antigen in stool. Journal of clinical microbiology, 1991, 29(6):1137–42. 2. Thompson RCA et al. Genetic variation in Giardia, Kunstler 1882: taxonomic and epidemiological significance. Protozool- ogy abstracts, 1990, 14:1–28. 3. Reitmeyer M, Robertson S. Giardiasis. Chief Medical Resident’s Clinical Medicine Conferences 1996–97. Charlottesville, Virginia, University of Virginia, 1997. 4. Brown HW, Neva FA. Basic clinical para- sitology, 5th ed. Appleton Century Croft, New York, 1983:43–6. 5. Dubey R et al. Intestinal giardiasis: an unusual cause for hypoproteinemia. In- dian journal of gastroenterology, 2000, 19(1):365–73. 6. Gillin FD, Reiner DS. Cell biology of the primitive eukaryote Giardia lamblia. Annu- al review of microbiology, 1996, 50:679– 705. 7. Thompson RCA. The future impact of societal and cultural factors on parasitic disease—some emerging issues. Inter- national journal for parasitology, 2001, 31:949–59. 8. Norhayati M et al. Prevalence and risk factors of Giardia duodenalis infection in a rural community. Southeast Asian journal of tropical medicine and public health, 1998, 29(4):735–8. 9. Thompson RCA. Giardia as a re-emerg- ing infection disease and its zoonotic potential. International journal for parasi- tology, 2000, 30:1259–67. 10. Yaeger GR. Protozoa: structure, clas- sification, growth and development. In: Baron S, ed. Medical microbiology, 4th ed. Galveston, Texas, University of Texas Medical Branch, 1996. 11. Beaver PC, Jung RC, eds. Animal agent and vectors of human diseases, 5th ed. Philadelphia, Leaf and Febiger, 1985:13– 4. 12. Al-Dabagh MA et al. Giardiasis in a group of preschool age children in Iraq. Jour- nal of the Faculty of Medicine Baghdad, 1967, 9:73–83. 13. Al-Jeboori T, Shafiq MA. Intestinal para- sites in Baghdad: a survey in two districts. Journal of the Faculty of Medicine Bagh- dad, 1976, 18:161–70. 14. Cheesbrough M, ed. District laborato- ry practice in tropical countries. Part 1. Cambridge, Cambridge University Press, 1998:192–205. 15. Mahdi NK, Jassim AH. Intestinal parasitic infections of primary school children in three regions of southern Iraq. Medical journal of Basra University, 1987, 6:55– 61. 16. Al-Rahaley IMK. Some aspects of en- teropathogenic Escherichia coli from di- arrheic children in hospitals and normal children in nurseries [MSc thesis]. Mosul, Iraq, University of Mosul, 1988. 17. Molan AL, Farag AM. Prevalence of in- testinal parasites in school children of Er- bil, Northern Iraq. Saudi medical journal, 1989, 10:107–10. 18. Gharbi T et al. Etude de l’anémie au cours de la giardiase chez des enfants Tu- nisiens d’âge préscolaire [Study of ane- mia in giardiasis intestinalis in Tunisian preschool children]. La Tunisie medicale, 1999, 77(11):558–61. 19. Boia MN et al. Cross sectional study of intestinal parasites and chaga’s disease in the municipality of Nova Airao, State of Amazonaz, Brazil. Cadernos de saúde pública, 1999, 15(3):497–504. 20. Hellard ME et al. Prevalence of enter- ic pathogens among community based Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 561 asymptomatic individuals. Journal of gastroenterology and hepatology, 2000, 15(3):290–3. 21. Al-Sa’eed ATM, Saeed AY, Mohammed JB. Prevalence of gastrointestinal para- sites among the population in Dohuk– Kurdistan region Iraq. Zanco—journal for medical sciences (special issue), 2001, 5:14–9. 22. Swadi AA. Epidemiological study on giardiasis in dogs in Baghdad province [MSc Thesis]. Baghdad, Iraq, Veterinary Medicine College University of Baghdad, 2000. 23. Farag AM. Intestinal infection with En- tamoeba histolytica and Giardia lamblia regular patients to Yafrin general hospital, Libya. Journal of Dohuk University, 1999, 2(2):407–13. 24. Markell EK, John DT, Krotoski WA, eds. Markell and Voge’s medical parasitology, 8th ed. Philadelphia, Saunders, 1999, 55–62. 25. Yassin MM et al. Prevalence of intestinal parasites among school children in Gaza City, Gaza strip. Journal of the Egyptian Society of Parasitology, 1999, 29(2):365– 73. 26. Mercado R, Otto JP, Perez M. Varia- cion estacional de las infecciones por protozoos intestinales en pacientes am- bulatorios del sector norte de Santiago, Chile, 1995-1996 [Seasonal variation of intestinal protozoa infection in outpatients of the north section of Santiago, Chile, 1995–1996]. Boletin chileno de parasito- logia, 1999, 54(1–2):41–4. 27. Bolbol AH, Mahmoud AA. Laboratory and clinical study of intestinal pathogenic parasites among the Riyadh population. Saudi medical journal, 1984, 5:159–66. 28. Dieng Y et al. Les parasitoses intesti- nales chez des habitants d’une zone peri- urbaine a nappe phreatique polluee par les nitrates d’origine fecale (Yeumbeul, Senegal) [Intestinal parasitosis in the inhabitants of a suburban zone in which the groundwater is polluted by nitrates of fecal origin (Yeumbeul, Senegal)]. Sante, 1999, 9(6):351–6. 29. Belding DL. Textbook of parasitology, 3rd ed. New York, Appleton Century Crofts, 1965:123–6. 30. Faust EC, Beaver PC, Jung RC, eds. Animal agents and vectors of human disease, 4th ed. Philadelphia, Lea and Febiger, 1978:25–7. 31. Meyer EA, Radulescu S. Giardia and gia- rdiasis. Advances in parasitology, 1979, 17:1–47. 32. Agro-Meteorological Sub-Sector. Month- ly bulletins (October 2001–July 2002). Duhok, Food and Agriculture Organiza- tion Coordination Office for Northern Iraq, 2001/2. 33. Al-Barzanjy RKA. Epidemiological study of Giardia spp. in Erbil Governorate [MSc thesis]. Erbil, Iraq, College of Science, University of Salahaddin, 1992. 34. Craun GF. Waterborne giardiasis in the United States: a review. American journal of public health, 1979, 69:817–9. 35. Farthing MJ. Giardiasis as a disease. In: Thompson RCA, Reynoldson JA, Lym- bery AJ, eds. Giardia: from molecules to disease and beyond. Wallingford, CAB International, 1994:15–57. 562 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Prevalence of helminth ova in soil samples from public places in Shiraz H. Motazedian,1 D. Mehrabani,2 S.H.R. Tabatabaee,3 A. Pakniat1 and M. Tavalali1 1Department of Parasitology and Mycology, School of Medicine; 3School of Public Health, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran (Correspondence to H. Motazedian: motazedm@sums. ac.ir). 2Razi Vaccine and Serum Research Institute, Shiraz University, Shiraz, Islamic Republic of Iran. Received: 28/06/04; accepted: 24/11/04 ABSTRACT To determine the prevalence of helminth eggs in public places and children’s playgrounds, 112 soil samples were collected in 26 sites in Shiraz, southern Islamic Republic of Iran, during Sept tember 2002–September 2003. Toxocara cati ova were found in 7 (6.3%) samples, 2 had Ascaris lumt bricoides ova, 3 had larvae morphologically similar to Strongyloides stercoralis. Coccidia oocysts were also observed in 4 samples. No contamination was observed during the dry season. 17 Prevalence of helminth ova in soil samples from public places in Shiraz ›ÍÉ·É«ì¶=Á=bÈb¶=zÇÉEe>nJ¾=¹b£ºg=m›ͺ>£¶=À²>ºÙ=ÀºÌcÇ]@™=ÍEf[J¶=L>¿ëÉ¢ Ê·¶ÇIa=gfú(Kɾµ>Eb—?(ÊÈ>F{>F{>uebɗbÉi(ʾ>EfúaÆÆ=a(Á>ÈbvJ£ºjUb»†  „=Í[qØ6d]?112ÍEf[IÀºÍ¿ëÉ¢26¹b[£ºb[Èb€ÍßÉá§àE(ÍɺØiÝ=Á=fÈCÍÈeÇÖHÇ¿Q›g=m›ð>£®Çº zÇÉEe>nJ¾=>«{Ù=G¢ØºÆͺ>£¶=À²>ºÙ=›ÍÉ·É«ì¶=Á=bÈb¶=¹¹Ç[·È?À[ºÌb[™=¹Ø]´¶cÆ(+»JF[i2002 ¹Ç·È?ÎJU+»JFi2003*›ÍçÈf=ÍÉ»Ãj¶=LbQǪ7L>¿É¢%6.3$!É{=f[„=fí«çr¶=zÇÉEÆ%kÈe>³[iÙ=$ ›ð>ÉQǶǪeǺÍÈg=¶=Íçɾ=Çìi×=ÄFnIL>®fÈÆ(ÀáÉßJ¿ëÉ¢›3ÍjëɳJ™=ÍçÉvÉF¶=L>çÈf²î?aÇQÆ UǶ>»²(L>¿É¢ ›4L>¿É¢*­>«‚=¼iǺ›PÇ·IË? ßUØàÈÆ*  Prévalence des œufs d’helminthes dans des échantillons de sol prélevés dans des lieux publics à Chiraz RÉSUMÉ Afin de déterminer la prévalence des œufs d’helminthes dans des lieux publics et des aires de jeux pour enfants, 112 échantillons de sol ont été prélevés sur 26 sites à Chiraz (sud de la Réput blique islamique d’Iran) entre septembre 2002 et septembre 2003. Des œufs de Toxocara cati ont été trouvés dans 7 échantillons (6,3 %), 2 échantillons avaient des œufs d’Ascaris lumbricoides, 3 avaient des larves morphologiquement similaires à celles de Strongyloides stercoralis. Des oocytes de coccit dies ont été également observés dans 4 échantillons. Aucune contamination n’a été notée pendant la saison sèche. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 563 Introduction Toxocara cati and T. canis are cosmopolit tan parasites of cats and dogs and have been most commonly incriminated as the cause of visceral larvae migrans and ocular larvae migrans [1–3]. Direct contact with animals that harbour adult Toxocara worms is unt likely to give rise to infection in humans; the ova must undergo a period of developt ment in the environment before they can become infective [1]. Previous reports have noted the presence of Toxocara in stray cats, stray dogs and primarytschool children in Shiraz [2–4]; in addition, Toxoplasma oocysts were found in stray cats and antibody response to Toxop plasma in primarytschool children [5,6]. These findings indicate that contact with soil in public places is a potential source of contamination. Stray dogs and cats roam freely in residential areas and public places in Shiraz, and the soil in these places is east ily contaminated with their faeces. As there is a large population of stray dogs and cats in Shiraz and no studies have been made on the extent of contamination of the environment with helminth eggs, this study was undertaken to determine the prevalence of helminth eggs in public places and playgrounds. Methods From September 2002 to September 2003, 112 soil samples were collected by cluster random sampling from the uppermost cent timetre (15 × 12 cm2) of soil in 26 public places and children’s playgrounds in 4 ret gions of Shiraz, Southern Iran. Sampling was carried out in all 4 seasons of the year. Selection of collecting areas was confined to 4 divisions, southtwestern (region 1), northtwestern (region 4), southt eastern (region 3) and northteastern (region 2) Shiraz. These are the divisions used by the Education and Culture Organization of Shiraz. The samples were first washed with running tap water, using a set of 3 sieves of mesh width 250 µm, 120 µm and 30 µm. The residue remaining in the 30 µm sieve was flushed into a 250 mL graduated cylint der. The liquid was decanted after 15 mint utes sedimentation then the sediment was transferred to a centrifuge tube, shaken with saline solution (specific gravity 1.19) and concentrated by zinc sulfate centrifugation– flotation (centrifugation for 5 minutes at 2500 rpm), and then identified microscopit cally. All samples were processed twice and recorded as positive if eggs or larvae were found at least once. Results Table 1 shows the distribution of soil samt ples from 26 sites in Shiraz. Helminth eggs were recovered from 12 of the 112 soil samt ples. The results during the whole year and the wet (autumn/winter) seasons are also summarized in Table 1. No contamination was observed during the dry season. Eggs of T. cati were recovered from 7 samples (Table 1), Ascaris lumbricoides ova from 2 and larvae morphologically similar to Strongyloides stercoralis from 3. In addition, 4 samples contained oocysts of coccidia. The burden of T. cati ova during the wet season and the whole year is shown in Table 1. The highest contamination rate was in downtown public places in the 3rd (22.2%) and the 4th (20.0%) regions. No contaminat tion was observed during the dry season. 564 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Discussion Toxocara cati eggs were recovered from 6.3% of soil samples tested. Earlier studt ies in Shiraz indicated an infection rate of 52.8% in stray cats [2] and 2.9% in stray dogs [4]; around 25% of sera samples from primarytschool children were positive for Toxocara [5]. In other studies, 10.78% of stray cats were infected and seropositivt ity for Toxoplasma gondi was 23.39% in primarytschool children [3,6]. Our findings indicate that there is a post sibility of human infection from the envit ronment in public places and playgrounds in Shiraz. Embryonated ova can remain viable for a considerable length of time in soil [1]. Small children are considered at risk from geohelminth contamination because of their lifestyle and their playing environment, est pecially those children with a history of pica [7]. Public parks, particularly playgrounds, may be an important source of contaminat tion [8]. Our findings on the prevalence of T. cati eggs corroborate those of other researchers: contamination with Toxocara eggs is widet spread in the soil in public places [9–11]. The high prevalence of T. cati ova in the soil samples from downtown parks in the 3rd and 4th regions of Shiraz is evidence that stray dogs and cats were infected and defecate in these areas. These findings are consistent with the parasite burden in chilt dren and stray cats in these areas [2,5]. The presence of Toxocara eggs and larvae in these places emphasizes the risk to children who play there of visceral larvae migrans. Similar findings have been reported previt ously from Iraq and Jordan [12,13]. As humans are the final host for Ascaris lumbricoides, the presence of this parasite probably reflects the lack of public latrines. The study demonstrates that the soil in public places and playgrounds in Shiraz is a potential source of contamination. Despite the high temperatures prevalent in Shiraz in summer, clearly identifiable ova were present in many of the specimens collected. The results are of public health importance for this area. Because of the mild temt peratures in winter and spring, people often spend their time in public places, especially at night. Table 1 Parasitic burden of Toxocara cati and helminth ova in the soil in public places in four regions of Shiraz during the whole year and the wet season, 2002 Region No. of Contaminated with Contaminated with samplesa helminth ova Toxocara cati ova All year Wet seasonb All year Wet seasonb No. % No. % No. % No. % 1 36 0 – 0 – 0 – 0 – 2 28 4 14.4 4 28.6 2 7.1 2 14.3 3 18 3 16.7 3 33.2 2 11.1 2 22.3 4 30 5 16.7 5 33.2 3 10.0 3 20.0 Total 112 12 10.7 12 21.4 7 6.3 7 12.5 aNo. of samples varies in accordance with the area of the region. bWet season is autumn and winter. No contamination was found during the dry season. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 565 For this reason, preventive measures should be implemented. These could int clude health education of the public, hygit enic waste disposal, good personal hygiene practices, control of stray dogs and cats and exclusion of dogs and cats from public places and children’s playgrounds by fenct ing. Acknowledgements We would like to thank the Office of the Vice Chancellor for Research of Shiraz University of Medical Sciences for financial support and the Centre for Development of Clinical Research for typing and editorial assistance. References 1. Glickman LT, Schantz PM. Epidemiolt ogy and pathogenesis of zoonotic toxot cariasis. Epidemiologic reviews, 1981, 3:230–50. 2. Sadjjadi SM et al. Prevalence and int tensity of infestation with Toxocara cati in stray cats in Shiraz, Iran. Veterinarski arhiv, 2001, 7(3):149–57. 3. Tahamtan Y et al. Prevalence of Toxot plasma gondii in stray cats in Shiraz, Southern Iran. Paper presented at the 26th World Veterinary Congress, 23–26 September 1999, Lyon, France. 4. Mehrabani D, Sadjjadi SM, Oryan A. Prevalence of gastrointestinal nematode parasites in stray dogs in Shiraz, Southt ern Iran. Journal of applied animal ret search, 2002, 22(1):157–60. 5. Sadjjadi SM et al. Seroprevalence of Toxocara infection in school children in Shiraz, Southern Iran. Journal of tropical pediatrics, 2000, 46(6):327–30. 6. Tahamtan Y et al. Prevalence of Toxot plasma gondii in primarytschool children in Shiraz, Southern Iran. Paper presented at the 5th International Epidemiological Association Eastern Mediterranean Ret gional Scientific Meeting, Bahrain, 23–25 October 2000. 7. Duwel D. The prevalence of Toxocara eggs in the sand in children’s playgrounds in Frankfurt/M. Annals of tropical medicine and parasitology, 1984, 7(6)8:633–6. 8. Gillespie SH, Pereira M, Ramsay A. The prevalence of Toxocara canis ova in soil samples from parks and gardens in the London area. Public health, 1991, 105(4):335–9. 9. Gunaseelan L et al. Incidence of Toxocara ova in the environment. Indian veterinary journal, 1992, 69:308–9. 10. O’Lorcain P. Prevalence of Toxocara canis ova in public playgrounds in the Dublin area of Ireland. Journal of helmint thology, 1994, 68(3):237–41. 11. Collins GH, Moore J. Soil survey of eggs of Toxocara species. Annals of tropit cal medicine and parasitology, 1982, 76(5):579–80. 12. AbotShehada MN. Prevalence of Toxot cara in some schools and public grounds in northern and central Jordan. Annals of tropical medicine and parasitology, 1989, 83(1):73–5. 13. Woodruff AW et al. Toxocara ova in soil in the Mosul District, Iraq, and their relt evance to public health measures in the Middle East. Annals of tropical medicine and parasitology, 1981, 75(5):555–7. 566 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Rapid assessment of trachoma in 9 governorates and Socotra Island in Yemen T.K. Al-Khatib,1 A.S. Hamid,1 A.M. Al-Kuhlany,2 M.H. Al-Jabal2 and Y.A. Raja’a1 1Faculty of Medicine and Health Sciences, University of Sana’a, Sana’a, Yemen (Correspondence to T.A. Al-Khatib: tawfik234@yahoo.com). 2Ministry of Public Health and Population, Sana’a, Yemen. Received: 20/10/04; accepted: 31/01/05 ABSTRACT This study described the pattern of trichiasis, active trachoma and trachoma risk factors in 9 governorates of Yemen plus Socotra Island, using a rapid assessment during October and February 2004. A total of 3169 children aged 1–9 years were examined in a central meeting point or at home. Ac- tive trachoma was found in a high percentage of children in Al-Jawf, Mareb and Shabwah governorates and the SAFE strategy (Surgery, Antibiotic treatment, Facial cleanliness, Environmental improvement) should be directed toward these governorates. Trichiasis cases were also found in Hadramout and Taiz, suggesting that eyelid surgery should be provided in these governorates. 1 Measles seroepidemiology among adolescents and young adults: response to £ª>ɶ=Ɛ¯Â=f™=EÍFrƒ=>ÉQǶÆiL>ÉÑ>EÆ6ìJ¶=Ìa>¢ÝÍE>RJi×=¼É£ (Á>[É·É·]>[ueÊ[·¢(ËaÇ[»†>[E>E´[¿Ufª(Ê[»R¢?¼[i>¯¶=Ç[E?(Ë[º?>ue¹AËbú(e>«qf«£Qb»† Åa=gÊjb—?(ÊÂ>mbÉUÆpÆeDz  „=Í[qØ6e>nJ¾×=¹b£º¼ÉɯJEÁÇNU>F¶=½>®ÍFr[ƒ=b[u¤[É¿»J¶=Ìa>¢ÝÍE>RJi×=ÆÍFrƒ=L=bvJj™Ê·r™= Ïb¶590Á?K[FNª7¼Ã»É[£ìI°Fið>£ª>ÈÆð>¯Â=fº263¸ r[™=·[i¼Ã¿[º*Ê[¶çÆÙ=\>[¯·¶=¸n[ª[EÍ[®f«J·¶Æ Ê¢>¿™=¶ÇEÇ·§¶=e>É¢¼É[ɯI(ËǾ>N¶=ÆGÊ¢>¿™=¶ÇEÇ·§¶=ÆMÊvºb£E2)4¶=Ìa>¢CÀº¤ÉE>i?¼É£ìJÏb¶ 144(ð=afª%Á?bQǪ105Ƹr™=ÊëÉF·i=Ǿ>²39¸r™=ÊëÉE>‹C*$H>RJi=b®Æ75Ìa>[¢Ý¸r[™=ÊëÉF·[iÀ[º Ëe>²cÝ=¼É£ìJ¶=%0.001<P$fÞ?>»¿ÉE(Í¢>¿™=¼ÃÈb¶LfÞÆ11Ê¢>¿™=¶ÇEÇ·§·¶ÍE>RJi=ð>r^mM%>š ʶçÆÙ=\>¯·¶=¸nª‘Cð>F¶>¦nÈ$7ÇV¿¶Ìfª=ÇJºÍÉ·r™=ÍÈ>»ƒ=K·ž>»¿ÉE38ÁÆa¸r™=ÊëÉE>‹C²e>n™=Àº bvJj™=e>É¢›ÍiÇ»·ºÌa>Èg%0.5779P*$ʶçÆÙ=±>«]Ý=¹b£ºÁ>²b®Æ4.7!ËǾ>N¶=Æ(27.1*!b[£E>º? XFq?b¯ª¼É£ìJ¶=Ìa>¢C87.3!ð>É·rº[ëÉ»†*  Rapid assessment of trachoma in 9 governorates and Socotra Island in Yemen ÍÉ¿»É¶=ÍÈeÇû‚=›Ïßfìî¯ àiÌfÈhQ›ÆL>Ÿª>†¤jI›>ºÇ]=f[J·¶¤Èfj¶=¼É[ɯJ¶= eb—?ÎɌ(¸F‚=ÀjUb»†(ʾØV³¶=b»†=bF¢(bɗfÂ>mhÈh¢(GÉì„=bÑ>®°ÉªÇIÐ>Q  „=Í[qØ6(Íìn[¿¶=>ºÇ]=¶=Æ(Íɾf¯¶=¤º>ò>³JU=ÆÀ«‚=¸]=aH=bÂÙ=ge>FI>”?Íi=eb¶=ÅdÂKuf£Ji= ›>ºÇ]=¶=e>ìJ]=¸º=Ç¢Æ9¹Ø[]¤Èf[i¼É[[ɯI½=b^J[i>E(Ïßfìî¯ àiÌfÈhQ›ÆÍÉ¿»É¶=ÍÈeÇû‚>EL>Ÿª>† ¹ÆÙ=ÀÈfnIáËßfÃm+>FmÆfEÇJ²?+f[È=ª2004*Æs[Vª3169¤j[IÆÍ¿[i[E¼Âe>[»¢?\Æ=f[[JIðØ[«{ ¹h¿™>EÆ?ÍÈh²fºÐ>¯J¶=Í쯾›L=Ç¿i*›¹>[«{Ù=À[ºÌF[²ÍFj[¾Ïb[¶Íìn[¾>[ºÇ]=fIaÇ[QÆf[Þb[®Æ ÍÉRÉI=i=ÄÉQÇIËeÆfv¶=Àº¸£‹>š(ÌÇFmÆ(He@ºÆ(­Ç‚=L>Ÿª>†SAFE(À[«‚=HØ[¯¾=Í[U=fQË? ƒ=L=a>v™>E͂>£™=ÆL>Ÿª>=Åd‘CÍÒÉF¶=j€Æ(ÄQǶ=ͪ>Ÿ¾Æ(ÍÈÇÉ*H=bÂÙ=ge>FIL×>ULbQÆ>»² Åd[›À«‚=Hد¾=L>U=fQªÇIÍÉ»Â?‘CnÈ>š(h£IÆLǺfvU›Íɾf¯¶=¤º>ò>³JU=ÆÀ«‚=¸]=a L>Ÿª>=*    Évaluation rapide du trachome dans 9 gouvernorats et dans l’Île de Socotra au Yémen RÉSUMÉ La présente étude décrit les caractéristiques du trichiasis et du trachome évolutif ainsi que les facteurs de risque de trachome dans 9 gouvernorats du Yémen et dans l’Île de Socotra, à partir d’une évaluation rapide effectuée durant les mois de février et d’octobre 2004. Au total, 3169 enfants âgés de 1 à 9 ans ont été examinés dans un point de rencontre central ou à domicile. Un trachome évolutif a été observé chez un fort pourcentage d’enfants dans les gouvernorats d’Al-Jawf, de Mareb et Shabwah et la stratégie CHANCE (Chirurgie, Antiobiothérapie, Nettoyage du visage et Changement de l’Environnement) devrait donc être focalisée sur ces gouvernorats. Des cas de trichiasis ont également été trouvés à Hadramout et Taiz, ce qui semble indiquer que la chirurgie des paupières devrait être assurée dans ces gouvernorats. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 567 Introduction Today, trachoma is still found in underp privileged communities with poor living conditions. The World Health Organization (WHO) calculated that blinding trachoma is still present in 46 countries, encompassp ing 150 million people. Yemen is one of these countries [1]. It is estimated that 15% of the blindness in the world is caused by trachoma [2]. The disease is found mainly in remote rural areas of most African counp tries and in several Eastern Mediterranean Region countries such as Saudi Arabia [3], Egypt [4], Sudan [5], Oman [6] and Yemen [7]. The Egyptian study revealed a prevap lence of active trachoma of 36.5% among preschool children [4]. In Yemen, a serop prevalence study of Chlamydia trachomatis infection among schoolchildren in rural and urban Sana’a revealed a rate of 45.9%. The rate was higher among rural (73.2%) than urban children (23.1%) [7]. The risk factors that predispose to infecp tion are mostly environmental and poor hygiene practices. The major risk factors are overcrowding, absence of a latrine [8], a home of wood and earth [9], poor personal hygiene and keeping animals within the dwelling [10]. When assessing trachoma at the community level, it is important to consider both the inflammatory disease in children and the potentially blinding comp plications (i.e. trichiasis) in adults. Several rapid assessments have been carried out in different countries. An asp sessment conducted in Ethiopia showed that more than half (51.1%) of the children aged 10 years or less had active trachoma [11]. On the other hand, active trachoma and trachomatous trichiasis each were found in 5.5% of individuals older than 10 years of age. Most of the households (97.6%) had no latrine and of the few that had one, only twopthirds of the occupants used it. In Burkina Faso, the presence of flies on children’s face and dirty faces were strongly associated with the rate of trachoma [12]. No national trachoma assessment survey has previously been reported in Yemen. Therefore, the need for a countrypwide rapid assessment in order to control for the disease is evident. Our study aimed to prioritize governorates by the rate of active trachoma and to describe the pattern of trichiasis, active trachoma and trachoma risk factors. Methods A survey of trachoma using rapid assessp ment methodology was conducted during October 2003 to February 2004 in 9 out of the 22 governorates of Yemen. Data about environmental factors were collected from households, while demographic and clinip cal data were collected from children and elderly people. Sample selection The selected governorates were: Mareb, Shabwah, Hadramout, Ibb, Taiz, AlpJawf, AlpHodiedah, Abyan, Lahj and Socotra Isp land. The selection of the governorates was the outcome of a 3pday workshop during September 2004. Reports of the Ministry of Public Health and judgements of senior exp perienced ophthalmologists were reviewed and discussed by the assessment team top gether with a WHO expert. The selection involved all 5 governorates where cases of active trachoma are frequently reported, plus another 4 governorates selected ranp domly from the list of governorates where active trachoma is rarely reported, plus Socotra Island. The selection technique was made according to the guidelines for rapid assessment for blinding trachoma [13]. 568 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 In each governorate, communities/vilp lages were selected when at least 1 of the following criteria applied: 1. Uncertain situation or suspicion of trap choma, based on a previous review or analysis. 2. Evidence of trachoma from previous reports or from key informants (using the field visit to validate the information derived from the previous review). 3. Isolated community of less than 500 people, with special attention to minorip ties and marginalized mobile or migrant population groups or tribes. 4. No easy or permanent access to water. 5. Primary health care services are weak, irregular or nonpexistent. 6. No school present in the community. Children included in the rapid clinical assessment were aged 1–9 years old and selected from at least 15–20 households/ compounds. In areas where villages conp sisted of continuous households with a wellp structured neighbourhood, we surveyed 15–20 households in one section or in each neighbourhood. In areas where villages consisted of widely spaced households, scattered households were assessed until the required sample size of 50 children was reached. If a selected village did not have enough children to reach the sample size, we examined all the children present. At least half of the 50 children were prepschool children. Data collection and analysis A total of 3169 children between the ages of 1–9 years were examined for the signs of active trachoma. The examination was conducted in a central meeting point or at home and each eye was examined separatep ly. The assessment of active trachoma and trichiasis was made according to the WHO simplified trachoma grading system [13] by a team consisting of an ophthalmic consultp ant, ophthalmologist and a candidate for the diploma in ophthalmology. The team used a binocular loupe with × 2.5 magnification. Elderly people with trichiasis, entropion and corneal opacities were also searched for and recorded when encountered. Environmental risk factors were opp erationally defined as: absence of latrine, presence of solid waste within the dwelling and inaccessible water supply (more than 30 minutes walk). Personal hygiene was operationally defined by unclean face; that is, if flies were observed on the face or discharges were seen on the eye or the nose. Both environmental factors and unclean faces were identified by observation. Data were processed using SPSS to calp culate frequencies and percentages. Results Active trachoma was found to affect a high percentage of children in 3 of the goverp norates: AlpJawf (48.0%), Mareb (25.0%) and Shabwah (17.0%). The trachoma rates were much lower in Ibb (6.0%), Hadramout (5.0%) and AlpHodeidah (4.0%), where some districts were also affected by active trachoma: Sayon, AlpMakhader, AlpUdain and AlpDoraihemi. Tachoma rates were very low in Abyan (0.9%), Lahj (0.9%), Taiz (0.9%) and Socotra (0.7%) (Table 1). The percentage of children with unp clean faces followed a similar pattern to the governorates with active trachoma: Alp Jawf (41.7%), Mareb (37.7%) and Shabwah (30.3%) had the highest rates, followed by AlpHodiedah, Abyan, Taiz, Ibb, Lahj, Sop cotra Island and Hadramout (Table 1). The percentage of children with unclean faces was found to correlate positively with the percentage with active trachoma (r = 0.92). Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 569 Ta bl e 1 Cl in ic al a nd e nv iro nm en ta l r ap id a ss es sm en t o f t ra ch om a in 9 g ov er no ra te s of Y em en p lu s So co tr a Is la nd G ov er no ra te Cl in ic al a ss es sm en t En vi ro nm en ta l a ss es sm en t To ta l Ch ild re n Ch ild re n Tr ic hi as is To ta l A bs en ce So lid W at er > 3 0 ch ild re n w ith w ith ca se s in ho us eh ol ds of la tr in e w as te m in . w al k ex am in ed ac tiv e un cl ea n co m m un ity vi si te d tr ac ho m a fa ce s N o. % % N o. N o. % % % A l-J aw f 30 2 48 .0 41 .7 5 14 3 88 .1 19 .6 18 .9 M ar eb 31 3 25 .0 37 .7 14 14 8 1. 4 87 .2 0. 0 Sh ab w ah 33 3 17 .0 30 .3 5 24 2 72 .3 76 .4 81 .9 Ib b 31 3 5. 8 13 .2 0 13 3 18 .8 0. 0 29 .3 H ad ra m ou t 31 5 5. 0 10 .5 9 94 65 .4 81 .9 0. 0 A l-H od ie da h 31 9 4. 0 22 .9 0 12 9 88 .4 76 .7 0. 0 A by an 32 2 0. 9 16 .5 2 20 3 20 .7 58 .2 36 .0 La hj 31 3 0. 9 11 .2 1 16 8 50 .6 74 .5 0. 0 Ta iz 33 2 0. 9 15 .1 7 17 1 32 .8 73 .7 0. 0 So co tr a 30 0 0. 7 10 .7 0 11 6 71 .7 8. 3 0. 0 570 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Cases of trichiasis among older people were found in the 3 governorates with high rates of active trachoma (Jawf, Mareb and Shabwah) but also in governorates with low rates of trachoma (Hadramout and Taiz), and to some extent in Abyan and Lahj. No trichiasis cases were found in AlpHodiedah, Ibb or Socotra Island (Table 1). The risk factors of trachoma such as presence of solid waste and houses with no latrines were found in a higher proportion of households in the endemic governorates of AlpJawf, Mareb and Shabwah (Table 1). For example, in AlpJawf latrines were not availp able for 88.1% of the population, in Mareb 87.2% of household had solid waste from animals, while the situation in Shabwah was worse with latrines lacking in 72.3% and solid waste seen in 76.4% of households. These 3 governorates also had the highest proportion of children with unclean faces. Discussion The assessment showed that AlpJawf, Mareb and Shabwah had the highest rates of active trachoma and are thus high priority governorates for application of the “SAFE” control strategy among the investigated govp ernorates. The SAFE strategy for trachoma control comprises Surgery, Antibiotics, Fap cial cleanliness and Environmental hygiene [14]. Some districts in Hadramout, Ibb and AlpHodiedah were also affected by active trachoma and therefore treatment with topip cal tetracycline or systemic azithromycin (the “A” component of the SAFE strategy) can be recommended in these areas. It was expected during the deskwork phase that Hadramout and AlpHodiedah would rank among the highly affected arp eas, as Hadramout governorate lies on the desert line and AlpHodiedah has reported a very high rate of active trachoma and trichip asis cases. The rapid assessment found, however, that there is better coverage with standpipe water in the 2 governorates than in other governorates. As findings from the field sometimes revealed that our predicp tions were not reliable, the situation in the other governorates need to be assessed in the field, especially Sa’da and AlpMahara, where environmental conditions are suitp able for transmission. The number of trichiasis cases was found to be high in Hadramout, Mareb, Taiz, AlpJawf and Shabwah. In view of the rate of active trachoma it is clear that Mareb, AlpJawf and Shabwah governorates have suffered and are still suffering from this health problem. This confirms the need for focusing the full SAFE control programmes in these 3 governorates. However, while the rate of active trachoma is not so high in Hadramout and Taiz governorates, the high number of trichiasis cases found in these 2 governorates suggest that surgery (the “S” component of the SAFE strategy) should also be directed to these governorates. The current assessment revealed a very high positive correlation between the rate of unclean faces and the rate of active trap choma. Unclean faces were observed in AlpJawf, Mareb, Shabwah, AlpHodiedah, Abyan and Taiz in descending order. The control programme in these areas should focus on health education about cleanlip ness and availability of safe water sources within a suitable distance (the “F” and “E” component of the SAFE strategy). Community risk factors, i.e. unavailabilp ity of a water source within a suitable disp tance and deficiency in functioning latrines, were predominant in the governorates most affected by active trachoma. However, there were anomalies. For example, while Mareb governorate currently enjoys good water access and presence of latrines, it still has a Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 571 high share of the burden of active trachoma. This could be attributed to the continuous contact with animals in the houses. Therep fore, the control strategy in this governorate should focus on health education, drug availability and surgery. Recommendations • To assess the situation in the other govp ernorates which have environmental and social similarities with the endemic areas investigated here (e.g. AlpMahara and Sa’da governorates). • To implement the SAFE control stratp egy in the 3 high priority governorates: AlpJawf, Mareb and Shabwah. To conp sider applying SAFE to some districts in Hadramout, Ibb, Taiz and AlpHodiedah. • To focus on health education about cleanliness in Mareb. • To provide access to eyelid surgery in Hadramout and Taiz governorates as these were high transmission areas in the past. Acknowledgements The researchers acknowledge with thanks the technical and financial support given by the WHO Sana’a Office and the WHO EMRO expert Dr AbdulHannan Chaudry who participated in the preparation workp shop. The participation of the new graduates of Diploma in Ophthalmology is apprecip ated. Special words of appreciation are due to Dr M. AlpMansoob for data analysis. References 1. Taylor HR. A trachoma perspective. Oph- thalmic epidemiology, 2001, 8(2–3):69– 72. 2. Thylefors B et al. Global data on blind- ness. Bulletin of the World Health Organi- zation, 1995, 73:115–21. 3. Tabbara KF. Trachoma: a review. Journal of chemotherapy, 2001, 13: S18–22. 4. Ezz al Arab G et al. The burden of tra- choma in the rural Nile delta of Egypt: a survey of Menofiya governorate. British journal of ophthalmology, 2001, 85:1406– 10. 5. Salim AR, Sheikh HA. Trachoma in the Sudan. An epidemiological study. Brit- ish journal of ophthalmology, 1975, 10: 600–4. 6. Khandekar R, Mohammed AJ, Courtright P. Recurrence of trichiasis: a long-term follow-up study in the Sultanate of Oman. Ophthalmic epidemiology, 2001, 8(2– 3):155–61. 7. Sallam TA et al. Chlamydia trachomatis infection among Yemeni school pupils in relation to environmental conditions. Saudi medical journal, 2003, 24(1):84–7. 8. Courtright P et al. Latrine ownership as a protective factor in inflammatory trachoma in Egypt. British journal of ophthalmology, 1991, 75:322–5. 9. Turner VM et al. Risk factors for trichi- asis in women in Kongwa, Tanzania: a case–control study. International journal of epidemiology, 1993, 22:341–7. 10. West S et al. Impact of face-washing on trachoma in Kongwa, Tanzania. Lancet, 1995, 345:155–8. 11. Bejiga A, Alemayehu W. Prevalence of trachoma and its determinants in Dalocha District, Central Ethiopia. Ophthalmic epi- demiology, 2001, 8(2–3):119–25. 12. Schemann JF et al. Trachoma, flies and environmental factors in Burkina Faso. 572 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Transactions of the Royal Society of Tropical Medicine and Hygiene, 2003, 97 (1):63–8. 13. Negrel AD, Taylor HR, West S. Guidelines for the rapid assessment for blinding tra- choma. Geneva, World Health Organiza- tion, 2001. 14. Paxton A, Singida Trachoma Study Team. Rapid assessment of trachoma preva- lence—Singida, Tanzania. A study to compare assessment methods. Ophthal- mic epidemiology, 2001, 8(2–3):87–96. Strategy to eliminate blinding trachoma Trachoma is one of the oldest infectious diseases known to mankind. It is caused by Chlamydia trachomatis which spreads through contact with eye discharge from the infected person (on towels, handker- chiefs, fingers, etc.) and through transmission by eye-seeking flies. After years of repeated infection, the inside of the eyelid may be scarred so severely that the eyelid turns inward and the lashes rub on the eyeball, scarring the cornea. If untreated, this condition leads to the formation of irreversible corneal opacities and blindness. Blinding trachoma is avoidable. The strategy to eliminate the disease is based on: eyelid surgery, antibiotics to treat the infection, educa- tion about facial cleanliness and personal hygiene and environmental improvements. Community development and intensified action by WHO’s Global Alli- ance for the Elimination of Blinding Trachoma by 2020, has reduced the number of people with blinding trachoma. The estimated number of people affected has fallen from 360 million people in 1985 to ap- proximately 80 million people in 2006. Documents and publications from the Global Alliance for the Elimina- tion of Trachoma can be accessed at: http://www.who.int/blindness/ publications/get2020/en/index.html. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 573 Measles seroepidemiology among adolescents and young adults: response to revaccination M.J Saffar,1 M. Alraza-Amiri,1 A. Ajami,1 F. Baba-Mahmoodi,1 A.R. Khalilian,1 C. Vahidshahi1 and A. Shamsizadeh1 1Department of Paediatrics, Paediatric Infectious Disease Ward, Bouali-Cina Hospital, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran (Correspondence to M.J. Saffar: saffar@softhome.net). Received: 23/11/04; accepted: 28/02/05 ABSTRACT We evaluated the seroprevalence of measles antibody and response to measles reim- munization in 590 previously vaccinated adolescents and young adults; 263 were seronegative. To differentiate between primary and secondary vaccine failure, anti-measles IgM and IgG titres were assessed again 2–4 weeks after revaccination in 144 (105 seronegative, 39 seropositive) individuals: 75 seronegative participants responded to revaccination anamnestically (P < 0.001) and developed im- munity, 11 also showed IgM response (probably primary vaccine failure); 38 seropositive participants remained seroprotected without significant increase in antibody titre (P = 0.577). Primary vaccine failure was 4.7%; secondary vaccine failure was 27.1%. After revaccination, 87.3% were seroprotected. 1 easles seroepidemiology among adolescents and young adults: response to £ª>ɶ=Ɛ¯Â=f™=EÍFrƒ=>ÉQǶÆiL>ÉÑ>EÆ6ìJ¶=Ìa>¢ÝÍE>RJi×=¼É£ (Á>[É·É·]>[ueÊ[·¢(ËaÇ[»†>[E>E´[¿Ufª(Ê[»R¢?¼[i>¯¶=Ç[E?(Ë[º?>ue¹AËbú(e>«qf«£Qb»† Åa=gÊjb—?(ÊÂ>mbÉUÆpÆeDz  „=Í[qØ6e>nJ¾×=¹b£º¼ÉɯJEÁÇNU>F¶=½>®ÍFr[ƒ=b[u¤[É¿»J¶=Ìa>¢ÝÍE>RJi×=ÆÍFrƒ=L=bvJj™Ê·r™= Ïb¶590Á?K[FNª7¼Ã»É[£ìI°Fið>£ª>ÈÆð>¯Â=fº263¸ r[™=·[i¼Ã¿[º*Ê[¶çÆÙ=\>[¯·¶=¸n[ª[EÍ[®f«J·¶Æ Ê¢>¿™=¶ÇEÇ·§¶=e>É¢¼É[ɯI(ËǾ>N¶=ÆGÊ¢>¿™=¶ÇEÇ·§¶=ÆMÊvºb£E2)4¶=Ìa>¢CÀº¤ÉE>i?¼É£ìJÏb¶ 144(ð=afª%Á?bQǪ105Ƹr™=ÊëÉF·i=Ǿ>²39¸r™=ÊëÉE>‹C*$H>RJi=b®Æ75Ìa>[¢Ý¸r[™=ÊëÉF·[iÀ[º Ëe>²cÝ=¼É£ìJ¶=%0.001<P$fÞ?>»¿ÉE(Í¢>¿™=¼ÃÈb¶LfÞÆ11Ê¢>¿™=¶ÇEÇ·§·¶ÍE>RJi=ð>r^mM%>š ʶçÆÙ=\>¯·¶=¸nª‘Cð>F¶>¦nÈ$7ÇV¿¶Ìfª=ÇJºÍÉ·r™=ÍÈ>»ƒ=K·ž>»¿ÉE38ÁÆa¸r™=ÊëÉE>‹C²e>n™=Àº bvJj™=e>É¢›ÍiÇ»·ºÌa>Èg%0.5779P*$ʶçÆÙ=±>«]Ý=¹b£ºÁ>²b®Æ4.7!ËǾ>N¶=Æ(27.1*!b[£E>º? XFq?b¯ª¼É£ìJ¶=Ìa>¢C87.3!ð>É·rº[ëÉ»†*  Rapid assessment of trachoma in 9 governorates and Socotra Island in Yemen ÍÉ¿»É¶=ÍÈeÇû‚=›Ïßfìî¯ àiÌfÈhQ›ÆL>Ÿª>†¤jI›>ºÇ]=f[J·¶¤Èfj¶=¼É[ɯJ¶= eb—?ÎɌ(¸F‚=ÀjUb»†(ʾØV³¶=b»†=bF¢(bɗfÂ>mhÈh¢(GÉì„=bÑ>®°ÉªÇIÐ>Q  „=Í[qØ6(Íìn[¿¶=>ºÇ]=¶=Æ(Íɾf¯¶=¤º>ò>³JU=ÆÀ«‚=¸]=aH=bÂÙ=ge>FI>”?Íi=eb¶=ÅdÂKuf£Ji= ›>ºÇ]=¶=e>ìJ]=¸º=Ç¢Æ9¹Ø[]¤Èf[i¼É[[ɯI½=b^J[i>E(Ïßfìî¯ àiÌfÈhQ›ÆÍÉ¿»É¶=ÍÈeÇû‚>EL>Ÿª>† ¹ÆÙ=ÀÈfnIáËßfÃm+>FmÆfEÇJ²?+f[È=ª2004*Æs[Vª3169¤j[IÆÍ¿[i[E¼Âe>[»¢?\Æ=f[[JIðØ[«{ ¹h¿™>EÆ?ÍÈh²fºÐ>¯J¶=Í쯾›L=Ç¿i*›¹>[«{Ù=À[ºÌF[²ÍFj[¾Ïb[¶Íìn[¾>[ºÇ]=fIaÇ[QÆf[Þb[®Æ ÍÉRÉI=i=ÄÉQÇIËeÆfv¶=Àº¸£‹>š(ÌÇFmÆ(He@ºÆ(­Ç‚=L>Ÿª>†SAFE(À[«‚=HØ[¯¾=Í[U=fQË? ƒ=L=a>v™>E͂>£™=ÆL>Ÿª>=Åd‘CÍÒÉF¶=j€Æ(ÄQǶ=ͪ>Ÿ¾Æ(ÍÈÇÉ*H=bÂÙ=ge>FIL×>ULbQÆ>»² Åd[›À«‚=Hد¾=L>U=fQªÇIÍÉ»Â?‘CnÈ>š(h£IÆLǺfvU›Íɾf¯¶=¤º>ò>³JU=ÆÀ«‚=¸]=a L>Ÿª>=*    Séroépidémiologie de la rougeole chez des adolescents et de jeunes adultes : réponse à la revaccination RÉSUMÉ Nous avons évalué la séroprévalence des anticorps antirougeoleux et la réponse à la re- vaccination contre la rougeole chez 590 adolescents et jeunes adultes ayant déjà été vaccinés ; 263 étaient séronégatifs. Pour faire la distinction entre l’échec vaccinal primaire et secondaire, le titre des anticorps IgM et IgG antirougeoleux a été réévalué 2-4 semaines après la revaccination chez 144 sujets (105 séronégatifs, 39 séropositifs) : 75 participants séronégatifs ont présenté une réponse anamnes- tique à la revaccination (p < 0,001) et ont développé une immunité, 11 ont également montré une réponse en IgM (probablement un échec vaccinal primaire) ; chez 38 participants séropositifs la séro- protection persistait sans augmentation significative du titre des anticorps (p = 0,577). L’échec vaccinal primaire était de 4,7 % ; l’échec vaccinal secondaire s’élevait à 27,1 %. Après la revaccination, 87,3 % étaient séroprotégés. 574 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Introduction Despite the availability of a safe and eff fective vaccine, measles remains a public health problem worldwide. It has been estif mated that 30 million people contract meaf sles every year, and that nearly 1 million die. Many of the cases occur in adolescents and young adults [1–4]. Measlesfrelated mortality also accounts for around 10% of all deaths in children < 5 years in developf ing countries [5]. There are only 2 reasons why older children remain susceptible to measles: failure to have been vaccinated and vaccine failure [6]. Vaccine failure remains a maf jor obstacle that must be overcome before measles can be controlled [7]. Primary vacf cine failure (PVF) is failure of immediate seroconversion, with a documented lack of detectable specific antibody. Administraf tion of a second dose of vaccine results in a high proportion undergoing a primary antif body response, with an initial IgM response followed by IgG seroconversion. Secondary vaccine failure (SVF) results when there is initial documented seroconversion in response to vaccination followed by loss of protection, usually linked to waning serum antibody levels [8]. On exposure to measles virus, an individual may contract the virus and only show anamnestic type of antibody response, or may become ill. Following a second dose of vaccination, a large boost in IgG antibody levels generally occurs, with little or no IgM response [8]. Around 95%–98% of individuals who receive a single dose of measles vaccine after 12 months of age develop measles antibodies [9]. Some studies have shown that children vaccinated twice have betf ter protection than single dose recipients [8,9]. The measles vaccine is, however, less immunogenic in the presence of maternal antibodies before 12 months of age [8], and some studies showed that additional doses of vaccine could not boost the antibodies to a satisfactory level, and that any boosting that did take place was only shortflived [7,10,11]. Since 1981, through the Expanded Programme on Immunization, the World Health Organization has recommended a single dose of measles vaccine at 9 months of age in countries where measles is a probf lem in the first year of life [12]. Despite this programme, measles continues to be a major child health problem in developing countries [6,13]. The Iranian immunization policy folf lows the World Health Organization’s recf ommendation for developing countries, and includes a monocomponent vaccine against measles at 9 months of age [12]. In addition, the Iranian Ministry of Health recommends that a second dose of the measles vaccine be given at the age of 15 months. After implementing the 2fdose vaccination schedf ule with high levels of coverage (> 95%), between 1988 and 1998 the incidence of measles decreased markedly in Iran. During recent years, however, the incidence of the disease has been increasing, with some incif dences in previously vaccinated individuals among all age groups, mainly adolescents and young adults [14,15]. This study was designed to determine the probable causes of this resurgence in measles cases, especially in adolescents and young adults who had been vaccinated against measles according to the Iranian vaccination schedule. We also evaluated the IgM and IgG antibody responses to reimmunization with measlesfcontaining vaccine to differentiate PVF from SVF. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 575 Methods Participants This study was carried out from October 2003 to February 2004. Healthy volunteers [with no history of medical problems (e.g. acute respiratory infection, febrile illnesses, skin rash), physicianfdiagnosed measles or chronic illness] between 15 and 25 years of age were recruited from the student populaf tion at Mazandaran University of Medical Sciences and at several secondary schools from different areas of Sari, the capital of Mazandaran province. Medical students were recruited through flyers circulated in the university and volunteers selected based on medical vaccination records (recipients of 1 dose of measles vaccine). Highfschool students were selected based on medical vaccination records (recipients of 2fdose measles vaccine) and student population density. If a student refused to participate, the next student was substituted. We did not have a substantial refusal rate. Written informed consent was obtained from all participants. For volunteers under the age of 18 years, informed consent was also obtained from a parent. The protocol was reviewed and approved by the Medical Ethics Committee of the university. Vaccine histories of the participants were obtained from the primary health cenf tre vaccine records. Up to 1982, measles vaccination policy in the Islamic Republic of Iran was to administer 1 dose of the vaccine after the age of 12 months (Measles vaccine, BiofMerieux, France). The 1981 recommendations of the Expanded Prof gramme on Immunization for measles vacf cination for developing countries have been implemented in the Islamic Republic of Iran since 1983 [6], with some modification, i.e. 2 doses of measles vaccine administered at 9 and 15 months of age (Measles vaccine, Razi Institute, Tehran). Blood sampling For initial screening, 5 mL of venous blood was drawn from each participant under the supervision of one of the researchf ers. Samples were taken during October 2003–December 2003 and for the second phase during January 2004–February 2004. Sera were stored at –20 °C until assayed. As part of the measles–rubella mass vaccinaf tion programme in the Islamic Republic of Iran (6–31 December 2003), all individuals 5–25 years of age were vaccinated with measles–rubella virusfcontaining vaccine (Serum Institute of India Ltd, Pune), i.e. all those in the study sample were revaccinated after the first blood sampling. Sera were obtained 2–4 weeks after revaccination to determine the IgM and IgG antibody ref sponses to revaccination. Serologic assay Measles IgG and IgM antibodies were def tected by enzymeflinked immunosorbent assay (Measles IgMfELISA and measles IgGfELISA, IBL, Hamburg). The tests were performed in the university laboratory acf cording to the manufacturer’s instructions. Quantitative antibody titres < 10 IU/mL were reported as negative and ≥ 10 IU/mL as positive. All sera (samples obtained bef fore and after revaccination) were tested for IgG measlesfspecific antibodies; IgM was measured only in blood samples taken after revaccination to differentiate primary and secondary response types. Statistical analysis Data were analysed as ordinal and conf tinuous variables. Antibody levels were logf transformed for calculation of geometric mean antibody concentrations. The student tftest was used to compare the mean values in the pref and postfvaccination groups. All statistical analysis was performed using SPSS, version 10. 576 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Results A total of 590 adolescents and young adults (39.7% female), mean age 21.1 years [standard deviation (SD) 5.0; range 15–25 years], were enrolled into the measles sef roprevalence study trial and underwent serological screening for measlesfspecific IgG antibody. All of these individuals had previously received measles vaccine, 2 doses (at 9 months and 15 months) in the 209 participants 15–19 years old and 1 dose (after 12 months) in the 381 participants aged 20 years and older), as part of the routine measles vaccination schedule in the Islamic Republic of Iran. We found that 263 (44.6%) participants were serologically negative for measles anf tibody, geometric mean concentration 4.09 (SD 2.6) IU/mL mean age 20.0 (SD 2.9) years, and 327 (55.4%) were seropositive, geometric mean concentration 56.5 (SD 45.3), mean age 22.2 (SD 7.0). The results of the serological assays are summarized in Table 1. All 590 individuals were revaccinated (as part of the catchfup programme, 6–31 December 2003), and 105 participants idenf tified as seronegative and 39 identified as seropositive agreed to provide blood samples for followfup studies. Seventyffive of the revaccinated seronegative individuals (71.4%) responded to revaccination and showed significant increase in the levels of IgG measles antibody (P < 0.001) (Table 2); 11 (10.5%) also showed IgM response (probably primary vaccine failure). Of the 39 revaccinated seroprotected individuals, 38 remained seropositive with no statistif cally significant increase in IgG measles antibody. No IgM response was detected in this group. To understand the effect of vaccine dose at initial immunization on seropositivity, response to reimmunization and amount of time elapsed between initial immunif zation and revaccination, we compared the seropositivity rates and responses to revaccination in 2 age groups: 15–19 years (previously received 2 doses of measles vaccine) and 20 years and older (previf ously received 1 dose of measles vaccine). As shown in Table 1, 103 (49.2%) of the 209 people in the younger group and 160 (42.0%) of the 381 in the older group were seronegative, P = 0.16. Also, 65.8% of the revaccinated indif viduals enrolled in the younger (2 dose) group responded to revaccination compared to 91.3% in the older (single dose) group (Table 3). Based on these results, extrapolaf Table 1 Seroprevalence status of adolescents and young adults before measles revaccination, Sari, Islamic Republic of Iran Measles Participants seroprevalence Total Age 15–19 years Age 20–25 years (n = 590) (n = 209) (n = 381) No. % No. % No. % Antibody positivea 327 55.4 106 50.8 221 58.0 Antibody negativeb 263 44.6 103 49.2 160 42.0 GMC (SD) (IU/mL) 30.3 (24.0) 59.7 (48.4) 53.3 (42.2) GMC = geometric mean antibody concentration. SD = standard deviation. aGMC 4.09 (SD 2.6). bGMC 56.5 (SD 45.3). Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 577 tions can be made regarding PVF, SVF and efficacy of initial vaccination and revaccinaf tion programmes. Thus, PVF was estimated at 4.7% [(263 × 100 × 11)/(590 × 105)] and SVF at 27.1% [(263 × 64 × 100)/(590 × 105)] and total vaccination and revaccination eff ficacy was estimated at 87.3% [327 + (263 × 75)/(590 × 105)], so community immuf nity on 95% vaccination coverage would be 82.9% [(87.3 × 95)/100], where 590 = total no. participants in primary screening, 263 = no. seronegative in primary screening, 105 = no. seronegative after revaccination, 75 = no. responding to revaccination (IgM, IgG), 64 = no. seronegative responding with IgG response only (probably SVF), 11 = no. seronegative responding with IgM (probably PVF) and 327 = no. immune in primary screening. Discussion In this study we measured antifmeasles IgG antibody titres 15 to 25 years after 1 or 2 doses of measles vaccination to determine the proportion of seropositivity. Of the studf ied population 44.6% were seronegative, and there was no difference between those who had had 1 dose of vaccine and those who had had 2 doses (P = 0.16). Reinfection and disease seem to occur in individuals who have previously had a measles immunization and when the titre has fallen below a critical level [16,17]. Vaccine failure may occur either because the immune response never developed or because it waned over time [18,19]. Ref ported rates of primary vaccine failure vary widely (0–74%) [8]. Some studies docuf mented lower rates of seroconversion when the first immunization was given before 12 months of age [7,10,11]. Linnemann et al. found that 40% of children who had received 2 doses of measles vaccine (first dose before 12 months of age) were seronf egative, and 33% of the seronegative ones did not respond to a third dose of vaccine [10]. Studies on seroconversion rates in children after the first and second doses of measles vaccination at 9 and 15 months of age showed seroconversion rates of 77.6% and 69.9% after the first dose and 81.9% Table 2 Comparison of response to revaccination between seronegative and seroprotected individuals, Sari, Islamic Republic of Iran Variable IgG response IgM response GMC P-value Pre- Post- vaccination vaccination No. % No. % Mean SD Mean SD Seronegative (n = 105) 75 71.4 11 10.5 4.2 2.6 37.5 44.2 < 0.001 Seropositive (n = 39) 38 97.4 0 – 68.3 64.4 63.0 56.4 0.577 GMC = geometric mean antibody concentration. SD = standard deviation. Table 3 Comparison of response to revaccination in seronegative individuals according to number of doses of measles vaccine originally given Doses Total (n = 105) Responded No. % 2 82 54 65.9 1 23 21 91.3 578 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 and 90.3% after the second dose of measles vaccine [20,21]. The phenomenon of SVF due to wanf ing immunity may become apparent only after the passage of years. There is some indication that antibody titres fall to low or undetectable levels in populations with little refexposure. This problem may be greater in areas where immunization was introduced early and the initial antibody response was lower [19,12–26]. The findings of a study on longfterm persistence of antibody titres induced by vaccination and natural infecf tion suggest that vaccinefinduced measles antibodies decline with time, and fall below protective levels [19]. Results of a study from China indicated that 14 years after prif mary immunization, around 10% of those vaccinated had lost their protective levels, with antibody titres beginning to convert to negative between the third and sixth year after immunization [26]. In our study, after revaccination, 71.4% of 105 people who were seronegative showed IgG antibody response to revacf cination. However, no significant increase in antibody level was observed in the 39 seropositive individuals we examined. These results are comparable with the findings of other studies. Cohen et al. demonstrated that 58% of seronegative individuals 10–30 years of age developed measlesfspecific IgG titres that remained positive at least 1 year after revaccination, and the remainder either developed only a transient response (30%) or never developed a positive titre (12%) [27]. Poland et al. showed that 19.2% of people vaccinated were seronegative 4–11 years after the primary series of vacf cination and 18.5% of 130 seronegative individuals remained seronegative after revaccination [28]. In an investigation on a measles outbreak in a fully vaccinated school population, 18% of 239 sera (26% of those > 17 years) collected from students just before revaccination were negative for measles antibodies, and 7.9% of students were unprotected against illness with rash and 44.8% against measles without rash; 9 to 11 months after revaccination these rates were 3% and 45%, respectively [29]. Two other studies showed that people with prof tective levels of antibodies did not respond to revaccination anamnestically, but seronf egative individuals did, although perhaps temporarily [24,30]. To determine whether the seronegativity had been induced by PVF or SVF, the IgM antibody responses were assayed. Eleven of 105 (10.47%) seronegative individuals showed IgM antibody response after revacf cination, the results suggested that they probably were a result of PVF. The lack of an IgM response in other responders sugf gests the previous response to vaccination had been lost over time [7]. Recent successes in interrupting measles transmission in the World Health Organizaf tion Region of the Americas, most other countries in Europe and selected countries in other regions provide evidence for the feasibility of global eradication [31–35]. The World Health Organization has develf oped a global plan for accelerated measles control which calls for implementation of a strategy based on that used to successf fully control measles in the Pan American Health Organization (PAHO): a catchfup campaign providing measles vaccine to all children regardless of prior history of immunization or disease, followed by high levels of routine coverage with measles immunization (keepfup) and periodic followfup campaigns targeting all children 1–4 years of age [35]. To interrupt virus transmission in a comf munity, > 95% of a population must be protected. It seems impossible to reach a sufficiently high level of protection by rouf tine vaccination. In this study among adof lescents and young adults in Mazandaran 15–25 years after scheduled measles vaccif Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 579 nation, PVF and SVF were 4.7% and 27.1% respectively. After revaccination, 87.3% of those vaccinated developed immunity. Considering the vaccine coverage of 95% and efficacy of 87%, only 83% of individuf als would be immune, a rate which may not prevent measles outbreaks. Conclusion Based on the results of this and previous studf ies on measles epidemiology in Mazandaran and the rest of the country [14,15], and also taking into account experiences on measles control in other parts of the world [31–34], we advise the implementation of World Health Organizationfrecommended strategies to ref duce and interrupt indigenous measles virus transmission in the Islamic Republic of Iran. Mass vaccination with a keepfup phase and followfup cyclic campaigns would reduce the number of susceptible individuals and to prevent new outbreaks. References 1. Hersh BS et al. Review of regional mea- sles surveillance data in the Americas, 1996–99. Lancet, 2000, 355(9219):1043– 8. 2. Study of measles epidemiology in Iran during 1991 to 1998. Annual report of the Minister of Health and Medical Education. 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The regional strategy for measles elimination includes: high routine measles vaccination coverage (> 90%) among children aged 1 year; one-time, nationwide mass immunization campaign or catch- up campaign targeting all children; second opportunity for measles immunization either through periodic follow-up campaigns every 3–5 years targeting all children born since the last campaign or achieving > 95% routine coverage with a second dose of measles vaccine; and optimal case management of children with acute disease. Raising coverage with ≥ 1 dose of measles-containing vaccine is a key element of the elimination strategy. In 2005, coverage was 82%, leaving an estimated 2.8 million children who were not vaccinated. More than 90% of these children reside in Afghanistan, Iraq, Pakistan, Somalia, Sudan and Yemen. In 2005, Afghanistan, Iraq, Sudan and Yemen made considerable progress in increasing coverage, and it is anticipated that this will continue. Based on campaign results, surveillance data and routine EPI cover- age, reduction in measles mortality has been > 50% since 1999. Source: DCD Newsletter Issue no. 8, June 2006 )http://www.emro.who.int/pdf/dcdnewsletter8.pdf(. Estimated regional deaths due to measles, 1999–2004 Year Estimated deaths 1999 102 000 2000 105 000 2001 89 000 2002 59 000 2003 58 000 2004 46 000 582 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Coeliac disease in Sudanese children with clinical features suggestive of the disease I.M. Mohammed,1 Z.E.A. Karrar1 and S.H. El-Safi 2 1Department of Paediatrics and Child Health; 2Department of Medical Microbiology and Parasitology, Faculty of Medicine, University of Khartoum, Khartoum, Sudan (Correspondence to I.M. Mohamed: awa36ame@Yahoo.com). Received: 01/07/03; accepted: 29/07/04 ABSTRACT Our prospective hospital-based study examined frequency, clinical presentation and se- rological indicators of coeliac disease that correlated with intestinal biopsy among high-risk Sudanese children. From July 2001 to July 2002, 80 children aged 15 months–18 years presented with poor ap- petite, weight loss, pallor and proximal muscle wasting. We diagnosed coeliac disease in 18 (22.5%). Antigliadin antibodies (AGA-IgG, AGA-IgA or both) were high in 44; endomysial antibody retest was high in 30. Guardians of 12 children refused consent for biopsy. The other 18 were biopsied: 5 had total villous atrophy, 8 subtotal and 5 partial. All improved with gluten-free diet. Degree of villous atrophy did not correlate with diarrhoea duration or severity, anaemia severity or serological titres. 1 Termination of second and early third trimester pregnancy O¶>N¶=ÍÈ=bEÆ?ʾ>N¶=PÇ·MîÙ=›¸»ƒ=Ð>þC6±f{PØM;e>¯º Ínº>ÂaÀjU(ºÇ™=a=fº(b¶>]E=¬Éu(ĺ>N¢±e>{(bÉme=E¼ÉÂ=fEC  „=Í[qØ6Jjº±f{PØMÍɾǺ@ºÆÌÐ>«²¼É[ɯJEÁÇNU>F¶=½>®›Í[çÉQØ¢ÌeÆf[uÄ«qÇE¸»ƒ=Ð>þC›ͺßb^ PÇ·MîÙ=trimesterÏb¶(O¶>N¶=PÇ·MîÙ=ÍÈ=bEÆ?ʾ>N¶=258¸³n[EÀãÈgÇ[IÊ[Iض=L>[ɾaeÙ=¸º=ǃ=Àº ÀÈb¾Ø¦>J[iƶ=À[ºÍ[É·Fút=f[®?Ð>[ì¢CÆ?GViÁÆbEÆ?¤ºʶǪe>ìN®°ÉFìJ¶ÊÑ=Çn¢E2*Á>[²b[®Æ >þC¸nª¹b£ºÁÆaʶǪe>ìN®½=b^Ji=Ïb¶η¢?¸»ƒ=Ð>þCEÆe>ìN¯¶=¹>]aCEÍɶ>–Ý=Ìb™=Ƹ»ƒ=Ð GVi%ÍFj¿E¸n«¶=¹b£ºa=gb¯ª16.5!ÍFj¿EÌb™=Æ16.5GVj[¶=¤[ºʶÇ[ªe>[ìN®½b^àJi=Ƕ>绢Í¢>i %¸n[«¶=¹b[£º¨[·EO[ÉU10!Ìb[™=Æ14.2!Í¢>[i$Ç[¶>[šð>v[[È?Î[·¢?Á>[²>[»²t=f[[®Ù=Kºb^J[i= ÀÈb¾Ø¦>Jiƶ=E2ÍÉ·FÙ=%¸n«¶=¹b£º¨·EOÉU8!Ìb™=Æ11.5Í¢>i*$Í[¯Èf{ʶǪÌfìN®èbߣàI(´¶c¤ºÆ >[ÃJɶ>£ªh[Èh£IÀ[³•Æ(Ä[¿ºO[¶>N¶=PÇ[·MîÙ=Í[È=bEÆ?ʾ>[N¶=PÇ[·MîÙ=›¸»ƒ=Ð>þݬɶ>³J¶=ÌbÉÂgÆ;Ǻ@º ISÑ>J¾Ð>ì¢ÝGVj¶=½=b^Ji>EÀÈb¾Ø¦>JiÆ·¶ÍÉ·FÙ=t=f®Ù=Ä¿¢f«jàI>ºÄE>nE2*  Celiac disease in Sudanese children with clinical features suggestive of the ÍÈfÈfiXºØº¼ÃÉ·¢ÆbFIÀÈd¶=[ëɾ=aÇj¶=¹>«{Ù=Ïb¶ʾ>ìàF¶=Ð=b¶=%Íɳɿɷ²C$zf™>EÊUÇI ›>r¶=ÀjUÌbÉi(e=çf²¼ÉUf¶=bF¢ÀÈbE>£¶=ÀÈg(b»†Ϋìrº½>C  „=Í[qØ6ʾ>[ìàF¶=Ð=b[¶=¥Ç[®Æfà[[I=ßÇß[I(hí³If»[[¶=ÍçÈÇí«n[Jj™=ÍÉ®>FJ[i×=Í[i=eb¶=Åd[¹Æ>¿JIceliacÄ[I>É·Æ ÍÈfÈfj¶=%Í[ɳɿɷ²Ý=$h„=SÑ>[J¾¤[ºÍìE=f[[JºK[¾>²[¶=ÍÉQǶÆj[¶=ÄI=f[ëmֺƹ>[«{?Ïb[¶Í[ÈÇ£™=L>[¢ e>ìJ]×=Ê£«Ifº[ëɾ=aÇi*›Íi=eb¶=K¿çÉEb®Æ80E¼Âe>»¢?\Æ=f[J[IðØ«{15Æð=fÃm18Ìf[J«¶=›ð>º>¢ gǓE>º+ÇɶÇÈ2001gǓÆ+ÇɶÇÈ2002¹=h[ÂÆHÇVn[¶=ÆÁgǶ=Á=b¯ªÆÍÉÃn¶=s¯¾ÀºÁǾ>£È=Ǿ>²¼Ã¾? Í[ɾ=b¶=LØv[£¶=*s^[mb[®ÆÏb[¶ʾ>[ìàF¶=Ð=b[¶=ÁÇNU>[F¶=18ðØ[«{%22.5*$!ÀÈa>[É·§¶=a=b[u?K[¾>²Æ  %ÍÉ¢>¿™=L>¿É¶ÇEÇ·§¶=ÀºAÆ?Gð>£º>»ÃÉ·²ÀºÆ?$Ïb[¶Í[£«Ifº44e>[FJ]=Ìa>[¢CSÑ>[J¾K[¾>²>[»²(ðØ[«{ Ïb¶Í£«IfºÊ·v£¶=¬É·¶=b»¦a=bu?30ðØ«{*Ð>ɶÆ?xªeb®Æ12=f[QCÎ[·¢Í[¯ª=Ǚ=ðØ[«{›(L>[¢h„=Ð Ïb¶L>¢h„=KÈfQ?U18Ïb¶ÀçÉFIOÉU(ðØ«{5Ïb[¶Æ(L>E>¦h¶=›¸º>²eÇ»uaÇQƼÿº8¼Ã¿[º Ïb¶Æ¸º>²¦eÇ»uaÇQÆ5L>E>¦h¶=›ÊÑhQeÇ»uaÇQƼÿº*ÀºÇ·ÊÑ=d¦½>Ÿ¿Eð>£É–=Ç¿j€b®Æ ¹>ÃiÝ=Ìb’L>E>¦h¶=eÇ»uÍQea°·£JIÆ(IÇ·§¶=ÍÉQǶÆj¶=L=e>É£¶>EÆ?½b¶=f¯ªÌbnEÆ?ÄIbnEÆ?*  La maladie cœliaque chez des enfants soudanais présentant des signes cliniques évocateurs de la maladie RÉSUMÉ Notre étude hospitalière prospective a examiné la fréquence, le tableau clinique et les indicateurs sérologiques de la maladie cœliaque qui sont en corrélation avec la biopsie intestinale chez des enfants soudanais à haut risque. De juillet 2001 à juillet 2002, 80 enfants âgés de 15 mois à 18 ans ont consulté pour manque d’appétit, perte de poids, pâleur et amyotrophie proximale. Nous avons diagnostiqué une maladie cœliaque chez 18 enfants (22,5 %). Les anticorps anti-gliadines (AAG- IgG, AAG-IgA ou les deux) étaient élevés chez 44 enfants ; les anticorps anti-endomysium recherchés par le test de confirmation étaient élevés chez 30 enfants. Les tuteurs de 12 enfants ont refusé de donner leur consentement pour la biopsie. Les 18 autres enfants ont subi une biopsie : 5 avaient une atrophie villositaire totale, 8 subtotale et 5 partielle. Tous ont connu une amélioration avec un régime sans gluten. Il n’y avait pas de corrélation entre le degré d’atrophie villositaire et la durée ou la gravité de la diarrhée, la sévérité de l’anémie ou les titres sérologiques. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 583 Introduction Coeliac disease has been thought to affect people of European ancestry more often than other ethnic groups [1]. Recent studies, however, have revealed increasing global prevalence [2]. The disease was first reported in Sudan in 1978 when 7 children were diagnosed [3]. Since then, many adult and paediatric cases have also been reported. The disease may in fact be under-diagnosed because of more prevalent conditions such as malnutrition, diarrhoeal diseases and intestinal parasitic infections. In Sudan diagnosis of coeliac disease has depended upon histological changes of the small bowel biopsy and improvement after withdrawal of gluten from the diet. Serological tests, although non-invasive and reliable, are not yet used routinely [4]. Our study aimed to determine the inci- dence of coeliac disease in Sudanese chil- dren who presented with clinical features suggestive of the disease by using serologi- cal tests as the initial screening tools. Our study also aimed to identify the sociodemo- graphic and clinical presentation of children with the disease and to correlate serological titres and degree of villous atrophy. Methods Our prospective hospital-based study ran from July 2001 to July 2002 in the main paediatric hospitals in Khartoum State (Khartoum Children’s Emergency Hospital, Omdurman Children’s Emergency Hospi- tal, Ahmed Gasim Teaching Hospital and Khartoum North Teaching Hospital). The study population included 80 children aged 15 months to 18 years who presented with 2 or more of the following: chronic diarrhoea, growth retardation, unexplained iron or folate deficiency anaemia or family history of coeliac disease. Children were excluded if they had systemic illnesses or bloody di- arrhoea; were on steroids or on gluten-free diets; or had social and nutritional histories and clinical examinations suggestive of pri- mary protein–energy malnutrition. Verbal consent was obtained from the parents or caregivers. The data were collected with a pre- designed questionnaire. Socioeconomic status was determined by assessing income, literacy, number of family members and lifestyle conditions such as refrigerator and television ownership or internet use. Each child had a complete clinical as- sessment with emphasis on anthropometric measurements, signs of nutritional deficien- cies and signs suggestive of coeliac disease, such as proximal muscle wasting, abdominal distension, aphthous ulcers or skin lesions of dermatitis herpetiformis. Each child had a complete blood count, total serum protein, serum albumin and stool examination for ova and parasites. Serological tests, or antigliadin antibod- ies (AGA) tests, i.e. both AGA-IgA and AGA-IgG, were done for all 80 children using enzyme-linked immunosorbent assay technique (ELISA, binding site MK 035, MK 036) [5]. Those with positive AGA tests were retested for endomysial antibod- ies (EMA) with the indirect immunofluo- rescence technique; monkey oesophagus was used as a substrate (binding site FK 208) [6]. An upper gastrointestinal endoscopy was performed for those with positive AGA and EMA. A second portion duodenal bi- opsy was taken and the biopsy specimens were fixed in formalin and stained with hae- matoxylin and eosin. Histological changes specific of coeliac disease were graded as per Levi et al. [7]: partial villous atrophy was defined as mild change, subtotal vil- lous atrophy was moderate change and total villous atrophy was severe change with flat mucosa. 584 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Data were analysed with SPSS, version 10. Chi-squared test was used to determine 95% significance level. We diagnosed coeliac disease if a child had 2 or more positive serological markers with biopsy-verified coeliac disease and showed clinical improvement when fol- lowing a gluten-free diet as per the revised criteria for diagnosis of coeliac disease [8]. Haematinics and vitamins were given as needed. Results Diagnosis The study included 80 children (46 boys and 34 girls), of whom 25 (31.3%) had high titres of both AGA-IgA and AGA-IgG. EMA retest was high for 24 of those 25 (96.0%). The parents or caretakers of 11 of these 24 children were among the 12 guard- ians who refused consent for biopsy. Of the 13 children from this group who underwent biopsy, 4 had total, 6 subtotal and 3 partial villous atrophy. Three (3.8%) in the study sample had high titre of AGA-IgA, but normal AGA- IgG. EMA titre was high for 2 of these children (66.7%): 1 refused endoscopy and the other had subtotal villous atrophy. Sixteen children (20.0%) had positive AGA-IgG, but negative AGA-IgA test. EMA titre was high for 4 (25.0%): 1 had total villous atrophy, 1 had subtotal villous atrophy and the remaining 2 had partial villous atrophy. Thirty-six of the study population (45.0%) were not diagnosed with coeliac disease because they had normal AGA-IgA and AGA-IgG titres. Twenty-six (32.5%) of the study popula- tion probably had the disease but were not confirmed by biopsy. Twelve (46.1%) had high titre of at least 2 serological markers but their caretakers refused to give consent for the biopsy. Five of the 12 responded to gluten-free diet, 1 improved spontaneously after 4 months, and the remaining 6 did not come for follow-up. Fourteen children had only AGA-IgG positive with negative AGA-IgA and EMA tests, so they were either not coeliac or had coeliac disease associated with IgA defi- ciency. Two of these followed gluten-free diets, but neither showed improvement. The remaining 12 were not available for follow-up. Eighteen (22.5%) of the study popula- tion had positive AGA and EMA test posi- tives and confirmatory biopsies. When they were put on a restricted gluten-free diet all showed satisfactory clinical improvement; thus, they were confirmed as cases of coe- liac disease. Sociodemographic characteristics No coeliac child presented during infancy. Of the children diagnosed with the disease, 7 (38.9%) were aged 1–4 years, 5 (27.8%) were aged 5–9 years, 2 (11.1%) were aged 10–14 years and 4 (22.2%) were aged 15 years or older. The mean age at onset of symptoms was 6 years and the mean age at diagnosis was 10 years. The female to male ratio was 1.3:1. Of the children with the disease, 15 (83.4%) were from north and central Su- dan and mainly of Arab ethnic groups, 2 (11.1%) had Egyptian and Turkish ancestry, and only 1 (5.6%) was from southern Sudan from a tribe of pure African ethnicity. Most with the disease were of moderate socioeco- nomic class (n = 11 or 61.1%), 6 (33.3%) were of low socioeconomic class, and only 1 child was of high socioeconomic class. Among the parents, 9 couples (50%) were first-degree cousins, 4 were second-degree cousins (22.2%) and 5 (27.8%) were not re- lated. There was a family history of coeliac disease for 4 children. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 585 Clinical features Nine (50%) children who were diagnosed with the disease presented with chronic diarrhoea that was persistent for 6 of the children and intermittent for 3. The fre- quency was 3–6 motions/day for 6 children and more than 6 motions/day for 3 children. The parents of 3 children described the stool as bulky, pale and offensive. Other significant symptoms were poor appetite (n = 14, 77.8%), abdominal distension (n = 12, 66.7%), vomiting (n = 11, 61.1%) and abdominal pain (n = 7, 38.9%). Pallor was the most common clinical observation (n = 16 patients, 88.9%); 13 children exhibited signs of iron deficiency anaemia. Proximal muscle wasting, abdominal distension and signs of vitamin B2 (riboflavin) deficiency were common. Fourteen (77.8%) cases had weight lower than the third centile for age, and 11 (61.1%) had height lower than the third cen- tile for age. Weight-for-height was lower than the third centile for 10 (55.6%). Mid upper arm circumference was less than 12.5 cm for 5 of the 7 coeliac children aged 1–4 years. Six (33.3%) coeliac children had head circumference lower than the third centile for age. Investigations One (5.6%) coeliac child had haemoglobin (Hb) less than 5 g/dL and 9 (50.0%) had Hb at 5–9 g/dL. The commonest type of anae- mia was iron deficiency (n = 11, 61.1%), followed by combined deficiency anaemia (n = 6, 33.3%); only 1 patient (5.6%) had folate deficiency anaemia. Serum albumin level was low for 5 children with the disease (27.8%). Stool examination for ova and parasites was negative for all 18 children with the disease. Degree of villous atrophy Table 1 shows that 6 children had diarrhoea for less than 5 years. Of these, 4 had partial villous atrophy and 2 had subtotal villous atrophy. Three patients had duration of more than 5 years even though 3 had subto- tal villous atrophy. This distribution was of no statistical significance (P-value = 0.53). Table 1 also shows that 1 patient who presented with diarrhoea of more than 6 motions/day had partial villous atrophy. Of those who had subtotal atrophy, 3 had diarrhoea with 3–6 motions/day and 2 had severe diarrhoea with more than 6 mo- tions/day. It is worth noting that all 5 chil- dren who displayed total villous atrophy presented without diarrhoea, although this correlation was not significant statistically (P-value = 0.8). Table 2 shows that 2 of the 5 cases with partial villous atrophy had Hb levels below 9 g/dL, 4 of those who had subtotal villous atrophy had Hb levels at 9–12 g/dL and the Table 1 Duration and severity of diarrhoea by degree of villous atrophy of 18 coeliac cases Degree Duration (years) Severity (motions/day) Total of villous No < 0.5 0.5–2 2–5 5–10 > 10 No 3–6 > 6 atrophy diarrhoea diarrhoea Partial 1 2 2 0 0 0 1 3 1 5 Subtotal 3 0 2 0 1 2 3 3 2 8 Total 5 0 0 0 0 0 5 0 0 5 Yates corrected χ2 = 0.39 Yates corrected χ2 = 0.06 P-value = 0.53 P-value = 0.8 586 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 1 child whose anaemia was severe (Hb < 5 g/dL) had subtotal villous atrophy. This correlation was not significant statistically (P-value = 0.76). Villous atrophy and serological titre Table 3 shows that serological titres for AGA-IgA, AGA-IgG and EMA tests were graded into normal, moderately high, high and very high titre and, when correlated with the degree of villous atrophy (partial, subtotal and total), were not statistically significant (P-values = 0.29, 0.35 and 0.54 respectively). Discussion Our study was the first in Sudan in which se- rological tests were used as a screening tool to diagnose coeliac disease. We diagnosed the disease with a high frequency (22.5%) in our high-risk group. Our frequency was higher than in a similar study of Indian children (16.6%) or than among children from north-eastern Libyan Arab Jamarihiya (31.7%) [9,10]. In a large sample of unse- lected Saharan children in western Algeria, the prevalence of EMA positivity was 5.6% [11]. The average annual incidence in Ku- wait among children was 1:3000 live births and among Jordanian children, 1:2800 live births [12,13]. The prevalence of coeliac disease in Israel in the general population was 1:157 [14]. In Saudi Arabia, 10 of 48 children (21.0%) who presented with chronic diarrhoea over a 5-year period were diagnosed as coeliac patients [15]. The high frequency in our study could be attributed to the genetic background of the Sudanese population, which is a mixture of different ethnic groups, but is primarily Arab and African. Also, Sudanese nutritional habits have changed as cereal-containing meals are now offered early in infancy. Consump- tion of wheat foodstuffs was not, however, a risk factor for coeliac disease occurrence in Burkina Faso [16]. The 4-year delay in diagnosis of the dis- ease in our study might have resulted from the distracting influence of more prevalent conditions in the country that clinically resemble coeliac disease, a lack of aware- ness of doctors about the occurrence of the disease in Sudan, and the unavailability of serological screening tests. Coeliac disease affects females more often than males in ratios ranging from 1.3–3:1 [10,11]. In our study the ratio was 1.3:1. Our study partially supports the hy- pothesis that the disease affects people of middle and high socioeconomic classes more than those of low social class [17]. In our study 61.1% of patients were of moderate socioeconomic status and 33.3% of low socioeconomic status, but only 5.6% were of high socioeconomic class. Sudan is Table 2 Severity of anaemia by degree of villous atrophy of 18 coeliac cases Degree of Severity of anaemia Total villous atrophy < 5 g/dL 5–9 g/dL 9–12 g/dL > 12 g/dL Partial villous atrophy 0 2 2 1 5 Subtotal villous atrophy 1 3 4 0 8 Total villous atrophy 1 4 1 0 5 Total 1 9 7 1 18 Yates corrected χ2 = 0.09; P-value = 0.76. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 587 a developing country in which the low and the middle classes are more prevalent than the higher social class. Nine coeliac children presented with chronic diarrhoea, i.e. classic presentation, whereas the other 9 had atypical presenta- tion. It has been reported that 50% of newly diagnosed patients have no gastrointestinal problems [18]. Signs of vitamin A deficiency and skin lesions of dermatitis herpetiformis were not observed for any child. This could have been due to our small sample size. In our study, 1 child with type 1 dia- betes mellitus was diagnosed with coeliac disease. The association between type 1 diabetes mellitus and coeliac disease has been well established [19]. We also diag- nosed a child who had features of Down syndrome with probable coeliac disease but for whom biopsy was refused; this as- sociation has also been well documented [20]. We diagnosed identical twin boys with probable coeliac disease and they showed remarkable improvement with a gluten-free diet. The concordance rate for identical twins is 70%–100% [18,21]. An 8-year- old boy presented with signs of myopathy in addition to his coeliac-like condition. He was diagnosed with probable coeliac disease and improved after gluten-free diet. This was similar to a report of a case of coeliac disease associated with rickets and myopathy that was attributed to calcium and vitamin D malabsorption [22]. Hb levels ranged from 5 to 12 g/dL in 16 patients and only 1 child had severe anaemia. Severe anaemia is rather uncom- mon in coeliac disease and should raise the suspicion of a malignant complication [1]. Low albumin levels indicated a severe form of the disease for 5 coeliac patients [18]. AGA-IgG is very sensitive but less spe- cific and AGA-IgA is less sensitive but Ta bl e 3 A nt ig lia di n- Ig A , a nt ig lia di n- Ig G a nd e nd om ys ia l a nt ib od ie s tit re in re la tio n to d eg re e of v ill ou s at ro ph y in 1 8 co el ia c ca se s D eg re e of AG A -Ig A ti tr e AG A -Ig G ti tr e EM A ti tr e To ta l vi llo us N or m al M od er at e H ig h Ve ry N or m al M od er at e H ig h Ve ry N or m al M od er at e H ig h Ve ry at ro ph y hi gh hi gh hi gh Pa rt ia l 2 2 1 0 0 3 2 0 0 3 2 0 5 Su bt ot al 1 3 3 1 1 1 6 0 0 4 3 1 8 To ta l 1 0 3 1 0 1 3 1 0 0 4 1 5 Ya te s co rr ec te d χ2 = 1 .1 1 Ya te s co rr ec te d χ2 = 0 .8 7 Ya te s co rr ec te d χ2 = 0 .3 6 P- va lu e = 0. 29 P- va lu e = 0. 35 P- va lu e = 0. 54 588 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 more specific. Their use in combination results in a high detection rate [23]. This was borne out by our study as 16 children were IgG positive and IgA negative; when EMA was retested, it was positive for only 4 (25.0%) of them. Furthermore, 25 children had both positive AGA-IgA and AGA-IgG and EMA retest was positive for 24 (96.0%) of them. 28 children had positive AGA-IgA, either alone or in combination with positive AGA-IgG, and 26 (92.8%) of them had positive EMA test. Three children had posi- tive AGA-IgA and negative AGA-IgG; 2 (66.6%) of them had positive EMA tests. EMA test has been the single most pre- dictive test for coeliac disease [6,24,25]. We found that all children with positive EMA test displayed mucosal changes char- acteristic of the disease. We expected that duration and severity of diarrhoea and severity of anaemia would correlate with degree of villous atrophy and that serological titres would correlate with degree of villous atrophy. We found no correlation, but these discrepancies could be attributed to our small sample size. Conclusions We confirmed that coeliac disease is a cause of malabsorption in Sudanese children. Its frequency in a selected high-risk group was 22.5%. Females were affected more often than males with a ratio 1.3:1. Ages between onset of symptoms and diagnosis were delayed. Children from Arabic tribes and from middle socioeconomic class were affected more often than others. Coeliac children presented with or without frank gastrointestinal symptoms. Pallor and se- vere weight loss were the predominant signs. The commonest type of anaemia was iron deficiency. AGA-IgG was very sensitive but less specific, AGA-IgA was less sensitive but more specific, and EMA test was highly specific. Our study revealed no correlation be- tween severity, duration of diarrhoea and severity of anaemia with degree of villous atrophy. There was no correlation between the serological titres and the degree of vil- lous atrophy. 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An analysis of 20 cases emphasiz- ing atypical presentations. South Africa medical journal, 1981, 59(18):628–32. 18. Ciclitira P. Coeliac disease. In: Yamada T et al., eds. Textbook of gastroenterology, 3rd ed. Philadelphia, Lippincott, Williams and Wilkins, 1999:1660–76. 19. Cronin CC, Shanahan F. Insulin depend- ent diabetes mellitus and coeliac disease. Lancet, 1997, 349(9058):1096–7. 20. Gale L et al. Down’s syndrome is strongly associated with coeliac disease. Gut, 1997, 40(4):492–6. 21. Ulshen M. Malabsorbtive disorders. In: Behrman RE, Kliegman R, Arvin A, eds. Nelson textbook of pediatrics, 15th ed. Philadelphia, WB Saunders, 2000:1159– 71. 22. Cimaz R, Bazzi P, Prelle A. Myopathy as- sociated with rickets and celiac disease. Acta paediatrica, 2000, 89:496–7. 23. Misra S, Ament ME. Diagnosis of coeliac sprue in 1994. Gastroenterology clinics of North America, 1995, 24(1):133–43. 24. Feighery C. Coeliac disease. British medi- cal journal, 1999, 319(7204):236–9. 25. Lerner A, Kumar V, Iancu TC. Immuno- logical diagnosis of childhood coeliac disease: comparison between antigliadin, antireticulin and antiendomysial antibod- ies. Clinical and experimental immunol- ogy, 1994, 95:78–82. 590 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Diabetes knowledge, beliefs and practices among people with diabetes attending a university hospital in Karachi, Pakistan G. Rafique,1 S.I. Azam1 and F. White2 1Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan (Correspondence to G. Rafique: ghazala.rafique@aku.edu). 2Department of Community Health and Epidemiology, Dalhousie University, Canada. Received: 23/05/04; accepted: 20/02/05 ABSTRACT A structured questionnaire on knowledge, beliefs and practices regarding diabetes was administered to 199 persons with diabetes (92.5% type 2) attending the Aga Khan University Hospital, Karachi. Mean age [standard deviation (SD)] was 53 (11) years. Mean duration of diabetes (SD) was 8 (7) years in men and 9 (6) years in women. Men had a significantly better knowledge score than women (P = 0.02); there was no significant difference in the beliefs and practices scores. Scores were classed as good (> 60%) in only 13.6% of participants for knowledge, 17.6% for beliefs and 11.2% for practices. About 38% of the participants had received education on diabetes care. 7 Diabetes knowledge, beliefs and practices among persons with diabetes Áǂ>£ÈÀÈd¶=[Èfõ³j¶=Ïb¶L>ie>»™=ÆL=b¯J£™=Æ­e>£™=  Á>Jj²>E(ÊnI=f²›ÍÉ£º>‚=L>É«nJj™=bU?› >F®CbÉi(°ÉªeͶ=h¦KÈ=Ɛ·³¾=fª(½=h¢¹  „=Í[qØ6Î[·¢¥ëgÆÆ(Ëfõ³j[¶>EÍ[q>„=L>ie>»™=ÆL=b¯J£™=Æ­e>£™=¹ÇUÊRÿºÁ>ÉFJi=çbå¢î?199À[º Á>²Àš[Èf³j¶=92.5!Ên[I=f²›Á>[]>¦?Í[£º>QΫnJjº›Áǂ>£ÈÆËf³j·¶ʾ>N¶=œ»¿¶=Àº¼Ã¿º* ¼ÊìiǶ=f»£¶=Á>²b®Æ35‰>Eð>º>¢Åe=b¯ºËe>É£º­=f11Ëf³j[¶>EÍE>[qÝ=Ìf[[Jªœ[iÇJºÁ>²Æ(Í¿i ¹>Qf¶=Ïb¶8Åe=b[¯ºËe>É£º­=f‰>EL=Ç¿i7Ð>j[¿¶=Ïb[¶Ëf³j[¶>EÍE>[qÝ=Ìf[[JªÆ(L=Ç¿[i9L=Ç¿[i Åe=b¯ºËe>É£º­=f‰>E6L=Ç¿[i*Ð>j[¿¶=g=f[U?À[º­e>[£»·¶ÍFj[¿¶>EÎ[·¢?¹>[Qf¶=g=f[U?Á?Xv[I=b[®Æ %0.029P$Æ(L>ie>»™=ÆL=b¯J£™=g=fU?›žÇV·º±e>ªµ>¿ÂÀ³È*Ìb[ÉQ‘Cg=fUÙ=K«ë¿àqb®Æ%f[N²? À[º60$!Ïb[¶13.6!Ïb[¶Æ­e>[£»·¶ÍFj[¿¶>Eœ[¯ª²e>n[™=À[º17.6!ÍFj[¿¶>Eœ[¯ª²e>n[™=À[º Ïb¶Æ(L=b¯J£»·¶11.2!L>ie>»»·¶ÍFj¿¶>Eœ¯ª²e>n™=Àº*Îõ¯ ·Ib®Æ38!j™=Àº¹Ç[U¬É¯NJ¶=»Â> Ëf³j¶=›ÍÈ>¢f¶=*  Connaissances, croyances et pratiques concernant le diabète chez les personnes diabétiques consultant dans un hôpital universitaire à Karachi (Pakistan) RÉSUMÉ Un questionnaire structuré sur les connaissances, croyances et pratiques concernant le diabète a été administré à 199 personnes diabétiques (92,5 % de type 2) consultant à l’hôpital universitaire Aga Khan de Karachi. L’âge moyen (écart-type [E.T.]) était de 53 ans (11). La durée moyenne du diabète (E.T.) était de 8 ans (7) chez les hommes et de 9 ans (6) chez les femmes. Les hommes avaient un score pour les connaissances significativement meilleur que les femmes (p = 0,02) ; il n’y avait pas de différence significative dans les scores pour les croyances et les pratiques. Les scores étaient classés comme bons (> 60 %) chez seulement 13,6 % des participants pour ce qui concerne les connaissances, 17,6 % pour les croyances et 11,2 % pour les pratiques. Environ 38 % des participants avaient bénéficié d’une éduca- tion en matière de soins du diabète. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 591 Introduction With an overall prevalence of over 10% among the adult population of Pakistan, type 2 diabetes has become a serious health problem for the nation [1,2]. Currently an estimated 6.5 million people aged 25 years and above are affected with diabetes in the country and, if no intervention strategies are adopted, the World Health Organization forecasts that the number will rise to 14.5 million by the year 2025 [3]. It is well established that poor control of diabetes results in markedly increased risk for heart disease, stroke, blindness, kidney failure, leg amputation and early death [4,5]. On the other hand, scientific evidence has clearly demonstrated that most diabetes-related pathologies are potentially avoidable if optimum metabolic control is achieved [6,7]. The management of diabe- tes is, however, dependent to a great extent on the affected person’s own abilities to carry out self-care in their daily lives, and patient education is considered an essential component of achieving this objective [8]. There is further evidence that people affect- ed with the disease often have inadequate knowledge about the nature of diabetes, its risk factors and associated complications [9–11], and that this lack of awareness may be the underlying factor affecting attitudes and practices towards its care [12]. Diabetes education, with consequent improvements in knowledge, attitudes and skills, leads to better control of the disease, and is widely accepted to be an integral part of comprehensive diabetes care [13–15]. At the same time, it is important to note that if recommendations are to be effective, they must be sensitive to and relevant to the culture of the people expected to carry them out [16,17]. Despite the high and increasing preva- lence and the evidence that better knowledge is associated with better outcomes, Pakistan currently lacks structured education and information programmes regarding diabetes both for people at risk of the disease and for people suffering from it. So far, little has been done to assess the current knowledge levels and behaviours of people with diabe- tes, or to evaluate their educational needs. Education programmes are likely to be more effective if these are known. This study attempted to assess disease- related knowledge, beliefs and practices among people with diabetes. As well as providing a baseline for evaluation, the data would be of use in developing an ap- propriate and culturally acceptable diabetes education programme. Methods The study was conducted in the outpatient clinics of a single centre, the Aga Khan University Hospital, Karachi, from Decem- ber 2001 to March 2002. The hospital is a tertiary care hospital offering quality care to outpatients and inpatients of all socio- economic classes. Patients were recruited from the consultant clinics, where the phy- sicians are mainly specialized consultants and endocrinologists, and the community health centre where family physicians offer services at minimal charges. The sample size was calculated using a 2-sided test of significance, an alpha level of 5% and 80% power to detect a bound on error for knowledge mean score of 2, with an estimated standard deviation of 10. The required sample size was calculated as 197. The study group comprised 199 adults with diabetes aged ≥ 25 years attending the community health centre and consultant clinics of the Aga Khan University Hospital. The participants were selected sequentially based on the appointment registers, and 592 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 were of both sexes. The number of patients attending the 2 locations differed, normally 10–15 per day attended the consultant clinic and 4–5 per day attended the community health centre during the study period, con- sequently, more patients were recruited from the consultant clinic. Citing lack of time, 8% of those we approached refused to participate. Participants were interviewed using a structured questionnaire to collect informa- tion on knowledge, beliefs and practices concerning their disease and management, in addition to demographic data. A structured questionnaire was compiled adapting questions from published studies and adding questions that were considered of value based on local beliefs and clinical observations [18,19]. The questionnaire covered knowledge regarding symptoms of diabetes, optimal control levels, hypogly- caemia, recognition of microvascular and macrovascular complications, diet and ex- ercise; beliefs about diabetes and use of insulin and nutrition related beliefs; and practices regarding diet, medication adher- ence and self-monitoring. Taking into con- sideration local myths, specific questions on belief were added. Data were collected by 2 trained in- terviewers, medical graduates working as research officers in the department. They visited each clinic 2 days per week. The questionnaire was pilot tested on 10 patients from the same clinics to assess the suitabil- ity of content, clarity and flow of questions. A scoring system was developed for each component: each correct answer was given a score of 1. Three categories were defined on the basis of the score obtained by each participant: poor (< 40% of the total score); acceptable (41%–60% of the total score); and good (> 60% of the total score). Data were analysed using SPSS, version 10. Chi-squared, independent samples t-test and 1-way analysis of variance were used to compare the groups. Results Descriptive statistics A total of 199 people (95 men, 104 women) participated in the study (Table 1). The mean age [standard deviation (SD)] of the participants was 53.3 (11.2) years with no significant difference between the sexes. The overall illiteracy rate was 14.6%; more women (18.3%) than men (10.5%) were illiterate (P = 0.008). Furthermore, it was noted that for all education levels, women had a lower overall percentage than men. The mean duration (SD) of diabetes was 8.9 (7.3) years among men and 8.8 (6.2) years in women. Of the 92.5% of participants who had type 2 diabetes, 11.4% were on diet alone, 76.0% on oral hypoglycaemic drugs and 12.5% on insulin. Approximately 38% of participants re- ported receiving some diabetes education at the clinics. We found 42.2% of the participants could not give a single symptom for hypo- glycaemia and only 22.3% could name ≥ 2 symptoms; nevertheless, 76.9% knew that the home treatment for hypoglycaemia is to take any sugared drink or food. Only 21.1% of the participants were aware of the target control levels for fasting blood sugar and 8.7% knew the target for the 2 hours post- prandial blood sugar level. Around 18% of men and 27% of women did not know that diabetes can affect other organs of the body and were unable to name a single complica- tion associated with diabetes. Some important local beliefs about nutrition and insulin use in diabetes are detailed in Table 4: 80.4% of participants believed that a person with diabetes should not eat root vegetables, while around 1 in Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 593 Even though 94.0% of the participants tested blood glucose levels to check their metabolic control, only 73.4% maintained records. Wide variations occurred in the frequency of testing, ranging from daily to more than a year (daily 7.0%; weekly 17.6%; monthly 39.2%; 3-monthly 11.6%). Only 4% of respondents were also being assessed for HbA1c. Overall, 29.6% of par- ticipants were self-monitoring their blood glucose levels, and 58.0% of those were on insulin. Although 92.3% of the participants on insulin were using a combination of regular and intermediate-acting insulin, no more than 57.8% of them administered their in- sulin injections half an hour before meals whereas others were injecting either 1 hour prior to the meal or immediately before or after meals. Almost 73.6% were injecting insulin at an angle of 90 degrees; only 47.2% were injecting subcutaneously while others were injecting intradermally or intra- muscularly. Even though 58.8% said that exercise should be done ≥ 4 times per week, only 29.0% were actually doing so. Knowledge, beliefs and practices scores The results of the diabetes knowledge, be- liefs and practice scores are given in Ta- ble 2. The mean score for knowledge was significantly lower in females, and more females had poor knowledge compared to males (P = 0.02). No significant difference was, however, evident in the mean scores for beliefs and practices. Table 3 gives the mean knowledge, be- liefs and practices scores. The mean knowl- edge scores decreased with increasing age (F = 4.62; P = 0.001). Significantly higher knowledge scores were found in males (F = 4.748; P = 0.03), those with a higher edu- cation level (F = 34.40; P < 0.001), white- collar workers (F = 8.055; P < 0.001), those Table 1 Characteristics of participants Variable No. % Age (years) 25–39 22 11.1 40–49 55 27.6 50–59 64 32.2 60–69 41 20.6 70+ 17 8.5 Sex Male 95 47.7 Female 104 52.3 Education level Illiterate 29 14.6 Primary 30 15.1 Secondary 62 31.2 Intermediate 26 13.1 University graduate & above 52 26.1 Occupationa Housewife 98 49.2 Blue-collar worker 17 8.5 White-collar worker 34 17.1 Self-employed 24 12.1 Retired 26 13.1 Duration of diabetes (years) < 1 20 10.1 1–5 72 36.2 6–15 88 44.2 > 15 19 9.5 Type of diabetes Type 2 184 92.5 Type 1 15 7.5 Type of treatment Diet 21 10.6 Oral hypoglycaemic drugs 140 70.4 Insulin 38 19.1 Place of treatment Consulting clinic 110 55.3 Community health centre 89 44.7 aBlue-collar workers included shopkeepers, drivers and labourers; white-collar workers included office workers and civil servants; self-employed was mostly businessmen. 4 believed that regular use of bitter gourd (Momordica charantia), a vegetable com- monly known as karela, can cure diabetes. 594 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 with type 1 diabetes (F = 12.30; P = 0.001), people on insulin treatment (F = 8.83; P < 0.001) and people attending the consult- ant clinics (F = 6.30; P = 0.013). The mean beliefs scores also decreased significantly with increasing age (F = 3.43; P = 0.010), while with increasing educa- tional levels the scores increased (illiter- ate to graduate and above) (F = 23.40; P < 0.001). The scores were also higher in males (F = 4.16; P < 0.04), people with white-collar jobs (F = 5.87; P < 0.001) and those with type 1 diabetes (F = 4.01; P < 0.04). People who were on insulin had higher mean beliefs scores compared to those who were on oral hypoglycaemic drugs or diet alone (F = 5.58; P = 0.004). The mean practices scores were sig- nificantly higher with longer duration of diabetes (F = 2.72; P = 0.04), for those on insulin therapy (F = 18.49; P < 0.001) and in people attending the specialist consulting clinics (F = 14.68; P < 0.001). Table 2 Distribution of participants according to their diabetes knowledge, beliefs and practices scores Variable Males Females Total (n = 95) (n = 104) (n = 199) No. No. No. (%) Knowledge score Poor 37 59 96 48.2 Acceptable 45 31 76 38.2 Good 13 14 27 13.6 Beliefs score Poor 46 62 108 54.3 Acceptable 32 24 56 28.1 Good 17 18 35 17.6 Practices score Poor 54 56 110 55.3 Acceptable 33 34 67 33.7 Good 8 14 22 11.0 Poor: < 40% of the maximum possible score (knowledge 59; beliefs 15; practices 14). Acceptable: 41%–60% of the maximum possible score. Good: > 60% of the maximum possible score. Discussion Very limited literature exists on the knowl- edge, beliefs and practices of people with diabetes in Pakistan. A study looking only at knowledge among diabetes patients in Karachi found significant deficits in the study population [9]. The results of our study suggest that not only knowledge, but also the beliefs and practices of diabetes patients were less than satisfactory. It is disturbing to note that the vast ma- jority of participants were unaware of the ideal blood glucose control target levels and many were unable to name a single complication associated with diabetes. This lack of information and understanding of potential risks is worrying, and indicates participants’ obliviousness to the gravity of their condition. This may be partially explained by the fact that diabetes, being almost asymptomatic, does not interfere with their daily routine and patients gener- ally tend to ignore the condition until the disease is advanced [20]. Health beliefs are often affected by folk- lore and hearsay [16,21]. Our study has also highlighted certain beliefs and misconcep- tions prevalent among people with diabetes that are based on such belief systems. Most common among these are the nutrition- related beliefs, thereby identifying the need to provide education and counselling re- garding diet. For example, there is a strong belief that a person with diabetes should not eat root vegetables as they are generally considered to be sweet. Another common perception in Pakistan is that there is no restriction on the amount of bread taken if it is prepared from gram flour (chickpea flour), indicating the need for understanding the concept of total calorie requirements. The use of traditional remedies is preva- lent in many cultures [16,22,23]. In the Indian subcontinent, traditional medicines Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 595 Table 3 Mean diabetes knowledge, beliefs and practices scores for different characteristics of the participants Characteristic Scorea Knowledge Beliefs Practices Mean (SD) Mean (SD) Mean (SD) Age (years) 25–39 28.1 (9.4) 8.1 (2.8) 6.3 (2.6) 40–49 26.0 (11.4) 7.1 (3.0) 6.3 (1.7) 50–59 22.6 (11.2) 6.2 (3.0) 6.3 (2.1) 60–69 20.2 (10.8) 5.9 (3.0) 5.8 (2.2) 70+ 15.9 (11.0) 5.2 (3.0) 5.9 (1.8) Sex Female 21.4 (11.8) 6.1 (3.3) 6.1 (1.9) Male 24.9 (10.7) 7.0 (2.7) 6.2 (2.2) Education level Illiterate 13.0 (8.6) 4.0 (2.9) 5.6 (2.1) Primary 14.6 (8.3) 4.6 (2.0) 5.8 (1.9) Secondary 21.6 (10.0) 6.1 (2.6) 6.1 (2.2) Intermediateb 29.0 (8.5) 8.0 (2.5) 6.4 (2.3) Graduate & above 32.4 (7.8) 8.65 (2.5) 6.6 (1.8) Occupation Housewife 20.7 (11.6) 5.9 (3.1) 5.9 (2.2) Blue-collar worker 17.6 (8.4) 5.2 (2.2) 5.8 (1.6) White-collar worker 31.7 (8.8) 8.4 (2.8) 6.6 (1.7) Self-employed 22.5 (11.1) 6.7 (2.5) 6.4 (2.4) Retired 24.8 (10.0) 7.0 (2.7) 6.5 (1.9) Duration of diabetes (years) < 1 19.0 (11.6) 5.6 (2.6) 5.0 (2.1) 1–5 21.8 (10.8) 6.2 (2.9) 6.3 (1.9) 6–15 24.1 (11.9) 6.7 (3.2) 6.3 (2.2) > 15 27.6 (9.8) 7.4 (2.9) 6.0 (1.6) Type of diabetes Type 2 22.3 (11.3) 6.4 (3.0) 6.1 (2.0) Type 1 32.7 (6.9) 8.0 (2.6) 6.9 (2.5) Type of treatment Diet 19.7 (11.9) 5.4 (3.1) 4.1 (1.8) Oral hypoglycaemic drugs 21.8 (10.9) 6.3 (2.9) 6.1 (1.8) Insulin 29.7 (10.7) 7.8 (3.3) 7.3 (2.3) Place of treatment Community health centre 20.9 (11.0) 6.1 (2.9) 5.5 (2.0) Consulting clinic 24.9 (11.5) 6.9 (3.1) 6.6 (2.0) Overall 23.1 (11.4) 6.5 (3.0) 6.2 (2.0) SD = standard deviation. aMaximum possible scores: knowledge 59; beliefs 15; practices 14. bUp to 12 years education in school. 596 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 play an important role in diabetes care, and a number of plants, herbs and vegetables are used therapeutically [24]. Among these, bit- ter gourd (M. charantia) is widely used as an alternative therapy for diabetes [23,25] and our study also found that around 25% of the participants thought that regular use could cure diabetes. While studies in diabetic rats [23] and humans [25] have shown that M. charantia has hypoglycaemic effects, no study has demonstrated that it can control diabetes. Moreover, sufficient data are not available on the potency and effectiveness of bitter gourd to recommend its use as an alternative therapy. The concept of insulin use indicating gravity of illness and becoming dependent on the drug has been documented in the Vietnamese population [21]. Many of the participants in our study also considered insulin use to be indicative of reaching the last stage of disease. The belief that insulin is an addictive drug is based on the fact that insulin needs to be taken daily and the person cannot do without it. There is evidence that people with type 1 or type 2 diabetes on insulin are more adher- ent to self-monitoring of blood glucose [26] and this finding was supported in our study. However, the observation that over three quarters of the study population did not perform self-monitoring or exercise regu- larly is noteworthy, and sends a worrying message to diabetes health care providers and educators. Self-monitoring, exercise and weight reduction programmes should be included as part of any diabetes educa- tion package. Few patients receive formal diabetes education in Pakistan. This study provides further evidence that there is a lack of in- formation available to people with diabetes, with a large proportion never receiving any diabetes education at all. As our study was conducted in a single centre, the results may not give a true reflec- Table 4 Main beliefs about nutrition and insulin use in people with diabetes Belief Yes No Don’t know % % % A person with diabetes is allowed to eat vegetables grown under the soil 17.1 80.4 2.5 A person with diabetes can eat as much basen ki rotia as he or she wants 60.3 27.6 12.1 Regular use of karelab can cure diabetes 25.1 59.3 15.6 A person with diabetes can eat “diabetic foods” in any quantity 8.5 43.7 47.7 Insulin use indicates that the person has reached the last stage of disease 32.7 28.6 38.7 Regular use of insulin can lead to addiction 33.7 22.1 44.2 Children and adolescents with type 1 diabetes should be allowed to adjust insulin dose on their own 16.1 31.6 52.3 Women with type 1 diabetes should avoid pregnancy 9.0 13.1 77.9 A woman taking insulin should breastfeed her baby 17.1 7.5 75.4 aBread made from gram (chickpea) flour. bBitter gourd (Momordica charantia). Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 597 tion of the general population. Nevertheless, the findings have significant implications for the quality of diabetes education available to people with diabetes in Pakistan. The fact that the study was conducted in an urban university hospital, where diabetes educa- tion may be more readily accessible, raises further concern as there is more likelihood that the majority of people, especially those living in the rural areas and having less ac- cess to information, will have even poorer diabetes perceptions and practices. There is, therefore, a need for increased effort towards developing and making wide- ly available diabetes education programmes that focus on empowering the person with diabetes, not only providing them with information and skills, but also the ability to make decisions and take ownership of controlling their diabetes. References 1. Shera AS, et al. 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Relationship between patient practice-oriented knowledge and metabolic control in intensively treated type 1 diabetic patients: results of the validation of the Knowledge and Practices Diabetes Questionnaire. Diabetes, nutri- tion & metabolism, 2000, 13(5):276–83. 16. Anderson RM et al. Barriers to improving diabetes care for blacks. Diabetes care, 1991, 14(7):605–9. 17. Hawthorne K. Effect of culturally appropri- ate health education on glycaemic control and knowledge of diabetes in British Pa- kistani women with type 2 diabetes mel- litus. Health education research, 2001, 16(3):373–81. 18. Fitzgerald JT et al. The reliability and validity of a brief diabetes knowledge test. Diabetes care, 1998, 21(5):706–10. 19. Schoenberg NE, Amey CH, Coward RT. Diabetes knowledge and sources of in- formation among African American and white older women. Diabetes educator, 1998, 24(3):319–24. 20. Brown JB et al. The role of patient, physi- cian and systemic factors in the manage- ment of type 2 diabetes mellitus. Family practice, 2002, 19(4):344–9. 21. Mull DS, Nguyen N, Mull JD. Vietnamese diabetic patients and their physicians: what ethnography can teach us. West- ern journal of medicine, 2001, 175(5): 307–11. 22. Lin CC. Crude drugs used for the treat- ment of diabetes mellitus in Taiwan. American journal of Chinese medicine, 1992, 20(3–4):269–79. 23. Kar A, Choudhary BK, Bandyopadhyay NG. Comparative evaluation of hypogly- caemic activity of some Indian medicinal plants in alloxan diabetic rats. Journal of ethnopharmacology, 2003, 84(1):105–8. 24. Platel K, Srinivasan K. Plant foods in the management of diabetes mellitus: vegeta- bles as potential hypoglycaemic agents. Nahrung, 1997, 41(2):68–74. 25. Ahmad N et al. Effects of Momordica charantia (Karolla) extracts on fasting and postprandial serum glucose levels in NIDDM patients. Bangladesh Medical Research Council bulletin, 1999, 25(1): 11–3. 26. Ruggiero L et al. Diabetes self-manage- ment. Self-reported recommendations and patterns in a large population. Diabe- tes care, 1997, 20(4):568–76. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 599 Profile of breast lesions among women with positive biopsy findings in Yemen A.K. Al-Thobhani,1 Y.A. Raja’a,2 T.A. Noman3 and M.A. Al-Romaimah3 1Department of Pathology; 2Department of Community Medicine; 3Department of Surgery; Faculty of Medicine and Health Sciences, University of Sana’a, Sana’a , Yemen (Correspondence to A.K. Al-Thobhani: abdulla_althobhani@yahoo.com). Received: 01/01/05; accepted: 07/03/05 ABSTRACT This study described the profile of breast pathology based on records from a reference his- topathology laboratory in Yemen of 773 women with positive biopsy or mastectomy findings. Cancers were classified according to the International classification of diseases for oncology. Benign lesions were found in 79.9% of cases. Fibroadenoma was the most prevalent lesion (30.0%) with a mean age at presentation of 22.2 years, followed by fibrocystic disease (27.4%) and breast inflammation (13.1%). Invasive carcinoma was found in 155 cases (20.1%), at a mean age of 44.7 years. 18 Profile of breast lesions among women with positive biopsy findings in Yemen ÍÉ¿»É¶=ÍÈeÇû‚=›Í¢h„=L>çÉE>‹Ý=Ð>j¿¶=Ïb¶ËbN¶=L>ªA¼ßjßIáfຠ=bF¢Í»Éºf¶=¸É·‚=bF¢b»†(Á>»£¾¤i=Ƕ=bF¢±e>{(Ð>Qeb—?ÎɌ(ʾ>}d¶=¼i>®  „=Í[qØ6>ÉQǶÇM>EÇJj[É=[J‡LØR[iÎ[·¢a>[»J¢×>EËb[N·¶ÊQǶÇM>[F¶=¼ßj[ßIáfà»[¶=Í[i=eb¶=Åd[ÂXäuÇI ÇV¿EÍq>„=(ÍÉ¿»É¶=ÍÈeÇû‚=›Ê£Qf™=773Á>{fj·¶Í¢h„=ÍÉE>‹CÌbÉiÀÃÈb[¶ËbN¶=¸qÖJi=Àç»[ºÆ?(* ½=eÆÙ=¼[·£¶ʶÆb[¶=¬É¿r[J·¶ð>[¯ªÆL>¾>{fj[¶=¥=Ǿ?¬É¿rIÆ*Ïb[¶Ìb[ɗL>[ªALb[QÆÆ79.9!À[º Ê«É·¶=Ëb§¶=½eǶ=ð=e>nJ¾=L>ªÛ=ÅdÂfN²?Á>²Æ(L×>ƒ=%30.0$!¨·FÈÊìiÆf»£E22.2eÇ[Þb[¿¢Í¿[i Ê[j[ɳ¶=Ê[«É·¶=Ð=b[¶=>[ÃÉ·È(zf™=%27.4$!Ëb[[N¶=H>[[ÃJ¶=¼[M%13.1*$!ÌÐ=çh[[¦Í[[¾>{fiLb[[QÆ>[»² invasive›155Í[[¶>U%20.1$!ÊìiÆf»£E44.7Í¿i*  Profil des lésions mammaires chez les femmes ayant des résultats de biopsie positifs au Yémen RÉSUMÉ La présente étude a décrit le profil de la pathologie mammaire sur la base des dossiers d’un laboratoire d’histopathologie de référence au Yémen pour 773 femmes ayant des résultats positifs de ponction-biopsie ou de biopsie de tissus suite à une mastectomie. Les cancers ont été classés selon la Classification internationale des maladies pour l’oncologie. Des lésions bénignes ont été trouvées dans 79,9 % des cas. Le fibro-adénome était le type de lésion le plus répandu (30,0 %), l’âge moyen à la présentation étant de 22,2 ans, suivi par la mastose sclérokystique (27,4 %) et l’inflammation mam- maire (13,1 %). Un carcinome invasif a été trouvé dans 155 cas (20,1 %) à l’âge moyen de 44,7 ans. 600 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Introduction Globally, breast cancer ranks first among cancers affecting women [1]. It has been found to be the main cause of death from cancer, second to lung cancer in some count tries [1,2]. Worldwide 1 in 10 women is aft fected by breast cancer during their lifetime [3]. There is also the problem of benign tumours reported to be premalignant and the increased risk of developing breast cant cer associated with proliferative fibrocystic diseases of the breast [4]. Furthermore, it is very important to differentiate between bet nign and malignant breast diseases in view of the clinical similarities between them [3]. Therefore, every change in the breast should be evaluated carefully for early detection of possible precancerous elements. In Yemen, the magnitude of the problem of breast diseases is not yet known. There has been one limited study of breast cancers in the southteastern governorates [5]. The current study aimed to describe the profile of breast lesions in the records of women with positive biopsy or mastectomy findt ings from a reference laboratory in Yemen. Methods The data were the results of all finetneedle breast biopsies, excisional breast biopsies and biopsies of mastectomies carried out between January 1997 and December 2001 in a histopathology laboratory in Yemen. The laboratory is one of the 4 major hist topathology laboratories in Yemen and a reference laboratory for different hospitals and clinics throughout the country. Biopsies from male patients and biopsies that did not produce a clear and confirmed diagnosis were excluded (n = 77). Data were complete for the purpose of the study in 773 out of 850 records (90.9%). Cancers were classified according to the International classification of diseases for oncology (3rd edition) [6]. Data about hist topathological diagnosis, site of the lesion and women’s age were analysed by SPSS to find means and standard deviations. Results Specimens from 773 patients had positive findings. The major diagnoses were fibrot adenoma (in 30.1% of cases) at a mean age of 22.2 years, fibrocystic disease (27.4%) at a mean age of 30.2 years, invasive carcit noma (20.1%) at a mean age of 44.7 years and breast inflammation (13.1%) at a mean age of 33.1 years (Table 1). Other disorders were lactating adenoma, tubular adenoma and miscellaneous disorders. Of the carcinoma cases, 137/155 (88.4%) were the ductal type. The remainder were lobular carcinoma (7 cases, 4.5%), medult lary carcinoma (5 cases, 3.2%), intraductal carcinoma with Paget’s disease (3 cases), mixed ductal–lobular carcinoma (2 cases) and tubular carcinoma (1 case). Most of the patients with fibrocystic changes had a simple type (181/212 cases, 85.4%); 30 patients (14.2%) had proliferat tive fibrocystic changes without atypia and 1 case was with atypia. Of the cases of inflammation, 45/101 (44.6%) were chronic mastitis. The others were duct ectasia (40 cases), galactocoele (6 cases), fat necrosis (5 cases), plasma cell mastitis (3 cases) and granulomatous mastitis (2 cases). Miscellaneous disorders found were: normal breast tissue (6 cases), hyperplastic adipose tissue (2 cases), phylloides tumour (3 cases), malignant fibrous histiocytoma (3 cases), benign fibrous histiocytoma (2 cases), nontHodgkin’s lymphoma (2 cases), Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 601 intraduct papilloma (2 cases), fibrosarcoma (2 cases), and leiomyoma, small cell tumour, stromal sarcoma, haemangioma, granular cell tumour, angiosarcoma and lipoma (1 case each). Carcinoma affected the left breast more than the right one (59.4% versus 40.6%), so too did inflammation. Fibroadenoma and fibrocystic disease, however, affected the right breast more than the left one (Table 1). Table 2 shows the age distribution of cases. The peak incidence for fibroadenoma cases was at ages 11–20 years (61.4% of cases) and for fibrocystic disease was 21–30 years (42.9%). For carcinoma cases the peak incidence was in the age group 41–50 years (34.2%), followed by age 31–40 years (24.5%). Discussion Most studies on female breast pathologies in different centres in the Eastern Meditert ranean Region have concentrated mainly on malignant neoplasms [5,7–12] and there are few reports addressing the pattern of all breast diseases [13–17]. The present study is the first focusing on the pattern of differt ent breast diseases in Yemen. This study revealed that about 80% of women with positive biopsy results had nontmalignant changes. This finding is comparable with other results reported in Saudi Arabia [13,14]. The most frequent bet nign tumour in our study was fibroadenoma, constituting 30.1% of all cases. Similar results were obtained from other studies in Saudi Arabia [13,14]. Different results were observed in studies from the United States of America (18.5%) [18], United Kingdom (7.7%) [19], American blacks (34.7%) [20] and Africans [21]. Racial pret disposing factors have to be considered in this issue, as the frequency of fibroadenoma is higher among blacks and lower among EurotAmerican female patients [4,22]. Nontneoplastic fibrocystic lesions of the breast ranked second in our study (27.4%), and this is comparable with one study from Saudi Arabia (24.1%) [14], but different from other studies in that country (13.1% and 12%) [13,23]. Fibrocystic diseases are more frequent in referrals in the United Table 1 Distribution of breast diseases in women with positive findings on breast biopsy and mean age Disease Total Left breast Right breast Both breasts Age (years) No. % No. % No. % No. % Mean (SD) Fibroadenoma 233 30.1 103 44.2 124 53.2 6 2.6 22.2 (6.8) Fibrocystic disease 212 27.4 94 44.3 108 50.9 10 4.7 30.6 (10.5) Carcinoma 155 20.1 92 59.4 63 40.6 0 – 44.7 (12.4) Inflammation 101 13.1 54 53.5 47 46.5 0 – 33.1 (10.0) Lactating adenoma 30 3.9 13 44.3 16 53.3 1 3.3 28.3 (6.4) Tubular adenoma 13 1.7 7 53.8 6 46.2 0 – 27.9 (7.8) Other 29 3.8 12 41.4 17 58.6 0 – 37.1 (16.2) Total 773 100.0 375 48.3 381 49.3 17 2.3 31.3 (12.8) SD = standard deviation. 602 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Kingdom (37%) [19] and the United States of America (33.9%) [18]. Hormonal imbalt ance with prolonged exposure to oestrogen is hypothesized to be the main cause of these disorders [4]. The lower frequency in our society could be due to cultural factors which deter women from consulting medit cal staff who are predominantly men. Simt ple fibrocystic disease comprised most of the cases of fibrocystic disease in our study (around 85%) and this is less dangerous than proliferative fibrocystic disease (15%), which is associated with an increased risk of breast cancer [4,22]. Research has shown an association with carcinoma of the breast among female relatives of patients suffering from proliferative fibrocystic disease; thus clinical surveillance should be carried out with both the patient and their female relat tives [4,24,25]. Inflammation of the breast was found in 13.1% of biopsies. The pattern of inflammat tory breast disease in our study is relatively close to that observed in Saudi Arabia and Jordan [14,15]. Social factors and personal behaviours could be the possible cause of this condition where repeated pregnancies and lactations with accompanying change of breast physiology predispose women to breast infections. Cancer of the breast constituted about 20% of biopsies in our study. This result is comparable with results from other studies in the region [13,14]. A previous study in Yemen showed that cancer of the breast ranked first among malignant neoplasms aft fecting women, along with gastrointestinal tract malignancies [26]. Invasive ductal carcinoma was the predominant type in our study, affecting 88% of women with carcit noma, a finding which is comparable with many studies [5,17,18,23,25,27]. The left breast was more affected than the right one, which was also seen in the study from Ta bl e 2 Ty pe o f b re as t d is ea se s by a ge Ag e Fi br oa de no m a Fi br oc ys tic Ca rc in om a In fla m m at io n La ct at in g Tu bu la r O th er s (y ea rs ) di se as e ad en om a ad en om a N o. % N o. % N o. % N o. % N o. % N o. % N o. % 11 –2 0 14 3 61 .4 41 19 .3 5 3. 2 7 6. 9 4 13 .3 4 30 .8 7 24 .1 21 –3 0 68 29 .2 91 42 .9 22 14 .2 42 41 .6 17 56 .7 4 30 .8 4 13 .8 31 –4 0 18 7. 7 50 23 .6 38 24 .5 39 38 .6 8 26 .7 5 38 .5 8 27 .6 41 –5 0 3 1. 3 20 9. 4 53 34 .2 10 9. 9 1 3. 3 0 – 5 17 .2 51 –6 0 1 0. 4 10 4. 7 24 15 .5 2 2. 0 0 – 0 – 2 6. 9 > 60 0 – 0 – 13 8. 4 1 1. 0 0 – 0 – 3 10 .3 To ta l 23 3 10 0. 0 21 2 10 0. 0 15 5 10 0. 0 10 1 10 0. 0 30 10 0. 0 13 10 0. 0 29 10 0. 0 Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 603 Oman [17]. The tendency for the left breast to be affected has been reported before [28], although the reasons are unclear. The mean age of our carcinoma patients was 44.7 years, which is close to that found in patients in other studies in Yemen [5], Oman [17], Saudi Arabia [12–14,23], Egypt [10], Kuwait [10], Sudan [29], Lebanon [30], Jordan [11,15] and Palestine [31]. This study and reports from other Arab countries all concur that the peak incidence of breast cancer is higher around 10 years earlier in Arab countries compared with Europe and America [18]. The current study cannot explain trends of breast diseases between different count tries. Factors such as age, genetics, racial, social, cultural, hormonal [4,22] and dietary habits may play a role. However, the overall results of this study are in concordance with studies performed in other Arab countries [5,10–15,17,23,29–31]. Conclusion This study has shown that fibroadenomas, fibrocystic diseases, invasive carcinomas and inflammations were the major breast disorders among Yemeni female patients. 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Received: 09/10/03; accepted: 07/03/05 ABSTRACT The efficacy and safety of 3 methods used in legal termination of pregnancy in the second and early third trimester was assessed in 258 women in Jordan randomly assigned to receive Foley catheter (with and without traction) or prostaglandin E2 vaginal tablets. The failure rate of termination and the total insertion-to-termination time was higher with Foley catheter without traction (16.5%, 16.5 hours) than with traction (10.0%, 14.2 hours) or prostaglandin (8.0%, 11.5 hours). However, Foley cath- eter as a method of termination of pregnancy in second and early third trimester is safe and inexpensive, and its efficacy can be enhanced with the use of traction to give similar results to prostaglandin E2. 1 Termination of second and early third trimester pregnancy: comparison of 3 O¶>N¶=ÍÈ=bEÆ?ʾ>N¶=PÇ·MîÙ=›¸»ƒ=Ð>þC6±f{PØM;e>¯º Ínº>ÂaÀjU(ºÇ™=a=fº(b¶>]E=¬Éu(Ä¿º>N¢±e>{(bÉme=E¼ÉÂ=fEC  „=Í[qØ6²¼É[ɯJEÁÇNU>F¶=½>®ÌeÆf[uÄ«[qÇE¸[»ƒ=Ð>[þC›ͺßb^Jj[ºÍ[ɾǾ>®±f[{PØMÍɾǺ@ºÆÌÐ>« PÇ[·MîÙ=›Í[çÉQØ¢trimesterÏb[¶(O[¶>N¶=PÇ[·MîÙ=Í[È=bEÆ?ʾ>[N¶=258Ê[Iض=L>[ɾaeÙ=¸[º=ǃ=À[º [iƶ=À[ºÍ[É·Fút=f[®?Ð>[ì¢CÆ?GViÁÆbEÆ?¤ºʶǪe>ìN®°ÉFìJ¶ÊÑ=Çn¢¸³nEÀãÈgÇIÀÈb¾Ø¦>J E2*½=b^J[i=Ïb[¶Î[·¢?¸»ƒ=Ð>þCEÆe>ìN¯¶=¹>]aCEÍɶ>–Ý=Ìb™=Ƹ»ƒ=Ð>þC¸nª¹b£ºÁ>²b®Æ GViÁÆaʶǪe>ìN®%ÍFj¿E¸n«¶=¹b£ºa=gb¯ª16.5!ÍFj¿EÌb™=Æ16.5e>[ìN®½b^àJ[i=Ç[¶>[绢Í¢>[i GVj¶=¤ºʶǪ%¸n«¶=¹b£º¨·EOÉU10!Ìb™=Æ14.2!Í¢>i$Kºb^J[i=Ç[¶>[šð>v[È?Î[·¢?Á>[²>»² ÀÈb¾Ø¦>Jiƶ=t=f®Ù=E2ÍÉ·FÙ=%¸n«¶=¹b£º¨·EOÉU8!Ìb[™=Æ11.5Í¢>[i*$Ìf[ìN®èb[ߣàI(´[¶c¤[ºÆ h[Èh£IÀ[³•Æ(Ä[¿ºO¶>N¶=PÇ·MîÙ=ÍÈ=bEÆ?ʾ>N¶=PÇ·MîÙ=›¸»ƒ=Ð>þݬɶ>³J¶=ÌbÉÂgÆ;Ǻ@ºͯÈf{ʶǪ >£ªÀÈb¾Ø¦>JiÆ·¶ÍÉ·FÙ=t=f®Ù=Ä¿¢f«jàI>ºÄE>nISÑ>J¾Ð>ì¢ÝGVj¶=½=b^Ji>E>ÃJɶE2*  Interruption de grossesse au deuxième trimestre et au début du troisième trimestre : comparaison de 3 méthodes RÉSUMÉ L’efficacité et l’innocuité de trois méthodes utilisées pour l’interruption légale de grossesse au deuxième trimestre et au début du troisième trimestre ont été évaluées chez 258 femmes en Jordanie qui ont été randomisées pour recevoir une sonde de Foley (avec ou sans traction) ou des ovules vaginaux de prostaglandine E2. Le taux d’échec pour l’interruption de grossesse et le temps total entre l’insertion et l’interruption de la grossesse étaient supérieurs avec la sonde de Foley sans traction (16,5 %, 16,5 heures) qu’avec traction (10,0 %, 14,2 heures) ou qu’avec la prostaglandine (8,0 %, 11,5 heures). Toutefois, la sonde de Foley, en tant que méthode d’interruption de grossesse au deuxième trimestre et au début du troisième trimestre, est sûre et peu coûteuse, et son efficacité peut être renforcée par le recours à la traction pour donner des résultats similaires à ceux de la prostaglandine E2. 606 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Introduction Despite recent advances in prenatal diagn nosis during the first trimester, terminan tion of pregnancy in the second and early third trimester of pregnancy due to fetal abnormalities or intrauterine fetal death still accounts for 10% of abortions in the USA [1]. Achieving termination after the first trimester of pregnancy is one of the great challenges facing obstetricians today. Unfortunately, not all women who need termination have a favourable cervix for induction. As first described by Bishop [2], cervical ripening is an important process preceding effacement and dilatation of the cervix. A variety of techniques for termin nation of midntrimester pregnancy can be used, but there is no consensus about which is the best [3]. Use of the Foley catheter for termination of pregnancy was first described by Krause in 1833 [4]. In 1967 Embrey and Mollison [5] reported a 94% successful induction rate after using the Foley catheter for cervical ripening in 100 women. The Foley catheter appears to affect cervical ripening by direct mechanical dilatation and also through ren lease of endogenous prostaglandin [6] and this effect can be enhanced when traction is applied. The vaginal or intracervical applican tion of prostaglandin E2 (PGE2) has been widely used for midntrimester termination because of its effect on both cervical ripenn ing and uterine contraction [7]. In most studies PGE2 has been applied locally in gel form and the high dosages frequently cause severe sideneffects, including vomiting, diarrhoea and fever [7–10]. In this study, we used tablets of PGE2 to replace the gel formulation, to diminish the sideneffects. The aim of this study was to compare the efficacy and safety of 3 methods of terminan tion of pregnancy in the second and early third trimester: PGE2 vaginal tablets, Foley catheter without traction and Foley catheter with traction. Methods The study was conducted from July 1998 to February 2000 at the Department of Obn stetrics and Gynaecology in Prince Hashem Ben AlnHussein and Prince Rashed Ben Aln Hassan Military Hospitals in Jordan. The study sample comprised healthy women who were 15–30 weeks pregnant and adn mitted for legal termination of pregnancy due to intrauterine fetal death or gross conn genital abnormality. Patients with known placenta praevia or unexplained vaginal bleeding and rupture of membranes were excluded from the study. The study was approved by the scientific committee in the Department of Obstetrics and Gynaecology of the King Hussein Medical Centre. Verbal consent was obtained from each woman after explaining the aims and design of the study. A total of 261 patients were entered into the study; 3 women were discharged after randomization but before the start of termination and were lost to follownup. During the study period the women were randomly assigned to 1 of 3 treatments until the time when the study was terminated: Foley catheter without traction (n = 91), Foley catheter with traction (n = 79), or PGE2 vaginal tablets (n = 88). Intravenous oxytocin drip was used for augmentation of termination in all 3 groups when cervin cal ripening was achieved. All patients were admitted to hospital and managed by the attending physician. The following were recorded: complete blood count and crossnmatch, vital signs and signs of uterine hyperstimulation from oxytocin. The group randomly assigned to receive PGE2 had tablets (3 mg) (Pharmacia & Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 607 Upjohn, Belgium) placed into the endocern vical canal or posterior vaginal fornix by sterile speculum examination. The dose was repeated every 6 hours as long as the Bishop score was still ≤ 5, to a maximum of 4 doses. Intravenous oxytocin was started when Bishop score reached > 5 (cervical effacement > 50%). Those in the Foley groups had a no.14 Foley catheter with 40 mL balloon inserted into the endocervical canal under direct visualization by sterile speculum examinan tion. Once it passed the internal os, 40 mL water was instilled in the balloon, then the catheter was placed inside the patient’s thighs and firmly attached. In the group of patients randomized to receive traction, a continuous traction by 500 mL normal saline was achieved by taping the end of the Foley catheter to the long side of the patient’s thigh, so that gentle, steady tracn tion was applied. The catheter was checked for Foley bulb extrusion every 4 hours by vaginal examination, and the traction was adjusted so that gentle traction continued. Because the aim of the trial was to evaluate the success of cervical ripening, the outcome measures for the 3 methods were: total time from insertion to expulsion of uterine contents, sideneffects, patients’ comfort (assessed by asking the women if they were comfortable with the procedure or if they were feeling any discomfort) and success/failure of termination. Analysis of variance was used to inn vestigate whether there was a difference between the 3 methods used. Student– Newman–Keuls postnhoc test was used to test the difference between the 3 methods. A probability of P < 0.05 was considered statistically significant. Results The mean age of the 258 women was 27.1 years and parity ranged from 0 to 7; 39.2% were nulliparous. The mean gestation age was 19 weeks. There was no statistically significant difference between the 3 groups with respect to maternal age, gestational age or parity. The main indication for terminan tion was intrauterine fetal death for differn ent reasons (84.6% of women), while gross congenital abnormality of the fetus, mainly due to anencephaly, was the indication for 15.4% of women. In the prostaglandin E2 group, most of the patients required 3 applications of PGE2 tablets (mean 2.3 applications). No Foley catheter needed to be replaced after the initial application. The overall failure rate of termination for all 3 methods was 11.6% (Table 1). The failure rate was higher when the Foley catheter was used without traction (16.5%) compared with Foley catheter with traction (10.0%), although the lowest failure rate in termination was with PGE2 tablets (8.0%) (P < 0.001). The average insertionnton termination time was longer with Foley catheter without traction compared with Foley with traction (16.5 hours versus 14.2 hours), while it was shorter (11.5 hours) with PGE2 tablets (P < 0.002). There were few maternal sideneffects in all groups. The most common sideneffect was discomfort at insertion of the Foley catheter (only 37 reported minimal to mild discomfort), while 4 of the patients in the PGE2 group reported nausea and vomiting. Uterine hyperstimulation, defined as 6 conn tractions per 10 minute period, occurred in only 2 patients. Despite reports of discomn 608 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 fort at the time of Foley catheter insertion there were few complaints of discomfort with any of the methods. Discussion Midntrimester labour induction is necesn sary in a variety of circumstances; the inn dications may be maternal or fetal, but it is usually accompanied by an unfavourable cervix. To solve this problem, different methods of artificial cervical ripening have been developed. Mechanical devices such as the cervical balloon [5,11,12] and lamin naria [13,14] have been used safely. In adn dition, preparations of prostaglandin have been used, in a variety of concentrations and application methods, to pharmacologically mature the cervix [10]. In this study we compared the use of a pharmacological method for cervical ripn ening, PGE2 tablets, with a mechanical method, the insertion of a Foley catheter with or without traction to enhance its efn fect. Early studies comparing the Foley catheter with PGE2 tablets found no difn ference in the time of cervical ripening or termination time [8,9]. Both Thomas et al. [8] and St Ong and Connors [9] comn pared the Foley catheter with PGE2 tablets and found both to be effective in changing the Bishop score, but neither found Foley catheter to be more effective than PGE2 tablets. It has been suggested that PGE2 tablets are costneffective in termination of pregnancy [15]. In our study, the alternan tive was Foley catheter, which is relatively inexpensive and safe and has almost similar results in achieving success in termination of pregnancy and insertionntontermination interval. With traction applied, it enhances the mechanical effect of Foley catheter to ripen the cervix, and this makes the method of traction competitive for PGE2 tablets and avoid the pharmacological sideneffects such as nausea and vomiting. To evaluate the efficacy of any method of termination for patients with unfavourn able cervix, nulliparity should be one if the main considerations, as the cervix is more prone to faster ripening. In our study around 40% of women were nulliparas. We can conclude that in locations where there is no experience with the use of PGE2, or when it is unavailable, the Foley catheter appears to be a safe, effective and relan tively inexpensive method for termination of pregnancy, particularly when gentle tracn tion is applied. Table 1 Outcome of pregnancy termination in second and early third trimesters using Foley catheter with and without traction or prostaglandin (PGE2) tablets Method Total Successful Failed Insertion to termination termination termination time (hours)a No. No. % No. % Mean SD Foley plus oxytocin, without traction 91 76 83.5 15 16.5 16.5 0.93 Foley plus oxytocin, with traction 79 71 89.9 8 10.1 14.2 1.24 Prostaglandin vaginal tablets 88 81 92.0 7 8.0 11.5 0.67 Total 258 228 88.4 30 11.6 P-value P < 0.001 P < 0.002 aTime between insertion of Foley catheter or PGE2 tablets until expulsion of uterine contents. SD = standard deviation Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 609 References 1. Abortion surveillance 1979—1980. Atlan- ta, Georgia, Centers for Disease Control, 1983. 2. Bishop EH. Pelvic scoring for elective induction. Obstetrics and gynecology, 1964, 24:266–8. 3. Liu HS et al. Second and early third tri- mester pregnancy termination by extra- amniotic balloon and intracervical PGE2. International journal of gynaecology and obstetrics, 1998, 60:29–34. 4. Hamilton J. Historical review of British obstetrics and gyneacology. Edinburgh, Livingston, 1954:1800–950. 5. Embrey MP, Mollison BG. The unfavo- rable cervix and induction of labor using a cervical balloon. Journal of obstetrics and gynaecology of the British Common- wealth, 1979, 74:44–8. 6. Ezimokhai M, Nwabinelli JN. The use of Foley’s catheter in ripening the unfavour- able cervix prior to induction of labour. British journal of obstetrics and gynaecol- ogy, 1980, 87:281–6. 7. Graves GR et al. The effect of vaginal administration of various doses of pros- taglandin E2 gel on cervical ripening and induction of labor. American journal of obstetrics and diseases of women and children, 1985, 151:178–81. 8. Thomas IL et al. Preparations for induc- tion of labour of the unfavorable cervix with Foley catheter compared with vaginal prostaglandin. Australian & New Zealand journal of obstetrics & gynaecology, 1986, 26:30–5. 9. St Ong RD, Conners GT. Preinduction cer- vical ripening: a comparison of intracervi- cal prostaglandin E2 gel versus the Foley catheter. American journal of obstetrics and gynecology, 1995, 172:687–90. 10. Keirse MJ. Prostaglandins in preinduc- tion cervical ripening. Meta analysis of worldwide clinical experience. Journal of reproductive medicine, 1993, 38:89–100. 11. Liu HS et al. Extra-amniotic balloon with PGE2 versus extra-ovular Foley catheter with PGF2alpha in mid-trimester pregnan- cy termination. International journal of gy- naecology and obstetrics, 1998, 63:51–4. 12. Lin A, Kupferminc M, Dooley SL. A ran- domized trial of extra-amniotic saline infusion versus laminaria for cervical rip- ening. Obstetrics and gynecology, 1995: 86:545–9. 13. Manabe Y. Laminaria tent for gradual and safe cervical dilatation. American jour- nal of obstetrics and gynecology, 1971, 110:743–5. 14. Kline SB, Meng H, Munsick RA. Cervical dilation from laminaria tents and synthetic osmotic dilators used for 6 hours be- fore abortion. Obstetrics and gynecology, 1995, 86:931–5. 15. Sullivan CA et al. Combining medical and mechanical methods of cervical rip- ening. Does it increase the likelihood of successful induction of labor? Journal of reproductive medicine, 1996, 41:823–8. 610 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Variation in repeat caesarean section complication rates among 3 hospitals in northern Jordan Z.O. Amarin,1 H.A. Alchalabi,1 Y.S. Khader,2 A.A. Gharaibeh2 and R.M. Shwayat3 1Department of Obstetrics and Gynaecology, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan (Correspondence to Z.O. Amarin: zoamarin@hotmail.com). 2Department of Public Health and Biostatistics, Jordan University of Science and Technology, Irbid, Jordan. 3Prince Rashid Military Hospital, Royal Medical Services, Irbid, Jordan. Received: 08/01/04; accepted: 07/03/05 ABSTRACT We investigated the complication rates of repeat caesarean deliveries in 3 hospitals (national health, military, university) in Irbid by examining the obstetric records of 989 women from 1 December 1999 to 30 March 2004. There was a statistically significant difference between the number of previous caesarean sections and hospital. In total, 579 (58.5%) patients underwent elective caesare ean section. There were statistically significant differences between hospitals for “failure to progress in labour” and “other” indications for caesarean section. After adjusting for the number of caesarean sections, regression analysis revealed that women from the military and university hospitals were more likely to have placenta praevia. There were no statistically significant differences between hospitals as regards posteoperative complications. 23 Variation in repeat caesarean section complication rates among 3 hospitals in ÁaeÙ=¹>›L>É«nJjºÍMØM›(Ìeëf³J™=ÍÈfrɯ¶=L>É·»£¶=L>«¢>vº›LÆ>«J¶= ·‚=Ê·¢Ð>«ÉÂ(ÀÈe>»¢ÌaÇ¢ÂgL>ÈÇmb»†ʺ=e(ÍFÈ=f¦oÈ>¢>?(ea>®>q¬iÇÈ(  „=Í[qØ6›Ìeëf[³J™=ÍÈfr[ɯ¶=L=a×Ç[¶=À[¢Í[–>¿¶=L>«¢>v™=¹b£ºÐ>r¯Ji>EÁÇNU>F¶=½>®3L>É«n[Jjº %Ê£º>[‚=Ϋn[Jj™=Æ(Ëf³j[£¶=ΫnJj™=Æ({Ƕ=ΫnJj™=$b[ɶÇJ¶=LØR[iÍ[i=ea¹Ø[]À[º(b[EeC› V¿EÍq>„=Ç989ÀºÌb™=¹Ø]ÌbÉi1¹ÆÙ=ÁǾ>[²1999‘C30e=cA+le>[º2004*±Æf[ªLb[QÆb[®Æ ÄEKÈfQ?Ëd¶=ΫnJj™=ÆÍ[¯E>j¶=Í[Èfrɯ¶=L=a×Ƕ=ab[¢OÉUÀ[ºð>[ÉÑ>rUC>[ÃEèb[ßJá£àÈ*ÍÉ·»£¶=K¾>²b®Æ b¿¢Ëe>ÉJ]×=¥Ç¿¶=ÀºÍÈfrɯ¶=579%58.5$!L=bÉj[¶=À[º*µ>[¿ÂK[¾>²Æ[Eð>ÉÑ>r[UC>[ÃEèb[ßJá£àȱÆf[ª L>E>FìJ[i×=Àº´¶c¦›ÆÍÈfrɯ¶=ÍU=f‚=Ð=fQÝH>FìJi>²z>^™=½èb¯I±>«]COÉUÀºL>É«nJj™=* ›L=bÉj[¶=Á?­èÇ[VJ¶=¸[É·€¬n[²(ÍÈfr[ɯ¶=L>[U=f‚=ab[¢e>[FJ¢×=›d[]@ÈËd¶=œFv¶=Ð=fQCb£EÆ É«nJj™=ÆÍÈf³j£¶=L>É«nJj™=±Æf[ªË?b[QÇIא[U›(Í[U=h¿™=Í»Én[™=PÆbƒÍuf¢fN²?ÍÉ£º>‚=L> ÍU=fR·¶Íɶ>J¶=L>«¢>v™=OÉUÀºL>É«nJj™=Eð>ÉÑ>rUC>ÃEèbßJá£àÈ*    Variation du taux de complications pour les césariennes itératives dans trois hôpitaux du nord de la Jordanie RÉSUMÉ Nous avons étudié les taux de complications pour les césariennes itératives dans 3 hôpitaux (public, militaire, universitaire) à Irbid en examinant les dossiers obstétricaux de 989 femmes entre le 1er décembre 1999 et le 30 mars 2004. Il y avait une différence statistiquement significative entre le nombre des césariennes précédentes et l’hôpital. Au total, 579 patientes (58,5 %) ont subi une césae rienne élective. Il y avait des différences statistiquement significatives entre les hôpitaux concernant l’arrêt de la progression du travail comme indication de la césarienne et les « autres » indications. Après ajustement sur le nombre de césariennes, l’analyse de régression a montré que les femmes des hôpitaux militaire et universitaire étaient plus susceptibles de présenter un placenta praevia. Il n’y avait pas de différence statistiquement significative entre les hôpitaux concernant les complications postopératoires. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 611 Introduction Caesarean sections have for some time been performed with impunity. Such deliveries are associated with immediate and delayed morbidity and mortality risks [1]. Comp pared with vaginal deliveries, caesarean sections carry a higher number of postp partum complications [2]. During the past few decades the worldwide incidence of caesarean births has increased markedly [3]. Approximately 1 out of 4 women will have a caesarean delivery [4] and it is the most frequently performed surgical procedure in the United States [5]. Worldwide variation exists in rates for caesarean delivery [6]; currently the rates range from 10% to 40% of all deliveries [7]. Caesarean deliveries have come under scrutiny for more than a decade. The high rate of caesarean section poses a unique threat in the developing world where family size has not dipped to the low levels seen rep cently in the more industrialized countries. Numerous studies have shown variation in caesarean delivery rates by race, hospital type and hospital location [8–10]. The incip dence in individual hospitals is dependent on the patient population [11]. About onepthird of caesarean sections are repeat procedures [12]. In developing countries in general, and Middle Eastern countries in particular, the prevalence of women with multiple previous caesarean sections is high [13]. Repeat caesarean deliveries are associated with increased morbidity [14,15] but little has been done to investigate complications that are specifip cally associated with repeat caesarean dep liveries. The impact of the type of hospital on clinical outcomes has been examined for a variety of medical procedures [16] Because little can be done to influence maternal factors that are associated with caesarean delivery complications [17], the aim of this study was to describe the role that individual hospitals play in complicap tions from repeat caesarean section. The hypothesis is that different types of hospital may have significantly different observed caesarean delivery complication rates. As part of an ongoing quality improvement project we investigated the variability in the rates of complications at 3 differently financed public hospitals in the city of Irbid, northern Jordan. Our objective was to asp sess the individual hospital contribution to intrap and postpoperative repeat caesarean delivery complications and to measure their magnitude. Methods We conducted a retrospective review of routinely collected admission data of all women with repeat caesarean section bep tween 1 December 1999 and 30 March 2004. We did not apply any exclusion crip teria. The settings were 3 public hospitals in the same city but which served differp ent populations. The first, Princess Badea Teaching Hospital (PBTH), is a National Health Service maternity hospital open to the general population. The second, Prince Rashid Military Hospital (PRMH), is a general hospital open to military personnel and their families. The third, King Abp dullah University Hospital (KAUH), is a semipprivate university hospital open to insured university staff and their families, public service employees and cash payers. All hospitals have a 24phour inphouse atp tending specialist or faculty coverage, and most births are attended by residents with specialist or faculty supervision. From the records of women with rep peat caesarean sections performed at these hospitals over the study period, demop graphic data and significant aspects of the 612 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 medical history were extracted and the indications for repeat caesarean delivery were recorded. When more than 1 indicap tion was found, a single main diagnostic variable was assigned for statistical analyp sis. Medical, antep and intrapartum obstetric complications were identified, including prep eclampsia, prepexisting and gestational diabetes, asthma, thyroid disease, placenta praevia, malpresentation, macrosomia, multiple gestation and placental abrupp tion. The main outcome measures were intraoperative, immediate and shortpterm postoperative complication rates. For each patient, outcome variables were recorded. These included haemorrhage (in excess of 800 mL) during the operation or in the puerperium, postoperative complicap tions such as fever (> 38 ºC on 2 consecup tive measurements 6 hours apart other than in the first 24 hours), uterine fenestration, bladder injury, placenta praevia, placenta praevia accreta, intestinal or urinary tract problems, emergency peripartum and postp partum hysterectomy, incision cellulites, thrombosis, embolism, and intensive care admission. Analysis of variance was used to test for the difference in maternal age, parity and gestational age between the 3 hospitals. Chipsquared test was used to analyse the distribution of caesarean section data. After adjusting for the number of previous caep sarean sections, binary logistic regression was used to analyse the difference in comp plication rates between hospitals. A Ppvalue < 0.05 was used for the level of signifip cance. Results A total of 989 women underwent repeat caesarean section in the 3 hospitals in the study period: 679 at PBTH, 185 at PRMH and 125 at KAUH. The demographic distribution of women according to hospital and clinical features, broken down by the number of repeat caep sarean deliveries is presented in Table 1. There were no statistically significant difp ferences between hospitals with respect to maternal age, parity or gestational age. Of the 989 patients reviewed, 480 (48.6%) Table 1 Demographic and clinical characteristics of repeat caesarean section patients by hospital Characteristic PBTH PRMH KAUH Pevalue (n = 679) (n = 185) (n = 125) Mean (SD) Mean (SD) Mean (SD) Maternal age (years) 31.5 (4.3) 31.4 (4.5) 31.2 (4.1) 0.766 Parity 3.2 (1.7) 3.1 (2.6) 3.1 (1.3) 0.735 Gestational age (weeks) 36.5 (1.9) 36.6 (2.4) 36.8 (2.5) 0.321 No. of previous caesarean No. (%) No. (%) No. (%) sections < 0.001 1 351 (51.7) 56 (30.3) 73 (58.4) 2 204 (30.0) 25 (13.5) 34 (27.2) ≥ 3 124 (18.3) 104 (56.2) 18 (14.4) PBTH = Princess Badea Teaching Hospital; PRMH = Prince Rashid Military Hospital; KAUH = King Abdullah University Hospital. SD = standard deviation. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 613 had undergone 1 previous caesarean secp tion, 263 (26.6%) had undergone 2 and 246 (24.8%) had undergone 3 or more. The proportion of women with previous caesarean section was not comparable in the 3 hospitals (low, 30.3% vs. high, 58.4% for 1 previous caesarean section), (low, 13.5% vs. high, 30.0% for 2 previous caesarean sections) and (low, 14.4% vs. high, 56.2% for 3 or more previous caesarean section) (P < 0.001). Of the total repeat caesarean deliveries, 579 (58.5%) patients underwent elective caesarean section. The KAUH caesarean section group had fewer patients undergoing elective caesarean section (61/125, 48.8%) compared to PRMH 97 (52.4%) (P = 0.530) and PBTH 417 (61.4%) (P = 0.008). PRMH had fewer patients with the dip agnosis of fetal distress (5/185, 2.7%) and PBTH had more patients with the diagnosis of failed trial of labour (97/351, 27.6%). The distribution of indications (only for patients with 1 previous caesarean section for whom normal labour could be attempted) and the corresponding number of patients of the 3 hospitals are presented in Table 2. There were statistically significant differences between the hospitals as regards failure to progress in labour as the indication for caesarean section and “other” indications. The details of the postoperative maternal complications according to the number of caesarean sections are presented in Table 3. Generally, there was a decrease in the incip dence of operative haemorrhage in women with higher number of previous caesarean sections. There was a difference between hospital rates for haemorrhage, especially for cases with 2 previous caesarean secp tions (low 7.3% vs. high 24.0%). However, analysis for this group and for women with 1 previous caesarean (low 14.8% vs. high 26.0%) and 3 or more previous caesarean sections (low 10.5% vs. high 18.5%) were not statistically significant. Table 2 Indication for caesarean section in patients with 1 previous caesarean delivery by hospital Indication PBTH PRMH KAUH Pevalue (n = 351) (n = 56) (n = 73) No. (%) No. (%) No. (%) Fetal distress 59 (16.8) 4 (7.1) 13 (17.8) 0.162 Failure to progress in labour 97 (27.6) 14 (25.0) 7 (9.6) 0.04 Placenta praevia 11 (3.1) 1 (1.8) 4 (5.5) 0.471 Placental abruption 10 (2.8) 0 (0.0) 4 (5.5) 0.184 Malpresentation 47 (13.4) 12 (21.4) 9 (12.3) 0.246 Preeeclampsia 34 (9.7) 3 (5.4) 6 (8.2) 0.558 Macrosomia 19 (5.4) 4 (7.1) 5 (6.8) 0.808 Multiple pregnancy 10 (2.8) 1 (1.8) 3 (4.1) 0.731 > 40 weeks gestation 21 (6.0) 0 (0.0) 5 (6.8) 0.127 Other 43 (12.3) 17 (30.4) 17 (23.3) 0.001 PBTH = Princess Badea Teaching Hospital; PRMH = Prince Rashid Military Hospital; KAUH = King Abdullah University Hospital. 614 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 There were 41 (4.1%) cases of placenta praevia in the women from the 3 groups. There was an increased incidence of plap centa praevia in relation to higher number of previous caesarean sections. There was 1 death of a mother with 3 previous caesarean sections and placenta praevia accreta. She died a few hours after undergoing caesarean hysterectomy. The cause was shock that could not be reversed. Nine (0.9%) women required caesarean hysterectomy. Placenta praevia accreta was present in 6 of these women, 1 woman had hysterectomy with a normally sited placenta accreta, 1 was due to intraoperative atonic bleeding, and another was due to postopp erative atonic bleeding of more than 1500 mL and severely lacerated uterine wound margins. Table 3 Caesarean section findings and postoperative complications by hospital and number of previous caesarean sections Complication Previous PBTH PRMH KAUH caesarean sections No. No. (%) No. (%) No. (%) Placenta praevia 1 8 (2.3) 5 (8.9) 1 (1.4) 2 2 (1.0) 2 (8.0) 1 (2.9) ≥ 3 4 (3.2) 16 (15.4) 2 (11.1) Uterine fenestration 1 3 (0.8) 2 (3.6) 2 (2.7) 2 3 (1.5) 2 (8.0) 1 (2.9) ≥ 3 4 (3.2) 3 (2.9) 1 (5.6) Haemorrhage 1 52 (14.8) 12 (21.4) 19 (26.0) 2 15 (7.4) 6 (24.0) 3 (8.8) ≥ 3 23 (18.5) 11 (10.6) 2 (11.1) Hysterectomy 1 0 0 1 (1.4) 2 2 (1.0) 0 0 ≥ 3 4 (3.2) 2 (1.9) 0 Fever 1 7 (2.0) 1 (1.8) 2 (2.7) 2 0 3 (12.0) 1 (2.9) ≥ 3 8 (6.4) 6 (5.7) 0 Wound infection 1 7 (2.0) 1 (1.8) 2 (2.7) 2 2 (1.0) 0 0 ≥ 3 5 (4.0) 7 (6.7) 0 Visceral injuries 1 1 (0.3) 1 (1.8) 0 2 2 (1.0) 0 0 ≥ 3 2 (1.6) 2 (1.9) 0 PBTH = Princess Badea Teaching Hospital; PRMH = Prince Rashid Military Hospital; KAUH = King Abdullah University Hospital. Percentages calculated from total for each hospital for number of previous caesarean sections. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 615 Eight (8) women had visceral injuries: 5 had bowel injury and in 3 the urinary bladder was attached high on the anterior abdominal wall where it was inadvertently entered and was repaired. There were 21 cases of uterine scar fenestration. The risk of fenestration did not seem to be affected by the number of previous caesarean sections. There were no cases of uterine rupture, thromboemp bolic events, anaesthetic complications or patients needing intensive postoperative care. One maternal death was recorded. The aggregate rate for analysed potentially avoidable complications of haemorrhage, hysterectomy, fever, wound infection and visceral injuries for the 3 hospitals in this study was 21.4% (212 complication/989 caesarean sections). Binary logistic regression analysis rep vealed that women from PRMH (odds ratio = 3.66) and KAUH (odds ratio = 3.41) were more likely to have placenta praevia comp pared to women from PBTH after adjusting for the number of caesarean sections. Odds ratios for postoperative maternal complicap tions (adjusted for the number of caesarean sections) and their 95% confidence intervals for women from PRMH and KAUH comp pared to women from PBTH are presented in Table 4. There were no statistically sigp nificant differences between the hospitals with regard to any of the postoperative complications. Discussion Giving birth is a ubiquitous event that usup ally occurs in a hospital setting. It has been calculated that the average woman in develp oped countries will have 3.3 pregnancies resulting in 2.1 live births [17]. Hospital births represent 12% of all hospitalizations [18]. Although patients presenting with 3 or more previous caesarean sections is not a common event in the industrialized world, its prevalence in developing countries is common [19,20]. This indicates the obvip ous importance of analysing the clinical outcomes of repeat caesarean deliveries. Teaching hospitals have lower unadjusted caesarean rates compared with other comp Table 4 Logistic regression analysis (adjusted for caesarean section) for repeat caesarean section and caesarean section findings and postoperative complications Complication PBTH PRMH (n = 185) KAUH (n = 125) (n = 679) OR OR 95% CI Pevalue OR 95% CI Pevalue Placenta praevia 1 3.66 1.71–7.84 0.001 3.41 1.39–8.38 0.101 Haemorrhage 1 1.20 0.74–1.94 0.470 1.52 0.09–2.51 0.101 Hysterectomy 1 0.59 0.11–3.13 0.533 1.05 0.12–8.92 0.964 Fever 1 0.74 0.31–1.71 0.481 1.20 0.34–4.28 0.771 Wound infection 1 1.41 0.54–3.65 0.477 0.78 0.17–3.53 0.758 Visceral injuries 1 1.58 0.32–7.63 0.567 –a –a –a Uterine fenestration 1 2.26 0.78–6.52 0.133 2.30 0.71–7.49 0.165 PBTH = Princess Badea Teaching Hospital; PRMH = Prince Rashid Military Hospital; KAUH = King Abdullah University Hospital. OR = odds ratio; CI = confidence interval. aOR were not calculated because the numbers were small. 616 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 munity hospitals [21]. Significant variations may be justified when individual hospitals serve different populations with varying risks. As a clinical measure of quality of care, studying the variations in rates among hospitals, especially those that are in the same area, may uncover inherent institup tional clinical differences in caesarean dep livery complication rates. Our elective repeat caesarean delivery rate was similar to that reported by other studies [22–25] and represents the largest contribution to the repeat caesarean delivery rate. Patients’ preference plays a significant role within this elective caesarean section group [26]. Failure to progress in labour was an indication for repeat caesarean secp tion in 27.6% of patients at PBTH, 25.0% at PRMH and 9.5% at KAUH. Although not all patients who undergo a scheduled repeat caesarean delivery are candidates for a trial of labour, some patients in the elective group could have been allowed a trial of labour. This would have potentially decreased the repeat caesarean delivery rate and the possible complications. This probably reflects both patient and physip cian attitudes toward vaginal birth after caesarean section. They may be reluctant to attempt a trial of labour when the fetus in a subsequent pregnancy is presumed larger. Macrosomia was an indication for a second caesarean section in 5.8% of women in our study. A study by Zelop et al. demp onstrated that a trial of labour after previp ous cesarean delivery may be a reasonable clinical option for pregnant women with suspected birth weights of > 4000 g, given that the rate of uterine rupture associated with these weights does not appear to be substantially increased when compared to lower birth weights [27]. However, some caution may apply when considering a trial of labour in women with infants weighing > 4250 g. A trial of labour may also be reasonable in women whose previous caep sarean was for dystocia in the second stage of labour. It has been demonstrated that patients who underwent a trial of labour after a previous cesarean for dystocia in the second stage had a 75% chance of achieving vaginal delivery [28]. There is a strong relationship between hospital volume and complications of delivery; the likelihood of complications decreases as volume increases [8]. A high volume institution, which in this study was PBTH, may perhaps serve a demographip cally distinct population. Adjusting for case mix enables improved identification of hospitals with caesarean delivery complip cation rates significantly lower or higher than others [29]. For comparison across hospitals some studies have used multivarip ate regression techniques to “adjust” for difp ferences, taking into consideration multiple copmorbidities [30,31]. In our study, we used binary logistic regression after adjustp ing for the number of previous caesarean sections to analyse the difference in comp plication rates between hospitals. Except for placenta praevia, which is not an avoidp able complication, we found no significant difference in observed caesarean delivery complication rates between the 3 hospitals covering 3 different population subpgroups of the same region. If 1 of these hospitals was found to have the best practice results for an avoidable complication, then risk adjustment could be based on that hospital’s data. Failing this, aggregate regional results can be used to provide the initial criteria. The overall rate for potentially avoidable complications (haemorrhage, hysterectomy, fever, wound infection and visceral injuries) for the 3 hospitals in this study was 20.6%, with no statistically significant difference between the hospitals. Therefore, no clear consensus exists regarding which clinical, Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 617 demographic or hospital factor should serve as a model. Although our study does not suggest an accepted average rate for caesarean secp tion complications, the wide variability observed within each risk category, sugp gests that surgery is often inappropriately used. In our study “other” was one of the variables that was significantly different between hospitals. Under this category we included all indications that were not on the study list of parameters. The data suggest, above all, that caesarean section is often practised when it is not clearly indicated. These circumstances make it necessary to devise interventions for the selective reducp tion of complications. Work in this area includes systematic review of all available evidence and research to increase the body of available evidence. Currently, the varip ous practices considered appropriate are at the discretion of the clinician. 1. Hager RM et al. Complications of caee sarean deliveries: rates and risk factors. American journal of obstetrics and gynee cology, 2004, 190:428–34. 2. Loverro G et al. Maternal complications associated with caesarean section. Joure nal of perinatal medicine, 2001, 29:322– 6. 3. Pinette MG et al. Vaginal birth after cesare ean rates are declining rapidly in the rural state of Maine. Journal of maternal–fetal & neonatal medicine, 2004, 16:37–43. 4. Ventura SJ et al. Births: final data for 1998. National vital statistics reports, 2000, 48:1–100. 5. Hanley ML et al. Analysis of repeat caee sarean section delivery indications: Ime plications of heterogeneity. American journal of obstetrics and gynecology, 1996, 175:883–8. 6. Martin JA et al. Births: final data for 2002. National vital statistics reports, 2003, 52:1–113. 7. Hacker N, Moore J G, eds. Essentials of obstetrics and gynecology, 3rd ed. Philae delphia, WB Saunders, 1998. 8. Garcia FA et al. Effect of academic afe filiation and obstetric volume on clinical outcome and cost of childbirth. Obstetrics and gynecology, 2001, 97:567–76. 9. Aron DC et al. Impact of riskeadjusting caesarean delivery rates when reporte ing hospital performance. Journal of the American Medical Association, 1998, 279:1968–72. 10. Gregory KD et al. Caesarean deliveries for Medicaid patients: a comparison in public and private hospitals in Los Angee les County. American journal of obstetrics and gynecology, 1999, 180:1177–84. 11. Guillemette J, Fraser WD. Differences bee tween obstetricians in caesarean section rates and management of labour. British journal of obstetrics and gynaecology, 1992, 99:105–8. 12. Takayama T et al. Risks associated with caesarean section in women with plae centa previa. Journal of obstetrics and gynaecology research, 1997, 23:375–9. 13. AbueHeija A, Zayed F. Primary and ree peat caesarean sections: comparison of indications. Journal of obstetrics and gynaecology, 1998, 18:432–4. 14. Zaki ZM et al. Risk factors and morbidity in patients with placenta previa accreta compared to placenta previa noneaccreta. Acta obstetricia et gynecologica Scandie navica, 1998, 77:391–4. 15. Waterstone M, Bewley S, Wolfe C. Incie dence and predictors of severe obstete References 618 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 ric morbidity: caseecontrol study. British medical journal, 2001, 322:1089–94. 16. Burns LR, Geller SE, Wholey DR. The effect of physician factors on the caesare ean section decision. Medical care, 1995, 33:365–82. 17. Kuhn EM et al. The relationship of hospital ownership and teaching status to 30e and 180eday adjusted mortality rates. Medical care, 1994, 32:1098–108. 18. Martin JA et al. Births: final data for 2002. National vital statistics reports, 2003, 17:1–113. 19. Simoes E et al. Association between method of delivery, puerperal complicae tion rate and postpartum hysterectomy. Archives of gynecology and obstetrics, 2005, 272:43–7. 20. Chama CM, EleNafaty AU, Idrisa A. Caee sarean morbidity and mortality at Maide uguri, Nigeria. Journal of obstetrics and gynaecology, 2000, 20:45–8. 21. Gillum BS, Graves EJ, Wood E. Natione al Hospital Discharge Survey. Vital and health statistics. Series 13, 1998, (133): i–v, 1–51. 22. Bailit JL, Love TE, Mercer B. Rising cee sarean rates: are patients sicker? Amerie can journal of obstetrics and gynecology, 2004, 191:800–3. 23. Macones GA et al. Obstetric outcomes in women with two prior cesarean deliveries: is vaginal birth after cesarean delivery a viable option? American journal of obstete rics and gynecology, 2005, 192:1223–8. 24. Durnwald C, Mercer B. Vaginal birth after cesarean delivery: predicting success, risks of failure. Journal of maternal–fetal, and neonatal medicine, 2004, 15:388–93. 25. Hendler I, Bujold E. Effect of prior vaginal delivery or prior vaginal birth after cesare ean delivery on obstetric outcomes in women undergoing trial of labor. Obstete rics and gynecology, 2004, 104:273–7. 26. Wax JR et al. Patient choice cesarean: an evidenceebased review. Obstetrical & gynecological survey, 2004, 59:601–16. 27. Zelop CM et al. Outcomes of trial of lae bor following previous cesarean delivery among women with fetuses weighing >4000 g. American journal of obstetrics and gynecology, 2002, 186:1104–5. 28. Bujold E, Gauthier RJ. Should we allow a trial of labor after a previous cesarean for dystocia in the second stage of labor Obe stetrics and gynecology, 2002, 99:520–1. 29. Elkousy MA et al. The effect of birth weight on vaginal birth after cesarean delivery success rates. American joure nal of obstetrics and gynecology, 2003, 188:824–30. 30. Glantz JC. Caesarean delivery risk ade justments for regional interhospital come parisons. American journal of obstetrics and gynecology, 1999, 181:1425–31. 31. Richman VV. Lack of local reflection of national changes in caesarean delivery rates: the Canadian experience. Amerie can journal of obstetrics and gynecology, 1999, 180:393–5. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 619 Fattening practices among Moroccan Saharawi women M. Rguibi1 and R. Belahsen1 1Training and Research Unit on Food Sciences, Laboratory of Physiology Applied to Nutrition and Feeding, Chouaib Doukkali University School of Sciences, El Jadida, Morocco (Correspondence to R. Belahsen: rbelahsen@yahoo.com). Received: 03/05/04; accepted: 31/01/05 ABSTRACT To study obesity in Moroccan Saharawi culture, 249 women were questioned about their desired body size and diet practices. The majority of women (90.4%) reported wanting to gain weight currently or at some time in the past. To gain weight, women used a fattening period (tablah) of at least 40 days of overeating with a reduction of physical activity and special traditional meals. Appetite enh hancers (therapeutic drugs or fenugreek) and traditional suppositories were also used. Some women used corticosteroids to gain weight rapidly. The study highlights the need for health education about the dangers of obesity and steroid use in this culture. 9 Fattening practices among Moroccan Saharawi women L>ÉEf§™=L>ÈÆ=fVr¶=EÍß¿á»ëj·¶ËëaÖI¶=L>ie>»™= jV·EÍÉ®e([ɲe=b»†À  „=Í[qØ6Àºe>j«Ji×=(ÍÉEf§™=ÍÈÆ=fVr¶=ÍÒÉF¶=›Íß¿á»ëj¶=Íi=eb¶249ÄÉ·¢ÁdzIÁ?Ž¦fÈ>»¢Ð>j¿¶=Àº ÍÉÑ=d§¶=ÀÃI>ie>šÆÀÂaÆb®*Ð>j¿¶=¼Ÿ£ºÏbE?b®Æ%90.4!Àÿº$Æ?fu>ƒ=K®Ç¶=›Àþ=gÆ?Ìa>ÈhEÀÃJF¦e ÎßvߺK®Æ›*ÌÇj¿¶=@R·IÁgǶ=Ìa>Èh¶Æ»jJ¶=Ìf[JªÐ>v®‘C%\ØFJ¶=$À[¢¸[¯I×Ìb[™40ßÀï{óf[ï«àÈ(ð>[ºÇÈ ÍÈbÉ·¯J¶=L>FQǶ=¹Æ>¿IÆʾbF¶=>n¿¶=t>¯¾C¤º½>£ì¶=¹Æ>¿I›>Ãɪ*ÍFï·åƒ=¸NºÍÉÃn¶=L>€>ªÀ·»£JjÈ>»² ÍÈÆaÙ=Æ?ÍÉF£n¶=¸Éº>VJ¶=Æ?*j³É¶L=bÉÑÆÉidzÉIdz¶=ÌÇj¿¶=x£E½b^Ji=b®ÆÍ¢fj[EÁgǶ=Ž*X[uÇIÆ Êò·=¤»J==d›L=bÉÑÆJj¶=½=b^Ji=e>ì]?ÆÍß¿á»ëj¶=e>ì]?¹ÇUÊVr¶=¬É¯NJ·¶ÍQ>ƒ=ÏbºÍi=eb¶=*  Pratiques des femmes sahraouies au Maroc pour engraisser RÉSUMÉ Afin d’étudier l’obésité dans la culture sahraouie au Maroc, on a interrogé 249 femmes sur le corps qu’elles souhaitaient avoir et sur leurs pratiques alimentaires. La majorité des femmes (90,4 %) ont déclaré vouloir prendre du poids au moment de l’étude ou l’avoir voulu à un moment donné dans le passé. Pour prendre du poids, les femmes utilisaient une période d’engraissement (tablah) d’au moins 40 jours de suralimentation avec une activité physique réduite et des repas traditionnels spéciaux. Des stimulateurs d’appétit (médicaments thérapeutiques ou fenugrec) et des suppositoires traditionnels étaient également utilisés. Certaines femmes utilisaient des corticostéroïdes pour prendre du poids rapidement. La présente étude souligne la nécessité d’une éducation sanitaire concernant les dangers de l’obésité et de l’utilisation des stéroïdes dans cette culture. 620 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Introduction As a precursor of a variety of chronic disease es, obesity is a major cause of preventable morbidity and mortality [1], and its mane agement is a complex issue that includes a wide range of cultural and psychosocial factors [2]. Several studies have indicated that there is a strong association between selfeperceived weight status and weight control behaviour [3,4]. However, the dee sirability of a particular body size is not simply an autonomous, individual choice, but is mediated by cultural factors. In many industrialized countries there is a desire to lose weight that may be accompanied by dieting or calorie restriction, use of diurete ics, vomiting or exercise [5]. Paradoxically, in many developing world communities, fatness is culturally associated with beauty, prosperity, health and prestige [6–8], and thinness is perceived to be a sign of ill health or poverty. Thus fattening rituals are sometimes practised, for example in some Pacific societies where women overfeed to induce body weight gain [8]. In Morocco, existing studies have ree ported that the prevalence of overweight and obesity has increased greatly during recent years and that the increase is greatest among women, half of whom are overweight or obese [9–11]. However, the etiology of obesity in Morocco is not well undere stood, especially in some ethnic groups. The present study was designed to investigate perceptions of desired body size and the diet practices used to lose or to gain weight among Moroccan Saharawi women. Methods Participants The survey was conducted between October 2001 and April 2002 on a sample of 249 urban nonepregnant women aged 15 to 70 years old, from Laayoune, a city in the south of Morocco. The sample was selected from women who visited public health centres during an immunization campaign. Only women of Saharawi origin and without any previous systemic diseases were eligible for this investigation. A number of criteria were used to identify women as belonging to the Saharawi ethnic group: their come munication skills in Hassaniyya dialects, their traditional clothing and the history of their family’s residence. Saharawi ethnic groups, characterized by the Hassaniyya dialect, have been a traditionally nomadic population undergoing a rapid process of urbanization and all Saharawi women, from the age of puberty, are expected to dress traditionally. All participants were intere viewed faceetoeface by an interviewer who belonged to this Saharawi ethnic group. Informed consent was obtained verbally from each participant before they took part in the survey. Data collection Body weight and height were measured while the participants wore light clothing with no shoes using a portable scale and a metric tape adhered to a wall. Body mass index (BMI) was calculated as weight (kg)/ height (m2). The World Health Organization (WHO) definitions were used for undere weight (BMI < 18.5 kg/m2), normal weight (18.5 ≤ BMI < 25 kg/m2), overweight (25 ≤ BMI < 30 kg/m2) and obesity (BMI ≥ 30 kg/m2) [12]. All participants were interviewed facee toeface by an interviewer from the same ethnic group. A discussion guide was developed including questions on socioe demographic characteristics, satisfaction with their body size, dietary history and practical behaviours used to lose or to gain body weight. The sociodemographic chare acteristics were: marital status (married, Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 621 divorced, widowed or single) and educae tion level (never attended school, attended primary school or secondary school). To determine the perceptions of body weight, participants were invited to answer the following questions: Have you wanted to gain weight in the past? Do you want to gain weight now? Do you want to lose weight now? Participants were asked to describe any actions that they have taken to lose or gain body weight. All fattening practices used by the women were recorded, as well as other details such as portion size, frequency of eating, food composition and food preparation techniques. Results A total of 249 women were interviewed, with a mean age of 36.8 years. Most were married, divorced or widowed (79.9%) and twoethirds were illiterate (62.2%) (Table 1). The mean BMI was 29.6 kg/m2 and 30% of women were overweight and 49% were obese. At the time of the survey, despite the high prevalence of obesity in this population, a large majority of women (79.9%) described their weight as appropriate (199/249) and only 50 described it as inappropriate (8 desired to lose weight and 42 desired to gain it). Among the 199, 175 had wanted to gain weight in the past and 168 of them had used a fattening practice before. Over 90% of the women were dise satisfied with their body size (225/249). Among the 8 women (2.4%) who wanted to be lighter, 2 were overweight and 6 were obese; only 2 obese women had made a previous attempt at losing weight using exercise activity and dieting. The majority of women wanted to gain weight rather than to lose it; 217 women reported that they had tried to gain weight at some time and 42 of them still desired to gain weight at the time of the survey. This desire to gain weight was in most cases accompanied by practise ing certain behaviours (Table 2). Only 12 women reported desiring to gain weight without practising any fattening behaviour whereas 168 women reported that they had already used (in the past) some fattening practices to grow fat, and at the survey time, 37 women were currently practising these. Drugs, overfeeding and restriction of physical activity were 3 of the ways used by women to achieve their goal (fattening). The use of medications was an important Table 1 Sociodemographic characteristics of the study sample (n = 249 women) Variable Value Mean (SD) Range Age (years) 36.8 (11.8) 15.0–70.0 BMI (kg/m2) 29.6 (5.3) 17.3–41.4 No. % Marital status Single 50 20.1 Married 166 66.7 Divorced 19 7.6 Widow 14 5.6 Education Never attended school 155 62.2 Primary school 47 18.9 Secondary school 47 18.9 Table 2 Fattening practices used by Saharawi women desiring to gain weight gain Practice In the past Currently (n = 175) (n = 42) Appetite stimulant 71 (40.6) 3 (7.1) Overeating 56 (32.0) 30 (71.4) Corticosteroids 41 (23.4) 4 (9.5) Other 7 (4.0) 5 (11.9) 622 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 alternative to gain weight in this population. Among women desiring to gain weight 40.6% had taken in the past and 7.1% were currently taking a therapeutic or traditional medication that increased hunger. Also, 23.4% of these women had taken in the past and 9.5% were currently taking drugs promoting weight gain as a sideeeffect (such as corticosteroids). In fact, in addition to the therapeutic medication, the women ree ported that some seeds such as fenugreek (halba) consumed directly or added to dishes have been used to stimulate hunger. It is important to note that in some of these women even though they knew there were risks accompanying drug use, they had used them because it allowed them to gain weight quickly. In addition, women used some traditional suppositories called ligue, composed of dates mixed with seeds and medicinal plants, specifically for increasing their peripheral fat. With regard to the role of dietary intake, some women said that prior to marriage they had gone through a fattening period of at least 40 days of intentional overeating with a high reduction of physical active ity, traditionally called tablah. This period could last longer until they achieved the goal of gaining weight. Information on diet consumed during this period of weight gain showed that the types of food traditionally used in the past had changed with the move to a more urban lifestyle. The older women whose lifestyle was formerly nomadic used only the consumption of a large quantity of camel milk that could reach up to 10 litres a day. Whereas after settling in an urban area, the women used several alternative foods in this traditional fattening period such as the soup and couscous of barley, the liver, fat and meat of camel, olive oil, and sugared milk and rice. On the other hand, other women used special traditional meals (aajna and lahssa) as a supplement consumed at least twice a day, particularly before breakfast and after dinner. These meals (aajna and lahssa) are prepared from a mixture of several foods, seeds and mee dicinal plants. These 2 traditional meals differ by the presence of the date in aajna replaced by honey in lahssa, and by the type of medicinal plants used in each meal. Discussion Cultural ideas on what is desirable and attractive have important implications in the development of body image and may influence practices to achieve or maintain this particular body image. The results of this study highlight the role of sociocultural factors in the maintenance of traditional vale ues about the desirability of body weight. Indeed, in spite of the high prevalence of overweight and obesity in this group of women, a large majority of them described their weight as appropriate. Walker has reported that in African cultures, obesity in women is regarded with far less disfavour than in industrialized countries and, accorde ingly, there is only a limited incentive in obese African women to reduce their weight [13]. This agrees with our observations in this population. In addition, even among the 6 overweight and obese women in this study who desired to lose weight only 2 had taken part in dieting or sports activities. The attitudes to weight loss in this Saharawi population are attributed to the cultural ace ceptance of fatness and the ignorance of the health risks associated with overweight and obesity. It has been reported that even when black women perceive themselves as being overweight, they still consider themselves physically attractive [14]. Fatness was often considered as prestigious in Cameroon, and as having an effect on getting alliances or Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 623 finding a marriage partner in Indian society [7]. It is also reported that in the Tahiti and Nauru Pacific societies, where fattening is associated with beauty and fertility, the women overfeed and undertake little active ity in order to grow fat [8]. In this study sample, the majority of Saharawi women desired to gain weight during their life, especially those of normal weight. This is a result of an association of beauty with overweight. Also, it is important to note that from puberty, the Saharawi culture obliges women to dress in traditional clothes, and there is a belief that this traditional clothing style requires a heavier body. Although the impact of obesity on health was mentioned by some women, the women’s desirable body image was determined by the socially acceptable body type rather than a healthy body. All these data highlight the great sociocultural pressure experienced by the thinner women considered not to have the cultural ideal beauty standard and may explain the high prevalence of overweight observed in young Saharawi women who could easily develop obesity at any time after early adulthood. Sedentary lifestyles and highefat, energyedense diets are reported to be among the principal causes of the accelerating problem of obesity worldwide [15]. This study also highlights the sociocultural face tors that affect dietary lifestyle behaviours. Indeed, the desire to gain weight expressed by Saharawi women motivates them even to use weightegain methods that are unhealthy. Discussions about weight gain across a Saharawi women’s lifeecycle showed that in this society there are periods of cule turally acceptable fattening characterized by overeating and reduction of physical activity. The women had entered the fate tening period as a preparation for marriage. Overeating and sedentary behaviour are the traditional methods of gaining weight in this population. Previously, in nomadic lifestyles, Saharawi women consumed a large quantity of whole camel milk as well as certain seeds and medicinal plants. After settling in an urban area where camel milk is not readily available, it is replaced by a variety of foods such as fat, meat and camel liver and meals prepared from barley flour and olive oil. In addition to fenugreek seeds consumed directly or added to dishes and to special traditional meals consumed as a supplement, Saharawi women used drugs to induce weight gain. What is serious in this population is not so much the utilization of drugs stimulating the appetite but that the drugs used are known to have repercussions on health. Corticosteroids, especially when taken for a prolonged period, can cause many other sideeeffects in addition to weight gain, such as osteoporosis [16,17]. In addition to the utilization of corticosteroids to increase their body weight rapidly, Saharawi women used traditional suppositories to increase their peripheral fat. We conclude that steps need to be taken to prevent obesity in this population in order to limit the occurrence of more serious conditions. Any attempts at prevention ree quire a change in social and cultural norms of beauty. Thus, interventions aiming at obesity prevention or management should primarily inform the population about the danger of corticosteroid utilization without a medical prescription, and educating Sahae rawi people about health issues related to overweight and obesity. Acknowledgements The authors wish to thank the Medical Delegation of Laayoune Province, Minise try of Health, Morocco, for their help with data collection. We also acknowledge the Director of Moulay Mehdi Hospital for 624 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 their cooperation as well as the staff in the laboratory of biological analysis at Moulay Mehdi Hospital, for their assistance. The survey was supported by the Ministry of Higher Education and Research, Morocco. 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Weighthrelated attitudes and behaviours of black women. Journal of the American Dietetic Association, 1993, 93:416–22. 15. James WPT, Ralph A. New understandh ing in obesity research. Proceedings of the Nutrition Society, 1999, 58:385–93. 16. Hedberg A, Rossner S. Body weight characteristics of subjects on asthma medication. International journal of obesh ity related metabolic disorders, 2000, 24(9):1217–25. 17. Walsh LJ et al. Use of oral corticosteroids in the community and the prevention of secondary osteoporosis: a cross sech tional study. British medical journal, 1996, 313:344–6. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 625 Effect of 5 years of dental studies on the oral health of Tunisian dental students F. Maatouk,1 W. Maatouk,2 H. Ghedira1 and S. Ben Mimoun3 1Paediatric Dentistry Department, Dental School, Monastir, Tunisia (Correspondence to F. Maatouk: fethi. maatouk@fmdm.rnu.tn). 2Regional Office of School and University Medicine, Monastir, Tunisia. 3Private practice, Megrine, Tunisia. Received: 15/04/04; accepted: 26/08/04 ABSTRACT This study is a follow-up of one made in 1998–99 on first-year dental students in Monastir. Now in their fifth year, we assessed the effect of dental studies on students’ oral health practices and dental health. Of the 155 students in the first study, 140 were still enrolled. Periodontal troubles, maloc- clusion and dental decay affected 84.3%, 80.0% and 43.0% of the students respectively. Compared with the previous study, students had achieved a better dental health status – tooth brushing rate was much higher, prevalence of dental decay and periodontal pockets had decreased, and DMF index had improved. However, the prevalence of smoking, bleeding and calculus had not changed, and the fre- quency of malocclusion had increased. 13 Effect of 5 years of dental studies on the oral health of Tunisian dental students k¾ÇI›Á>¿iÙ=G{ÍÉ·²HØ{Ïb¶Á>¿iÙ=Ƽ«¶=ÍVqη¢L=Ç¿ik˜ÌbºÍi=eb¶=M@I ÁǻɺÀE\>(ÌfÈb¦½>nÂ(±ÇJ£ºÍFÉÂÆ(±ÇJ£ºÊVJª  „=Í[qØ6ð×>»³J[i=(Á>¿iÙ=G{ÍÉ·³Ekº>„=¬r¶=ÍF·{Ïb¶Á>¿iÙ=Ƽ«¶=ÍVq¹ÇUÍi=eb¶=ÅdÂJ£I Ëd¶=OVF·¶½>¢›Jjß¿à»[¶=›ÍF·ì¶=k«¾η¢ËfQ?1998)1999¹ÆÙ=¬r¶>E=Ǿ>²>ºb¿¢*­bÃIÊÂÆ ¼ÃÈb¶Á>¿iÙ=Ƽ«¶=ÍVqL>ie>šη¢Íi=eb¶=aÆafº¼É[ɯI‘C*Í[i=eb¶=ÅdÂK·b®Æ140ð>Éj[¾ÇIð>[F¶>{ ÍF·ì·¶Ê·³¶=ab£¶=Àº%155ð>F¶>{$‘ÆÙ=Íi=eb¶=¼ÃJ·ÀÈd¶=*ž?ÆÁ?SÑ>J¿¶=LfÃ84.3!z=fº?ÀºÁdznÈ Æ(Á>¿iڶͻ¢=b¶=ÍRj¾Ù=80.0!Æ(±>F{Ý=ÐÇiÀºÁǾ>£È43!lèÇjJ¶=ÀºÁdznÈ*Åd[¸[É·€gfE?b®Æ Á>¿[iÙ=´ÈÇj[I¹b[£º¤[«Ie=O[ÉU(Á>¿[iÙ=Ƽ[«¶=ÍV[q›ð>º>¢ð>¿èj€ͯE>j¶=Íi=eb¶=¤º;e>¯™>ESÑ>J¿¶= £ºx«Š=Æ(Ì>mf«¶>EÌeÇ^¿™=Á>¿iÙ=àGßjá¿ßºÀçj€>»²(Á>¿iڶͻ¢=b¶=ÍRj¾Ù=HÇÉQÆlèÇjJ¶=e>nJ¾=¹b ÌÇn=Æ͢Ƿ¯™=ÆDMF±>F{Ý=ÐÇi¹b£ºa=g>»²(fçɧJÈXí·í¯ ¶=Æ(­h¿¶=Æ(]bJ¶=e>nJ¾=¹b£ºÁ?bÉE(*  Impact sur la santé bucco-dentaire des étudiants tunisiens en médecine dentaire de 5 années d’études RÉSUMÉ La présente étude est un suivi de celle qui a été réalisée en 1998-1999 chez les étudiants de première année de médecine dentaire à Monastir. Alors que ces étudiants se trouvent maintenant en cinquième année, nous avons évalué l’impact des études dentaires sur leurs pratiques de santé bucco-dentaire et sur leur santé dentaire. Sur les 155 étudiants de la première étude, 140 sont toujours inscrits. Les troubles parodontaux, les malocclusions et les caries dentaires touchent 84,3 %, 80,0 % et 43,0 % des étudiants respectivement. Par rapport à la première étude, les étudiants ont un meilleur état de santé bucco-dentaire – le taux de brossage est beaucoup plus élevé, la prévalence des caries dentaires et des poches parondontales a diminué, et l’indice CAO s’est amélioré. Toutefois, la préva- lence du tabagisme, des saignements et du tartre n’a pas changé, et la fréquence des malocclusions a augmenté. 626 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Introduction One of the general objectives of teaching dentistry is to train experts whose principal task is to motivate patients to adopt good oral hygiene practices. They are more likely to be able to do this if they themselves are motivated. Reports on the impact of education on the oral hygiene of dental students differ. Both Lang et al., in a study undertaken on Danish students [1], and Cavaillon et al., in an investigation into students at the University of Paris V [2], noted a clear improvement in the oral hygiene practices of students during their studies. On the other hand, Ainamo and Ainamo, in a study on Finnish and Indian students [3], El-Mostehy et al., in an investigation of 100 Egyptian students [4], and Meister et al., in a study at the University of Marquette (Michigan) in the United States of America [5], all noted the absence of improvement in the practices of oral hygiene in students, in spite of hav- ing received information and education. Since 18 November 1975, the date of the establishment of the dental school in Tunisia, very few studies involving Tuni- sian dental students have been conducted. Among them, a retrospective survey was performed with 155 first-year dental stu- dents in 1998 (90 girls and 65 boys) from 18 to 22 years [6]. This study, which aimed to assess social conditions, school history and the oral health status of the students, showed that the most frequent oral conditions affect- ing the students were periodontal diseases (88.4%), dental caries (70.3%), malocclu- sion (62.6%) and fluorosis (52.3%). In this study we report the results of a follow-up descriptive study carried out 5 years later on the same sample of stu- dents when they were in their final year (2002–2003). The study aimed to assess the changes in oral health indicators and analyse the effect of dental studies on the students’ oral hygiene practices. Methods Of the 155 Tunisian dental students regis- tered in the first year for the academic year 1998–1999, 140 went through to the final year in 2003. These students were aged from 21 to 25 years [mean 22.7 (SD 0.7) years]. About 53.6% of them came from medium socioeconomic background (based on parental jobs) and women constituted more than half the sample (61.4%). To assess the prevalence of oral dis- eases, the students were examined by the same dentist at the university dental clinic. The clinical examination was performed according to the World Health Organization (WHO) criteria using normal dental exam- ining instruments (mouth mirrors, explorers and WHO periodontal probe) [7]. Data were recorded on a simplified WHO form [7]. The decayed (D), missing (M) and filled (F) teeth index (DMF) and the commu- nity periodontal index for treatment needs (CPITN) were calculated. In addition, the students were requested to complete a self- administered questionnaire about oral hy- giene, habits and choice of professional practice. Data were analysed using Epi-Info, 6.04 and compared with the previous study. The Pearson chi-squared test was used to com- pare different percentages at the 5% level of significance [8]. Results The findings revealed that three-quarters of students (75.0%) intended to choose a career in the private sector after graduating, Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 627 either as specialists (44.0%) or as general practitioners (46.4%); only 7% wanted to teach in dental school. As regards oral hygiene practices, 86.0% of the students brushed their teeth at least twice a day; the mean frequency of daily tooth brushing was 2.52 (SD 0.89). The majority of our sample used a com- mercial toothpaste (91.4%) and about half of them used one or more means comple- mentary to brushing, mouthwash (25.7%), flossing (2.9%), other (10.7%), more than one (10.7%). Nearly 18% of the students smoked (14.3% men and 3.7% women) with an average of 15 cigarettes per day. Over 90% of them had visited a dentist prior to the previous year, but only 64.3% had seen a dentist in the last year, generally for a periodontal concern (in 13% of cases). Of these, 12.9% were for periodontology, 10.7% for oral surgery, 10.7% for dentistry concerns and 3.6% for orthodontics. Table 1 shows the dental conditions affecting the students: 112 students had malocclusion; 31.4% of these needed or- thodontic treatment, but only 3.6% were already having such treatment. Periodontal problems affected 84.3% of the students; fortunately 75.6% of these lesions were reversible; calculus was the most frequent periodontal problem (55.8% of students), on average found in 3 sextants of dentition (Table 1). Regarding dental caries, 43.0% of stu- dents were affected. The D, M and F scores among the 140 students were: 147 decayed (mean 1.05), 21 missing (mean 0.15) and 157 filled (mean 1.12) teeth giving 325 affected teeth overall and mean DMFT of 2.32. Dental fluorosis affected 23 (16.4%) of our sample, primarily Dean stages 2 and 3 (Table 2). More girls (75%) opted for private prac- tice (25%) than boys (χ2, P < 0.0001). The rate of smoking among the students had increased since 1998 but the difference between the 2 periods was not significant. Comparison with previous study Table 3 gives a comparison of the results of the 1998–1999 study compared with the current study. In 1998–1999, 30% of the students were undecided on what career to take up after graduation. In the current study, only 3.6% were still undecided (P < 0.0001). Three- quarters of all the students had chosen pri- vate practice (75.0%) (Table 3). Table1 Prevalence of malocclusion and periodontal disease by sex in the dental students Condition Males (n = 54) Females (n = 86) Total (n = 140) No. % No. % No. % Malocclusion Mild 21 39.0 47 54.7 68 48.6 Moderate or severe 21 39.0 23 26.7 44 31.4 Periodontal diseasea Bleeding 11 20.4 19 22.0 30 21.4 Calculus 29 53.7 49 57.0 78 55.7 Pockets (4–5 mm) 4 7.4 6 7.0 10 7.1 aMean no. of sextants (standard deviation) affected with bleeding = 0.32 (0.77), with calculus = 3.24 (2.28) and with pockets = 3.69 (2.72). 628 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 A large proportion of the students (77.4%) brushed their teeth twice daily or more in 1998–1999. This improved appreci- ably in 2002–2003 to 86.5% (P < 0.05). In addition, more students used commercial toothpaste than pharmaceutical ones in the current study compared with the previous one (P < 0.0001) and also used additional means of hygiene, primarily mouthwash (P < 0.0001). More students had visited the dentist than in the previous study (P < 0.0001) because of greater motivation and ease of access to dental consultation. Therefore the dental therapeutics index had increased from 19.1% 5 years ago to 51.6% in 2003 (P < 0.0001), notably those of periodontology and oral surgery. The prevalence of malocclusion had in- creased appreciably (P < 0.0001) as a result of an increase in the rate of mild malocclu- sion from 28.4% to 48.6%, which may be due to a noncompensated dental extraction and/or differences in judgement between the 2 investigators. The rate of moderate to severe malocclusion remained unchanged (31%) suggesting insufficient orthodontic management. Table 2 Prevalence of dental fluorosis among the dental students by Dean stage Dental fluorosis stage No. (n = 140) % Questionable 4 2.9 Very mild 7 5.0 Mild 11 7.9 Moderate 1 0.7 Severe 0 0 Total 23 16.4 Table 3 Comparison of students’ practices and dental status between 1998 and 2003 Variable 1998–999 2002–2003 Success rate in (n = 155) (n = 140) exams (%) % % Males 42.0 38.6 83.0 Females 58.0 61.4 95.5 Future practice χ2, Significance Private 61.3 75.0 6.33, P < 0.01 Undecided 30.0 3.6 18.53, P < 0.0001 Practised oral hygiene 77.4 86.5 3.99, P < 0.05 Use of commercial toothpaste 70.0 91.4 19.72, P < 0001 Use of additional means of hygiene 30.3 50.0 34.11, P < 0.0001 Ever visited dentist 63.2 90.7 30.7, P < 0.0001 Mild malocclusion 28.4 48.6 12.7, P < 0.0001 Periodontal pockets (4–5 mm) 20.0 7.1 10.16, P < 0.001 Dental caries 70.3 42.8 22.68, P < 0.0001 Therapeutics index (had undergone dental treatment) 19.1 51.6 34.97, P < 0.0001 Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 629 As in 1998, the prevalence of periodon- tal trouble remained at an alarmingly high level (84.3% in 2002–03 versus 88.4% in 1998–99) but the difference was not statisti- cally significant. Detailed analysis showed that the rate of shallow pockets (4–5 mm) however had appreciably decreased (P < 0.001) (Table 3). The prevalence of dental caries had significantly decreased since 1998 from 70.3% to 42.8% (P < 0.0001 ). In the DMF index, we noted a clear reduc- tion in the D component, an improvement in the F component, and the M component remained the same. Discussion The predominance of women seen in our study was also noted in other countries such as France [3,9,10], the United States [11] and Japan [12,13]. With an average academic success rate of 95.5%, the women were ahead of the men. Tooth brushing fre- quency was significantly higher in girls (P < 0.0001); Polychronopoulou et al. noted the same tendency in Greece [14]. Although the girls brushed their teeth more frequently, the boys had lower frequency of periodontal trouble: 81.5% versus 86.0% (P < 0.01). Private practice attracted most of the students which is in agreement with Cross- ley and Mubarik [15]. Teaching as a career attracted only a few students. More girls opted for hospital practice than boys, possi- bly because of family responsibilities, safety and job security. Winters and Butters noted the same tendency in their study [16]. The rate of smoking among the students had increased since 1998 but the difference between the 2 periods was not significant. In the current study, the prevalence of smoking was greater in males (P < 0.0001) as was also shown by Ghannem et al. and a WHO report which reported males consti- tuting 70% of smokers in the world [17,18]. A large body of epidemiological research indicates that tobacco use is generally as- sociated with periodontal disease [19–21]. The percentage of smokers in 2002–2003 remained lower than that reported in a study by Malbrunot where 33% of dental students of Clermont Ferrand (France) smoked [10], but it was about the same as that noted by Fakhfakh who reported that of 257 Tunisian medical students examined, 24% smoked [22]. An effort needs to be made to tackle this problem especially as these students, as health professionals, should be setting a good example. This is supported by the study of Koerber, Crawford and O’Connell in the United States [23]. Yip et al. have gone as far as suggesting including an ac- tion against smoking in this direction in the American dental course [24]. The paradox between a large percentage of students brushing their teeth (86%) and a high prevalence of periodontal lesions (84%) was also reported by Carlos et al. in their study on 100 Philippine dental stu- dents who had excellent oral hygiene [25]. They explained this by bad tooth brush- ing techniques, inadequate toothbrushes or over-brushing. Regarding periodontal treatment needs, 84.3% of our students re- quired oral hygiene improvement and 78% required scaling. In spite of some changes, statistically, we had overall in 2003 the same population of students as that of 1998. Therefore, we can consider that our comparisons are valid and justified. However, there may be a pos- sible difference in judgement between the 2 investigators in the 2 studies, which is a frequent bias in a “before–after” survey. In general, at the end of their course, the dental students had achieved a better dental 630 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 health status, particularly in the following areas: the tooth brushing rate, which was much higher; the prevalence of dental decay had de- creased; the DMF index, where the D component had decreased whereas the F component had clearly increased; the rate of periodontal pockets had de- creased. In spite of these improvements, there were the following negative points: • smoking prevalence had not decreased; • • • • • the prevalence of bleeding and calculus had not changed; • the frequency of malocclusion had in- creased. Dental school lecturers should address the dental practices of their students and consider introducing modifications to the courses tackling this issue. Acknowledgement The authors are grateful to all those who helped them in this study, especially the dental students. References 1. Lang NP, Cumming BR, Loe HA. Oral hy- giene and gingival health of Danish dental students and faculty. Oral epidemiology, 1977, 5:237–42. 2. Cavaillon JP et al. Longitudinal study on oral health of dental students at Louis VII University. Community dentistry and oral epidemiology, 1982, 10:137–43. 3. Ainamo J, Ainamo A. Development of oral health during studies in India and Finland. International journal of dentistry, 1978, 24:427–33. 4. El-Mostehy MR, Zaki ATT. The dental stu- dent’s attitude towards the profession as reflected in his oral cavity. Egyptian dental journal, 1996, 15:104–9. 5. Meister F Jr et al. Comparison of the oral hygiene and periodontal health status of a class of dental students as freshmen and as seniors. Journal of preventive dentistry, 1980, 6:245–52. 6. Maâtouk F et al. Profil de l’étudiant de première année médecine dentaire en Tunisie. Revue de santé de la Méditer- ranée orientale, 2001, 7(1–2):52–9. 7. Oral health surveys. Basic methods, 4th edition. Geneva. World Health Organiza- tion, 1997. 8. Abramson JH, Abramson ZH. Making sense of data: A self-instruction manual on the interpretation of epidemiological data. New York, Oxford University Press, 2001. 9. Demoor J, Vandendrissche J. Change- ment dans le monde des dentistes. Re- vue belge de médecine dentaire, 1982, 37(5):209–14. 10. Malbrunot X. Situation socio-économique des étudiants enodontologie à Clermont– Ferrand en 1991/1992 [Thèse chirurgie dentaire]. Clermont–Ferrand, 1993. 11. Hyson JM Jr. Women dentists: the origins. Journal of the California Dental Associa- tion, 2002, 30:444–53. 12. Kawamura M et al. A cross cultural com- parison of dental health attitudes and be- havior among freshman dental students in Japan, Hong Kong and West China. Inter- national dental journal, 2001, 51:159–63. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 631 13. Motoko A et al. [The relationship among eating, lifestyles and oral health status of students.] Kokubyo gakkai zasshi, 2002, 69:290–5 [In Japanese]. 14. Polychronopoulou A, Kawamura M, Atha- nasouli T. Oral self-care behavior among dental school students in Greece. Journal of oral science, 2002, 44:73–8. 15. Crossley ML, Mubarik A. A comparative investigation of dental and medical stu- dent’s motivation towards career choice. British dental journal, 2002, 193:471–3. 16. Winter PA, Butters JM. An investigation of dental student practice preference. Jour- nal of dental education, 998, 62(8):565–72. 17. Ghannem H et al. Study of cardiovas- cular disease risk factors among urban schoolchildren in Sousse, Tunisia. East- ern Mediterranean health journal, 2000, 6(5–6):1046–54. 18. Tobacco or health: a global status re- port. Geneva, World Health Organization, 1997. 19. Papapanou PN. Periodontal diseases: epidemiology. Annals of periodontology, 1996, 1:1–36. 20. Hashim R, Thomson M, Pack A. Smoking and periodontal diseases. Dental news, 2002, 9(4):9–21. 21. Howat A, Trabelsi I, Bradnock G. Oral hy- giene levels and behaviors in pre-clinical and final-year dental students. Journal of clinical periodontology, 1979, 6:177–85. 22. Fakhfakh R. Le tabagisme des étudiants en médecine en Tunisie: tendance des comportements et des attitudes. Cahiers de Santé, 1996, 6(1):37–42. 23. Koerber A, Crawford J, O’Connell K. The effects of teaching dental students brief nutritional interviewing for smoking– cessation counseling: a pilot study. Jour- nal of dental education, 2003, 67:439– 47. 24. Yip JK et al. Dental students’ attitudes toward smoking cessation guidelines. Journal of dental education, 2000, 64:641–50. 25. Carlos MC et al. The prevalence and distribution of gingival recession among UE dental students with a high standard of oral hygiene. Journal of the Philippine Dental Association, 1996, 47:27–48. 632 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Dimensional accuracy of 3 silicone dental impression materials A.K. Hassan1 1Medical Services of Qatar Armed Forces, Doha, Qatar (Correspondence to A.K. Hassan: amir_ alagidi@yahoo.com). Received: 12/01/04; accepted: 01/03/05 ABSTRACT This study was carried out to measure the dimensional changes in silicone impression material, which can affect the fitness of the prosthesis. Using both single and double mix techniques, 20 impression samples for each of 3 different proprietary silicones, Xantopren-H, President and Fulldent, were made. Selected measurements were made on the stone casts made from each impression. In all 3 cases, the single mix gave more accurate casts than the double mix technique. The Xantopren-H impressions had the most accurate dimensions. 8 Dimen ional accuracy of three silicone dental impression materials ÍɾdzɷÉj¶=ÍÉ¿j¶=L>£Fì¶=a=ǺÀºPØN¶a>£EÙ=ÍäÉ{ÇFvº ÀjUb¶>]fº>¢  „=Í[qØ6£Fì¶=a=Ǻ›a>£EÙ=›L=fèɧJ¶=l>ɯ¶Íi=eb¶=ÅdÂKÈfQî?fë[[MÖIb[®[¶=Æ(ÍɾdzɷÉj[¶=ÍÉë¿j¶=L> ÍÉ¿j¶=L×bF¶=ͺÐغη¢*a=b¢Cb®Æ20Ê[ÂÆ(Í[MØN¶=ÍɾdzɷÉj[¶=a=Ç[™=À[º¸[³¶ÍÉ¿j[¶=L>[£F췶Ϳɢ ÀÈfEÇJ¾=h¶=–bUÆÙ=Th™=ÆTÆah™=Th™=±f{½=b^Ji>E´¶cÆ(K¾b¶ÇªÆK¾bÈhÈfEÆ[Â*L>[i>É®KÈfQî?¼M ®η¢Ì>¯J¿ºK[¶A>šÍ®afN²?G¶=Ç®‘CbUÆÙ=Th™=Ïa?>ãɖÍMØN¶=L×>ƒ=›Æ(Í£F{¸³¶ÍÈfRUG¶=Ç TÆah™=Th™=ͯÈf{ÄɶC*ÀÈfEÇJ¾=h¶=L>£F{K¾>²Æ–ðÍçÉ{ÇFvºfN²Ù=L>£Fì¶=ÊÂ[Â*  Exactitude dimensionnelle de trois matériaux d’empreinte dentaire à base de silicone RÉSUMÉ La présente étude a été réalisée pour mesurer les changements dimensionnels du matériau d’empreinte dentaire à base de silicone qui peuvent affecter l’ajustement de la prothèse. Au moyen des techniques des simple et double mélanges, 20 prélèvements d’empreintes ont été effectués pour chacune des trois différentes silicones : Xantopren H, President et Fulldent. Certaines mesures ont été réalisées sur des moulages en plâtre fabriqués à partir de chaque empreinte. Dans l’ensemble des trois cas, le simple mélange a produit des moulages plus précis que la technique du double mélange. Les empreintes Xantopren H avaient les dimensions les plus précises. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 633 Introduction Several studies have been carried out aimed at enhancing the physical properties of silicone impressions. Of the physical prope erties which may adversely affect the fit and retention of dental prostheses, dimene sional change in the impression material is considered the most serious. It is therefore considered the main feature of any imprese sion material, and needs to be taken into consideration to achieve a good restoration [1,2]. Accuracy of impressions depends on the composition and manipulation teche nique of the impression as well as the die cast material itself [1,3]. A number of stude ies have been carried out to evaluate the accuracy of impression techniques [4–8]. In many, metal or ceramic casts were used [9–11]; acrylic resin casts have also been used [10]. The mixing technique for silicone ime pressions can be either single or double mix. This study was carried out to examine the dimensional accuracy of 3 silicone imprese sion materials and the single and double mixing techniques for each of them. Methods This study was carried out in 2003 in Garafa Medical Complex, Doha, Qatar. Sample impressions made with 3 differe ent silicones, XantopreneH (Bayer Dental, Leverkusen, Germany), President (Coltene AG, Altsatten, Switzerland) and Fulldent (JTCeFulldent SA, Arsier, Switzerland) were used to prepare stone casts (GC Come pany, Tokyo). For each material, 20 imprese sions were made, 10 using the single mix technique and 10 using the double mix. All the impressions were mixed following the manufacturer’s instructions. The single mix technique was carried out by mixing and applying the putty (heavy body) and allowe ing it to harden before applying the wash (light body). The double mix technique was carried out by mixing the heavy and light bodies together before applying. The impressions were taken over a resin master cast. This was used in view of its low wettability, low thermal conductivity and low price [12]. Undercut areas of the cast, especially in the embrasure areas, were blocked out with cold cure acrylic prior to impression. Reference grooves to be used as mease urement points were first cut on the mase ter cast using a wide, straight fissure bur (the grooves would then be duplicated on the stone casts produced from the experie mental impressions). These grooves were positioned as follows: on the buccolingual surface of the distobuccal cusp of the left second molar, on the buccolingual surface of the buccal cusp tip of the first premolar; and mesiodistally on the distolingual cusp of the left and right first molars [10]. Three measurements were taken for each cast by measuring the distance between the left first premolar and the distobuccal cusp of the left second molar (mesiodistal) and a straight measurement (buccolingual) was taken between the distolingual cusp of the first molar and the distolingual cusp on the opposite side (Figure 1) [10]. The third measurement (diagonal) was taken from the left first premolar to the mesiobuccal cusp tip of the right second molar [10]. These measurements were carried out in duplicate for the casts made from each of the 3 materials and the mean distances cale culated. All measurements were taken by a single examiner using an electronic vernier calliper. Measurements of the resin master cast were taken in a similar manner as for the controls. 634 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Results Table 1 shows the reference measurements for the master cast. The results obtained for each measurement of each subgroup, single and double mix, are shown in Table 2. XantopreneH silicone gave the most accurate dimensions as the measurements taken were almost equal to the dimensions of the standard master cast. The other 2 silicones showed slight dimensional inace curacy. For all 3 materials, the single mix same ple showed better accuracy than the double mix, but the differences were not statistie cally significant. Discussion Silicone is considered one of the best availe able impression materials for fixed prose theses [2,3]. The dimensional accuracy of different silicone impression materials and the benefit of different mixing procedures, single and double mix, were studied. The mixing technique is considered an essential factor in impression accuracy [9,10]. The difference between single and double mix in accuracy and elasticity may be attributed to the rate of polymerization: faster polyme erization will prohibit the penetration of free radicals. The light body component oce cupies a minute volume, so its effect on the resultant deformation will be slight [4,5]. In this study it was shown that Xantoe preneH gave better dimensional accuracy than President and Fulldent impressions. Figure 1 Diagram showing the reference points and measurement lines (DL = diagonal; MD = mesiodistal; BL = buccolingual) on the casts Table 1 Measurement of master cast Line Teeth Distance (cm) Mean (SD) Buccolingual 6–6 4.5 (0.6) Mesiodistal 4–7 (same side) 3.0 (0.2) Diagonal 4–7 (opposite sides) 5.2 (0.1) SD = standard deviation. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 635 Besides, the study illustrates that the single mix techniques is better than the double mix technique in all samples. This agrees with the findings of previous studies, which recommend using single mix rather than double mix [10,12–15]. Table 2 Measurement of casts made from the 3 test materials Line Distance (cm) Fulldent mix President mix Xantopren-H mix Single Double Single Double Single Double Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Buccolingual 4.1 (0.8) 4.1 (1.0) 4.0 (1.6) 4.0 (0.2) 4.5 (0.6) 4.1 (1.6) Mesiodistal 2.8 (0.7) 2.9 (1.1) 2.9 (1.5) 2.9 (1.2) 3.0 (0.8) 3.0 (0.2) Diagonal 5.0 (0.3) 5.1 (1.2) 5.1 (1.7) 5.1 (0.8) 5.1 (0.9) 5.1 (1.0) SD = standard deviation. A 3escale measurement was used for each sample to minimize the effect of ere ror in the results. Therefore, it is believed that this method is the best and the most suitable for dimensional accuracy tests of elastomeric impressions. References 1. Shillinburg HT Jr et al. Fundamentals of fixed prosthodontics, 3rd ed. Chicago, Quintessence Publishing, 1997:281–305. 2. Rosenstiel S, Land MF, Fujimoto J. Con- temporary fixed prosthodontics, 2nd ed. St. Louis, Mosby, 1998:332–6. 3. Philips RW. Skinner’s science of dental materials, 9th ed. Philadelphia, WB Saun- ders, 1991:265–78. 4. Osrland G. Some properties of rubber base materials. Odontologisk tidskrift, 1957, 65:94–104. 5. Brown D. An update on elastomeric im- pression. British dental journal, 1981, 150(2):35–40. 6. Dahl BL, Dymbe B, Valderhaug J. Bond- ing properties and dimensional stability of hydrocolloid impression. Journal of pros- thetic dentistry, 1985, 53(6):796–800. 7. Chen SY, Liang WM, Chen FN. Factors affecting the accuracy of elastomeric im- pression materials. Journal of dentistry, 2004, 32(8):603–6. 8. Sawyer HF, Sandrik J, Neiman R. Accu- racy of casts produced from alginate and hydrocolloid impression materials. Jour- nal of the American Dental Association, 1976, 93:806–8. 9. Shaheen HM. A new method for evaluat- ing deformity of alginate impression ma- terial from the practical aspect. Egyptian dental journal, 1974, 20(2):43–8. 10. Instruments and devices. Chicago, Ameri- can Dental Association, 1970 (Specifica- tion no. 19). 11. Cohen BI et al. Dimensional accuracy of three different alginate impression ma- terials. Journal of prosthodontics, 1995, 4(3):195–9. 12. Mansfield MA, Wilson HJ. Elastomeric impression materials. A comparison of methods for determining working and setting times. British dental journal, 1972, 132(3):106–10. 13. Goldberg AJ. Viscoelastic properties of silicone, polysulfide, and polyether im- 636 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 pression materials. Journal of dental re- search, 1974, 53(4):1033–9. 14. Kaloyannides IM. Elasticity of elastomer impression materials: 11. Permanent de- formation. Journal of dental research, 1973, 52(4):719–24. 15. Martignoni M, Schonenberger L. Precision fixed prosthodontics: clinical and labora- tory aspects, 1st ed. Chicago, Quintes- sence Publishing, 1990:33–56. Oral Health Country/Area Profile Programme The WHO Oral Health Country/Area Profile Programme (CAPP) was established in collaboration with WHO Noncommunicable Diseases Cluster, several WHO Collaborating Centres, and organizations and individuals around the world in 1995. The objective of CAPP is to present global information on dental diseases and oral health services for various countries/areas. The main server is located at the WHO Col- laborating Centre for Education, Training and Research at the Faculty of Odontology, Malmö, Sweden. CAPP has developed enormously over the past decade, dealing with an average of 7934 successful requests per day (December 2005). The database can be accessed from the CAPP home page at http:// www.whocollab.od.mah.se/. Data for countries of the WHO Eastern Mediterranean Region can be found at: http://www.whocollab.od.mah. se/emro.html Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 637 ÏbUCL>É«nJjº›ͪ>Ÿ¿¶=¹>»£¶ÍɿÙ=ͺØj¶=¤®=ÆÍÉ¿Éìj·«¶=L>Ÿª>=  GÉì„=b—?½>r¢1 Íq؄=6(ÍÉ¿Éìj[·«¶=L>É«nJj™=›ͪ>Ÿ¿¶=¹>»£¶ÍɿÙ=ͺØj¶=¤®=Æη¢ÐÇv¶=œÉ·jI‘CÍi=eb¶=Åd­bÃI nJj™=Åd›ÍÉFì¶=L>È>«¿¶=¤ºÊ{>£J¶=¤®=ÇE´¶cͮآÆL>É«*ͺØj[¶=ÏÇJj[ºÁ?Íi=eb¶=SÑ>J¾ÀºFIb¯¶ ÀºfN²?Á?Æ(ÍÉr^n¶=ÍÈ>®Ç¶=L=çb£º¼Ã»Ÿ£ºÏb¶fª=ÇJI×cC(HÇ·ì™=ÏÇJj™=ÁÆaͪ>Ÿ¿¶=¹>»£¶ÍɿÙ=40! ÍÉFì¶=L>È>«¿¶=¤ºÄ·º>£IÐ>¿M?fEÝ>Eh]Ç·¶zf£Ib®¼Ã¿º*[U>¯·¶=Ð>[ì¢ÝÌab[†Í[i>ÉiaÇ[Qƽb¢ UǶÆL> ÅÐ>[¿M?Æ?¬[ɞÇJ¶=¸[F®Í[ÉF{L>[qÇVªÐ=f[QC¼JÈ׾?>»²(ÍÈb£™=z=fºÙ=Àº¼ÃJÈ>®Ç¶ͪ>Ÿ¿¶=¹>»£¶*a>[ª?Æ 37.2!Á?Æ(ÍÉFì¶=L>È>«¿¶=¤ºÊ{>£J¶=Íɫɲ¹ÇU>FÈebI=ǯ·I¼Ã¾@Eͪ>Ÿ¿¶=¹>»¢Àºœ¯ª23.2!ÁÇ·»£È¼Ã¿º 15aÇQƽb¢ UǶÆ(½Çɶ=›fN²?Æ?Í¢>iÁ?F[IcC(¼Ã[·»¢›Í[ª>Ÿ¿¶=¹>[»£¶e=f¯Ji=55.8!¹>[»¢À[º Ϋn[Jj™=›¼Ã[·»¢Î[·¢¸[®?Æ?b[U=ƽ>[¢ÏÇi=Çàvá»àÈͪ>Ÿ¿¶=*F[²½>[»JÂ=aÇ[Qƽb[¢ UÇ[¶´¶d[² [È>«¿¶=¤[º¸[º>£J¶>EÍ[q>„=Í[ÉJVJ¶=ÍÉ¿F¶=›F²s¯¾µ>¿ÂÆ(¼Â>ue°É¯€ÆÍɿÙ=¹>»£¶=ͺØjE¶ÆÖj»·¶L> Î[·¢¼Ã[·»£E½>[ɯ¶=À[º¼Ã¿[ɳ»J¶7¼>ªÇIʧF¿ÈL>É«nJj™=›ͪ>Ÿ¿¶=¹>»£¶ÌN²L>Q>ÉJU=µ>¿ÂÆ(ÍÉFì¶= ¼Ã·»¢À¢Ð>uf¶=ƼÍɿÙ=ͺØj¶=°É¯€Æ(ÄQÆ]*  Occupational safety of cleaning personnel in Palestinian district hospitals ABSTRACT This study examined occupational safety among cleaning workers in Palestinian hospitals and its relation with the medical waste management in these hospitals. The level of occupational safety was below standard requirements, as protective equipment and clothes are not available for most workers. Over 40% of workers had been pricked with needles while handling medical waste. There was no clear policy for vaccination of workers against infectious diseases and no medical examination for workers before or during employment. Only 37.2% were trained in handling medical waste and 23.2% were working 15 hours per day or more; 55.8% had spent 1 year or less in their work. ìj·ª(KÈgEÍ£º>Q(ÍÉ£»J=Æͺ>£¶=ÍVr¶=bãº)1(  ikhatib@birzeit.edu ʾƳ¶Ý=bȶ=(GÉì„=b—?½>r¢6 ½ØJi×=613/10/05(¹ÇF¯¶=626/12/05  Issam A. Al-Khatib. Institute of Community and Public Health, Birzeit University, Palestine. ccupational safety of cleaning personnel in Palestinian district hospitals ABSTRACT This study examined occupational safety among cleaning workers in Palestinian hospitals and its relation with the medical waste management in these hospitals. The level of occupational safety was below standard requirements, as protective equipment and clothes are not available for most workers. Over 40% of workers had been pricked with needles while handling medical waste. There was no clear policy for vaccination of workers against infectious diseases and no medical examination for workers before or during employment. Only 37.2% were trained in handling medical waste and 23.2% were working 15 hours per day or more; 55.8% had spent 1 year or less in their work. La sécurité au travail du personnel de nettoyage dans des hôpitaux de district palestiniens RÉSUMÉ La présente étude a examiné la sécurité au travail chez les agents de nettoyage des hôpitaux palestiniens et sa relation avec la gestion des déchets médicaux dans ces hôpitaux. Le niveau de séc curité au travail n’était pas conforme aux normes exigées, l’équipement et les vêtements de protection n’étant pas disponibles pour la plupart des employés. Plus de 40 % des agents s’étaient piqués avec des aiguilles lors de la manipulation des déchets médicaux. Il n’y avait pas de politique claire pour la vaccination du personnel contre les maladies infectieuses et pas de visite médicale pour le personnel avant ou pendant l’emploi. Seuls 37,2 % des agents étaient formés à la manipulation des déchets médicaux et 23,2 % travaillaient 15 heures par jour ou plus ; 55,8 % occupaient cet emploi depuis 1 an ou moins. 638 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 2 ëb¯™=ͺ º>¢ÄÈaÖÈËd¶=¸»£¶=HÇ·i?Æ­ÆfžÆÍ£ÉF{ÁCª>Ÿ¿¶=¸L>É«nJj™=›Íz=fº@EÄJE>qÝ>âFFiÁdzÈÁ?À³• ÄI>ÉUÆÄJVqη¢fMÖI¸»¢L>E>qCÆ(ÄJÉQ>J¾CÆÄIÐ>«²Àº¸·¯IÆ(¤[»J=>r[ºÆL>ºb[]Î[·¢ʶ>[J¶>EfMÖIÆ ͶÆb¶=Æ*¸º>£ªJ£ÈΫnJj™=›ͪ>Ÿ¿¶=âfr¿¢=Éi>i?7Íɺǻ£¶=ÍVr¶=ÆΫnJj™=ͪ>Ÿ¾η¢͟ª>=›ð>d¶G‹= äÉVqÄJÈ>¢eÆÄJÈ>—ð>äÉj«¾Æð>›Äɪj¶=Ķeäbî®Æ?Åe>J]=Ëd¶=¸»£¶=Í£ÉF{ÄÉ·¢>Ãj³£I¶=­ÆfŸ¶=Æe>MÛ=Àº Ì>Ƀ=ÅdÂ*  ¼J[ÈÁC(Í[ɺǻ£¶=ÍVr[¶=Ƥ[»J=Î[·¢ÍÉF·j[¶=>[Âe>MAGFj[E´[¶cÆ7Ìfì]L>È>«¾ÍÉFì¶=L>È>«¿¶=J£I ¼É·i¸³nE>㺸º>£J¶=*H>[ÃJ¶=¸[NºÍ[ÉFì¶=L>[È>«¿¶=°[Èf{À[¢¸¯J¿IÁ?À³•¶=z=fºÙ=ÀºbÈb£¶=´¶>¿Ãª ÊiÆ«¶=bF³¶=ÊEÊiÆ«¶=bF³¶=H>ÃJ¶=ÆÊiz=fºÙ=Àº>ÃɶC>ºÆgbÈÝ=Æ]1[(zf[£J¶=°[Èf{À¢´¶cÆ d¸N™·º>ƒ=Îuf™=½bEÍMÇ·™=fEÝ>²Ìa>ƒ=ÍÉFì¶=L>«·^™>E\ÆfR·¶¸ë[[N“L>É«n[Jj™=Á?e>[FJ¢>E(¼ÉM=f‚=Å ÍÉFì¶=L>È>«¿¶=T>J¾ÝÊjÉÑf¶=ebr™=*  Í[ÉFì¶=L>[È>«¿·¶Í[«·J^™=L>¾Ç³™=hÉÉ»J¶ͺb^Jj™=¬É¿rJ¶=Í»Ÿ¾?ÀºbÈb£¶=´¶>¿Â(Æ[¶=b[·EÀ[º¬[·J f]Û(Ïf]ÙÍjiÖºÀºÆ?*Æb®Íə>£¶=ÍVr¶=Í»Ÿ¿ºK£uÆb[¶>Eð>[q>]ð>«É¿r[I¹ÆÍ[ɺ>¿¶=(z=f[¦Ù´[¶cÆ ÍÉ·»¢(Ê·È>º›ÄrÉ^·IÀ³•Æ]2[6  %?$ ¶=L>È>«¿¶=¦ÍÉFì„=Ìfì%¶=L>È>«¿¶=ͺ>£$  %H$Ù=L=ÆaÌa>ƒ=  %T$¶=L>È>«¿™=ÏÆb£·¶ÍFFj%¦ÍÈb£™=Ìa>ƒ=Ð>ÉmÙ=$  %a$¶=L>È>«¿¶=ÆÍÉÑ>ɻɳ¶=ÍÉFì  %[Â$ÉFì¶=Ìfì„=L>È>«¿¶=Àº>Â¦Í  ½>j®?Íj˜‘CÄìÉjFIÍɺ>¿¶=¹Æb¶>Et>„=¬É¿rJ¶==dÂ([íª¸Ãj[ÈÎJUárà¸Í[ÉFì¶=L>[È>«¿¶=(>[ãɻÆ( >ÿÈhÆ(>÷¯¾Æ¸]=a>ÃQe>]ÆÍÉFì¶=Íji֙=*ľCcC­>¿[qÙ=La=ag=>[»·²(>[ÿÈhÆ>[ã–Æ>÷r[ªXF[q? 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Standard handbook of hazardous waste treatment and disposal. New York, McGraw–Hill, 1989. 10. Baker KH, Herson DS, eds. Bioremediation. New York, McGraw–Hill, 1994. 11. Hasan SE, ed. Geology and hazardous waste management. Upper Saddle River, New Jersey, Prentice Hall, 1998. 12. Cropley M, Steptoe A, Joekes K. Job strain and psychiatric morbidity. Psychological medicine, 1999, 29:1411–6. 13. Mausner-Dorsch H, Eaton WW. Psychosocial work environment and depression: epidemiologic assessment of the Demand–Control model. American journal of public health, 2000, 90:1765–70. 14. Kuper H, Marmot M. Job strain, job demands, decision latitude, and risk of coronary heart disease within the Whitehall II study. Journal of epidemiology and community health, 2003, 57:147–53. 15. Parslow RA et al. The impact of employee level and work stress on mental health and GP service use: an analysis of a sample of Australian government employees. BMC public health, 2004, 4(1):41. 16. Michie S, Wren B, Williams S. Reducing absenteeism in hospital cleaning staff: pilot of a theory based intervention. Occupational and environmental medicine, 2004, 61:345–49. f 1. Safe management of wastes from healthc care activities. Geneva, World Health Organization, 1999. 2. Managi g medical wa te in devel ping countries. Geneva, World Health Organic zation, 1994. 3. FacilitiesNet. Managers in h alth care orc ganizations search for opportunities and resources that can make facilities more environmentally friendly. Trade Press Publishing Corp ration, 2005 (http://www. facilitiesnet.com/ms/article.asp?id=3228, accessed 17 July 2006). 4. Anderson GK. Incineration as a waste disposal option in EMRO. Amman, World He lth Organization Regi nal Office for the Eastern Medit rranean, 1995. 5. Hall T. Health care waste management handbook. Gateshead, Environmental Technology Con ultants Limited, 1994. 6. Monreal J. Considerations on the managec m nt of hospital w stes in Latin America. Washington DC, Pan American Health Organization, 1991. 7. Medical waste management in the United States. First Interim Report to Congress. Washington DC, United States Environc mental Protection Agency, Office f Solid Waste, 1990 (EPA/530cSWc90c051a). 8. Management of waste from hospitals. Copenhagen, World Health Organizati n Regional Office for Europe, 1985. 9. Freeman HM, ed. Standard handbook of hazardous waste treatment and disposal. New York, McGraw–Hill, 1989. 10. Baker KH, Herson DS, eds. Bioremediac tion. New York, McGraw–Hill, 1994. 11. Ha an SE, ed. Geology and hazardou waste manag ment. Upper Saddle River, New Jersey, Prentice Hall, 1998. 12. Cropley M, Steptoe A, Joekes K. Job strai a d psychiatric morbidity. Psychoc logical medicine, 1999, 29:1411–6. 13. MausnercDorsch H, Eaton WW. Psychoc social work environment a d depresc sion: epidemiologic assessment of the Demand–Control model. American jourc nal of public health, 2000, 90:1765–70. 14. Kuper H, Marmot M. Job strain, job dec mands, decision latitude, and risk of c roc nary heart disease within the Whitehall II study. Journal of epidemiology and comc munity health, 2003, 57:147–53. 15. Parslow RA et al. The impact of employee level and work stress on mental health and GP service use: an analysis of a samc ple of Australian government employees. BMC ublic health, 2004, 4(1):41. 16. Michie S, Wren B, Williams S. Reducing absenteeism in hospital cleaning staff: pilot of a theory based intervention. Occ cupational and environmental medicine, 2004, 61:345–49. 17. Anderson GK. Clinical waste disposal. Amman, World Health Organization Rec gional Offic for the Eastern Mediterrac nean, 1992. 18. NHS Estates, Health Guidance Note. Safe disposal of clinical wa te whole hosc pital policy guidance. London, Her Majesc ty’s Stationery Office, 1995. 652 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 .19 .2001 20. Ferrie JE et al. Effects of chronic job security and change in job security on selfcreported health, minor psychiatric morbidity, physiologic measures, and health related behaviours in British civil servants: the Whitehall II Study. Journal of epidemiology and community health, 2002, 56:450–4. 21. Australian Public Service Commission. Management Advisory Committee. Orc ganisational renewal. Canberra, Comc monwealth of Australia, 2003. 22. D’Souza R et al. Work and health in conc temporary society: Demands, control and insecurity. Journal of epidemiology and community health, 2003, 57:849–54. Íɕa>²?Vr¶=Í http://www.who.int/healthacademy/ar/index.html  J£IÍɕa>²?(ÍVr¶=¶=î?KÒn¾Àº¸ßFå®Í»Ÿ¿ºÍVr¶=Íə>£¶=›fÃmÁǾ>² ¹ÆÙ=+»jÈa2003(Ìea>FºÌbÈbQjVJ¶ÍVr¶=À¢°Èf{>ÉQǶǿ³J¶= *OÉUfòªÇI Íɕa>²Ù=½Ç·£¶=ÍÉVr¶=Íçº>£·¶Àº¹Ø]¼ö·£J¶=ʾÆf[J³¶Ý=>šb¢>jÈa=fªÙ=η¢c>= ±fì¶=ÍVÉVr¶=ÍÈ>®Ç·¶Àºz=fºÙ=¥>FëI=ÆÌ>ÉUÍÉVq¸vª?.  ¸ù³nIÆea>r™=ÍÉI>ºÇ·£™=ÍÉ¿§¶=¶=b¿JjI>ÃɶCÍ»Ÿ¿ºÍVr¶=Íə>£¶=>ÃI]ÆǶ=Í£i=› ¹>…(ÍVr¶=ͪ>uÝ>E‘C>ÃIeb®¹ÇqÇ·¶‘CL>ºÇ·£™=ÍÉVr¶=›¤É–(¹Æb¶=ebr™= ÊjÉÑf¶=ÏÇJV»·¶ÊVr¶=Êf¶=Íɕa>²Ú¶ÍÉVr¶=*  ÁCÍÉ¿¯I¼ö·£J¶=ʾƳ¶Ý=ͺßb^Jj™=Àº­f{Íɕa>²?ÍVr¶=×frJ¯Iœ¯ªη¢ÍÉ·»¢ ¼ö·£J¶=À¢(bá£àE¸E>þC¸ÂÖI=¼ù·£J™Á?këiÖÈÄJªf£ºÀºÔa>F™=ÍÉi>iÙ=¶=lçebàIÀºÆ ç¼ß[Me=f»Ji×=›Ð>¿F¶=η¢ÅdÂͪf£™=*>»²b¢>jIÅdÂÍÉ¿¯J¶=η¢ÍÉ»¿Ikƒ=Ëb¯¿¶=bÈhIÆ ÀºÌeb¯¶=η¢hɲf[J¶=.  Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 653 Knowledge and practices of health care workers and medical students towards universal precautions in hospitals in Mazandaran Province N. Motamed,1 F. BabaMahmoodi,2 A. Khalilian,3 M. Peykanheirati4 and M. Nozari4 1Department of Community Medicine, Bushehr Medical School, Bushehr University of Medical Sciences, Bushehr, Islamic Republic of Iran (Correspondence to N. Motamed: nilo1351@yahoo.com). 2Department of Infectious Diseases; 3Department of Community Medicine; Sari Medical School, Sari, Islamic Republic of Iran. 4Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran. Received: 14/06/04; accepted: 12/09/04 ABSTRACT This study investigated knowledge of and practices towards universal precautions among 540 health care workers and medical students in 2 university hospitals in Mazandaran Province, Islamic Republic of Iran. Only 65.8% and 90.0% staff in the 2 hospitals and 53.5% of medical students had heard about universal precautions. Overall, there was a low understanding of precautions, except conc cerning disposal of sharps, contact with vaginal fluid, use of mask and gown or cleaning spilled blood. Health workers had difficulty distinguishing between deep body fluids and body secretions that are not considered infectious. Good practices were reported regarding handcwashing, disposal of needles, and glove, mask and gown usage. 10 Knowledge and practices of health care workers and medical students towards Gì¶=HØ{ÆÍÉVr¶=ÍÈ>¢f¶=Ð>JÈCη¢·º>£¶=Ïb¶L>ie>»™=Æ­e>£™=  Jj™=›Í·º>n¶=L>{>ÉJU×=¹ÇUÁ=e=b¾=g>ºÍÈ×Æ›L>É«n ËecǾ¼Èfº(ÊIUÁ>³ÉEͺÇr£º(Á>É·É·]>u·¢(ËaÇ»†>E>E´¿Âfª(b»J£ºfªÇ·É¾  „=Í[qØ6Ïb¶Í·º>n¶=L>{>ÉJU×=¹ÇUL>ie>»™=Æ­e>£™=Íi=eb¶=ÅdÂÊr¯JjI540Ð>[JÈC›·º>[£¶=Àº ›[É£º>Q[É«nJjº›Gì¶=HØ{ÆÍÉVr¶=ÍÈ>¢f¶=ÍɺØ[iÝ=Á=f[ÈCÍ[ÈeÇÖ›Á=e=b[¾=g>ºÍ[È×Æ*b[®Æ η¢Í·º>n¶=L>{>ÉJU×=À¢¤À™ÍÈÇҙ=ÍFj¿¶=LfrJ®=65.8!Ɛ[É«n[Jj™=b[U?›·º>£¶=Àº90!À[º Æf]Û=ΫnJj™=›·º>£¶=53!HØì¶=Àº*>ºÐ>¿NJi>E(L>{>ÉJUض¤u=ÇJº¼Ãªµ>¿ÂÁ>²ʶ>–C¸³nEÆ =s½b[¶=p>[ßmße¬[ɟ¿IÆeh[ҙ=Æ¥>¿¯¶=½=b^Ji=Æ(ÍÉ·FÙ=¸Ñ=Çj¶=¤ºl>»J¶=ÆÌa>ƒ=L=ÆaÙ=Àºsö·^J¶* ð=ebrºJ£I׶=ÁbF¶=L=g=fªCEÆͯɻ£¶=ÁbF¶=¸Ñ=ÇiEhÉ[É»J¶=›ÍEÇ£qÀºÁÇÉVr¶=ÁÇ·º>£¶=ʾ>£ÈÆ ÏÆb£·¶*J™=Ìbɂ=L>ie>»™=´¶d²áKí·ëRàib®ÆL=g>[«¯¶=½=b^J[i=Æf[EÝ=À[ºs·^J[¶=ÆÀÈb[ɶ=¸j[§EÍ·ëN» egB™=ÆÍ£¿®Ù=Æ*  Connaissances et pratiques des agents de soins de santé et des étudiants en médecine concerc nant les précautions universelles dans des hôpitaux de la Province de Mazandaran RÉSUMÉ La présente étude a examiné les connaissances et les pratiques concernant les précautions universelles chez 540 agents de soins de santé et étudiants en médecine dans deux hôpitaux univerc sitaires de la Province de Mazandaran (République islamique d’Iran). Seulement 65,8 % et 90,0 % du personnel des deux hôpitaux et 53,5 % des étudiants en médecine avaient entendu parler des précauc tions universelles. De manière générale, il y avait une faible compréhension des précautions, sauf pour ce qui concerne l’élimination des objets piquants et tranchants, le contact avec les sécrétions vaginales, le port du masque et de la blouse ou le nettoyage des souillures de sang. Les agents de santé avaient du mal à faire la distinction entre les liquides internes de l’organisme et les secrétions corporelles qui ne sont pas considérées comme infectieuses. Des bonnes pratiques étaient signalées en ce qui concerne le lavage des mains, l’élimination des aiguilles et l’utilisation des gants, du masque et de la blouse. 654 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Introduction Since medical history and examination cann not reliably identify all patients infected with human immunodeficiency virus (HIV) and other bloodborne pathogens, the United States Centers for Disease Control (CDC) has proposed a series of procedures that health care workers’ (HCWs) should use with all patients [1]. “Universal precaun tions” are designed to prevent health care staff being exposed to blood and body fluids by applying the basic principle of infection control through handnwashing, utilization of appropriate protective barriers, such as gloves, mask, gown and eyewear, and safe handling of needles. Universal precautions practices are imn portant, as any health care organization has a responsibility to protect its staff from potential danger and itself from loss of mann power if staff suffer occupational injuries or illnesses [2]. Patients too may be harmed if staff are uniformed about safe handling of blood or body fluids or they may be deprived of appropriate care due to inapn propriate fears or misunderstandings [3,4]. HCWs working in hospitals frequently provide care to patients whose hepatitis B virus (HBV) or HIV status is unknown. The Islamic Republic of Iran is a medium endemic area for hepatitis B infection, with about 3.1% of the population being carriers of HBV and 30%–50% of the population having evidence of previous infection with the virus [5]. The risk of HBV infection afn ter a known occupational exposure is about 25%. Furthermore, there is a 0.3%–0.5% occupational risk of infection with HIV after percutaneous exposure to HIVnconn taminated blood [6], although the cumulan tive career risk may be as high as 1%–2% among emergency service staff or surgeons [7]. Occupational exposure to HIV is comn mon in the developing world. A survey assessing exposure to HIV among HCWs in South Africa showed that 13% of the staff reported accidental exposure when caring for HIVnpositive patients [8]. Data from a study in Sweden [9] showed that the majority of reported cases of ocn cupational blood exposure were among nurses and a minority were among physin cians. Other data [10] showed that nurses are the staff most frequently involved in occupationally acquired HIV infection. A study assessing the frequency of body fluid exposure among midwives showed that 65.1% of them had experienced exposure to amniotic fluids or blood at least once in the past 6 months and 25% reported 5 or more such exposures [11]. Lymer et al. showed that of 1180 incidents, only 9% had been reported [9]. Surveys have shown that the use of unin versal precautions significantly decreases the number of incidents of occupation exn posure to blood [12,13]. Nevertheless, the level of compliance with universal precaun tions is generally low [14-16]. The weakest aspects reported are not practising hand decontamination, [17], not using barrier protection and recapping needles [18,19]. The objectives of the present study were to measure knowledge about universal precautions among HCWs and medical students, to investigate their practice ton wards universal precautions and to look for any relationship between knowledge and practice. Such information would be useful in identifying specific areas that may need further attention in the continuing educan tion of nursing and medical students and in providing feedback to these groups about improving safe practices. Methods This was a crossnsectional survey. The sample was all medical staff (ancillary staff, Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 655 nurses, operating room staff and laboratory technicians) and medical students at the 2 university hospitals in Sari, Mazandaran Province, Islamic Republic of Iran (hospital A and hospital B). Scale A selfnadministered questionnaire was conn structed, consisting of 3 parts. Part I coln lected demographic data, including age, sex, years of experience in job, level of edun cation and type of occupation (laboratory, operating room, nursing, health service, medical student). Part II asked respondents if they had heard about “universal precaun tions”, and then measured knowledge of universal precautions, with 10 statements (scored “true” or “false”; maximum score 10). Part III investigated their practice ton wards universal precautions in 8 questions about use of protective devices, disposal of sharps, and decontamination of spills and used articles (scored “agree” or “disagree”; maximum score 8). The statements measn uring knowledge of and practice towards universal precautions were based on the universal precautions guidelines recomn mended by the CDC in 1996 (12 items) [1] and a questionnaire devised by Chan et al. in Hong Kong [2]. The content validity of the questionnaire was assessed using the ideas of experts from the infection control committee of the 2 hospitals. A pilot study with 20 subjects was used to test the feasibility and internal consistency of the questionnaire. The relin ability coefficient for the questionnaire (usn ing Cronbach’s α coefficient) was 0.71. Data analysis Frequencies, means and standard devian tions were used to summarize the data. Knowledge was scored with 1 for a correct answer and 0 for a wrong answer, then the total score was calculated. The relationship between the knowledge scores and practice rates toward universal precautions was caln culated using the Pearson correlation coefn ficient. The Kruskal–Wallis 1nway analysis of variance or Mann–Whitney U tests were used to examine knowledge and practice in relation to demographic data, depending on the data level of measurement. Ethical considerations The research proposal was sent to the 2 hosn pital managers for approval in order to gain access to the staff. Distributors provided information about the study to the particin pants and the anonymity and confidentiality of the responses, voluntary participation and the right to refuse participation were emphasized. Results Demographic data Of the 650 questionnaires distributed, 540 (83.1%) were completed and returned (283 from staff at hospital A, 173 from staff at hospital B, and 84 from medical students). Only 65.8% of hospital A staff had heard about universal precautions compared with 90.0% of hospital B staff. Among the staff respondents, 40.6% had 0–5 years of expen rience in their job, 10.3% had 6–10 years, 15.1% had 11–15 years and 34.0% had more than 15 years of experience (Table 1). The majority (64.3%) had a bachelor degree in nursing. The demographic profile of medical students was similar except that 67.7% were female and 33.3% male. Staff knowledge of universal precautions The mean knowledge score of hospital A staff was 7.34, of hospital B staff was 8.63 and of medical students was 7.81. Most of the staff in both hospitals answered corn 656 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 rectly the items related to disposal of sharps (94.9% and 99.3% correct respectively), clearing up blood spills (70.8% and 93.9%), use of mask and gown (96.3% and 99.3%), application of universal precautions with all patients irrespective of their underlying illness (92.6% and 94.3%), and application of universal precautions when in contact with vaginal fluids (97.5% and 95.6%) and not with saliva (79.0% and 76.8%) (Tables 2 and 3). Nevertheless, many of them had the misconception that the universal precaun tions should be applied when in contact with sweat (80.8% and 39.6% respectively) (Table 2). In addition, many of the hospital A staff had the misconception that washing with ordinary detergents is insufficient for decontamination of devices that are only in contact with skin (51.6%). Practice of universal precautions Concerning the use of protective devices, almost all respondents agreed on the pracn tice of wearing gloves, gown and eye wear when they were exposed to deep body fluids or blood products (Table 3). Concerning the use of gloves when exposed to sweat, pracn tices were poor, as only 19.2% of hospital A staff, 60.3% of hospital B and 33.9% of medical students answered this quesn tion correctly. For the care of patients by a health care worker with nonnintact skin, only 16.1%, 50.4% and 25.2% of hospital A and B and medical students answered corn rectly. Also the respondents’ practices ton ward disposal of sharps into a sharp box was good (94.8%, 99.3%, 100% respectively). Regarding wearing gloves as the first step in cleaning surfaces, the practices of hospital B staff was slightly better than the 2 other groups. Also only 74.5% of medical students agreed that washing with soap and water for 5 minutes is the first step after contact with infective materials. Relationships between knowledge and practices A significant relationship between the ren spondents’ knowledge of and practices toward universal precautions was shown in hospital B (r = 0.58, P < 0.001). Also knowledge and practices of hospital B staff was better than in hospital A. In Hospital A, using the Kruskall– Wallis analysis of variance, it was found that knowledge was highest in the 30–40 years old age group and lowest in the > 50 Table 1 Demographic data of the sample of hospital health care workers in Mazandaran Province (excludes medical students) Variables No. % (n = 456) Age (years) 20–29 177 38.8 30–39 152 33.3 40–49 109 23.9 50+ 18 3.9 Sex Male 159 34.9 Female 297 65.1 Years of experience 0–5 185 40.6 6–10 47 10.3 11–15 69 15.1 > 15 155 34.0 Level of education Below diploma 34 7.5 Diploma 57 12.5 University diploma 72 15.8 Bachelor degree or above 293 64.3 Occupation Ancillary staff 70 15.4 Laboratory worker 46 10.1 Operating room 59 12.9 Midwife 18 3.9 Nurse specialist or officer 263 57.7 n = total number of respondents. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 657 years group. Also the group with a univern sity diploma had the highest knowledge of universal precautions, followed by the group with a bachelor degree. There was no significant relationship between knowledge and practice score and years of experience. The analysis also revealed that laboratory workers had the highest knowledge, foln lowed by midwives, nurses and operating room staff. In Hospital B, a significant relationn ship was shown between knowledge and practice and occupation, as nurses obtained the highest score. The group with the fewest years of experience (0–5 years) had the highest knowledge score and the group with a bachelor degree or more had the highest knowledge of and practice toward universal precautions. The 20–30 year old age group had the highest knowledge and practice score. There was a significant relationship between age and knowledge of and practice toward universal precautions, as the 20–30 year old age group had the highest and the > 50 year group the lowest. Using the Mann–Whitney U test, it was found that women had a significant higher level of knowledge of and practice toward Table 2 Knowledge of universal precautions (UP) among health care workers (HCWs) and medical students in Mazandaran Province Item % answering correctly HCWs HCWs Students hospital A hospital B (n = 283) (n = 173) (n = 84) Have you ever heard of UP?a 65.8 90.0 53.5 UP are applied to patients with HIV and HBV only (F) 87.9 86.3 96.3 UP should be applied to all persons regardless of their infection status (T) 92.6 94.3 90.9 Isolation is necessary for patients with bloodcborne infections (F) 53.7 77.4 81.8 Used needles can be recapped after giving an injection (F) 89.9 90.7 58.1 For decontamination of devices such as manometer (with only contact with skin) washing with usual detergent is enough (T) 48.4 85.6 87.2 Subcutaneous injuries during intravenous injections are the most common cause of occupational infections (T) 78.4 92.8 72.7 Universal precautions are not necessary in situations that might lead to contact with saliva (T) 79.0 76.8 81.8 There is effective anticHCV vaccine (F) 77.9 88.5 100.0 HCWs with noncintact skin should not be involved in direct patient care until the condition resolves (T) 55.8 77.4 32.7 Blood spills should be cleaned up promptly with sodium hypochlorite (T) 70.8 93.9 80.0 a% who heard of UP. n = total number of respondents. T = true, F = false (researchers’ views). HCV = hepatitis C virus; HIV = human immunodeficiency virus. 658 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 universal precautions than men (z = 2.86, P = 0.006; z = 3.78, P < 0.0001 in hospital A and B respectively). Discussion The study showed an overall low undern standing of universal precautions among health staff and medical students, except concerning disposal of sharps, contact with vaginal fluid, use of mask and gown or clearing up spilled blood. Universal precaun tions were not only insufficiently but also selectively understood. Chan et al. likewise showed that nurses’ knowledge of universal precautions was inadequate [2], despite the fact that the majority of occupational blood exposures involved nurses [9]. Furthern more, the knowledge score in our study was less than optimal, especially in hospital A, where only 65.8% of staff had even heard about universal precautions. This may be related to the lack of regular postnemployn ment education on issues of universal pren cautions, especially in that hospital. Although the efficacy of universal pren cautions is controversial [20], they remain a valuable way to minimize or prevent accidental exposure of staff to pathogens. It is necessary to reinforce and clarify the concept of universal precautions and inn fection control guidelines among hospital staff, especially the staff of the operating room. Universal precautions are usually incorporated in the current student training curriculum of HCWs; however, there is a lack of regular integration of universal precautions guidelines as part of onnthenjob Table 3 Practice of universal precautions among health care workers (HCWs) and medical students in Mazandaran Province Item % answering correctly HCWs HCWs Students hospital A hospital B (n = 283) (n = 173) (n = 84) I assume that blood and all body fluids of patients are infectious (T) 98.7 98.6 100.0 I wear mask, gown and eye wear if procedures and patient care activities are likely to cause splashing of blood and deep body fluids (T) 96.3 99.3 100.0 I dispose of used needles into a sharp box after injection (T) 94.9 99.3 100.0 I wear gloves as the first step in cleaning surfaces contaminated with blood or other bloody body fluids (T) 90.6 95.2 89.0 Washing with soap and water for 5 minutes is my first step after contact with infective material (T) 89.9 89.2 74.5 I apply universal precautions in situations that might lead to contact with sweat (F) 19.2 60.3 33.9 If I have a wound, I wear gloves before caring for patients (T) 16.1 50.4 25.2 I apply universal precautions in situations that might lead to contact with vaginal discharge (T) 97.5 95.6 98.1 n = total number of respondents. T = true, F = false (researchers’ views). Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 659 training in our hospitals. Although infecn tion control committees in both hospitals have programmes of regular training and examination, it seems that this curriculum has not been implemented effectively. In general, hospital B staff performed better than hospital A staff, presumably because the current activity of the hospital B infecn tion control committee is more regular and comprehensive. Ryan et al. [21] also recn ommend that there should be a systematic evaluation of nursing students’ knowledge pertaining to universal precautions. A more comprehensive ongoing educational pron gramme on universal precautions should be organized and this should be considered as a mandatory refresher course for all HCWs in the hospitals. As suggested by Van Wissen [22], one way to achieve this is to select tarn get groups on the basis of prior knowledge. The content of the programme should be tailornmade according to the recommendan tions of the target group, and there could be a sympathetic forum in which more pern sonal issues can be confidentially discussed. Support sessions should be provided for nurses in which feelings and fears can be openly discussed [23]. Although we did not test their actual practices in universal precautions, most respondents in all the groups agreed that universal precautions should be used for all patients irrespective of their bloodborne infection status. Hown ever, Young et al. showed that nurses did not always use adequate protection if they thought a patient was HIV negative or if they did not know the patient’s HIV status [24]. Meunier et al. showed that 30% of third and forth year students who already have experience in clinical practice described blood exposure accidents during their hosn pital training and only 45% of these acn cidents were reported [25]. In our study, medical students were less knowledgeable than staff in some aspects: only 53.5% had heard about universal precautions and only 58.1% knew that used needles cannot be recapped. It seems that medical students have no systematic programme of education about universal precautions during clinical practice. Occupational safety and health regulan tions require both employers and employees to reduce or eliminate occupational risks. Protective barrier use is a major element of universal precautions. To encourage their use, protective barriers must be readn ily available, easy to use, effective and comfortable. Therefore, staff managers and infection committee members should take a leadership role to ensure safe practices and resolve related practical issues. Also the edn ucation of medical students during the years of clinical practice is very important. Postn educational surveys or observational studies about universal precautions as practiced in clinical settings need further attention. Further studies should include physicians as well as support staff in order to gain a more comprehensive picture of the practice of universal precautions in hospitals. References 1. Centers for Diseases Control and Prevenc tion. Recommendations for prevention HIV transmission in healthccare settings. Morbidity and mortality weekly report supc plements, 1987, 36(SU02). 2. Chan R et al. Nurses’ knowledge of and compliance with universal precautions in an acute care hospital. International jourc nal of nursing studies, 2002, 39:157–63. 3. Van Servellen GM, Lewis CE, Leake B. Nurses’ responses to the AIDS crisis: implications for continuing education proc grams. Journal of continuing education in nursing, 1988, 19:4–8. 660 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 4. Walsh G. AIDS: fear of contagion among nurses. British journal of nursing, 1992, 1(2):66–71. 5. National protocol of prevention of HBV. Tehran, Iranian Ministry of Health, 2000. 6. Chin JE. Control of communicable disease manual, 17th ed. Washington, American Public Health Association, 2000:1–9. 7. Wears RL et al. An analysis of emergency physicians cumulative career risk of HIV infection. Annals of emergency medicine, 1991, 20:749–53. 8. Gounden YP, Moodley J. Exposures to human immunodeficiency virus among healthcare workers in South Africa. Interc national journal of gynecology and obstetc rics, 2000, 69(3):265–70. 9. Lymer UB, Schutz AA, Isaksson B. A descriptive study of blood exposure inc cidents among healthcare workers in a university hospital in Sweden. Journal of hospital infection, 1997, 35:223–5. 10. Centers for Diseases Control and Prevenc tion. HIV/AIDS surveillance report, 1993, 5(3):13. 11. Turner JG. AIDScrelated knowledge, atc titudes, and risk for HIV infection among nurses. Annual review of nursing rec search, 1993, 11:205–24. 12. Beeckmann SE et al. Temporal associac tion between implementation of universal precautions and a sustained, progressive decrease in percutaneous exposures to blood. Clinical infectious diseases, 1994, 18:562–9. 13. Wong ES et al. Are universal precautions effective in reducing the number of occ cupational exposures among healthcare workers? A prospective study of physic cians on a medical service. Journal of the American Medical Association, 1991, 265:1123–8. 14. Gershon RR et al. Compliance with unic versal precautions among healthcare workers at three regional hospitals. Amerc ican journal of infection control, 1995, 23:225–36. 15. Nelsing S, Nielsen TL, Nielsen JO. Nonc compliance with universal precautions and the associated risk of mucocutac neous blood exposure among Danish physicians. Infection control and hospital epidemiology, 1997, 18:692–8. 16. Gershon RR, Karkashian C, Felknor S. Universal precautions: an update. Heart and lung, 1994, 23:352–8. 17. Gould D, WilsoncBarnett J , Ream E. Nurses’ infectionccontrol practice: hand decontamination, the use of gloves and sharp instruments. International journal of nursing studies, 1996, 33(2):143–60. 18. Hersey JC, Martin LS. Use of infection control guidelines by workers in healthc care facilities to prevent occupational transmission of HBV and HIV: results of a national survey. Infection control and hospital epidemiology, 1994, 15:243–52. 19. Marcus R. The Centers for Disease Conc trol cooperative needle stick surveillance group. Surveillance of healthcare workers exposed to blood from patients infected with HIV. New England journal of medic cine, 1988, 319:1118–23. 20. Gerberding JL, Lewis FR, Schecter WP. Are universal precautions realistic? Surc gical clinics of North America, 1995, 75:1091–104. 21. Ryan ME et al. Integrating HIV/AIDS policies and curricular content into bacc calaureate nursing programs. Journal of nursing education, 1991, 30(8):347–51. 22. Van Wissen KA, Siebers RWL. Nurses’ attitudes and concerns pertaining to HIV and AIDS. Journal of advanced nursing, 1993, 18:912–7. 23. Steele A, Melby V. Nurses’ knowledge and beliefs about AIDS: comparing nursc es in hospital, community and hospice Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 661 settings. Journal of advanced nursing, 1995, 22:879–87. 24. Young EW, Forti EM, Preston DB. Rural nurses’ use of universal precautions in rec lation to perceived knowledge of patient’s HIV status. International journal of nursing studies, 1996, 33(3):249–58. 25. Meunier O et al. Accidents d’exposition au sang chez les étudiants en médecine. [Blood exposure accident among medical students.] Médecine et maladies infecc tieuses, 2001, 31(9):537–43. Communitycbased initiatives Investing in health, particularly the health of the poor, is central to the achievement of the Millennium Development Goals. In support of this strategy, WHO Regional Office for the Eastern Mediterranean is actively promoting in the countries of the Region communitycbased initiatives (CBI) such as Basic Development Needs, Healthy Cities, Healthy Vilc lages and Women in Health and Development. These approaches are based on the principle that good health status is central to creating and sustaining the capabilities of poor people to meet their basic needs and to escape from poverty. Currently, all the countries in the Region have implemented at least one of the CBI initiatives. Under varying sociopolitical conditions, these initiatives have proved their effectiveness and sustainability through flexible and locallycsensitive mechanisms. The CBI approach has rec sulted in improved nutritional status, lowered mortality during epidemc ics, effective malaria and tuberculosis control measures, increased use of safe drinking water, higher school enrolment and promotional activities leading to healthy lifestyles in the communities where projc ects have been implemented. Further information can be found on the CBI homepage at http://www.emro.who.int/cbi/index.htm. 662 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Job burnout in psychiatric and medical nurses in Isfahan, Islamic Republic of Iran A.R. Yousefy1 and Gh.R. Ghassemi2 1Medical Education Research Centre, Isfahan University of Medical Sciences, Isfahan, Islamic Republic of Iran. 2Department of Psychiatry, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Islamic Republic of Iran (Correspondence to Gh.R. Ghassemi: ghassemi@med.mui.ac.ir). Received: 29/04/03; accepted: 26/01/05 ABSTRACT By means of the Maslach Burnout Inventory, we examined job burnout among randomly selected nurses working on psychiatric (55 nurses) and medical units (51 nurses) at 2 university hospit tals in Isfahan during 2003. Psychiatric nurses experienced a greater degree of emotional exhaustion than the medical nurses (P < 0.05). Significant positive correlation was noted between age, years of experience and frequency of ontcalls and emotional exhaustion for the psychiatric nurses. Frequency of ontcalls was also significantly associated with a sense of nontaccomplishment. Longer duration of service was accompanied by higher degree of emotional depersonalization for the medical nurses. 14 Job burnout in psychiatric and medical nurses in Isfahan, Islamic Republic of ÍÉFì¶=ÍÈ>¢f¶=L>ufšÆÍÉj«¿¶=ÍÈ>¢f¶=L>ufšÏb¶Ù=>FUÝ=  ÍɺØiÝ=Á=fÈCÍÈeÇÖ(Á>ëq?› Ê>®>ue½Ø¦(Ê«iÇÈ>ueÊ·¢  „=Í[qØ6Í[¢Ç»…[E[Ù=>[FUÝ=Í[i=ebE>[¿»®(Ù=>FUÞ¶µØi>º>ãuƶ=ÍÈbö¯ «J¶=Í»Ñ>¯·¶ð>¯ªÆ Í[Éj«¿¶=Í[È>¢f¶=L=b[UÆ›LØ[º>£¶=L>[uf»™=À[ºð>[ÉÑ=Çn¢Ì>[¯J¿º%55Í[ufš$Í[[ÉFì¶=Í[È>¢f¶=L=b[UÆÆ %51Íufš$½>¢¹Ø]Á>ëq?›ÍÉ£º>‚=L>É«nJj™=Àº¿M=›2003*ÍÉj«¿¶=ÍÈ>¢f¶=L>ufšÁ?ÀçÉFIb®Æ ʶ>£«¾×=a>ÃQÝ=Àº²?ÍQeb¶ßÀáuçf£Ib®ÍÉFì¶=ÍÈ>¢f¶=L>uf»’ð;e>¯àº%0.05<P*$Á>[NU>F¶= [U×b[®Æ Ïb[¶ʶ>[£«¾×=a>[ÃQÝ=¹b[£ºÆ(Ð>¢bJ[i×=e=f[³IÆ(Ì[„=L=Ç¿iÆ(f»£¶=Eð>ÉÑ>rUCÄEäbßJá£àÈð>ÉE>‹Cð>ìE=fI ÍÉj«¿¶=ÍÈ>¢f¶=L>ufš*„=L=f[[JªÁ?>[»²(g>ˆÝ=½b£EeÇ£mÄFU>rÈÐ>¢bJi×=e=f³JªœFIf[IÍ[·ÈÇì¶=Í[ºb ÍÉFì¶=ÍÈ>¢f¶=L>ufš¸ßFå®Àºʶ>£«¾×=Êr^n¶=b¢>FJ¶=Àºη¢?ÍQebE*  L ’épu i sement p ro fe s s ionne l chez l e s i n f i rm iè res p sych ia t r iques e t méd i ca le s à Ispahan (République islamique d’Iran) RÉSUMÉ Au moyen de l’inventaire d’épuisement professionnel de Maslach, nous avons examiné l’épuisement professionnel chez des infirmières choisies au hasard dans les services psychiatriques (55 infirmières) et les services médicaux (51 infirmières) de deux hôpitaux universitaires à Ispahan en 2003. Les infirmières psychiatriques connaissaient un degré plus important d’épuisement psychologit que que les infirmières médicales (p < 0,05). Une corrélation positive significative a été constatée entre l’âge, les années d’expérience, la fréquence des astreintes et l’épuisement émotionnel des infirmières psychiatriques. La fréquence des astreintes était également associée de manière significative à un sentiment de nontaccomplissement. Une plus longue durée du service s’accompagnait d’un degré plus élevé de dépersonnalisation pour les infirmières médicales. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 663 Introduction As a prototype of stress, job burnout is bei ing increasingly recognized as one of the most serious occupational health hazards, resulting in job dissatisfaction, lowered proi ductivity, absenteeism, high turnover, and a state of disequilibrium [1]. Workirelated factors such as work pressure without supi port, everichanging expectations, new job requirements, role conflict, and role ambii guity comprise some of the stressors which can cause job burnout syndrome [2]. Personi ality traits such as idealism and a need for selfiaffirmation and work orientation can increase the risk of job burnout [3]. Maslach views job burnout as a response to chronic interpersonal and emotional stressors on the job, resulting in negative feelings such as incompetence, lack of achievement and productivity at work [4]. Emotional exhausi tion ranging from mild boredom to severe depression, depersonalization and treating people in an unfeeling way and poor sense of personal accomplishment are viewed as the key elements of job burnout [5]. As a result of burnout people develop negative selficoncept and become detached, apai thetic, angry or hostile in their work place [5]. Job burnout has cumulative effects on mental health, quality of life, family life and last but not least on productivity [5]. Burnout is a major problem in the helpi ing professions such as nursing, medicine, social work, law enforcement and education [6]. Nursing staff face working places with blood and urine, disturbed sleeping pattern, frequent emergency situations, inapproprii ate expectations from patients and their relatives, insufficient nursing staff and lack of authority in decisionimaking, all of which can cause job burnout for nurses [7–9]. Bearing in mind the nature of the nursing profession, attempts have been made over the past 2 decades to investigate the magnii tude and implications of job burnout among nurses working in various departments [8–19]. Some of the factors that have been reported to be associated with job burnout are: individual characteristics, threats to job control, hardness of training, workload, interpersonal relationships with colleagues, knowledge of nursing, bureaucratici political constraints, level of education, night shifts, being hospitalibased, working on medical and surgical wards and negative work–home interference. Stress managei ment had a pivotal role in controlling jobi induced stress and burnout [20]. Attempts have also been made to study the phenomenon of burnout among nurses working in mental health fields, yielding interesting findings. In studying 296 nurses working with medical units, critical units, operation rooms, and psychiatric units in different hospitals, CroniniStubbs and Rooks observed significant differences in the frequency and intensity of occupational stress and burnout among the subjects [21]. Critical and medical nurses in this study eni countered occupational stressors more frei quently and intensely than psychiatric and operation room nurses. Stress in psychiatric nurses is further attributed to administrative and organizational factors. Fagin and coi workers (1996) attributed burnout among psychiatric nurses to staff shortages, health service changes, poor morale and not being notified of changes before they occurred [22]. As regards sex, female nurses were characterized by fewer symptoms of burni out, relatively high emotional intelligence profiles, and lower social skills than male nurses [23]. Most of these studies were conducted in Europe and the United States and have foi cused primarily on nurses in general. There is a dearth of literature about working coni ditions and job burnout among psychiatric nurses in the Iranian context. With special 664 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 reference to psychiatric nurses, most studies suggest that they deal with atypical patients and receive less recognition by the admini istrative authorities and community in geni eral [23]. It is argued that psychiatric nurses face unique job challenges compared to their counterparts who work in nonipsychii atric wards. Given the lack of information, the present study was an attempt to gauge and compare burnout experience between hospital nurses working in psychiatric and nonipsychiatric units in Isfahan, Islamic Republic of Iran. Methods This study was based on a sample drawn from the nursing staff working with 2 major university hospitals in Isfahan during May– December 2003 (Khorshid Medical Centre and Al Zahra Medical Centre). The former is a general hospital with a psychiatric ward and the latter is a postgraduate hospital with critical care unit and intensive care unit where the medical nurses were working. Adopting a random sampling method, nurses working in psychiatric and general wards with more than 1 year of work exi perience were approached. While assuring them about the confidentiality, their pari ticipation in the study was made voluntary. Thus, 55 nurses working in psychiatric units and 51 nurses working in general wards were recruited and completed the questioni naire satisfactorily. The participants were matched for age, sex, education, marital status and years of experience. Data were collected by means of the Maslach Burni out Inventory (MBI) which was originally designed by Maslach and Jackson in 1981 [24]. Personal data (such as age, years of experience, education) were collected in a separate interview with closei and openi ended questions. The MBI, which is originally in English, was translated into Farsi by a group of 5 professors from nursing and medicine fields. In order to test language validity, the Farsi version obtained was translated back to English by another group of 5 professors. Then the Farsi version was reviewed and revised. The final Farsi version was pilot tested on a sample group of nursing lecturi ers. It was concluded that the Farsi version obtained was highly valid for use. There were 22 items for which the minimum score was 0 and the maximum possible score was 96. A score of at least 48 was considered a case of burnout. Higher score indicated higher chances of burnout. The nurses comi pleted questionnaire by themselves and anonymously. The MBI has 3 subiscales: Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA). EE consists of 9 items measuring the perception of being used up, frustrated, tired or stressed. DP consists of 5 items which pertain to perceptions of treating others impersonally, becoming callous and/or hardened emotioni ally. PA consists of 8 items which measure perceptions of having an influence on othi ers, working well with others and dealing well with patients and their problems. High EE and DP, and low PA are considered to indicate burnout [25]. Each item consisted of a 5ipoint rating scale (0 = never; 1 = a few times a year; 2 = a few times a month; 3 = a few times a week; 4 = every day). Attempts have been made to establish a relationship between certain ascribed and achieved characteristics of an individual in an organization and job burnout. To this end we attempted to establish the correlation between certain work and the demographic characteristics of the participants with the parameters of burnout. Cronbach alpha reliabilities for the 3 subiscales ranged from 0.72 to 0.89 and Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 665 test–retest reliabilities ranged from 0.61 to 0.82. Data were analysed using SPSS, version 10 and the Student titest, Pearson correlation coefficient (r) and analysis of variance were computed. Results The sample comprised 55 psychiatric nursi es as the study group and 51 medical nurses as the control group. The mean age (standi ard deviation) for the study group was 35 (4.6) years and 33.2 (4.5) years for the whole group. The nurses were typically female, unmarried and graduates in nursing. The majority of the nurses working with psychiatric and general units were gradui ates; a small percentage of them were not graduates, but they had had long working experience (about 12 years) in their field. The average number of years of work exi perience for the psychiatric nurses was 12.8 (3.9) years and for controls it was 10.7 (4.6) years. Demographic characteristics of the participants are given in Table 1. As per the operational definition, EE, DP, PA constituted the 3 aspects of job burnout. Analysis of the data showed that nurses working in psychiatric units expei rienced a higher degree of EE [21.07 (SD 8.87)] as compared to those who worked in other units [16.64 (SD 7.54)], indicating the feelings of being used up, frustrated, tired or stressed (P < 0.05). In terms of DP, the mean score for nonipsychiatric nurses was higher [4.96 (SD 5.5)] than that of psychiatric nurses [4.38 (SD 5.1)] but this was not statistically significant. The mean score for PA was higher among psychiatric nurses [15.87 (SD 11.63)] compared to nonipsychiatric nurses [13.82 (SD 9.83)] indicating that psychiatric nurses felt that they had less influence over their patients and units, or could not work well or the way they wanted to be with their patients. However, this difference was not statistii cally significant (Table 2). Table 3 shows the correlation between job burnout and the demographic characteri istics of the nurses. For psychiatric nurses, Table 1 Frequency distribution of the participants by demographic characteristics Characteristic Psychiatric Medical nurses (n = 55) nurses (n = 51) No. % No. % Sex Male 24 43.6 16 31.4 Female 31 56.4 35 68.6 Marital status Married 5 9.1 11 21.5 Single 50 90.9 39 76.5 Education University graduate 22 40.0 18 35.3 Hightschool graduates 33 60.0 33 64.7 Mean age (SD) (years) 35 (4.6) 31.2 (5.4) Mean work experience (SD) (years) 12.8 (3.9) 10.7 (4.6) SD = standard deviation. 666 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 there was significant positive correlation between age (r = 0.3), years of work experii ence (r = 0.3), and frequency of onicalls (r = 0.6) with degree of EE and PA. In the case of nonipsychiatric nurses, there was a negative correlation between their years of work experience and emotional exhaustion (r = –0.5). Discussion It is reported that at the global level nurses face several challenges and are ranked 27th among 130 professionals requesting psyi chological counselling [8]. This study was an endeavour to assess the magnitude and extent of job burnout among hospital nurses working in psychiatric and nonipsychiatric units in Isfahan. There is ample evidence to show the implications and cumulative effects of job burnout on mental health, quality of life, family life and work life. Job burnout can typically manifest itself in the form of boredom, severe depression, negative selficoncept, sense of detachment, apathy, anger and hostility in the affected individual’s work place [26]. Job burnout is a response to chronic interpersonal and emotional stressors on the job, resulting in negative feelings such as incompetence, lack of achievement and productivity at work [4]. The results of this study reveal high levels of job burnout in 2 dimensions of the job burnout syndrome among our sample of nurses, EE and PA. Also, significant differences were observed in the EE dimeni sion of burnout syndrome between nurses Table 2 Differences between psychiatric and nontpsychiatric nurses in mean scores for the 3 dimensions of job burnout Dimensions Psychiatric Medical ttvalue Ptvalue nurses (n = 55) nurses (n = 51) Emotional exhaustion 5.06 0.001 Mean (SD) 21.07 (8.87) 16.64 (7.54) Depersonalization 0.58 0.423 Mean (SD) 4.38 (5.10) 4.96 (5.50) Personal accomplishment 1.96 0.213 Mean (SD) 15.87 (11.63) 13.82 (9.83) SD = standard deviation. Table 3 Significant relationships between demographic characteristics and the dimension of burnout syndrome Characteristic Dimension No. Group r Ptvalue Age (years) EE 45 Psychiatric nurse 0.3 < 0.001 Years of experience EE 32 Psychiatric nurse 0.3 < 0.001 Frequency of ontcall EE 55 Psychiatric nurse 0.6 < 0.001 Frequency of ontcall PA 55 Psychiatric nurse 0.5 < 0.001 Years of experience DP 31 Medical nurse 0.5 < 0.001 EE = Emotional exhaustion; PA = personal accomplishment; DP = depersonalization. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 667 working in psychiatric and nonipsychiatric units. EE experienced by nurses is generally attributed to the nature of their job in terms of patient’s behaviour as well as the interaci tion of the superiors with the nurses. This observation may be attributed to the overall environment which prevails in psychiatric wards. Our study showed a positive correlation between age and years of experience with EE. It is possible this observation is related to the very fact that with age one’s tolerance for demanding situations and stressful work environment decreases. In the beginning of their career, nurses may be more motivated but in due time their eagerness to continue as an ordinary nurse may decline, as they do not see coherence between their needs and the stresses which they experience. Comi parison of male and female nurses working in psychiatric units showed that male nurses experienced a higher degree of EE. This difi ference, though statistically not significant, may be attributed to nurse’s expectations from their job and their adjustment in their work place. Krausz and associates hold the view that male nurses have poorer coping ability as compared to their female counteri parts [27]. It has been reported that worki setting satisfaction is the most significant predictor of EE, of DP, of job pressure, of job satisfaction, and of PA [28]. In terms of health service delivery, job burnout in health professionals and espei cially in nurses has a direct impact on the health care system. These include poor quality of health care delivery and loss of people’s lives and material resources. To this end, several measures have been proi posed to prevent the harmful consequences of this phenomenon. Jansen and coiworkers believe that instead of changing the work content we can decrease the feelings of burnout by paying attention to supervisory support, peer relationships and individual training programmes [29]. Health authorii ties are particularly advised to undertake a systematic and continuous assessment of the nursing staff work performance. Results of Jansen and coiworkers’ study once again confirm that stress is a problem for wardibased mental health nurses. These observations have 2 main implications: first, we need models of the stress process that are empirically based and which help us identify the moderating variables that can reduce the impact of stressors on nurses. Secondly, we need to use their knowledge to deliver stress management interventions for staff. Employee stress can have profound effects on an organization, such as increases in worker’s compensation claims and cost of production. Both health and legal experts assert that the time to deal with workplace stress is before it manifests itself in the costly worker compensation claims. Knowing the negative consequences of job burnout, it is imperative to combat stress in the work place. Health managers are expected to dei termine if their employees are experiencing harmful stress in the work place before it is too late. They should provide a conduci tive environment for the employees to talk freely and confidently about their problems and by, introducing wellness programmes, involve them in appropriate physical aci tivities to vent out their anger and hostility. Hospitals are strongly advised to conduct regular training courses for the nursing staff in order to manage the art of stress management and develop healthy coping strategies to neutralize the negative impacts of workload. Prior organizational comi mitment, selfiefficacy, and healthy coping skills have a key role in predicting high risk nurses for job burnout [1,30]. Some suggest involvement of psychiatric liaison service as a possible method to provide support to the nurses [31]. Adequate supervisory and 668 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 organizational support, peer relationships and individual training courses are able to improve the quality of patient care and dii minish the chances of postitraumatic stress disorder, job dissatisfaction and burnout [15,18,32]. References 1. Greenglass ER, Burke RJ. Hospital ret structuring and burnout. Journal of health and human services administration, 2002, 25(1):89–114. 2. Constanti A et al. Relationship between hardiness and risk of burnout in a sample of 92 nurses working in oncology and AIDS wards. Psychotherapy and psychot somatics, 1997, 66(2):78–82. 3. Crotty M. Burnout and its implications for the continuing education of nurses. Nurse education, 1987, 7(6):278–84. 4. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annual review of psychology, 2001, 52:397–422. 5. Maslach C, Leiter MP. The truth about burnout. San Francisco, CA, Jossey– Bass, 1997:36–60. 6. 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Stress, coping and burnout in mental health nurses: findings from three research studies. International journal of social psychiatry, 1996, 42(2):102–10. 23. Gerits L et al. Emotional intelligence prot files of nurses caring for people with set vere behaviour problems. Personality and individual differences, 2005, 38(1):33–43. 24. Maslach C, Jackson SE. The measuret ment of experienced burnout. Journal of occupational behavior, 1981, 2:99–113. 25. Mayou R. Burnout, British medical jourt nal, 1987, 295:284–5. 26. Musick JL. How close are to burnout you? Family practice management, 1997, April:30–46. 27. Krausz M, Sagie A, Bidermann Y. Act tual and preferred work schedules and scheduling control as determinants of job related attitudes. Journal of vocational behavior, 2000, 56(1):1–11. 28. Cam O. The burnout in nursing academit cians in Turkey. International journal of nursing studies, 2001, 38:201–7. 29. Jansen PGM et al. The effects of job characteristics and individual charactert istics on job satisfaction and burnout in community nursing. International journal of nursing studies, 1996, 33(4):407–21. 30. Cejka S. How to ban job burnout. Medical economics, 1999, 76(1):31, 34, 37. 31. Fawzy FI et al. Preventing nursing burnout: A challenge for liaison psychiatry. General hospital psychiatry, 1983, 5(2):141–9. 32. ArmstrongtStassen M. The influence of prior commitment on the reactions of layt off survivors to organizational downsizing. Journal of occupational health psycholt ogy, 2004, 9(1):46–60. 670 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Hospital financial performance in the United States of America: a follow-up study M.Z. Younis,1 H.Z. Younies2 and F. Okojie3 1Department of Health Policy and Management, Robert Stempel School of Public Health, Florida International University, Miami, Florida, United States of America. 2College of Business and Economics, United Arab Emirates University, Al Ain, United Arab Emirates. 3Department of Research and Development, Jackson State University, Jackson, Mississippi, United States of America (Correspondence to M.Z. Younis: mustafa.younis@ccaix.jsums.edu). Received: 04/08/04; accepted: 20/02/05 ABSTRACT To clarify and validate the factors that influence hospital profitability in the United States of America, we used a cross-sectional design to examine data for 1998. Several changes and government regulations introduced in the early 1990s influenced hospital performance. We included those variables to give a better understanding of the hospital payment system. Among the explanatory variables con- sidered, geographic location, competition, hospital size and occupancy rate were identified as the main contributors to hospital profitability. 12 Hospital financial performance in the United States of America: a follow-up ÍɳÈfºÙ=ÌbVJ™=L>È×Ƕ=›L>É«nJj»·¶ʶ>™=Ð=aÙ=6Í£E>J»·¶Íi=ea ÊQDzÆ?k³·Éª(k¾ÇÈÁ>jU(k¾ÇÈÁ=bÈgΫìrº  „=Í[qØ6=½>®Í¿[iL>[É죺e>[FJ]=›L>[¢>ì®Ìçb£¶¸º>m¼É»rI½=b^Ji>EÁÇNU>F¶1998XÉ[uÇI­b[ÃE >[ÿº°[ö¯VJ¶=Æ(Í[ɳÈfºÙ=Ìb[VJ™=L>È×Ƕ=›L>É«nJj™=ÍÉ}eη¢fë[MÖI¶=¸º=Ç£¶=*À[ºb[Èb£¶=fç[[M?b[®Æ Ð=a?η¢L>É¿É£jJ¶=¸ÃJjº›K·]a?¶=Íɺdzƒ=¼Ÿ¿¶=ÆL=[ɧJ¶=L>É«nJj™=*T=eaD[EÁÇNU>[F¶=½>[®b[®Æ Ÿ¿¶\>vÈÝ=ÀºbÈh»·¶L=fëɧJ™=ÅdÂL>É«nJj™=›L>¢Çªb™=½>*(>[Æ>¿I[¶=ÍÉU>vÈÝ=L=fëɧJ™=EÀºÆ Í[É}e›¼Ãj[àI[¶=¸[º=Ç£¶=¼[Â?À[º(¹>§[mÝ=¹b[£ºÆ(Ϋn[Jj™=¼[RUÆ(Íj[ª>¿™=Æ(›=f[§‚=¤®Ç™=àJ¢= ΫnJj™=*  Performance financière des hôpitaux aux États-Unis d’Amérique : étude de suivi RÉSUMÉ Afin de clarifier et de valider les facteurs qui influencent la rentabilité hospitalière aux États- Unis d’Amérique, nous avons utilisé un modèle transversal pour examiner les données disponibles pour l’année 1998. Plusieurs modifications et réglementations gouvernementales introduites au début des années 90 ont influencé la performance des hôpitaux. Nous avons inclus ces variables pour permettre une meilleure compréhension du système de paiement hospitalier. Parmi les variables explicatives examinées, la situation géographique, la concurrence, la taille de l’hôpital et le taux d’occupation ont été identifiés comme les principaux éléments qui contribuent à la rentabilité hospitalière. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 671 Introduction Many changes took place in hospitals in the United States of America (USA) after 1998 owing to the introduction of the Bala anced Budget Act (Balanced Budget Act of 1997, PL 105a33). The provisions included an experimental payment programme that waived certain small rural hospitals from the prospective payment system mechanism and provided others with extra payment for providing services to uninsured and Meda icaid patients. The prospective payment system, introduced in 1983, promised to change the way hospitals were reimbursed: payment was determined based on type of treatment or diagnostic related group. Since the introduction of this system, a large number of studies have examined its effect on hospital economic and financial performance and uncompensated care to the indigent population [1–3,4]. This report is a followaup to the study conducted by Younis, Rice and Barkoulas which identified a number of economic and financial variables as significant contribua tors to hospital profitability for the years 1991 and 1995. Geographic region, ownera ship status, teaching affiliation and hospital size were the factors that determined hosa pital profitability [1]. That study, however, ignored the repeated measure to validate their result over a period of time since cera tain events or actions, e.g. technological ada vancements or new regulations which affect hospital performance, may have had an efa fect on the validity. Furthermore, additional variables crucial to hospital profitability such as critical access status (critical access hospitals are rural hospitals with < 30 beds and mean length of stay ≤ 96 hours), age of the facility and outlier payments to safetya net hospitals were not included. A study done in Florida examined the issue of profitability in a sample of 50 investoraowned or foraprofit hospitals and 60 not-for-profit hospitals (the legal dis-a tinction between foraprofit and notafora profit hospitals lies in issues related to tax exemption status, the ability to receive taxadeductible donations and limitation in the distribution of profits) during the period 1982–88 [2]. Foraprofit hospitals were more profitable than notaforaprofit hospitals, and the average length of stay and wages per adjusted patient day were important in explaining hospital profita ability. Using a logit regression model, Walker found that financial variables by themselves failed to discriminate between profitable and nonaprofitable hospitals and thus did not provide a complete explanaa tion of financial conditions [3]. Watt et al. reported that foraprofit hospitals had higher average revenues than their notaforaprofit counterparts [5]. Herzlinger and Krasker found that notaforaprofit hospitals neither perform as well financially nor compensate for this by returning higher levels of social benefits [6]. Those findings have, however, been disputed on conceptual and methodoa logical grounds [7–9]. The notaforaprofit hospitals were less profitable than the fora profit hospitals, but provided more access to care to the indigent population through the admissions to their emergency rooms. They showed that hospital performance varied according to ownership. In a study on a sample of hospitals in Florida in 1980, foraprofit and notaforaprofit hospitals were virtually identical in terms of profitability [10]. Two later studies found that foraprofit hospitals tended to be half the size of nota foraprofit hospitals, with a lower case mix, shorter length of stay, higher cost per day, lower cost per case, and greater profitability [4,11]. In the present study, we reaexamined the issue of factors that influence hospital profitability by using more recent data and 672 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 adding other variables that affect hospital profitability in the USA. We considered a broad set of potential empirical determia nants of hospital financial performance cova ering the year 1998. The sample period is in the prospective payment system era, under which payment is based on a predetermined rate. Our data set was comprehensive as it used a diverse and representative sample of hospitals from all 4 regions of the USA. The econometric methodology employed is piecewise, linear regression which accounts for the presence of a certain type of nonlina earity in the estimated relationships. The piecewise regression method provides the policy analyst with a simple way to examine and split off groups of hospitals by size. Basic data for use in this report were supplied by Solucient LLC, Evanston, Illia nois. Any analysis, interpretation or conclua sions based on these data are solely those of the authors and Solucient LLC specifically disclaims responsibility for any analysis, interpretation or conclusions. Methods The dependent variable for economic pera formance of hospitals is the return on assets (ROA), a continuous financial status varia able defined as net income divided by total assets. It reflects hospital operating revenue scaled by the size of the hospital. It is also a type of efficiency ratio as it relates hospital output to nonalabour inputs [12]. To understand the factors affecting ROA, we estimated the following regresa sion model: ROA = f(LOCATION, OWNER, TEACH, CONVERTFP, CONVERTNFP, CAH, SOLE, AGE OF FACILITY, LENGTHSTAY, B E D C A PA C I T Y, E M P L OY E E S , OCCURATE, MEDIDAYS) where: • LOCATION = geographic location of hospital, modelled as a dummy variable as follows: SOUTH = 1 if a hospital is located in the southern region and 0 otherwise, MIDWEST = 1 if a hospital is located in the midwestern region and 0 otherwise, WEST = 1 if a hospital is located in the western region and 0 otha erwise, with NORTHEAST being the reference category; • OWNER = dummy variable indicating type of ownership, 1 for investoraowned or foraprofit status, 0 for notaforaprofit status; • TEACH = dummy variable, taking the value of 1 if a hospital provides media cal education (primarily graduate) and intern training, 0 otherwise; • CONVERTFP = dummy variable, taka ing the value of 1 if a hospital was cona verted from notaforaprofit to foraprofit status between 1991 and 1998, 0 othera wise; • CONVERTNFP = dummy variable, taka ing the value of 1 if a hospital was cona verted from foraprofit to notaforaprofit status between 1991 and 1998, 0 othera wise; • CAH = dummy variable, taking the vala ue of 1 if a hospital was designated as a critical access hospital, 0 otherwise; • SOLE = dummy variable capturing the degree of competition facing a hospital, 1 if a hospital was the sole Medicare provider, 0 otherwise; • AGE OF FACILITY = a proxy variable that influences the dominator (total asa sets) due to depreciation of buildings (expected to have positive coefficient); • LENGTHSTAY = total number of acute care impatient days in a hospital dia vided by the total number of acute care Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 673 discharges from the hospital, adjusted for the complexity of the case mix of a particular hospital; • BEDCAPACITY = number of beds in service, entering the regression equation as follows: BEDCAPACITY 0 to 100 = number of beds in service if BEDa CAPACITY < 100, = 100 if BEDCAa PACITY ≥ 100; BEDCAPACITY 100 to 500 = 0 if BEDCAPACITY < 100, = number of beds in service minus 100 if 100 ≥ BEDCAPACITY < 500, = 500 if BEDCAPACITY ≥ 500; BEDCAPAC-a ITY over 500 = 0 if BEDCAPACITY < 500, = number of beds in service mia nus 500 if BEDCAPACITY ≥ 500; • EMPLOYEES = number of fullatimea equivalent employees per 100 discharga es, adjusted for case mix; • OCCURATE = percentage of beds in service occupied, entering the regresa sion equation as follows: OCCURATE 0 to 10 = number of beds in service if OCCURATE < 10, = 10 if OCCURATE ≥ 10; OCCURATE 10 to 50 = 0 if OC-a CURATE < 10, = number of beds in service minus 10 if 10 < OCCURATE < 50, = 50 if OCCURATE ≥ 50; OCCU-a RATE > 50 = 0 if OCCURATE < 50, = number of beds in service minus 50 if OCCURATE ≥ 50; • MEDIDAYS = the number of inpatient Medicaid days divided by the total hosa pital days. While case mixaadjusted average length of stay does not take quality into account, it allows for highalevel comparison between groupings related to hospital efficiency. Favourable values are below the median length of stay [case mix adjusted] = (total inpatient days, acute care/total discharge, acute care)/Medicare case mix index (Media care case mix index is a measure of the coma plexity of the Medicare cases treated by an individual hospital relative to complexity of the average Medicare patient nationwide). We assumed linearity in the functional relationship between ROA and all predictors except for BEDCAPACITY and OCCUa RATE. For these 2 regressors, we modelled their effect on ROA as piecewise linear with 2 changes in the slope coefficients. Such modelling is supported by the data and represents a relatively parsimonious way of relaxing the assumption of linearity in the relationship. Specifically we assumed the linear relationship between profitability and occupancy rate may differ over a certain range of occupancy rate. For example we hypothesize that profitability may increase (or decrease in case of diseconomy of scale) at a rate > 10% and < 50% of occupancy, i.e. the slope will change when occupancy rate = 10% and occupancy rate = 50%. Therefore, the model proposes a different linear relationship for a different interval over the range of the occupancy rate. The same applies for hospital size. The estimation methodology, using SAS, version 7.1, used the ordinary least squares regression with heteroscedasticity adjusta ment to standard errors according to White [13]. Results The data set contained 3461 hospitals (out of 5400 hospitals) for the year 1998. The source of the data was the Medicare Cost Report [12] (provided by Solucient LLC). Table 1 provides descriptive statistics for the variables of the sample year. The empirical results from the piecewise linear regression are presented in Table 2. The Fatest statistic was significant at the 674 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 5% level, thus providing empirical support to our modelling strategy. The dummy variable for hospital locaa tion in the south was statistically significant. SOLE, the dummy variable for competition was also statistically significant. Hospital size, measured by the number of beds in service and denoted by BEDCAa PACITY, varied nonlinearly with profitaa bility. The relationship was nonamonotonic, piecewise linear with threshold values at 100 and 500 beds. Similarly, there was a piecewise lina ear relationship between OCCURATE and ROA with thresholds at 10% and 50%. Occupancy rates up to 50% were associated with increased profitability. Discussion In their 2001 study, Younis, Rice and Barka oulas concluded that teaching status and ownership status had a negative effect on profitability, while sole community proa vider hospitals were more profitable [1]. In this followaup study, we found that teaching hospitals were more profitable than nona teaching hospitals and hospital monopoly did not improve profitability. We included several variables that were not discussed in the previous study, such as critical access hospitals and age of the facility. We cona sider our current study more comprehensive and providing a more upatoadate insight on this topic. Regional differences in profitability apa pear to exist as the dummy variable for hospital location in the south of the USA was statistically significant. Given that the reference category was the northeast, the positive coefficient for the indicator varia able for the south suggests that hospitals in that region were more profitable. The indicator variable for ownership status, OWNER, does enter significantly in the regression equation, suggesting that the effect of ownership status (investoraowned versus notaforaprofit) on the economic pera formance of hospitals was small. Foraprofit hospitals appear to have a higher ROA than notaforaprofit hospitals. The small weight of Table 1 Descriptive statistics (mean) for dependent and some independent variables, 1998 Variable Mean value Return on assets (%) 2.46 OWNER: ownership status (hospitals) 857 TEACH: teaching status (hospitals) 942 CONVERT: conversion of ownership status during 1991–1998 (hospitals) From NFP to FP 189 From FP to NFP 54 Critical access hospitals (hospitals) 14 SOLE: sole community provider (hospitals) 368 LENGTHSTAY: length of stay per adjusted acute case mix (days) 3.28 EMPLOYEES: full-time employees per 100 adjusted discharges, adjusted for case mix (employees) 8.13 MEDIDAYS (days) 0.41 Regional distribution (hospitals) Total 3461 Northeast 1328 Midwest 619 West 838 South 676 BEDCAPACITY: hospital size (beds in service) 205.38 OCCURATE: occupancy rate (%) 49.96 NFP = not-for-profit. FP = for-profit. Source: Medicare Cost Report Data. Data provided by Solucient LLC, Illinois. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 675 Table 2 Piecewise linear generalized least squares regression of return on assets on hospital characteristics for 1998 (n = 3461) Independent variable Coefficient estimate (t-statistic) Constant (alpha value) 5.3789 (3.79) OWNER 0.003 (1.98) TEACH 0.0013 (2.24) CONVERTFP 0.0034 (1.72) CONVERTNFP 0.0068 (1.03) CAH 0.0142 (0.94) SOLE 0.00017 (–2.03)*** AGE of FACILITY 0.0047 (1.79) LENGTHSTAY 0.00323 (0.920) EMPLOYEES 0.0001 (0.36) MEDIDAYS 0.0009 (0.49) Geographic location dummy variablea Midwest –0.0035 (–0.97) West –0.0018 (–0.57) South 0.0014 (3.13)*** BEDCAPACITY 0–99 0.000016 (1.65) 100–499 –0.0013 (–2.76)*** 500 –0.0021 (–1.983)* OCCURATE 0–9 –0.0017 (–0.86) 10–49 0.0008 (2.35)*** 50 0.00012 (0.79) F statistic (marginal significance level) 3.84 (0.00821) R2 0.3521 aReference category northeast. Sandard errors are adjusted for heteroscedasticity according to White [13]. CAH = critical access hospital. BEDCAPACITY 0 to 100 = number of beds in service if BEDCAPACITY < 100, = 100 if BEDCAPACITY ≥ 100. BEDCAPACITY 100–500 = 0 if BEDCAPACITY < 100, = number of beds in service minus 100 if 10 ≥ BEDCAPACITY < 500, = 500 if BEDCAPACITY ≥ 500. BEDCAPACITY over 500 = 0 if BEDCAPACITY < 500, = number of beds in service minus 500 if BEDCAPACITY ≥ 2/3 500. OCCURATE = percentage of beds in service occupied, entering the regression equation as follows: OCCURATE 0 to 10 = percentage of beds in service occupied if OCCURATE < 10, = 10 if OCCURATE ≥ 10; OCCURATE 10 to 50 = 0 if OCCURATE < 10, = percentage of beds in service occupied minus 10 if 10 ≤ OCCURATE < 50, = 50 if OCCURATE ≥ 50. The F-test statistic corresponds to the null hypothesis that the coefficient estimates for all variables included in the regression equation are jointly zero. R2 is the coefficient of determination. ***Statistically significant at the 1% level. *Statistically significant at the 10% level. 676 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 type of ownership could be an effect of the strict regulations on the hospital industry and the universal set payment per diagnosis, (the prospective payment system). Type of ownership was, therefore, irrelevant to hospital profitability. The conversion in ownership status from notaforaprofit to foraprofit and vice versa (CONVERTFP and CONVERTNFP) did not show a major effect on the economic performance of the hospitals, possibly owa ing to the culture of management and/or constraining regulation in the health care industry. It also is likely that the sample sizes for these groups were too small to obtain significant results (189 hospitals in CONVERTFP and 54 hospitals in CONa VERTNFP). The indicator variable for critical access hospitals [small rural hospitals having 15 or fewer acute care beds and at least 35 miles (15 miles in mountainous terrain or over secondary roads) from the next hospital] was not significant. The small number of critical access hospitals in our sample, howa ever, did not allow for enough variation to detect statistical significance. The dummy variable indicating whether a hospital is the sole community provider (measure of lack of competition, SOLE) enters negatively in the regression equaa tion: profitability was lower for groups with monopoly power. It appears that the hospital power emanating from being a sole community provider produces managerial inefficiencies manifested in reduced profita ability because the prospective payment system provided a uniform payment system. Owing to the uniform payment system and regulations, hospitals with monopoly status are not in general able to use market forces to their advantage. Furthermore, hospitals with such a market position had to offer uncompensated care to their communities regardless of their monopoly power in the market. Hospitals with > 100 beds in service were less profitable than hospitals with < 100 beds. Small hospitals, usually located in rural areas, are characterized with no, or low, penetration of managed care. Moreoa ver, rural hospitals usually face less compea tition and provide a wider range of services. Larger hospitals usually operate in urban locations with more local competition and a higher penetration of managed care, which puts substantial downward pressure on reva enues and shifts a greater uncompensated charity care burden onto the hospitals [14]. The slope for the variable EMPLOYa EES, the number of fullatime employees adjusted for case mix, was not statistically significant. Number of employees was included to represent variable cost even though it has a low coefficient. Case mix index (CMI) is analogous to product mix in a manufacturing context. It is a measure of the mix of patient illness types treated in the hospital, relative to the national average, and proxies for relative resource consumpa tion. Thus, a hospital with an aboveaaverage CMI is expected to consume more resources than a hospital with a lower CMI. Employee fullatimeaequivalents are divided by the CMI to provide an adjusted (standardized) fullatimeaequivalents measure. A fullatime employee is a good proxy for the variable cost of the hospital. The lack of significance for EMPLOYEES in our study suggests that hospitals may have been operating on an optimal number of employees, and any reduction in the number of employees would not lead to significant improvement in profitability. Occupancy rates up to 50% were associa ated with increased profitability. Increases in OCCURATE above the 50% level did not appear to make any significant contribution Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 677 to profitability. Therefore, a declining trend in occupancy rate would have an adverse effect on efficiency, profitability and liquida ity. At a lower rate of occupancy, operating expenses per adjusted discharge will be greater which will hinder the ability to opera ate efficiently. Since the implementation of the prospective payment system and with the current decline in use of inpatient services in comparison with outpatient treatments, occupancy rate has been considered a key predictor of financial performance, which is confirmed by our empirical findings. The cutaoff points at 10% and 50% produced the most significant results. Conclusion The prospective payment system dramatia cally influenced the profitability of the hospital industry. However, other factors also influenced profitability: geographic location, hospital size, occupancy rate and competition. The southern region appeared to be the most profitable, probably because there is less regulation in comparison with the other geographic regions [15]. Since the age of the equipment and facility will influence the magnitude of the ROA, it is suggested this ratio be used with other profa itability ratios such as total profit margin and return on equity. Hospital conversion did not have any efa fect on hospital profitability. Furthermore, hospitals with monopoly position did not have any advantage in generating abnora mal profit in comparison to other hospitals owing to the federal and state regulations and the standardized prospective payment system. This should lessen the fear of civic groups regarding consolidations in the hosa pital industry. References 1. Younis M, Rice J, Barkoulas J. An empiri- cal investigation of hospital profitability in the post-PPS era. Journal of health care finance, 2001, 28(2):65–72. 2. Sear AM. Operating characteristics and comparative performance of investor- owned multihospital systems. Hospital and health services administration, 1992, 37(3):403–15. 3. Walker C. A cross-sectional analysis of hospital profitability. Journal of hospital marketing, 1993, 7(2):121–38. 4. Forgione DA, Schiff AD, Crumbley DL. As- sessing hospital performance: an inven- tory of financial and nonfinancial metrics. International Association of Management journal, 1996, 8(2):65–83. 5. Watt JM et al. The effects of ownership and multihospital system membership on hospital functional strategies and econom- ic performance. In: Gray BH, ed. For-profit enterprise in health care. Washington DC, National Academy Press, 1986:260–90. 6. Herzlinger R, Krasker W. Who profits from non-profits? Harvard business review, 1987, 65(1):93–105. 7. Fitzgerald J, Jacobson B. Study fails to prove for-profits superiority. Health progress, 1987, 32–7. 8. Haddock C, Arrington B, Skelton A. Who profits from not-for-profits: a reconsid- eration. Health services management research, 1989, 2(2):82–104. 9. Arrington B, Haddock CC. Who really profits from not-for-profits? Health serv- ices research, 1990, 25(2):291–304. 10. Sloan FA, Vraciu RA. Investor-owned and not-for-profit hospitals: addressing some issues. Health affairs, 1983, 2(1):25–37. 11. Forgione DA. Incentives and performance of the health care industry: the case of for/ 678 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 non-profit multihospital systems [thesis]. Amherst, Massachusetts, University of Massachusetts Amherst, 1987. 12. Kane NM, Magnus SA. The Medicare Cost Report and the limits of hospital ac- countability: improving financial account- ing data. Journal of health politics, policy and law, 2001, 26(1):81–105. 13. White H. A heteroscedasticity-consistent covariance matrix estimator and a direct test for heteroscedasticity. Econometrica, 1980, 48:817–38. 14. Younis MZ. Length of hospital stay of Medicare patients in the post-prospective- payment-system era. Journal of health care finance, 2004, 31(1):23–30. 15. Needleman J, Chollet D, Lamphere J. Hospital conversion trends. Health affairs, 1997, 16(2):187–95. Correction Rate of hepatitis B seropositivity following mass vaccination in the Islamic Republic of Iran. M-R. Zali, K. Mohammad, A-A. Noorbala, B. Noorimayer and S. Sahraz. Eastern Mediterranean Health Journal, 2005, Vol. 11 Nos 1/2, pages 62–67. The name of the fifth author should read: S. Sharaz. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 679 Short communication Alternative drugs against Trichomonas vaginalis N.K. Mahdi,1 Z.H. Gany2 and M. Sharief3 1Department of Microbiology; 3Department of Obstetrics and Gynaecology, College of Medicine; 2Department of Pharmacology, Toxicology and Allied Sciences, College of Pharmacy, University of Basra, Basra, Iraq (Correspondence to N.K. Mahdi: nadhammahdi@yahoo.com). Received: 1/10/02; accepted: 06/07/04 ABSTRACT To investigate the effect of drugs other than metronidazole, 3 non-pregnant women in- fected with Trichomonas vaginalis were treated with doxycycline, 2 × 200 mg/day for 1 week. Another 3 women were treated with praziquantel, single dose, 40 mg/kg body weight. No therapeutic effect was detected for either drug. In vitro, oxytetracycline led to death of T. vaginalis at a concentration of 15 mg in 0.5 mL medium. Extract of Myrtus communis caused death of T. vaginalis at pH 4.65, but failed to do so at pH 6.00. Extract of Eucalyptus comaldensis (50 mg in 0.1 mL medium) at pH 5.35 caused death of T. vaginalis after 24 hours. 3 Alternative drugs ag inst Trichomonas vaginalis ÍÉ·FÙ=Ìfç£n»·¶Ìa>v™=Í·ÈbF¶=ÍÈÆaÙ= ¬ÈfmÁÇjɺ(¦bɗG¿Èg(Ëbú¼ž>²¼ž>¾ „=Í[qØ6­èf£J·¶¹Æg=bɾÆf[J™=¦Ïf]Ù=ÍÈÆaÙ=fM?η¢Ìfç£n™>EÏÆb£¶>EL>E>rº¸º=ÇUPØMK‚Ç¢( >ÿº¸²e=b¯ºð>ɺÇȐJ¢f|·³ÉiÊj²Æb¶>EÍÉ·FÙ=200¸[º=ÇUPØ[MK[‚Ç¢>[»Éª(¥ÇF[i?Ìb[™Æ¨[º >Âe=b¯ºÌbÉUÆÍ¢f|(¸ÉJ¾=dzÈg=¶>EL>Èf]?40¨º+¼j[‚=ÁgÆÀº¨²*[³ÈÆúËÙÊ[QØ¢M@[IèË?¬n ÀáÈßÐ=Æb¶=Àº*hɲf[JEÍÉ·FÙ=Ìfç£n™=LǺ‘C·³Éi=f[J[IÊj²ÆÙ=Ïa?b¯ª(ÍÈJ^™=He>RJ¶=›>º?15¨º ›0.5Ð>[Â>EÍ[[Qea›Í[É·FÙ=L=f[ç£n[™=LÇ[º‘C¤[Ñ>n[¶=lÛ=fR[mÍqØ]La?>»²(KF¿Jj™=Àº¸º 4.65pH›K·n[ª>ÿ³¶ÆÐ>[Â>EÍ[Qea›>Ã[·J®6.00pH*Èb[¶>ºÇ³¶=lÇJFɶ>[²Çɶ=Í[qØ]KFF[i>[»² hɲf[JE50›¨º0.1Ð>Â>EÍQea›ÆKF¿Jj™=Àº¸º5.35b£EÍÉ·FÙ=L=fç£n™=LǺ‘C24Í¢>i*  Traitements alternatifs contre Trichomonas vaginalis RÉSUMÉ Afin d’examiner l’effet d’autres médicaments que le métronidazole, 3 femmes non enceintes infectées par Trichomonas vaginalis ont été traitées à la doxycycline, 2 x 200 mg/jour pendant une semaine. Trois autres femmes ont été traitées au praziquantel en dose unique de 40 mg/kg de poids corporel. Aucun effet thérapeutique n’a été détecté pour ces deux médicaments. In vitro, l’oxytétracy- cline a entraîné la mort de T. vaginalis à une concentration de 15 mg dans 0,5 mL de milieu. Un extrait de Myrtus communis a causé la mort de T. vaginalis à un pH de 4,65 mais pas à un pH de 6,00. Un extrait d’Eucalyptus comaldensis (50 mg dans 0,1 mL de milieu) à un pH de 5,35 a entraîné la mort de T. vaginalis après 24 heures. 680 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Introduction Trichomonas vaginalis is a flagellate prot tozoan which infects the urogenital tract of men and women [1]. It is transmitt ted by sexual intercourse [2,3], by nont venereal means such as sharing of contamit nated towels or underclothing, or the use of nontsterile medical examination tools [2,3]. In women it causes vaginitis and cystitis and in men it causes urethritis and prostat titis [4]. Metronidazole is the mainstay of treatt ment for T. vaginalis infection and can be given as a single dose, 2 g orally (divided into 1 g in the morning and 1 g at night), or 250 mg 3 times/day for 7 days [5,6]. Appropriate treatment with metronidat zole cures 60%–80% of cases with a single dose, but the cure rate increases to > 90% when sexual partners, who are usually asymptomatic, are treated simultaneously to prevent retinfection [7]. The chemotherapeutic trial presented in this study is the first attempt in Iraq to try to identify alternatives to metronidazole, the only currently available treatment for trichomoniasis. Under the circumstances of economic sanctions and shortage of drugs, it is essential to carry out therapeutic invest tigations on chemical and plant sources. Tetracycline has an antiprotozoal effect against Dientamoeba fragilis and Balantid dium coli [9]; therefore, tetracycline det rivatives doxycycline and oxytetracycline were chosen for this investigation. Both are readily available, the treatment course is short, resistance has not been recorded and they do not have the bitter taste that is associated with metronidazole. In addition, oxytetracycline is the drug of choice in the treatment of T. foetus in cattle (veterinary use) [10,11]. The drug oxytetracycline and plant extracts of Myrtus communis and Eucalyptus camaldulensis were chosen for in vitro investigation because they have antiparasitic activity [10–12]. Methods Samples were obtained from the vaginal discharges of infected women by sterile vaginal swab and cultured in selective met dium, Bacto trichomonas broth, (Difco No. 0911.02, Difco Laboratories, Michigan), incubated at 37 °C and checked for the prest ence of T. vaginalis after 48–72 hours. This was done by taking a drop from the bottom of the culture using a sterile Pasteur pipette, transferring to a slide and examining under the high power objective for ≥ 10 minutes. Two drugs were tested experimentally in vivo, and 1 drug and 2 plant extracts in vitro, in order to study their effect on T. vaginalis. In vivo This study was carried out in the first 6 months of 2001 in Basra Maternity Hospit tal, the main centre for gynaecology and obt stetrics in the city. Diagnosis of T. vaginalis infection was made by 2 of the authors by wet preparation and in vitro cultivation. All 7 nontpregnant, infected women presentt ing during the study period were informed about the study and all but 1 agreed to part ticipate in the in vivo study. The age range of the women was 23–45 years. Two drugs were used, doxycycline and praziquantel. The diagnosis and treatment outcome were assessed by wet preparation microscopy and culture methods [3]. Three nontpregnant patients infected with T. vaginalis were treated orally with doxycycline 200 mg (Vidipha, Ho Chi Minh City, Socialist Republic of Viet Nam), 2 capsules/day for 1 week. A second group of 3 nontpregnant patients infected with T. vaginalis were Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 681 treated with praziquantel (Shin Poong Phart maceutical Company Ltd., Seoul, Republic of Korea), 40 mg/kg body weight in a single dose divided into 2 parts taken 5 hours apart. Retexamination was done on the 3rd and the 5th days after completing treatment. In vitro The antibiotic oxytetracycline, 100 mg/mL preparation (CibatGeigy Ltd., Basle, Switt zerland), was added to tubes containing 0.5 mL Bacto trichomonas broth in the folt lowing amounts: 0.1 mL, 0.15 mL, 0.2 mL and 0.5 mL. The mixtures were used on the same day they were made up. They were inoculated with T. vaginalis (5 × 106 to 10 × 106 organisms/mL) and incubated at 37 °C. The tubes were examined for T. vaginalis activity immediately and over a 24thour period. Plant material and extraction Two plants, M. communis L. (Myrtaceae) and E. camaldulensis L. (Myrtaceae) were investigated. Both of these are grown in Basra. Extraction was carried out according to the method described in Harborne [8]. Briefly: • leaves were separated from other parts of the plant and washed with water; • the leaves were then dried under sunlight with good ventilation and then ground finely in a mill; • 10 g of the ground leaves was mixed with 100 mL of distilled water in a flask and heated on a magnetic stirrer at 40 °C–50 °C for 4 hours/day for 12 days; • the suspension was then centrifuged at 6000 rpm for 30 minutes; • the supernatant was decanted and clarit fied by filtration through a sterile filter paper (0.45 μ) then made up to 100 mL with distilled water. The pH of the M. communis extract was 4.65 and that of the E. camaldulensis extract 5.35. The liquid plant extracts were tested at different concentrations with T. vaginalis, 106 organisms/mL. Myrtus communis Tubes were prepared with 0.1 mL of met dium (Bacto trichomonas broth). Plant ext tract was added in the following amounts: 0.1 mL, 0.2 mL, 0.5 mL and 1.0 mL. Cont trol tubes were prepared in a similar mant ner, omitting the extract. Since T. vaginalis is not viable at pH < 4.9, the pH of the ext tract (4.65) was adjusted to 6.00 with 10% NaOH, and a second series of tubes pret pared. All samples were examined by the same investigator at 0.0 hours, 0.5 hours, 1.0 hour and 24.0 hours. Eucalyptus camaldulensis Test and control tubes were prepared and examined in a similar manner. Plant ext tract was added in the following amounts: 0.2 mL, 0.5 mL, 1.0 mL and 2.0 mL. Results In vivo In the 3 women who were treated with doxycycline, T. vaginalis was still alive and active when they were retexamined after treatment. Similarly, praziquantel had no effect on T. vaginalis infection. In vitro Oxytetracycline caused death of T. vagid nalis immediately in the tubes which had 0.15 mL, 0.2 mL and 0.5 mL of the drug in 682 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 0.5 mL medium. Flagellae remained active only in the tube with 0.1 mL oxytetracyt cline in 0.5 mL medium (Table 1). Aqueous extract (pH 4.65) of M. comd munis showed an effect against T. vaginalis (Table 2): the organism was dead immet diately in the tubes containing 50 mg and 100 mg extract, and within 0.5 hours in the tube with 20 mg extract. At pH 6.00, however, M. communis extract had no effect against the organism (Table 3). Aqueous extract (pH 5.35) of E. cad maldulensis showed some effect on vit ability of T. vaginalis. After 24 hours, T. vaginalis was dead in the tubes containing 50 mg, 100 mg and 200 mg aqueous plant extract (Table 4). Discussion Interestingly, this study has shown that although doxycycline had no effect on T. vaginalis infection in vivo, oxytetracycline had a lethal effect in vitro. Since this drug is available in several countries other than Iraq as a broad spectrum antibiotic in human medicine [12], it is possible it could, after careful evaluation, be used as an alternative drug if it was available in the country, est pecially among women who cannot tolerate the bitter taste of metronidazole and those having resistant infection. Even though praziquantel has a good therapeutic effect on the intestinal flagellate Giardia lamblia and the intestinal amoeba Entamoeba histolytica [13], no effect was observed in our study against the urogenital flagellate T. vaginalis. Table 1 Effect of oxytetracycline on viability of Trichomonas vaginalis examined immediately after inoculation Oxytetracycline, Viability of amount added to T. vaginalis 0.5 mL medium 0.0 mL (control) Alive 0.1 mL (10 mg) Active flagellae 0.15 mL (15 mg) Dead 0.2 mL (20 mg) Dead 0.5 mL (50 mg) Dead Alive = normal activity and movement of the organism and the flagellae. Active flagellae = flagellae only moving. Dead = no normal activity at all. Table 2 Effect of Myrtus communis extract (pH 4.65) on viability of Trichomonas vaginalis (in vitro) Amount of Viability of T. vaginalis in 0.1 mL medium extract added Incubation period (hours) 0.1 mL medium 0.0 0.5 1.0 24.0 0.0 mL (control) Alive Alive Alive Alive 0.1 mL (10 mg) Active Active Active Dead flagellae flagellae flagellae 0.2 mL (20 mg) Active Dead Dead Dead flagellae 0.5 mL (50 mg) Dead Dead Dead Dead 1.0 mL (100 mg) Dead Dead Dead Dead Alive = normal activity and movement of the organism and the flagellae. Active flagellae = flagellae only moving. Dead = no normal activity at all. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 683 As part of this study, 2 plants were int vestigated for the first time because they are known to have some antibacterial and ant tiparasitic activity [14–17]. We found that Table 3 Effect of Myrtus communis extract (pH 6.00) on viability of Trichomonas vaginalis (in vitro) Amount of Viability of T. vaginalis extract added Incubation period (hours) to 0.1 mL medium 0 0.5 1 24 0.0 mL (control) Alive Alive Alive Alive 0.1 mL (10 mg) Alive Alive Alive Alive 0.2 mL (20 mg) Alive Alive Alive Alive 0.4 mL (40 mg) Alive Alive Alive Alive 0.5 mL (50 mg) Alive Alive Alive Alive 1.0 mL (100 mg) Alive Alive Alive Active flagellae 1.5 mL (150 mg) Alive Active Active Active flagellae flagellae flagellae 2.0 mL (200 mg) Alive Active Active Active flagellae flagellae flagellae 3.0 mL (300 mg) Alive Active Active Active flagellae flagellae flagellae Alive = normal activity and movement of the organism and the flagellae. Active flagellae = flagellae only moving. Table 4 Effect of Eucalyptus camaldulensis extract (pH 5.35) on viability of Trichomonas vaginalis (in vitro) Amount of Viability of T. vaginalis in 0.1 mL medium extract added Incubation period (hours) to 0.1 mL medium 0 0.5 1 24 0.0 mL (control) Alive Alive Alive Alive 0.2 mL (20 mg) Active Active Active Less active flagellae flagellae flagellae flagellae 0.5 mL (50 mg) Active Active Less active Dead flagellae flagellae flagellae 1.0 mL (100 mg) Active Less active Less active Dead flagellae flagellae flagellae 2.0 mL (200 mg) Active Less active Less active Dead flagellae flagellae flagellae Alive = normal activity and movement of the organism and the flagellae. Active flagellae = flagellae only moving. Dead = no normal activity at all. M. communis extract killed the organism at pH 4.65, but no such effect was observed at pH 6.00 (the optimal pH for growth of T. vaginalis). 684 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Promising results were obtained with E. camaldulensis extract. Consequently, this plant extract needs further investigation. Research into other chemical and plant sources to look for alternative drugs against T. vaginalis is essential. The characteristics required of such drugs are: inexpensive; available in the country; not having a bitt ter taste (cf. metronidazole); no parasite resistance (cf. metronidazole); safe to use in pregnancy; and short treatment course. References 1. Tanaka T, Kaneda Y. Seroepidemiol- ogy of urogenital trichomoniasis in Ja- pan. Japan journal of parasitology, 1989, 38(5):296–300. 2. King A, Nicol C. Venereal disease, 3rd ed. London, Bailliere Tindall, 1975:283–9. 3. Sehgal VN. Venereal disease, 2nd ed. New Delhi, Jaypee Brothers, 1987:124–5. 4. Omer EE. Trichomoniasis in clinical prac- tice. Postgraduate doctor, 1987, 10:33–40. 5. Fridrich EG. Vaginitis. American jour- nal of obstetrics and gynecology, 1985, 152(3):247–51. 6. Nash TE, Weller PE. Protozoal intestinal infection and trichomoniasis. In: Braun- wald E et al., eds. Harrison’s principles of internal medicine, 14th ed. New York, McGraw Hill Book Company, 1998:1205. 7. Essential drugs for sexually transmitted diseases. WHO drug information, 1992, 61(1):19–26. 8. Harborne JB. Phytochemical methods, 2nd ed. New York, Chapman & Hall, 1984:4–7. 9. Beaver PC, Jung RC. Animal agents and vectors of human diseases, 5th ed. Phila- delphia, Lea and Febiger, 1985:15–6. 10. Swan GE et al. The safety of dimetrida- zole alone and in conjunction with oxytet- racycline in Hereford crossbred steers. Journal of the South African Veterinary Association, 1991, 62(2):55–9. 11. Arthur GH et al. Veterinary reproduction and obstetrics, 7th ed. Philadelphia, WB Saunders Company, 1998:405–8. 12. Dey NC, Dey TK, Sinha MD. Medical parasitology, 10th ed. Kolkata, India, New Central Book Agency Ltd, 1997:4.2–4.3. 13. Mohammed KA et al. Effectiveness of praziquantel in treatment of intestinal amoebiasis and giardiasis. Eastern Medi- terranean health journal, 1998, 4(1):161– 3. 14. Majeed SH. Mahmood MG. Iraqi plants between traditional medicine and scien- tific research. Baghdad, Dar Al-Thora Press, 1988:76 (in Arabic). 15. Al-Hakeem LM. The plants and public health. Baghdad, Al-Afaq Library Publish- ers, 1989:10–25 (in Arabic). 16. Ramezani H et al. Antifungal activity of the volatile oil of Eucalyptus citriodora. Fitoterapia, 2002, 73(3):261–2. 17. Cimanga K et al. Correlation between chemical composition and antibacterial activity of essential oils of some aromatic medicinal plants growing in the Demo- cratic Republic of Congo. Journal of eth- nopharmacology, 2002, 79(2):213–20. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 685 Short communication Hexadecyl-phosphorylcholine ointment for treatment of cutaneous leishmaniasis: an animal trial J. Iqbal,¹ I. Bukhari,¹ M. Jamshid,³ S. Bashir,¹ M. Masoom Yasinzai² and M. Anwar 4 1Department of Pharmacy; 2Institute of Biochemistry; 4Department of Chemistry, University of Balochistan, Quetta, Pakistan. 3Faculty of Pharmacy, University of the Punjab, Lahore, Pakistan (Correspondence to J. Iqbal: drjaveidiqbal@ hotmail.com). Received: 03/08/04; accepted: 26/10/04 ABSTRACT A placebo-controlled trial compared 6% hexadecyl-phosphorylcholine (HePC) and 12% benzethonium chloride ointment with placebo ointment for treatment of cutaneous leishmaniasis. Cuta- neous lesions were experimentally induced by inoculation with leishmania promastigotes in 60 golden hamsters. Forty (40) animals were treated with drug and 20 with placebo ointment applied twice daily for 15 days. After treatment, all lesions were significantly reduced in size in the treatment group compared with the placebo ointment. No parasites were detected in smears from 35/40 of the drug-treated lesions and no relapses occurred over 120 days of observation. 5 Efficacy of hexadecyl-phosphorylcholine ointment for treatment of cutaneous Ëb·‚=L>ɾ>»nÉ·¶=Ð=a͂>£º›¶Ç²¸ÈeÇ«jª¸ÉjÈa>j³É¼Âfº6L>¾=ÇɃ=η¢ÍEf eǾ?b»†(Ëg>¿Éi>ȽÇr£º(nEbQ>i(bÉn–b»†(Ëe>~Lfn¢(¹>F®CbÈÆ>Q  „=Í[qØ6¸Éj[Èa>j³É¼Âf[ºM@[I¸[«§¶=Ð=Æb[¶>EÌbçÃn™=Íi=eb¶=ÅdÂÁe>¯Ihɲf[[JE¶Ç[²¸ÈeÇ«j[ª6! ›L>ɾ>»nÉ·¶=Ð=a͂>£º›¸«§¶=¼Âf™>E½ÇɾÆh¿F¶=bÈeÇ·²¤ºð>QÆhš60Ç¢cC(ÍÉFÂd¶=a=b¯¶=L>¾=ÇÉUÀº ÀÈf[]Û=ð>[¾=ÇÉUÀÈfn[£¶=Î[·¢ð>[ɺÇȐIfº¸î«î¦¼Âfº°äF{U›L>¾=ÇɃ=ÅdÂÀºÁÇ£Ee?ÊÑ=Æb¶=¼Âf™>E* Ç[¶͂>£™=b£EÆðÍ[¾e>¯ºÊÑ=Æb[¶=¼Âf™>[EÍ[‚>£™=L>[¾=ÇɃ=›L>[ªÛ=¼[RUÆÍU>j[º›žÇ[V·ºs[ö·¯I U À[ºÌcÇ]@[™=L>[]>ì·¶=›Íɾ>»nÉ·¶=L>É·É«ì¶= ßUØàIÆ7¸«à§¶=¼Âf™=>ÃÉ·¢°äF{¶=L>¾=ÇɃ>E35ð>[¾=ÇÉU ð>v[È?Pb[ŒÆÐ=Æb[¶>EK‚Ç¢¶=[£EeÙ=L>[¾=ÇɃ=EÀ[ºLf[[»Ji=Í[[ŸUغÌf[[Jª¹Ø[]k[ï³à¾èË? 120ð>ºÇÈ*  La pommade d’héxadécylphosphocholine pour le traitement de la leishmaniose cutanée : essai sur l’animal RÉSUMÉ Un essai contrôlé contre placebo a comparé une pommade contenant 6 % d’héxadécyl- phosphocholine et 12 % de chlorure de benzéthonium avec une pommade placebo pour le traitement de la leishmaniose cutanée. Les lésions cutanées ont été induites expérimentalement par inoculation de promastigotes de leishmania sur 60 hamsters dorés. Quarante (40) animaux ont été traités avec le médicament et 20 avec la pommade placebo appliquée deux fois par jour pendant 15 jours. Après le traitement, toutes les lésions ont significativement diminué en taille dans le groupe du traitement par rapport à la pommade placebo. Aucun parasite n’a été détecté dans les frottis de 35 des 40 lésions traitées par le médicament et aucune rechute ne s’est produite pendant 120 jours d’observation. 686 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Introduction The principal causative agents of leishman niasis in Asia, Middle East, Africa and parts of Europe are Leishmania donovani, L. major, L. tropica and L. infantum [1]. Curn rently, the disease appears to be on the rise in Pakistan. Both cutaneous and visceral leishmaniasis are prevalent. The cutaneous form of the disease is seen throughout the country, being highly endemic in Balun chistan, whereas the visceral form is prevan lent in the northern part of the country [2]. The cutaneous form occasionally becomes epidemic. In the absence of a vaccine, drug treatn ment with pentavalent antimonials is still the first line of treatment for leishmanian sis in Pakistan and worldwide. The major drawback associated with the treatment is that it is painful and costly, relapses occur and above all, resistance develops. During the last 2 decades, many attempts have been made to develop effective new compounds for treating cutaneous leishmaniasis (CL) that would be economical, that could be applied topically to lesions and that would avoid the development of resistance. Many other drugs have been tested for leishmanin cidal activity, including allopurional, ketan conazole and dapsone [3]. Paromomycine, an aminoglycoside, has been tested as a topical ointment for the possible treatment of CL but more clinical trials are needed against the main parasite causing CL [4]. Hexadecylnphosphorylcholine (HePC), an alkylphosphorylcholine compound, is the most promising of the new class of antintumour agent. The compound is an inhibitor of mammalian protein kinase and has been applied topically for the treatn ment of skin metastasis showing good local tolerability [5]. HePC also appears to be useful for CL [6–8]. We have shown that this compound has potent antinleishmanial activity in vitro [6]. The toxicity data of pron tein kinase inhibitors in humans is also well established [5]. In order to investigate the effectiveness of HePC ointment as a topical antinleishmanial preparation, we tested its efficacy on experimentally induced lesions in hamsters. Methods Preparation of HePC ointment An ointment containing 6.0% HePC and 12.0% benzethonium chloride was prepared according to the British Pharmacopoeia and British Pharmaceutical Codex methods by fusion techniques. Benzethonium chloride (Sigma, USA) was used as a surfactant and penetration enhancer. HePC was genern ously gifted by Asta Pharma, Germany. Other chemicals and reagents used were of Analar grade. Parasite cultures For primary isolation of parasites for inn oculation into experimental animals a drop of aspirate was taken from underneath a cutaneous leishmaniasis lesion infected with L. tropica and inoculated onto 1% agar base containing 0.9% saline and 10% rabbit defibrinated blood. This was supplemented with an overlay of Medium 199 + antibiotic + 1% sterile human urine. Parasites were grown to a density of 5 ×107 parasites/mL, spun down, reconstituted in Medium 199 (Gibco, Eggenstein, Germany) at a density of 10 million parasites/20 µL. Parasites were initially maintained in modified Tobies medium overlaid with Medium 199, 10% heat inactivated fetal bovine serum (HIFBS) and 2% urine at 20 ºC in a cooled incubator. Parasites were subsequently bulk cultivated in monophasic liquid culture Medium 199 supplemented with 10% HIFBS and 2% urine at 20 ºC in a cooled incubator. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 687 Induction of lesions Sixty (60) golden hamsters (Mesocricetus auratus) aged 8 to 25 weeks were obtained from the Institute of Health, Islamabad, Pakistan. Parasites maintained in Medium 199 were sedimented down at 3000 rpm for 15 min and washed twice with sterile phosn phate buffered saline. The washed parasites were resuspended in sterile phosphate buffn ered saline to a final concentration of 107 parasites/mL. The parasite culture was used at a concentration of 5 × 106 cells/mL to inoculate the hamsters on their nose. Hamsters were monitored for lesion development and the size of lesions was measured daily with vernier callipers until they were full developed (15 days on avern age). Treatment Two preparations were compared as treatn ments: HePC ointment containing 6.0% HePC with 12% benzethonium chloride in a simple ointment base, and placebo ointment containing simple ointment base only. The hamsters were divided into 6 groups of 10 animals and were kept in different cages: 4 groups received the HePC ointment and 2 groups received placebo ointment. A standard amount of ointment was applied to lesions twice daily at 09.00 and 18.00 h and the lesions left uncovered. At the end of the study all hamsters had received 15 consecun tive days of treatment with HePC or placebo ointment. The size of the lesions was inspected visually every day during treatment and were measured using callipers after the end of treatment at 120 days. The mean lesion size was determined by measuring the lesion diameter at its widest point and then at right angles and taking the average diameter. Samples were taken from the lesions, stained and examined under the microscope for Leishmania parasites. Analysis was made using analysis of variance. Results In the 4 treatment groups the mean lesion size decreased significantly after treatment with HePC ointment (Table 1). In the 2 conn trol groups, mean lesion sizes also decreased significantly (from 0.6 cm to 0.4 cm) in one group and increased slightly (from 0.5 cm to 0.6 cm) in the other group. On day 7 of treatment, the lesions of most of the hamsters in the experimental groups were parasitologically negative as assessed by in vitro culture. After 7 weeks, the len sions in 35 out of 40 treated rodents were totally cured, while in the placebo groups, still no healing was observed after 120 days of observation. There were no relapses in the experimental groups of animals. Discussion The results of topical HePC in cutaneous leishmaniasis were encouraging. HePC ointment significantly reduced the size of cutaneous lesions produced by experimenn tally induced infection with L. tropica in susceptible golden hamsters. Most of the lesions were parasitologically negative after treatment and there were no relapses after 120 days of observation. The ED50 value of 20 µM for HePC was obtained for Leishmania isolates from Baluchistan [7,8]. HePC also suppressed the differentiation of amastigotes to pron mostigotes, even at a concentration as low as 1.0 µM [9]. We have found that this 688 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 compound shows potent antinleishmanial activity in vitro [6]. However, further study of its mechanism of action is needed in the mammalian system as this compound is known to be a protein kinase inhibitor. We tried to find out if the mechanism was the same in the case of leishmania. The leishn manial protein kinase was isolated, partially purified and the effect of HePC studied on the partially purified enzyme. It was obn served that HePC effectively inhibited the activity of leishmanial protein kinase [5]. The inhibitory effect was stronger than the other known protein kinase inhibitors. The study needs to be repeated with a larger group of animals before any conclun sion about the efficacy of HePC can be reached. Plans are underway to test HePC ointment in human patients. Table 1 Effect of hexadecyl-phosphorylcholine (HePC) ointment on golden hamsters inoculated with promastigotes. HePC and placebo ointment was applied twice daily to experimentally induced lesions for 15 days Group Treatment Days of Lesion size (cm) treatment Before After treatment treatment Mean SD Mean SD 1 (n =10) HePC 15 0.6 0.11 0.0* 0.02 2 (n =10) HePC 15 1.0 0.27 0.0* 0.003 3 (n =10) HePC 15 0.7 0.18 0.1* 0.29 4 (n =10) HePC 15 0.7 0.20 0.2* 0.006 5 (n =10) Placebo 15 0.6 0.16 0.4* 0.18 6 (n =10) Placebo 15 0.5 0.32 0.6 0.009 *P > 0.01, comparing lesion sizes before and after treatment. n = number of hamsters per cage. SD = standard deviation. References 1. Sukkar F et al. Leishmaniasis in the Mid- dle East, USSR, India, North Africa and China. In: Chang KP, Bray RS, eds. Leish- maniasis. Amsterdam, Elsevier, 1985: 353–478. 2. Control of the leishmaniases. Report of a WHO Expert Committee. Geneva, World Health Organization, 1990 (WHO Techni- cal Report Series, No. 793). 3. Grimaldi G, Tesh RB. Leishmaniasis of the New World: current concepts and implications for future research. Clinical microbiology reviews, 1993, 6(3):230–50. 4. Burney MI, Lari FA. Status of cutaneous leishmaniasis in Pakistan. Pakistan jour- nal of medical research, 1986, 25(2):101– 8. 5. Unger C et al. Hexadecylphosphocholine in the topical treatment of skin metastasis in breast cancer patients. Cancer treat- ment reviews, 1990, 17:243–6. 6 Nagi AG, Nasimullah M. Visceral leishma- niasis in Balochistan. Pakistan pediatric journal, 1993, 17:7–10. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 689 7. Kuhlencord A et el. Hexadecylphospho- choline: oral treatment of visceral leish- maniasis in mice. Antimicrobial agents and chemotherapy, 1992, 36:1630–4. 8. Herwaldt BL, Berman JD. Recommen- dations for treating leishmaniasis with sodium stibogluconate (Pentostam) and review of pertinent clinical studies. Ameri- can journal of tropical medicine and hy- giene, 1992, 46:296–306. 9. Pareek SS. Combination therapy of so- dium stibogluconate and rifampin in cuta- neous leishmaniasis. International journal of dermatology, 1984, 23:70–1. Leishnet: web-based database and information system on Leishmania/HIV co-infection There is an emerging problem related to the increased overlap between leishmaniasis and AIDS. A WHO surveillance network for Leishmania/ HIV co-infections already exists and includes 28 member institutions worldwide. The Leishnet database has recently been created on the basis of a standardized case report form used by each member institu- tion to report to WHO/HQ. The problem, initially restricted to southern Europe, has now moved to eastern Africa and Asia. Objectives: • to improve the reliability and standardization of collected epide- miological information through frequent updates; • to make the information accessible, not only to the network mem- bers but also to other interested persons through the web using a decentralized database (graphs, maps and tables); • to improve coordination between the member institutions and between the institutions and WHO; • to involve each centre more directly in the process of surveillance and to implement remote data entry; • to evaluate the dynamics of the Leishmania/HIV co-infection world- wide. Further information can be obtained from leishnet@who.int, or on the home page at http://www.who.int/leishmaniasis/home_leishnet/en/. 690 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Short communication Urinary tract infection in infants and children with diarrhoea M.H. Fallahzadeh1 and F. Ghane2 1Department of Paediatrics; 2Department of Paediatric Nephrology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran (Correspondence to M.H. Fallahzadeh: fallahzadeh@dr. com). Received: 29/03/04; accepted: 02/12/04 ABSTRACT To determine when children with acute diarrhoea should be investigated for urinary tract infection (UTI), we studied 120 patients and 120 healthy age- and sex-matched controls aged 4 weeks to 5 years. In those with positive or suspicious urine cultures, bacteriuria or pyuria, urine culture was repeated. We detected UTI in 8 patients (all < 2 years) and 1 boy in the control group. In those with UTI, invasive diarrhoea was observed in 1, fever in 7 and vomiting in 5 patients. In children with acute diarrhoea, investigation for UTI is only recommended for febrile, female infants aged 5–15 months. 22 Urinary tract infection in infants and children with diarrhoea ¹>ÃiÝ>EE>r™=¤çuf¶=ƹ>«{Ù=Ïb¶ÍɶÇF¶=´¶>j™=ÏÆb¢ jUb»†¤¾>®Í»{>ª(Åa=g\ت  „=Í[qØ6η¢Íi=ebEÁ>NU>F¶=½>®120Æð>vÈfº120\Æ=f[JI(k¿‚=k«¾ÀºÆÀj¶=k«¾Àºð>VÉVqð=bÂ>m E¼Âe>»¢?4ƤÉE>i?5E>r[™=¹>[«{Ù=Ïb¶ÍɶÇF¶=´¶>j™=ÏÆb¢À¢sV«¶=G‹ÎJºbÈbVJ¶(L=Ç¿i ¹>ÃiÝ>E*ÇF¶=¥e=h™=e=f³Ib®ÆÆ?Í[ɶÇF¶=¼Ã¢e=h[º›µÇ³n[™=¹>[«{Ú¶Í[ɺÇMf‚=Í·ÉF¶=ÆÍÉVɯ¶=Í·ÉF·¶Íɶ SÑ>J¿¶=ÊëÉE>‹Ý=*Ïb¶ÍɶÇF¶=´¶>j™=ÏÆb¢K«nJ²=b®Æ8L>vÈfº%Í[ɾ>N¶=Í¿j¶=ÁÆaÀãɖ$f[²c¸[«{Æ [E>rºÍ[¶>U¼ÃE(´¶>j™=ÏÆb[£E[E>r™=›b[QàǪ7Ìb[Â>n¶=Í[¢Ç»=›bU=ÆfÑ>[Q¹>[[ÃiDEÍinvasive( Æ7L×>UÍE>rºÆ(λƒ>E5ʯ¶>EÍE>rºL×>UÐ*¹>Ã[iDEE>r[™=¹>[«{Ù=Í[¶>U›Á>NU>F¶=ÊqÇÈ´¶d¶ [EÀ[[Âe>»¢?\Æ=f[JIÊIض=Æ(Î练>EL>[E>r™=P>¾Ý=À[º¤uf·¶ÍçɶÇF¶=´¶>j™=ÏÆb¢À¢sV«¶>E(a>U 5Æ15ð=fÃm*  L’infection urinaire chez le nourrisson et l’enfant présentant une diarrhée RÉSUMÉ Afin de déterminer le moment où l’enfant présentant une diarrhée aiguë devrait être examiné à la recherche d’une infection urinaire, nous avons étudié 120 patients et 120 sujets témoins sains appariés selon l’âge et le sexe, âgés de 4 semaines à 5 ans. Pour ceux qui avaient une uroculture positive ou douteuse, une bactériurie ou une pyurie, une nouvelle uroculture a été effectuée. Nous avons détecté une infection urinaire chez 8 patients (tous âgés de moins de 2 ans) et chez 1 garçon dans le groupe témoin. Dans le groupe de patients ayant une infection urinaire, une diarrhée invasive a été observée chez 1 patient, une fièvre chez 7 patients et des vomissements chez 5 patients. Chez les enfants présentant une diarrhée aiguë, la recherche d’une infection urinaire n’est recommandée que pour les nourrissons de sexe féminin, âgés de 5 à 15 mois, qui sont fébriles. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 691 Introduction Diarrhoea is common in infants and child dren, and urinary tract infection (UTI) is the second most common bacterial infection [1]. Diarrhoea may be the presenting sympd tom in younger children with UTI [2,3]. There have been a limited number of studies on the correlation between UTI and acute diarrhoea [4,5], and it is still not clear when to investigate for UTI in young children presenting with diarrhoea. Therefore, this study aimed at answering this question. Methods In this study 120 infants and children red ferred to the 2 teaching hospitals at Shiraz University were studied. The study was carried out over a 3dmonth period, August– October 2002. Patients were selected cond secutively. Informed consent was obtained from the parents. There were no refusals to participate. In addition to diarrhoea, 92 patients had vomiting and 32 had fever. Sample size was determined based on the incidence of UTI in the general population and in previous reports [5,6]. The exclusion criteria were: • age < 4 weeks or > 5 years; • duration of diarrhoea > 2 weeks; • use of antibiotics or antiseptics during the preceding 48 hours; • bladder extrophy or colostomy. Nine patients were excluded. A complete history was taken and a physical examination done for each patient by a paediatrician who had training in nephd rology. A stool sample was evaluated. If the number of pus cells and/or red blood cells was > 5/high power field, a stool culture was done. If the number of pus cells was > 10/high power field or a stool sample cultured using routine methods on selenite EMB agar and SS agar (Merck, Darmstadt, Germany) was positive for a pathogenic organism, it was considered invasive diard rhoea [5]. A urine sample was taken for all the patients. This was midstream in those who were toilet trained and by bag collection in the others. The urine samples were transd ported immediately at 4 °C to the research laboratory in Nemazee hospital. All positive or suspicious urine cultures were repeated; if at least 2 positive cultures with similar sensitivities were found, the sample was accepted as UTI (associated with abnormal enhanced urinalysis or UTI symptoms). In addition to routine urine culture, end hanced urinalysis and Gram stain were done for all uncentrifuged samples. If the number of white blood cells was ≥ 10/mm3 in uncentrifuged urine, it was considered pyuria. If ≥ 1 microorganism was found in 10 oil immersion fields, it was labelled as bacteriuria [7]. For the patients with pyuria, mixed growth or 103–105 colonies/mL of urine, 2 separate urine samples were taken for routine culture before starting antibiotic therapy. UTI was defined as 2 positive urine culd tures with > 105 colonydforming units/mL with similar sensitivity patterns. In the control group, 120 infants and children from kindergartens, matched for sex and age with the study group, were selected. Those who had diarrhoea or had used antibiotics during the preceding 48 hours were excluded from the control group. Urine samples for routine culture were taken as for the patients. If the urine culture was positive, it was repeated and enhanced urinalysis was also done. Statistical analysis was done using Fishd er’s exact test. 692 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Results In both the patient and control groups, male to female ratio was 1.03:1. Mean age was 17.15 (standard deviation 14.5) months for boys and 17.78 (standard deviation 14.1) months for girls; 91 patients (43 males and 48 females) were ≤ 2 years old and there were 17 males among those who were 3–5 years of age. In 27 (22.5%) patients, duration of diard rhoea was > 5 days. Only 8 patients (6.7%) were identified as having UTI (Table 1) and in the control group UTI was documented in only 1 boy (20 months old, uncircumcised) (0.8%, P = 0.02). He also had pyuria and bacteriuria and the microorganism isolated was Escherichia coli. The characteristics of the 8 patients (6.7%) with UTI in the study group are illustrated in Table 2. Pyuria was present in 14 patients with diarrhoea but whose urine culture was negad tive (10 with dehydration, 2 with fever and 2 with undetermined cause). Both urine and stool cultures were positive in only 1 pad tient, but with different organisms (Shigella sp. in stool and E. coli in urine). Three samples had mixed growth. All were negative when the tests were repeatd ed. The proportion of girls was high in the patients who had UTI (87.5%; P < 0.05), and also the proportion which occurred in infants < 1 year (87.5%; P < 0.05). Fever was observed in 15.5% of the patients with nondinvasive diarrhoea and 87.5% of those with UTI (P < 0.05). The presence of vomitd ing in the group with or without UTI was not statistically significant. For pyuria, sensitivity was 100% and specificity 87.5%; for positive Gram stain in uncentrifuged urine, sensitivity was 87.5% and specificity 95.6% in those with UTI. Discussion When an infant or child presents with did arrhoea, the physician wonders when to consider UTI. Even if UTI is documented in such a patient, it may have no relation to the diarrhoea (asymptomatic bacteriuria) or the microorganism causing the diarrhoea may also produce UTI [5,8]. In some pad tients with acute or persistent diarrhoea, the UTI may present with parenteral diarrhoea [4–6,9] as was found in our study. Because none of the patients with UTI in our study had positive stool culture with the same microorganism, we did not consider diard rhoea as the cause of the UTI. Compared to the control group the incid dence of UTI in patients with diarrhoea was higher and this was statistically significant. The incidence of UTI in our study was comparable to that in 2 other reports (7.3% and 8.0%) [4,5]. The presence of pyuria and/or bacteriud ria by enhanced urinalysis can be suggestive of UTI [2,5]. Duration of diarrhoea was not Table 1 Symptoms and clinical findings in 120 children with acute diarrhoea Condition All patients UTI patients (n = 120) (n = 8) No. % No. % Diarrhoea > 5 days 27 22.5 2 25.0 Vomiting 92 76.6 5 62.5 Pyuria 22 18.3 8 100.0 Invasive diarrhoea 15 12.5 1 12.5 Bacteriuria 11 9.2 7 87.5 UTI 8 6.7 8 100.0 UTI = urinary tract infection. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 693 predictive of the presence of UTI in this study. Therefore, in children presenting with acute diarrhoea, we do not recommend routine investigation for UTI except for female infants with fever in the age range 5–15 months. Table 2 Characteristics of diarrhoea patients who had urinary tract infection Patient Age Vomiting Fever Duration of Pyuria Bacteriuria Organism no. (months) diarrhoea (urine) (days) 1 5 – + 2 + + Pseudomonas sp. 2a 7 + + 2 + + E. coli 3 8 + – 8 + + E. coli 4 8 + + 1 + + E. coli 5 10 + + 3 + + E. coli 6a,b 10 + + 4 + + E. coli 7c 11 – + 1 + – E. coli 8 15 – + 10 + + E. coli aInvasive diarrhoea. bPatient 6 was male; all the others were female. cUrinary symptoms present (irritability during voiding). Acknowledgement This work has been supported by the viced chancellor of research, Professor Alborzi, Clinical Research Centre, Shiraz University of Medical Sciences (Grant No. 80d1213). References 1. Synder HM. Urologic emergencies. In: Fleisher GR, Ludwig S, eds. Textbook of pediatric emergency medicine, 4th ed. Baltimore, Lippincott, Williams & Wilkins, 2000:1585–93. 2. Shaw KN, Gorelick MH. Urinary tract infection in the pediatric patient. Pedi- atric clinics of North America, 1999, 46(6):1111–23. 3. Dairiki Shortliffe LM. Urinary tract infec- tions in infants and children. In: Walsh PC et al. Campbell’s urology, 8th ed. Phila- delphia, WB Saunders, 2002:1846–84. 4. Pryles CV, Luders D. The bacteriology of the urine in infants and children with gas- troenteritis. Pediatrics, 1961, 28:877–84. 5. Thakar R et al. Urinary tract infection in infants and young children with diarrhea. Indian pediatrics, 2000, 37(8): 886–9. 6. Sibal A et al. Associated infections in persistent diarrhoea—another perspec- tive. Journal of tropical pediatrics, 1996, 42(2):64–7. 7. Hoberman A et al. Is urine culture neces- sary to rule out urinary tract infection in young febrile children? Pediatric infec- tious disease journal, 1995, 15(4):304–9. 8. Allerberger FJ et al. Urinary tract infection caused by nontyphoidal salmonella: re- port of 30 cases. Urologia internationalis, 1992, 48(4):395–400. 694 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 9. Jeena PM, Coovadia HM, Adhikari MA. Bacteriuria in children attending a primary heath care clinic; a prospective study of catheter stream urine samples. Annals of tropical pediatrics, 1996, 16(4):293–8. Child-related millennium development goals Of direct relevance to the work that the Child and Adolescent Health and Development unit of WHO’s Regional Office for the Eastern Medi- terranean is pursuing in the Eastern Mediterranean Region is millen- nium development goal 4 “Reduce child mortality”, for which the target set is to “reduce by two-thirds, between 1990 and 2015, the under-five mortality rate”. For this target, three indicators have been selected to help track progress: • under-five mortality rate, • infant mortality rate, • proportion of 1-year-old children immunized against measles. Of the total list of 18 targets, those of key importance to our work in the Region are: • Target 2 “Halve between 1990 and 2015, the proportion of people who suffer from hunger”, with indicator 4 on “Prevalence of underweight children under 5 years of age”; • Target 8 “Have halted by 2015 and begun to reverse the inci- dence of malaria and other major diseases”, with indicators 21 on “Prevalence and death rates associated from malaria” and 22 on “Proportion of population in malaria risk areas using effective malaria prevention and treatment measures”. Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 695 Short communication Support for cancer patients: the Bahrain experience M.S. Awadallah1 1College of Health Sciences, Nursing Programme, Ministry of Health, Manama, Bahrain (Correspondence to M.S. Awadallah: muyassar@yahoo.com). Received: 13/06/04; accepted: 24/11/04 ABSTRACT Cancer, a disease people avoid talking about, is the second leading cause of death in Bahr rain. The Bahrain Cancer Society established a support group in 1993 with the goals of helping patients and their families cope with this disease and increasing public awareness concerning early detection. Services provided by the group include a weekly 2rhour session to encourage patients to express their feelings and concerns, distribution of informational booklets and visits to people at home and in hospir tal. Furthermore, the group organizes recreational activities for children with cancer. Patients or their families can also page the group to discuss their problems. The main goal of this paper is to share the Bahrain experience of supporting cancer patients, their families and friends. 21 Support of cancer patients: the Bahrain experience Á>{fj¶=Îufº¼¢a6ÀÈfVF¶=ÍEf =zÇ¢Ëqfçjɺ  „=Í[qØ6JÈzfºÇÂÆ(Á>{fj¶=J£ÈÀÈf[VF¶=›L>[ɪǶ=H>F[i?[²?ʾ>M(Ä¿¢OÈbƒ=l>¿¶=Ïa>«*b[®Æ ½>[¢›Á>{fj[¶=Î[ufº¼¢b¶͢ǻ…¸É³nJEÍÉ¿ÈfVF¶=Á>{fj¶=ÍVª>³ºÍÉ£–Kº>®1993Ìb¢>j[º­b[ÃE Ī>n[J²>E³FJ¶=ÍÉ»Â@EeÇû‚=ÍÉ¢ÇIÆ(zf™==d¤º¼·®@J¶=η¢¼Âfßiî?ÆÎuf™=*Åd[ÂL>ºb[]K¿»v[IÆ =¤[ÈgÇIÆ(¼ÃªÆ>[‡Æ¼ÂeÇ£[mÀ[¢F[£J¶=Î[·¢Î[uf™=¤ÉRn[J¶J¢>iÏbºη¢ÍÉ¢ÇFi?ÌÆb¾b¯¢͢ǻ ¼g>[¿º›ÆL>É«n[Jj™=›Î[uf»·¶L=e>ÈhE½>ɯ¶=Æ(ÍɺآCL>FÉJ²*Íìn[¾Ù=¼É[Ÿ¿JEÍ[¢Ç»=K[º>®>[»² Á>{fj¶>EE>r™=¹>«{Ú¶ÍÉÃɪf[J¶=*dÂOUfßiîÙ=ÆÎuf»·¶À³•Æ¼Ã·²>nºÍn®>¿ºη¢͢ǻ=Å*­bÃIÆ ¼ÃÑ>®bq?ƼÂfßiî?ÆÁ>{fj¶=Îufº¼¢a›ÀÈfVF¶=ÍEfÀºÌa>ªÝ=‘CÍÉNVF¶=Í®eǶ=ÅdÂ*  Soutien aux patients cancéreux : l’expérience de Bahreïn RÉSUMÉ Le cancer, maladie dont les gens évitent de parler, est la deuxième cause de décès à Bahreïn. La Société bahreïnie de lutte contre le cancer a mis en place un groupe de soutien aux patients cancéreux en 1993 avec pour objectifs d’aider les patients et leurs familles à faire face à la maladie et de sensibiliser au dépistage précoce. Les services fournis par le groupe comprennent une session hebdomadaire de 2 heures visant à encourager les patients à exprimer leurs sentiments et leurs préocr cupations, la distribution de brochures d’information et des visites à domicile ou à l’hôpital. Par ailleurs, le groupe organise des activités récréatives pour les enfants cancéreux. Les patients ou leurs familles peuvent aussi contacter le groupe par alphapage pour discuter de leurs problèmes. Le présent article vise principalement à faire partager l’expérience de Bahreïn en matière de soutien aux patients cancér reux, à leurs familles et leurs amis. 696 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 Introduction In Bahrain, cancer is the second leading cause of death after circulatory heart dise ease. However, with improved cancer serve ices, the 5eyear survival rate may increase. The reported number of cancer cases has increased over the past 5 years. This is bee cause of improvements in early detection as well as extended life expectancy, leading to an increase in the number of elderly peoe ple, who are more prone to cancer than the younger age group [1]. Diagnosis of cancer, a lifeethreatening disease, initiates a period of crisis accompae nied by considerable psychological distress such as fear and anxiety. The following is a quote from a patient talking about her reaction when she was informed by her physician that she had been diagnosed with cancer: “The first time I heard that I had breast cancer, I panicked. I could not stop crying. Why me, I am still too young to leave my children? All I could think about was my husband and children and how my family was going to take it if I died.” A diagnosis of cancer makes patients feel emotionally distressed, angry and uncertain about the future [2]. In addition 25% of patients experienced depression at the time of diagnosis [3], and approximately 50% may experience depression and anxiety while receiving anticancer treatment [4,5]. Furthermore, the psychological effects of cancer can affect the quality of life and increase the length of hospitalization [6]. Thus, living with cancer is an experience of great suffering for the patient, mainly arising from his reminiscence of a healthy past. Therefore, most people do not like to discuss or talk about cancer; and as soon as they hear someone has got cancer, they believe that this person will suffer and die. For these reasons, patients and their families seek available resources to help with coping with cancer diagnosis and treatment in order to restore their overall equilibrium. Coping with cancer A major illness like cancer may have a deve astating impact, not only on patients but also on the immediate family and others with whom the patient has a relationship. Many patients report that a confirmed diagnosis, or even waiting for the result of a biopsy, provokes feelings of uncertainty and fear of death and dying, prompting them to reorder the priorities in their life. These patients go through the common stages of reaction such as denial, bargaining, depression and guilt. Most cancer patients will require proe longed treatment; so coping with the disease is an exhausting process. Support groups are an important source of help for people cope ing with the emotional and physical impact of cancer [7]. Furthermore, it as been shown that cancer support groups help to prolong survival [8], decrease psychological sympe toms and reduce the number of visits to hose pital or oncology clinics [9]. Patients with cancer need help, and patients with strong support systems have better coping mechae nisms. Faceetoeface (traditional) support groups are used to help patients deal with their illness by fostering effective coping mechanisms [10]. This also helps people feel less lonely and they are able to express a positive change in attitudes towards their illness [11]. Access to a support group may thus serve as an effective psychotherapeutic tool for the coping process. Support group in Bahrain The cancer support group was established in 1993 by a television broadcaster and cancer victim. The Bahrain Cancer Society was formed 1989 with a mission to support cane cer patients. The group is now a committee Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 697 under the Bahrain Cancer Society. It is come posed of a small group of volunteers, some of whom are cancer survivors, their relae tives and friends, and other people involved with cancer patients such as doctors, nurses and social workers. Cancer survivors often feel a desire to share their experiences with others. The support group plans gatherings of individuals in faceetoeface encounters. The meetings are held regularly and are designed to accomplish common goals: to help people cope with cancer, provide emoe tional support, offer information on cancer and its treatment, facilitate psychosocial adjustment and increase public awareness about preventive measures against cancer. Reasons for seeking a cancer support group People seek support groups because they want to belong to a group sharing the same problems, and because they need to get supe port from others with similar experiences. This process will also enhance their security and comfort in coping with their disease. People may also seek a support group to get assistance in formulating a plan of action during a stressful time. In Bahrain, women use the support group more than men: the Bahrain Cancer Society records show that around 90% of their ate tendees were women (unpublished report, Bahrain Cancer Society, 2005). Men may feel they are stronger and think they can cope on their own. Samarel et al. studied a group of women attending a cancer support group and found that the women reported that the group helped them to verbalize their feelings, reduce loneliness and gain useful information [11]. In addition, over the past 2 years (2004, 2005) the Bahrain Cancer Support Group has provided telephone support; during 2005 they received approximately 1000 calls. The majority of callers were suffering breast, colon, lung or kidney cancer. NoneBahrainis attend the group sessions more often than Bahrainis, possibly due to lack of family support systems. Patients join to find answers to their questions and cone cerns about the disease process, treatment and prognosis. Some cancer patients ask for assistance and advice on how to inform their children. When children are properly and accurately informed, their uncertainty, fear and anxiety will be reduced. Accurate information, for example will explain when one of the family members goes bald sude denly. Finally, attending group meetings is an affirmation of the patient’s need to face reality, restore selfeesteem and find hope. Methods of supporting cancer patients The Bahrain cancer support group generally uses the traditional method of faceetoeface support group meetings. People are allowed to verbalize their feelings, which will help them feel better and more able to cope with their illness, which will in turn decrease distress. Other choices are available regarde ing means of receiving support. Individuals can contact the group by pager, or they can come to a weekly 2ehour group meeting at one of the local hospitals. Those who prefer not to join the weekly sessions may receive support via telephone. The support group is designed to meet the need for reassurance of worth, answer questions and concerns and provide guidance or required information. They distribute booklets in Arabic or Enge lish with information related to the diagnoe sis and treatment of cancer. Support group members visit patients on national and ree ligious holidays and generally spend time with them and distribute gifts. The group organizes recreational activities for children 698 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 5, 2006 who have cancer and their families. These include drawing competitions for greeting cards that are sold by the Bahrain Cancer Society for fund raising. Other activities include musical events or dinner parties in restaurants, which may help reduce stress, anxiety and fear. The group may assist in putting people in touch with the Bone Marrow Donor Rege istry in San Francisco, California; providing prostheses for patients who are unable to afford their own; raising funds for patients who need treatment abroad; and visiting and giving condolences to the patient’s family on their death. Group dynamics The support group deals with a variety of topics during their meetings. The topics ree flect the attendees’ experiences and feelings and what they want to share with the group. This enables patients and their families to decrease their psychological trauma and adopt an effective coping behaviour. During support group meetings, the sideeeffects of chemotherapy are discussed and patients share their feelings and experie ences. For example, one lady who received support before starting chemotherapy and then experienced fewer sideeeffects stated, “I never realized with my busy life that there were people to help me face the disease and have a positive attitude, which helps a lot while I am taking my chemotherapy.” This is a dialogue illustrating how pae tients support each other sharing a common experience: One patient stated, “I can’t stop crying. I look at myself in the mirror most of the time. I am a weak person. I cry anye time, anywhere.” Another one responded, “I understand your pain, I have been through the same experience, but look at me: I got hair and wear a prosthesis. I look normal.” A third patient responded, “I can get some more hair, but I can’t get another life.” Someone also stated, “I am lucky to be alive, taking care of my family.” The cancer support group respects pae tients’ religious backgrounds and encoure ages their faith. The group increases hope in cancer patients by focusing on patients’ belief in themselves, their individual abilie ties, relationships with others and active involvement, while acknowledging that they also have a future. This allows patients to see things around them differently. One patient reported, “The support helped me enjoy my life today. I see how nice it is to walk on the seaside and enjoy the sea and watch the sunset.” Another explained his reasons for coming to the group session, “I feel weak today. I came to the meeting to get the spiritual energy that I need.” The following statement reflects the tae boo of cancer: “My neighbour is my friend. She started to hide from me once she knew that I was a cancer patient. She does not like to visit me. When I discussed this with her, she said, ‘I do not like to see you suffering like my daughter. Then you will leave like my daughter’.” It is also one of the responsibilities of the support group to recognize dying patients, meet their spiritual needs and try to support them in order to assist them to die peacee fully and with dignity. This is a quote from a patient, expressed just a few hours before she died: “Stay with me. I feel that someone is here when you hold my hand.” Conclusion Hope is considered an important factor for people coping with cancer. Support groups may give hope and act as sources of infore mation for cancer patients, their families and significant others. The Bahrain Cancer Support Group encourages people to share their feelings and provides an atmosphere Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 699 of courage, humour and hope. The group now needs to realize its full potential by developing an active volunteer support nete work in order to continue being a significant resource. In addition, public awareness of the group needs to be enhanced and more people encouraged to use the service, both within and outside the network. No one need suffer alone. References 1. Ministry of Health. Health statistics. Manr ama, Bahrain. 1999:3–5. 2. Ferrell BR et al. Quality of life in breast cancer survivors: implications for develr oping support services. Oncology nursing forum, 1998, 25(5):887–95. 3. Mermelstein HT, Lesko L. Depression in patients with cancer. Psychoroncology, 1992, 1:199–215. 4. Carroll BT et al. Screening for depresr sion and anxiety in cancer patients usr ing the Hospital Anxiety and Depression Scale. General hospital psychiatry, 1993, 15(2):69–74. 5. De WaldenrGaluszko K, Prevalence of psychological morbidity in terminallyrill cancer patients. Psychoroncology, 1996, 5:414–9. 6. Sellick SM, Crooks DL. Depression and cancer: an appraisal of the literature for prevalence, detection and practice guideline development for psychological interventions. Psychoroncology, 1999, 8:315–33. 7. Brag FK, Gullatte MM. Cancer support group: meeting the needs of African Americans with cancer. Seminars in onr cology nursing, 2001, 17(3):171–8. 8. Spiegel D et al. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet, 1989, 2(8668):888–91. 9. Stanton AL et al. Emotionally expressive coping predicts psychological and physir cal adjustment to breast cancer. Journal of consulting and clinical psychology, 2000, 68(5):875–82. 10. Klemm P, Hardie T. Depression in internet and facertorface cancer support groups: a pilot study. Oncology nursing forum, 2002, 29(4):E45–51. 11. Samarel N et al. Women’s perceptions of group support and adaptation to breast cancer. Journal of advanced nursing, 1998, 28(6):1259–68.

Eastern Mediterranean Health Journal, Vol. 12, No. 5, 2006 709 Guidelines for authors 1. Papers submitted for publication must not have been published or accepted for publication elsewhere. The Eastern Mediterranean Regional Office reserves all rights of reproduction and republication of material that appears in the Eastern Mediterranean health journal (EMHJ). 2. Original papers written in Arabic, English or French may be sent for consideration to the Editor-in-chief, Eastern Mediterranean health journal, WHO Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City (11371), Cairo, Egypt. Papers can also be submitted by email to EMHJ@emro.who.int. Papers will be abstracted in all three languages. 3. The subject of the paper should pertain to public health or some other related technical and scientific subject within the field of interest of the World Health Organization, with special reference to the Eastern Mediterranean Region. 4. Three copies of each manuscript should be provided. The text, together with the accompanying tables and figures, should not exceed 15 double-spaced typewritten or printed A4 pages (4500 words) and should be printed on one side only. When the manuscript is accepted or conditionally accepted, the author will be requested to submit a 3.5 inch computer diskette containing the text, tables, graphs and illustrations. For English and French papers, please provide the text, upon the editor's request, in both wordprocessed format (we prefer Microsoft Word for the PC but can translate most other formats) and also saved as a text/ ASCII file. Papers submitted in Arabic should follow the same guidelines as papers written in English or French. If the paper is a translation of all or part of another unpublished work, a copy in the original language should be submitted too. Where possible, graphs should be provided in Harvard Graphics under Windows or Excel, and the illustrations and photographs should be provided in EPS or TIFF format. However, it is necessary to provide three sets of original photographs and figures with the background data. If there is any text or lettering on the photographs, an additional clean set should be provided without the text/lettering. 5. All papers received will be peer reviewed, and on the basis of the reviewer's comments, the Editorial Board reserves the right to accept or reject any paper. Papers are accepted on the understanding that they are subject to statistical and editorial revision as deemed necessary, including abridgement of the text and omission of tabular or graphic material. 6. The title of the paper should be as concise as possible, preferably around 10 words, and should be placed on a separate sheet, together with the full name(s) of the author(s), institutional affiliations(s) and highest scientific degrees obtained. The mailing address, as well as any other contact information ( email address, fax, telephone) of the corresponding author should be provided. The number of authors should not exceed five. All authors should have made material contribution to either the design, analysis or writing of the study and have approved the final version submitted. Authors may be asked to verify their contribution. Other names may be included in the acknowledgements. 7. To facilitate the translation of abstracts and authors' names, authors whose mother tongue is written in Arabic characters and writing in English or French should supply their full names in Arabic script and provide transliterations.