Eastern Mediterranean Health Journal [2010; Vol.16, Issue 8]

طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ةيبيللا ةيبرعلا ةييرهمالجا . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . ةينميلا ةيروهملجا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما Subscriptions and Distribution Enquiries regarding subscriptions and distribution of the print edition of EMHJ should be addressed to: Printing and Marketing of Publications at: email: pam@emro.who.int; tel: (+202) 2276 5000; fax: (+202) 2670 2492 or 2670 2494 Permissions Requests for permission to reproduce or translate articles, whether for sale or non-commercial distribution should be addressed to EMHJ at: emhj@emro.who.int Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libyan Arab Jamahiriya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Republic of Yemen Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Jamahiriya arabe libyenne . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar République arabe syrienne . Somalie . Soudan . Tunisie . République du Yémen Correspondence Editor-in-chief EMHJ WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: sabrib@emro.who.int/emhj@emro.who.int EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con- cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col- laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser-vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collabora- teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line) and the ExtraMed-Full text on CD-ROM, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), CAB International, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). ©World Health Organization 2010 All rights reserved Disclaimer The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. ISSN 1020-3397 Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تاسايسلا لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما طسوتلما قشرل ةيحصلا ةلجلما Cover 6.indd 2 5/24/2010 11:46:47 AM Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 16 No. 8 8 ددع شرع سداسلا دلجلما•  2010  • Letter from the Editor .................................................................................................................................................................................................................................................................................811 Research articles Characterization of Mycobacterium tuberculosis of Lebanese patients by double-repetitive-element polymerase chain reaction M. Hamze, A. Rahmo and M. Saade .................................................................................................................................................................................................................................................. 812 Characterization of Mycobacterium tuberculosis in Syrian patients by double-repetitive-element polymerase chain reaction A. Rahmo and M. Hamze .......................................................................................................................................................................................................................................................................820 Prevalence and associated factors of persistent diarrhoea in Iranian children admitted to a paediatric hospital N.A. Kermani, F. Jafari, H.N. Mojarad, N. Hoseinkhan and M.R. Zali .................................................................................................................................................................................. 831 Cancer incidence in Jordan, 1996–2005 M. Al-Tarawneh, S. Khatib and K. Arqub ......................................................................................................................................................................................................................................... 837 Epidemiological, clinical and laboratory profile of glucose-6-phosphate dehydrogenase deficiency in the middle and north of Iraq: a comparative study M.D. Al-Mendalawi .................................................................................................................................................................................................................................................................................. 846 Macrovascular complications and their associated risk factors in type 2 diabetic patients in Sana’a city, Yemen A. Al-Khawlani, Z.A. Atef and A. Al-Ansi ......................................................................................................................................................................................................................................... 851 Nutrition knowledge, beliefs and dietary habits among elderly people in Nizwa, Oman: implications for policy A. Al Riyami, S. Al Hadabi, M.A. Abd El Aty, H. Al Kharusi, M. Morsi and S. Jaju .......................................................................................................................................................... 859 Comparing bone mineral density in postmenopausal women with and without vertebral fracture and its value in recognizing high-risk individuals B. Heidari, S. Hoshmand, K. Hajian and P. Heidari ..................................................................................................................................................................................................................... 868 A study on preference and practices of women regarding place of delivery S.S. Mahdi and O.S Habib ...................................................................................................................................................................................................................................................................... 874 Connaissances et pratiques des femmes de la région de Monastir (Tunisie) concernant l’allaitement maternel I. Bouanene, S. ElMhamdi, A. Sriha, A. Bouslah et M. Soltani ................................................................................................................................................................................................... 879 Impact of using essential drug list: analysis of drug use indicators in Gaza Strip R. Fattouh and B. Abu Hamad .............................................................................................................................................................................................................................................................. 886 Correction. Evaluation of effect of silymarin on granulosa cell apoptosis and follicular development in patients undergoing in vitro fertilization. ..............................................................................................................................................................................................................................................................................892 Immunoinflammatory markers and disease activity in systemic lupus erythematosus: something old, something new M.A. Elwy, Z.A. Galal and H.E. Hasan ............................................................................................................................................................................................................................................. 893 HIV-related knowledge and AIDS stigma among college students in Yemen A.M. Badahdah and N. Sayem ............................................................................................................................................................................................................................................................901 Review Burden of HIV/AIDS infection before and during the civil war in Somalia B.H. Ahmed, M.R. Giovagnoli, H. Mahad and G.G. Tarsitani .................................................................................................................................................................................................907 Short communication Public–private partnership scenario in the health care system of Pakistan F. Ahmed and N. Nisar ............................................................................................................................................................................................................................................................................. 910 Case report Primary hydatid cyst of the round ligament: case report M. Akinci, O. Yigitbasi, Z. Ergul,E. Olcucuoglu and H. Kulacoglu ............................................................................................................................................................................................. 913 Belgacem Sabri MD, MPA, MA (Econ), Editor-in-chief Muhammad Afzal MSc, MPhil, PhD, Executive Editor Editorial Board Mohammad Abdur Rab MBBS, DTM&H, MPH&TM, PhD Naeema Al Gasseer MSc, PhD Mohamed M. Ali BSc, MSc, PhD, DTMH Abdulla S. Assaedi MBBS, MPH Mounir Farag MD, DGS, DEmS, DPH Abdul Ghaffar MD, MPH, MHA, PhD Malekafzali Hossein MK, MPH, PhD Jaouad Mahjour MD, MPH Mamunur Rahman Malik MBBS, Dip (Health Economics), MSc, MPhil Kassem Sara MD International Advisory Panel Dr S. Aboulazm. Professor of Orthodontics. Egypt Dr Abdul Rahman Al-Awadi BSc, MD, MPH, Honorary FRCM, Ireland Dr Law, Korea, Honorary FRCS & P, Glasgow, FRCP, Edinbugh. Kuwait Dr Fariba Al-Darazi RN, MSc, PhD. Bahrain Dr M. Al-Nozha, MD, FRCP, FACC, FESC. Professor of Medicine and Consultant Cardiologist. Saudi Arabia Dr Ala’din Alwan MD, FRCP, FFPHM. Iraq Dr F. Azizi. Professor of Internal Medicine and Endocrinology. Islamic Republic of Iran Dr K. Bagchi BSc, MD, PhD. India Professor K. Dawson BA, MD, PhD, FRCP, FRACP, FRCPCH, DObst, RCOG. New Zealand Professor Kaussay Dellagi MD. Tunisia Dr R. Dybkaer MD. Denmark Dr M. Aziz El-Matri. Professor of Medicine. Tunisia Professor F. El-Sabban BSc, MS, PhD. United States of America Dr A.H. El-Shaarawi MSc (Stat), PhD (Stat). Canada Professor N. Fikri-Benbrahim PhD (Pub health) (SocSci). Morocco Professor A.T. Florence BSc (Pharm), PhD, DSc, FRSC, FRPharmS, FRSE. United Kingdom Professor Cheherezade M.K. Ghazi BS (Nursing), MS (Nursing), DPH, MPA. Egypt Professor M.A. Ghoneim MD, MD (Hons). Egypt Dr J.A. Hashmi DTM&H, FRCP. Pakistan Professor J. Jervell MD, PhD. Norway Professor G.J. Johnson MA, MD, BChir, FRCS (C), FRCOphth, DCEH. United Kingdom Dr M. Kassas. Emeritus Professor of Plant Ecology. Egypt Professor M.M. Legnain MBBS, MRCOG, FRCOG. Libyan Arab Jamahiriya Professor El-Sheikh Mahgoub DipBact, PhD, MD, FRCPath. Sudan Professor A.M.A. Mandil MSc (Paediatr), MPH, DrPH. Egypt Professor A.B. Miller MB, FRCP. Canada Professor S.S. Najjar MD. Lebanon Dr Abubaker A. Qirbi BSc, MD (Edin), FRCPC (Can), FRCP FRCPath (UK). Republic of Yemen Professor O.S.E. Rasslan MD, PhD. Egypt Professor W.A. Reinké MBA, PhD. United States of America Professor I.A. Sallam, MD, Dip High Surgery Cairo, Honorary FRCS, PhD (Glasgow), LRCP, MRCS, FRCS (London), ECFMG. Egypt Dr C.Th.S. Sibinga FRCP (Edin), FRCPath. The Netherlands Mr Taoufik Zeribi Eng BSc, MSc. Tunisia Editors Fiona Curlet, Eva Abdin, Alison Bichard, Guy Penet Graphics Suhaib Al Asbahi, Hany Mahrous, Diana Tawadros Administration Nadia Abu-Saleh, Yasmine El Sakhawy المجلة الصحية لشرق المتوسط المجلد السادس عشر العدد الثامن 118 رسالة من المحرر rotidE eht morf retteL لقد ازدادت الجهود الدولية مضاًء وعزمًا لمكافحة فيروس العوز المناعي البشري منذ الإعلان عن المرامي الإنمائية للألفية في عام 0002. وتؤدي منظمة الصحة العالمية دورها الريادي ضمن أسرة الأمم المتحدة باعتبارها السلطة التوجيهية والتنسيقية للصحة في العالم، وذلك بالعمل على تعزيز استجابة القطاع الصحي على الصعيد العالمي للإيدز وللعدوى بفيروسه، وبهذه الصفة، تعدُّ منظمة الصحة العالمية جزءًا من الجهود العالمية لكبح جماح وباء الإيدز والعدوى بفيروسه، وحسر موجات انتشاره. ويوضح الالتزام المتواصل الذي يبديه الشركاء على الصعيد العالمي؛ ومنهم منظمة الصحة العالمية وبرنامج الأمم المتحدة المشتـرك لمكافحة الإيدز وفيروسه، وقادة الدول الثمانية الكبرى، بالإتاحة الشاملة، مدى الحاجة لتسريع وتيرة النهوض بإعداد مضمومة شاملة تضم إجراءات الوقاية من العدوى بفيروس العوز المناعي البشري، ومعالجة مرضاه، وتقديم الرعاية لهم، وللتعزيز السريع لُنُظم الرعاية الصحية. إلا أن الجهود المبذولة للتصّدي للإيدز تضعف بسبب عدم معرفة معظم المعايشين لفيروس الإيدز بوضعهم الصحي. وتعزز برامج منظمة الصحة العالمية لمكافحة الإيدز والعدوى بفيروسه إدراج اختبارات كشف العدوى بفيروس الإيدز ضمن طيٍف واسٍع من الخدمات، من خلال العمل مع الشركاء لتوسيع نطاق الاختبارات، وتقديم المشورة، وذلك من خلال الحملات الإعلامية، والتنسيق، وتوطيد الشراكات، والتوجيه الذي يستند على المعايير والِقَيم، وتقديم الدعم التقني للبلدان. ويهدف البرنامج الإقليمي لشرق المتوسط لمكافحة الإيدز والعدوى بفيروسه ومكافحة العدوى المنقولة جنسيًا إلى تطوير القدرات على الصعيد الوطني في القطاع الصحي، وتعزيز جميع جوانب الوقاية، والمعالجة، والرعاية، والارتقاء بها. ويعمل هذا البرنامج بتعاون وثيق مع الحكومات الوطنية، والمعاهد الأكاديمية، والمجتمع المدني، والمنظمات الدولية الشريكة. وتعتمد كفاءة وفعالية الاستجابة للعدوى بفيروس العوز المناعي البشري على المدى الذي يتم ضمنه قياس التدخلات ذات الأولوية. ويغلب أن تنتشر الوصمة والتمييز المرتبطان بالعدوى بفيروس العوز المناعي البشري ضمن مواقع تقديم الخدمات الصحية، وهو أمر عرف على الدوام على أنه عقبة بالغة الجسامة، تقف في طريق تنفيذ التدخلات التي يقوم بها القطاع الصحي، والانتفاع بها؛ إذ تؤدي الوصمة إلى انخفاض مستوى الإقبال على خدمات الوقاية من العدوى بفيروس العوز المناعي البشري، وعلى الاستفادة من رعاية مرضاه ومعالجتهم. من الممكن التصّدي لكل من الوصمة ومن التمييز الناجم عن العدوى بفيروس العوز المناعي البشري من خلال إجراءات بسيطة وعملية تتخذ ضمن النظام الصحي، مثل تزويد الناس بالمعلومات الصحيحة التي تبدِّ د مخاوفهم، وتصحِّ ح ما لديهم من مفاهيم مغلوطة عن فيروس العوز المناعي البشري، وطرق سرايته. ومما يؤسف له أن هذين الأمرين لا يحظيان بما يستحقانه من استجابة كافية على الصعيد الوطني. فقد كان للقوانين والتشريعات والسياسات المتعلقة بفيروس العوز المناعي البشري أثرًا هامًا على حياة الناس المعايشين لهذا المرض، ويمكن للممارسات التمييزية أن تعّطل حياتهم، وأن تستبعدهم من الحياة، مما يزيد من عبء الوصمة التي تلحق المصابين بهذا الداء الوبيل. ni dehsilbatse erew slaoG tnempoleveD muinnelliM eht ecnis yllaitnatsbus desaercni sah VIH thgfi ot noitazilibom lanoitanretnI  gnidael eht syalp )OHW( noitazinagrO htlaeH dlroW eht ,htlaeh lanoitanretni no ytirohtua gnitanidrooc dna gnitcerid eht sA .0002 pots ot troffe labolg a fo trap si OHW yticapac taht nI .SDIA/VIH ot esnopser rotces htlaeh labolg eht no ylimaf NU eht nihtiw elor ,OHW .e.i ,srentrap labolg eht fo tnemtimmoc eht fo noitamrffiaer gniunitnoC .SDIA/VIH fo daerps eht esrever dna fo ssergorp eht VIH fo egakcap evisneherpmoc a fo pu-elacs detarelecca na rof deen eht sthgilhgih ssecca lasrevinu ot ,sredael 8G dna SDIANU .smetsys erac-htlaeh fo gninehtgnerts dipar erom a rof dna ,erac dna tnemtaert ,noitneverp .sutats VIH rieht fo erawanu era VIH htiw gnivil esoht fo ytirojam eht taht tcaf eht yb denimrednu era noitautis eht sserdda ot stroffE ot srentrap htiw gnikrow yb secivres fo egnar daorb a otni gnitset VIH fo noitargetni eht setomorp emmargorP SDIA/VIH OHW eTh lacinhcet dna ecnadiug evitamron ,spihsrentrap fo tnemhsilbatse eht ,noitanidrooc ,ycacovda hguorht gnillesnuoc dna gnitset dnapxe SDIA/VIH( emmargorp snoitcefni dettimsnart yllauxes dna SDIA/VIH lanoigeR naenarretideM nretsaE eTh .seirtnuoc ot troppus .erac dna tnemtaert ,noitneverp fo stcepsa lla pu elacs dna nehtgnerts ot rotces htlaeh eht ni yticapac lanoitan poleved ot smia )ITS dna .snoitazinagro rentrap lanoitanretni dna yteicos livic ,snoitutitsni cimedaca ,stnemnrevog lanoitan htiw ylesolc skrow tI no tnegnitnoc osla si tI .snoitnevretni ytiroirp eht fo noitatnemelpmi fo elacs eht no sdneped esnopser VIH eht fo ssenevitceffe eTh ot tnemtimmoc ytinummoc fo level eht dna ,txetnoc laicos dna larutluc daorb eht ,noisivorp ecivres fo scitsiretcarahc dna ytilauq eht nihtiw tnelaverp nefto era noitanimircsid dna amgits detaler-VIH .noitanimircsid dna amgits retnuoc ot stroffe ni noitapicitrap dna .snoitnevretni rotces htlaeh fo ekatpu dna noisivorp ot selcatsbo lacitirc sa defiitnedi yltnetsisnoc neeb evah dna secivres htlaeh sa hcus ,metsys htlaeh a nihtiw serusaem lacitcarp dna elpmis hguorht delkcat eb nac VIH ot eud noitanimircsid dna amgits htoB .noissimsnart sti dna VIH tuoba snoitpecnocsim rieht slepsid dna sraef rieht syalla taht noitamrofni etarucca htiw elpoep gnidivorp  VIH gnidrager seicilop dna selur ,swal s’yrtnuoc A .VIH ot sesnopser lanoitan ni desserdda yletauqeda modles era htob ,yletanutrofnU elpoep edulcxe dna tceffasid nac secitcarp yrotanimircsiD .esaesid eht htiw gnivil elpoep fo sevil eht no tceffe tnacfiingis a evah nac .esaesid eht gnidnuorrus amgits eht gnicrofnier ,VIH htiw gnivil EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 812 Characterization of Mycobacterium tuberculosis of Lebanese patients by double-repetitive-element polymerase chain reaction M. Hamze,1 A. Rahmo 2 and M. Saade3 ABSTRACT Molecular studies have been successfully applied in evaluating epidemiological linkages in tuberculosis. A total of 87 isolates of Mycobacterium tuberculosis were collected from patients in all regions of Lebanon and characterized in terms of drug sensitivity. Double-repetitive-element polymerase chain reaction was used to differentiate between strains. Various correlations related to age, sex, region, sensitivity and genotype were examined. Several genotypes were more common in certain age ranges. Male patients appeared more likely either to be infected by or to develop multi-drug resistant strains. There was also evidence for a distribution of genotype groups indicating some level of geographical isolation and hence separate evolution of M. tuberculosis strains. 1Faculty of Public Health, Lebanese University, Tripoli, Lebanon (Correspondence to M. Hamze: mhamze@ul.edu.lb). 2National Commission for Biotechnology, Damascus, Syria. 3National Tuberculosis Programme, Ministry of Public Health, Beirut, Lebanon. Received: 14/01/08; accepted: 29/06/08 ةجودزلما ةرركتلما صرانعلا يذ زارميلوبلل سلسلسلا لعافتلاب ينينانبللا ضىرلما ىدل ةيلسلا ةرطفتلما صئاصخ لىع ف ُّرعتلا ةداعس سويناطم ،وحمر رداقلا دبع ،ةزحم رذنم اهعجم ةيلسلا تارطفتملل ةدرفتسم 87 عمجب نوثحابلا ماق دقف .لسلا في ةيئابولا تاطباترلا مييقت في حاجنب ةيئيزلجا تاساردلا قبطت :ةـصلالخا لعافتلا نوثحابلا مدختسا دقو .ةيودلأل اهتيساسح ثيح نم ةيلسلا تارطفتلما تافص اوددحو ،ةينانبللا ميلاقلأا عيجم نم ضىرم نم نوثحابلا ،سنلجاو ،رمعلاب ةقلعتلما ةفلتخلما تاقلاعلا اوسردو ،ةيلسلا تارطفتلما يرارذ ينب قيرفتلل ةجودزلما ةرركتلما صرانعلا اذ زارميلوبلل ليسلسلا ًلايم رثكأ روكذلا ضىرلما نأو ،ةيرمعلا تلااجلما ضعب في ًاعويش رثكأ ةديدع ةينيج ًاطمانأ نأ نوثحابلا دجوو .ينيلجا طمنلاو ةيسالحاو ،ةقطنلماو ،فيارغلجا دارفتسلاا ىوتسم لىإ يرشي ةينيلجا طمانلأا تاعوممج عزوت نأ لىع تانيب كانه تناكو .ةددعتم ةيودلأ ةمواقم يرارذ ريوطتل وأ ىودعلل .ةيلسلا تارطفتلما يرارذل لقتسم روطت لىإ لياتلابو Caractérisation de Mycobacterium tuberculosis chez des patients libanais par PCR d’éléments répétitifs doubles RÉSUMÉ Des études moléculaires ont été utilisées avec succès pour évaluer les liens épidémiologiques de la tuberculose. Au total, 87 isolats de Mycobacterium tuberculosis issus de patients de toutes les régions du Liban ont été recueillis et caractérisés en termes de sensibilité aux médicaments. Une PCR d’éléments répétitifs doubles (DRE-PCR) a été utilisée afin de différencier les souches. Différentes corrélations relatives à l’âge, au sexe, à la région, à la sensibilité et au génotype ont été étudiées. Certains génotypes étaient plus fréquents dans certaines tranches d’âge. Il est apparu que les patients de sexe masculin présentaient un risque plus important de développer des souches polypharmacorésistantes ou d’être infectés par de telles souches. Des preuves de distribution des groupes de génotypes, indiquant un certain degré d’isolement géographique et donc une évolution différente des souches de M. tuberculosis, ont également été observées. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 813 Introduction The spread of extensively drug-resistant  tuberculosis (TB) poses a serious threat  that could reverse recent achievements  in TB control  [1].  In particular,  treat- ment of patients with multidrug resist- ant (MDR) strains  is  long and costly,  and requires the use of drugs which fre- quently cause severe adverse reactions.  The  treatment outcome  is poor, with  low cure  rates  and high  fatality  ratios  [2]. MDR TB cases may remain  infec- tious in the community for a prolonged  period of  time. The emergence of  so- called TB “hot-spots” around the world  highlights  the need  for more  research  and application of current knowledge. Molecular  epidemiological  studies  have been successfully applied in evaluat- ing epidemiological  linkages  in TB, and  the discovery of unexpected ones. They  were essential  in distinguishing  relapse  from  reinfection  in  recurrences of TB  [3] in establishing evidence of laboratory  cross-contaminations  (false positives)  [4]  and  in  documenting  the  associa- tion of particular genotypes with hyper- virulence and multi-resistance [5]. The  importance of  large-scale genotyping of  Mycobacterium tuberculosis has prompted  countries  such as  the United States of  America  to  implement  large-scale  rapid  genotyping of all local cases [6]. Various methods have been used for  the genotyping of M. tuberculosis TB. The  double-repetitive-element polymerase  chain reaction (DRE-PCR) method  is  relatively  fast,  simple and cost-effective  [7,8]. The technique serves as a tailored  approach  for preliminary  genotyping  and has the potential for efficient imple- mentation  in  low-resource  countries,  where TB  is generally widespread and  endemic. In  this  study we  isolated  various  strains of MTB from Lebanese patients  in  various  regions of  the  country,  fol- lowed by characterization of  their sensi- tivity to antibiotics and genotyping via a  slightly modified DRE-PCR method.  Methods Sample Following  an  agreement with  the  National Tuberculosis Programme of  the Lebanese Ministry of Health,  spu- tum samples from newly-detected cases  of  pulmonary TB  (84  samples)  and  from patients with a past history of the  disease who were still under  treatment  (3  samples) were  collected between  April  2004  and October  2005  from  all  Lebanese  provinces  (muhafazat).  Samples were  sent  refrigerated  to  the  laboratory of the hospital at the Middle  East Health Centre in Bsalim/Metin in  Lebanon, accompanied by all related in- formation. No information on the HIV  status of the patients was obtained.  Specimen preparation and culture Specimens were  decontaminated  by  the  2%  N-acetyl-L-cysteine  NaOH  method. After neutralization and cen- trifugation, 0.2 mL of the concentrated  specimen was  inoculated onto a  slant  of Lowenstein–Jensen medium (Bec- ton Dickinson Microbiology Systems,  Cockeysville, Maryland); 0.5 mL was  also  inoculated  into modified Middle- brook  7H9  broth  (BD  BBL MGIT,  Becton-Dickinson)  supplemented  with PANTA antibiotic mixture (BBL  MGIT PANTA,  Becton-Dickinson)  and OADC enrichment. The 2 media  were  incubated  at  35–37  °C and  the  Lowenstein–Jensen  slant was  exam- ined  for growth  twice weekly. The BD  BBL MGIT  tube was  read daily with  UV light using a positive and a negative  control. A positive tube was subcultured  and an acid-fast smear prepared.  Susceptibility testing Antibiotic susceptibility  testing was  performed using the BBL mycobacteria  growth  indicator  tube  (MGIT) AST  system (Becton-Dickinson) based on  comparing growth of the Mycobac terium strains  in a drug-containing  tube with  that of a drug-free tube. The day after a  positive MGIT  tube became positive,  final concentrations of antibiotics were  added  to MGIT  tube:  streptomycin  (STR) (0.8 µg/mL),.  isoniazid (INH)  (0.1 µg/mL),  rifampicin (RIF) (1 μg/ mL and ethambutol  (EMB) (3.5 μg/ mL).  A  control  tube  was  set  up  for  each  antibiogram. A  control  strain of  M. tuberculosis   (H37  Rv,  ACTCC  27294) susceptible to all standard anti- TB drugs was included. The tubes were  read with a 365 nm UV transilluminator  on  the  third  incubation day  [9]. The  patterns of antibiotic sensitivity (S) and  resistance (R) are described in the text  using  the notation RRSR, RRRS etc.,  with  the  following sequence:  rifampin  (RIF)–isoniazid  (INH)–ethambutol  (EMB)–streptomycin (STR).  Identification Identity  of  strains was  based  on  the  following biochemical  characteristics:  production of niacin, nitrate  reductase  and  catalase  at  laboratory  tempera- ture; production of  catalase  at 68  °C;  hydrolysis  of  Tween  80  in  10  days,  urease  in 18 hours and arylsulfatase  in  3 days [10]. DRE-PCR procedure For DNA extraction, a  loopful of each  culture was  suspended  in ATL buffer  (0.2 mL) and DNA was extracted using  QIAamp DNA blood mini-kit  (Qia- gen). The manufacturer’s  procedure  was adhered  to except  for  the  incuba- tion period, which was extended  to 3  hours. DNA was eluted in 100 μL PCR  water (Gibco). The DRE-PCR proce- dure was followed as reported by Harris  [11], a modification of Friedman et al.  [12]. The PCR amplification mixture  contained 67 mM tris (pH 8.8) 16 mM  (NH 4 ) 2 SO 4 , 0.01% tween 20 (1 × reac- tion buffer; Euroclone), 2.5 mM MgCl 2 (Euroclone), 200 μM each deoxynucle- oside  triphosphate (MBI Fermentas),  0.5 μM of each of the 4 primers (MWG  Biotech, HPSF grade), and 2.5 U of taq  polymerase (Euroclone). The sequence  of the primers is described in elsewhere  EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 814 [11,12]. Then 5 μL of DNA solution was  used in the final reaction volume of 50  μL. Amplification was done according  to Harris  [11], using  the Mastercycler  thermal cycler (Eppendorf). The ampli- fication products were analysed using  parametric analysis of gene set enrich- ment (PAGE),  at 10% concentration,  stained with  ethidium bromide,  and  visualized under UV  light  (312 nm).  The modifications  introduced were:  the  use  of  a DNA extraction  kit,  the  inclusion of  ammonium sulfate  in  the  reaction mixture and  the use of PAGE  for band pattern analysis.  Statistical analysis SPSS,  version 12 was used  for analysis.  A confidence interval of 95% (2-tailed)  was applied. Results The 87 isolates were collected from 62  males, mean age 44 years (range 10–77  years),  and 25  females, mean  age 30  years (range 16–54 years). Most of the  isolates came  from patients  resident  in  Mount Lebanon region (33%) followed  by  Beirut  (23%),  Tripoli  (including  Doumia)  (20%),  Akkar  (10%),  the  South (9%) and Beqaa (5% each). All  isolates  came  from new cases of TB,  except  for 3  that were  from previously  treated cases. The  isolates  included  21  resistant  isolates (24.1%) (18 primary-resistant):  4  (4.6%)  single-resistant  (1R);  11  (12.6%) double-resistant (2R), 4 (4.6%)  triple-resistant  (3R);  and  2  (2.3%)  quadruple-resistant (4R) (Table 1). A  total of 8 (9.2%) isolates were MDR; 3  of  the MDR cases were  the previously  treated patients (3.5%). The resistance  pattern was: RIF 42,9%,  INH 81.0%,  EMB 19.1%, STR 76.2%. The 87 isolates resulted in 17 differ- ent DRE-PCR patterns, while 12 isolates  produced no detectable genotypes and  were designated genotype Gx  (Table  2). The diversity  ratio  (i.e. number of  genotypes/number of  isolates, exclud- ing  isolates with no genotype pattern  detected) was  therefore 0.23 (17/75)  (Table  1).  A  total  of  9  clusters were  observed, which  included 67  isolates;  8  isolates had unique genotypes. The  number of different bands was 14 and  ranged from 1–3 for each genotype. The  genotypes were  assigned  to 3  groups  depending on the total number of bands  (I–III). With 1 exception, all genotypes  contained a 350 bp band and, with 1  exception, all in genotype group III con- tained  the same 2 bands (350 bp, 450  bp) (Table 2). The  largest cluster was  genotype G3, containing the single band  350 bp,  followed by cluster genotypes  G9 and G12; together these represented  62% of the isolates (Table 2).  The profile of the 3 previously treat- ed cases of TB were as  follows: 1 male  aged 41 years  from Beqaa  (genotype  Gx,  resistance pattern RRSS); 1 male  aged 65 years  from Beirut  (genotype  Gx, resistance pattern RRRR); 1 female  aged 54 years  from Beirut  (genotype  G1, resistance pattern RRSS).  Correlations Various  correlations  between  geno- type,  sex,  age,  resistance and  region of  collected  isolates  from  the Lebanese  population were investigated.  Correlations related mainly to sex The general M:F ratio was 2.5 (62/25)  considering all  isolates. For  the Beirut  region, it was 4.0 (16/4), while the ratio  for  the  regions  outside  Beirut  taken  together was 2.2 (46/21) (OR = 1.83,  Table 1 Distribution of Mycobacterium tuberculosis isolates from different regions of Lebanon Variable Total Region Beirut Beqaa South Mount Lebanon Tripoli Akkar Total no. of isolates 87 20 4 8 29 17 9 No. of isolates in cluster genotypesa 67 12 3 8 23 13 8 No. of genotypes represented 17 9 1 2 10 6 3 No. of resistant isolates All 19 + 2Gx 2 + 1Gx 1Gx – 9 5 3 1R 4 – – – 1 3 – 2R 11 1 1 – 4 2 3 3R 4 1 – – 3 – – 4R 2 1 – – 1 – – MDR 6 + 2Gx 2 + 1Gx 1Gx – 4 – – Diversity ratiob 0.23 0.56 0.33 0.25 0.40 0.40 0.38 Gx = no genotype pattern found; – = no isolates. MDR = multidrug resistant. 1R = single-resistant; 2R = double-resistant, 3R = triple-resistant; 4R = quadruple-resistant. aExcluding unknown genotypes, Gx; bDiversity ratio = no. of genotypes/no. of isolates (excluding Gx isolates). طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 815 Ta bl e 2 Se x di st ri bu ti on o f M yc ob ac te ri um tu be rc ul os is is ol at es fr om d iff er en t r eg io ns o f L eb an on a nd b y ge no ty pe G en ot yp e gr ou p/ ba nd s (b p) G en ot yp e To ta l n o. o f is ol at es Re gi on Be ir ut Be qa a So ut h M ou nt L eb an on Tr ip ol i A kk ar A ll M F A ll M F A ll M F A ll M F A ll M F A ll M F G ro up I 35 0 G 3 41 8 7 1 3 3 – 6 2 4 10 6 4 9 5 4 5 2 3 G ro up II 10 0 , 3 0 0 G 1 1 1 – 1 – – – – – – – – – – – – – – – 10 0 , 3 50 G 2 1 – – – – – – – – – – – – 1 – 1 – – – 15 0 , 3 50 G 4 2 1 1 – – – – – – – – – – 1 1 – – – – 20 0 , 3 50 G 5 2 – – – – – – – – – 2 2 – – – – – – – 25 0 , 3 50 G 6 3 – – – – – – – – – 2 2 – – – – 1 1 – 30 0 , 3 50 G 7 2 – – – – – – – – – 1 – 1 1 1 – – – – 35 0 , 4 0 0 G 8 2 1 1 – – – – – – – 1 1 – – – – – – – 35 0 , 4 50 G 9 8 1 – 1 – – – 2 1 1 5 5 – – – – – – – 35 0 , 5 0 0 G 10 1 1 1 – – – – – – – – – – – – – – – – G ro up II I 11 0 , 3 50 , 4 50 G 11 1 – – – – – – – – – 1 1 – – – – – – – 15 0 , 3 50 , 4 50 G 12 5 – – – – – – – – – 1 – 1 2 2 – 2 2 – 27 5, 3 50 , 4 50 G 13 1 1 1 – – – – – – – – – – – – – – – – 27 5, 3 50 , 6 0 0 G 14 1 – – – – – – – – – 1 1 – – – – – – – 35 0 , 4 50 , 6 50 G 15 2 1 1 – – – – – – – 1 1 – – – – – – – 35 0 , 4 50 , 8 0 0 G 16 1 1 1 – – – – – – – – – – – – – – – – 35 0 , 4 50 , 6 0 0 G 17 1 – – – – – – – – – – – – 1 1 – – – – N o ge no ty pe pa tte rn fo un d G x 12 4 3 1 1 1 – – – – 4 3 1 2 1 1 1 1 – To ta l 87 20 16 4 4 4 – 8 3 5 29 22 7 17 11 6 9 6 3 M = n o. o f i so la te s f ro m m al es ; F = n o. o f i so la te s f ro m fe m al es ; G = g en ot yp e (b ol d = cl us te r g en ot yp es ); G x = no g en ot yp e pa tte rn fo un d. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 816 age, which was especially obvious for re- sistance to RIF (Table 4). We observed  a  greater  tendency  for  the  genotype  group  III  to affect older people: 6/12  isolates were  from patients  in  the age  range 50–79 years (OR = 3.5, 95% CI:  0.98–12.45, P  = 0.055).  All  cases  of  MDR, defined as  resistance  to at  least  INH and RIF, were concentrated within  patients aged 40–69 years, which was  true for all genetic groups. Furthermore  75% (6/8) of MDR cases came  from  the age  range 50–69 years  (Table 4),  even  though only 19% of  total  isolates  were from this age range. Correlations related mainly to geno- type and resistance The percentage of  resistant  isolates  to total isolates was 24% (21/87): 25%  (17/67)  among  clustered  genotypes  and 25% (2/8)  for  the unique geno- types (Table 4). Nonresistant  isolates  had a diversity  ratio of 0.20 (13/66),  while resistant ones had a value of 0.38  (8/21). The diversity ratio for resistant  isolates belonging  to cluster genotypes  (shown  in bold  font on Table 2) was  0.35 (6/17) and for MDR isolates was  0.83  (5/6). There were  4  genotypes  (G1, G5, G15, G17)  that  appeared  exclusively  in  resistant  isolates  (OR  = 29, 95% CI: 3.24–251.1, P = 0.003), 9  genotypes (G2, G7, G8, G10, G11, G12, G13, G14, G16) appeared exclusively in  nonresistant  isolates  and 4 genotypes  (G3, G4, G6, G9) were shared. Some genotypes exhibited no resist- ance  to  any drugs  (e.g. none of  the 5  isolates of G12), whereas for genotypes  G15 and G5 drug resistance was demon- strated for all the collected isolates. The  2  isolates belonging  to genotype G15 demonstrated MDR, while  12  other  genotypes, representing 26 isolates, did  not include any MDR cases (OR = 34,  95% CI: 3.22–338.8, P = 0.004). These  2  isolates also  showed  identical  resist- ance patterns (Table 4).  The percentage of  resistant  isolates  was 20% (8/41) for the genotype group  I,  and  36%  (8/22)  and  25%  (3/12)  respectively  for  the genotype groups II  and  III  (Table 2). For STR resistance  the proportion of  resistant  isolates de- creased with increasing genotype group  number (I >  II >  III) whereas  the op- posite pattern was observed for RIF and  INH resistance (I < II < III) (Table 5).  Most genotyped MDR cases (5 out of  6) belonged to genotype groups II and  III, even though these represented only  45% (34/75) of all  typed isolates (OR  = 6.9,  95% CI: 0.77–62.2, P  = 0.085)  (Table 3). Correlations related mainly to region The ratio of resistant to total isolates  in  Beirut was  0.15  (3/20), while  for  outside Beirut it was 0.27 (18/67) (OR  = 0.48, 95% CI: 0.126–1.82, P = 0.085)  (Table  1). Only  a  few  cases  of  ENB  resistance  (16% of  resistant  isolates)  were  observed  (Table  5);  and  these  95% CI: 0.54–6.14, P  = 0.33)  (Table  2). The M:F ratio of cluster isolates was  2.4 (47/20), while the ratio for unique  genotypes was 3.0 (6/2). The M:F ratio  for  resistant  isolates was 2.5  (15/6);  however  the specific genotype G3 had  5 resistant  isolates  from females out of  the  total of 8  resistant  isolates  (Table  4). All MDR cases,  except  for 1, were  males,  resulting  in  a M:F  ratio of  7.0  (7/1) (OR = 3.1, 95% CI: 1.27–7.39, P = 0.3) (Table 3). The isolates of patients  aged 20–49 years produced a M:F ratio  of 1.9 (37/20), whereas the ratio for the  rest of  the age groups was 5.0 (25/5).  The M:F  ratio was  11.6  (25/16)  for  genotype  group  I  (single  band  pat- tern) (OR = 0.33, 95% CI: 0.11–0.97,  P  = 0.029),  3.4  (17/5)  for  genotype  group  II  (2-band  pattern)  and  11.0  (11/1) for genotype group III (3-band  pattern) (OR = 5.5, 95% CI: 0.67–45.6,  P = 0.11).  Correlations related mainly to age A majority of  isolates  came  from pa- tients  in  the  age  range  20–49  years.  This was mainly true in all regions, with  female  patients  among  the  collected  cases  rarely affected after  the age of 50  years. The diversity  ratio of genotypes  within  the age  range 20–49 years was  0.22  (12/54),  excluding  unknown  genotypes,  less  than  the diversity  for  the remaining age groups, 0.33 (9/27).  There was an apparent  increase  in  the  likelihood of resistance proportional to  Table 3 Distribution of Mycobacterium tuberculosis isolates (excluding cases where no genotype pattern was found) by patient’s sex and multi-drug resistance for the various designated genotype groups by region of Lebanon Region Total no. of isolates Genotype group I II III All M F MDR All M F MDR All M F MDR Beirut 16 8 7 1 0 5 3 2 1 3 3 0 1 South 8 6 2 4 0 2 1 1 0 0 0 0 0 Beqaa 3 3 3 0 0 0 0 0 0 0 0 0 M. Lebanon 25 10 6 4 1 11 10 1 2 4 3 1 1 Tripoli 15 9 5 4 0 3 2 1 0 3 3 0 0 Akkar 8 5 2 3 0 1 1 0 0 2 2 0 0 Total 75 41 25 16 1 22 17 5 3 12 11 1 2 All = total no. of isolates in genotype group; MDR = no. of multi-drug resistant isolates; M = no. of isolates from males; F = no. of isolates from females. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 817 were restricted to cases from the Mount  Lebanon and Tripoli area. Most  forms  of resistance to drugs involved INH and  STR  (each  covered  79% of  resistant  genotyped  isolates) (Table 4). Of  the  total of 21  resistant  isolates, 17  resist- ance patterns were observed more than  once and 9 of these 17 isolates also came  from the same regions. However, only 2  of  the 9  isolates  resulted  in  the  same  genotypes (2 were genotype G3, both  showing resistance pattern SRSR). We  found 4  isolates of  identical genotype  and  resistance pattern  (genotype G3,  resistance pattern SRSR) that were dis- tributed in 3 regions (Mount Lebanon,  Tripoli and Akkar) (Table 4). The vari- ous regions demonstrated similar levels  of genotype diversity. The diversity ratio  of genotypes for Beirut was 0.56 (9/16)  and for outside Beirut was 0.22 (13/59)  (Table 1). Mount  Lebanon  alone  included  34%  (23/67)  of  all  cluster  isolates  (Table 2). All  the 9 cluster genotypes,  except G4,  included isolates of patients  from Mount  Lebanon, while  the  re- maining 8 unique genotypes  included  only 2  from the Mount Lebanon area.  The cluster genotypes could be divided  into  2  categories:  clusters  in  which  several  isolates belonged  to  the  same  region (G3, G6, G9, G12) and clusters  that  had  single  isolates  belonging  to  different regions (G4, G7, G8, G15). In  the second category all cases involved 1  isolate from Beirut or Mount Lebanon  and Tripoli  (Table  4);  this  category  also demonstrated a deviation  for  the  Table 4 Distribution of various antibiotic resistance patterns of resistant isolates, including sex of patient and genotype, in different regions of Lebanon by patients’ age group Age group (years) Region Beirut Beqaa Mount Lebanon Tripoli Akkar Pattern Gen.; Sex Pattern Gen.; Sex Pattern Gen.; Sex Pattern Gen.; Sex Pattern Gen.; Sex 10–19 – – – – – – SSRS G3; F – – 20–29 – – – – – – SSSR G3; F SRSR G3; F – – – – – – – – SRSR G3; F – – – – – – – – SRSR G6; M 30–39 – – – – SRSR G3; M – – – – – – – – RSSR G3; M – – – – – – – – SRSR G5; M – – – – – – – – SSSR G9; M – – – – 40–49 – – RRSS Gx; M RRRR G5; M SRSR G3; F – – – – – – SRRR G9; M SRSR G4; M – – – – – – – – SRSS G17; M – – 50–59 RRSS G1; F – – RRSR G3; M – – – – RRSR G15; M – – – – – – – – 60–69 RRRR Gx; M – – RRSS G6; M – – – – – – – – RRSR G15; M – – – – 70–79 – – – – – – – – – – Antibiotic resistance pattern sequence: rifampin (RIF)–isoniazid (INH)– ethambutol (EMB)–streptomycin (STR). R = resistant; S = sensitive. Gen. = genotype; Gx = no genotype pattern found; M = isolates from males; F = isolatea from females; – = no isolates. Table 5 Number of resistant isolates and single resistance contribution associated with the genotype groups Genotype group No. of resistant isolates No. of resistances in each isolate Antibiotic resistances RIF INH EMB STR M F 1R 2R 3R 4R No. % No. % No. % No. % I 3 5 2 5 1 – 2 25 5 63 1 13 7 88 II 7 1 1 5 1 1 3 38 7 88 2 25 6 75 III 3 0 1 – 2 – 2 67 3 100 0 0 2 67 Total 13 6 4 10 4 1 7 37 15 79 3 16 15 79 RIF = rifampin, INH = isoniazid, EMB = ethambutol, STR = streptomycin. M = isolates from males; F = isolates from females. 1R = single-resistant; 2R = double-resistant, 3R = triple-resistant; 4R = quadruple-resistant. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 818 M:F ratio (ratio 7, OR = 3.1, 95% CI:  0.36–26.3, P = 0.31).  Discussion The well-documented gender dis- parity  for  reported TB has been attrib- uted  to  socioeconomic  and  cultural  barriers in access to health care [13] as  well  as biological  and epidemiological  characteristics  [14,15].  In  this  study  the higher ratio of males to females that  we detected shifted even more towards  males  when  only  MDR  cases  were  considered  (7:1). Male  patients  ap- peared more likely either to be infected  by MDR strains or  to develop MDR.  The  apparent  targeting  of males was  also  confirmed by  the very high  ratio  of males  to  females  (10:1)  in  isolates  belonging  to genotypes  that were only  observed within  the age  range 20–49  years. The sex ratio for cases from Beirut  differed from those from outside Beirut.  This,  however,  is  consistent with  the  prevalence of genotype group I, which  had a lower male to female ratio outside  Beirut. In general the sex ratio—which  may demonstrate a host-sex preference  of M. tuberculosis TB—was an average  of dissimilar ratios that depended heav- ily on the genotype of the M. tuberculosis TB strains. This was clearly shown when  these ratios were calculated individually  for each separate genotype group. The  clear  variation  in host-sex preference  according  to genotype strain holds  the  potential  for determining  the genetic  factors within M. tuberculosis TB  that  may underlie this phenomenon. Between July 2002 and April 2004  Araj et al.  studied the sensitivity of  iso- lates  from Lebanon and  found 23.8%  resistant  isolates,  almost  identical  to  the 24.1% obtained in the current study  [15,16]. The  regional  distribution of  drug resistance varies most clearly with  regard to MDR strains, which were con- centrated  in  the Mount Lebanon area  and neighbouring Beirut. The latter was  not the case considering resistant strains  in general. Again, MDR strains did  not  behave  like  the  bulk  of  resist- ant strains. Some forms of resistance  were more  common  than  others.  The  resistance  pattern  was  domi- nated by  INH and STR resistance,  while few isolates showed resistance  to ENB. The 4 isolates with identical  resistance and genotype patterns are  likely candidates  for  transmission of  resistant  strains of M. tuberculosis.  It  was noted that all these strains shared  a  common  resistance  to  INH and  STR. Considering  that  the underly- ing genetics of resistance are  impor- tant for transmission dynamics [17];  this might affect  the distribution of  resistance patterns in cluster isolates.  In the present study in Lebanon,  most TB patients were young adults;  72% were below the age of 50 years  and 7% were aged 20 years or less. It  appears  that  several genotypes may  be restricted to, or favour, certain age  ranges.  Some genotypes  appeared  only  in  the  age  range where most  cases  of  TB were  obtained,  while  others were seen only at age  ranges  where there were fewer isolates. The  genotypes  belonging  to  genotype  group III showed a tendency to affect  older people, a finding which, if con- firmed, could  indicate  the presence  of genetic  factors within  the  strains  that are associated with age suscepti- bility of the host [18]. The increased  occurrence  of  specific  resistance  depending  on  age  was  consistent  with  the elderly patients being most  affected by MDR strains. An explana- tion  for  that  shift might be  that  the  elderly are generally too weak to fight  successfully against the less fit resist- ant MTB strains [19]. Genotype  groups  appeared  to  be slightly selective regarding the pat- tern of drug resistance. The increase  in  the  relative  occurrence  of  RIF  and  INH resistance  from genotype  group  I  through  to genotype group  III is also consistent with the finding  that most cases of MDR belonged to  genotype groups II and III. The underly- ing  genetic  cause of  these  groupings  and the shifts towards specific genotype  groups (equivalent to a higher number  of bands) could be  a  consequence of  the possible  increase  in  the numbers  of  the mobile genetic element  IS6110;  such an increase has been implicated or  suspected  in genotypic  instability  that  could be associated with drug resistance  and adaptation [20].  The higher diversity ratio of resistant  isolates  0.42  (8/19)  compared with  nonresistant  ones  0.23  (13/56)  and  the high  ratio  seen  for MDR  isolates  0.83(5/6)  could be  explained by  the  proposed  lower  level of  relative fitness  of many resistant  isolates [17]. Cluster  formation of genotypes was seemingly  not  related  to  the presence or absence  of  resistance. However,  at  the  level of  individual genotypes,  some seemed  to  be more prone to resistance acquisition,  persistence or spread than others.  Lebanon is considered an endemic  country for TB, with a general incidence  estimate for 2005 of 11 per 100 000 for  all cases. However,  the geographic dis- tribution of  the disease varies depend- ing on  the  region.  Studies  presented  by  the Ministry of Health  indicate  the  highest  ratio of  cases  is  in  the  regions  of Beirut  and  the North (Tripoli  and  Akkar regions) [21].  The observed similarities in the pat- terns  suggested  a  close  relationship  between most strains. However, the cur- rent  study demonstrated  that  various  genotypes tended to be more common  in specific regions than others. This se- lective distribution of genotype groups  indicates some level of geographic isola- tion  and hence  separate  evolution.  It  justifies also the initial assignment of the  genotypes  to major groups depending  on the general band pattern. Earlier  concerns  about  a  large TB  reservoir  existing  in  the  larger  area of  Beirut  (which  would  include  many  former  inhabitants  of Mount  Leba- non)  [21]  appear  to  be  validated by  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 819 the presence of  isolates  from  this  area  in all  genotypes  forming clusters,  sug- gesting an important role for the active  spread of TB in Lebanon. The increased  relative diversity of genotypes present in  the  region of Beirut compared with all  regions outside Beirut as a whole seems  to confirm the epidemic importance of  this region, and its role as a major source  for the spread of MTB strains.  Conclusions The  presented  study  demonstrates  the  importance  of  genotype  charac- terization of MTB isolates incorporated  within  the  essential  framework of  an  adapted  DOTS  programme.  Low- resource countries can still benefit from  a plethora of available molecular  tech- niques  and  adopt  a  programme  that  is  relatively  simple  to  implement  and  modest  in  its  required  resources. The  widespread international incorporation  of molecular  strain differentiation  into  TB  control  programmes,  associated  with accurate epidemiological  tracing,  will  provide  a  growing body of  clini- cally applicable  evidence.  It may also  shift the balance of control and cure in  the battle against  the growing threat of  virulent MDR strains. Acknowledgements We were  able  to  achieve  this  project  owing  to  the financial  support of  the  Lebanese University,  the Syrian Minis- try of Higher Education, represented by  the Syrian High Council of Science, the  Syrian National Commission of Bio- technology, and Al-Azm wa Al-Saadeh  Society  in Tripoli. We would  like  to  express our  appreciation  to Professor  Fawaz Al Azmeh, head of  the NCBT,  for his cooperation. We also thank Miss  Sandy Nasr, Miss Zeina Merhi, Mrs  Rana Nader, Mrs Mayssoun Elwi, Mrs.  Nibal Qirahkahya, Miss Buthainah Al- Salamah for their efforts. Zigol M et al. Global incidence of multidrug-resistant tubercu-1. losis. Journal of Infectious Diseases, 2006, 194:479–485. Senol G, Komurcuoglu B, Komurcuoglu A. Drug resistance of 2. Mycobacterium tuberculosis in Western Turkey: a retrospective study from 1100-bed teaching hospital. Journal of Infection, 2005, 50(4):306–311. Verver S et al. Rate of reinfection tuberculosis after success-3. ful treatment is higher than rate of new tuberculosis. Ameri- can Journal of Respiratory and Critical Care Medicine, 2005, 171:1430–1435. Martínez M et al. Impact of laboratory cross-contamination 4. on molecular epidemiology studies of tuberculosis. Journal of Clinical Microbiology, 2006, 44(8):2967–2969. European Concerted Action on New Generation Genetic 5. Markers and Techniques for the Epidemiology and Control of Tuberculosis. Beijing/W genotype Mycobacterium tubercu- losis and drug resistance. Emerging Infectious Diseases, 2006, 2(5):736–743. Clark CM et al. Universal genotyping in tuberculosis control 6. program, New York City, 2001–2003. Emerging Infectious Dis- eases, 2006, 12(5):719–724. Montoro E, Valdivia J, Leão SC. Molecular fingerprinting of 7. Mycobacterium tuberculosis isolates obtained in Havana, Cuba, by IS6110 restriction fragment length polymorphism analysis and by the double-repetitive-element PCR method. 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Gender differences in delays in diagnosis and 13. treatment of tuberculosis. Health Policy and Planning, 2007, 22(5):329–334. Hamid Salim MA et al. Gender differences in tuberculosis: a 14. prevalence survey done in Bangladesh. International Journal of Tuberculosis and Lung Disease, 2004, 8(8):952–957. Araj G, Saade H, Itani L. Nationwide study of drug resistance 15. among acid-fast baulle positive pulmonary tuberculosis cases in Lebanon. International Journal of Tuberculosis and Lung Dis- ease, 2006, 10(1):63–67. Hamze M, Araj G. Drug resistance among mycobacterium 16. tuberculosis isolates in Lebanon. International Journal of Tuber- culosis and Lung Disease, 1997, 1(4):314–318. Gagneux S et al. Impact of bacterial genetics on the transmis-17. sion of isoniazid-resistant Mycobacterium tuberculosis. PLoS Pathogens, 2006, 2(6):603–610. McShane H. Susceptibility to tuberculosis—the importance of 18. the pathogen as well as the host. Clinical and Experimental Im- munology, 2003, 133:20–21. Andersson DI. The biological cost of mutational antibiotic 19. resistance: any practical conclusions? Current Opinion in Micro- biology, 2006, 9:461–465. 20. Tanaka MM, Rosenberg NA, Small PM, The control of copy 20. number of IS6110 in Mycobacterium tuberculosis. Molecular Biology and Evolution, 2004, 21:2195–2201. 21. Kalaajieh WK. Epidemiology of tuberculosis in Lebanon. 21. International Journal of Tuberculosis and Lung Disease, 1999, 3(9):774–777. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 820 Characterization of Mycobacterium tuberculosis in Syrian patients by double-repetitive-element polymerase chain reaction A. Rahmo1 and M. Hamze 2 ABSTRACT The role of previous treatment in the dynamics of tuberculosis transmission has not been adequately investigated. Mycobacterium tuberculosis isolates from previously treated patients (n = 88) from all regions of Syrian Arab Republic were characterized in terms of antibiotic sensitivity and genotyping using double-repetitive- element polymerase chain reaction (DRE-PCR) method for the proximity of the repetitive DNA elements IS6110 (a mobile genetic element) and PGRS. The 88 isolates resulted in 59 different DRE-PCR patterns. Correlations related to age, sex, region, sensitivity and genotype were examined. All regions of the country showed high levels of genotype diversity, suggesting a low level of transmission of M. tuberculosis strains in previously treated patients. 1National Commission for Biotechnology, Damascus, Syrian Arab Republic. 2Faculty of Public Health, Lebanese University, Tripoli, Lebanon (Correspondence to M. Hamze: mhamze@ul.edu.lb). Received: 14/01/08; accepted: 29/06/08 ةجودزلما صرانعلل زايرميلوبلل ليسلسلا لعافتلا للاخ نم ينيروسلا ضىرلما ينب ةيلسلا تارطفتلما صئاصخ لىع فرعتلا ةرركتلما ةداعس سويناطم ،وحمر رداقلا دبع ،ةزحم رذنم تارطفتلما تادرفتسم صئاصخ لىع نوثحابلا فرعت دقو .لبق نم ةيفاك ةساردل لسلا ةياسر تايكيمانيد في ةقبسلما ةلجاعلما رود عضيخ لم :ةـصلالخا اهتيساسح ثيح نم كلذو ،ةيروسلا ةيبرعلا ةيروهملجا في قطانلما عيجم لىإ نومتني ،)88 مهددعو( ،اولجوع نأ قبس ضىرم نم ْتَعِ ُمجم يتلا ةيلسلا برق ىدم لىع فرعتلل ،ةرركتلما ةجودزلما صرانعلل زايرميلوبلل ليسلسلا لعافتلا ةقيرط مادختساب ،ةينيلجا اهطمانأ ثيح نمو ،ةيويلحا تاداضملل ًةدرفتسم 88 اهددع غلبي يتلا تادرفتسلما تجتنأ دقو .PGRSو ،)كرحتم ينيج صرنع يهو( IS6110 يه صرانعلا هذهو اندلا لىع ةرركتلما صرانعلا ةنايدلاو رمعلاو سنلجاب ةقلعتلما طباورلا نوثحابلا سرد دقو .ةرركتلما ةجودزلما صرانعلل زايرميلوبلل ةيلسلسلا تلاعافتلا نم ًافلتمخ ًاطمن 59 ةياسر نم ضفخنم ىوتسم لىإ يرشي امم ،ةينيلجا طمانلأا في عونتلا نم ةعفترم تايوتسم ةيروس ءاجرأ عيجم ترهظأ دقو .ينيلجا طمنلاو سسحتلاو .ًاقباس اولجوع نيذلا ضىرلما ىدل ةيلسلا تارطفتلما يرارذ Caractérisation de Mycobacterium tuberculosis par PCR d’éléments répétitifs doubles chez des patients syriens RÉSUMÉ Le rôle des traitements antérieurs dans la dynamique de la transmission de la tuberculose n’a pas été étudié de manière adéquate. Les isolats de Mycobacterium tuberculosis issus de patients précédemment traités (n = 88) provenant de toutes les régions de la République arabe syrienne ont été caractérisés en termes de sensibilité aux antibiotiques et en fonction de leur génotype au moyen de la méthode de PCR d’éléments répétitifs doubles (DRE-PCR) pour la proximité des éléments d’ADN IS6110 répétés (élément génétique mobile) et des séquences répétées PGRS (Polymorphic GC-rich repetitive sequence). Les 88 isolats ont fait apparaître 59 profils DRE-PCR différents. Les corrélations avec l’âge, le sexe, la région, la sensibilité et le génotype ont été étudiées. Une forte diversité des génotypes a été constatée pour toutes les régions du pays, ce qui suggère un faible niveau de transmission des souches de M. tuberculosis chez les patients précédemment traités. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 821 Introduction Patients  with  a  previous  history  of  tuberculosis  (TB)  treatment  have  been  shown  worldwide  to  have  the  highest  risk of harbouring multidrug- resistant (MDR) and even extensively  drug-resistant  strains of Mycobacterium tuberculosis. There  is  some  evidence  that positive selection of  strains occurs  within patients [1]. However, the role of  previous  treatment  in  the dynamics of  M. tuberculosis TB transmission and the  multitude of  factors underlying  treat- ment  failure have not been adequately  investigated [2].  Molecular  studies have been  suc- cessfully  applied  in  evaluating  epide- miological linkages and in the discovery  of unexpected ones. These have been  essential for distinguishing relapse from  reinfection in recurrences of TB [3] and  for establishing evidence of  laboratory  cross-contaminations (false positives)  [4]  and  the  association  of  particular  genotypes  with  hypervirulence  and  multi-resistance [5].  Different methods have been used  for  the  genotyping  of M. tuberculosis TB. These vary in the time required for  testing and  their  resolution,  specificity,  typeability,  reproducibility,  robustness,  complexity,  cost  and  amenability  to  databank  construction. The  double- repetitive-element  polymerase  chain  reaction  (DRE-PCR)  genotyping  method  addresses  variations  in  the  proximity presence and  the  interspace  distance  separating  2  exceptionally  important  repetitive DNA elements:  insertion sequence (IS) 6110 and poly- morphic GC rich repeat (PGRS). The  method  is  relatively  fast,  simple  and  cost-effective  [6].  It  suffers,  however,  from a  lack of  reproducibility due  to  the occasional absence of low-intensity  bands  and  from only  an average  level  of  resolution  [7].  At  minimum,  the  technique serves as a tailored approach  for preliminary genotyping and has the  potential  for  efficient  implementation  in a  low-resource country, where TB is  generally widespread and endemic. The presented  study  in  the Syrian  Arab Republic was based on  isolating  various strains of M. tuberculosis TB from  previously treated patients from various  regions of the country, followed by char- acterizing their sensitivity to antibiotics  and their genotyping through a slightly  modified DRE-PCR method. The phe- notypic correlation with  the genotypes  of  various  strains, based on adjacency  of the 2 repetitive elements IS6110 and PGRS, was examined.  Methods Sample Following an agreement with  the Syr- ian Ministry of Health, we were  able  to  obtain  samples  from  88  patients  previously  treated  for pulmonary TB,  which included cases of failure after first  treatment and of relapse or reinfection.  The 88 samples, provided by  the Min- istry’s central laboratory, were collected  between July 2003 and October 2005  from all Syrian provinces (muhafazat).  Samples were  shipped,  accompanied  by  the  related  information,  to  the  biomedical  laboratory of  the National  Commission  for Biotechnology  in  the  Syrian Arab Republic. The research was  approved  by  the  responsible  ethical  committee  at  the Ministry of Higher  Education.  Specimen preparation and culture Processing of  sputum specimens was  based on liquefaction and decontamina- tion by 2% N-acetyl-L-cysteine-NaOH.  Bacterial culture was performed on solid  Lowenstein–Jensen medium [8].  Susceptibility testing Antibiotic  susceptibility  testing  was  done using  the proportion method of  the National Committee  for Clinical  Laboratory Standards [9] on inoculum  preparations of  freshly grown colonies  from Lowenstein–Jensen medium after  transfer and resuspension using beads.  The  patterns  of  antibiotic  sensitivity  (S)  and  resistance  (R)  are described  in  the  text using  the notation RRSR,  RRRS etc., with the following sequence:  rifampicin  (RIF)–isoniazide  (INH)– streptomycin  (STR)–ethambutol  (EMB).  DRE-PCR procedure For DNA extraction, a  loopful of each  culture was extracted using the QIAamp  DNA blood mini  kit  (Qiagene). The  manufacturer’s  instructions  were  adhered  to  except  for  the  incubation  period, which was extended to 3 hours.  The DRE-PCR procedure was followed  as reported by Harris [10], a modifica- tion of Friedman et al.  [11]. The PCR  amplification  mixture  contained  67  mM tris (pH 8.8), 16 mM (NH 4 ) 2 SO 4 ,  0.01%  tween-20  (1 × reaction buffer;  Euroclone),  2.5  mM MgCl 2   (Euro- clone), 200 μM each deoxynucleoside  triphosphate (MBI Fermentas), 0.5 μM  of each of the 4 primers (MWG Biotech,  HPSF grade), and 2.5 U of taq polymer- ase (Euroclone). The sequence of  the  primers is described elsewhere [10,11].  Amplification was done  according  to  Harris  [10],  using  the Mastercycler  thermal cycler (Eppendorf). The ampli- fication products were analysed using  parametric analysis of gene set enrich- ment (PAGE),  stained with ethidium  bromide. The modifications introduced  were:  the use of a DNA extraction kit,  the  inclusion of ammonium sulfate  in  the PCR reaction mixture and the use of  PAGE for band pattern analysis.  Statistical analysis SPSS,  version 12.0 was used. A confi- dence  interval  of  95% (2-tailed) was  applied.  Cross-tables  that  did  not  fulfil Cochrane  rules were  tested  for  significance using  the Fisher exact  test  (2-sided). Unpaired Student  t-test was  used  for continuous variables. Correla- tions were assessed using spearman and  Kendall coefficients (rs, τ). EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 822 Results The mean and standard deviation (SD)  age of the 88 TB patients was 36.5 (SD  2.7) years, median 34.5,  range 17–69  years. There were 63 males, mean age  37.6 (SD 3.2) years (median 35,  range  17–69 years) and 25 females, mean age  33.9 (SD 5.0) years (median 35,  range  17–62 years) (Table 1). Most  isolates  belonged  to patients  in  the age  range  20–39 years. All patients had been previ- ously treated for M. tuberculosis TB.  Of  the  88  isolates  collected,  85  (96.6%)  were  resistant;  18  (20.5%)  were  single-resistant, 12 (13.6%) were  poly-resistant  and  55  (62.5%)  were  MDR  strains. The  resistance  pattern  was: RIF 69.4%, INH 77.6%, STR 82.4%  and EMB 61.2%. The most  common  resistance pattern was RRRR (resist- ance sequence RIF–INH–STR–EMB)  in 45.9% of  resistant  isolates (39/85).  The most common drug resistance was  to STR and so the most common single- resistance pattern was SSRS  in 16.5%  (14/85) of resistant isolates (Table 2). The 88 isolates resulted in 59 differ- ent DRE-PCR patterns, while 6 isolates  produced  no  detectable  genotypes.  The Hunter–Gaston  discrimination  index [12] was calculated as D = 0.98.  The number of different bands was 24,  ranging  from 1  to 7  for each genotype  (Table  3). We  observed  9  clusters,  which  included 32  isolates. Altogether  cluster  isolates  represented 36% (32)  of the isolates (Table 4); unique geno- types  were  observed  for  50  isolates.  The  largest cluster was genotype G20,  containing  the  single  band  300  bp,  followed by cluster genotypes G3 and G23. The genotypes were assigned to 7  genotype groups (I–VII) depending on  the total number of different bands ob- served (Table 3). Most cluster  isolates  belonged to genotype group I, and all to  I and II. A gradual decrease was observed  in the number of isolates with increasing  number of bands (Figure 1).  Correlations Correlations were investigated between  patient’s  sex, age and region,  the geno- types, and the resistance pattern.  Correlations related mainly to sex The general ratio of males to females was  2.5 (63/25) considering all isolates (Ta- ble 1). For  the Aleppo region,  the ratio  was 1.4 (21/15), while the M:F ratio for  the rest of the regions taken together was  4.2 (42/10). The M:F  ratio of  cluster  isolates was 5.4 (27/5) (Table 3). The  M:F ratio for resistant strains in clusters  was 4.6 (23/5), while the M:F ratio for  the unique genotypes (all were resistant  isolates) was 1.9 (33/17) (Table 2). The  general M:F ratio for MDR isolates was  2.6 (40/15) (Table 2), but the ratio was  Table 1 Mycobacterium tuberculosis isolates by age, sex and region of the Syrian Arab Republic Variable Total isolates Genotypes Isolates by age (years)a 10–19 20–29 30–39 40–49 50–59 60–69 No. No. No. No. No. No. No. No. Total 88 59 + ctr. 5 24 30 8 15 4 Sex Male 63 42 2 15 + 1Gx 23 + 1Gx 3 13 2 + 1Gx Female 25 22 3 8 5 + 1Gx 4 + 1Gx 1 + 1Gx 1 Region Aleppo 36 30 2 11 9 4 6 + 1Gx 2 + 1Gx Damascus 13 9 1 4 + 1Gx 6 + 1Gx 0 0 0 Deir ez-Zor 9 7 0 1 3 + 1Gx 1 3 0 Rif Dimashq 2 2 1 0 1 0 0 0 Latakia 5 4 0 2 1 1Gx 1 0 Homs 4 4 0 1 1 0 1 1 Al-Hasakah 3 3 0 1 1 0 1 0 Hama 3 3 1 0 1 1 0 0 Al-Qamishli 2 2 0 0 0 0 2 0 Ar-Raqqah 2 2 0 1 1 0 0 0 Abu Kamal 1 1 0 0 0 0 0 0 Adra 1 1 0 0 0 0 0 0 As-Suwayda' 1 1 0 0 1 0 0 0 Quneitra 1 1 0 1 0 0 0 0 Iraq 5 5 0 1 3 1 0 0 aAge was unknown for 2 cases. ctr. = control; Gx = genotype unknown. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 823 Ta bl e 2 A nt ib io ti c re si st an ce p at te rn s of M yc ob ac te ri um tu be rc ul os is g en ot yp es b y pa ti en t’s s ex a nd b y re gi on o f t he S yr ia n A ra b Re pu bl ic Va ri ab le A nt ib io ti c re si st an ce p at te rn a RR RR RR SS RR SR RR RS SS RS SR SS SR RR SR RS RS SS RS RS SR SR SS RR SS SS N o. o f i so la te s M al e 24 5 5 6 8 2 5 2 2 1 0 0 3 Fe m al e 15 0 0 0 6 0 1 0 0 1 1 1 0 To ta l 39 5 5 6 14 2 6 2 2 2 1 1 3 G en ot yp es b y re gi on A le pp o G 10 , G 25 , G 30 , G 44 G 45 , G 47 , G 51 , G 52 G 59 , G 61 , G 67 , G 71 G 72 , G 74 , G 82 , G x G 20 , G 31 G 43 , G 20 – G 3, G 19 , G 23 , G 27 G 28 , G 32 G 39 , G 21 G 23 ; G 49 ; G 70 ; G x G 54 G 57 – G 20 – G 32 D am as cu s G 20 , G 23 , G 29 , G 53 , G 78 , G 81 , G x – – G 20 , G x G 20 – – – G 3 G 55 – – G 45 D ei r e z- Zo r G 20 , G 60 , G x – G 20 G 79 – – G 3 G 42 – – – G 35 G 22 Ri f D im as hq G 23 – – – G 76 – – – – – – – –- La ta ki a G 3, G 38 – – G 62 G x G 48 – – – – – – – H om s G 21 – G 22 – G 80 – – – – G 20 – – – A l-H as ak ah G 40 G 24 – – G 37 – – – – – – – – H am a G 20 – – G 26 G 43 – – – – – – – – A l-Q am is hl i G 36 , G 20 – – – – – – – – – – – A r- Ra qq ah G 50 – – – – – G 56 – – – – – – A bu K am al – G 24 – – – – – – – – – – – A dr a – G 34 – – – – – – – – – – – A s- Su w ay da ’ – – – – G 64 – – – – – – – – Q un ei tr a G 33 – – – – – – – – – – – – Ira q G 69 , G 75 , G 77 – G 22 G 65 – – – – – – – – – a A nt ib io tic re si st an ce p at te rn se qu en ce : r ifa m pi n (R IF )– is on ia zi d (IN H )– st re pt om yc in (S TR )– et ha m bu to l ( EM B) . R = re si st an t; S = se ns iti ve . G = g en ot yp e (b ol d = is ol at es fr om fe m al es ); G x = no g en ot yp e pa tte rn fo un d; – = n o is ol at es . EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 824 17 (17/1) for MDR isolates  in clusters  (OR = 6.8, 95% CI: 0.67–70.1, P = 0. 1)  (Table  2). Most  noticeable  was  the  clearly deviating M:F ratio  for MDR in  Aleppo, 0.8 (9/11) (OR = 0.27, 95% CI:  0.065–1.14, P = 0.075) (Table 2). The diversity  ratio  (i.e. number of  genotypes/number of  isolates, exclud- ing  isolates with no genotype pattern  detected, 3  in males and 3  in  females)  for isolates from males was 0.7 (42/60)  and  this was clearly different  from the  diversity  ratio  for  isolates  from females  which was 1 (22/22). The dispropor- tionately high number of affected males  was obvious  for most but not all geno- type groups: The ratio was 9 (27/3) for  the genotype group  I  (OR = 5.7, 95%  CI: 1.5–21.4, P = 0.01), while genotype  groups VI and VII included only females  (OR = 0.09, 95% CI: 0.009–0.818, P = 0.023) (Table 5).  Correlations related mainly to age The mean age of patients for cluster iso- lates was 36.6 (SD 4.6) years (median 32,  range 17–64 years) and that  for cluster  genotype G20 was 38.7 (SD 7.9) years  (median  32,  range  25–64  years);  for  MDR isolates it was 37.1 (SD 3.4) years  (median  35,  range  17–65  years)  and  for MDR cluster  isolates 39.1 (SD 6.1)  years (median 35, range 17–64 years).  Correlations related mainly to geno- type and resistance The  largest  cluster genotype G20  (11  isolates) had 6  isolates  that  shared  a  resistance pattern. The  rest  had  each  a unique  resistance pattern; genotype  G23 had 2 out of 4 and genotype G3 Table 3 Band pattern of the different designated Mycobacterium tuberculosis genotypes and assigned genotype groups by isolate’s resistance and patient’s sex Genotype group/band (bp) Genotype Sensitive strains Resistant strains MDR strains M + F M F No. No. No. No. No. Group I 350 G3 0 4 3 1 1M 250 G19 0 1 1 0 0 300 G20 0 11 10 1 8M 325 G21 0 2 2 0 1M 400 G22 1M 2 2 0 2M 450 G23 0 4 3 1 2M 500 G24 0 2 2 0 2M 550 G25 0 1 1 0 1M 1500 G26 0 1 1 0 1M 2000 G27 0 1 1 0 0 Group II 125, 500 G28 0 1 1 0 0 150, 300 G29 0 1 1 0 1M 150, 325 G30 0 1 0 1 1F 150, 450 G31 0 1 1 0 1M 150, 500 G32 1M 1 0 1 0 150, 750 G33 0 1 1 0 1M 175, 450 G34 0 1 1 0 1M 225, 300 G35 0 1 0 1 0 275, 300 G36 0 1 1 0 1M 275, 325 G37 0 1 0 1 0 300, 400 G38 0 1 0 1 1F 300, 450 G39 0 1 1 0 0 325, 1500 G40 0 1 1 0 1M 350, 500 G10 0 1 0 1 1F 400, 1500 G42 0 1 1 0 0 450, 500 G43 0 2 2 0 1M 450, 600 G44 0 1 1 0 1M 450, 1500 G45 1M 1 0 1 1F طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 825 Table 3 Band pattern of the different designated Mycobacterium tuberculosis genotypes and assigned genotype groups by isolate’s resistance and patient’s sex (concluded) Genotype group/band (bp) Genotype Sensitive strains Resistant strains MDR strains M + F M F No. No. No. No. No. Group III 100, 250, 300 G47 0 1 0 1 1F 150, 500, 1500 G48 0 1 1 0 0 175, 300, 500 G49 0 1 1 0 0 175, 325, 450 G50 0 1 1 0 1M 200, 300, 500 G51 0 1 0 1 1F 225, 325, 450 G52 0 1 0 1 1F 250, 300, 350 G53 0 1 1 0 1M 250, 300, 400 G54 0 1 1 0 0 250, 300, 500 G55 0 1 0 1 0 250, 300, 1000 G56 0 1 0 1 0 250, 300, 1500 G57 0 1 1 0 0 250, 550, 650 G59 0 1 0 1 1F 275, 450, 600 G60 0 1 1 0 1M 300, 400, 450 G61 0 1 1 0 1M 350, 1500, 2000 G62 0 1 1 0 1M 450, 500, 1500 G63 – ctr. – – ctr. 450, 550, 2500 G64 0 1 1 0 0 450, 1500, 2000 G65 0 1 1 0 1M Group IV 175, 250, 300, 550 G67 0 1 1 0 1M 250, 300, 450, 550 G69 0 1 1 0 1M 250, 300, 1000, 1500 G70 0 1 1 0 0 275, 300, 350, 450 G71 0 1 0 1 1F 275, 300, 550, 1500 G72 0 1 0 1 1F 275, 350, 350, 500 G74 0 1 1 0 1M Group V 150, 400, 600, 650, 2000 G75 0 1 1 0 1M 175, 225, 275, 325, 450 G76 0 1 1 0 0 175, 250, 300, 1500, 2000 G77 0 1 0 1 1F 200, + 200, 300, 325, 500 G78 0 1 1 0 1M 300, 350, 450, 500, 1500 G79 0 1 1 0 1M Group VI 175, 200, 225, 350, 450, 550 G80 0 1 0 1 0 275, 300, 350, 400, 500, 2000 G81 0 1 0 1 1F Group VII 125, 225, 275 300, 350, 375, 425 G82 0 1 0 1 1F Total (genotyped) 3M 79 57 22 38M;13F No genotype pattern found Gx 0 6 3 3 2M;2F MDR = multi-drug resistant; M = number of isolates from males; F = number of isolates from females; ctr. = control. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 826 had no  islolates  that  shared  the  same  resistance pattern (Table 1). Genotype  groups I, II and III had a combined ratio  for MDR strains of 0.59 (40/68), while  genotype groups IV, V, VI and VII had  a combined ratio of 0.79 (11/14) (OR  = 2.6,  95% CI:  0.66–10.1, P  = 0.17)  (Table 4). The  percentage  of MDR  strains  was  63%  (55/88),  higher  in  unique  genotypes  (74%,  37/50)  than  in  cluster  genotypes  (56%, 18/32). For  genotype G20 it was 73% (8/11) (OR  = 2.1, 95% CI: 0.46–9.29, P  = 0.348).  Starting with genotype group  IV and  going  to higher genotype group band  numbers, all  showed 100% STR resist- ance (Table 6). The STR resistance was  most prevalent in unique isolates (94%,  47/50) (OR = 10.1, 95% CI: 2.5–40.7,  P < 0.002). However, in cluster isolates,  resistance  to  INH  and  not  to  STR  was  the most  common pattern  (OR  = 1.56, 95% CI: 0.73–3.34, P  = 0.25).  The  fraction of  isolates  that  exhibited  the full resistant pattern (RRRR) in the  total resistant and in the MDR isolates  tended to increase with increasing band  number (rs = 0.949, P = 0.026, τ = 0.913,  P = 0.035), and this was especially  true  if only  the genotype groups  (I,  II,  III,  IV)  that  included  the bulk of  isolates  (90% of  total  resistant, 88% of MDR)  were considered (rs = 1, P < 0.001, τ = 1, P = 0.021) (Figure 2).  Discussion The Syrian Arab Republic is considered  an  endemic  country  for TB, with  an  intermediate burden of disease,  an es- timated  incidence  for all cases  in 2006  of 32 per 100 000 population and a TB  prevalence of 40 per 100 000 population  [13]. However, the geographic distribu- tion of the disease varies depending on  the  region. No previous  studies  in  the  country  have  been  published  using  molecular epidemiological  techniques  applied  to M. tuberculosis TB. The cur- rent  study demonstrates  that  various  genotypes tended to be more common  in specific  regions  than others. The se- lective distribution of genotype groups,  in addition  to  the observed high  level  of  variability,  indicated  some  level of  geographic  isolation,  and hence  sepa- rate evolution. It justifies also the initial  assignment of  the genotypes  to major  groups according  to  the general band  pattern. All  regions of  the country  showed  high levels of genotype diversity, which  is  consistent with a  low  level of  trans- mission of  strains  in previously  treated  patients. However,  this  requires confir- mation using a  larger pool of patients  that would  include  new  cases  of TB  infection. Not a single case of previously  treated TB was  observed  in which  a  match  in genotype,  resistance pattern  and location was present. The diversity  ratio of 1  for  isolates  from females and  < 1 for isolates from males, if confirmed,  might  suggest  that  females have a  ten- dency not to transmit the disease among  their  sex, but  instead  infect and are  in- fected by males. One major drawback  of using DRE-PCR is  the absence of a  worldwide accessible databank, mainly  due to difficulties of digitizing the results  and  lack of optimization. Associating  obtained patterns with that of digitized  genotypes would make  future  global  comparisons of strains possible. The disproportionately high  resist- ance  in  isolates of  previously  treated  patients from the Aleppo region should  be a cause for further investigation into  local  treatment procedures,  as well  as  local  strain  characteristics,  given  that  69%  of  these  strains were  unique  to  this  region and  that  there were  some  indications of deviating characteristics.  Furthermore,  the  generally  observed  prevalence of STR resistance  in Syrian  patients  suggests a need  to  reconsider  Table 4 Contribution of each drug resistance form to resistant strains of the 32 Mycobacterium tuberculosis isolates in 9 genotype clusters Cluster genotype No. isolates in cluster % of all isolates (n = 88) Single-resistant isolates RIF in INH in EMB in STR in No. %a No. %a No. %a No. %a G20 11 12.5 9 82 9 82 7 64 7 64 G3 4 4.6 2 50 2 50 2 50 3 75 G23 4 4.6 2 50 3 75 3 75 4 100 G22 3 3.4 2 100 2 100 2 100 0 0 G21 2 2.3 1 50 2 100 1 50 1 50 G24 2 2.3 2 100 2 100 0 0 0 0 G32 2 2.3 0 0 0 0 0 0 1 100 G43 2 2.3 1 50 1 50 1 50 1 50 G45 2 2.3 1 100 1 100 1 100 1 100 Total 32 36.4 20 69 22 76 17 59 18 62 aof resistant cluster isolates. RIF = rifampin; INH = isoniazid; EMB = ethambutol; STR = streptomycin. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 827 the inclusion of STR in current first-line  drug treatment.  The well-documented sex disparity  for reported TB has been attributed by  some  authors  to  socioeconomic  and  cultural barriers in access to health care  [14],  and by others  to biological  and  epidemiological characteristics [15,16].  Some studies were able to detect varia- tions  in  sex distribution depending on  disease  category  [17,18]. The overall  reported ratio of males to females in the  Syrian Arab Republic was 1.8 accord- ing  to  the World Health Organization  country TB profile of 2006 [13]. In the  current study the higher ratio of males to  females was similar whether  isolates  in  general were considered or only resistant  ones or only MDR cases. However, the  ratio for clustered genotypes was shifted  towards males  for unique  genotypes,  and the ratio was highly shifted towards  males when MDR cases in clusters were  considered. In this pool of patients males  appeared more  likely  to be  infected by  MDR  strains  and  to  develop MDR,  and  that was  true  for  specific  strains.  Females of  the  same pool were more  likely to be affected by MDR in the pres- ence of strains with a higher number of  bands (e.g. higher designated numbers  of  genotype  groups). The overall  sex  ratio of 2.5 (males to females)—which  seems  to  reflect  a host  sex preference  of MTB strains—was  in  fact  an aver- age of dissimilar ratios that appeared to  depend heavily on the genotype of  the  MTB strains.  Resistance  to all 4 drugs (RRRR),  was  the most common pattern  in  this  pool  of  previously  treated  patients.  The  resistance  pattern was  generally  50 45 40 35 30 25 20 15 10 5 0 1 2 3 4 5 6 7 N. Band N. MDR female N. female N. MDR male N. male Figure 1 Correlation of patients to number of bands obtained using double-repetitive-elements polymerase chain reaction M M M M M F F F F F F F 4R/tot 4R/MDR1.2 1 0.8 0.6 0.4 0.2 0 1 2 3 4 5 6 7 N. Band 0.5 0.31 0.47 0.75 0.47 0.8 0.8 1 0.75 0.5 0.6 1 1 1 Figure 2 Fraction of fully resistant patients of total and multi-drug resistant (MDR) cases correlated to number of bands obtained using double-repetitive-elements polymerase chain reaction EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 828 dominated by STR resistance, with EMB  resistance  being  the  least  observed;  however this was not the case in cluster  isolates,  in which  INH  resistance  be- came  the dominant  form of  resistance,  whereas RIF and EMB resistance  rates  did not alter. Association of INH resist- ance with clustering may be explained  by the  fact  that katG 315 mutations are  less likely to attenuate bacterial virulence  than mutations causing STR resistance  [19].  The resistance patterns SSSR, RSSR  and RSRR were absent.  It  is noticeable  that these all  include resistance to EMB  and sensitivity  to  INH. Considering all  observed  resistance patterns,  resistance  to EMB was associated with resistance to  INH (and not vice versa). The patterns  of  concurrent  resistance  to EMB and  INH (4 patterns) involve 51 isolates. The  only  exception was  the pattern SSRR,  involving only 1 isolate, which was prob- ably caused by a different mechanism of  resistance  to EMB. Noticeable also was  the fact that all absent resistance patterns  (3 patterns) represented EMB resistance  and sensitivity  to  INH. These observa- tions are consistent with both drugs af- fecting  the constitution of  the cell wall  and with  the  reported pleiotropic effect  of EMB resistance, which causes  resist- ance to other drugs such as INH [20,21].  EMB and  INH are also  reported  to be  targets of an efflux pump which confers  tolerance to both drugs [22].  The assigned  genotype  groups  ap- peared to correlate with certain patterns  of drug  resistance. We observed an  in- crease  in  the  relative occurrence of  the  total  resistance  pattern RRRR,  being  low in the genotype group I and high in  genotype group VII. MDR was generally  more  likely  to occur when there were a  higher number of genotype bands. The  underlying genetic cause of these group- ings,  and  shifts  towards  specific geno- typic groups, could be a consequence of  the possible  increase  in  the number of  IS6110  elements;  such an  increase has  been implicated or suspected in genotype  instability associated with drug resistance Ta bl e 5 D is tr ib ut io n of M yc ob ac te ri um tu be rc ul os is is ol at es b y pa ti en t’s se x an d m ul ti -d ru g re si st an ce fo r t he v ar io us d es ig na te d ge no ty pe g ro up s b y re gi on o f t he S yr ia n A ra b Re pu bl ic Re gi on To ta l is ol at es G en ot yp e gr ou p I II II I IV V V I V II A ll M D R A ll M D R A ll M D R A ll M D R A ll M D R A ll M D R A ll M D R N o. N o. N o. N o. N o. N o. N o. N o. N o. N o. N o. N o. N o. N o. N o. A le pp o 36 7M ;3 F 3M 6M ;4 F 3M ;3 F 4M ;4 F 1M ;4 F 3M ;2 F 2M ;2 F 0 0 0 0 1F 1F D am as cu s 13 5M 3M 2M 1M 1M ;1 F 1M 0 0 1M 1M 1F 1F 0 0 D ei r e z- Zo r 9 4M 2M 1M ;1 F 0 1M 1M 0 0 1M 1M 0 0 0 0 Ri f D im as hq 2 1M 1M 0 0 0 0 0 0 1M 0 0 0 0 0 La ta ki a 5 1M 1M 1F 1M 2M 1M 0 0 0 0 0 0 0 0 H om s 4 3M 2M 0 0 0 0 0 0 0 0 1F 0 0 0 A l-H as ak ah 3 1M 1M 1M ;1 F 1F 0 0 0 0 0 0 0 0 0 0 H am a 3 2M 2M 1M 0 0 0 0 0 0 0 0 0 0 0 A l-Q am is hl i 2 1M 1M 1M 1M 0 0 0 0 0 0 0 0 0 0 A r- Ra qq ah 2 0 0 0 0 1M ;1 F 1M 0 0 0 0 0 0 0 0 A bu K am al 1 1M 1M 0 0 0 0 0 0 0 0 0 0 0 0 A dr a 1 0 0 1M 1M 0 0 0 0 0 0 0 0 0 0 A s- Su w ay da ' 1 0 0 0 0 1M 0 0 0 0 0 0 0 0 0 Q un ei tr a 1 0 0 1M 1M 0 0 0 0 0 0 0 0 0 0 Ira q 5 1M 1M 0 0 1M 1M 1M 1M 1M ;1 F 1M ;1 F 0 0 0 0 To ta l 88 27 M ;3 F 18 M 14 M ;7 F 8M ;4 F 11 M ;6 F 6M ;4 F 4M ;2 F 3M ;2 F 4M ;1 F 3M ;1 F 2F 1F 1F 1F Al l = to ta l n um be r o f i so la te s i n ge no ty pe g ro up ; M D R = nu m be r o f m ul ti- dr ug re si st an t i so la te s; M = n um be r o f i so la te s f ro m m al es ; F = n um be r o f i so la te s f ro m fe m al es . طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 829 and adaptation [23,24]. Moreover,  the  IS6110  sequence has been  shown  to  possess a 3ʹ outward directed promoter  (OP6110)  that  is  able  to  upregulate  downstream genes  [25,26]. Given  the  importance assigned to the PGRS locus  and other nearby genes  in  the context  of virulence [27], multiple adjacency of  IS6110, or  the  increased  likelihood of  correct positioning  in  the presence of  multiple adjacency, may relate to some  of  the relevant phenotypic correlations  observed  and  is  consistent  with  the  recent  importance  assigned  to  strain  variations in TB [28,29].  Conclusions The genotyping of M. tuberculosis TB  strains, using a  slightly modified DRE- PCR, resulted in a Hunter–Gaston dis- crimination index of D = 0.98. The study  of  strain variations within  this pool of  previously treated patients found Table 6 Distribution of Mycobacterium tuberculosis isolates by antibiotic resistance for the various designated genotype groups Antibiotic No. resistant isolates Genotype group I II III IV V VI VII No. % No. % No. % No. % No. % No. % No. % RIF 55 20 69 12 63 12 71 5 83 4 80 1 50 1 100 INH 61 22 79 13 68 14 82 6 100 4 80 1 50 1 100 STR 64 19 66 16 84 15 88 6 100 5 100 2 100 1 100 EMB 48 16 55 11 58 10 59 6 100 3 60 1 50 1 100 RIF = rifampin, INH = isoniazid, STR = streptomycin, EMB = ethambutol. a  degree  of   isolation  between  • M. tuberculosis TB strains  in different  regions of  the Syrian Arab Republic,  suggesting  evolution  of  significant  strain variations;  a gender disparity in the • M. tuberculosis transmission dynamic; distinctive phenotype characteristics • of genotype groups assigned based on  the number of obtained bands; phenotypic relevance of the adjacen-• cy of mobile  elements  IS6110 and PGRS;  a correlation between female suscep-• tibility to MDR strains and molecular  strain characteristics. The distinction of  strains based on  loci  that contribute  to virulence  is  im- portant  for determining  the potential  causes of disparities  in TB  incidence  and  resistance.  Routine,  large-scale  molecular  studies  are  necessary  for  investigating  the  transmission dynam- ics  and mechanisms of disease  in  the  Syrian Arab Republic and neighbouring  countries. Relating  various  strains  to  strains obtained  in other countries us- ing different genotyping procedures  is  important. 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My- cobacterium tuberculosis PE and PPE multigene families and their association with the duplication of the ESAT-6 (esx) gene cluster regions. BMC Evolutionary Biology, 2006, 6:95 (doi: 10.1186/1471-2148-6-95). Gillespie SH. Evolution of drug resistance in 28. Mycobacterium tuberculosis: clinical and molecular perspective. Antimicrobial Agents and Chemotherapy, 2002, 46(2):267–274. Hanekom M et al. A recently evolved sublineage of the 29. Myco- bacterium tuberculosis Beijing strain family is associated with an increased ability to spread and cause disease. Journal of Clini- cal Microbiology, 2007, 45(5):1483–1490. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 831 Prevalence and associated factors of persistent diarrhoea in Iranian children admitted to a paediatric hospital N.A. Kermani,1 F. Jafari,1 H.N. Mojarad,1 N. Hoseinkhan1 and M.R. Zali1 ABSTRACT To identify the frequency and associated factors of persistent diarrhoea in a paediatric hospital in Tehran, Islamic Republic of Iran, children admitted with acute diarrhoea were followed prospectively until resolution of the episode. Persistent diarrhoea developed in 19.6% of the 424 diarrhoea cases. Children with persistent diarrhoea were significantly younger than those with acute diarrhoea (15.3 versus 29.4 months). Enteroaggregative Escherichia coli was the most prevalent pathogen in both groups, but otherwise the profile of symptoms and isolated organisms was similar in the 2 groups. History of dietary change prior to admission and use of antibiotics and anticholinergic drugs in the acute phase were significantly higher in the persistent than acute diarrhoea cases. 1Research Centre for Gastroenterology and Liver Diseases, Shahid Beheshti University, Tehran, Islamic Republic of Iran (Correspondence to N.A. Kermani: nahid_arjmand_k@yahoo.com & arjmand_k@irimc.org). Received: 01/08/08; accepted: 09/11/08 لافطلأا تايفشتسم ىدحإ لىإ اولخدأ نيذلا ينّـِ يناريلإا لافطلأا ىدل هل ةقفارلما لماوعلاو ميدتسلما لاهسلإا راشتنا لدعم لياز اضر دممح ،ناخ ينسح يننزان ،درمج ينيسلحا مظان ناسح ،يرفعج ةتشرف ،نيامرك دنجمرأ ديهان ،ةيملاسلإا ناريإ ةيروهجم في ،نارهط في لافطلأا تايفشتسم ىدحإ لىإ داح لاهسإب مهتباصإ ببسب اولخدأ نيذلا لافطلأا نوثحابلا عبات :ةـصلالخا ميدتسلما لاهسلإا نأ حضتاو .هل ةبحاصلما لماوعلاو ميدتسلما لاهسلإا راركت لىع ف ُّرعتلا فدبه كلذو ،ةمجلها نم مهئافش ىتح ،ةيلابقتسا ةعباتم لافطلأا نم ًايئاصحإ هب دتعي ٍدح لىإ )ًارهش 15.3( ًانس رغصأ ميدتسلما لاهسلإاب نوباصلما لافطلأا ناك دقو ،لاهسإ ةلاح 424 نم %19.6 باصأ دق تناك دقف كلذ نود مايفو ،ًاراشتنا رثكلأا يه ءاعملأل ةيزاغلا ةينولوقلا ةيكيشريلإا تناك ينقيرفلا لاك فيو ،)ًارهش 29.4( دالحا لاهسلإاب ينباصلما مادختساو ىفشتسلما في لاخدلإا لبق يئاذغلا ماظنلا يريغت قباوس نأ نوثحابلا ظحلاو .ينقيرفلا في ةبهاشتم تابوركلما تادرفتسمو ضارعلأا تماس تلااح في هنم ميدتسلما لاهسلإا تلااح ىدل ًايئاصحإ هب دتعي ٍردقب لىعأ ناك دالحا روطلا في ينلوكلا تاداضم نم ةيودلأاو ةيويلحا تاداضلما .دالحا لاهسلإا Prévalence et risques associés de diarrhée persistante chez des enfants iraniens consultant en hôpital pédiatrique RÉSUMÉ Afin d’identifier la fréquence de la diarrhée persistante, et les facteurs associés, au sein d’un hôpital pédiatrique de Téhéran (République islamique d’Iran), des enfants hospitalisés souffrant de diarrhée aiguë ont fait l’objet d’un suivi prospectif jusqu’à résolution de l’épisode. Une diarrhée persistante est apparue dans 19,6 % des 424 cas de diarrhée. Les enfants souffrant de diarrhée persistante étaient nettement plus jeunes que ceux atteints de diarrhée aiguë (15,3 mois contre 29,4). Dans les deux groupes, l’agent pathogène ayant la plus forte prévalence était Escherichia coli entéroaggrégatif. En revanche, le profil des symptômes et des organismes isolés était similaire dans les deux groupes. Les antécédents de changement de régime alimentaire précédant l’hospitalisation et l’utilisation d’antibiotiques et d’anticholinergiques lors de la phase aiguë étaient sensiblement plus élevés dans les cas de diarrhée persistante que dans les cas de diarrhée aiguë. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 832 Introduction Diarrhoea  is  still  an  important  cause  of child morbidity and mortality, caus- ing about 2.2 million deaths  annually  in  the paediatric population [1]. With  recent  improvements  in  rehydration  therapy  programmes,  a  decline  has  been  observed  in  deaths  associated  with acute watery diarrhoea,  and  thus  the problem of persistent diarrhoea has  become more  concerning. Persistent  diarrhoea—defined  by  the  World  Health Organization  as  a  diarrhoeal  episode  with  an  acute  onset  and  a  presumptive  infectious etiology  lasting  ≥ 14 days—comprises only 3%–20%  of diarrhoea episodes, but up to 50% of  diarrhoea-related deaths [2]. Persistent  diarrhoea  also  imposes  a  heavy  eco- nomic burden on  low socioeconomic  status countries with  its devastating ef- fects on nutritional  status, growth and  development of children [3,4].  There is little information about per- sistent diarrhoea in the Islamic Republic  of Iran. A 7.7% prevalence was reported  in a study from the west of the country,  and young age, non-breastfeeding, use  of antibiotics and presence of mucoid  or bloody diarrhoea were factors associ- ated with  it  [5]. These  factors,  in addi- tion to malnutrition, were also observed  in  other  studies  of  Iranian  children  [6,7]. We conducted the present study  to  identify  the pattern and etiology of  persistent  diarrhoea  among  children  admitted a paediatric hospital in Tehran  and to compare these cases with cases of  acute diarrhoea. Methods A  cross-sectional  prospective  study  was performed from June 2006 to June  2007  in Mofid Paediatric Hospital,  a  university-associated  referral hospital  in Tehran.  Sample size Estimated sample size was approximate- ly 400, considering the 7.7% prevalence  of persistent diarrhoea  in  Iranian chil- dren reported  in a  study with a similar  methodology [5], and 95% confidence  level and 2.5% acceptable error. Patients The study population was all  children  below  12  years  of  age who were  ad- mitted  for  acute diarrhoea during  the  study  period.  Previously  diagnosed  cases of  inflammatory bowel disease,  coeliac disease and cystic fibrosis were  excluded. Also children whose parents  were not willing to take part in the study  were excluded. Finally, 537 data collec- tion forms were completed. As we were  not able  to  follow up 113 patients due  to missing or  incorrect contact details  or non-response, 424 data  collection  forms were available for analysis. Data collection Data were  collected  from  the  child’s  medical  record and an  interview with  the parents. Trained nurses visited all  the  children admitted  to  the hospital  with gastroenteritis. After a brief expla- nation of the study to one of the parents  and acquiring verbal informed consent,  a data collection  form was completed.  This  included  the demographic  char- acteristics of  the child and  the episode  of diarrhoea (duration, signs and symp- toms,  changes  in  diet  and  any  drugs  used during the episode).  Diarrhoea was defined as  the pas- sage of at  least 3 non-bloody stools or  1 bloody  loose stool per 24 hours. For  exclusively breastfed  infants,  increased  frequency or decreased consistency of  stool compared with the previous bowel  habit of the infant and noticeable by the  mother was considered diarrhoea. The  duration of  the  episode of  diarrhoea  was  calculated  from  the onset of  the  disease as  stated by  the parents. Cases  were  defined  as  persistent  diarrhoea  (duration ≥ 14 days) or acute diarrhoea  (duration < 14 days). The  child’s   body  weight  was  measured  after  rehydration. Weight- for-age z-score was calculated using Epi- info, version 6.01, based on the National  Center for Health Statistics (NCHS) ta- bles and was used to categorize the cases  as normal weight (z-score ≥ –1.0), mild  underweight  (–1.0 < z-score ≤ –2.0),  moderate underweight (–2.0 < z-score  ≤ –3.0)  and  severe  underweight  (z- score < –3.0). We analysed nutritional  status based on weight-for-age z-score  score  (to  avoid  bias, we  disregarded  height-for-age  and weight-for-height  scores since we observed mistakes dur- ing height measurements). The patients were followed up until  resolution of the diarrhoea episode, even  if they were discharged from hospital. Laboratory methods A fresh stool specimen was obtained for  laboratory testing during the initial days  of the diarrhoea. Each specimen was first  examined by a light microscope. A saline  and iodine wet-mount preparation was  used  for detection of amoebae species,  Giardia lamblia and Blastocystis hominis,  and a formol-ether concentration meth- od  for  cysts. Trichrome  staining  and  polymerase chain  reaction (PCR) was  performed  to differentiate Entamoeba histolytica/dispar  complex  from other  non-pathogenic  intestinal amoeba and  E. histolytica  from E. dispar  respectively.  In order to distinguish Cryptosporidium spp., Cyclospora  spp.  and  Isospora belli,  a Ziehl–Neelsen acid-fast  stained slide  was prepared. We used modified  tri- chrome stain for Microsporidium spp. Bacterial  cultures  were  done  on  MacConkey  and  xylose–lysine– deoxycholate agar plates  for Salmonella spp., Shigella  spp.  and  diarrheogenic  Escherichia coli. PCR was used to detect  isolates that carried the eae and bfp genes for  enteropathogenic E. coli  (EPEC),  pCVD432 plasmid  for enteroaggrega- tive E. coli  (EAEC),  heat-labile  (LT)  and heat-stable (ST) genes of entero- toxigenic E. coli (ETEC),  stx1 and stx2 genes  for Shiga-toxin-producing E. coli (STEC),  ial and ipaH  genes  for enter- oinvasive E. coli  (EIEC)  and Shigella spp., and invA gene for Salmonella spp. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 833 Statistical analysis For comparison of proportions between  acute and persistent diarrhoea cases, the  χ2 or Fisher exact  tests were used and  for comparison of means  the Student  t-test was used. We considered a P-value  < 0.05 as  statistically  significant. Data  were analysed using SPSS, version 13.0.  Results Patient characteristics A  total of 424 children were enrolled  in  the  study. Persistent diarrhoea de- veloped in 83 (19.6%) cases, both hos- pitalized and discharged patients. The  mean age of  the study population was  26.6 months, and 57.3% of the patients  were male. The prevalence of persistent  diarrhoea  reached  24.4%  in  the  291  children aged < 2 years  and 21.8%  in  the  372  aged  <  5  years. The male  to  female ratio was not significantly differ- ent between  the  acute diarrhoea  and  persistent diarrhoea group (1.4:1 and  1.1:1,  respectively). More  than  80%  of  the persistent diarrhoea cases were  aged <  18 months. The mean  age  in  the persistent diarrhoea group was 15.3  months compared with 29.4 months in  the acute diarrhoea group (P < 0.001).  There was also a significant difference in  mean age between the 2 groups, when  we considered children < 2 years: 12.1  months in the 220 acute diarrhoea cases  versus 9.5 months  in  the 71 persistent  diarrhoea cases (P = 0.002).  Symptoms and characteristics of the diarrhoeal episodes The mean  duration  of  the  diarrhoea  episode  in  the  acute diarrhoea group  was 5.9 (SD 2.7) days; median 6 days,  and  in  the persistent diarrhoea group  24.9 (SD 18.6) days,  median 19 days. Data  regarding  related  symptoms  and  some  characteristics  of  the diar- rhoeal  episodes  are  summarized  in  Table 1. Among the symptoms related  to diarrhoeal diseases (abdominal pain,  nausea  and vomiting,  loss of  appetite  and  fever) only  fever was  significantly  different between the 2 groups (86.2%  in the acute versus 74.7% in the persist- ent diarrhoea group). Defecation times  per 24 hours and  frequency of bloody  or mucoid  stool  (which may  indicate  severity of the disease) were not statisti- cally significant between the groups. The  frequency of  concurrent  dis- eases,  including other  infections  and  immunodeficiency and gastrointestinal  disorders, was similar in acute diarrhoea  and persistent diarrhoea cases (21.4%  and  20.5%,  respectively  P  =  0.853)  (Table  1).  A  history  of  major  diet  change  (i.e.  introducing  complemen- tary  food or animal milk, changing  the  formula brand or introducing wheat to  the child) 2 weeks prior  to admission  was  found  in 10.6% of acute diarrhoea  and 20.5% of persistent diarrhoea cases  (P = 0.014).  Table 1 Demographic data, related symptoms and some characteristics of children hospitalized with acute and persistent (acute phase) diarrhoea Symptoms and characteristics Acute diarrhoea (n = 341) Persistent diarrhoea (n = 83) P-value No. % No. % Mean (SD) age (months) 29.4 (29.6) 15.3 (17.4) < 0.001 Male:female ratio 1.4 1.1 0.258 Signs and symptoms Abdominal pain 166 48.7 31 37.3 0.063 Nausea and vomiting 256 75.1 57 68.7 0.234 Loss of appetite 261 76.5 58 69.9 0.207 Fever 294 86.2 62 74.7 0.010 Defecation ≥ 6 times per 24 hours 210 61.6 60 72.3 0.069 Bloody stool 80 23.5 21 25.3 0.724 Mucoid stool 13 3.8 6 7.2 0.177 Clinical history Concurrent diseases presenta 73 21.4 17 20.5 0.853 History of previous persistent diarrhoea 18 5.3 7 8.4 0.298 History of major diet change 36 10.6 17 20.5 0.014 Antibiotics 284 83.3 78 94.0 0.013 Anticholinergic drugs 18 5.3 10 12.0 0.026 Breastfedb 144 65.5 46 64.8 0.513 aInfections, immunodeficiency and gastrointestinal disorders. bData for children aged < 2 years only (n = 220 for acute diarrhoea and n = 71 for persistent diarrhoea group). SD = standard deviation. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 834 Antibiotic  and  anticholinergic  drug use during  the  acute phase was  significantly higher  in the persistent di- arrhoea than the acute diarrhoea group  (Table 1). A  summary of medication  administered during the acute phase of  the diarrhoeal disease (including drugs  administered in the hospital before and  after admission by parents or other phy- sicians) is shown in Figure 1. The mean of weight-for-age z-score  was similar  in both groups: –0.76 (SD  1.54) in acute diarrhoea and –0.77 (SD  1.28) in persistent diarrhoea patients. In the age group < 4 months, 20 out  of 36 (55.6%) were exclusively breast- fed  and  in  the  age group < 6 months  26 out of 73 (35.6%) were exclusively  breastfed. The  proportion  of  exclu- sively breastfed infants was significantly  higher  in  the persistent diarrhoea  than  the  acute diarrhoea  group,  analysing  only those aged < 2 years (14.5% versus  4.4%, P = 0.001). There was no differ- ence between  the acute and persistent  diarrhoea  groups  in  the  frequency of  breastfed  and non-breastfed  children  (age < 2 years only).  Two deaths occurred during  this  study  and  both  were  related  to  the  underlying disease of  the patient  and  not to the diarrhoeal disease. Enteropathogens in stool specimens Laboratory  testing of  stool  specimens  for  enteropathogens  gave  a  positive  result  in only 42% of acute and 36% 0f  persistent diarrhoea cases (Figure 2).  EAEC was the most frequently iso- lated enteropathogen  in both groups.  No clear difference in the profile of infec- tion was  found between cases of acute  and  persistent  diarrhoea  (Table  2).  Salmonella  spp. was  the only pathogen  with a significantly higher prevalence in  persistent diarrhoea (2/83 cases)  than  acute diarrhoea cases (0/341 cases) (P = 0.038), although the number of cases  was very small.  Discussion Due to the fact that this was a hospital- based  study  performed  in  a  referral  centre,  a high  frequency of persistent  diarrhoea was expected. The prevalence  of persistent diarrhoea (19.6% overall  and 21.8%  in children aged < 5 years)  was higher than that reported in a study  from west of  Islamic Republic of  Iran  (7.7%). This may be because of the dif- ference in admission status of the cases  (inpatient versus outpatients). The rate  of persistent diarrhoea is lower than that  from a hospital-based  study  in Brazil  (56.9%) [8] but higher than in Nigeria  (11.7%)  [9]. Age  is  a major determi- nant  in  the development of persistent  diarrhoea. Our results showed that diar- rhoea was more likely to be persistent in  younger children and this  is consistent  with  the  findings of  previous  studies  in Kenya, Peru, Egypt and Guatemala  [2,10–13].  Comparing some related symptoms  and  characteristics  of  the  diarrhoeal  disease, we  found  that  the  illness was  similar in severity in persistent diarrhoea  and acute diarrhoea cases. Studies from  Nigeria and Egypt have reported similar  findings [9,12]. A major dietary change  (such as  introducing  complementary  food or animal milk to the child) 2 weeks  prior  to admission was more common  in persistent diarrhoea than the acute di- arrhoea cases. This may underscore the  role of non-infectious causes, especially  allergies, in the development of persistent  Figure 1 Frequency of drug administration to children hospitalized with acute (n =341) and persistent diarrhoea (n = 83) before, during or after hospitalization (any time during acute phase of the diarrhoeal episode) Acute Persistent Drug type % o f c hi ld re n طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 835 diarrhoea. The  frequency of  exclusive  breastfeeding was not very high among  the children,  so most of  them were al- ready exposed to  foodborne  infections.  A diet change such as introducing animal  milk or complementary food to an infant  who is not exclusive breastfed or chang- ing  formula brand may  indicate other  causes of diarrhoea. Supported by  the  results of previous  studies, we noticed  that antibiotic and anticholinergic drug  use during the initial days of a diarrhoeal  episode was associated with longer dura- tion of the disease [14–17].  Enteropathogens were  identified  in  only 42% of acute and 36% of persist- ent diarrhoea  cases. There  are  several  reasons for this relatively low rate. First,  we  did  not  exclude  patients  treated  with  antibiotics prior  to  stool  exami- nation, which might  result  in negative  bacterial growth. Secondly, we did not  test  the  specimens  for  some bacterial  enteropathogens—e.g. Clostridium dif- ficile, Aeromonas spp. and Campylobacter spp.—or for any viral enteropathogens.  Thirdly,  a  proportion  of  diarrhoeal  episodes may be due to non-infectious  causes such as food allergies or chronic  non-specific diarrhoea of childhood, as  noted by Vernacchio et al. [18].  Several  studies  from Bangladesh,  India and Brazil have recognized EAEC  as an  important pathogen  in develop- ing persistent diarrhoea  [19–22]. We  also  found  it  as  the  most  prevalent  pathogen  in  cases  of  both  acute  and  persistent  diarrhoea  albeit  with  no  significant  difference  between  the  2  groups. Surprisingly, protozoa, especially  Cryptosporidium  spp.  which  is  pre- sumed to be one of the main etiological  agents of persistent diarrhoea, was not  associated with prolonged diarrhoea  in our  study [2,17,23]. Salmonella  spp.  was  the only pathogen with  a  signifi- cantly higher prevalence  in persistent  diarrhoea than acute diarrhoea cases in  this  study, although  the numbers were  very small. When  assessing  malnutrition,  a  demonstrated risk factors for persistent  diarrhoea [9,24,25], we found no differ- ence between the 2 groups.  Breastfeeding  is a protective  factor  for persistent diarrhoea, as indicated in  several studies [5,7,23], but in our study  Table 2 Frequency of enteropathogens in stool specimens of children hospitalized with acute and persistent diarrhoea Enteropathogen Acute diarrhoea (n = 341) Persistent diarrhoea (n = 83) P-value No. % No. % Giardia lamblia trophozoite 1 0.3 1 1.2 0.35 Cryptosporidium spp. 6 1.8 1 1.2 1.00 Blastocystis hominis 13 3.8 1 1.2 0.32 Salmonella spp. 0 0.0 2 2.4 0.04 Shigella spp. 7 2.1 2 2.4 0.69 Enteroaggregative Escherichia coli (EAEC) 60 17.6 15 18.1 0.92 Enteropathogenic E. coli (EPEC) 18 5.3 5 6.0 0.79 Shiga-toxin-producing E. coli (STEC) 25 7.3 6 7.2 0.97 Enterotoxigenic E. coli (ETEC) 21 6.2 5 6.0 0.96 Enteroinvasive E. coli (EIEC) 31 9.1 5 6.0 0.37 Figure 2 Number of pathogens isolated from stool specimens of children hospitalized with acute (n = 341) and persistent diarrhoea (n = 83) % o f c hi ld re n Number of pathogens EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 836 the  frequency of breastfeeding  in chil- dren < 2 years of age was similar in the  acute and persistent diarrhoea groups.  However,  it should be mentioned that  the proportion of exclusively breastfed  infants was  significantly higher  in  the  persistent diarrhoea  than  the acute di- arrhoea group (14.5% versus 4.4%). We  also observed that only 55.6% of infants  under  4 months  and  35.6% under  6  months of age were exclusively breast- fed. This, along with the fact that moth- ers  tend  to discontinue breastfeeding  during  a  diarrhoeal  episode,  implies  the need for an extended public health  education programme  for diarrhoeal  disease in the Islamic Republic of Iran. Follow-up of  the children  showed  no deaths associated with acute or per- sistent diarrhoea. This may be a result of  good hospital care especially in the case  of rehydration and nutritional care.  This study presents some data about  persistent diarrhoea in a hospital setting  and although the findings are not repre- sentative of the community, they clarify  some aspects of persistent diarrhoea in  Iranian  children. Persistent diarrhoea  seems to be a benign disease in the Ira- nian paediatric population. Young age,  antibiotic and anticholinergic drug use,  a history of a  significant diet change 2  weeks before the onset of diarrhoea and  presence of Salmonella  spp.  are  some  factors  that may be  involved  in persist- ent diarrhoea. Acknowledgements The authors wish to thank Ms F. Mola,  Ms M. Ghafoori, Dr B. Noorinayer, Dr  M.A. Pourhoseingholi and Dr F. Firoozi  for their kind assistance. This study was  funded  by  the  Research  Center  for  Gastroenterology and Liver Diseases,  Shahid Beheshti University. Black RE, Morris SS, Bryce J. Where and why are 10 million chil-1. dren dying every year? Lancet, 2003, 361:2226–2234. Persistent diarrhoea in children in developing countries: mem-2. orandum from a WHO meeting. Bulletin of the World Health Organization, 1988, 66:709–717. Bhutta ZA et al. Persistent and chronic diarrhoea and mal-3. absorption: Working Group report of the second World Congress of Pediatric Gastroenterology, Hepatology, and Nu- trition. Journal of pediatric gastroenterology and nutrition, 2004, 39(Suppl. 2):S711–716. Ochoa TJ, Salazar-Lindo E, Cleary TG. Management of children 4. with infection–associated persistent diarrhoea. Seminars in Pediatric Infectious Diseases, 2004, 15:229–236. Batebi A et al. A study of effective factors on persistent diar-5. rhoea in under five years old children. Iranian Journal of Public Health, 1997, 26:31–40. Honarpisheh A et al. A study on the relationship between mal-6. nutrition and persistent diarrhea. Journal of Kashan University of Medical Sciences, 1997, 1(1):29–33. Pourahmadi S, Vakili R. Predisposing factors in persistent diar-7. rhoea. Iranian Journal of Pediatrics, 1999, 42:20–24. Lins MD, Silva GA. Doenca diarreica em criancas hospitaliza-8. das - importancia da diarreia persistente [Diarrheal disease in hospitalized children—importance of the persistent diarrhoea]. Jornal de Pediatria, 2000, 76:37–43. Sodeinde O et al. Persistent diarrhoea in Nigerian children 9. aged less than five years: a hospital-based study. Journal of Diarrhoeal Diseases Research, 1997, 15:155–160. Mbori-Ngacha DA et al. Prevalence of persistent diarrhoea in 10. children aged 3–36 months at the Kenyatta National Hospital, Nairobi, Kenya. East African Medical Journal, 1995, 72:711–714. Lanata CF et al. Epidemiologic, clinical, and laboratory char-11. acteristics of acute vs. persistent diarrhoea in periurban Lima, Peru. Journal of Pediatric Gastroenterology and Nutrition, 1991, 12:82–98. Mahmud MA et al. Sociodemographic, environmental and 12. clinical risk factors for developing persistent diarrhoea among infants in a rural community of Egypt. Journal of health, popula- tion, and nutrition, 2001, 19:313–319. References Cruz JR et al. Epidemiology of persistent diarrhoea among 13. Guatemalan rural children. Acta Paediatrica, supplement, 1992, 381:22–26. Karim AS et al. Risk factors of persistent diarrhoea in children 14. below five years of age. Indian Journal of Gastroenterology, 2001, 20:59–61. Shahid NS et al. Risk factors for persistent diarrhoea. 15. British Medical Journal, 1988, 297:1036–1038. Araya M et al. Persistent diarrhoea in the community. Charac-16. teristics and risk factors. Acta Paediatrica, 1991, 80:181–189. Sodemann M et al. Episode-specific risk factors for progression 17. of acute diarrhoea to persistent diarrhoea in West African chil- dren. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1999, 93:65–68. Vernacchio L et al. Characteristics of persistent diarrhoea in a 18. community-based cohort of young US children. Journal of Pedi- atric Gastroenterology and Nutrition, 2006, 43:52–58. Henry FJ et al. Epidemiology of persistent diarrhoea and etio-19. logic agents in Mirzapur, Bangladesh. Acta Paediatrica, supple- ment, 1992, 381:27–31. Fang GD et al. Etiology and epidemiology of persistent diar-20. rhoea in northeastern Brazil: a hospital-based, prospective, case–control study. Journal of Pediatric Gastroenterology and Nutrition, 1995, 21:137–144. Bhatnagar S et al. Enteroaggregative 21. Escherichia coli may be a new pathogen causing acute and persistent diarrhoea. Scandi- navian Journal of Infectious Diseases, 1993, 25:579–583. Bardhan PK et al. Small bowel and fecal microbiology in chil-22. dren suffering from persistent diarrhoea in Bangladesh. Journal of Pediatric Gastroenterology and Nutrition, 1998, 26:9–15. Lima AA et al. Persistent diarrhoea signals a critical period of 23. increased diarrhoea burdens and nutritional shortfalls: a pro- spective cohort study among children in northeastern Brazil. Journal of Infectious Diseases, 2000, 181:1643–1651. Bhandari N et al. Association of antecedent malnutrition with 24. persistent diarrhoea: a case–control study. British Medical Jour- nal, 1989, 298:1284–1287. Black RE, Brown KH, Becker S. Malnutrition is a determining 25. factor in diarrhoea l duration, but not incidence, among young children in a longitudinal study in rural Bangladesh. American Journal of Clinical Nutrition, 1984, 39:87–94. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 837 Cancer incidence in Jordan, 1996–2005 M. Al-Tarawneh,1 S. Khatib 2 and K. Arqub1 ABSTRACT Cancer causes 14% of all deaths in Jordan. This paper presents the incidence of cancer in Jordan from 1996 to 2005. Over the 10-year period there were 33 661 cases of cancer. The average crude incidence rate was 66.2 per 100 000 for males and 70.0 per 100 000 for females (age-standardized rates: 119 per 100 000 adult males and 116 per 100 000 adult females). The 5 most frequently reported cancers among adult males were: lung (10.6%), colorectal (9.8%), leukaemia (9.3%), urinary and bladder (8.6%) and prostate (7.4%). For adult females these were: breast (32.0%), colorectal (9.0%), leukaemia (6.7%), thyroid (4.9%) and corpus uteri (4.6%). Cancer rates have changed little since 1996. 1National Cancer Registry, Amman, Jordan (Correspondence to M. Al-Tarawneh: amman992001@yahoo.com). 2King Hussein Institute for Biotechnology and Cancer, Amman, Jordan. Received: 19/11/08; accepted: 08/01/09 2005 - 1996 ندرلأا في ناطسرلا عوقو لدعم بوقرع وبأ لماك ،بيطلخا دحمأ يماس ،ةنوارطلا لوسر دممح للاخف .2005 لىإ 1996 نم ةدلما في ندرلأا في ناطسرلا عوقو لدعم ةقرولا هذه ضرعتستو .ندرلأا في تايفولا نم %14 ناطسرلا ببسي :ةـصلالخا نم فلأ ةئم لكل 70و روكذلا نم فلأ ةئم لكل 66.2 عوقولل مالخا يطسولا لدعلما ناكو .ناطسر ةلاح 33 661 كانه ناك شرعلا تاونسلا كلت نع غلبلما تاناطسرلا تناكو )ةغلاب ىثنأ فلأ ةئم لكل 116و ،غلاب ركذ فلأ ةئم لكل 119 :ةيرمع ةئف لكب ةصالخا عوقولا تلادعم تناكو( ،ثانلإا ،)%9.3( مدلا ضاضيباو ،)%9.8( ميقتسلماو نولوقلا ناطسرو ،)%10.6( ةئرلا ناطسر :يه ينغلابلا روكذلا ىدل لىولأا سملخا بتارلما لتتح انهأ نولوقلا ناطسرو ،)%32.0( يدثلا ناطسر :يهف تاغلابلا ثانلإل ةبسنلابو ،)%7.4( ةتاتسوبرلا ناطسرو ،)%8.6( ةناثلماو ليوبلا زاهلجا ناطسرو ًا ُّريغت تاناطسرلا تلادعم تيغت دقل .)%4.6( محرلا مسج ناطسرو ،)%4.9( ةيقردلا ناطسرو ،)%6.7( مدلا ضاضيباو ،)%9.0( ميقتسلماو .1996 ماع هيلع تناك ماع ًافيفط Incidence du cancer en Jordanie entre 1996 et 2005 RÉSUMÉ Le cancer est à l’origine de 14 % des décès en Jordanie. Cet article présente l’incidence du cancer en Jordanie entre 1996 et 2005. Au cours de la période de 10 ans sur laquelle a porté l’étude, 33 661 cas de cancer ont été détectés. Le taux d’incidence brut moyen était de 66,2 pour 100 000 chez les hommes et de 70,0 pour 100 000 chez les femmes (taux d’incidence standardisé en fonction de l’âge : 119 pour 100 000 chez les hommes et 116 pour 100 000 chez les femmes). Les cinq cancers les plus fréquents chez les hommes étaient le cancer du poumon (10,6 %), le cancer colorectal (9,8 %), la leucémie (9,3 %), le cancer urinaire et de la vessie (8,6 %) et le cancer de la prostate (7,4 %). Chez les femmes, les cinq cancers les plus fréquemment observés étaient le cancer du sein (32,0 %), le cancer colorectal (9,0 %), la leucémie (6,7 %), le cancer de la thyroïde (4,9 %) et le cancer du corps utérin (4,6 %). Les taux de cancer ont peu évolué depuis 1996. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 838 Introduction Cancer is a major public health problem.  In 2005, 7.6 million people died of can- cer out of 58 million deaths worldwide  [1]. More than 70% of all cancer deaths  occur in low- and middle-income coun- tries, where  the  resources available  for  prevention, diagnosis and treatment of  cancer are  limited or nonexistent. The  World Health Organization (WHO)  estimates  that  there will be 20 million  new cases and 12 million deaths  from  cancer alone by the year 2020 [2]. In  a  study  comparing  4 member  countries of  the Middle East Cancer  Consortium (Cyprus, Egypt, Israel and  Jordan) with the Surveillance, Epidemi- ology and End Results (SEER) survey  in the United States of America (USA),  the  overall  incidence  of  cancer  was  substantially higher  in  the USA and  in  Israeli  Jews  than  in other Middle East  populations  [3]. Egyptians and  Israeli  non-Jews (who are mostly Arabs) had  intermediate  rates, while  the  rates  in  Jordanians were  the  lowest. A high  in- cidence of breast cancer was  found  in  Israeli Jews compared with Arab popu- lations and these differences provide an  example of the potential role of lifestyle  and genetic  factors  in  the  etiology of  breast cancer [3].  The  implementation  of  different  strategies for the control and prevention  of  many  communicable  diseases  of  childhood,  along with  rapid  improve- ments in socioeconomic status and im- provements in health services in Jordan  have led to the emergence of noncom- municable  diseases  as  the  dominant  source of ill health. Cancer is the second  leading cause of death in the country.  As cancer  incidence  rates have not  been  described  in  a  comprehensive  manner  in  Jordan  we  present  here  epidemiological data on cancer  cases  reported to the national cancer registry  during the 10-year period 1996–2005.  Methods Background—Jordan cancer registry The Jordan cancer  registry (JCR) was  established  in  1996  as  a  population- based  registry  to  collect data  from all  relevant health  facilities: public, Royal  Medical Services, university and private  as well  as pathology  laboratories. The  registry includes all malignant and in situ malignancies diagnosed  since  January  1996 in people resident in Jordan. The  JCR  employs  a  combination  of active and passive methods of case- finding. Active collection involves regis- try personnel visiting different  facilities  on a  regular basis and abstracting data  onto  cancer  registry  forms.  Passive  reporting  involves  trained personnel  in  the different hospitals abstracting cancer  data from patients’ files, completing the  notification forms and forwarding them  to the registry. Figure 1 shows the cancer  statistics for Jordan going back to 1980.  The number of cases registered approxi- mately doubled  in 1996 when the JCR  was  transformed  from a hospital-based  to a population-based registry. All cancer cases are coded using the  3rd  revision  of  the  International clas- sification of diseases for oncology (ICD- O-3)  [4]. CanReg4  software  is used  for  data  entry  [5]. Duplicate  entries  are  avoided  by  checking  by  name,  age,  diagnosis  and place of  residence.  JCR  relies  for  the most part on histology or  cytology reports when defining incident  cases. Data obtained  from the pathol- ogy laboratories for all cancer cases are  compared with  those  received  from  the hospitals. Missing data are  sought  from  the  respective  institutions. The  validity of  the data  is  verified  through  internal quality checks, external checks  and computer checks. Data collection For the current study we extracted and  analysed the data on cancer cases regis- tered  from January 1996 to December  2005 using a  team of  trained medical  coders who checked  the data  against  the  information originally  registered.  Figure 1 Trend of number of cancer cases, all sites, in the Jordan cancer registry, 1980–2005 Year طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 839 To assess the accuracy of the data we re- captured cases from files and case notes  from hospitals  and  compared  it with  other data  sources. Also visual editing  and  automated  software  applications  were applied  to  improve  the accuracy  of  the data and  to eliminate duplicate  cases. Accuracy was generally high  for  demographic, diagnostic and treatment  details, but less so for grade of differen- tiation,  staging  variables  and dates of  treatment.  Although  the  JCR collects data on  all cancer cases occurring in Jordan, the  present analysis was restricted to people  of Jordanian nationality  in order to en- sure completeness of data and avoid the  difficulty of estimating the age-adjusted  rates for non-Jordanian populations.  Analysis Jordan had  a population  in 2000–01  of  5.2 million,  approximately  38% of  whom were under  the age of 15 years  and only 3.6% over the age of 65 years.  The average crude incidence rates were  calculated using the average population  for the index years 2000–01. The world  standard population  [6] was used  to  obtain age- standardized incidence rates  (ASRs). Epi-Info, version 6, was used for  statistical analysis. Results Between January 1996 and December  2005, 33 661 cases of cancer in Jordani- ans were reported to the JCR: 16 981 in  males and 16 680 in females, a male to  female ratio of 1:1.2.  Crude incidence rates The highest  crude  incidence  rate  for  males was 74.7 per 100 000 in 1996 and  for  females 75.2 per 100 000  in 1997.  The highest annual  rates were noticed  during the early years of establishing the  registry at a  time when data collection  was most active; subsequently the rates  stabilized (Figure 2). The average annual crude incidence  rate was 66.2 per 100 000 population  for males and 70.0 per 100 000 popu- lation  for  females. When analysed by  governorate  the highest average crude  incidence was  in Amman,  the  capital,  at  101.4 per 100 000 population,  fol- lowed by  Irbid (53.3) (Figure 3). The  lowest average crude  incidence was  in  Mafraq governorate (20.1 per 100 000  population).  In Jordan lung cancer was the lead- ing cancer among males (10.6%),  fol- lowed by colorectal (9.8%),  leukaemia  (9.3%),  urinary  and  bladder  (8.6%)  and prostate cancer (7.4%) (Table 1).  Among  females, breast cancer was  the  most  common malignancy  (32.0%),  followed by colorectal (9.0%),  leukae- mia (6.7%), thyroid (4.9%) and corpus  uteri cancer (4.6%) (Table 2).  Figure 2 Crude incidence of cancer (per 100 000 population), all sites, 1996–2005 s s Year In ci de nc e .0 . . . . . . . . . . . . . . . . . . . EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 840 Age-specific incidence rates Figure 4  shows  the ASRs  for  all  can- cers  in males and  females. The overall  average ASRs  for all  cancers were 119  per 100 000 adult males  and 116 per  100 000 adult  females (Table 3). The  median age at diagnosis was 56 years  for males and 53 years  for  females. By  site  of  cancer  the ASRs  per  100 000  population  for  lung cancer were 16.3  and 3.6 per 100 000  in males  and  fe- males  respectively  and  for  colorectal  cancer were 20.1 and 14.6 per 100 000  respectively. The ASR for breast cancer  was 39.9 per 100 000 females.  The incidence of lung cancer in Jor- dan  rose  sharply with  age, with  a first  peak of increase of ASR in the age group  40–49 years for both males and females,  which continued to rise steadily among  males to a peak in the age group 70–74  years (Figure 5).  Colorectal cancer was rare under 40  years of age, after which the rates began  to rise steadily. By the age of 40–59 years,  the rates were 18.7 and 24.3 per 100 000  for  males  and  females  respectively (Figure 6). Discussion Cancer  is usually considered a disease  of  industrialized  countries. However,  increases  in  life expectancy  in most de- veloping  countries,  even  in  the  least  developed  [1],  together  with  recent  changes  in  lifestyle, have  led  to an epi- demic of cancer in developing countries.  With current  trends  it  is estimated that  by the year 2020 70% of the new cases of  cancer will be diagnosed in people living  in developing countries [12].  Since  the  1970s  Jordan  has  wit- nessed  a  transition of morbidity  and  mortality  from communicable diseases  of  childhood  to  noncommunicable  diseases  in adults. This  is partly due  to  improvements of  the  socioeconomic  status  in  the country,  the expansion of  health services and the strengthening of  the primary health care system. With the  successful control of most communica- ble diseases of  childhood,  the  leading  causes of mortality and morbidity have  become cardiovascular diseases, cancer  and injuries.  The  ASR  per  100 000  males  in  Jordan  is  similar  to  the  rates  reported  in  some other Arab countries  such as  Kuwait  [7], Bahrain  [7]  and Tunisia  [10]. The ASR per 100 000  females  in  Table 1 Frequency of the 10 most common cancers among Jordanian males, 1996–2005 Rank Cancer site No. (n = 16 981) % 1 Lung 1836 10.6 2 Colorectal 1685 9.8 3 Leukaemia 1602 9.3 4 Urinary & bladder 1481 8.6 5 Prostate 1274 7.4 6 Non melanoma skin 1106 6.4 7 Brain & central nervous system 848 5.2 8 Non-Hodgkin lymphoma 824 4.7 9 Stomach 814 4.7 10 Hodgkin disease 582 3.3 Figure 3 Average crude incidence of cancer (per 100 000 population), all sites, by governorate, Jordan, 1996–2005 .0 .0 In ci de nc e . . . . . . . . . . Governorate طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 841 Jordan is similar to rates among females  in Kuwait  [7].  comparison with other  countries  of  the REgion  is  shown  in  Table  3. The ASRs  for  all  cancers  in  Jordan, in males and females, were sub- stantially  lower  than  those  in  the USA  (162.7 and 110.4 respectively) and the  United Kingdom (173.7 and 121.3  re- spectively) [13].  These differences between  Jordan  and other countries, particularly  indus- trialized countries, can be attributed  to  many  factors,  especially differences  in  lifestyle, which have become more ap- parent only in the past 2 decades. These  include  smoking and physical  inactiv- ity;  in  the 2005 behavioural  risk  factor  survey 51% of Jordanian males and 7%  of females reported being smokers [14].  Fat  intake  is  relatively  low compared  with industrialized societies and the tra- ditional diet of Jordanians consists of a  moderate intake of fruits and vegetables  rather  than meat  [14]. The recent de- mographic changes in Jordan—charac- terized by  low  infant mortality (22 per  1000 live births), a high total fertility rate  (3.7) and  life  expectancy comparable  to  that  in  the developed world  (71.5  years for both sexes)—indicate that the  elderly population will  increase  in  the  future [15].  Breast cancer  is  the most common  cancer  in women, with 900 000 new  cases  occurring  annually  worldwide  [2,12] and  is becoming ever more sig- nificant  in many developing countries  [16,17]. It has been found to be a major- cause of death  from cancer,  second  to  lung cancer, in Jordan. Our data indicate  that  it  is  the dominant  cancer  among  Jordanian women, with approximately  500–550 new cases occurring annually.  The ASR was 39.9 per 100 000 females,  higher than that of Saudi Arabia, Oman,  Algeria,  Bahrain  and  Tunisia  (13.9,  14.9, 16.7, 28.6 and 34.6  respectively),  but  lower than that  in Lebanon, Egypt,  Kuwait and the USA SEER population  (76.1, 49.6, 46 and 97.3  respectively)  [3,18]. Breast cancer arises from a mul- tifactorial process and can be viewed as  a disease predominantly  influenced by  risk  factors  related  to  lifestyle,  as only  about  15% of  all  breast  cancer  cases  can  be  attributed  to  familial  and  ge- netic influences [19]. Differences in the  prevalence of exposure to these lifestyle  and genetic risk factors among women  from different countries  in  the Middle  East  are probably  responsible  for  the  Table 2 Frequency of the 10 most common cancers among Jordanian females, 1996–2005 Rank Cancer site No. (n = 16 680) % 1 Breast 5373 32.0 2 Colorectal 1517 9.0 3 Leukaemia 1132 6.7 4 Thyroid 829 4.9 5 Corpus uteri 758 4.6 6 Non melanoma skin 751 4.5 7 Brain & central nervous system 606 3.6 8 Ovary 605 3.3 9 Non-Hodgkin lymphoma 545 3.3 10 Stomach 461 2.7 Figure 4 Average age-specific-incidence rate of cancer (per 100 000 population), all sites, Jordan, 1996–2005 ss Age (years) In ci de nc e EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 842 variability  in breast  cancer  incidence  seen  between  countries  in  this  area  [20,21]. Time trends  in the prevalence  of the lifestyle risk factors can be directly  correlated with  time  trends  in breast  cancer incidence.  Most known risk  factors  for breast  cancer can be  linked  to  the hazardous  effects of hormone exposure, although  other  risk  factors  such as  exposure  to  ionizing  radiation are  also  relevant  in  some populations  [22,23].  Increasing  parity  and early  age  at  first parity  are  protective against breast cancer devel- opment  [24]. Women’s breast  cancer  risk reduces by 4% for every 12 months  of  breastfeeding  [25]. There  is  clear  evidence in the general population that  obesity is associated with a significantly  higher risk of breast cancer [26]. History  of benign breast disease  is also  related  to  increased  risk of breast cancer. The  risk,  however,  is mostly  restricted  to  women who have undergone biopsies  and especially  those  in whom atypical  hyperplasia was found in such biopsies  [27]. Most studies have focused on the  influence on breast cancer incidence of  modern  lifestyles  such as  a high cho- lesterol  intake,  alcohol  consumption  and smoking. Dietary  fat has been  the  most  investigated  food  constituent  studied in this regard and it is currently  believed that a high-fat diet is related to  the risk of breast cancer among women  with no history of benign breast disease  [28]. Active and passive smoking have  recently been  shown  to be  related  to  breast cancer risk [29,30].  Worldwide,  colorectal  cancer  rep- resents 9.4% of  all  incident cancers  in  men and 10.1%  in women.  In  Jordan  colorectal cancer was  the second most  common  cancer  among  both males  and  females, while globally  the ASR of  colorectal cancer  in 2002 was 20.1 per  100 000 males  and 14.6 per 100 000  females. There are notable differences  in  colorectal  cancer  incidences  in  more developed versus  less developed  countries.  In  the  developed  parts  of  the world, the ASR per 100 000 is 40.0  in males  and  26.6  in  females;  in  less  developed areas  the  rates are 10.2 and  7.7 respectively. In Jordan, the ASR was  11.5  and 11.2  for males  and  females  Table 3 Age-specific incidence rates (ASR) for all cancers in Jordan compared with other countries of the Eastern Mediterranean Region Country Source All cancers ASR per 100 000 population Males Females Jordan Current study 119 116 Bahrain [7] 118 108 Egypt [8] 152 136 Kuwait [7] 121 120 Lebanon [9] 169 176 Morocco [10] 96 87 Oman [7] 110 93 Qatar [7] 180 152 Saudi Arabia [7] 68 66 Sudan [10] 102 95 Syrian Arab Republic [11] 180 167 Tunisia [] 114 78 United Arab Emirates [7] 78 70 Figure 5 Average age-specific-incidence rate (per 100 000 population), lung cancer, Jordan, 1996–2005 s s In ci de nc e Age (years) طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 843 respectively. The highest ASR  in males  was observed  in Australia/New Zea- land (48.2), followed by North America  (44.4) and Western Europe (42.9). At  the other end of  the  scale,  the  rates  in  South-Central Asia (4.7) and Central  Africa (2.3) were the lowest [10].  In Jordan colorectal cancer was rare  under  40  years  of  age,  and  the  rates  began  to  rise  steadily after  this age. By  the age of 40–59 years,  the  Jordanian  population had  rates  per  100 000 of  18.7  and 24.3  for males  and  females  respectively. These rates were relatively  close  to  those  among Egyptians  but  lower  than  the  rate  of  the US SEER  population  (43.3  and 32.8  for males  and  females  respectively)  [3].  In  Jor- danians,  the  rates  rose by  about 20%  for  each  5-year  period  between  the  ages of 50 and 75 years. Evidence from  epidemiological studies seems to show  consistently  that  intake of dietary  fat  and meat is linked to colorectal cancer.  Consumption of animal  fat was  found  to be associated with  increased  risk of  colon cancer [31]. Throughout  the world,  lung cancer  is  the most commonly diagnosed can- cer  and causes more deaths  than any  other cancer [10].  In  Jordan, 14.7% of  cancer deaths  are due  to  lung  cancer  [3]. International variations in the inci- dence are striking, with ASRs < 10 per  100 000  in parts of Africa, China,  and  South America and > 100 per 100 000  in  the USA  [18].  In  Jordan  the ASR  of  lung  cancer per 100 000 was 16.3  per 100 000  in males, which  is  similar  to  that among Egyptians and Kuwaitis  (14.0 and 11.3 respectively), but  lower  than  that  among Tunisians, Bahrainis  and Qataris  (27.8,  33.5  and  36.3  re- spectively) [18]. As expected, lung can- cer ASRs  increased with age  from the  youngest age group (< 50 years of age)  to the oldest (age 70+ years). The overall ASR of  lung cancer  in  the Jordan population was much lower  than in the USA SEER population [3],  between one-third and one-quarter of  the US SEER rates.  In  Jordan the  lung  cancer ASR  in  females was  lower  than  in males (3.6 versus 16.3 per 100 000  population). Rates of cancer of the lung/ bronchus are similar among Israeli Jews  and non-Jews and about twice as high as  in Jordanians [32]. Worldwide statistics  show  that  the  lung  cancer ASRs  per  100 000  for males  in other Arab coun- tries, such as Algeria (17.1) and Kuwait  (11.3), were  relatively  close  to  those  in Jordan (16.3), while  the rate among  Jordanian males was lower than that in  Tunisia, Bahrain and Qatar (27.8, 33.5  and 36.3  respectively)  [18]. However,  the  rate  per  100 000 was  lower  than  in Western countries  such as Canada  (59.0),  Ireland  (42.3)  and  the USA  (61.9). All  the  female populations of  the EMR including Jordan, display rates  far  lower  than  the USA SEER  female  population [3]. The ASRs per 100 000  females in Algerians (1.9) and Omanis  (2.6) [33] were  somewhat  lower  than  in Jordanians (3.5) and Egyptians (3.6),  although Kuwaitis  (4.1) had a  slightly  higher rate.  By far the most important risk factor  in  the development of  lung  cancer  is  tobacco use.  Smoking more  than 20  cigarettes per day has been  shown  to  confer  a 15-  to 25-fold higher  risk of  lung  cancer  relative  to  nonsmokers  [34]. Both  the duration and  intensity  of cigarette smoking  increases  the  risk,  as does the tar content and the lack of a  filter [35]. The risk decreases with time  after  cessation of  smoking, with  long- term exsmokers  approaching but not  reaching  the  risk of nonsmokers  [36].  Other  types of  tobacco smoking,  such  Figure 6 Average age-specific-incidence rate (per 100 000 population), colorectal cancer, Jordan, 1996–2005 Age (years) In ci de nc e s s Total EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 844 World health report 2005. Make every mother and child count.1. Geneva, World Health Organization, 2005. Parkin DM et al. Global cancer statistics, 2002. 2. CA: a Cancer Journal for Clinicians, 2005, 55:74–108. Freedman L et al. 3. Cancer incidence in four member countries (Cyprus, Egypt, Israel, and Jordan) of the Middle East Cancer Con- sortium (MECC) compared with US SEER. (MECC Monograph). Bethesda, Maryland, National Cancer Institute, 2006 (NIH Publication No.06-5873). Fritz A et al. 4. International classification of diseases for oncology, 3rd ed. Geneva, World Health Organization, 2000. CanReg4 manual5. . Lyon, International Agency for Research on Cancer, 2001. Plummer M, Parkin D, et al. 6. Cancer incidence on five continents. Lyon, International Agency for Research on Cancer, 1997:66– 68 (IARC Scientific Publications, No. 143). Cancer incidence report of Gulf Cooperation Council States.7. Riyadh, Gulf Center for Cancer Registration, 2003. Cancer incidence in Egypt, Gharbiah8. . Triennial report of 2000– 2002. Gharbiah population-based registry. Cairo, Ministry of Health and Population, 2007. Salim M, Adib, Daniel J. 9. Cancer in Lebanon. Beirut, Ministry of Health, National Cancer Registry, 2003. Ferlay J et al. 10. GLOBOCAN 2002: cancer incidence. Mortality and prevalence worldwide. IARC cancer base no. 5, version 2.0. Lyon, International Agency for Research on Cancer Press, 2004. Cancer incidence report. National Cancer Registry11. . Damascus, Ministry of Health of the Syrian Arab Republic, 2006. Stewart BW, Kleihues P. 12. World cancer report. Geneva, World Health Organization/Lyon, International Agency for Research on Cancer, 2003. Landis S, Murray T, Bolden S. Cancer statistics. 13. CA: a cancer journal for clinicians, 1998, 48:6–29. Behavioral risk factors survey.14. Amman, Ministry of Health of Jordan, 2005. Annual statistical book15. . Amman, Ministry of Health of Jordan, 2005. Parker SL et al. Cancer statistics, 1996. 16. CA: a Cancer Journal for Clinicians, 1996, 46:5–27. References Veronesi U, Goldhirsch A, Yamold J. Breast cancer. In: Peck-17. ham M, Pinedo HM, Veronesi U, eds. Oxford textbook of oncol- ogy. Oxford, Oxford Medical Publications, 1995:1243–1289. Parkin DM, Whelan SL, et al. 18. Cancer incidence in five continents, volume VIII. IARC Scientific Publication, No. 155. Lyon, Interna- tional Agency for Research on Cancer, 2002. Martin AM, Weber BL. Genetic and hormonal risk factors in 19. breast cancer. Journal of the National Cancer Institute, 2000, 92:1126–1135. Chlebowski RT et al. Ethnicity and breast cancer: factors influ-20. encing differences in incidence and outcome. Journal of the National Cancer Institute, 2005, 97:439–448. Bernstein L et al. Ethnicity-related variation in breast cancer risk 21. factors. Cancer, 2003, 97:222–229. Ronckers CM, Erdmann CA, Land CE. Radiation and breast 22. cancer: a review of current evidence. Breast Cancer Research, 2005, 7:21–32. Carmichael A, Sami AS, Dixon JM. Breast cancer risk among the 23. survivors of atomic bomb and patients exposed to therapeutic ionizing radiation. European Journal of Surgical Oncology, 2003, 29:475–479. Antoniou AC et al. parity and breast cancer risk among BRCA1 24. and BRCA2 mutation cancers. Breast Cancer Research, 2006, 8(6):R72. Breast cancer and breast feeding: collaborative reanalysis of in-25. dividual data from 47 epidemiological studies in 30 countries. Lancet, 2002, 360:187–195. Friedenreich CM. Review of anthropometric factors and 26. breast cancer risk. European Journal of Cancer Prevention, 2001:10(1):15–32. Vogel VG. Atypia in the assessment of breast cancer risk: im-27. plications for management. Diagnostic Cytopathology, 2004, 30:151–157. Velie E et al A. Dietary fat, fat subtypes, and breast cancer in 28. postmenopausal women: a prospective cohort study. Journal of the National Cancer Institute, 2000, 92:833–839. Collaborative Group on Hormonal Factors in Breast Cancer. 29. Alcohol, tobacco and breast cancer—collaborative reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without the disease. British Journal of Cancer, 2002, 87:1234–1245. as pipe,  cigar  and waterpipe  smoking,  are also linked to lung cancer, although  the  relative  risks are not as high as  for  cigarette smoking. Exposure  to passive  smoking  or  environmental  tobacco  smoke  is  also  related  to  an  increased  risk of lung cancer, although the relative  risk is much lower than in active smok- ers. Worldwide,  the  incidence of  lung  cancer  among males  is much higher  than among  females, due primarily  to  the lower prevalence of smoking among  females.  Several other  risk  factors  for  lung cancer have been identified. Occu- pational exposures that increase the risk  of  lung cancer  include asbestos, which  also  causes  an  increase  in  the  risk of  mesothelioma. Asbestos exposure and  cigarette  smoking  act  synergistically,  together  raising  the risk of  lung cancer  multiplicatively [37]. Conclusion This is the first comprehensive report on  cancer incidence in Jordan since the JCR  was established  in 1996 and expanded  its work to cover the entire country. The  study was based on data  from 33 661  cases diagnosed during a 10-year period.  At present,  the actual burden of cancer  in  Jordan remains acceptable, with  less  than 5000 cases per year. However, as  the  country  undergoes  demographic  and socioeconomic changes, the burden  of cancer may increase in future decades.  The pattern of cancer among males and  females  in Jordan is consistent with the  Regional picture, with breast cancer be- ing  the most  common cancer  among  females and  lung cancer  the dominant  cancer  among males  throughout  the  study period.  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 845 Reynolds P et al. Active smoking, household passive smok-30. ing, and breast cancer: evidence from the California Teachers Study. Journal of the National Cancer Institute, 2004, 96:29–37. Boyle P, Langman JS. ABC of colorectal cancer: Epidemiology. 31. Student BMJ, 2000, 8:435–476. Freedman L et al. A comparison of population-based cancer 32. incidence rates in Israel and Jordan. European Journal of Cancer Prevention, 2003, 12:359–365. Blot WJ, Fraumeni JF, eds. 33. Cancer of the lung and pleura. Cancer epidemiology and prevention, 2nd ed. New York, Oxford Uni- versity Press, 1996:637–665. Hammond EC. Smoking in relation to the death rates of one 34. million men and women. National Cancer Institute Monograph, 1966, 19:127–204. Lubin JH et al. Patterns of lung cancer risk according to type 35. of cigarette smoked. International Journal of Cancer, 1984, 33:569–576. Tobacco smoking: monographs on the evaluation of carcinogenic 36. risk of chemicals to man, volume 38. Lyon, International Agency for Research on Cancer, 1986. Berry G, Newhouse ML, Antonis P. Combined effect of asbes-37. tos and smoking on mortality from lung cancer and mesothe- lioma in factory workers. British Journal of Industrial Medicine, 1985, 42:12–18. Towards a strategy for cancer control in the Eastern Mediterranean Region Although the incidence of cancer is still well below that in developed countries, the Eastern Mediterranean Region is  expected to experience the highest increase among all WHO regions in the coming two decades. The increasing trend can  be attributed to many factors including population ageing and exposure to risk factors such as smoking, unhealthy diet,  etc. It is estimated that 40% of cancers can be prevented by risk factor modification; prevention therefore offers the greatest  public health potential and the most cost-effective long‐term approach for cancer control. Towards a strategy for cancer control in the Eastern Mediterranean Region was developed in response to the increasing burden of  cancer and the need for coordinated action in this regard. This publication reflects a shared commitment to reducing the  incidence of cancer and improving the quality of life of those who develop cancer. . Full text is available at: http://www.emro.who.int/dsaf/dsa1002.pdf EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 846 Epidemiological, clinical and laboratory profile of glucose-6-phosphate dehydrogenase deficiency in the middle and north of Iraq: a comparative study M.D. Al-Mendalawi 1 ABSTRACT This study determined the epidemiological, clinical and laboratory profile of glucose-6-phosphate dehydrogenase (G6PD) deficiency in Baghdad (central Iraq) and compared it with previous data from Mosul (northern Iraq). We reviewed the records of 156 under-5-year-olds with G6PD deficiency admitted to 3 hospitals in Baghdad over a 6-year period. A preponderance of males was noted in both Baghdad and Mosul (1.6:1 and 3.4:1 respectively). Family history of G6PD deficiency was positive in 19.2% of patients in Baghdad and 13.6% in Mosul. A majority of patients in Baghdad (69.2%) and Mosul (76.1%) showed haemolysis within 1–3 days of exposure to noxious agents. Similarities in the profiles from Baghdad and Mosul suggest that there are similar G6PD variants and similar exposure to precipitating agents. 1Department of Paediatrics, Al-Kindy College of Medicine, University of Baghdad, Baghdad, Iraq (Correspondence to M.D. Al-Mendalawi: mdalmendalawi@yahoo.com). Received: 21/01/09; accepted: 19/02/09 :قارعلا لماشو طسو في زوكولغ 6-تافسوفلا ينجورديه ةعزان ميزنإ زوعل ةيبرتخلماو ةيريسرلاو ةيئابولا حملالما مسترم ةنراقم ةسارد يولادنلما رهاظ دوممح ،)قارعلا طسو( دادغب في زوكولغ 6-تافسوفلا ينجورديه ةعزان ميزنإ زوعل ةيبرتخلماو ةيريسرلاو ةيئابولا حملالما ةساردلا هذه مسرـت :ةـصلالخا ةعزان ميزنإ زوعب باصم رمعلا نم تاونس 5 نود ًلافط 156 تلاجس ثحابلا عجار دقو .)قارعلا لماش( لصولما نم ةقباس تايطعمب هنراقتو في ثانلإا دادعأ لىع روكذلا دادعأ ةبلغ ظحول دقو .تاونس 6 ةدم للاخ دادغب في تايفشتسم 3 في اولخدأ نمم زوكولغ 6- تافسوفلا ينجورديه %19.2 ىدل ةيبايجإ زوكولغ 6- تافسوفلا ينجورديه ةعزان ميزنإ زوعب ةباصلإل ةيلئاعلا قباوسلا تناك ماك .)1:3.4( لصولماو )1:1.6( دادغب نم لك دعب )%76.1( لصولما فيو )%69.2( دادغب في ضىرلما مظعم ىدل مدلا للاحنا ثدح دقو .لصولما في ضىرلما نم %13.6 ىدلو ،دادغب في ضىرلما نم ينجورديه ةعزان ميزنإ زوعل ةبهاشتم بوضر دوجو لىإ يرشي لصولماو ،دادغب في حملالما مسترم ينب هباشتلا نإ .ةرئاضلا ةدمالل مهضرعت نم مايأ 3-1 .ةببسلما لماوعلل لثماتم ضرعتو زوكولغ 6- تافسوفلا Étude comparative du profil épidémiologique, clinique et biologique du déficit en glucose-6-phosphate déshydrogénase au nord et au centre de l’Iraq RÉSUMÉ La présente étude a permis de déterminer le profil épidémiologique, clinique et biologique de la carence en glucose-6-phosphate déshydrogénase (G6PD) à Bagdad (centre de l’Iraq) et de le comparer avec des données antérieures recueillies à Mossoul (nord de l’Iraq). Nous avons examiné les dossiers de 156 enfants âgés de moins de 5 ans qui présentaient une carence en G6PD, hospitalisés dans trois hopitaux de Bagdad sur une période de six ans. Une prépondérance masculine a été constatée aussi bien à Bagdad qu’à Mossoul (1,6 garçon pour 1 fille et 3,4 garcons pour 1 fille respectivement). Des antécédents familiaux de cette maladie ont été observés chez 19,2 % des patients à Bagdad et 13,6 % de ceux de Mossoul. Dans les deux villes, la majorité des patients présentaient une hémolyse un à trois jours après une exposition à des agents nocifs (69,2 % à Bagdad et à 76,1 % à Mossoul). Des analogies entre les profils de Bagdad et ceux de Mossoul laissent penser qu’il existe des variants similaires de la G6PD et une exposition semblable à des facteurs déclenchants. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 847 Introduction A  functional  deficiency of  glucose-6- phosphate dehydrogenase (G6PD)— which  oxidizes  glucose-6-phosphate  to  6-phosphogluconolactone  in  the  pentose–monophosphate  shunt with  formation  of  reduced  nicotinamide  adenine  dinucleotide  phosphate  (NADPH)—leads to oxidant-induced  red-blood cell destruction [1].  It  is  the  most  common  enzymopathy  in  the  world  and  it  has been estimated  that  more than 200 million people through- out the world are G6PD deficient. This  genetic defect  shows sex-linked  inher- itance  and  a  marked  heterogeneity.  More than 300 abnormal variants with  deficient  biochemical  characteristics  and about 100 diverse mutations have  been  identified  [2,3]. The most  com- mon clinical  consequences of G6PD  deficiency  are neonatal  jaundice  and  sporadic haemolytic  crises  caused by  infections, certain drugs or, in the Medi- terranean variant, by  ingestion of  fava beans or inhalation of their pollen [1,4]. The  study of G6PD deficiency  in  Iraq dates back  to 1963 [5] when  the  first published study triggered a cascade  of research on the problem in the coun- try. The present  study aimed  to deter- mine  the epidemiological,  clinical  and  laboratory profile of G6PD deficiency in  Baghdad in the centre of Iraq and com- pare  it with previously published data  from Mosul in the north of the country.  Unfortunately,  similar published data  from Basra, south of Baghdad, was una- vailable for comparison.  Methods The study was conducted on 156 under  5-year-olds with documented G6PD  deficiency by G6PD enzyme essay. Data  were collected over  the period 1  Janu- ary 2000  to 31 December 2006  from  the records of patients admitted with a  haemolytic episode to one of the 3 hos- pitals  in Baghdad city (Al-Khadimyiah  paediatric hospital, Al-Karama teaching  hospital department of paediatrics and  Al-Noor  teaching hospital department  of paediatrics).  Through a review of medical records,  data concerning age, sex, clinical presen- tation, onset of haemolysis, past history  of neonatal  jaundice,  family history of  G6PD  deficiency,  laboratory  results  and final outcome were obtained. The  above data were compared with  those  reported previously in Mosul city [6].  Results Out of  156 patients  recruited  to  the  study, 97 (62.2%) were males  and 59  (37.8%) were females, a male to female  ratio  of  1.6:1. The mean  age was  2.8  (standard deviation 1.2)  years. More  than half  the patients (58.3%) were  in  the age group 1–4 years.  The  characteristics  of  the  study  patients are shown in Table 1. Past his- tory of neonatal  jaundice was recorded  in 11.5% and a positive family history of  G6PD deficiency  in 19.2%. Recurrent  episodes of haemolysis were reported by  10.9% of patients. A majority of patients  (69.2%) had experienced haemolytic  episodes within 1–3 days of exposure  to  precipitating  agents  (usually  fava beans and to a  lesser extent drugs such  as  trimethoprime-sulfamethoxazole or  nalidixic acid. Clinically, symptoms and  signs of dark colour urine and pallor were  universal presenting symptoms (100%),  whereas jaundice was reported in 82.7%  and hepatosplenomegaly  in 56.4% of  patients. Half  the patients (52.6%) had  moderate anaemia (5–7 g/dL).  Reticulocyte  count  and  total  white  blood  cell  counts  ranged  from  4.5%  to 19.6% and 4.9  to 25 × 109/L  respectively. The  range of  total  serum  bilirubin  (mainly  indirect  type) was  2.6–13.8 mg/dL. Blood urea and serum  creatinine ranged from 35 to 47 mg/dL  and 0.7 to 1.1 mg/dL respectively.  All  patients  received blood  trans- fusions  in  various  amounts  and were  discharged within 2–4 days of hospitali- zation. No deaths were recorded. Discussion Iraq  is  situated  within  a  region  of  a  high  frequency  of  G6PD  deficiency  genotype, with a carrier frequency in the  population of 6.3%  [7].  Studying  the  pattern  of  G6PD  deficiency  in  the  population  is essential  for a number of  reasons:  the  increasing costs of health  care associated with frequent hospitali- zations [8]; the substantial morbidity in  terms of psychosocial burden and dis- turbed  family environment  for parents  coping with children with chronic  ill- ness  [9];  and  for planning preventive  strategies [10]. A preponderance of males was not- ed in both the present study in Baghdad  and the previous study in Mosul (1.6:1  and 3.4:1 respectively). The preponder- ance of females noted in some studies in  other countries in the Eastern Mediter- ranean Region may be due to high rates  of  consanguinity,  leading  to  increased  numbers  of  homozygous  females  in  addition to a high frequency of inactiva- tion of  the normal X chromosome  in  female heterozygotes, which  leads  to  disturbances  in  the Hardy–Weinberg  equilibrium. Moreover,  the presence  of an  “enhanced” gene  that makes  the  expression of G6PD deficiency more  likely has been suggested [11,12].  A past history of neonatal  jaundice  was found in similar proportions of chil- dren  in  this  study  in Baghdad (11.5%)  and  the  previous  study  in  Mosul  (14.8%) [6]. Severe neonatal  jaundice,  particularly when  it  requires exchange  transfusion,  should alert paediatricians  to  the possibility of G6PD deficiency.  Currently, most hospitals routinely test  for G6PD when  screening  neonates  before they are discharged from hospi- tal [13].  A positive  family history of G6PD  deficiency was reported at a higher rate  in the Baghdad (19.2%) than in Mosul  EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 848 (13.6%). This may be due to the obser- vation  that many patients  are  asymp- tomatic  and unaware  they  are G6PD  deficient unless they are investigated or  exposed to an oxidizing agent. A majority of patients  in Baghdad  (69.2%) and Mosul  (76.1%)  showed  haemolysis within 1–3 days of exposure  to precipitating agents. This is similar to  what has been reported elsewhere [14– 16].  Recurrent  haemolytic  episodes  were  recorded  in a  slightly  lower per- centage of children in Baghdad (10.9%)  and Mosul  (9.1%). Prevention of  fur- ther attacks needs awareness of patients  and  their  families  to  the need  to avoid  exposure to oxidative stress.  Dark colour urine, pallor,  jaundice  and hepatosplenomegaly were the lead- ing clinical presentations in both areas of  Iraq. This observation is consistent with  previous  studies  [14–16]. When  liver  function  is normal,  jaundice  typically  does not occur until more than 50% of  erythrocytes  have  been  haemolysed  [17]. The size of the spleen and liver in  both studies varied from just palpable to  3–4 cm below the costal margin. Fever was documented in 37.8% of  the patients in the Baghdad study com- pared with 44.3%  in  the Mosul  study.  Many  individuals  develop  fever  after  the onset of  infections such as urinary  Table 1 Epidemiological, clinical and laboratory variables of the studied children with glucose-6-phosphate dehydrogenase (G6PD) deficiency in Baghdad and Mosul Variable Baghdad studya (n = 156) Mosul studyb (n = 88) No. % No. % Sex Male 97 62.2 68 77.3 Female 59 37.8 20 22.7 Male:female (ratio ) 1.6:1 3.4:1 Clinical history Positive past history of neonatal jaundice 18 11.5 13 14.8 Positive family history of G6PD deficiency 30 19.2 12 13.6 Recurrent attacks of haemolysis 17 10.9 8 9.1 Onset of haemolysis Few hours 10 6.4 4 4.5 1–3 days 108 69.2 67 76.1 4–7 days 38 24.4 17 19.3 Clinical presentation Dark colour urine 156 100.0 88 100.0 Pallor 156 100.0 88 100.0 Jaundice 129 82.7 69 78.4 Hepatosplenomegaly 88 56.4 55 62.5 Fever 59 37.8 39 44.3 Abdominal pain 33 21.1 14 15.9 Haematological tests Haemoglobin (g/dL) < 5 42 26.9 29 32.9 5–7 82 52.6 39 44.3 7–9 32 20.5 20 22.7 Reticulocyte count (%) 4.5–19.6 3.0–25.0 White blood cell count (/L) 4.9–25.0 × 109 3.9–40.0 × 109 Biochemical tests Total serum bilirubin (mainly indirect) (mg/ dL) 2.6–13.8 1.2–28.2 Blood urea (mg/dL) 35–47 Normal Serum creatinine (mg/dL) 0.7–1.1 Normal Outcome Recovery (days) 2–4 2–3 Mortality rate (%) 0 0 Sources: aPresent study; b[6]. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 849 tract  infection,  enteric  fever and chest  infections.  The  mechanism  linking  infection  and haemolysis  is  complex  and poorly understood. However it has  been  suggested  that during phagocy- tosis  leukocytes damage erythrocytes  in  their vicinity by discharging reactive  oxygen species. Moreover, certain infec- tious organisms,  such  as Plasmodium,  Clostridium, Babesia and Bartonella spp.,  are directly toxic to red blood cells [18].  Recently, it was noted that a mild degree  of G6PD deficiency (comparable to the  human  class  III G6PD deficiencies)  worsens erythrocyte dysfunction during  sepsis. Increased erythrocyte rigidity and  a tendency for haemolysis, together with  alterations  in  the  interaction between  erythrocyte band 3 protein and spectrin,  may contribute to the immunomodula- tory effect of G6PD deficiency observed  after major trauma and infection in hu- mans  [19]  .Unfortunately,  screening  for  infectious diseases was not done  in  either of the Iraqi studies.  Variable grades of anaemia,  reticu- locytosis and  leukocytosis were noted  in both studies. A higher  rate of mod- erate  anaemia  (5–7g/dL) was  found  in  Baghdad  (52.6%)  than  in Mosul  (44.3%). The oxidized and denaturated  haemoglobin forms cross-links and pre- cipitates intracellularly, forming red-cell  inclusion bodies  that  are  identified as  Heinz bodies on supravital  staining of  peripheral blood  smears. These  inclu- sion bodies are  removed  in  the spleen,  leaving erythrocytes with a missing sec- tion of cytoplasm. These “bite cells” can  be seen in the routine blood smear [1]. Although hyperbilirubinaemia, par- ticularly of  the unconjugated  type,  is  the main criterion  for  the diagnosis of  haemolytic anaemia,  it  is mild and self- limiting when  liver  function  is normal  [1]. In the Baghdad and Mosul studies,  variable grades of hyperbilirubinaemia  particularly  the  indirect  type were seen  (2.6–13.8 mg/dL and 1.2–28.2 mg/ dL  respectively). The higher  range of  serum bilirubin in the Mosul study may  be attributed  to  the preponderance of  cases of severe neonatal jaundice neces- sitating ultimately phototherapy and/or  exchange transfusion. Renal  function  was  preserved  in  patients  in  the  Baghdad  and Mosul  studies, as manifested by nearly normal  blood urea and serum creatinine levels.  Azotaemia can complicate severe intra- vascular haemolysis and oliguria. There- fore, therapy must focus on maintaining  a high urine output.  All patients  in both studies showed  uneventful recovery within 2–4 days of  hospitalization after  receiving various  degrees of blood transfusion. No deaths  were  reported  in either  study. Deaths  reported during acute haemolytic epi- sodes are attributed  to severe anaemia  causing congestive heart failure, oliguric  renal  shutdown, malaria  and hepatic  encephalopathy [20–23]. The  epidemiological ,   c l inical  and  laboratory  picture  of G6PD de- ficiency  was  very  similar  in  patients  from Baghdad and Mosul cities.  It has  been observed that in areas with a high  occurrence  of  red  blood  cell  genetic  abnormalities,  such as  sickle-cell gene,  G6PD and α- and β-thalassaemias, vari- ous genes frequently coexist in the same  population. Coinheritance of 2 or more  abnormal genes  in  the same  individual  is  frequently encountered, particularly  in certain  “closed”  tribes  in which con- sanguineous marriages  are  the norm.  Such genetic  interactions modify  the  clinical presentation of the disease state  [24,25]. In conclusion, the similar epidemio- logical,  clinical  and  laboratory profile  of G6PD deficiency  in  the middle and  north of Iraq suggest genetic similarities  in  the G6PD variants  and  similar  ex- posure  to precipitating agents. Studies  in  the other parts of  the  country par- ticularly  the  south would  further  elu- cidate  the picture of G6PD deficiency  in Iraq, and a national survey is needed  to  address  the exact biochemical  and  epidemiological variants of G6PD de- ficiency. Further studies would also be  useful  to determine possible  interac- tions  between  various  abnormal  red  blood  cell  genotypes notably G6PD,  thalassaemia and sickle cell haplotypes.  Educational programmes are needed to  increase public awareness about G6PD  deficiency. Acknowledgements Great thanks are due to the administra- tors of the aforementioned hospitals in  Baghdad  for  their kind help  in accom- plishing the study.  Beulter E. 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Merenstien D, Egleston B, Diener-West M. Lengths of stay and 8. costs associated with children’s hospitals. Pediatrics, 2005, 115(4):839–844. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 850 Genomic Resource Centre The World Health Organization (WHO) is one of several international organizations which have expressed concern about  the widening knowledge and technology gap between the more developed and less developed countries, which could lead  to the neglect of the health needs of low-income nations. WHO is therefore working to build international networks that  involve researchers from all over the world, creating reliable, accessible information and knowledge-sharing tools specifically  tailored for middle- to low- income countries. The Genomic Resource Centre (GRC). is an example of such a tool. The Human Genetics Programme has created a comprehensive Internet-based resource on genomics. The GRC’s primary  mandate is to consolidate information from a variety of sources and provide links through easily accessible frameworks.This  is the first website of its kind dedicated to providing reliable information on genomics and health to developing countries.  The mission of the GRC is to enhance the transfer of genomic information, to encourage global networks, to foster  informed dialogue, and to improve health services in genetics, especially in low to middleincome countries. Further information on this resource is available at: http://www.who.int/genomics/en/ Rao P, Pradhan PV, Shati H. Psycho-pathology and coping in 9. parents of chronically ill children. Indian Journal of Pediatrics, 2004, 71(8):695–699. Atwood K, Colditz GA, Kawachi I. From public health sci-10. ence to preventive policy: placing science in its social and political contexts. American Journal of Public Health, 1997, 87:1603–1606. Abdulrazzaq YM et al. Diversity in expression of glucose-6-11. phosphate dehydrogenase deficiency in females. Clinical Genetics, 1999; 55(1):13–19. Warsy AS, El-Hazmi MAF. G6PD deficiency, distribution and 12. variants in Saudi Arabia: an overview. Annals of Saudi Medicine. 2001, 21(3–4):174–177. Iwai K et al. A rapid single-step screening method for glucose-13. 6-phosphate dehydrogenase deficiency in field application. Japanese Journal of Tropical Medicine and Hygiene, 2003, 31:93–97. Verle P et al. Glucose-6-phosphate dehydrogenase deficiency 14. in Northern Vietnam. Tropical Medicine and International Health, 2000, 5(3):203–206. Grunfeld A. Acute hemolytic crisis in patients with G6PD de-15. ficiency: a case series. Prehospital and Disaster Medicine, 2001, 16(2):S33. Laosombat V et al. Glucose-6-phosphate dehydrogenase 16. variants associated with favism in Thai children. International Journal of Hematology, 2006, 83(2):139–143. Edwards CQ. Anemia and the liver: hepatobiliary manifesta-17. tions of anemia. Clinical Liver Diseases, 2002, 6:891–897. Berkowitz FE. Hemolysis and infections: categories and mecha-18. nisms of their interrelationship. Reviews of Infectious Diseases. 1991, 13:1151–1162. Spolarics Z et al. Red blood cell dysfunction in septic glu-19. cose-6-phosphate dehydrogenase-deficient mice. American Journal of Physiology. Heart and Circulatory Physiology, 2004, 286(6):H2118–H2126. Sarkar S et al. Acute intravascular hemolysis in glucose-6-phos-20. phate dehydrogenase deficiency. Annals of Tropical Pediatrics. 1993, 13(4):391–394. Ali M et al. Acute viral hepatitis with severe hyperbilirubinemia 21. and massive hemolysis in glucose-6-phosphate dehydroge- nase deficiency. Journal of Clinical Gastroenterology, 2001, 32:461–462. Balaka B et al. Insuffisance renale post-hemolytique chez 22. l’enfant deficient en glucose-6-phosphate deshydrogenase au Centre Hospitalier Universitaire de Lome. [Post-hemolytic renal failure in children with glucose-6-phosphate dehydro- genase deficiency at the university hospital center in Lome.] Medicine Tropicale, 2003, 63(2):151–154. Drout M, Gorgels AP, Bast A. Cardiac failure associated with 23. G6PD deficiency. Circulation Research, 2003, 93(8):e75. Awamy BH. Effect of G6PD deficiency on sickle cell disease in 24. Saudi Arabia. Indian Journal of Pediatrics, 1992, 59(3):331–334. El-Hazmi MAF et al. Genetic compounds—Hb S, thalassaemias 25. and enzymopathies: spectrum of interactions. Journal of Tropi- cal Pediatrics, 1994, 40(3):149–156. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 851 Macrovascular complications and their associated risk factors in type 2 diabetic patients in Sana’a city, Yemen A. Al-Khawlani,1 Z.A. Atef 1 and A. Al-Ansi 1 ABSTRACT A cross-sectional survey in Sana’a city, Yemen, aimed to determine the prevalence of preventable macrovascular complications and their association with glycaemic control and other risk factors in patients with type 2 diabetes mellitus (DM). Some features of macrovascular disease were found in 79 (25.4%) of the 311 patients: 17.8% had coronary heart disease, 9.1% had peripheral vascular disease and 5.8% had cerebrovascular disease. Significant positive associations were found between coronary heart disease and age, duration of DM, systolic blood pressure, diastolic blood pressure and insulin treatment. Peripheral vascular disease was associated with male sex, age, duration of DM and current tobacco smoking. Cerebrovascular disease was associated with systolic blood pressure, diastolic blood pressure and insulin treatment. 1Department of Internal Medicine, Faculty of Medicine, University of Sana’a, Al-Thawra Teaching Hospital, Sana’a, Yemen (Correspondence to A. Al-Khawlani: aalkhawlani@yemen.net.ye). Received: 08/10/08; accepted: 08/01/09 نميلا ،ءاعنص ةنيدم في يرّكسلا نم نياثلا طمنلا ضىرم ىدل راطتخلاا لماوعب اهطابتراو ةيربكلا ةيعولأا في تافعاضلما سينعلا مساق دحمأ ،فطاع دحمأ دياز ،نيلاولخا حلاص دممح ميركلا دبع في اهنم ةياقولا نكمي يتلا تافعاضلما راشتنا لدعم لىع ف ُّرعتلا فدهتسي ،نميلا في ،ءاعنص ةنيدم في ًايضرع ًاحسم نوثحابلا ىرجأ :ةـصلالخا ضعب نوثحابلا ظحلاو .يرّكسلا نم نياثلا طمنلا ضىرم ىدل راطتخلاا لماوع نم اهيرغبو ركسلا ىوتسم طبضب اهطابتراو ،ةيربكلا ةيعولأا %9.1 ىدلو ،ةيجاتلا ينـياشرلا في ضرم مهنم %17.8 ىدل ناك دقف ؛ًاضيرم 311 لصأ نم )%25.4( ًاضيرم 79 ىدل ةيربكلا ةيعولأا ضارمأ حملام يجاتلا بلقلا ضرم ينب ًايئاصحإ هب دتعي ًايبايجإ ًاطبارت نوثحابلا دجو ماك .ًايغامد ًايئاعو ًاضرم مهنم %5.8 ىدلو ،ةيفرطلا ةيعولأاب ًاضرم مهنم ةروكذلاب فيرطلا يئاعولا ضرلما طبترا ماك .ينلوسنلأاب ةلجاعلماو ،يطاسبنلاا مدلا طغضو ،ضيابقنلاا مدلا طغضو ،يرّكسلا ةدمو ،رمعلا ينبو ةلجاعلماو يطاسبنلاا مدلا طغضو ضيابقنلاا مدلا طغضب طبترا دقف يغامدلا يئاعولا ضرلما امأ .غبتلل ليالحا ينخدتلابو ،يركسلا ةدمبو ،رمعلابو .ينلوسنلأاب Complications macrovasculaires et risques associés chez des patients souffrant de diabète de type 2 à Sanaa (République du Yémen) RÉSUMÉ Une étude transversale réalisée à Sanaa (République du Yémen) avait pour objectif de déterminer la prévalence des complications macrovasculaires évitables et leur association avec le contrôle de la glycémie et d’autres facteurs de risque chez des patients souffrant de diabète de type 2. Sur 311 patients, 79 présentaient des signes de maladie macrovasculaire (soit 25,4 %) : 17,8 % souffraient d’une cardiopathie coronarienne, 9,1 % d’une maladie vasculaire périphérique et 5,8 % d’une maladie cérébrovasculaire. Des associations positives significatives ont été constatées entre les cardiopathies coronariennes et l’âge, la durée du diabète de type 2, la pression artérielle systolique, la pression artérielle diastolique et le traitement par insuline. La maladie vasculaire périphérique était associée au sexe masculin, à l’âge, à la durée du diabète de type 2 et la consommation de tabac au moment de l’étude. La maladie cérébrovasculaire était associée à la pression artérielle systolique, la pression artérielle diastolique et au traitement par insuline. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 852 Introduction Diabetes mellitus (DM)  is  associated  with  a number of  vascular  complica- tions.  Microvascular  complications  such as  retinopathy, nephropathy and  neuropathy are specific to DM, whereas  macrovascular  complications  such  as  peripheral  vascular  disease  (PVD),  coronary heart disease (CHD) and cer- ebrovascular disease (CVD) can occur  in the absence of DM [1,2]. Macrovascu- lar complications in DM consist mainly  of an accelerated form of atherosclerosis  that  affects  the  coronary,  carotid  and  peripheral  arteries,  thus  increasing  the  risk of myocardial infarction, stroke and  diabetic  foot disease  [3,4]. CHD has  been associated with DM in numerous  studies, notably the Framingham study  [5]. More  recent  studies have  shown  that the risk of myocardial infarction in  people with DM is equivalent to the risk  in nondiabetic patients with a history of  previous myocardial infarction [6].  These discoveries have  lead  to new  recommendations  by  the  American  Diabetes  Association  and American  Heart  Association  that DM be  con- sidered  a  coronary  artery disease  risk  equivalent  rather  than a  risk  factor [7].  Patients with DM are 2 to 4 times more  likely to develop cardiovascular diseases  than the general population and have a  2–5-fold greater risk of dying from these  diseases [7]. DM is also a strong  inde- pendent predictor of  the  risk of  stroke  and CVD [8] and patients with type 2  DM have a 150%–400% higher risk of  stroke  [9].  Similarly,  the  risk of PVD  in DM patients  is 4  times higher  than  normal  [10]  and patients more com- monly have  infrapopliteal  arterial oc- clusive disease and vascular calcification  than nondiabetic cohorts  [11]. DM is  known to increase the risk of lower limb  amputation by 15–40 times compared  with the general population [9].  The prevalence  of macrovascular  complications  among  DM  patients  has not been  studied  in Yemen. Such  data  are  important  given  that  these  complications  account  for  approxi- mately 50% of  all  deaths  among DM  patients  in  industrialized  countries  [9,10]. The  aim  of  this  study was  to  determine  the prevalence of macrov- ascular  complications  in Yemeni pa- tients with  type 2 DM and  to  identify  the role of glycaemic control and other  risk factors in patients with and without  macrovascular complications. Methods This was a multi-centre, cross-sectional  study,  conducted  from  July  2006  to  January 2007. The study was approved  by  the ethics committee of  the Faculty  of Medicine and Health Sciences at the  University of Sana’a. Sample Patients aged ≥ 25 years with type 2 DM  were  recruited  to  the study when  they  visited one of the 2 primary care diabe- tes  clinics  in Sana’a  city or visited  the  outpatient clinics at, or were admitted  to, one of  the 2 government hospitals  (Al Thawra and Al-Kuwait)  in the city.  Patients who attend clinics  in Sana’a,  the capital  city of Yemen,  come  from  all regions of the country. Patients were  invited to participate in the study by the  physicians  in  the outpatient clinic and  were examined according  to  the study  protocol after they had given informed  consent. Type 2 DM was diagnosed  based on World Health Organization  (WHO) criteria [12]. Patients who were  diagnosed with  gestational  diabetes,  type 1 DM, ketonuria or autoimmune  disease were excluded from the study.  Data collection Demographic data and medical history  were obtained by a personal  interview  and by  review of  the patient’s medical  records. Age, sex, duration of DM, type  of  treatment and family history of DM  were recorded. Patients were also asked  if  they  currently  smoked  tobacco  (at  least 10 cigarettes per day) or chewed  khat leaves (daily).  The physicians  took  the patient’s  history  of  macrovascular  complica- tions by interviewing the patients using  locally understood  terms  if necessary.  A hospital discharge record was required  to certify the event. PVD was diagnosed  by manifestations of  intermittent clau- dication, ulcers or gangrene or a history  of amputation or when one or more foot  pulses were absent during medical ex- amination. CHD was diagnosed based  on  definitive  myocardial  infarction,  ischaemic electrocardiographic changes  (Q/QS and ST/T changes) and by a  history of  angina pectoris, myocardial  infarction, coronary artery bypass graft  or percutaneous coronary angioplasty.  CVD was  defined  to  include  both  a  history of cerebral infarction or transient  ischaemic  attacks  and was diagnosed  on  the basis of  clinical manifestations  and findings on computed tomography  and a positive answer  to  the question  “Have you ever had a stroke?” Patients  with cerebral haemorrhage and embo- lism originating  from cardiac  thrombi  were excluded from this study. Blood pressure was measured on  the  right  arm, with  the  subject  seated  after 10 minutes  rest, using a  standard  clinical mercury  sphygmomanometer  with  an  appropriate  cuff  size. Hyper- tension was  diagnosed  according  to  WHO criteria  [13]  if  systolic pressure  was ≥ 140 mmHg or diastolic pressure  ≥ 90 mmHg or if the patient was taking  antihypertensive drugs.  Height  and weight were  recorded  with  the patient wearing clothing and  without shoes. Body mass index (BMI)  was  defined  as  weight  (kg)/height2 (m2). Obesity was classified according  to WHO criteria [14].  Blood was  drawn  after  overnight  fasting  for determination of  the  levels  of  fasting plasma glucose, glycosylated  haemoglobin  (HbA1c)  and  the  lipid  profile. A second venous blood sample  was  taken 2 hours  later,  to determine  the 2-hour postprandial glucose. All bio- chemical measurements were  carried  out on the same day as blood collection  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 853 using  standard  laboratory  automated  techniques. Plasma glucose  level was  assessed by means of  the glucose hex- okinase method  (Roche Diagnostic,  Mannheim,  Germany).  Serum  total  cholesterol,  high-density  lipoprotein  (HDL)  and  low-density  lipoprotein  (LDL) cholesterol  and  serum  triglyc- erides were measured using enzymatic  techniques  (Boehringer-Mannheim,  Germany).  Low-density  lipoprotein  (LDL) cholesterol was calculated using  the Friedewald equation.  The cut-offs were as follows: fasting  plasma glucose < 126 mg/dL, 2-hour  postprandial glucose < 140mg/dL, total  cholesterol > 200 mg/dL,  triglycerides  > 150 mg/dL, HDL cholesterol < 40  mg/dL and LDL cholesterol > 150 mg/ dL [12,15].  HbA1c level < 7% was taken to indi- cate good glycaemic control.  Statistical analysis Statistical analysis was performed using  SPSS  software,  version 15. Mean and  standard deviation  (SD) were deter- mined  for  quantitative data.  Student  t-test was conducted  to determine  the  significance of observed difference be- tween the means of clinical parameters  of males and females. Chi-squared tests  were used  to ascertain  the association  between macrovascular  disease  and  clinical  variables. P < 0.05 was consid- ered significant. Results Patients’ background characteristics A total of 311 patients with type 2 DM  were  studied. There were  155 males  (49.8%)  and  156  females  (50.2%),  mean age 53.9 (SD 10.9) years (range  25–85  years). The  duration  of  DM  varied between 1–35 years. Of the total  patients 53.4% had hypertension [150  (48.2%)  systolic hypertension and 97  (31.2%) diastolic hypertension]. The  mean BMI was 24.1 (SD 4.1) kg/m2,  and the prevalence of overweight (BMI  > 25–< 30 kg/m2) was 34.1% and of  obesity  (BMI > 30 kg/m2) was 8.7%.  HbA1c levels showed that 211 (87.9%)  had poor  glycaemic  control  (HbA1c  ≥ 7%).  DM was  being  treated  with  diet  alone  for 29 patients (9.3%), with oral  hypoglycaemic agents  for 227 (72.9%)  and with  insulin  in  the  remaining 55  (17.7%). Table 1  showed  the charac- teristic of  the DM patients by  type of  treatment.  Insulin-treated patients had  a significantly longer duration of disease  than individuals on diet or oral hypogly- caemic therapy (P < 0.001). Patients on  insulin therapy had a higher prevalence  of CHD and PVD compared with pa- tients under oral hypoglycaemic therapy  and diet  alone, but  the difference was  only  significant  for CHD (P < 0.006).  Patients on oral hypoglycaemic therapy  had  a  significantly  higher  prevalence  of CVD  compared with  patients  on  insulin  therapy or controlled with diet  alone (P < 0.037).  Table  2  shows  the  demographic,  clinical and  laboratory findings  for  the  total sample and for males and females.  Overall 79 (25.4%) DM patients had  symptoms of macrovascular complica- tions: 28 (9.1%) had PVD, 55 (17.8%)  had CHD and 18  (5.8%) had CVD.  Two patients had  all  3  types of mac- rovascular  complication,  10  patients  had both PVD and CHD, 11 patients  had CHD and CVD and 3 patients had  PVD and CVD. The prevalence of PVD  was  significantly  higher  in men  than  women (14.1% versus 8.8%, P < 0.001)  but  there was no significant difference  between  males  and  females  in  the  prevalence of CVD (6.5% versus 5.1%,  P = 0.07) or CHD (20.6% versus 14.7%,  P = 0.17). Overall 21.2% of patients re- ported being current cigarette smokers  and  50.8%  chewed khat  leaves  daily.  Significantly more men  than women  were smokers (P = 0.005) and khat users (P < 0.001).  Relationship between DM and macrovascular complications The  clinical  parameters  of  patients  in  each  subgroup  of  macrovascular  disease—PVD,  CHD  and  CVD— were compared with those without the  condition (Tables 3–5).  The significant predictive risk factors  for PVD were male sex (P < 0.001), age  Table 1 Characteristics of patients with type 2 diabetes mellitus (DM) by mode of therapy Variable Insulin (n = 55) Oral hypoglycaemic agents (n = 227) Diet alone (n = 29) P-value Mean SD Mean SD Mean SD Age (years) 55.8 9.3 53.3 11.2 55.6 11.0 0.22 Duration of DM (years)a 11.9 7.3 5.1 5.5 4.9 7.1 < 0.001a No. % No. % No. % Peripheral vascular disease 7 12.0 18 7.9 3 10.3 0.51b Coronary heart disease 16 29.0 37 16.3 2 6.9 0.006b Cerebrovascular disease 1 1.8 17 7.5 0 0.0 0.037b aANOVA test; bChi-squared test. SD = standard deviation. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 854 (P < 0.004), duration of DM (P < 0.001)  and  smoking  (P  < 0.015)  (Table  3).  The  significant predictive  risk  factors  for CHD were age (P < 0.001), dura- tion of DM (P < 0.001), systolic blood  pressure (P < 0.001), diastolic pressure  (P  < 0.002) and  insulin  treatment  (P < 0.021) (Table 4). Mean systolic blood  pressure  (P  < 0.028),  diastolic blood  pressure (P <  0.035) and  the propor- tion of  patients  on  insulin  treatment  (P < 0.037) were significantly higher in  patients with CVD than those without  it (Table 5). No significant associations  were found for glycaemic control, BMI,  total  cholesterol,  triglycerides, HDL- cholesterol, LDL-cholesterol  and khat use in any of the 3 categories of macrov- ascular disease. Discussion The  present  study  investigated  the  prevalence and risk  factors of macrov- ascular  complications  in  a  sample of  Yemeni patients with type 2 DM. Little  is known about  the prevalence of DM  in Yemen,  except  for  a  study  in 2004  which found a prevalence of DM in the  Yemeni population of  4.6% (7.4%  in  males and 2.0%  in  females)  [16]. Our  results  strongly suggest  that DM is as- sociated with  chronic macrovascular  complications. The overall prevalence  of macrovascular complications among  Yemeni patients with  type 2 DM was  25.4%: 17.8% had  a history of CHD,  9.1% had evidence of PVD and 5.8%  were diagnosed with CVD.  The  rates  of macrovascular  com- plications  in  type 2 DM in  the present  study are consistent with the finding of  other  studies  in  the  region. A study  in  the United Arab Emirates (UAE) found  similar  rates  for  total macrovascular  disease (29.5%), PVD (11.6%), CHD  (14.4%) and CVD (3.5%) [17]. In Saudi  Arabia the prevalence of acute coronary  syndrome (14.8%) and myocardial  in- farction (23.1%) were higher  than our  rate of CHD [18]. The rate of foot infec- tion was 4.3% and amputation was 1.9%;  these  results were  lower  than our  rate  for PVD, while the rate of stroke (10%)  was  twice a high as our  rate  for CVD.  In Bahrain  the  rate of PVD  reported  (11.8%)  is  consistent with our  results  [19]. Compared with the rates reported  Table 2 Clinical feature of the patients with type 2 diabetes mellitus (DM) by sex Variable All (n = 311) Males (n = 155) Females (n = 156) P-value (males vs females) Mean SD Mean SD Mean SD Age (years) 53.9 10.9 54.7 11.7 53.2 10.0 0.20 Duration of DM (years) 6.3 6.5 6.2 6.9 6.4 6.1 0.76 BMI (kg/m2) 24.1 4.1 24.1 4.2 24.3 4.0 0.61 Glycaemic profile Fasting blood glucose (mg/dL) 211.1 89.5 205.3 85.5 216.7 93.0 0.25 2-hour postprandial blood glucose (mg/dL) 311.2 110.9 306.9 111.5 315.4 110.6 0.50 HbA1c (%) 9.5 2.2 9.3 1.9 9.7 2.4 0.153 Lipid profile Total cholesterol (mg/dL) 189.2 49.1 188.0 48.5 189.8 49.9 0.82 HDL cholesterol (mg/dL) 42.3 28.8 41.7 27.7 42.8 25.8 6.70 LDL cholesterol (mg/dL) 142.2 43.2 141.1 42.4 143.2 451.9 0.67 Triglycerides (mg/dL) 222.5 116.9 233.1 127.9 212.1 104.4 0.12 No. % No. % No. % Macrovascular disease Peripheral vascular disease 28 9.1 22 14.1 6 8.8 < 0.001 Coronary heart disease 55 17.8 32 20.6 28 14.7 0.17 Cerebrovascular disease 18 5.8 10 6.5 8 5.1 0.07 Hypertension Systolic hypertension 150 48.2 71 47.3 79 52.7 0.31 Diastolic hypertension 97 31.2 47 48.5 50 51.6 0.74 Smoking/substance use Smokes tobacco 66 21.2 43 27.7 28 14.7 0.005 Chews khat daily 158 50.8 100 64.5 58 37.2 < 0.001 Family history Family history of DM 188 50.8 76 48.1 82 51.9 0.64 SD = standard deviation; BMI = body mass index; HbA1c = glycosylated haemoglobin; HDL = high-density lipoprotein; LDL = low-density lipoprotein. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 855 by the London follow-up to the WHO  multinational  study of vascular disease  in diabetics [20]  the  rate of CHD was  3  times  lower  in our  study,  the  rate of  CVD was similar and  the rate of PVD  was twice as high. In the United States of  America (USA), after a mean follow-up  of 13 years,  the prevalence of CHD in  type 2 diabetics was 48.1%, 3-fold higher  than the prevalence in our study, and the  prevalence of CVD (25.6%) was  sev- eral times higher than our rate [21]. The  difference  in our  rate of macrovascular  complications among patients with type  2 diabetes  and  the  results mentioned  above can be explained by the different  study designs, differences in sample size  and ethnic variations.  Table 3 Characteristics of patients with type 2 diabetes (DM) mellitus with and without peripheral vascular disease Variable Peripheral vascular disease P-value Yes (n = 28) No (n = 282) Mean SD Mean SD Age (years) 59.5 9.4 53.4 10.6 0.004 Duration of DM (years) 11.3 8.8 5.8 6.0 < 0.001 BMI (kg/m2) 23.1 3.8 24.3 4.1 0.13 HbA1c (%) 8.7 1.9 9.5 2.2 0.10 Total cholesterol (mg/dL) 183.3 56.8 189.8 48.3 0.50 HDL cholesterol (mg/dL) 42.2 28.6 42.3 25.5 0.99 LDL cholesterol (mg/dL) 136.0 49.3 142.5 42.6 0.65 Triglycerides (mg/dL) 284.5 112.7 24.3 117.5 0.57 Systolic blood pressure (mmHg) 145.4 24.6 137.9 26.2 0.15 Diastolic blood pressure (mmHg) 88.2 15.1 83.7 12.4 0.08 No. % No. % Insulin treatment 7 25.0 48 17.0 0.51 Smoking tobacco 11 38.2 55 24.2 0.015 Chewing khat leaves 18 64.3 140 49.6 0.14 Family history of DM 13 40.4 144 51.1 0.64 SD = standard deviation; BMI = body mass index; HbA1c = glycosylated haemoglobin; HDL = high-density lipoprotein; LDL = low-density lipoprotein. Table 4 Characteristics of patients with type 2 diabetes (DM) mellitus with and without coronary heart disease Variable Coronary heart disease P-value Yes (n = 55) No (n = 254) Mean SD Mean SD Age (years) 59.3 10.6 52.8 10.6 < 0.001 Duration of DM (years) 9.8 7.8 5.5 5.9 < 0.001 BMI (kg/m2) 24.5 3.8 24.1 4.2 0.48 HbA1c (%) 9.1 2.2 9.6 2.2 0.23 Total cholesterol (mg/dL) 184.7 52.4 190.1 48.5 0.46 HDL cholesterol (mg/dL) 46.6 44.6 41.3 19.5 0.17 LDL cholesterol (mg/dL) 142.8 42.9 142.0 43.4 0.91 Triglycerides (mg/dL) 242.4 155.4 218.5 106.9 0.17 Systolic blood pressure (mmHg) 149.1 28.9 136.3 25.5 < 0.001 Diastolic blood pressure (mmHg) 89.0 15.6 83.1 11.8 0.002 No. % No. % Insulin treatment 16 20.1 88 15.0 0.02 Smoking tobacco 12 21.8 54 21.3 0.93 Chewing khat leaves 30 54.5 128 50.4 0.58 Family history of DM 26 47.3 131 51.6 0.56 SD = standard deviation; BMI = body mass index; HbA1c = glycosylated haemoglobin; HDL = high-density lipoprotein; LDL = low-density lipoprotein. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 856 Analysis  of  the  risk  factors  in our  study showed that systolic hypertension  and diastolic hypertension were impor- tant risk factors for CHD and CVD, but  not  for PVD. Moreover, age and dura- tion of DM were significantly associated  with PVD  and CHD,  but  not CVD.  Smoking and male sex were significant- ly  associated with PVD, while  insulin  treatment was  significantly  associated  with CVD. These results are consistent  with findings elsewhere  in  the Eastern  Mediterranean  Region  (EMR).  For  example,  in  the UAE a cross-sectional  study done to determine the prevalence  and risk  factors of macrovascular com- plications among diabetic patients  re- vealed a significant association between  macrovascular disease and male sex, age,  duration of DM and hypertension [17].  A study in Pakistan showed that subjects  with CHD were more  likely  to  have  hypertension and be current  smokers,  and that subjects who had experienced  a  cerbrovascular  accident were more  likely to have had DM for more than 5  years and  to be current  smokers  [22].  In the Islamic Republic of Iran, a study  revealed  that  the prevalence of CHD  increased with age, BMI,  smoking and  insulin treatment [23].  Outside  the  EMR,  in  the USA,  a  study revealed  that age,  fasting glucose  levels,  smoking and  triglyceride  levels  were  independent  risk  factors  for de- velopment of CHD events  in  type 2  DM, while  age, hypertension, glucose  and  smoking predicted development  of  CVD  [21].  Generally,  in  our  re- sults  and  the  results  of  other  studies  mentioned above,  the greatest  risk  fac- tors  for macrovascular  complications  were male  sex,  age,  duration  of DM  and hypertension. We were not  able  to detect any association between  the  presence of macrovascular disease and  glycaemic  control  as  determined  by  HbA1c level. This negative correlation is  not unique.  Indeed, many  longitudinal  studies were unable  to  establish  such  a  link  [20,24,25]. The  reason may be  because ofthe  relatively  small  sample  size  studied and  the  small number of  patients with complications, or  it may  be  related  to  the multi-factorial nature  of macrovascular disease, as reported in  other studies [26]. Furthermore, unlike  experience  elsewhere  [27], our  study  was unable  to demonstrate an associa- tion between BMI and dyslipidaemia in  the  study  population,  but  this  is  not  uncommon. For example,  in Pakistan,  macrovascular complications increased  with  age,  duration  of DM  and were  more prevalent in uncontrolled diabet- ics (HbA1c > 8.6%), but macrovascular  complications were not associated with  BMI or dyslipidaemia  [28].  In Saudi  Arabia,  a  study  to determine  the  fre- quency of cardiovascular risk factors  in  Saudi and non-Saudi diabetics showed  that hypertension, hyperlipidaemia and  smoking were common CVD risk  fac- tors  in  both  Saudis  and  non-Saudis,  while obesity was less common in both  groups. Both groups had poor blood  glucose control [29].  Smoking was a significant risk factor  for PVD but not for CHD or CVD. We  also  found no  significant difference  in  the  rate  of macrovascular  complica- tions in patients chewing khat in any of  the subgroups of CHD, PVD or CVD.  Khat  leaf  chewing  is widely practised  in Yemen, especially among diabetics,  who believe that it reduces blood sugar.  Furthermore  an  association between  Table 5 Characteristics of patients with type 2 diabetes (DM) mellitus with and without cerebrovascular disease Variable Cerebrovascular disease P-value Yes (n = 18) No (n = 292) Mean SD Mean SD Age (years) 57.6 12.4 53.8 10.7 0.15 Duration of DM (years) 9.1 4.3 6.2 6.6 0.33 BMI (kg/m2) 23.8 4.3 24.2 4.2 0.69 HbA1c level (%) 9.5 2.5 9.5 2.2 0.98 Total cholesterol (mg/dL) 192.9 50.0 188.9 49.1 0.74 HDL cholesterol (mg/dL) 42.6 19.2 42.3 26.1 0.95 LDL cholesterol (mg/dL) 137.5 42.1 142.4 43.3 0.64 Triglycerides (mg/dL) 255.6 165.1 220.5 113.4 0.22 Systolic blood pressure (mmHg) 151.7 27.1 137.8 28.9 0.028 Diastolic blood pressure (mmHg) 90.3 13.1 83.8 12.7 0.035 No. % No. % Insulin treatment 1 5.6 54 18.5 0.037 Smoking tobacco 5 27.7 61 20.8 0.49 Chewing khat leaves 10 55.5 148 50.7 0.69 Family history of DM 8 44.4 149 51.0 0.59 SD = standard deviation; BMI = body mass index; HbA1c = glycosylated haemoglobin; HDL = high-density lipoprotein; LDL = low-density lipoprotein. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 857 khat  chewing  and  hypertension  has  been reported previously [30]. The prevalence of CHD in our study  was rather low compared with studies in  other geographical settings. This may be  explained by the fact that patients in our  study were  slightly younger and had a  lower  rate of hypertension. The preva- lence  of  overweight  and obesity was  considerably lower than the prevalence  found in other studies in the region. For  example,  in a  study  in Riyadh, obesity  was  reported  in 33% of adult diabetics  [31]  and  in  the UAE  in 37% [17].  In  another study in Saudi Arabia, the mean  age of  the patients was 58.4 (SD 14.2)  years,  the prevalence of hypertension  was 78% and the rates of overweight and  obesity were 39.0% and 44.8% respec- tively  [18].  In  the  Islamic Republic of  Iran the study group had a mean age of  62.2 (SD 12.4) years and hypertension  was present in 91% [32].  Other  studies  considered  ethnic  differences  to explain  the variation  in  the  risk of  cardiovascular disease be- tween populations [33]. Among those,  a USA-based  study  concluded  that  a  substantial part of  the  risk  associated  with ethnicity  can be attributed  to  so- cioeconomic  status  and geographical  location rather than ethnicity [33]. The  results of our study clearly demonstrate  that DM  is  associated with  chronic  complications,  including PVD, CHD  and CVD in this sample of Yemeni dia- betic patients. These findings highlight  the need  for primary  care physicians  to be  aware of  the possible presence  of  these  complications  among  their  patients. The general  awareness of  the  community  also  needs  to  be  raised  about  individual  risk  factors  for DM  and its complications. 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Ameri- can Heart Journal, 2005, 149:1066–1072. Second Annual Conference of the Global Diabetes Alliance (GDA 2), Cairo, Egypt, 26–29 October, 2010 Cairo will host the second Global Diabetes Alliance Congress, a very special event whose goal is to unify protocols for  epidemiological surveys and prevention and management of diabetes and its related disorders. This Congress will be  dedicated to the presentation of updates on the diabetes epidemic in various parts of the world (including the Middle  East and Africa) and workshops designed to initiate collaborative research projects among groups of investigators  throughout the world. The programme can be accessed from the conference website at: http://conf.global-diabetes. org/index.htm طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 859 Nutrition knowledge, beliefs and dietary habits among elderly people in Nizwa, Oman: implications for policy A. Al Riyami,1 S. Al Hadabi,2 M.A. Abd El Aty,1 H. Al Kharusi,1 M. Morsi1 and S. Jaju1 ABSTRACT The nutritional needs of the ageing population require special attention. We undertook a cross- sectional, community-based, household survey in Nizwa wilayat, Oman to study nutrition-related knowledge and beliefs and self-reported dietary habits among a sample of elderly people. The response rate for the household interview was 99.3% from a total sample of 2041. About 45% of the elderly were overweight or obese. Overall we found poor knowledge of nutrition plus some nutritional imbalances and low levels of physical activity. Significant sex differences existed in elderly peoples’ nutritional knowledge, consumption of fluids, milk and sweets, use of dietary regimens and experience of appetite change. The findings warrant reorientation of the existing health promotion strategy for the elderly. 1Directorate of Research and Studies, Directorate General of Planning, Ministry of Health, Muscat, Oman (Correspondence to A. Al Riyami: asyariyami@gmail.com). 2Directorate of Health Services, Al Dakhliya Region, Nizwa, Oman. Received: 28/10/08; accepted: 12/01/09 ةسايسلا راثآ :نماُع ،ةوزن في يننسلما ىدل ةيئاذغلا تاداعلاو تادقتعلماو فراعلما وجاج ياجنس ،سيرم يدمج ،صيورلخا للاه ،ةيطع دوممح ،بيادلها حلاص ،يمايرلا ايسآ ،ىوزن ةيلاو في عمتجلما لىع زكتري ناكسلل ًايضرع ًاحسم نوثحابلا ىرجأ دقو .ًاصاخ ًامماتها يننسملل ةيوذغتلا تاجايتحلاا بلطتت :ةـصلالخا ةباجتسلاا ةبسن تغلب دقو .يننسلما نم ةنيع ىدل ةيئاذغلا مظنلاو تاداعلا نع تياذلا غلابلإاو ،ةيذغتلا لوح تادقتعلماو فراعلما ةساردل ،نماُع في نع فراعلما نأ نوثحابلا دجوو .ءاندب وأ نزولا يطرفم يننسلما نم %45 ناك دقو .2041 اهددع غلابلا ةنيعلا لماك لصأ نم %99.3 ناكسلا ةلباقلم ينب ًايئاصحإ ابه دتعي تافلاتخا كانه ناكو .ةيندبلا ةيلاعفلا نم ضفخنم ىوتسمو ،يوذغتلا نزاوتلا للاتخا عم ،ةفيعض لياجمإ لكشب ةيذغتلا هِّبنتو .ةيهشلا في ُّريغتلا ةاناعمو ،ةيئاذغلا مظنلا مادختساو ،تايوللحاو ،بيللحاو ،لئاوسلا لوانتو ةيوذغتلا فراعلما ثيح نم يننسلما ىدل ينسنلجا .ينّنسلما ىدل ةحصلا زيزعتل ةيلالحا ةيجيتارـتسلاا في هاتجلاا يـيغت لىإ ةساردلا Connaissances et croyances en nutrition et habitudes alimentaires chez des personnes âgées à Nizwa (Oman) : répercussions sur les politiques RÉSUMÉ Une attention particulière doit être portée aux besoins nutritionnels de la population des personnes âgées. Nous avons réalisé une étude transversale communautaire auprès des ménages de la wilaya de Nizwa (Oman) afin d’étudier les connaissances et croyances en termes de nutrition et les habitudes alimentaires autodéclarées dans un échantillon de personnes âgées. Le taux de réponse des ménages à l’étude a été de 99,3 % pour un échantillon total de 2 041 sujets. Près de 45 % des personnes âgées souffraient de surcharge pondérale ou d’obésité. Dans l’ensemble, les résultats montrent que les personnes âgées avaient de faibles connaissances en nutrition, qu’elles présentaient des déséquilibres alimentaires et qu’elles pratiquaient peu d’activité physique. Des différences significatives liées au sexe ont été observées en termes de connaissances en nutrition, de consommation de liquides, lait et sucreries, de recours aux régimes alimentaires et d’antécédents de modifications de l’appétit. Les résultats justifient une réorientation de la stratégie existante de promotion de la santé destinée aux personnes âgées. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 860 Introduction The  World  Health  Organization  (WHO) has  acknowledged  that  age- ing  and nutrition  is  a  growing  global  challenge  [1]. Modifying  lifestyle  fac- tors  such as diet  can prevent,  slow or  reverse the onset of many of the chronic  diseases associated with ageing.  Iden- tifying dietary patterns and specific di- etary components that offer protection  against chronic disease is important [2].  Perceptions of healthy eating and food  group consumption practices of elderly  men are largely unexplored [3]. The  Food  Habits  in  Later  Life  project of  the  International Union of  Nutritional  Sciences  highlighted  the  value of  rapid assessment procedures  for  developing  food-based  dietary  guidelines  for  their aged members [4].  Elderly patients with  a  compromised  nutritional  status  increase  the burden  on  the existing health  care  infrastruc- ture. The  inpatient  burden of  elderly  people in Oman is around 10% [5].  This  study was  undertaken  to  as- sess nutrition-related knowledge  and  beliefs and self-reported dietary habits  among a sample of elderly Omanis and  to determine sex differences in their re- sponses. It was hoped that the findings  would be utilized for developing health  promotion policy.  Methods A cross-sectional,  community-based,  household  survey  of  the  profile  and  needs of non-institutionalized elderly  Omanis aged 60 years and above was  conducted  in  the  Nizwa wilayat,  Al  Dakhliya region of Oman in 2005.  Sample Our sampling frame was the 2003 cen- sus data [6]. The Ministry of National  Economy provided a list of households  where elderly people were resident,  to- gether with the corresponding enumer- ation area maps  for  the Nizwa wilayat. Supervisors were  involved  in updating  the maps  and numbering  the houses.  The elderly who had moved  to  a dif- ferent  location  in  the wilayat  and were  residing in houses newly built since the  census were also  traced and  recruited.  Inhabitants of Jabal Akhdar and remote  scattered houses were excluded due  to  logistic constraints. After updating  the  list of elderly people we found a total of  1508 houses  inhabited by elderly peo- ple, which yielded 2041 elderly people.  The  response  rate  for  the household  interview was 99.3% (n = 2027), while  for the clinical examination and investi- gation it was 80.8% (n = 1650). Data collection After  approval  by  the  research  ethics  committee of  the Ministry of Health,  Oman, informed consent was obtained  from  the  participants.  A  structured  questionnaire  to assess 9 different do- mains of health  relevant  to  the elderly  in Oman was constructed, based on a  literature  review  and  expert opinion;  only  the nutrition domain  is  reported  in  this paper. The data were collected  by personal interviews at home. The in- terviewers were health educators  from  the Ministry of Health and volunteers  from community  support groups who  received 6 days of  standardized  inten- sive training. A second questionnaire to  collect data  from clinical examinations  and  investigations was  completed by  a medical  doctor  in  the Nizwa  com- munity  research centre. After  the pilot  study, data  collection was  conducted  between June and August 2005.  The questionnaire  collected basic  demographic data about  respondents:  age,  sex, marital  status,  education, oc- cupation, personal income and whether  living with  their  family. The next  sec- tion assessed  respondents’ knowledge  and  beliefs  about  nutrition: whether  the quality and quantity of food should  change in older ages, what types of food  to  eat  and whether  certain  food  can  protect or control diseases  in  later  life.  A section on dietary habits asked about  number of meals eaten, whether  their  appetite  had  changed,  the  quantities  of  various  food groups  that  they con- sumed  and whether  they  consumed  any special diets, took vitamin/mineral  supplements, etc. Currently there are no uniform food  guidelines  for  the Arab  region or por- tion  size and  food composition  tables  to suit the Arab food habits and culture  [7]. For our nutrition analysis we  took  account of  the  traditional  regional  [8]  and local dietary habits to establish ap- propriate frequencies of dietary intakes.  In  the  questionnaire  the  responses  were assessed as adequate/inadequate  intake. Except  for  fluids,  information  about portion  sizes was not collected.  Adequate consumption of fish/meat/ chicken (animal proteins) was defined  as  consumption  >  3  times  per week  and  inadequate as ≤ 3  times per week.  The same criteria were applied for veg- etables, fruits and cereals. Intake of milk  and milk products ≤ 3  times per week  was  classified  as  less  than  adequate  while 4+ times per week was adequate.  Milk and milk products were classified  as full-fat if 2 or more items out of milk,  yoghurt and  laban were reported to be  full-fat. Information about portion sizes  was not collected. Fluid consumption  per day (water, milk,  laban,  fruit  juices  and other drinks) ≤ 1500 mL per day  (measured by number of oral dehydra- tion  solution glasses) was  considered  inadequate.  We also assessed  levels of physical  activity based on daily chores and walk- ing, with  the cut-off  set  at 30 minutes  exercise per day [9]. Body mass  index  was calculated and underweight, over- weight and obesity were defined based  on WHO criteria [10]. Analysis Data entry was done in the region with  Epi-Info,  version 3.1, and data manage- ment  and  analysis  was  done  using  SPSS,  version 9.0. Descriptive analysis  of  the nutrition-related data was done.  Chi-squared  tests of  significance, with  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 861 P  < 0.05  as  significant,  were  used  to  assess  sex differences  for  the  relevant  variables. Results Background characteristics The sample of  respondents  consisted  of  51.6%  females  and  48.4%  males (Table 1). There were significantly more  women  in  the 60–69 years  age group  (59.7% of women, 53.8% of men) and  fewer in the 70–79 years group (24.2%  of women,  31.3% of men), while  the  sex distribution of the very elderly (age  80+ years) was  similar. A majority of  participants resided in urban areas. The  illiteracy  rate  among  the women was  95.3%, with only 3.9% having studied up  to semi-primary  level;  the correspond- ing proportions  for men were 67.6%  and 25.8%  respectively. Nearly 7% of  men  had  primary  level  of  education  or above, compared with  less  than 1%  of women (P  < 0.001). Among men,  91.3% were married and 5.3% widowed  compared with 45.1%  and 48.7%  re- spectively among women (P < 0.001).  Occupational  status  showed  that  16.7%  of  elderly  men  were  work- ing while  98.9%  of  the women were  housewives. Almost  three-quarters of  women (72.0%) but only one-fifth of  men (20.8%) had no personal  income.  Overall 21.0% earned < 100 Omani rials  (OR) per month while 26.0% earned  100–199 OR. The difference in income  levels between males and  females was  significant (P < 0.001). Almost  all  the  men (97.3%) had been  resident with  the  same  family  for  the  previous  5  years compared with 93.8% of women  (P < 0.001).  There was  a higher  rate of obesity  in women (15.7%)  than men (10.5%)  (P = 0.02) and 31.5% of  the  total  sam- ple was  overweight with  7.6%  being  underweight. Of  the  total, 49.4% were  not physically active, while among  the  active  respondents, more males were  physically active than women (21.6% of  men versus 14.3% of women took ≥ 30  min exercise/day) (P < 0.001).  Nutrition knowledge and beliefs In  the assessment of nutrition knowl- edge and beliefs (Table 2), 43.0% of the  total sample believed that the quality of  nutrition  should  change with  age but  only 17.2% believed  that  the quantity  should change, with no significant dif- ference between the sexes. Only 23.5%  accepted that they should include some  specific  types of  food with  advancing  age, while about 26.7% were not certain  about  this. There was a  significant  sex  difference on  this  issue, with a higher  proportion of men giving  affirmative  answers. With  respect  to moderating  the consumption of specific food types  with  age,  significantly  fewer  women  gave a negative  reply  than males,  and  more women were unsure (P = 0.022).  However,  a  slightly higher proportion  of  women  replied  positively  to  the  questions about the need to reduce the  intake of sweets/sugar, fat and salt. Respondents’ detailed knowledge  about  the  value  of milk  and  dietary  fibreswas quite poor, with 12.3% aware  of the value of milk in protecting against  osteoporosis while only 1.7% knew  it  as a rich source of calcium. There were  significant  sex differences, with  fewer  women  than men having  knowledge  about milk for osteoporosis prevention  (10.1% versus 14.6%) and as a source of  calcium (1.1% and 2.4%). Only 7.3% of  the  total had heard about dietary fibre  and, of those, less than 3% knew its im- portance in daily diet. A majority of the  elderly did not know which foods were  rich  in dietary fibre. Significantly  fewer  women than men (29.4% versus 31.5%)  (P = 0.004) were aware that changes in  dietary habits could help  in prevention  and control of health problems. Only  20.4% of  the  total  sample were aware  that  this  could  help  in  hypertension  and diabetes, while  less  than 5% were  knowledgeable about the role of dietary  habits in other specific illnesses.  Nutrition practices The  practice  of  consuming  3  meals  per day was  reported by 91.4% of  the  respondents  (Table 3). One-third of  women (33.5%) compared with 27.3%  of men had noticed a change in their ap- petite (P = 0.003). The most common  reason was sickness (17.7%), although  12.5% said  they had  lost  their appetite  for no reason, with women mentioning  these  factors more  than men. Taking  medicines was attributed as a reason by  2.5% of the elderly.  Respondents’ self-reported levels of  consumption showed  that only 16.4%  consumed adequate  amounts of milk  and there was a significant difference be- tween the sexes as regards consumption  of milk and milk products, with signifi- cantly  fewer women than men (14.1%  versus  18.8%)  consuming  adequate  amounts  (P  = 0.004).  Full-fat  dairy  products were  the preference of 38.8%  of the sample. Of the total respondents  59.0%  consumed  adequate  amounts  of fish/meat/chicken, 83.4% adequate  amounts of cereals and 85.0% adequate  amounts  of  fruits.  Vegetable  intake,  however, was  inadequate  for 88.6% of  the total. Proportionately more women  did not consume any type of sweets (P = 0.01) but 58.4% of  the  total  sample  had a  sweet  intake 1–3  times a week.  There was no sex difference  in  the ad- equacy of consumption of fish/meat/ chicken, cereals, vegetables or fruits.  One-fifth of the sample (19.4%) took  additional salt in their diet and 9.3% took  vitamin/mineral supplements. Women  had significantly  lower fluid  intake per  day (P < 0.001). More women followed  a diet regimen (P < 0.001), with 14.0%  having  fat  and  cholesterol  restriction  and around 10% having salt and sugar  restrictions. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 862 Table 1 Distribution of background characteristics of elderly respondents by sex Characteristic Males (n = 982) Females (n = 1045) Total P-value No. % No. % % Residence Urban 877 89.3 935 89.5 89.4 > 0.05 Rural 105 10.7 110 10.5 10.6 Age groups (years) 60–69 528 53.8 624 59.7 56.8 0.005 70–79 307 31.3 253 24.2 27.6 80–89 104 10.6 119 11.4 11.0 ≥ 90 43 4.4 49 4.7 4.5 Education Illiterate 662 67.6 996 95.3 81.9 < 0.001 Semi primary 253 25.8 41 3.9 14.5 Primary & above 65 6.6 8 0.8 3.6 Marital status Never married 14 1.4 13 1.2 1.3 < 0.001 Married 896 91.3 471 45.1 67.5 Widowed 52 5.3 509 48.7 27.7 Divorced 19 1.9 52 5.0 3.5 Work status Working 164 16.7 11 1.1 8.6 n/a Not working 818 83.3 0 0.0 40.4 Housewife 0 0.0 1034 98.9 51.0 Personal income (OR/month) 0 204 20.8 752 72.0 47.2 < 0.001 < 100 205 20.9 221 21.1 21.0 100–199 468 47.7 60 5.7 26.0 200–299 63 6.4 4 0.4 3.3 300–399 15 1.5 3 0.3 0.9 400+ 27 2.7 5 0.5 1.6 Living with same family for last 5 years Yes 955 97.3 980 93.8 95.5 < 0.001 No 27 2.7 65 6.2 4.5 BMIa Underweight 55 7.8 53 7.4 7.6 0.020 Normal 358 50.7 325 45.1 47.9 Overweight 219 31.0 230 31.9 31.5 Obese 74 10.5 113 15.7 13.1 Physical activity (min/day) 0 435 44.3 567 54.3 49.4 < 0.001 < 30 335 34.1 329 31.5 32.8 ≥ 30 212 21.6 149 14.3 17.8 aSome data missing. BMI = body mass index. OR = Omani rials. n/a = not applicable. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 863 Table 2 Dietary knowledge and beliefs of the elderly respondents by sex Dietary knowledge/belief Males Females Total P-value (males vs females)No. % No. % % Agree quality of nutrition should change with age 424/966 43.9 434/1030 42.1 43.0 0.617 Agree quantity of nutrition should change with age 177/957 18.5 163/1019 16.0 17.2 0.216 Type of foods to eat at older ages (n = 980) (n = 1043) Certain types of food should be eaten < 0.001 Yes 248 25.3 228 21.9 23.5 No 511 52.1 496 47.6 49.8 Don’t know 221 22.6 319 30.6 26.7 Types of food to eat: Vegetables 107 10.9 113 10.8 10.9 0.952 Fruits 77 7.9 75 7.2 7.5 0.570 Milk 63 6.5 71 6.8 6.6 0.732 Water 87 8.9 83 7.9 8.4 0.456 Moderation of diet at older ages (n = 969) (n = 1031) Certain types of food should be moderated Yes 387 39.9 428 41.5 40.8 0.022 No 375 38.7 343 33.3 35.9 Don’t know 207 21.4 260 25.2 23.4 Types of food to moderate: Protein 37 3.8 33 3.2 3.5 0.453 Cereals/starch 47 4.9 34 3.3 4.1 0.150 Sweets/sugar 206 21.3 239 23.2 22.3 0.302 Fat 210 21.7 238 23.1 22.4 0.449 Milk 6 0.6 11 1.1 0.9 0.276 Eggs/liver/brain 10 1.0 4 0.4 0.7 0.084 Salt 115 11.9 182 17.7 14.9 0.000 Fruits/vegetables 10 1.0 5 0.5 0.8 0.156 Water 1 0.1 0 0.0 0.0 0.302 Benefits of milk at older ages (n = 980) (n = 1043) Rich in calcium 24 2.4 11 1.1 1.7 0.016 Rich in vitamin D 11 1.1 7 0.7 0.9 0.280 Offers protection from osteoporosis 143 14.6 105 10.1 12.3 0.002 Rich in protein 7 0.7 5 0.5 0.6 0.492 Helps to prevent constipation 35 3.6 38 3.6 3.6 0.931 Benefits of dietary fibre at older ages (n = 978) (n = 1042) Heard about dietary fibre 80 8.2 67 6.4 7.3 0.130 Benefits of dietary fibre: Regulates intestinal movements 36 3.7 28 2.7 3.2 0.203 Relieves constipation 17 1.7 10 0.9 1.3 Other uses 27 2.8 26 2.5 2.6 0.709 Foods rich in dietary fibres: Fruits 14 1.4 11 1.0 1.2 0.445 Vegetables 42 4.3 26 2.5 3.3 0.025 Whole cereals 18 1.8 24 2.3 2.1 0.466 Plant proteins 2 0.2 2 0.2 0.2 0.949 EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 864 Discussion This was  the first  study of nutrition  in  the  elderly  conducted  in Oman. The  high  illiteracy  rate of  respondents  can  be  explained  by  the  fact  that  all  the  respondents  had  reached  adulthood  before the country’s recent renaissance  which began  in 1970,  at  a  time when  few Omanis had access  to education.  Females  in  the  Arab  world  had  less  opportunity  for  formal  education  at  that  time and this accounts  for  the sig- nificant  sex differences. The same was  true  for work opportunities and hence  the  income of  the elderly  respondents  differed significantly between the sexes.  Changes  in  lifestyle  and  socioeco- nomic status have led to more sedentary  lifestyles in Oman and levels of physical  activity have decreased sharply  in most  Arab countries  [11]. Half our overall  sample  took no physical  activity  and  women  spent  significantly  less  time  in physical  activity  than men,  as most  have domestic helpers  for daily chores  and there is little awareness of the value  of walking as exercise. This, along with  higher rates of multiparity [11], accounts  for  the higher prevalence of obesity  in  women than men (15.7% versus 10.5%).  Similar findings on obesity have been  noted in elderly women in Egypt [8]. Although the proportion of females  among  the  elderly  is  generally higher  due to their higher survival rates, in this  interior region of Al Dakhliya, we found  a  lower  proportion of women  in  the  70–79 years age range and similar pro- portions  in  the 80+ years age group. A  possible reason could be unavailable or  incorrect birth records,  leading  to mis- classification of age in some cases. There  are  fewer cultural and social barriers to  multiple marriage  and  remarriage by  men, which accounts for a significantly  higher proportion of men being married  at the time of this study, while a higher  percentage of women were widowed.  The  elderly  in  our  study  lacked  knowledge  about  the benefits  of  nu- tritional  foods  and a majority of men  and women believed that there was no  need  to change  the quantity and qual- ity of nutrition with  increasing  age. A  European  study  reported  that 86% of  elderly people believed  that  they did  not need  to change  their eating habits  as they already ate healthily [12]. How- ever,  researchers  in Assuit governorate  in Upper  Egypt  reported  otherwise.  They  found  that  44.0%  of  men  and  63.4% of women  in  rural  settings and  77.3% and 63.8% respectively  in urban  settings believed  that diet  should differ  with age, either decreasing the amount  of  food  in general or  restricting certain  types of food [8].  Older people residing outside insti- tutions eat  reasonably well  [13]. There  is  ample  availability of  foodstuff  from  different parts of the world in Oman. A  majority of the elderly in this study lived  with  their  family,  and  there  is  a  tradi- tion  in Arab countries of caring for the  elderly. Although there were significant  differences between men and women  in education and  income  level and the  proportion  living with  their  families,  this was not  reflected  in differences  in  dietary intake of meat, cereals, fruits and  sweets or in the frequency of meals per  day Energy  intakes  fall with advancing  age, but average protein intakes remain  adequate [13]. High energy intake over  decades leads to overweight in both sex- es [14]. There is a shift in the Arab world  from consuming  traditional  foods  to  more “fast-foods”, which are character- ized by high fat, cholesterol and sodium  and low fibre [11]. A high proportion of  our  sample were overweight or obese.  The impact of the promotional activities  of the regional health care system and of  the WHO Nizwa Healthy City project  Table 2 Dietary knowledge and beliefs of the elderly respondents by sex (concluded) Dietary knowledge/belief Males Females Total P-value (males vs females)No. % No. % % Changes in dietary habits at older ages (n = 980) (n = 1043) Changes in diet can protect and control health problems Yes 309 31.5 307 29.4 30.4 0.004 No 355 36.2 328 31.4 33.8 Don’t know 316 32.2 408 39.1 35.8 Diseases that can be controlled by diet: Hypertension 194 19.8 218 20.9 20.4 0.537 Diabetes 200 20.4 203 19.5 19.9 0.595 Hyperlipidaemia 57 5.8 39 3.7 4.7 0.028 Coronary heart disease 35 3.6 27 2.6 3.1 0.200 Obesity 36 3.7 23 2.2 2.9 0.050 Anaemia 13 1.3 10 0.9 1.1 0.436 Gastric/duodenal problems 8 0.8 8 0.8 0.8 0.900 طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 865 on nutrition  seems  to work positively  only  for  the  small  proportion  of  the  population who are aware of the health  promotion programmes  for hyperten- sion and diabetes.  A high proportion of older  adults  in  England  had  little  basic  nutrition  knowledge  and  this  was  a  barrier  to  healthier eating. Knowledge of associa- tions between diet and diseases was par- ticularly  poor;  90%  of  subjects were  unaware of the benefits of high fruit and  vegetable consumption [15]. We found  no  sex differences  in  consumption of  fruits  and  vegetables  but  the  lack  of  knowledge related to fruits and vegeta- bles was reflected in poor consumption  of vegetables but not  fruits  in our study.  We noted a significant sex difference for  knowledge about the need to eat specific  types of  food,  the need  for moderation  Table 3 Dietary habits of the elderly respondents by sex Dietary habit Males Females Total P-value (n = 982) (n = 1045) No. % No. % % Meals eaten (per day) 1 15 1.5 11 1.0 1.3 NS 2 67 6.8 81 7.8 7.3 3 900 91.6 953 91.2 91.4 Noticed change in appetite Yes 265 27.3 348 33.5 30.5 0.003 Reasons for change in appetite Sickness 147 15.1 209 20.1 17.7 Taking medicine 26 2.7 24 2.3 2.5 Death of someone close 3 0.3 13 1.3 0.8 No apparent reason 116 11.9 135 13.0 12.5 Adequate consumption of foods(per week Fish/meat/chicken 559 58.4 611 59.6 59.0 NS Cereals 797 83.0 853 83.7 83.4 NS Vegetables 104 10.9 119 11.8 11.4 NS Fruits 810 83.7 885 86.2 85.0 NS Consumption of sweets (times per week) 0 315 38.4 393 44.6 41.6 0.01 1–3 506 61.6 489 55.4 58.4 Consumption of extra salt in diet 194 19.9 197 19.0 19.4 NS Consumption of fluidsa (mL per day) Inadequate 228 23.3 357 34.4 29.0 < 0.001 Adequate 749 76.7 680 65.6 71.0 Consumption of milk & milk products (times per week) Inadequate 796 81.2 896 85.9 83.6 0.004 Adequate 184 18.8 147 14.1 16.4 Types of milk & milk products consumed Low fat/skimmed 534 59.1 591 63.2 61.2 NS Full fat 370 40.9 344 36.8 38.8 Take vitamin/mineral supplements 83 8.6 104 10.0 9.3 NS Follow diet regimen 325 33.3 432 41.6 37.6 < 0.001 Restrict fat and cholesterol 123 12.6 160 15.4 14.0 Restrict sugar 94 9.6 125 12.0 10.9 Restrict salt 84 8.6 130 12.5 10.6 Eat more iron-containing foods 6 0.6 0 0.0 0.3 Eat more fibre 7 0.7 7 0.7 0.7 Totals do not add up to sample size due to missing data; awater, milk, laban, juices, other drinks; NS = not significant. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 866 of  certain  types of  food  and whether  changes  in dietary habits  can protect  and control health problems at older  ages. In another study men were found  to have poorer knowledge about nutri- tion  than women [16], whereas  in our  sample women had poorer knowledge.  In  a  study  related  to  fat  intake  from  meat, meat products, dairy products and  fried foods, women had higher nutrition  knowledge  scores  and more negative  views of fatty foods than did men [17].  More of our women had negative views  about  specific  items  such  as  sweets,  fat  and  salt  consumption. However,  when  it  came  to  actual  consumption,  only  sweets were  significantly  less  fre- quently consumed by women, the other  items being consumed equally by both  sexes. Although women  in our  survey  knew about the need to moderate their  intake of fatty foods, they still consumed  these foods, perhaps due to the existing  belief  systems  and  attitudes  towards  such food. Nutritional knowledge about dairy  products has been shown to be a better  predictor of the type of milk consumed  (e.g. lower fat milk to reduce fat intake)  than the frequency of milk consumption  [18]. We noted similar findings. Knowl- edge about the nutritional value of milk  was  very  poor  and women were  less  informed than men. Overall only 16.4%  of  the  total  sample,  and  significantly  fewer  women  than men,  consumed  adequate amounts of milk. This shows  the poor impact on this age group of the  ongoing women’s health programme in  Oman. Among  those who consumed  milk products,  40% used  full-fat milk  and milk products, which again reflects  traditional habits.  In  the Ageing Nutrition project  in  Europe  a  comparative  analysis  of  36  studies  showed  that  energy  intake  was  too high, especially  in some of  the  “younger old”  and  seemed not  to be  adjusted  to  the  energy  expenditure,  whereas it was considerably lower than  recommended  in  some very old  sen- iors in some countries [19]. We cannot  comment  on  the  age  difference,  but  energy intake was higher in our sample,  which may be inferred from the number  of meals per day,  the adequacy of  food  consumption (meat, cereals, sweets and  fruits) and the finding that only 7.5% of  the  total  sample was underweight. The  prevalence of obesity  and overweight  were also  found  to be higher  than un- derweight  in elderly men and women  in Egypt  [8].  In  contrast  to our find- ings, undernutrition  in older people  is  considered  to be  a  significant public  health  issue  in  the UK [20].  “Willing- ness to eat” plays a central role with re- gard to appetite among the elderly [21].  In our study decreased appetite noticed  by  the  elderly people  themselves was  mainly  attributed  to unexplained  fac- tors  and  sometimes  illness  and use of  medications.  Sex differences were  found  in  food  choices and energy and nutrient intakes  in older British people, especially those  aged 65–79 years [22]. Meal frequency  has been found to increase in older peo- ple of both sexes, especially men [14].  Women have more  regular consump- tion of  fruits and vegetables  [23], milk  and diary products and vitamin supple- ments  [14]. Almost  all  types of meat,  eggs,  and  vegetables  are preferred by  men and their energy intake also tends  to be higher. In both sexes, fat has been  shown to represent a higher ratio of en- ergy  intake (39%) than recommended  [14]. In our study the dietary consump- tion patterns of men and women dif- fered  significantly  only  for milk  and  milk products,  sweets  and fluids, with  women consuming less of these. The major  limitations of our  study  were  that we did not  use  a  validated  questionnaire. Also we could not quan- tify  the  food consumption due  to  the  unavailability of  food consumption  ta- bles for Oman [24].  Intervention trials demonstrate that  there are worthwhile health advantages  for older people  in changing  their  risk  factors—e.g. weight reduction, sodium  restriction, saturated  fat reduction—to  make  their  later  years healthier, more  active  and  more  independent  [25].  Effective  intervention  is  required  for  improving knowledge among  the eld- erly in our study. Dietary advice should  be  based  on  elderly  women’s  food  preferences  and habitual  foods  [26].  It  is  important  to  inform  the  elderly  about  known  relations between  food  and disease. This  is  especially  impor- tant for women, who have higher levels  of obesity. The WHO Regional Office for the  Eastern Mediterranean has addressed  the  issue of health of  the  elderly  for  over a decade and has identified a need  for appropriate food and nutrition care  for the elderly. However, a draft of the  proposed model  national  policy  for  the elderly by EMRO does not explic- itly mention the nutrition component  [27]. Similarly,  the recommendations  of the Third Arab Conference on Nu- trition 2007 resulted in the Abu Dhabi  Declaration  to  Promote  Healthy  Nutrition  in  the Arab  countries  [7],  but  did  not  specifically  address  the  growing global challenge of ageing and  nutrition.  Conclusions Our findings  that  nearly  45% of  eld- erly people  in Nizwa were overweight  or obese,  and had poor knowledge of  nutrition, along with nutritional  imbal- ances and low levels of physical activity,  warrants  reorientation of  the  existing  health promotion  strategy  for  the eld- erly. The  significant  sex differences  in  nutritional knowledge need  to be ad- dressed. The above findings need to be  incorporated  into  the  awareness  and  education programme of  the national  strategy for “Active ageing and self care”  proposed by the Ministry of Health and  the Ministry of Social Welfare. A further  detailed  study  is necessary  in order  to  prepare a micronutrient  supplementa- tion programme  for vulnerable groups  including the elderly.  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 867 Nutrition for older persons1. . 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EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 868 Comparing bone mineral density in postmenopausal women with and without vertebral fracture and its value in recognizing high-risk individuals B. Heidari,1 S. Hoshmand,1 K. Hajian 2 and P. Heidari 3 ABSTRACT Vertebral fracture, the hallmark of osteoporosis, usually occurs in postmenopausal women with low bone mineral density (BMD). The aim this study was to determine which BMD parameter can best predict women at high risk of fracture. BMD values at the spine and femoral neck were compared in 34 women with vertebral fracture and 34 controls. Mean BMD (g/cm2), T-score, and Z-score values at both femoral neck and spine were significantly lower in the fracture than the nonfracture group. Z-score was more sensitive than BMD T-score for detecting low bone mass. T-score was not sensitive enough to identify low BMD in the spine, whereas the femoral neck T-score could recognize women at high risk of fracture with higher accuracy. 1Department of Internal Medicine; 2Department of Social Medicine, Shaheed Beheshti Hospital, Babol University of Medical Sciences, Babol, Islamic Republic of Iran (Correspondence to B. Heidari: heidaribeh@yahoo.com). 3Faculty of Medicine, Islamic Azad University, Tehran, Islamic Republic of Iran. Received: 10/01/09; accepted: 26/02/09 في ةنراقلما ةميقو ،ابه تاباصلما يرغ عم راقفلا في روسكب تاباصلما نم سأيلا نس دعب ءاسنلا ىدل ماظعلل ةيندعلما ةفاثكلا ةنراقم عفترم رطلخ ينضرعلما صاخشلأا لىع ف ُّرعتلا يرديح زانراب ،نايجح ميرك ،دنماشوه نييرش ،يرديح دازبه ةيندعلما ةفاثكلا نيهدل لقت نمم ،سأيلا نس دعب ءاسنلا ىدل ةداع ثديح يذلاو ،ماظعلا لخلختل ةقرافلا تاملاعلا نم ةرقفلا سرك دعي :ةـصلالخا عفترم رطلخ تاضرعلما ءاسنلاب ؤبنتلا نم ءابطلأا ن ِّكتم يتلاو ،ماظعلل ةيندعلما ةفاثكلل ةتباثتلما ميقلا لىع ف ُّرعتلا لىإ ةساردلا هذه فدتهو .ماظعلل ،يرقف سركب تبيصأ ةأرمإ 34 ىدل ذخفلا قنع فيو يرقفلا دومعلا في ماظعلل ةيندعلما ةفاثكلا ميق ينب ةنراقم نوثحابلا ىرجأ دقو .سركلاب ةباصلإل قنع نم لك في Z زرحو ،T زرحو ،)عبرم ترميتنس لكل مارغلاب ةر َّدقم( ماظعلل ةيندعلما ةفاثكلا ميق نأ حضتاو .تادهاشلا ةوسنلا نم 34 ىدل ام ينبو Z زرلحا ناك دقو .روسكلاب تاباصلما يرغ ةعوممج ىدل ماع روسكلاب تاباصلما ةعوممج في ًايئاصحإ هب دتعي رادقمب ضفخأ يرقفلا دومعلا فيو ذخفلا امأ ،تارقفلا في ماظعلل ةيندعلما ةفاثكلا ضافخنا لىع ف ُّرعتلل ةيفاك ةيساسح T زرحلل نكي لمو ،ماظعلل ةيندعلما ةفاثكلل T زرلحا نم ةيساسح رثكأ في .سركلل عفترم رطلخ تاضرعلما ءاسنلا ،ةيلاع ٍةقدب ،فّرعي نأ نكمي T زرلحا نإف ذخفلا قنع في Comparaison de la densité minérale osseuse chez des femmes ménopausées présentant ou non une fracture vertébrale et sa valeur dans l’identification d’individus à haut risque RÉSUMÉ La fracture vertébrale, caractéristique de l’ostéoporose, survient généralement chez la femme ménopausée ayant une faible densité minérale osseuse (DMO). Cette étude visait à déterminer quel paramètre de la DMO était susceptible d’identifier au mieux les femmes qui pourraient être à haut risque de fracture. Des mesures dela DMO réalisées au niveau de la colonne vertébrale et du col du fémur chez 34 femmes présentant une fracture vertébrale et 34 témoins ont été comparées. Par rapport au groupe témoin, les valeurs moyennes de la DMO (g/cm2), du T-score et du Z-score relevées sur le col du fémur et la colonne vertébrale étaient considérablement inférieures chez les femmes souffrant de fractures. Le Z-score s’est avéré plus sensible que le T-score de la DMO pour détecter une faible densité osseuse. Il est apparu que le T-score n’était pas assez sensible pour identifier une faible DMO de la colonne vertébrale, alors qu’il permettait d’identifier avec une meilleure précision les femmes présentant un risque élevé de fracture du col du fémur. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 869 Introduction Vertebral fracture is the most common  osteoporotic  fracture  and  also  a hall- mark of postmenopausal osteoporosis.  It  is associated with back pain, disabil- ity,  functional  limitation and decreased  quality of life [1–6]. Bone mineral den- sity (BMD)  is an  important predictor  of  future  fractures. Low BMD at  the  spine  or  femoral  neck  in  postmeno- pausal women has been shown  in sev- eral prospective studies to be associated  with increased risk of vertebral  fracture  [7–10]. In the elderly population, how- ever,  factors other  than BMD, such as  age, might play  a  role  in  the develop- ment of fracture, because older patients  are much more susceptible to fractures  at  any  given BMD  than  are  younger  patients, perhaps due  to  the quality of  ageing bone [4,5,11–13]. Several studies have found a relation- ship between increasing risk of vertebral  fracture and decreasing BMD values in  women [14,15]. There  is also a  strong  association between  age  and  femoral  neck BMD with vertebral fracture [16].  Nevertheless, many postmenopausal  women with  fractured vertebra are not  osteoporotic,  so BMD measurements  cannot  accurately predict  individuals  who will develop fractures. This issue has  been attributed to discordance between  the site of BMD measurement and the  site of  fractures;  low  sensitivity of  the  BMD T-score criterion;  inconsistency  between BMD measurement and  the  time of the fracture; and false elevation  of BMD values due  to  the presence of  degenerative changes at the site of BMD  measurement  [17,18]. Given  the bur- den of vertebral fractures in the elderly,  detection of low bone mass for preven- tion of fractures is important. At present,  the  BMD T-score  (which measures  how much bone mass deviates from the  average bone mass of a healthy adult)  is used as a  tool  for evaluation of bone  mass as well as  for  fracture assessment,  as recommended by the World Health  Organization (WHO) [19].  We hypothesized  that  the magni- tude of differences in the BMD of spine  or  femoral neck would be comparable  in women with and without  fractures  irrespective  of  the  BMD  parameter  used. The aim of this study was to deter- mine which parameter of BMD is more  sensitive  in diagnosis of  low BMD and  can more  accurately  identify women  susceptible to vertebral fractures.  Methods The study compared postmenopausal  women with and without vertebral frac- tures with  respect  to bone mass at  the  spine and femoral neck. Sample A sample of 34 postmenopausal women  with back pain  and vertebral  fracture  and 34 aged-matched postmenopausal  women  with  back  pain  but  without  vertebral fracture entered the study. The  study patients attended or were referred  to an outpatient medical clinic from the  general  population of Babol,  Islamic  Republic of Iran. The women who met  the  selection criteria were  selected  se- quentially over a 6-month period  from  June to December 2007.  Only patients with recent back pain  who  had  pain  and  tenderness  at  the  lumbar spine with symptom duration of  less than 6 weeks were included. Those  with previous spinal surgery, malignan- cy,  traumatic  fracture or  inflammatory  skeletal disease and patients on steroids  or anti-osteoporosis treatment were ex- cluded. Patients with fractures at the site  of BMD assessment in the lumbar spine  were also excluded from the study.  This study was approved by the eth- ics  committee of Babol University of  Medical Sciences. Data collection Data  regarding  demographic  and  clinical characteristics were collected by  interview and questionnaire. Clinical,  radiographic  and bone densitometry  data were provided by clinical  exami- nation, X-ray  examination  and BMD  measurements. At  the first  visit  all patients under- went a complete clinical  examination,  spinal X-ray, and BMD measurements  at the lumbar spine (L2–L4) and femo- ral neck by dual X-ray absorptiometry  (DXA) with  a  single Dorland densi- tometer. BMD was evaluated based on  a  reference database provided by  the  manufacturer. The mean  duration  of  back  pain  prior to spinal radiography and the mean  duration between diagnosis of vertebral  fracture  and BMD measurement was  < 2 weeks in about 80% of patients and  < 6 weeks in the remainder. Clinical vertebral  fracture was diag- nosed by history,  clinical  examination  and spinal X-ray. Vertebral fracture was  assessed by  the Genant  semiquantita- tive method  in a  lateral-view spinal X- ray by an experienced physician [20]. In  this method, the extent of the vertebral  height  reduction  and morphological  changes are assessed visually and scored  using  a  grading  scale  to  differentiate  fracture  from  other  nonfracture  de- formities. Thoracic  and  lumbar verte- bra  from T4–L4 were  graded  based  on  the  approximate degree of  height  reduction. Vertebrae with a 20%–25%  or greater reduction in anterior, middle  and/or posterior height  relative  to ad- jacent vertebrae of normal appearance  were considered as fractured vertebrae.  Women with nonosteoporotic  verte- bral deformity and  traumatic  fractures  were excluded from the study. Osteoporosis  was  confirmed  ac- cording to WHO criteria [19], defined  as BMD value > 2.5 standard deviation  (SD) below  the  young normal mean  BMD (T-score < –2.5).  Analysis For the statistical analysis patients with  vertebral  fractures (at  least 1  fractured  vertebra) were  compared with  those  without  fractures  in  terms  of  bone  EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 870 density values (BMD, T-score and Z- score (which measures how much bone  mass deviates  from  the  average bone  mass of people  the same age and sex),  frequency of osteoporosis at  the  spine  or  femoral neck  regions and duration  of menopause. The  differences were  expressed  as mean percentage differ- ence  of  the  fracture  group  from  the  nonfracture group. The  association  between  osteo- porosis  and vertebral  fracture was de- termined by calculation of odds  ratio  (OR) and  its 95% confidence  interval  (CI) using the chi-squared test. Student  t-test was used for comparison of BMD  values. Receiver operating  characteristics  (ROC) curve was applied  to evaluate  the  trade-off between  sensitivity  and  1–specificity  for various cut-off points  of BMD values to assess the diagnostic  accuracy of BMD parameters and age  in discriminating between  the  fracture  and  the nonfracture  group. Diagnos- tic accuracy of BMD parameters were  compared with respect to values of the  area  under  the  curve  (AUC)  and  its  95% CI in comparison with the chance  level (AUC = 50%). The impact of age  on diagnostic accuracy was assessed by  comparison of AUC values between 2  age groups (< 65 and ≥ 65 years).  Statistical  analysis was performed  using SPSS software, version 10.  Results The mean age of the study patients was  66.6 (SD 8.4) years and the mean dura- tion of menopause was 17.9 (SD 9.2)  years. Two-thirds of women (64.7%)  were aged over 65 years. Vertebral frac- ture was associated with acute back pain  in 84.6% of cases versus 23.5% of those  without fractures. As shown  in Table 1  the mean age  of patients with vertebral  fractures was  67.5  (SD 9.7)  years  and  those with- out  fractures was 65.6 (SD 7.0) years  (not significant). The mean duration of  menopause  in patients with and with- out  fractures was 19.6 (SD 10.4) years  and 16.2  (SD 7.7)  years  respectively  (not  significant). The mean BMD (g/ cm2),  T-score  and Z-score  values  at  both the femoral neck and spine regions  in  the  fracture group were significantly  lower  than  in  the  nonfracture  group  (Table 1). In the fracture group the mean spine  BMD T-score was 35%  lower whereas  the spine Z-score was 58%  lower  than  in  the nonfracture  group. The  corre- sponding  values  for  femoral  neck T- score and Z-score were 24% and 100%  respectively. The size of  the difference  between  the 2 groups varied with age  and site of BMD measurements. In the  fracture group aged < 65 years the cor- responding differences between  spine  T-score and Z-score were 59% and 92%  respectively and  in patients ≥ 65 years  were 20% and 51%. In the femoral neck  the  corresponding  values  for  femoral  neck T-score  and Z-score  in women  aged < 65 years were 30% and 160% and  in women aged ≥ 65 years were 19% and  71% respectively. Vertebral  fracture  developed  in  61.7%  of  patients  with  spinal  oste- oporosis versus 37.1% patients without  spinal osteoporosis (OR = 2.7, 95% CI:  1.3–7.2, P < 0.05). The corresponding  values  for  patients with  and without  femoral neck osteoporosis were 60.0%  and 25.0% respectively (OR = 4.6, 95%  CI: 1.4–14.6, P = 0.015). Femoral  neck  osteoporosis  was  more strongly associated with vertebral  fracture in women aged < 65 years ver- sus  those aged ≥ 65 years (OR = 10.0,  95% CI: 1.4–69.2, P = 0.036) whereas  the  association  between  spinal  oste- oporosis and vertebral fracture was not  different comparing patients aged < 65  years with older patients. The presence  of osteoporosis  at both  sites,  femoral  neck  and  spine,  increased  the  risk of  vertebral fracture by almost 6-fold (OR  = 5.8, 95% CI: 1.5–21.9, P < 0.011). Comparison of bone mass at  frac- ture  and nonfracture  sites with BMD  T-score and Z-score gave different  re- sults with respect  to BMD parameters.  Based  on  BMD T-scores,  low  bone  Table 1 Comparison of bone mineral density (BMD) values at the femoral neck and spine in postmenopausal women with and without vertebral fracture Variable Vertebral fracture present (n = 34) Vertebral fracture absent (n = 34) P-valuea Mean SD Mean SD Age (years) 67.0 9.7 65.6 7.0 0.36 Duration of menopause (years) 19.7 10.4 16.2 7.7 0.13 Femoral neck BMD (g/cm2) 0.57 0.09 0.66 0.12 < 0.001 Spine BMD (g/cm2) 0.64 0.12 0.75 0.15 0.003 Femoral neck T-score –3.6 0.76 –2.9 0.83 < 0.001 Spine T-score –2.7 0.79 –2.1 0.95 < 0.001 Femoral neck Z-score –1.5 0.80 –0.8 0.67 < 0.001 Spine Z-score –1.9 0.66 –1.2 0.84 < 0.001 aStudent t-test. SD = standard deviation. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 871 mass (T-score < –2.5, as recommended  by WHO)  at  the  femoral  neck  was  more frequent in women with fractures  than at  the spine (85.3% versus 61.7%,  P = 0.007). In contrast, based on BMD  Z-score < –1, low bone mass at the spine  was more  frequent  than at  the  femoral  neck (97.0% versus 76.4%, P < 0.015). The  overall  accuracy  of  BMD  parameters  (femoral  neck  and  spine  BMD g/cm2, T-score and Z-score)  in  discriminating  high-risk  women  are  presented  in Table 2  in  terms of  the  AUC and standard error (SE). All pa- rameters showed a significant ability to  recognize high-risk (fracture) patients,  but femoral neck BMD Z-score yielded  the highest accuracy among all  the pa- tients  in discriminating  fracture  from  nonfracture patients  [AUC 0.77  (SE  0.05), P  < 0.001]. This was  followed  by  femoral neck BMD T-score [AUC  0.75  (SE 0.06), P  < 0.001]  and  spine  BMD Z-score  [AUC 0.74  (SE 0.06),  P  < 0.001],  whereas  the  spine  BMD  T-score  yielded  the  lowest  accuracy  [AUC 0.71 (SE 0.62), P = 0.002]. The accuracy of BMD parameters  were compared between the 2 age groups  ≥ 65 and < 65 years with respect to AUC  values. In patients aged < 65 years, AUC  values  for  femoral neck BMD g/cm2 [AUC 0.87 (SE 0.07), P = 0.002] and  femoral neck T-score  [AUC 0.82 (SE  0.08), P  = 0.007]  yielded  the highest  and spine T-score the lowest predictive  accuracy values [AUC 0.77 (SE 0.09),  P  = 0.007]. However  in patients ≥ 65  years  the  femoral neck T-score [AUC  0.74 (SE 0.07), P = 0.006] yielded  the  highest  accuracy  followed by  femoral  neck Z-score [AUC 0.73 (SE 0.08), P = 0.009]. In patients aged ≥ 65 years the AUC  values  for  spine  and  femoral neck T- scores decreased by 11.6% and 11.0%  respectively compared with those aged  < 65 years (P < 0.01), whereas  the de- creases in spine and femoral neck BMD  Z-score  were  7.6%  and  7.5%  lower  respectively(P < 0.01) Discussion The present  study  found  that  in  postmenopausal women with ver- tebral fracture, BMD values at the  fracture as well as nonfracture sites  were significantly lower than those  without vertebral  fractures. Pres- ence of osteoporosis at both spine  and  femoral neck was associated  with an increased risk of vertebral  fracture but osteoporosis  at  the  femoral neck was more  strongly  associated with vertebral  fracture  than at the spine. However, about  40% of vertebral  fractures devel- oped in patients with spine BMD  values at the range of osteopenia. In  this  study,  comparison of  fracture  and  nonfracture  sites  indicated higher bone density val- ues at the fracture site using BMD  T-score, whereas based on BMD  Z-scores  fracture  sites  demon- strated lower values. Furthermore,  the magnitude of spine bone den- sity  difference  between women  with  and  without  fracture  was  greater using  the BMD Z-score  than  the BMD T-score. Moreo- ver, spine BMD Z-score yielded a  larger AUC and higher accuracy  in  recognizing  the  fracture group  compared with the spine T-score.  On  the  other  hand,  the  BMD  T-score yielded higher sensitivity  for femoral neck BMD and higher  diagnostic accuracy in recognizing  women with  fracture  compared  with BMD Z-score, particularly in  those aged < 65 years.  These findings indicate greater  sensitivity of  spine BMD Z-score  compared  with  spine  BMD  T-score  in  demonstrating  low  bone mass as well as the extent of  bone  loss at  the spine. At present  the  BMD  T-score  is  the  most  widely used parameter  for  recog- nizing high-risk patients as well as  for planning treatment. However,  the sensitivity and accuracy of this  Ta bl e 2 Pr ed ic ti ve a cc ur ac y of b on e m in er al d en si ty (B M D ) m ea su re m en t p ar am et er s de te rm in ed b y re ce iv er o pe ra ti ng c ha ra ct er is ti c an al ys is a nd a re a un de r t he c ur ve (A U C ) i n re co gn iz in g hi gh -r is k po st m en op au sa l w om en fo r v er te br al fr ac tu re w it h re sp ec t t o ag e gr ou p an d si te o f B M D m ea su re m en t BM D p ar am et er A ge < 6 5 ye ar s A ge ≥ 6 5 ye ar s To ta l A U C SE 95 % C I P- va lu e A U C SE 95 % C I P- va lu e A U C SE 95 % C I P- va lu e Fe m or al n ec k BM D (g /c m 2 ) 0 .8 7 0 .0 7 0 .7 4– 1.0 0 0 .0 0 2 0 .6 7 0 .0 8 0 .5 1– 0 .8 4 0 .0 5 0 .7 4 0 .0 6 0 .6 2– 0 .8 6 < 0 .0 0 1 Sp in e BM D (g /c m 2 ) 0 .7 4 0 .10 0 .5 6– 0 .9 4 0 .0 46 0 .6 8 0 .0 8 0 .5 1– 0 .8 4 0 .0 45 0 .7 0 0 .0 6 0 .5 7– 0 .8 3 0 .0 5 Fe m or al n ec k BM D T -s co re 0 .8 3 0 .0 8 0 .6 6– 0 .9 9 0 .0 0 7 0 .7 4 0 .0 8 0 .5 9– 0 .8 9 0 .0 0 6 0 .7 5 0 .0 6 0 .6 3– 0 .8 7 < 0 .0 0 1 Sp in e BM D T -s co re 0 .7 7 0 .0 9 0 .5 8– 0 .9 6 0 .0 26 0 .6 8 0 .0 8 0 .5 2– 0 .8 4 0 .0 4 0 .7 2 0 .0 6 0 .5 9– 0 .8 3 0 .0 0 2 Fe m or al n ec k BM D Z -s co re 0 .7 9 0 .0 9 0 .6 0 –0 .9 8 0 .0 15 0 .7 3 0 .0 8 0 .5 8– 0 .8 8 0 .0 0 9 0 .7 7 0 .0 5 0 .6 6– 0 .8 8 < 0 .0 0 1 Sp in e BM D Z -s co re 0 .7 8 0 .0 9 0 .6 0 -0 .9 7 0 .0 19 0 .7 2 0 .0 8 0 .5 6– 0 .8 7 0 .0 13 0 .7 4 0 .0 6 0 .6 2– 0 .8 6 < 0 .0 0 1 Ar ea u nd er th e cu rv e w as co m pa re d w ith c ha nc e le ve l. SE = st an da rd e rr or o f A U C ; C I = co nfi de nc e in te rv al . EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 872 parameter varies according  to age and  site  of measurement,  whereas  BMD  Z-score is less affected by age and site. Discordance  in  BMD  T-score  between  the  spine  and  femoral  neck  can  be  explained  by  the  presence  of  osteoarthritis, which occurs at a higher  rate in the spine than femoral neck. Ad- ditionally, accuracy and reproducibility  errors which usually occur during BMD  measurement may  lead to discordance  between sites. Spinal osteophytosis falsely elevates  BMD T-score without  affecting  frac- ture  risk  [17,18]. The  impact of  vari- ous  forms of degenerative diseases on  BMD was  investigated  in  a  study  in  which BMD measurement by quantita- tive computed  tomography and DXA  were compared in 209 postmenopausal  women.  In  that  study,  the BMD value  by posterior–anterior measurement of  spine BMD via DXA (PA-DXA) was  significantly higher  in women with de- generative diseases changes, particularly  when osteophytes were present at  the  vertebral bodies or facet joints, whereas  BMD by lateral DXA (L-DXA) was less  affected  [18].  In  cross-sectional  stud- ies of postmenopausal women of vari- ous age groups the accuracy of  lumbar  spine BMD measurement decreased  with  increasing  age because of  spinal  osteoarthrosis  in  the  elderly  popula- tion [21]. The accuracy errors for spine  PA-DXA can vary  from 4%–10% and  the accuracy error  for proximal  femur  DXA measurement was  estimated  at  6% [22]. The  amount  of  fat  to  lean  body  mass  surrounding  tissues could affect  the  tissue-density gradient assessed by  DXA and  influence  the  accuracy  and  reproducibility of BMD measurements.  Postmenopausal women with greater  body weight, mediated by  lean body  mass or fat body mass, have both higher  lumbar  spine,  hip  and  femoral  neck  BMD and lower rate of bone loss [23].  In the present study, disproportionately  higher than expected values of BMD T- score in the spine of the fracture group  compared to the femoral neck site could  be attributed  to  the higher prevalence  of osteoarthritis  in the spine compared  with  the hip. Although we did not de- termine  the  frequency of osteoarthritis  at the spine or hip, a high proportion of  degenerative  joint disease  is  expected  to be present  in our patients based on  another  study  in  the  Islamic Republic  of Iran in which spine degenerative dis- eases were found in 16.6% of the urban  population aged 15 years and over, and  hip osteoarthritis  in only 0.32% of  the  10 921  study population  [24]. A  low  prevalence  of  hip  osteoarthritis  was  also  reported  in other  studies  [25,26],  whereas arthritis of  lumbar  facet  joints  is a common radiographic finding which  has been  linked  to  low back pain.  In a  study of 647 cadaveric human  lumbar  spines examined by a  single examiner,  facet  arthrosis was  a universal finding  in 100% of patients aged 60 years and  over [27]. Low  sensitivity  of  BMD T-score  was  also  shown  in  a  study of 74 men  from the MINOS study.  In  that  study,  27%–47% of incident fractures occurred  in men with  BMD T-scores  –1  and  –2, whereas  the percentage of  incident  fractures occurring with BMD T-score  < –2 ranged from 13.7%–44.6%. BMD  T-score had  limited value  in determin- ing men at increased risk of fracture and  its  sensitivity  for  recognizing high-risk  individuals was low [28]. Site-discordant fracture risk, as seen  in  the present study was also observed  in a study of 200 men with mean age of  54.7 years. In that study, a T-score < –2.5  in the femoral neck was associated with  a 2.7-fold increase in the risk of vertebral  fracture, while a T-score < –2.5  in  the  spine was associated with only a 2-fold  increase in risk. Both femoral neck and  spine BMD were significant predictors  of  the presence of  a  vertebral  fracture  but the femoral area was the best site for  BMD measurements [16]. The sensitivity and accuracy of BMD  parameters have not been compared in  any previous  studies. The findings of  the present study provide new data and  extend  the evidence-based knowledge  about  the  utility  of  BMD Z-score  in  discriminating between the fracture and  the nonfracture  group. Based on our  findings,  the BMD Z-score may be  a  useful  tool, not only  for BMD assess- ment, but also for recognizing high-risk  patients.  In  addition, our findings  are  consistent with  the  results of  a previ- ous  study concerning  the accuracy of  femoral  neck T-score  in  recognizing  postmenopausal women at high risk for  vertebral fracture [16]. The limitations of our study should  be  considered. The  study  sample was  small and the study design did not per- mit us to perform statistical analysis for  prediction of future fractures. However,  to compensate for the small sample we  employed appropriate tools for charac- terizing the utility of BMD for discrimi- nating fracture and nonfracture sites.  Another  issue  is  that  the data pro- vided  in  this  study were susceptible  to  information bias with  respect  to bone  density measurement  at  the  time  of  vertebral  fracture  as well  as  early per- formance of  radiographic  intervention  at  the  time of presentation with acute  back pain. Despite  the clinical  criteria  for  sample  selection, we could not be  certain that the vertebral fractures under  review were  incident  fractures  rather  than prevalent  fractures with symptom  exacerbation. However, development  of acute back pain and presence of local- ized tenderness at the site of the fracture  are  evidence  in  favour of  their  being  incident fractures.  The focus of this study was to deter- mine  the contributive  role of BMD in  the development of vertebral fracture, so  the influence of other factors that might  be  responsible  for  the occurrence of  vertebral fractures were not considered  in  the statistical analysis. On the other  hand,  since both  the  fracture  and  the  nonfracture  groups were drawn  from  a population of  the  same geographic  location with similar racial and cultural  characteristics,  the  influence of other  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 873 factors  would  be  expected  to  affect  both  fracture and non-fracture groups  equally.  In  conclusion,  the findings of  this  study  indicate  that  postmenopausal  women with vertebral fracture have sig- nificantly lower BMD values at the spine  as well as at the femoral neck compared  with women without  fracture.  Since  the presence of  degenerative disease  in  the elderly population  leads  to  false  elevation of  spine BMD in postmeno- pausal women with vertebral  fractures,  BMD Z-score may be more  sensitive  and  diagnostic  than  BMD  T-score  both  for detecting  low bone mass and  for  recognizing women at high  risk of  fracture. However,  femoral neck BMD  T-score is  less affected by degenerative  joint disease and remains highly  sensi- tive with greater accuracy in recognizing  high-risk women. The  results  of  this  study require to be confirmed by further  studies with larger samples. 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Bone mineral density predicts osteoporotic frac-28. tures in elderly men: the MINOS study. Osteoporosis Interna- tional, 2005, 16:1184–1192. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 874 A study on preference and practices of women regarding place of delivery S.S. Mahdi1 and O.S Habib 2 ABSTRACT This was a cross-sectional study in Basra, and involved 353 women who had recently given birth drawn from health care institutions. The main objective was to determine the factors that helped determine the women’s choice of place of delivery: hospital or home. Only 16.1% delivered at home, while 83.9% delivered in hospital. The main reasons for choosing hospital delivery were safety and security (96.6% of the women), better hygiene (66.6%) and because of medical advice (63.2%). The main reasons for the choice of home delivery were social support and privacy (98.2%). The women were consistent in their choice of delivery place across different pregnancies (previous, present and future). 1Directorate of Health Services, Basra, Iraq (Correspondence to O.S Habib: omran49_basmed@yahoo.com). 2Department of Community Medicine, College of Medicine, University of Basra, Basra, Iraq. Received: 28/12/08; 15/02/09 ةدلاولا ناكم لوح ءاسنلا تاسراممو ليضفت بيبح ركس نارمع ،يدهم نمالس ةيفص ضرغلا ناك دقو .ةيحصلا ةياعرلا تاسسؤم في ًاثيدح اهدولوم تعضو ةأرما 353 تلمش ،ةصربلا في ةيضرع ةسارد نوثحابلا ىرجأ :ةـصلالخا نأ نوثحابلا ظحلا دقو .تيبلا مأ ىفشتسلما ؛ةدلاولا ناكم ءاقتنا لوح رارقلا ءاسنلا ذاتخا في تدعاس يتلا لماوعلا لىع ف ُّرعتلا ةساردلل سييئرلا ةملاسلاو ناملأا يه ىفشتسلما في ةدلاولا نهرايتخلا ةيسيئرلا بابسلأا نأو ،ىفشتسلما في ندلو نهنم %83.9و ،لزنلما في ندلو طقف نهنم %16.1 يعماتجلاا معدلا يهف لزنلما في ةدلاولا رايتخلا ةيسيئرلا بابسلأا امأ .)%63.2( ةيبط ةزهجأ دوجو ببسبو )%66.6( لضفأ ةفاظنو ،)%96.6( .)ةقحلالاو ةيلالحاو ةقباسلا( ةفلتخلما لوملحا برع نتهدلاو ناكلم ءاسنلا رايتخا في قاستلاا نوثحابلا ظحلا دقو .)%98.2( ةيصوصلخاو Étude portant sur les préférences et les pratiques des femmes quant au lieu d’accouchement RÉSUMÉ Cette étude transversale réalisée à Bassora concernait 353 femmes ayant accouché peu de temps auparavant dans un établissement de soins. L’objectif principal était de déterminer les facteurs ayant influencé le choix de ces femmes en ce qui concerne le lieu d’accouchement : à l’hôpital ou à domicile. Seules 16,1 % des parturientes ont accouché chez elles, contre 83,9 % à l’hôpital. Les principales raisons ayant motivé les femmes à choisir l’hôpital pour accoucher étaient la sûreté et la sécurité (pour 96,6 % d’entre elles), une meilleure hygiène (66,6 %) et les conseils médicaux (63,2 %). Le soutien social et le respect de la vie privée (98,2 %) constituaient les raisons majeures ayant motivé les femmes à accoucher chez elles. Les femmes sont restées fidèles à leur choix concernant le lieu d’accouchement, y compris pour les grossesses à venir. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 875 Introduction One  of  the  issues  to  be  considered  in  studying  the  place  of  delivery  for  pregnant women  is  the  importance of  women’s choice,  and  the  role of  tech- nology as a  facilitator,  allowing choice  to be exercised safely [1]. The view of professionals on where  women  should  deliver  is mixed  [1].  Some consider pregnancy  is always as- sociated with risk and hospital delivery  is recommended for all pregnant wom- en. Others  suggest  that home delivery  might be safe for women with a low-risk  profile and when supervision is made by  trained professionals. A third view  is  in  the middle and sees the place of delivery  a  joint  judgement between profession- als  and  clients. These  views  illustrate  the  current  differences  between  the  medical and midwifery models of care.  The former declares that  labour is only  ever normal in retrospect (i.e. all labour  should be considered a complication),  whereas the latter says that most labours  are  normal  and  should  be  treated  as  such [1]. As  a  trend,  the  demand  for  birth  centres  and midwifery  services  varies  in different countries. Birth centres and  midwifery  services  grew  substantially  over the last decades of the 20th century  in the United States of America (USA)  [2].  In  the  United  Kingdom  (UK),  after a low point in the mid-1970s, mid- wifery has regained popularity after the  wide-spread  introduction of midwifery  teams with improved continuity and full  responsibility  for  total  care  in normal  cases [1]. In Turkey, home delivery rep- resents only a small fraction of the total  reported deliveries [2], while in Tunisia,  community health  centres  staffed by  university-educated midwives are well  dispersed  throughout  the country and  most deliveries are  in these health cen- tres, or in local hospitals or clinics [2]. Utilization of health  care  services,  including maternal  services,  is  deter- mined by complex  interacting  factors [3–6]. Common determinants are level  of  need,  distance,  economic  factors,  awareness  and  satisfaction,  sociode- mographic characteristics and admin- istrative arrangements. With respect  to  delivery, these factors definitely operate.  Other determinants  include  traditions,  fear of death,  the perception of  risk on  health,  the perception of  intervention,  presence of special problems and com- plications, level of information available  to clients and cost of care or  family  in- come [2,5–8]. Previous field studies carried out in  Basra  indicated  that hospital delivery  represented about 76.2% of all reported  deliveries. The  remaining  deliveries  took place at home either under the su- pervision of  trained midwives (11.4%)  or  untrained  midwives  (12.4%)  [9,  Department of Primary Health Care/ Basra, unpublished report, 2007].  The governmental health care  sys- tem in Iraq is the main source of health  care. Hospitals and health centres where  delivery care  is available are  staffed by  doctors and trained midwives. The sys- tem has been extensively damaged  in  the past 2 decades  [10]. Accordingly,  patient  interaction  with  the  system  might  have  changed with  respect  to  changed perception of quality of  care  by consumers. It would be useful there- fore to explore the views of consumers  on  their preferences  regarding specific  items of care,  such as place of delivery  for pregnant women. Understanding  the  forces  behind  choice  of  place  of  delivery will improve the health services  delivery  and assist  in directing efforts  towards better use of  resources. Thus  this  study was  carried out  to  identify  the  factors  affecting  the preference of  women regarding place of delivery. Methods This was a cross-sectional  study  to  in- vestigate  the preference of women  in  Basra about  the place of delivery (hos- pital or home) and factors affecting this  preference. The study was carried out in  Basra City over a period of 10 months  from January to October 2007. The  studied  women  were  those  who  had  delivered  a  baby within  40  days of the interview. They were drawn  from 2 sources: Al-Basra Maternity and  Children’s Hospital, covereing women  admitted with  their babies  for  reasons  unrelated to delivery; the second source  was primary health  care  (PHC) cen- tres and included women attending the  centres  for BCG vaccination of  their  babies.  Four PHC centres were  ran- domly  selected  from a  list of 20 PHC  centres in the first health sector in Basra.  Women were  selected  from  those  at- tending  the health  centres during  the  morning working hours and who had a  baby born within 40 days of the date of  the  interview. The study  included 353  women, 117  from  the primary health  centres and 236  from the hospital. Of  theses,  226 women were  from Basra  City centre and 127 from outlying dis- tricts and remote areas of Basra gover- norate. A special unvalidated questionnaire  form was designed by  the  researchers  to obtain  information on  sociodemo- graphic characteristics of the women, the  distance between the place of residence  and nearest official delivery facility, par- ity, place of delivery of present, first, pre- vious and  future child when applicable  and reasons behind choosing home or  hospital delivery. Data were collected  through direct interviews of the women  by  the  investigators. The women gave  informed verbal consent  to participate  and there were no refusals. Data were analysed with SPSS, ver- sion 11 and frequencies are presented. Results Demographic characteristics of the women Table 1 shows the age distribution of the  women. Women aged 20–29 years rep- resented the highest proportion (56.9%)  EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 876 while there were very few women aged  40 years and above, accounting for only  0.8%  .  Just  above  one-third  (34.3%)  of  the women had completed primary  education, while 37.4% were either  il- literate or  just  able  to  read and write.  Almost 14% had an education  above  secondary  level (Table 1). Most of  the  women were housewives not working  outside the home (90.7%). The majority  of  the women were  from Basra City (64.0%) with far fewer  coming  from the other 4 areas (Table  1). The great majority (82.4%) needed  less than half an hour to reach a place of  delivery; only 2.5% needed more  than  1 hour. Parity and use of prenatal care Most  of  the  women  had  had  either  2–3 previous births (39.1%) or 1 birth  (36.3%) (Table 2). Only 8.2% had par- ity above 5. Just under two-thirds of the  women (64.6%) had 5 or more visits to  prenatal  care clinic. Less  than 6% had  had no prenatal visits at all. Place of delivery Most previous deliveries of the women  took  place  in  hospital  (Table  3). Nearly 84% of the present children were  delivered at hospital and only 16% were  delivered at home. Similarly the place of  delivery of  the first child and previous  child was hospital  in 82.2% and 75.1%  of women respectively. When women  were asked where they would have their  next  child delivered,  83.3%  said  they  would have it in hospital.  Reasons for choice of delivery site The most  frequent  reason  given  for  preferring a hospital delivery was  that  the hospital was safe and secure (from  the  health  point  of  view)  (96.6%  of  the women) (Table 4). The hygiene of  hospitals was the reason given by 66.6%  of the women. Emergency transfer from  midwife  to  hospital was  reported  by  5.4% of  the women and  lack of  avail- ability of a midwife by 2.4%. The  reasons  reported  by women  who delivered at home  for preferring  home delivery are also shown in Table  4. Social  support  and privacy was  the  predominant reason given by 98.2% of  the women who had home delivery of  their present child. Fear of interventions  and repeated examinations at hospitals  was the concern of 71.9% of the women  who preferred home delivery. About  17.5% had an unplanned home delivery  as a  result of quick  labour or  the secu- rity  situation did not allow  transfer  to  hospital. Discussion We attempted  to understand some of  the  factors  that  influence  the choice of  women regarding  the place of delivery  as  reported  by  women  themselves.  Hospital delivery prevailed among  the  studied women: 83.9% had  their  last  delivery  in  hospital  and  only  16.1%  took place at home. This result is similar  to  the  findings  reported  by  primary  health  care  centres  in Basra  [Depart- ment of Primary Health Care/Basra,  unpublished report, 2007] for the years  2004, 2005 and 2006 and showed that  Table 1 Distribution of the women according to age, education, occupation, place of residence and time taken to travel to the nearest place of delivery (n = 353) Variable No. % Age (years) < 20 59 16.7 20–29 201 56.9 30–39 90 25.5 ≥ 40 3 0.8 Education Illiterate 85 24.1 Read and write 47 13.3 6 years 121 34.3 7–9 years 39 11.0 10–12 years 12 3.4 ≥ 13 49 13.9 Occupation Housewife 320 90.7 Working outside the home 33 9.3 Place of residence Basra City Centre 226 64.0 Northern Areaa 43 12.2 Western Areab 47 13.3 Southern Areac 28 7.9 Eastern Aread 9 2.5 Travel time to place of delivery (minutes) < 10 31 8.8 10–19 135 38.2 20–29 125 35.4 30–59 53 15.0 ≥ 60 9 2.5 aQurna, Mdaina and Hartha. bZubair, Safwan and Um-Qasr. cAbul-Khasib and Fao. dShatt-Al-Arab. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 877 hospital  delivery  represented  68.7%,  72.9% and 74.9%  respectively. These  figures  indicate 2  things: first, hospital  delivery is common and, second, hospi- tal delivery is increasing with time. Such  a high use of hospital delivery care could  reflect a high degree of people’s aware- ness of  the need  for a  safe and  secure  place  for delivery where qualified staff  and opportunities for medical interven- tion,  if needed, are available, unlike  the  situation  in home deliveries. The  issue  of safety is a matter of judgement. Some  studies have shown that home delivery  in some communities may be as safe as  hospital delivery,  for  example  a  study  carried out on Nordic women in 1994  [11]. The reasons given by the women for  preferring hospital delivery are rational.  Safety and security were the reasons be- hind the choice of 96.6% of the women  who had a hospital delivery and  these  are undoubtedly valid. It indicates a high  level of  awareness among  the women  of health  issues  regarding delivery and  the value given to their own health and  that of  their unborn baby. Child birth  is not a  laboratory project  that can be  reproduced  at will  [12] but  a natural  event that in many situations cannot be  predicted  in exact  time,  sequence and  ease or difficulty. Hygiene was the second  important  reason  for  the choice of hospital deliv- ery,  reported by 66.6% of  the women.  This  reflects  both  the  recognition  of  women of the importance of hygiene for  delivery and  their expectation of good  hygiene standards in hospitals. Medical  advice  was  a  common  reason  for preferring hospital delivery,  reported by 63.2% of  the women who  had hospital delivery. This  is an impor- tant point. As  the  influence of doctors  and other health staff increases, as could  happen  if  the  family  health model  is  widely adopted, the demand for hospi- tal delivery is likely to increase.  Having  a  hospital  delivery  be- cause  of  a  recognized  risk  (high-risk  pregnancy)  reflects  the  success  of  prenatal  care  in  identifying high-risk  women and encouraging them to make  the  appropriate  choice  for  delivery.  Similar  results have been  reported by  other  studies  carried  out  in  the UK  [13] and Canada [14] where high-risk  pregnancies were more frequent among  hospital-delivered women than home- delivered women. As  regards personal  choice, 71.9%  of hospital-delivered women claimed  that  it was  their own personal  choice  to  request hospital as  the place  for de- livery. This was also reported in a study  in Canada  in 1999  [7]. The study  in  Canada  also  reported  the  role of  the  family  in  determining  the  place  and  even the mode of delivery. The predominant  reason  reported  by home-delivered women  for prefer- ring home delivery was  social  support  and/or privacy,  reported by 98.2% of  the women. Social support was through  birth  attendant,  relatives,  friends  and  others, and is a very important factor for  reassurance and support in the progress  and  outcome  of  labour. This  feeling  Table 2 Distribution of women according to parity and use of prenatal care (n = 353) Characteristic No. % Parity 1 128 36.3 2–3 138 39.1 4–5 58 16.4 > 5 29 8.2 No. of prenatal visits None 20 5.7 1–2 41 11.6 3–4 64 18.1 Sub-total (inadequate use) 125 35.4 5–6 115 32.6 7–8 56 15.9 9–10 42 11.9 11–12 11 3.1 ≥ 13 4 1.1 Sub-total (adequate use) 228 64.6 Table 3 Distribution of the women according to place of delivery (n = 353) Place of delivery No. % Present child Home 57 16.1 Hospital 296 83.9 First child Home 40 17.8 Hospital 185 82.2 Previous child Home 56 24.9 Hospital 169 75.1 Next child Home 59 16.7 Hospital 294 83.3 EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 878 James DK et al., eds. 1. High risk pregnancy. Management options in labour, 2nd ed. London, WB Saunders, 1999:1071–2. Mother-baby package.2. Implementing safe motherhood in coun- tries. Geneva, World Health Organization, 1994 (WHO/FHE/ MSM/94.11). Habib OS, Vaughan, P. The determinants of health services 3. utilization in Southern Iraq. International Journal of Epidemiol- ogy, 1986, 15:395–403. Habib OS. [4. Health services in Basrah: facts and future perspec- tives]. Basra, Ahmed Al-Ali Press, 2008 [In Arabic]. Ouakrim M, Badr A. Overall view of the health status of women 5. and its determinants in the Eastern Mediterranean Region. Eastern Mediterranean Health Journal, 1996, 2:545–556. Kaartinen L, Diwan V. Mother and child health care in Kabul, 6. Afghanistan with focus on mother: Women’s own perspec- tive. Acta Obestetricia et Gynecologica Scandinavica, 2002, 81(6):491–501. Blais R. Are home births safe? 7. Canadian Medical Association Journal, 1999, 166(30):335–337. Live births by place of delivery and race of mother8. . Atlanta, Cent- ers for Disease Control and Prevention, 1992:246. References Habib OS, Al-Azawi HKF, Ajeel NAH. Household surveys as 9. a source of information to support primary health care: An example from Basrah. Medical Journal of Basrah University, 2000, 18:13–18. Alwan AA. 10. Health in Iraq: A review of the current health situation, challenges facing reconstruction of the health sector and vision for the immediate future. Baghdad, Al-Adib Press, 2004. Olsen O. Hjemmefodsler og videnskabelig tankegang [Home 11. delivery and scientific reasoning]. Tidsskrift for den Norske Laegeforening, 1994, 114(30):3655–3657. The compleat mother12. . Homebirth: as safe as birth gets. (http:// www.compleatmother.com/homebirth/hb_safety.htm, ac- cessed 25 April 2010). Chamberlain G, Wraight A, Crowley P, eds. 13. Home births - The report of the 1994 Confidential Enquiry by the National Birthday Trust Fund. Carnforth, Parthenon Publishing, 1997. Tyson H. Outcome of 1001 midwife attended home birth in 14. Toronto, 1983–1988. Birth, 1991, 18(1):14–19. MacVicar J et al. Simulated home delivery in hospital: A ran-15. domised controlled trial. British Journal of Obstetrics and Gynae- cology, 1993, 100(4):316–323. Olsen O. Meta-analysis of safety of the home birth. 16. Birth, 1997, 24(1):4–13. may make  it  less  feasible  to  convince  such women  to have hospital delivery  and undermines the view that all labour  events should be considered a compli- cation waiting  to happen until proved  otherwise  [1]. The  privacy  of  home  does make it a more comfortable place  for delivery and  if  the birth  is attended  by  trained midwives,  it may be as  safe  as hospital delivery  [1]. Other  studies  agree with our finding of the importance  of support in home delivery. In the UK,  for example, a number of studies found  that home delivery provided more than  just  sympathetic care  in a nicely deco- rated room [13,15]. For many women,  the benefit of delivering at home comes  from  the  feeling of privacy  and being  surrounded  by  family members  and  friends. Our study also showed that fear  Table 4 Reasons given by the women for the choice of hospital or home delivery Reasona No. % Hospital delivery (n = 296) Safe and secure 286 96.6 More hygienic place 197 66.6 On medical advice 187 63.2 Recognized high risk factor 99 33.4 Emergency 16 5.4 Others (No midwife available) 7 2.4 Home delivery (n = 57) Social support and/or privacy 56 98.2 Fear of intervention in hospital 41 71.9 Unplanned (delivery quick or at night) 10 17.5 aMore than one reason could be given. of  interventions  (medical  and  surgi- cal) and  repeated vaginal examination  in hospital was an  important  factor  in  avoiding hospital delivery as  reported  by 71.9% of  the women who preferred  home delivery.  Indeed, a  study carried  out  in Denmark  in 1997 on  low-risk  women  planning  home  or  hospital  births  showed  that  the planned home  birth group had less severe maternal lac- eration,  fewer  interventions and  fewer  episiotomies [16]. The results of our study represent  the studied women only and we can- not claim to generalize these results to  all women in Basra governorate. How- ever, there is no reason to believe that  these results do not reflect the general  situation  in  the community of Basra  governorate.  In  conclusion, most of  the women  in our  study preferred a  hospital delivery but nearly 1 in 6 pre- ferred home delivery. Both groups had  their own expressed  justifications  for  their choices. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 879 Connaissances et pratiques des femmes de la région de Monastir (Tunisie) concernant l’allaitement maternel I. Bouanene,1 S. ElMhamdi,1 A. Sriha,1 A. Bouslah2 et M. Soltani1 RÉSUMÉ Nous avons étudié la prévalence, les connaissances, les pratiques et les facteurs déterminants de l’allaitement maternel auprès de 354 mères amenant leur nourrisson pour la vaccination du sixième mois aux centres de santé de base de la région de Monastir en 2008. L’âge moyen des femmes interrogées était de 30 ans (ET 5,5). La majorité (90,8 %) savait que l’allaitement au sein permet de prévenir les infections chez le bébé mais 38,5 % seulement savaient que le lait maternel peut couvrir à lui seul les besoins de l’enfant jusqu’à l’âge de 6 mois. Alors que 94,4 % des femmes ont allaité au sein à la naissance, uniquement 1,9 % d’entre elles ont poursuivi l’allaitement exclusif jusqu’à l’âge de 6 mois. Les causes d’abandon de l’allaitement maternel étaient principalement l’insuffisance du lait, suivie par la reprise du travail. Une durée d’allaitement maternel exclusif prolongée au-delà de 3 mois était associée au contact peau à peau (OR = 1,93 ; IC 95 % : 1,016-3,69) et aux connaissances des mères des bénéfices du lait maternel (OR = 2,8 ; IC 95 % : 1,2-6,6). Cependant, l’utilisation de la tétine et la prescription de compléments de lait artificiel étaient associées à un sevrage précoce (OR = 0,17 ; IC 95 % : 0,08-0,36 et OR = ,14 ; IC 95 % : 0,05-0,38, respectivement). 1Département de Médecine communautaire, Faculté de Médecine de Monastir, Monastir (Tunisie) (Correspondance à adresser à I. Bouanene : bouaneneines@gmail.com). 2Service régional des Soins de Santé de Base, Monastir (Tunisie). Reçu : 18/10/09; accepté : 08/12/09 )سنوت( يرتسنولما في ءاسنلا ىدل يدثلا نم يعيبطلا عاضرلإا في تاسرمالماو فراعلما نياطلس دممح ،حلاصوب لامآ ،ةيحسر ءماسأ ،يدمحلما ءانس ،نانعوب سانيإ زكارم عجارـت ةأرما 354 ىدل كلذو ،ههاتج نهفقاومو ءاسنلا فراعمو ،هتاددمحو ،يدثلا نم يعيبطلا عاضرلإا راشتنا لدعم نوثحابلا ميق :ةـصلالخا ءلاؤه مظعم نأو ،)5.5 يرايعم فارحناب( ًاماع 30 ةوسنلل يطسولا رمعلا نأ اودجوو ،2008 ماع في يرتسنولما ةقطنم في ةيلولأا ةيحصلا ةياعرلا يدثلا نبل نأ نفرعي طقف نهنم %38.5 نأ لاإ ،ىودعلاب نادلولا ةباصإ نم ةياقولا في دعاسي يدثلا نم يعيبطلا عاضرلإا نأ نفرعي )%90.8( ةوسنلا نهنم طقف %1.9 نإف ،يدثلا نم ننهادلو عاضرإب نأدب دق نهنم 94.4 نأ مغرو .رمعلا نم سداسلا رهشلا غلبي ىتح ماعطلا نم هجاتيح ام ديلولل مدقي ،ٍفاك يرغ يدثلا نبل نأب داقتعلاا يه يدثلا نم ةعاضرلا فاقيلإ ةيسيئرلا بابسلأا تناكو .روهش تس ىتح يدثلا لىع صرتقلما عاضرلإاب رمتسا ،1.93 ةيحجرلأا لدعم( ديلولاو ملأا ينب ميملحا سماتلاب روهش 3 ةدلم يدثلا نم عاضرلإا لىع راصتقلاا قفارـت دقو .لمعلا لىإ ةدوعلا كلذ ولتيو تحوارـتو ،%95 ةقثلا ةلصافو ،2.8 ةيحجرلأا لدعم( يدثلا نبل دئاوف نع ملأا فراعمبو .)3.69و 1.016 ينب ميقلا تحوارـت ذإ ،%95 ةقث ةلصافو ،0.36و 0.08 ينب ميقلا تحوارـتو %95 ةقثلا ةلصافو ،0.17 ةيحجرلأا لدعم( ةياهللا مادختساب ركبلما ماطفلا قلعت دقو .)6.6و 1.2 ينب ميقلا .)0.38و 0.05 ينب ميقلا تحوارـتو 95% ةقثلا ةلصافو ،0.14 ةيحجرلأا لدعم( يدثلا نبل لئادبو Knowledge and practices of women in Monastir, Tunisia regarding breastfeeding ABSTRACT We assessed the prevalence of breastfeeding and its determinants and mothers’ knowledge and practices towards this issue among 354 women attending primary health centres for their child’s 6- month vaccination in the region of Monastir in 2008. The mean age of the women was 30 (SD 5.5) years. Most (90.8%) knew that breastfeeding helped prevent infections in babies but only 38.5% knew that breast milk supplies all infant feeding needs until 6 months of age. While was 94.4% breastfed their babies to start, only 1.9% continued exclusive breastfeeding until 6 months. Main reasons for stopping breastfeeding were perceived breast milk insufficiency followed by return to work. Exclusive breastfeeding over 3 months was associated with skin-to-skin contact (OR = 1.93; 95% CI: 1.016–3.69) and mothers’ knowledge about breast milk benefits (OR = 2.8; 95% CI: 1.2-6.6). Early weaning was related to using pacifiers and breast-milk substitutes (OR = 0.17; 95% CI: 0.08–0.36 and OR = 0.14; 95% CI: 0.05–0.38 respectively). EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 880 Introduction Les  vertus  de  l’allaitement maternel  concernent aussi bien la santé de la mère  que celle de son enfant, et s’observent à  court et à  long terme, se traduisant par  une  réduction  de  la morbi-mortalité  infantile [1,2]. L’OMS  recommande  un  allaite- ment maternel  exclusif  durant  les  six  premiers mois de vie du bébé [3]. Selon  les experts,  la poursuite de l’allaitement  exclusif  pendant  six mois  permet  un  développement optimal des nourrissons  et doit être encouragée,  l’introduction  d’une  alimentation  complémentaire  entre  quatre  et  six mois  n’apportant  aucun bénéfice particulier. En effet,  le  rôle de  l’allaitement maternel exclusif  dans la prévention des infections, des al- lergies et des maladies chroniques ainsi  que  dans  le  développement  cognitif  favorable a été mis en exergue dans  la  littérature scientifique récente [4]. En  Tunisie,  avant  1960,  la  pra- tique  de  l’allaitement maternel  était  la  règle  conformément  aux  normes  religieuses et  sociales  [5]. Par ailleurs,  notre pays a vécu, après l’indépendance,  l’émancipation  des  femmes  liée  à  la  promulgation du  code du  statut per- sonnel, permettant à celles-ci  l’accès à  l’éducation et  au  travail,  avec  comme  corollaire  un  abandon  précoce  de  l’allaitement maternel ces dernières an- nées, malgré  les  nombreuses  actions  législatives et promotionnelles en faveur  de la protection de cette pratique.  Les données nationales montrent  un recul du pourcentage des enfants al- laités exclusivement au sein jusqu’à l’âge  de 6 mois [6]. En effet, ce taux est passé  de 46,5 % en 2000 à 6,2 % en 2006. Pour pouvoir mettre  en place des  interventions  visant  à  promouvoir  l’allaitement maternel dans  la durée,  il  est important de connaître les différents  déterminants en jeu. C’est dans ce cadre  que s’inscrit notre travail qui vise l’étude  des connaissances et des pratiques des  mères vis-à-vis de l’allaitement maternel  et  l’identification des  facteurs détermi- nants d’un sevrage précoce.  Méthodes C’est une étude transversale descriptive  exhaustive  réalisée durant  le deuxième  trimestre de l’année 2008, portant sur les  connaissances et les pratiques des mères  en matière d’allaitement maternel. Notre population d’étude était con- stituée de  l’ensemble des  femmes qui  ont amené leur nourrisson pour la vac- cination du 6e mois (3e prise du DTCP  + HBV) aux centres de santé de base de  la région sanitaire de Monastir. À partir  de cette population et en se basant sur  une prévalence d’allaitement maternel  de 6,2 % (données du Multiple Indicator Cluster Survey  - MICS  III  [6])  et une  précision de 3 %, nous avons étudié un  échantillon de 354 mères. Nous  avons  exclu  de  cette  étude  toutes  les  femmes qui n’ont pas allaité  leur  bébé  à  cause  d’une maladie  de  l’enfant entravant cette pratique (mal- formations du  tube digestif,  anomalie  congénitale du métabolisme, hospitali- sation en soins intensifs, etc.), ainsi que  toutes les femmes n’ayant pas allaité leur  enfant dès l’accouchement à cause d’une  maladie contre-  indiquant  l’allaitement  maternel  (maladie mammaire,  infec- tion  par  le VIH,  hyperprolactinémie  majeure, etc.).  Le  recueil des données était  réalisé  à l’aide d’une entrevue structurée basée  sur  un  questionnaire  préalablement  testé  et  administré  aux mères par des  enquêteurs formés.  Le questionnaire explore les dimen- sions suivantes :  le profil  socioéconomique et démo-• graphique  des mères :  âge,  origine  urbaine  ou  rurale,  niveau  d’ins- truction, profession, parité et âge du  dernier enfant ; les caractéristiques de  la grossesse et • de  l’accouchement :  suivi et compli- cations éventuelles ; les  connaissances  et  les  pratiques • des mères  concernant  l’allaitement  maternel  et  la  diététique  infantile :  bénéfices  du  lait  maternel,  durée  d’allaitement maternel exclusif, délai  entre  l’accouchement et  la première  tétée,  utilisation  de  tétine,  supplé- mentation en  lait  artificiel  et  âge de  diversification alimentaire ; le  rôle du père,  de  la  famille  et des • professionnels de santé ; les   causes   d’arrêt   précoce  de • l’allaitement maternel. Dans  notre  travail,  nous  avons  considéré que  les mères qui  savaient  au  moins  quatre  des  huit  bénéfices  de  l’allaitement maternel  cités dans  le  questionnaire  avaient de bonnes con- naissances. Les données ont été rassem- blées,  codées  et  saisies  sur  matériel  informatique avec le logiciel SPSS 15.0.  Les facteurs associés au sevrage précoce  ont été recherchés parmi les caractéris- tiques  citées  ci-dessus. Les  comparai- sons ont été  réalisées à  l’aide des  tests  statistiques appropriés (test du χ2,  test  exact de Fischer),  au seuil de significa- tion de 5 %. Définitions opérationnelles L’allaitement est exclusif lorsque le nou- veau-né ou le nourrisson reçoit unique- ment du  lait maternel à  l’exception de  tout autre  ingestat,  solide ou  liquide, y  compris  l’eau. L’allaitement est partiel  lorsqu’il est associé à une autre alimen- tation comme des substituts de lait, des  céréales, de l’eau sucrée ou non ou toute  autre nourriture [3]. Le  critère  de  jugement  principal  que nous avions choisi pour évaluer les  déterminants d’une durée prolongée  de  cette  lactation était  le  sevrage pré- coce, défini comme étant  la  cessation  de  l’allaitement maternel exclusif avant  l’âge de 3 mois.  Résultats Caractéristiques de la population étudiée L’âge  moyen  de  notre  population  d’étude  était  de  30  (écart  type  [ET]  5,5) ans avec des extrêmes allant de 18  à 46 ans. Les femmes aux âges extrêmes  de la procréation (< 20 ans ou ≥ 35 ans)  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 881 représentaient 1,7 % et 21,5 % respec- tivement. Parmi   les   354  mères   inter - rogées, 329 étaient  issues d’un milieu  urbain  (93,5  %).  Près  de  60  %  des  mères  (58,8 %)  étaient  sans  profes- sion  et  80,8  %  avaient  un  niveau  socioéconomique  moyen.  Un  bas  niveau d’instruction (analphabète ou  de niveau primaire) a été retrouvé chez  36,3 % des cas. La répartition des femmes  selon  la  parité  a montré  que  24,6 % étaient  des primipares  et  58,3 %  des  paucipares (Tableau 1). Connaissances des mères en matière d’allaitement Il  ressort  de  cette  étude  que  90,8 %  des  femmes  interrogées  savaient que  le  lait maternel  assure  la  prévention  des  infections chez  le bébé. Le  rôle de  l’allaitement maternel  dans  le  dével- oppement psychoaffectif de  l’enfant  a  été  signalé par 43,3 % des mères. Par  contre 8,8 % d’entres elles savaient que  l’allaitement maternel préserve  la  santé  de la mère (Tableau 2). Selon 99,3 % des femmes, la prise de  poids du bébé constituait  le  signe ma- jeur d’un allaitement maternel efficace  chez  l’enfant. Et  seulement 38,5 % des  mères savaient que le lait maternel peut  couvrir à lui seul les besoins de l’enfant  jusqu’à l’âge de 6 mois. Parmi  les  354  femmes  de  notre  série,  67 %  ont  bénéficié  de  séances  d’éducation sanitaire par les profession- nels de  santé en matière d’allaitement  maternel .   Cette  éducation  a  été  pratiquée  pendant  la  grossesse  dans  60,8   %  des   cas .   Les   médecins  représentaient  la  principale  source  d’information (72,4 %). Pratiques concernant l’allaitement maternel Près de trois quarts des mères (75,4 %)  ont déclaré avoir vécu antérieurement  l’expérience d’un  allaitement  au  sein.  Le choix du mode d’allaitement a  été  effectué pendant la grossesse dans 93,8  % des cas. L’encouragement du mari a  majoritairement (96,5 %) contribué à la  décision des femmes d’allaiter au sein.  Le  taux d’enfants  allaités  à  la nais- sance était de 94,4 %. Un contact peau  à peau entre mère et enfant a eu lieu en  salle d’accouchement dans 63,8 % des  cas. Concernant le délai de mise au sein  après  la naissance, 12 % des bébés ont  reçu  leur première  tétée à  la première  heure de vie, 21 % dans les 2 heures qui  suivent la naissance et 67 % à la 3e heure  de vie.  La durée moyenne de  l’allaitement  maternel  exclusif  était  de  40  (ET  45)  jours  avec des  extrêmes allant de  1  à  180  jours.  Plus  de  la moitié  des  femmes (55,6 %) ont allaité leur enfant  exclusivement au  sein  jusqu’à  l’âge de  1  mois.  À  l’âge  de  3  mois,  15,3  %  des  nourrissons  bénéficiaient  d’un  allaitement  maternel  exclusif.  Cette  pratique  continuait  à  diminuer  pour  atteindre 1,9 % à l’âge de six mois(Figure 1).  Le  recours  à  la  supplémentation  Tableau 1 Caractéristiques sociodémographiques de la population d’étude Variables Effectif % Âge (ans) < 25 54 15,3 25-35 224 63,3 > 35 76 21,5 Niveau d’instruction Aucun 15 4,3 Primaire 112 32,0 Secondaire 141 40,3 Supérieur 82 23,4 Origine Urbaine 329 93,5 Rurale 23 6,5 Profession Sans 207 58,8 Ouvrière 83 23,6 Cadre moyen 37 10,5 Cadre supérieur 21 6,0 Étudiante 4 1,1 Niveau socio-économique Bas 44 12,6 Moyen 282 80,8 Élevé 23 6,6 Parité 1 enfant 86 24,6 2-3 enfants 204 58,3 4 enfants et plus 60 17,1 Tableau 2 Connaissances des mères concernant les bénéfices de l’allaitement maternel Bénéfices % Prévention des infections 90,8 Développement psychoaffectif du bébé 43,3 Prévention des allergies 14,0 Préserve la santé de la mère 8,8 Prévention de l’obésité 1,2 Favorise la croissance du bébé 0,3 Prévention du diabète type 1 0,3 Prévention du risque vasculaire 0,0 EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 882 en  lait  artificiel  a  été  constaté  chez  16,7 % des enfants âgés de 3 mois. L’âge  moyen d’introduction de ce lait était de  2,6 mois.  Les mères étaient 78,9 % à déclarer  avoir utilisé une tétine pour leur enfant  avant l’âge de 3 mois. La diversification alimentaire pré- coce à partir de l’âge de 3 mois a été rap- portée dans un  tiers des  cas (33,3 %).  Cette  supplémentation  concernait  61,4 %  des  nourrissons  âgés  de  3  à  6 mois. À l’étude des raisons ayant con- duit  à  une  cessation  de  l’allaitement  avant  trois  mois,  on  a  constaté  que  la  première  cause  évoquée  par  les  mères pour  abandonner  l’allaitement  materne l   é t a i t   l e   manque   de  lait  (46,4 %),  suivi  par  la  reprise  du  travail (26,2 %) (Tableau 3). Facteurs associés à un allaitement maternel prolongé au-delà de trois mois L’étude des déterminants d’une durée  d’allaitement maternel exclusif > 3 mois  a  fait  ressortir  une  association  statis- tiquement significative avec  le contact  peau  à  peau  (p  <  0,03, OR  =  1,93  ;  IC 95 %  :  1,016-3,69)  et  le  niveau  des  connaissances des mères des bénéfices  de  l’allaitement maternel  (p  <  0,02 ;  OR = 2,8 ; IC 95 % :  1,2-6,6).  À  l’inverse,  l’utilisation  précoce  d’une tétine ou d’une sucette (p < 10-4)  ou  le  fait de donner des compléments  de lait artificiel (p < 0,003) était défavo- rable à  la poursuite de  l’allaitement. En  effet, ces deux  facteurs étaient associés  à un sevrage précoce avec OR = 0,17  ;  IC 95 %  :  0,08-0,36 et OR = 0,14  ;  IC 95 % :  0,05-0,38 respectivement (Tableau 4). Discussion Notre  étude  a  porté  sur  toutes  les  femmes de  la  région  sanitaire de Mo- nastir  ramenant  leur  enfant  pour  la  vaccination du  6e mois. Ce  choix  de  la population d’étude a permis de dé- terminer  la prévalence de  l’allaitement  maternel  exclusif  à  l’âge de 6 mois  tel  que recommandé par l’OMS. L’avantage principal du  lait mater- nel pour  l’enfant est  indiscutablement  la  protection contre les infections. D’autres  effets,  comme  la prévention de  l’atopie  ou  la réduction du risque d’obésité,  ren- dent  l’allaitement maternel déterminant  dans  l’état de santé ultérieur de  l’enfant.  D’après  toutes  les données de  la  littéra- ture, une durée  supérieure à  trois mois  est la durée à partir de laquelle tous les bé- néfices précédemment évoqués sont ob- servés. Et il a été démontré que si sa durée  Tableau 3 Principales raisons d’un sevrage précoce Causes de sevrage précoce % Manque de lait 46,4 Reprise du travail 26,2 L’enfant ne croît pas bien 16,7 Survenue de complications (crevasse, infection) 9,6 Prise de médicaments 3,6 Survenue de grossesse 3,6 Activité astreignante pour la mère 2,4 Raisons esthétiques 0,0 À la demande du mari 0,0 Autres 13,1 Durée d’allaitment maternel exclusif (mois) % d e fe m m es 60 50 40 30 20 10 0 1 2 3 4 5 6 55.6 15.3 15.3 8.1 3.8 1.9 Figure 1 Répartition des femmes selon la durée d’allaitement maternel exclusif طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 883 est  supérieure à  trois mois,  l’allaitement  maternel exclusif diminue  l’incidence et  la  gravité des  infections digestives, des  infections  oto-rhino-laryngologiques  (ORL) et respiratoires [7,8].  Pour  toutes  ces  raisons,  il  nous  a  paru  judicieux d’utiliser comme critère  de  jugement  principal  une  durée  d’allaitement maternel  exclusif  au-del  de 3 mois plutôt que 6 mois pour évaluer  les déterminants de cette pratique. Le  premier  fait   notable  dans  notre  étude  est  que  la  prévalence  de  l’allaitement maternel  à  la  naissance  était de 94,4 % .  Selon différentes  en- quêtes nationales réalisées entre 1996 et  2006, la quasi-totalité (93 à 97,5 %) des  femmes tunisiennes allaitent leur enfant  à  la naissance [6,9]. Ces valeurs  rejoi- gnent  les données de certains pays de  l’Europe du Nord [10]. À titre d’exemple,  la prévalence de l’allaitement maternel à  la naissance est de 90 % en Suède, en Su- isse et au Danemark, et de plus de 95 %  en Norvège et en Finlande. À  l’opposé,  cette prévalence en France est une des  plus faibles des pays européens (56 %).  Tableau 4 Association des caractéristiques sociodémographiques, des connaissances et des pratiques des femmes à une durée d’allaitement maternel exclusif > 3 mois Variablea Durée d’allaitement maternel exclusif p OR IC95 % < 3 mois > 3 mois Nbre (%) Nbre (%) Âge maternel (ans) (n=339) < 25 4 (16,3) 3 (6,8) 0,151 - - 25-35 187 (63,4) 28 (63,6) ≥ 35 60 (20,3) 13 (29,5) Instruction (n = 335) Néant ou primaire 108 (37,1) 12 (27,3) 0,135 - - Secondaire ou supérieur 183 (62,9) 32 (72,7) Profession (n = 338) Sans 173 (58,9) 26 (59,1) 0,55 - - Avec 121 (41,2) 18 (40,9) Parité (n = 336) 1 enfant 71 (24,3) 10 (22,7) 0,86 - - 2-3 enfants 171 (58,6) 25 (56,8) ≥ 4 enfants 50 (17,1) 9 (20,5) Origine (n = 337) Urbaine 278 (94,6) 39 (90,7) 0,24 - - Rurale 16 (5,4) 4 (9,3) Niveau socio-économique (n = 335) Bas 36 (12,4) 5 (11,4) 0,98 - - Moyen 236 (81,1) 36 (81,8) Élevé 19 (6,5) 3 (6,8) Contact peau à peau (n = 334) Oui 22 (18,6) 195 (90,2) 0,033 1,93 1,016-3,69 Non 96 (81,4) 21 (9,8) Connaissances des mères (n = 313) < 4 bénéfices 247 (96,5) 34 (60) 0,02 2,8 1,2-6,6 ≥ 4 bénéfices 9 (3,5) 23 (40) Utilisation du lait artificiel (n = 216) Oui 46 (17,5) 1 (2,3) 0,003 0,14 0,05-0,38 Non 217 (82,5) 42 (97,7) Utilisation de la tétine (n = 190) < âge de 3 mois 130 (81,8) 11 (52,4) < 10-4 0,17 0,08-0,36 ≥ âge de 3 mois 29 (18,2) 10 (47,6) aLes totaux varient en raison des données manquantes. OR = odds ratio ; IC = intervalle de confiance. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 884 La durée de  l’allaitement maternel  était  très  courte dans notre étude  :  sa  durée moyenne a été estimée à 40 jours.  L’allaitement à 4 mois a été maintenu  dans 8,1 % des cas. Cette prévalence de  l’allaitement maternel à  l’âge de 4 mois  est de plus de 65 % en Suède et en Suisse,  34 % au Canada, 27 % au Royaume-Uni  et 5 % en France [11]. Dans   notre   t rava i l ,   l e   t aux  d’allaitement maternel  exclusif main- tenu  jusqu’à  l’âge de 6 mois  était  très  faible (1,9 %). Ce résultat est compatible  avec des études menées dans d’autres  pays [12,13]. Ainsi, dans notre série, les pratiques  des mères demeurent  insuffisantes. En  témoigne  aussi  le démarrage précoce  de la diversification alimentaire à partir  de l’âge de 3 mois qui concernait le tiers  des nourrissons.  La  perception  d’une  insuffisance  de  lait  semble  être  la  raison majeure  amenant les mères à introduire le lait ar- tificiel et/ou à mettre fin à l’allaitement  maternel.  Cette  constatation  a  été  rapportée   dans   de   nombreuses  études  [14-16]. Or,  selon  le  rapport  de  l’Agence Nationale d’Accréditation  et  d’Évaluation  en  Santé  (ANAES),  l’insuffisance  de  lait  physiologique  est  très  rare  [3]. Dans  la majorité des  cas,  il s’agit soit de  la perception d’une  insuffisance de  lait,  qui  pourrait  être  liée  à un manque de confiance en  soi  de  la mère,  soit d’une  insuffisance de  lait  secondaire  à  un  allaitement mal  géré (suite  à une  fréquence ou  à une  durée des tétées inadéquate, par exem- ple), à  l’introduction de compléments,  à une position du bébé incorrecte ou à  un problème de succion [14]. Dans  notre  étude,  la  reprise  du  travail  était  le 2e motif  avancé par  les  mères pour  abandonner  l’allaitement  maternel. Selon Scott et al. [17] et Rojja- nasrirat [18], malgré l’intention de nom- breuses  femmes de continuer d’allaiter  après  le  retour au  travail,  l’emploi de  la  mère constitue un  facteur significative- ment associé à un sevrage précoce. Contrairement à ce qui a été rapporté  dans de nombreux travaux [19,20], nous  n’avons pas  trouvé d’association statis- tiquement significative entre une durée  courte d’allaitement maternel et le jeune  âge de  la mère (< 25 ans). En effet,  la  tranche d’âge 18-25 ans ne représentait  que 15,3 % de notre population d’étude.  Ce phénomène peut  s’expliquer par  le  recul de l’âge au mariage. En effet, selon  les données du MICS III, la tranche d’âge  40-49 ans représentait 41 % des femmes  mariées en âge de reproduction [6]. Dans  la  littérature,  la  primiparité  était  associée  à  une  durée  courte  de  l’allaitement maternel  [21,22]. Cette  différence entre primipare et multipare  serait expliquée par une habilité et une  facilité acquise de la multiparité à la mise  au sein. Cependant, certains auteurs ont  récemment  apporté  une  explication  d’ordre physiologique puisque,  après  un  second accouchement,  la quantité  de lait aurait été retrouvée supérieure à  celle produite  lors de  la première nais- sance [23]. Dans ce travail, la primiparité n’était  pas un facteur significatif. Cette consta- tation peut être expliquée par le fait que  les  femmes primipares  représentaient  seulement  le  quart  de  la  population  d’étude. Nous  avons  trouvé que  le  niveau  des connaissances des mères en matière  d’allaitement maternel était significative- ment associé à une durée d’allaitement  plus longue. Ceci a été rapporté dans les  études faites par Gilmour  et al. [24] et Baptista et al. [25]. Un  manque  d’informations  sur  la  durée  optimale  de  l’allaitement  maternel est  associé à un  sevrage plus  précoce [16],  tandis  que  la  connais- sance de la durée optimale d’allaitement  exclusif de  six mois (connue par 65 %  des mères  dans  l’étude  de  Peters et al. [15]) est significativement associée à  un allaitement maternel plus long [15]. D’autre  part,  l’étude  de  Blyth et al. [14] a montré une relation significa- tive entre  l’information et  le degré de  soutien reçu en prénatal et  la durée de  l’allaitement. Tout ceci met en exergue  l’importance de  l’information apportée  en prénatal  sur  le  taux  et  la durée de  l’allaitement. Les conséquences des pratiques en  salle de naissance sur l’allaitement mater- nel  sont  connues  depuis  longtemps.  Elles  ont  été  décrites  à  propos  de  la  première mise au sein [26]. La mise au  sein précoce après l’accouchement a été  soulignée comme bénéfique sur la durée  d’allaitement [15,27], tandis qu’une mise  au sein différée semble être un facteur de  risque de sevrage plus précoce. Dans  la méta-analyse de Bernard- Bonnin et al., quatre des études retenues  envisageaient non pas explicitement  la  mise  au  sein mais  le  contact précoce  mère-enfant, peau à peau (avec ou sans  tétée) :  il  s’agissait d’un  facteur qui  fa- vorisait la prolongation de l’allaitement  maternel  de  façon  significative  [28].  Cette constatation a été retrouvée dans  d’autres études plus récentes [29]. Ces  données  concordent  bien  avec  nos  résultats. Par  contre,  nous  avons  constaté  que l’introduction précoce d’une tétine  diminue  significativement  la durée de  l’allaitement maternel. Ce facteur a été  retrouvé de  façon  très  fréquente  [17]. L’influence de  l’utilisation d’une  tétine  sur  l’allaitement maternel ne  se  limite  probablement  pas  aux  interférences  avec  le mécanisme physiologique de  la succion. Il semblerait que l’usage ha- bituel de  la  tétine  soit  aussi  le  témoin  de  facteurs psychologiques et compor- tementaux maternels (faible confiance  en  soi,  comportement  rigide) moins  propices à  la poursuite de  l’allaitement  maternel [30]. Dans notre  étude,  la  prescription  de  compléments de  lait  artificiel  était  associée  à  un  risque  plus  élevé  de  sevrage précoce. Ceci  est  conforme à  ce qui a été rapporté dans de nombreux  travaux [31-33]. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 885 Ip S et al. 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Enquête nationale sur la santé et le bien-être de la mère6. et de l’enfant MICS III (2008). Tunisie, Ministère de la Santé pub- lique/UNICEF/Office National de la Famille et de la Popula- tion, 2008. Bachrach VRG, Scharz E, Bachrach LR. Breastfeeding and the 7. risk of hospitalization for respiratory disease in infancy. A meta- analysis. Archives of Pediatrics and Adolescent Medicine, 2003, 157:237–243. Oddy WH et al. Breast feeding and respiratory morbidity in 8. infancy: a birth cohort study. Archives of Disease in Childhood, 2003, 88:224–228. Enquête nationale9. sur la santé de la mère et de l’enfant PAP CHILD. Tunisie, Ministère de la Santé publique, Direction des Soins de Santé de Base, 1996. Groupe de travail pour la promotion de l’allaitement mater-10. nel dans le Nord. Dossier pour la promotion de l’allaitement maternel dans le département du Nord. Archives de Pédiatrie, 2001, 8:865–874. Castetbon K, Duport N, Hercberg S. Bases épidémiologiques 11. pour la surveillance de l’allaitement maternel en France. Revue d’Épidémiologie et de Santé Publique, 2004, 52:475–480. Oommen A et al. Breastfeeding practices of urban and rural 12. mothers. Indian Pediatrics, 2009, 46(10):891–894. Xu F et al. A comparison of breastfeeding among Han, Uygur 13. and other ethnic groups in Xinjiang, PR China. BMC Public Health, 2006, 6:196. Blyth RJ et al. Breastfeeding duration in an Australian popula-14. tion: the influence of modifiable antenatal factors. Journal of Human Lactation, 2004, 20:30–38. Peters E et al. Breastfeeding duration is determined by only a 15. few factors. European Journal of Public Health, 2006, 16:162– 167. Taveras EM et al. Opinions and practices of clinicians associ-16. ated with continuation of exclusive breastfeeding, Pediatrics, 2004, 113:e283–e290. References Scott JA et al. Predictors of breastfeeding duration: evidence 17. from a cohort study, Pediatrics, 2006, 117:e646–e655. Rojjanasrirat W. Working women’s breastfeeding experi-18. ences, MCN. American Journal of Maternal Child Nursing, 2004, 29:222–227. Thulier D, Mercer J. Variables associated with breastfeeding 19. duration. Journal of Obstetric, Gynecologic and Neonatal Nurs- ing, 2009, 38(3):259–268. Baxter J, Cooklin AR, Smith J. Which mothers wean their babies 20. prematurely from full breastfeeding? An Australian cohort study. Acta Paediatrica. 2009, 98(8):1274–1277. Lebours B 21. et al. L’alimentation du nourrisson jusqu’à quatre mois en Seine-Maritime. Archives Françaises de Pédiatrie, 1991, 48:391–395. Bulk-Bunschoten AM et al. Reluctance to continue breastfeed-22. ing in The Netherlands. Acta Paediatrica, 2001, 90(9):1047– 1053. Ingram J, Woolridge M, Greenwood R. Breastfeeding: it is worth 23. trying with the second baby. Lancet, 2001, 90:1047–1053. Gilmour C et al. Factors associated with early breastfeeding 24. cessation in Frankston, Victoria: a descriptive study. Breastfeed- ing Reviews, 2009, 17(2):13–19. Baptista GH et al. [Factors associated with duration of breast-25. feeding for children of low-income families from southern Curitiba, Paraná State, Brazil]. Cadernos de Saúde Pública, 2009, 25(3):596–604. Righard L, Alade MO. Effect of delivery room routines on suc-26. cess of first breastfeed. Lancet, 1990, 336:1105–1107. Branger B 27. et al. Facteurs influençant la durée de l’allaitement maternel chez 150 femmes. Archives de Pédiatrie, 1998, 5:489– 496 Bernard-Bonnin AC 28. et al. Pratiques hospitalières et durée de l’allaitement maternel : méta-analyse. Revue d’Épidémiologie et de Santé Publique, 1989, 37:217–225. Moore ER, Anderson GC, Bergman N. Early skin-to-skin contact 29. for mothers and their healthy newborn infants. Cochrane Data- base of Systematic Reviews, 2007, 18(3):CD003519. Victora CG et al. Pacifier use and short breastfeeding dura-30. tion: cause, consequence, or coincidence? Pediatrics, 1997, 99:445–453. Asole S et al. Effect of hospital practices on breastfeeding: a 31. survey in the Italian region of Lazio. Journal of Human Lactation, 2009, 25(3):333–340. Declercq E et al. Hospital practices and women’s likelihood 32. of fulfilling their intention to exclusively breastfeed. American Journal of Public Health, 2009, 99(5):929–935. Blomquist HK et al. Supplementary feeding in the maternity 33. ward shortens the duration of breast feeding. Acta Paediatrica, 1994, 83(11):1122–1126. Conclusion Malgré  la  prévalence  élevée  de  l’allaitement maternel  à  la naissance,  beaucoup d’insuffisances  au niveau  des  connaissances  et  surtout  des  pratiques des mères restent à combler.  Ceci  requiert  des  stratégies de pro- motion  de  l’allaitement  maternel  axées d’une part  sur  l’information et  l’éducation des femmes et d’autre part  sur  la  formation des professionnels  de  santé au cours de  leurs  études et  pendant  la  formation  continue. De  même, certaines  initiatives  telles que  les « Hôpitaux amis des bébés » sont  de nature à encourager  la promotion  de l’allaitement maternel. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 886 Impact of using essential drug list: analysis of drug use indicators in Gaza Strip R. Fattouh1 and B. Abu Hamad 1 ABSTRACT A descriptive cross-sectional study evaluated the compliance of physicians with the Palestinian essential drug list (EDL) in all the government primary care clinics in the Gaza Strip. While 67.4% reported currently using the EDL 51.2% of these physicians reported problems in using it. The mean number of drugs per prescription was 1.92, the percentage of drugs prescribed from the EDL was 97.9% but the percentage of drugs prescribed by generic name was only 5.5%. A copy of the EDL was available in 28.3% of clinics and the availability of key drugs was 82.6%. The compliance of physicians with the EDL was generally good, but more efforts are needed to encourage prescribing by generic name and to ensure the supply of key drugs. 1School of Public Health, Al-Quds University, Gaza, Palestine (Correspondence to R. Fattouh: r_m_11@hotmail.com). Received: 12/10/08; accepted: 13/01/09 ةزغ عاطق في ةيودلأا مادختسا تاشرؤم ليلتح :ةيساسلأا ةيودلأا ةمئاق مادختسا رثأ دحم وبأ ماسب ،حوتف اشر عاطق في ةيموكلحا ةيلولأا ةياعرلا تادايع عيجم في ةيساسلأا ةيودلأا ةمئاقل ءابطلأا لاثتما مييقتل ةيضرع ةيفصو ةسارد ناثحابلا ىرجأ :ةـصلالخا في لكاشلما ضعب اودجو مهنم %51.2 و ضرالحا تقولا في ةيساسلأا ةيودلأا ةمئاق اومدختسي اوناك ءابطلأا نم %67.4 نأ جئاتنلا ترهظأ ماك .ةزغ يتلا ةيودلأل ةيوئلما ةبسنلا تغلبو ،1.92 وه ةدحاولا ةيئاودلا ةفصولا في ةفوصولما ةيودلأا ددع طسوتم نأ جئاتنلا ترهظأ دقف .اله مهمادختسا ةمئاق نم ةخسن تناكو .%5.5 زواجتت نكت لم سينلجا اهمساب فصوت يتلا ةيودلأل ةيوئلما ةبسنلا نأ لاإ ،%97.9 ةيساسلأا ةيودلأا ةمئاق نم فصوت ةمئاقب ءابطلأا لاثتما نأ حضتا اذكهو .%82.6 ةيسيئرلا ةيودلأا رفاوتل ةيوئلما ةبسنلا تناك مايف ،تادايعلا نم %28.3 في ةرفاوتم ةيساسلأا ةيودلأا ةيودلأاب دادملإا نماضلو ،ةسينلجا ءماسلأا فصو لىع عيجشتلل دوهلجا نم ديزلما لذبل ةجاح كانه نكلو ،ماع لكشب ًاديج ناك ةيساسلأا ةيودلأا .ةيسيئرلا Impact de l’utilisation de la liste des médicaments essentiels : analyse des indicateurs d’utilisation des médicaments dans la Bande de Gaza RÉSUMÉ Une étude transversale descriptive a évalué la manière dont les médecins respectaient la liste de médicaments essentiels palestinienne dans l’ensemble des centres de soins de santé primaires publics de la Bande de Gaza. Si 67,4 % des médecins ont affirmé recourir à cette liste, 51,2 % d’entre eux ont déclaré rencontrer des problèmes lors de son utilisation. Le nombre moyen de médicaments par prescription était de 1,92 ; le pourcentage de médicaments prescrits à partir de la liste était de 97,9 %, mais le pourcentage de médicaments prescrits par nom générique atteignait seulement 5,5 %. Un exemplaire de la liste était disponible dans 28,3 % des centres et les principaux médicaments étaient disponibles à 82,6 %. En général, les médecins se conformaient bien à la liste des médicaments essentiels, mais des efforts supplémentaires pour encourager la prescription de médicaments par leur nom générique et pour assurer l’approvisionnement en principaux médicaments essentiels doivent être réalisés. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 887 Introduction Since 1994,  there have been 4 major  players involved in the health services of  the Palestinian  territories:  the Ministry  of Health (MOH), the United Nations  Relief and Works Agency  for Palestine  Refugees in the Near East (UNRWA),  various  nongovernmental  organiza- tions (NGOs) and  the private  sector.  The MOH  is  responsible  for  provid- ing a significant portion of  the primary  health  care  (PHC),  secondary  care  and some tertiary care [1]. In 2005, the  MOH spent 17.9% of its total budget on  pharmaceuticals [1]. Research findings  indicate that over-prescribing, irrational  prescribing and prescribing expensive  brand-name drugs are common in Pal- estinian health facilities [2].  The development of the Palestinian  essential drug  list  (EDL)  in 2000 was  an important step towards rational pre- scribing [3]. In line with World Health  Organization  (WHO)  suggestions,  the present study was designed to pro- vide guidelines  for updating  the EDL.  Uniquely, the study explored physicians’  compliance with  the EDL within  the  Palestinian context, which  is character- ized by diverse socioeconomic, political  and managerial challenges.  The general objective of  the  study  was  to  evaluate  the  compliance  of  physicians with  the Palestinian EDL  in government PHC facilities  in order  to highlight measures  to  improve  the  utilization of the EDL, thus contributing  to health system efficiency and effective- ness. The  specific  objectives were  to  assess physicians’ prescribing practices  with reference to selected WHO indica- tors;  to  appraise physicians’  attitudes  and practices  regarding  the Palestinian  EDL;  to examine  the  relationship be- tween prescribing practices and other  variables; and to  identify strengths and  weaknesses  in physicians’ prescribing  practices with reference  to compliance  with the EDL. Methods This was  a  cross-sectional descriptive  analytical study with a self-administered  questionnaire  to  physicians  and  an  analysis of prescriptions collected from  PHC clinics.  Sample Because  the study population  is  small,  all 276 physicians working  in govern- ment PHC clinics  in Gaza Strip were  recruited  for  the questionnaire  survey.  For  the  prescribing  analysis  a  retro- spective multi-stage random sample of  1656 prescriptions  from  the previous  6 months were selected. In compliance  with WHO guidelines, 36 prescriptions  were  taken  from each of  the 46 clinics  [4].  Because  the  study  included all  the  clinics,  the time-scale for the study was  limited  and  it  was  difficult  to  access  older  prescriptions,  therefore  a  time  interval of 6 months was  judged  to be  sufficient  to  monitor  prescriptions,  based on the WHO guidelines [4]. Be- cause drug availability varies across the  days of the month, 3 prescriptions were  randomly drawn from each month and  for each group (< 3 years and ≥ 3 years):  1 from the first 10 days of the month, 1  from the middle 10 days and 1 from the  last 10 days. Data collection Two  instruments were used. The first  was a  self-administered questionnaire  distributed to physicians to collect some  relevant  organizational  and personal  data  and  to  assess  their  attitudes  and  practices towards the EDL.  The second was a checklist using the  WHO recommended format to record  selected WHO drug use indicators [4].  The researcher and 2  trained assistants  filled  the checklist. The mean number  of  drugs  prescribed  per  encounter,  the  percentage  of  drugs  prescribed  by  generic name  and  the percentage  of drugs prescribed  from  the EDL or  local  formulary were  calculated using  standard methods [5]. The survey also  checked  the percentage availability of  12 key drugs in the surveyed clinics and  whether a copy of the EDL or formulary  was available at the health facilities. The  short-list of key drugs that are essential  to treat common health problems were  drawn  up  after  discussions with  key  stakeholders  and  policy-makers  [6].  The researcher reviewed the filled ques- tionnaires  and checklists  and entered  them into the database.  Official  approval  to  conduct  the  study was obtained  from the  research  ethics committee in the Gaza Strip. Ad- ditionally, the MOH officially approved  conducting the study and provided ac- cess to the study population. Data analysis Prescribing indicators were analysed by  patient’s age group, time of the month,  governorate and by health care  facility  level. Because  the  local health  system  treats patients who are  younger  than  3  years  in  a different way  from older  patients,  the prescriptions  from each  month in each clinic were divided into 2  groups: patients aged < 3 years (treated  free-of-charge)  and patients  aged ≥ 3  years (medical insurance required) [4].  The health care  levels were defined as  follows: level 1 (clinic has a community  health worker and a nurse all weekdays  and is visited twice per week by a physi- cian);  level 2 (physician and  full-time  nurse work  in  the clinic all weekdays);  level 3 (physicians and nurses work all  weekdays and the clinic provides basic  laboratory  services, X-ray, dental  care  and emergency  care 12 hours daily);  level  4  (full-time  physicians,  nurses,  laboratory  services, ultrasound, X-ray,  family planning and emergency care 24  hours daily in addition to some specialty  services). Data entry, cleaning and analysis was  done using SPSS  software,  version 11.  Descriptive analysis and then inferential  analysis were done based on the nature  of the study variables. Means and stand- ard deviations (SD) were computed for  EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 888 the continuous numeric  variables  fol- lowed by  recoding of certain variables.  The selected WHO drug use indicators  were computed using the statistical for- mulae developed by WHO.  In order  to  explore  the potential  relationships  between  the study variables,  advanced  statistical analysis were conducted,  in- cluding independent t-test, 1-way analy- sis of variance and the chi-squared  test  for categorical variables. P-value < 0.05  was considered statistically significant. Results Physicians’ knowledge, attitudes and practices A  total  of  242 out of  276 physicians  completed the questionnaire, a response  rate of 87.7%.  Only 2.8% of respondents had been  involved in the preparation of the EDL,  34.4% had  attended  training  courses  on the EDL and 88.9% were interested  in  having  further  training  (Table  1).  Only  two-thirds of physicians (67.4%)  reported currently using  the EDL, and  around half of  this  subgroup (51.2%)  said they faced many problems in using  the EDL,  especially  concerning  inad- equate supplies of the listed drugs.  Table 2 shows the responses of phy- sicians according to whether they were  using the EDL or not. As expected, phy- sicians who  reported  that EDL drugs  were exclusively available in their clinics  (94.1%) were using EDL drugs more  than the others and the differences be- tween  the 2  groups were  statistically  significant (P < 0.001) (Table 2).  Table 2  also  shows  that 83.1% of  physicians  who  had  undergone  an  evaluation of their prescribing practices  were currently using the EDL. Similarly,  83.3% of  those who  received written  feedback about  their prescribing prac- tices were using the EDL.  Physicians who had attended train- ing courses on EDL were currently us- ing it (83.1%), a higher proportion than  those who had not had training (58.6%)  and  the  differences  between  the  2  groups were  statistically  significant (P < 0.001). Moreover,  significantly more  physicians who  found  the EDL  easy  to use were currently using  it  (91.3%)  compared with  those who perceived  its use as difficult (57.9%) (P < 0.001)  (Table 2).  Fewer physicians who agreed  that  they were strongly influenced by clients’  requests  for drugs were using the EDL  (55.6%) than those who reported never  being influenced by clients’ requests for  drugs (72.4%). The difference between  the groups was  statistically  significant  (P = 0.013). WHO drug use indicators The mean number of drugs prescribed  per encounter was 1.92 (SD 0.99), with  a median of 2 (range 1–8).  Table 3 shows the drug use  indica- tors by patient’s  age group. The 2 age  groups of patients  (< 3 years  and ≥ 3  years) had  similar mean  scores  in  all  drug use  indicators, and no statistically  significant differences were  found be- tween them. As  shown  in Table  4,  there were  statistically  significant differences be- tween  the number of drugs prescribed  per prescription with regard to the time  of the month (P < 0.001), with the high- est mean number (2.03) in the first 10  days of the month.  The  mean  percentage  of  drugs  prescribed by generic name was 5.4%  (SD 0.4%),  range  0%–10.8%  (Table  5). However,  as  illustrated  in Table 6  there were  statistically  significant dif- ferences between  the  rates of  generic  prescribing  across  governorates, with  the highest percentage  in Gaza gover- norate (10.8%).  The  mean  percentage  of  drugs  prescribed  from  the EDL or  the  for- mulary was  97.8%  (SD  0.97),  range  94.4%–100% (Table 5). Table 1 Attitudes and practices of physicians in Gaza Strip towards the essential drugs list (EDL) Variable No. % Use EDL in prescribing Use it currently 155 67.4 Used in the past 22 9.6 Don’t use 53 23.0 Total 230 100.0 Experience problems in using EDL (if used) Yes, many 88 51.2 Yes, a few 54 31.8 None 28 17.0 Total 170 100.0 Attended training courses on EDL Yes 77 34.4 No 147 65.6 Total 224 100.0 Involved in preparation of EDL Yes 6 2.8 No 206 97.2 Total 212 100.0 Interested in attending other training courses on EDL Yes 200 88.9 No 25 11.1 Total 225 100.0 طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 889 Less than 30% of surveyed facilities  were able  to show the  research  team a  copy of  the EDL (Table 5).  Interest- ingly, more PHC clinics at  level 3 had  copies  than other  level clinics and  this  difference was statistically significant (P = 0.001). Differences  in  the availability  of  the EDL across governorates were  also statistically  significant (P = 0.001)  (Table 6). The mean proportion of the 12 key  drugs  available  at  clinics  was  82.6%  (SD 15.2%),  range 41.6%–100% (Ta- ble  5). The  researcher  validated  the  availability of drugs  listed  in  the EDL  Table 2 Attitudes and practices of physicians in Gaza Strip towards the essential drugs list (EDL) by current use of the list Variable Currently using EDL Used in the past Not used at all χ2-value P-value No. % No. % No. % Influence on physicians of clients’ request for drugs Very strong 10 55.6 4 22.2 4 22.2 16.13 0.013 To some extent 52 74.3 2 2.9 16 22.9 Weak 45 58.4 14 18.2 18 23.4 Never 42 72.4 2 3.4 14 24.1 Physicians have evaluation for their prescribing practices Yes 49 83.1 4 6.8 6 10.2 13.22 0.01 No 69 58.0 15 12.6 35 29.4 Don’t know 33 73.3 2 4.4 10 22.2 Physicians receive feedback about their prescribing practices Yes, written 15 83.3 2 11.1 1 5.6 5.89 0.208 Yes, verbal 55 71.4 4 5.2 18 23.4 None 79 63.2 14 11.2 32 25.6 Ease of use of EDL Yes, easy 136 91.3 13 8.7 n/a – 17.17 0.001 No, not easy 11 57.9 8 42.1 n/a – Availability of EDL drugs in the pharmacy Exclusively present 16 94.1 1 5.9 0 0.0 27.33 0.001 Partially present 118 73.3 15 9.3 28 17.4 No 14 48.3 4 13.8 11 37.9 Don’t know 3 23.1 2 15.4 8 61.5 Attended training course on EDL Yes 64 83.1 8 10.4 5 6.5 19.03 0.001 No 85 58.6 13 9.0 47 32.4 n/a = not applicable. Table 3 Drug use indicators from clinics in Gaza Strip by patient’s age (i.e. treatment category) Drug use indicator Age of patient t-value P-value ≥ 3 years (insurance required) (n = 849) < 3 years (qualify for free treatment) (n = 807) Mean SD Mean SD No. of drugs per prescription 1.93 1.09 1.91 0.87 0.458 0.647 % of drugs prescribed by generic name 5.2 0.3 5.8 0.4 –1.020 0.308 % of drugs prescribed from EDL 97.4 1.07 98.4 0.9 0.004 0.997 n = number of prescriptions analysed; EDL = essential drugs list; SD = standard deviation. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 890 by  checking  clinic  pharmacies  and  confirmed subjects’ responses, revealing  availability of all 12 drugs  in only 7.7%  of the clinics surveyed and partial avail- ability of  the  list  in 73.4%. Physicians  reported  different  reasons  for  drug  shortages,  including  inadequate  sup- plies of drugs at the MOH central store  (66.2%),  inaccurate estimation of  the  quantities of drugs  required  (35.1%),  management problems  and bureauc- racy  (22.5%)  and  a  lack  of  financial  resources (21.2%).  Discussion Physicians  who  reported  that  EDL  drugs  were  exclusively  available  in  their  clinics  were  using  EDL  drugs  significantly more than the others. This  is  a  clear  indication  that  the availabil- ity of EDL drugs  in clinics encourages  physicians  to  comply with  the  EDL  and  this  stimulates  the MOH to exert  more efforts to ensure continuous avail- ability of drugs.  It was noticed  that  in  some  facilities,  although  the EDL was  available,  physicians used Medic  (the  Israeli drugs guide) in their prescribing,  despite of  the  fact  that Medic  contains  many brand-name drugs  that are nei- ther  listed  in  the Palestinian EDL nor  present in the clinic pharmacies. More  of  the  physicians who  had  undergone an evaluation of  their pre- scribing practices (83.1%) or who had  received written  feedback about  their  prescribing practices (83.3%) were cur- rently using  the EDL  than  the overall  percentage (67.4%). This points  to  the  importance of monitoring  and  super- vision  as  the distribution of  the EDL  is  not adequate  by  itself.  Physicians  who  found  the EDL easy  to use were  significantly more  likely  to use  it  than  those who perceived its use as difficult.  Therefore health managers  and other  stakeholders  should organize periodic  assessments of  the EDL and  regularly  update it to produce more user-friendly  versions [7].  The  mean  number   of   drugs  prescribed  per  encounter  (1.92)  is  consistent with the international stand- ard recommended by the WHO (below  2) [8].  It was also close  to  the average  in  Egypt,  the United  Arab  Emirates  and Morocco (2 drugs per encounter)  [9–11]. There were  statistically  significant  differences  between  the  numbers  of  drugs  per  prescription  at  different  times of  the month. Drug orders  are  distributed  to PHC clinics within  the  first 10 days of  the month. As a  result,  patients became aware of this and tend  to go  to  the clinics more within  these  days to ensure that they will receive the  needed drugs. Moreover,  physicians  also become familiar with that situation  and prescribe drugs more within  the  first 10 days of the month. Needless to  say,  there are many  factors potentially  contributing  to  the  above  results.  In  the Gaza Strip,  clients have access  to  other health providers who  freely pro- vide drugs. Additionally,  there  is  the  phenomenon of prescribing drugs on  informal prescriptions to be dispensed  from private pharmacies.  Table 4 Drug use indicators of clinics in Gaza Strip by time of the month in which the prescriptions were prescribed Drug use indicator Time of month F-valuea P-value First 10 days (n = 552) Days 11 to 20 (n = 550) Last 10 days (n = 554) Mean Mean Mean No. of drugs per prescription 2.03 1.92 1.81 7.25 0.001 % of drugs prescribed by generic name 6.4 4.7 5.5 1.93 0.145 % of drugs prescribed from EDL 97.0 97.3 98.3 5.38 0.005 % of key drugs available in clinics 84.4 79.4 83.3 0.49 0.617 a1-way ANOVA. n = number of prescriptions analysed; EDL = essential drugs list. Table 5 Drug use indicators of clinics in Gaza Strip by level of primary health care (PHC) facility Drug use indicator Overall PHC level F-value P-value Level 2 (n = 540) Level 3 (n = 828) Level 4 (n = 288) Mean Mean Mean No. of drugs per prescription 1.92 1.99 1.90 1.84 2.419 0.089 % of drugs prescribed by generic name 5.4 2.0 7.9 4.9 17.47 0.001 % of drugs prescribed from EDL 97.8 97.9 97.3 98.9 2.596 0.750 % of key drugs available in clinics 82.6 89.4 79.3 79.1 2.391 0.104 % of clinics with copy of EDL 28.3 16.3 34.2 33.6 4.615 0.015 n = number of prescriptions analysed; EDL = essential drugs list. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 891 The percentage of drugs prescribed  by generic name  is  an  important  ele- ment  of  the  essential  drugs  concept.  The rate of generic prescribing of 5.5%  in our  study  is  very  low compared  to  the standard WHO value (100%) [8].  Decision-makers  should put more ef- fort  into  increasing  the knowledge of  physicians  about  the positive  impact  of generic prescribing. The MOH also  needs  to promote generic drugs  in all  aspects of the commodity management  cycle (procurement,  selection and or- dering). Another factor contributing to  the tendency of physicians to prescribe  brand-name drugs  is  the  false  impres- sion of the public, and of physicians, that  generic drugs are of poorer quality and  efficacy [12].  There were  significant differences  between the rates of generic prescribing  across  governorates, with  the highest  rate  in Gaza  governorate. This  could  be  attributed  to  the  proximity  effect,  as  the pharmacy management  centre  is based  in Gaza governorate where all  the implementation and training for the  EDL takes place before  it  is  rolled out  to other governorates. Also,  there  are  some PHC facilities  in Gaza governo- rate which independently held training  courses for their physicians [13]. The  overall  percentage  of  drugs  prescribed  from  the EDL (97.9%)  is  one of  the highest  in  the world as  it  is  near  the  standard value of 100% [8].  This  result  shows a positive  result  for  implementation of EDL and physician  compliance with  it. This was achieved  was mainly  as  a  result of managerial  interventions, by which all drugs pro- vided  to  facilities  are  from  the EDL.  Drugs  prescribed  from  outside  the  EDL were donated ones. It is therefore  essential to apply WHO guidelines for  drug  donation,  emphasizing  that  all  drug donations should comply with the  local EDL. It is worth noting that donat- ed drugs  represent an  important drug  resource  in Palestine  [14].  Ironically,  the  researcher noted  that physicians  prescribed drugs  not  from  the EDL  on  informal  prescriptions. This may  indicate  that physicians’  compliance  is mainly  based on drug  availability,  regardless of whether  these drugs are  from the EDL or not. The fact that the  MOH only provides drugs on the EDL  list forces physicians to prescribe these  available  drugs  without  being  fully  aware of the value of the EDL. This calls  for  additional  training  programmes  with follow-up and monitoring.  Less than 30% of surveyed facilities  had  a  copy of  the EDL,  a  rate much  lower  than  the  standard  (100%)  [8].  This highlights the need for an appropri- ate dissemination plan for the EDL, fol- lowed by monitoring and supervision.  Although the presence of the EDL is es- sential for compliance,  it  is not enough  by itself to ensure it [15]. Dissemination  of the EDL should be accompanied by  training on it content and use. The  availability  of  key  drugs was  82.6%,  which  is  low  compared with  the  standard value  advised by WHO  (100%)  [8].  The  lack  of  availabil- ity of key drugs reflects problems in the  MOH which are frequently manifested  by drug shortages in clinics [1]. Possible  factors  leading  to drug  shortages  are  insufficient financial  resources  for drug  procurement,  the overuse of drugs by  physicians,  pharmacists  and patients  and Israeli border closures, which delay  the arrival of drugs. Additionally, most  of  the MOH drugs are  funded by  the  World Bank  through  lengthy  proce- dures which  cause delay,  particularly  in  the unstable and unpredictable po- litical situation in the area [1]. Rational  drug use here plays an important role in  overcoming drug shortages;  therefore,  training  and  awareness,  appropriate  regulations and supervision physicians  and dispensers are essential, particularly  in  relation  to  the  rational use of drugs  and its impact.  Conclusions and Recommendations The compliance  level of PHC physi- cians was generally good and could be  explained mainly by managerial/regula- tory  factors  affecting  the provision of  drugs  that  are  listed on  the EDL. The  results  of WHO drug  use  indicators  were positive in certain aspects such as  Table 6 Drug use indicators of clinics in Gaza Strip by governorate Drug use indicator Governorate F-value P-value North (n = 252) Gaza (n = 504) Mid-Zone (n = 468) Khanyounis (n = 324) Rafah (n = 108) Mean Mean Mean Mean Mean No. of drugs per prescription 2.07 1.99 1.86 1.87 1.62 5.291 0.001 % of drugs prescribed by generic name 5.8 10.8 3.2 1.1 0.0 24.01 0.001 % of drugs prescribed from EDL 94.2 96.4 100.0 100.0 100.0 2.531 0.039 % of key drugs available in clinics 82.1 73.2 80.1 96.2 97.2 5.53 0.001 % of clinics with copy of EDL 42.9 42.9 15.4 0.0 66.7 2.49 0.058 n = number of prescriptions analysed; EDL = essential drugs list. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 892 Health status in Palestine. Annual report.1. Ramalla, Palestine, Ministry of Health, Palestinian National Authority, 2005. Obeidallah W et al. 2. Drug situation analysis for the West Bank and Gaza Strip. Geneva, World Health Organization, 2000 (EDM/ DAP/2000.1). Palestinian drug formulary3. , 1st ed. Ramalla, Palestine, General Directorate of Pharmacy, Ministry of Health, Palestinian Na- tional Authority, 2002. How to investigate drug use in health facilities4. . Geneva, World Health Organization, 1993 (WHO/DAP). Quality assurance of pharmaceuticals. A compendium of guide-5. lines and related materials. Volume 1. Geneva, World Health Organization, 1997. How to use applied qualitative methods to design drug use inter-6. ventions. Geneva, World Health Organization, 2000. How to develop and implement a national drug policy7. . Geneva, World Health Organization, 2001. Dumoulin J. 8. Guide to drug financing mechanisms. Geneva, World Health Organization, 1998. Zaki A et al. The use of medication in infants in Alexandria, 9. Egypt. Eastern Mediterranean Health Journal, 1999, 5(2):320– 327. References Hasan M, Das M, Mourad F. Drug utilization and antibiotic use 10. in primary health care centres in Sharjah. Eastern Mediterranean Health Journal, 1997, 3:444–451. Simon N et al. Drug prescription and utilization in Morocco. 11. Therapies Journal, 1998, 53(2):113–120. Medical and pharmaceutical situation inside the West Bank in 12. primary health care. Ramalla, Palestine, Pharmaciens Sans Frontieres, 2003. Essential drugs list and Palestinian national formulary training 13. course report. Quality improvement program. Ramalla, Palestine, Palestinian National Authority, Ministry of Health, 2001. Kousa M et al.14. West Bank and Gaza Update: World Bank report on impact of intifada. A quarterly publication of the West Bank and Gaza Office. Ramalla, Palestine, World Bank, 2003. Grimshaw J, Russell I. Effect of clinical guidelines on medical 15. practice: a systematic review of rigorous evaluations. Lancet, 1993, 342:1317–1322. Management Science for Health and World Health Organiza-16. tion. Managing drug supply, 2nd ed. West Hartford, Connecti- cut, Kumarian Press, 1997. Practical guidelines on pharmaceutical procurement for countries 17. with small procurement agencies. Manila, Philippines, World Health Organization Regional Office for the Western Pacific, 2002. Correction Evaluation of effect of silymarin on granulosa cell apoptosis and follicular development in patients undergoing in vitro fertilization. N. Moosavifar,1 A.H. Mohammadpour,2,3 M. Jallali,1 G. Karimi 2,4 and H. Saberi 2Eastern Mediterranean health journal, 2010, 16(6):642–650. The affiliation for the fourth authori should be changed from G. Karimi 2,4 to G. Karimi 3,4. 1Women’s Health Research Centre; 2Pharmaceutical Research Centre ; 3School of Pharmacy; 4Medical Toxicology Resarch Centre, Mashhad University of Medical Sciences, Mashhad, Islamic Republic of Iran. the  low  rate of polypharmacy  (1.92),  but negative  in others  such as  the  low  rate  of  prescribing  by  generic  name  (5.5%). Efforts are needed  to  improve  the use of generic names on prescrip- tions,  the availability of key drugs and  the availability of the EDL document at  clinics. Developing an effective dissemi- nation plan for the EDL with appropriate  follow up and  supervision  is  essential,  and policy-makers need to  improve the  drug management cycle at PHC facilities,  with  special  attention  to  ensuring  the  availability  of  essential  drugs  [16,17].  Further  research  is needed  to evaluate  prescribing practices  in other  settings  and sectors. Follow-up assessments are  also recommended in the future.  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 893 Immunoinflammatory markers and disease activity in systemic lupus erythematosus: something old, something new M.A. Elwy,1 Z.A. Galal2 and H.E. Hasan3 ABSTRACT This study assessed the utility of some novel inflammatory markers compared with traditional laboratory markers in patients with systemic lupus erythematosus (SLE). In a cohort of 43 SLE patients (19 with inactive and 24 with active SLE) and 20 healthy controls, serial measures of soluble vascular cell adhesion molecule (sVCAM-1) were significantly associated with SLE disease activity, scored using the British Isles Lupus Assessment Group index. Inflammatory markers neopterin and soluble intercellular adhesion molecule (sICAM-1) appeared to be clinically useful for isolated assessments of disease activity. Both antibodies to double-stranded DNA (anti- dsDNA) and sVCAM-1 were relatively good markers of disease activity and could help to predict remission or monitor the therapeutic response in SLE. 1Department of Rheumatology and Rehabilitation; 2Department of Clinical Pathology; 3Department of Internal Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt (Correspondence to M.A. Elwy: elwy.mohamed@yahoo.com). Received: 27/03/08; accepted: 06/05/08 ميدق اهضعبو ديدج اهضعب :ةيعومجلما ةيممالحا ةبئذلا في ةيضرلما ةيلاعفلاو ةيباهتللاا ةيعانلما تماساولا نسح نانح ،للاج بنيز ،يولع دممح ةيممالحا ةبئذلا ضىرم ىدل ةيديلقتلا ةيبرتخلما تماساولاب انهونراقيو ،ةديدلجا ةيباهتللاا تماساولا ضعب ةساردلا هذه في نوثحابلا مِّيقي :ةـصلالخا بناج لىإ ،)لاعفلا روطلا في مهنم 24و لاعفلا يرغ روطلا في مهنم 19( ،ةيزاهلجا ةيممالحا ةبئذلاب ًاضيرم 43 نم ًابارتأ نوثحابلا سرد دقو .ةيعومجلما ةيلاعف عم ًايئاصحإ هب دتعي ًاطبارـت طبارـتي با َّوذلا يئاعولا يوللخا يقصلاتلا ءيزجلل ةيلاتتلما تاسايقلا نأ اودجوو .ءاحصلأا دهاوشلا نم 20 ءيزلجاو نيتربوين ْنيَيباهتللاا يمساولا نأ ادب مايف .ةبئذلا مييقتل ةيناطيبرلا رزلجا ةعوممج بسنم زارحأ مادختساب كلذو ،ةيزاهلجا ةيممالحا ةبئذلا ءاد ءيزجللو ،قاطلا جودزلما اندلل دادضلأا نم ًلاك نأ ماك .ءادلا ةيلاعفل ةلزعنلما تماييقتلا في ةيريسر ةدئاف ماله با َّوذلا يوللخا لخاد يقصلاتلا ةباجتسلاا ةبقارم في وأ ،ضرلما ةأدبه ؤبنتلا في دعاست نأ اهنكميو ،ضرلما ةيلاعفل ةديج تماساوك ناديفم با َّوذلا يئاعولا يوللخا يقصلاتلا .هل ةلجاعملل Marqueurs immuno-inflammatoires - anciens et nouveaux - et évolutivité du lupus érythémateux disséminé RÉSUMÉ La présente étude a évalué l’utilité de nouveaux marqueurs immuno-inflammatoires par rapport aux marqueurs de laboratoire conventionnels chez des patients atteints de lupus érythémateux disséminé (LED). Dans une cohorte de 43 patients atteints de lupus érythémateux disséminé (19 présentant un lupus érythémateux disséminé stable et 24 un lupus érythémateux disséminé évolutif) et un groupe témoin comprenant 20 sujets sains, la présence répétée de molécules d’adhésion des cellules vasculaires sous forme soluble (sVCAM-1) était associée de manière significative à l’activité du lupus érythémateux disséminé. Ces mesures ont été effectuées selon l’indice du British Isles Lupus Assessment Group (Groupe d’évaluation du lupus des îles britanniques). Les marqueurs inflammatoires comme la néoptérine et la molécule d’adhésion intercellulaire (sICAM-1) se sont révélés utiles sur le plan clinique pour réaliser des évaluations isolées de l’activité de la maladie. Les anticorps anti-ADN double brin (anti-dsDNA) ainsi que les sVCAM-1 se sont avérés être de bons marqueurs d’activité de la maladie contribuant à prévoir une rémission ou à surveiller la réponse thérapeutique du lupus érythémateux disséminé. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 894 Introduction Systemic  lupus erythematosus  (SLE)  is  a progressive autoimmune disorder  associated with chronic  stimulation of  various  components  of  the  immune  system, affecting the skin, joints, kidneys,  heart and nervous and haematopoietic  systems. The etiology of SLE is unknown  and  its clinical course  is highly variable,  with periods of flare-ups and remission  [1,2]. A characteristic  feature of SLE  is  that  the pattern of organ  involvement  differs  from  one  patient  to  another,  suggesting  differences  in  pathogenic  mechanisms, a hypothesis supported by  differences  in  the autoantibody profiles  that correlate with involvement of differ- ent organs [2–4]. The clinical evaluation  of the disease still lacks a reliable marker  that is both sensitive and specific for the  diagnosis as well as for the measurement  of disease activity [5,6].  The accepted measures of disease  activity in SLE include erythrocyte sedi- mentation  rate (ESR), plasma/serum  complement  component 3  (C3) and  component  4  (C4)  and  presence  of  antibodies  to  double-stranded DNA  (anti-dsDNA). Some patients, however,  have abnormalities in these tests for con- siderable periods yet  show  few clinical  symptoms or  functional deterioration  of a major organ; others are markedly  symptomatic with only minor aberra- tions in these test results [4,7,8]. The  utility  of  some  relatively  new  markers of SLE disease activity are  still  disputed  [2]. Neopterin  is  specifically  produced by human macrophages when  stimulated by interferon-gamma released  from  activated T-lymphocytes,  and  is  therefore an  indirect marker of  the up- regulation of the cellular immune system  [9,10]. Intracellular adhesion molecule-1  (ICAM-1)  and  vascular  cell  adhesion  molecule-1 (VCAM-1) are members of  the  immunoglobulin  supergene  family  and play a central role  in cell-to-cell and  in cell-to-extracellular matrix-mediated  immune  responses  [11]. During  exac- erbations of  SLE,  endothelial  cells  are  activated  to  increase  their expression of  adhesion molecules [12,13].  The objectives of this study were to  compare  some of  the newer markers  (neopterin, sICAM-1, sVCAM-1) with  conventional laboratory measures (anti- dsDNA, C3 and C4) and the nonspe- cific  inflammatory marker C-reactive  protein (CRP), using a standard  index  of  disease  activity,  and  to  investigate  whether  certain  variables  correlated  with any type of specific organ involve- ment in an unselected group of patients  with SLE.  Methods Sample The  study  group  were  patients  who  were regular attendees at the outpatient  clinics of the rheumatology units of the  department of  internal medicine  and  the department of  rheumatology and  rehabilitation at Ain Shams University  Hospitals, Cairo, Egypt between August  2005 and March 2007. A convenience  sample of 43 patients (40  females and  3 males) who were present at  the time  of the researchers’ visit and who agreed  to participant were selected. All of them  fulfilled 4 or more of  the 1982 revised  American  Rheumatism  Association  (ARA)  criteria  for  the  classification  of SLE [14]. Their mean age was 41.0  [standard deviation (SD)] 13.2 years  and  the mean disease duration of  the  patients at  the time of recruitment was  10.7  (SD 9.4) years. A  control  group  of 20 age- and sex-matched, apparently  healthy  individuals  (18  females and 2  males) was also selected  for  the study;  their mean age was 38.1 (SD 9.3) years.  All participants were informed and will- ing to be included in the study. Data collection Clinical All the patients had documented medi- cal histories of SLE and were subjected  to  a  full  history-taking  and  thorough  clinical  examination  for  this  study by  qualified  internists. Case documenta- tion,  assessment  of  disease  activity,  damage events  and  therapeutic  inter- ventions were made by the same group  of rheumatologists throughout. In  this  study  the overall disease ac- tivity was scored using  the British  Isles  Lupus  Assessment Group  (BILAG)  index of disease activity  [15]  to assess  lupus activity in the major organ systems  (mucocutaneous, musculoskeletal,  re- nal, nervous,  cardiovascular,  vasculitis  and haematological) and general con- stitutional manifestations. All the organ  systems were graded A to E and then to  obtain a global BILAG score  the com- ponent scores were assigned numerical  values  [A (most active disease) = 9, B  (intermediate activity) = 3, C (mild and  stable disease activity) = 1, D (inactive  disease) = 0 and E (no activity ever) =  0],  resulting  in a potential global  score  ranging  from 0  to 72. This numerical  score as well as  the  total BILAG score  have been  shown  to be valid  [10,16].  SLE patients were arbitrarily categorized  into 2 groups:  active disease (BILAG  score > 5) and inactive disease (BILAG  ≤ 5). A  total BILAG score > 5 usually  consists of  at  least 1 organ  score of 3  (which signifies 1 organ system with a  minor flare-up).  Renal  lesions were classified histo- logically according to the World Health  Organization (WHO) classification for  lupus glomerulonephritis [17]. Hyper- tension was also diagnosed according to  WHO definitions. Systolic and diastolic  blood pressure (BP) were determined  using an average of 2  consecutive  sit- ting BP readings taken 5 minutes apart.  Patients were considered  to be hyper- tensive if over the study period they had  mean systolic BP > 140 mmHg and/or  diastolic BP > 90 mmHg and/or were  taking antihypertensive drugs. None of the patients or controls had  a concomitant viral or bacterial  infec- tion or other disorders such as diabetes  mellitus,  liver or  thyroid disease at  the  time of the study. Subsequent follow-up  supported  this  clinical opinion. None  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 895 of the participants was pregnant or had  drug-induced  lupus erythematosus  at  the time of the study.  Laboratory methods The following laboratory investigations  were completed for all the participants: ESR  and  complete  blood  count • (CBC) using standard methods.  Serum creatinine,  blood urea,  liver • function  tests,  fasting  lipid profiles  and  fasting blood  sugar were deter- mined using  an  autoanalyser  (Syn- chron CX-7, Beckman). Complete urine analysis for the pres-• ence of  red blood cells (RBCs), pus  cells,  albumin and urinary casts (ei- ther granular, hyaline, tubular and/or  mixed type).  CRP detected by ELISA  technique • (Active Diagnostic  Systems), with  normal levels defined as < 6 mg/L.  Antinuclear  antibodies  (ANA) and • anti-dsDNA were detected by  indi- rect  immunofluorescent  assay  on  mouse kidney and stomach slides and  Crithidia luciliae  slides  (Immco Di- agnostics). The slides were analysed  with a Nikon epifluorescent micro- scope. A  titre ≥ 1:80 was considered  positive for ANA and > 1:40 IU/mL  for anti-dsDNA detection.  Complement  C3  and  C4  were • determined  by  single  radial  im- munodiffusion  plates  (Diffu-Plate,  Biocientifica).  Soluble VCAM-1 and ICAM-1 were • quantified with an  immunoassay kit  (R & D Systems), with normal levels  for sICAM-1 defined as 115–306 ng/ mL [mean 211 (SD 2SD) ng/mL]  and  for  sVCAM-1 as 349–991 ng/ mL [mean 557 (SD 139.6) ng/mL]. Detection of  serum neopterin was • performed using an enzyme  immu- noassay  kit  (DRG  Instruments),  following the basic principles of com- petitive ELISA. The serum neopterin  normal value was < 10 nmol/L (< 2.5  ng/mL), with  the  range of  normal  values 3–9 nmol/mL. Blood and urine samples from SLE  patients and controls were obtained at  the time of recruitment to the study. All  blood specimens were collected under  aseptic conditions and were allowed to  clot for about 30 min at room tempera- ture. Sera were obtained after centrifu- gation, and routine laboratory tests were  carried out immediately. The remaining  sera were  stored  frozen  in  aliquots  at  –20  °C  for  the  subsequent assays and  thawed only once. Grossly haemolytic,  icteric or  grossly  lipaemic  specimens  were discarded  to  avoid  aberrant  re- sults; repeated freeze–thaw cycles were  avoided. Stored samples were protected  from  light. Urinary  sediment  analysis  was carried out by routine microscopy.  The samples of the SLE cohort and  controls were analysed  together at  the  same time to avoid methodological er- rors.  All markers and the disease activity  index were measured at 3  time points  over 6 months,  at  the beginning (the  baseline measurement)  and  3  and  6  months after joining the study. Data analysis Statistical analysis of  the data was per- formed with SPSS, version 11.0 software,  and  continuous  variables  were  pre- sented as means and SD. Comparisons  between the SLE disease groups and the  control group were carried out using the  Mann–Whitney  test. The relationship  between  inflammatory markers  levels  and clinical parameters was determined  using the Spearman correlation analysis  and  the  linear  regression method. P- values  <  0.05 were  considered  to  be  statistically significant. Results Background characteristics of patients Using  the BILAG score  cutoff > 5  to  separate  active  from  inactive SLE, 24  (55.8%) patients were classified with ac- tive disease at  the time of  investigation  and 19 (44.2%) with inactive disease.  Of  the 24 patients with active dis- ease, 16 patients had active extrarenal  disease and 8 had active  renal disease  defined by  the presence of: persistent  proteinuria  >  0.5  g/day  or  dipstick  proteinuria > 3+  if measurement was  not performed; or cellular urinary casts  (haeme, granular, red cell or mixed) and  cells present (> 5 RBCs or WBCs per  high-power field); or unexplained  rise  in serum creatinine (> 1.5 mg/dL). Of  these 8 patients, 5 patients had a  renal  biopsy: 3 were diagnosed with diffuse  proliferative nephritis  (class  IV)  and  2 with  focal  segmental nephritis (class  III). Of  the  remaining 3 patients with  active  renal disease, 1 had  thrombocy- topenia that was not considered safe for  the biopsy procedure and 2 had  lupus  nephritis with clear clinical and  labora- tory findings.  A total of 39 (90.7%) patients were  receiving drugs  at  the  time of  assess- ment: 13 were on low-dose corticoster- oids (prednisone 47.5 mg/day), 4 on  antimalarials,  3 on methotrexate  and  1 on  azathioprine  as  the  single  treat- ment. The remaining 18 patients were  receiving  combined drug  treatments:  2 were on antimalarials plus  low-dose  corticosteroid, 1 on methotrexate plus  corticosteroid  (>  7.5 mg/day),  6  on  azathioprine plus corticosteroid (> 7.5  mg/day), 5 on cyclophosphamide plus  corticosteroid (> 7.5 mg/day) and 4 on  cyclosporin A plus corticosteroid (> 7.5  mg/day).  All the 5 patients treated with cyclo- phosphamide had active lupus nephritis:  2 were classified as IV.B and 1 was III.B  according to the WHO classification. A  renal biopsy was not performed on 2 pa- tients, but their kidney involvement was  obvious from the clinical and laboratory  findings  (proteinuria  >  1  g/day). Of  the 4 patients  treated with cyclosporin  A, lupus nephritis was present in 3, and  was documented by histology in 2 cases  (1  III.A and 1  IV.B);  in 1 of  them the  presence of  lupus nephritis was  clear  from  the  clinical  and  laboratory find- ings. There were 3 patients treated with  EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 896 cyclophosphamide and 1  treated with  cyclosporine A, who received immuno- suppressive therapy before inclusion in  the study. Organ system involvement Of  the 24 patients with active disease,  15 (62.5%) had  involvement of only 1  organ  system and 9  (37.5%) had  in- volvement of more than 1 organ system.  Large variations in disease activity were  found. On average, 38% of the patients  showed no activity ever  in at  least 1 of  the organ systems (category E). The ac- tive and inactive SLE groups did not dif- fer significantly  in  terms of age, disease  duration and number of ARA criteria  fulfilled (Student  t-test)  (Table 1).  In  this  study more patients had  activity  (categories A to C) in the musculoskel- etal, mucocutaneous and haematologi- cal systems (22, 21 and 19 respectively)  as compared with the renal, neurological  and cardiovascular systems (10, 4 and 5  respectively) (Table 2). Laboratory markers Table 3  shows  the data  for  the  con- ventional  laboratory  measures  of  inflammation  and SLE disease  activ- ity  (elevated CRP  level, positive  anti- dsDNA  titre  and C3  and C4  levels)  compared with  the novel  immunoin- flammatory markers. As expected,  the  proportion of  patients with  elevated  CRP  level was  significantly  different  between SLE patients and  the control  group and between inactive and active  SLE patients (P < 0.001). The percent- age of  anti-dsDNA-positive  patients  was not significantly different between  the 2 SLE groups. None of the controls  had  anti-dsDNA  antibodies  in  their  sera. No  significant differences were  found  in  the mean serum levels of  the  complement C3 and C4 in those with  inactive versus active SLE.  The  mean  levels  of  neopterin,  sICAM-1 and  sVCAM-1 were higher  in SLE patients compared with controls  (P  < 0.01). Mean  levels of neopterin  and sVCAM-1 were significantly differ- ent comparing active and  inactive SLE  groups (P < 0.05). Correlations between different laboratory markers Significant  positive  correlations  be- tween the different markers are shown  on Table 4. There were significant cor- relations between neopterin and CRP  levels  (P  <  0.05),  between neopterin  and dsDNA antibody level (P < 0.001)  and between neopterin and sVCAM-1  levels (P < 0.001). In addition, correlations were calcu- lated between  the different  serological  markers  and  the  total  BILAG  score.  There  was  a  significant  correlation  between  total BILAG score and CRP  level (P < 0.001), but not between total  BILAG score and anti-dsDNA or C3  and C4 levels. Also, no correlation was  found between total BILAG score and  sICAM-1  levels,  but  significant  cor- relations were  found with  sVCAM-1 (P  <  0.01)  and neopterin  (P  <  0.05)  levels (Table 4).  To  calculate  the  correlations  be- tween  the serological markers and dis- ease activity of different BILAG organ  systems, we chose the 3 organ systems  where  the number of  patients with  a  BILAG score > 3 was high enough (n > 9) for a statistical analysis (i.e. muco- cutaneous, musculoskeletal  and  renal  involvement). No positive correlation  was  found between any of  the  tested  Table 1 Characteristics of patients with active and inactive systemic lupus erythematosus (SLE) Variable Active SLE (n = 24) Inactive SLE (n = 19) Mean (SD) age (years) 42.3 (14.7) 40.1 (11.9) Mean (SD) disease duration (years) 11.1 (7.1) 10.4 (9.1) No. of ARA criteria 6.4 5.2 SD = standard deviation; ARA = American Rheumatism Association. Table 2 Disease activity by organ system of patients with systemic lupus erythematosus (SLE) as assessed by the British Isles Lupus Assessment Group index scores Organ system SLE disease activity (no. of patients) A Strong B Moderate C Low D None presently E None ever Musculoskeletal 1 4 17 15 6 Mucocutaneous 1 9 11 14 8 Haematological 0 3 16 14 10 Vasculitis 0 0 13 12 18 Renal 1 6 3 13 20 General 1 0 4 23 15 Nervous system 0 0 4 8 31 Cardiovascular/ respiratory 0 0 5 15 23 طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 897 markers and  the disease activity of dif- ferent BILAG organ  systems. Higher  levels  of  neopterin  and  sVCAM-1  were  identified  in patients with  lupus  nephritis (mean 14.8 nmol/L and 1780  nmol/L  respectively)  compared with  patients without  kidney  impairment  (mean 13.7  (ng/mL) and 1710 (ng/ mL) respectively). Serial measurements of markers and disease activity index Among the 43 SLE patients complete  follow-up data were only available  for  22 patients who were  included  in  the  next  step,  in which  all markers  and  disease activity index were measured at  3 time points over 6 months, at the be- ginning (the baseline measurement)  and after 3 and 6 months. They were  divided  into 3 subgroups (active with  flare-ups,  active with  remission  and  inactive patients). Patients with  lupus  nephritis were present  in both active  subgroups with  initially high disease  activity. However,  they were not ho- mogeneous  enough  to  be  included  in  the  final  evaluation  as  a  separate  subgroup. The descriptive statistics for  anti-dsDNA, complement C3 and C4,  neopterin,  sICAM-1 and  sVCAM-1  levels  in  the  subgroups  over  the  6  months are shown in Table 5. The  serum  levels  of  anti-dsDNA  antibodies  were  the  lowest  in  the  inactive subgroup. A significant differ- ence  in anti-dsDNA  levels was  found  between  the  inactive  subgroup  and  the  subgroup with active flare-ups at  baseline, 3 months and 6 months (P < 0.001). The  inactive  subgroup and  the  active with  remission  subgroup  differed  significantly  in  the  baseline  measurements  (P  <  0.001). Among  the  subgroup who were  active with  remission a  significant difference was  found between measures  at baseline  and 6 months (P > 0.01).  The  serum  levels  of C3 were  the  highest  in  the  inactive  subgroup, but  differences between the subgroups did  not  reach  significant  levels,  nor were  there  significant differences within  the  subgroups over  the 3 measurements.  The highest  levels  of C4 were  in  the  inactive  subgroup, but  the differences  were not statistically significant. Chang- es in C4 levels at follow-up within each  subgroup were not significant.  The differences  in serum neopterin  levels were  significant  comparing  the  inactive subgroup and both active sub- groups at baseline and at 6 months (P < 0.01and P < 0.001 respectively). There  were no significant differences between  the active  subgroups when compared  with each other or when  the changes  within each subgroup were compared.  The  highest  levels  of  sVCAM-1  were  in  the subgroup with active flare- ups at baseline. Although the differences  between active subgroups were not sig- nificant statistically, significant decreas- es between baseline  and  the 6-month  measurements of sVCAM-1 levels were  Table 3 Frequency of elevated traditional laboratory parameters and mean levels of inflammatory markers in the control group and in subgroups of patients with systemic lupus erythematosus (SLE) Marker Controls (n = 20) Active SLEa (n = 24) Inactive SLE (n = 19) P-value Elevated CRP level [no. (%) of patients] 1 (5.0) 17 (70.8) 5 (26.3) < 0.05b,c Positive anti-dsDNA [no. (%) of patients] 0 (0.0) 15 (62.5) 9 (47.3) < 0.05b Mean C3 level (g/L) 1.23 0.64 0.89 < 0.05b Mean C4 level (g/L) 0.31 0.16 0.15 < 0.05b Mean neopterin level (nmol/L) 6.7 14.3 10.1 < 0.05b,c Mean sICAM-1 level (ng/mL) 275.1 669.7 490.6 < 0.05b Mean sVCAM-1 level (ng/mL) 782 1721 1465 < 0.05b,c aTotal BILAG score > 5. b P < 0.05 between SLE patients and controls; cP < 0.05 between active and inactive SLE patients. CRP = C-reactive protein; anti-dsDNA = antibodies to double-stranded DNA; C3 and C4 = complement components 3 and 4; sICAM-1 = soluble intercellular adhesion molecule; sVCAM-1 = soluble vascular cell adhesion molecule. Table 4 Significant positive correlations between inflammatory markers in patients with systemic lupus erythematosus Marker Marker CRP anti-dsDNA Neopterin sICAM-1 sVCAM-1 C3 CRP 1 – – – – – anti-dsDNA – 1 – – – – Neopterin < 0.05 < 0.001 1 – – – sICAM-1 – – – 1 – – sVCAM-1 – – < 0.001 – 1 – C3 – – – – – 1 BILAG score < 0.001 – < 0.05 – < 0.01 – CRP = C-reactive protein; anti-dsDNA = antibodies to double-stranded DNA; sICAM-1 = soluble intercellular adhesion molecule; sVCAM-1 = soluble vascular cell adhesion molecule; C3= complement component 3; BILAG = British Isles Lupus Assessment Group index. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 898 found within all subgroups (P < 0.001, P < 0.001 and P < 0.01 respectively).  No  significant   differences   in  sICAM-1  levels  were  found  among  subgroups or within subgroups. Discussion Levels of complement C3 and C4, and  dsDNA antibodies,  classic  laboratory  markers for disease activity in SLE, did  not differentiate  between  active  and  inactive disease  in our patient cohort.  This was in agreement with other stud- ies  suggesting  that  serum neopterin  [2,18,19] and sVCAM-1 [2,13,20,21]  are more  sensitive markers of disease  activity.  Levels  of  anti-dsDNA  antibod- ies  are  a widely  accepted measure  for  evaluating disease activity in SLE. How- ever,  anti-dsDNA does not necessar- ily fluctuate with disease activity and a  substantial proportion of SLE patients  are  anti-dsDNA negative  [4].  SLE  is  characterized  by  hyperactivity  of  B  cells  and by  the production of organ  non-specific autoantibodies. Levels of  anti-dsDNA antibodies are very specific  tests, particularly  in diagnosis  [7,8].  In  this  study,  the correlation of anti-dsD- NA with  the disease activity  index was  weaker than in the case of sVCAM-1. In  some studies  the  limited value of serial  measurement of anti-dsDNA antibod- ies  for  the prediction of  lupus  relapse  has been discussed [2,13].  The complement components C3  and C4 are also  traditional markers of  disease  activity  and  their  use  reflects  the  important  role  that  the  comple- ment system plays in SLE pathogenesis  [5,6]. An impaired complement system  might affect  the clearance of apoptotic  material  and  thus enhance  the vicious  circle  in SLE, but  the clinical measure- ment of  complement  components  is  not  sensitive enough  to detect disease  activity  in  SLE  [2,18].  According  to  the  results  of  our  study,  their  levels  did not correlate  significantly with  the  disease activity  index. C3 and C4 did  Table 5 Mean serum levels of selected markers in subgroups of patients with systemic lupus erythematosus (SLE) at baseline and after 3 and 6 months Marker Active SLE with flare-ups (n = 10) Active SLE with remission (n = 8) Inactive SLE (n = 4) Mean (SD) Mean (SD) Mean (SD) Anti-dsDNA (IU/mL) Baseline 71.5 (67.6)*a 86.3 (55.1)*a 33.2 (35.3) 3 months 86.1 (67.3)*a 52.3 (56.8) 29.9 (25.8) 6 months 68.2 (51.9)*a 32.4 (51.2)*a,b 24.1 (11.5) C3 (g/L) Baseline 0.63 (0.17) 0.54 (0.14) 0.72 (0.22) 3 months 0.62 (0.15) 0.59 (0.19) 0.76 (0.19) 6 months 0.57 (0.19) 0.60 (0.16) 0.69 (0.20) C4 (g/L) Baseline 0.16 (0.07) 0.15 (0.08) 0.19 (0.08) 3 months 0.15 (0.06) 0.17 (0.06) 0.16 (0.06) 6 months 0.13 (0.05) 0.16 (0.07) 0.16 (0.05) Neopterin (nmol/mL) Baseline 14.1 (8.3)*a 13.9 (9.4)*a 10.5 (8.4) 3 months 13.3 (8.7)*a 12.7 (7.6) 10.8 (9.6) 6 months 12.8 (7.2)*a 10.2 (6.1)*a 8.7 (6.7) sICAM-1 (ng/mL) Baseline 724 (236) 662 (173) 529 (252) 3 months 628 (152) 636 (152) 538 (156) 6 months 645 (273) 611 (139) 501 (134) sVCAM-1 (ng/mL) Baseline 2105 (312)*a 1722 (426) 1564 (385) 3 months 1662 (325)*a 1347 (374) 1456 (491) 6 months 1265 (296)*a,b 961 (463)*a,b 1057 (269)*a,b *aP < 0.05 versus inactive subgroup; *bP < 0.05 versus baseline measurement. SD = standard deviation; anti-dsDNA = antibodies to double-stranded DNA; C3 and C4 = complement components 3 and 4; sICAM-1 = soluble intercellular adhesion molecule; sVCAM-1 = soluble vascular cell adhesion molecule. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 899 not decrease  significantly during SLE  disease flare-ups  in  individual patients,  even though their levels correlated (but  not significantly) with the BILAG score.  Furthermore, their levels did not change  significantly  and  rapidly  enough with  the declining  activity over  the period  of  the  follow-up  in  the  subgroup with  declining BILAG index. Their utility as  a reliable marker of disease activity and  therapy  response  is  therefore  limited  [18].  In  accordance  with  some  earlier  studies,  sICAM-1  levels were elevated  above  the normal  range  in all our pa- tients  but  did  not  differ  significantly  between patients with active and  inac- tive disease [2,6,18,22]. It is noteworthy  that neither  the  values of  the C3 and  C4 nor  the  levels  sICAM-1 correlated  significantly with  the disease  activity  index and this agrees with other studies  [16,22]. These results contrast with data  reported in other studies [16,23]. Of  all  the  immunoinflammatory  variables we  investigated, CRP, neop- terin  and  sVCAM-1  correlated  best  with disease  activity measured by  the  total BILAG score.  Interestingly,  sev- eral studies of CRP autoantibodies have  claimed that serum levels of CRP often  remain low despite high disease activity  and despite high  levels of other  acute  phase  proteins  [24],  suggesting  that  the  presence  of  low CRP  levels may  not reflect the presence of antibodies to  CRP which may play an important role  in SLE pathogenesis [25].  The  important question  is whether  the  involvement  of  different  organ  systems  in SLE correlates with differ- ent patterns of  immunoinflammatory  markers. This is likely, as it is well known  that anti-dsDNA correlates with  renal  disease, but not with musculoskeletal  involvement in SLE [6]. We chose the BILAG scoring scale  because  it  gives  an  accurate  organ- specific measurement  of  disease  ac- tivity,  and would  allow correlation of  immunoinflammatory markers  with  disease activity  in  the different organs  involved. However, we  could not  es- tablish  a  relationship between  any of  the  tested markers  and organ-specific  BILAG scores. This may have been be- cause of the limited numbers of patients  in each group and  the wide variety of  organ-specific BILAG groups  included  in our study (7 groups). Our  results  contrast  with  other  studies where,  for example, changes  in  anti-dsDNA and complement concen- trations were reported predominately to  accompany flare-ups of  lupus nephritis  [20,26,27]. Significant correlations have  been  found between other biological  laboratory markers  and  some BILAG  organ  system scores,  such as between  interleukin-1  receptor antagonist  (IL- 1ra), and the musculoskeletal score [7]  and between  soluble  tumour necrosis  factor receptors p55 and p75 (sTNFR- 55/sTNFR-75) and renal BILAG score  [6]. Their findings, but not ours, support  the hypothesis of different pathologi- cal mechanisms  in  the different organ  systems. Although we  found higher  values  of  sVCAM-1  in  patients  with  lupus  nephritis compared with patients with- out kidney  impairment  the differences  were not statistically significant, a result  that agrees with other studies [27–29].  However,  another  study  showed  that  the  serum  level of  sVCAM-1 was  sig- nificantly higher  in patients with active  lupus nephritis  (WHO classes  III  and  IV)  than  in patients  in  inactive  lupus  nephritis  and  there was a positive cor- relation between  sVCAM-1 and SLE  disease activity, which decreased during  remission [20]. Similarly,  an  increased  level  of  neopterin was  reported with  lupus nephritis [10]. In  this  study,  time-series modelling  was adopted to investigate if serial meas- urements of some inflammatory mark- ers could predict the BILAG score and  hence SLE disease activity in individual  patients. Time-series  analysis  showed  that  sVICAM-1  increased significantly  during flare-ups  in SLE disease  activ- ity. Similarly,  a  significant decrease  in  concentrations was observed in patients  with active SLE who went  into disease  remission,  as  shown  in  another  study  [20].  In  those patients whose disease  remained active or  in remission on the  third successive assessment, concentra- tions were found to be correspondingly  greater or smaller compared with initial  values.  Levels of  sICAM-1 were predomi- nantly within  the baseline  range dur- ing maximal  disease  activity  and did  not  change  in  the  time period before  remission. These findings might in part  be  explained by binding of  the  func- tionally  active  soluble  molecules  to  their  respective  ligands  on  activated  leukocytes [13]. The present finding of  high sVCAM-l levels, however, conflicts  with  this hypothesis,  although  it might  be  explained by  an excess of  released  molecules compared with  the number  of  accessible molecules  [13,23,29,30].  Generally, none of  the other study pa- rameters was  found to mirror SLE dis- ease activity as effectively as sVCAM-1  using both single  time-point and time- series analyses.  In  conclusion,  this  study  indi- cates  that  serial  concentrations  of  sVCAM-1 are significantly associated  with SLE disease activity scored using  the BILAG  index. Measurement  of  neopterin  and  sVCAM-1  appeared  to be clinically useful  for  isolated as- sessments  of  disease  activity.  Both  anti-dsDNA and sVCAM-1 were rela- tively good markers of disease activity  in SLE. It seems that both are suitable  for  the monitoring of disease activity  and could help to predict remission or  to monitor  the  therapeutic  response.  Assessment of the possible advantages  of  sVCAM-1  over  anti-dsDNA  re- quires  additional  information  from  future studies. 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Lack of correlation with levels of circulating vascular cell adhesion molecule 1. Arthritis and Rheumatism, 1993, 36(4):519–527. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 901 HIV-related knowledge and AIDS stigma among college students in Yemen A.M. Badahdah 1 and N. Sayem 2 ABSTRACT The present study analysed data from 501 Yemeni university students to examine their knowledge about HIV and their attitudes towards people with HIV/AIDS. The findings indicate that participants had several serious misunderstandings about HIV/AIDS and held negative attitudes toward people living with HIV/ AIDS. Although female students were less knowledgeable about HIV/AIDS than were male students, they held more positive attitudes toward people with HIV/AIDS. An overwhelming number of students expressed their willingness to get tested for HIV and recognized that AIDS is a serious issue facing their country. The study provides suggestions for HIV prevention efforts and ideas for future studies in Yemen. 1Department of Sociology, University of North Dakota, Grand Forks, North Dakota, United States of America (Correspondence to A.M. Badahdah: abdallah.badahdah@und.edu). 2Department of Psychology, University of Sana’a, Sana’a, Yemen. Received: 31/10/08; accepted: 14/01/09 نميلا في تاعمالجا بلاط ينب زديلإا ةمصوو يشربلا يعانلما زوعلا سويرف لوح فراعلما ليلخ مئاص ةاجن ،حدحداب دممح للها دبع يعانلما زوعلا سويرف لوح مهفراعم لىع فرعتلا دصقب ةينميلا ةعمالجا نم ًابلاط 501 لوح تايطعلما ةساردلا هذه في ناثحابلا للح :ةـصلالخا يرطخ مهف ءوس ةساردلا في ينكراشلما ىدل نأ لىإ ناثحابلا اهيلع لصح يتلا جئاتنلا تراشأ دقو .زديلإا سويرفل ينشياعلما نم مهفقاومو ،يشربلا زديلإا لىع ًاعلاّطا لقأ تابلاطلا نأ مغرو .زديلإا سويرفل ينشياعلما هاتج ةيبلس فقاوم نوفقي منهأو ،هسويرفب ىودعلاو زديلإا نع بناولجا ددعتمو فشك رابتخا ءارجإب مهبيحرـت نع بلاطلا نم ةيرفغ دادعأ تبرعأ دقو .زديلإا سويرفل ينشياعلما هاتج ةيبايجإ رثكأ فقاوم نفقي ننهإف ،بلاطلا نم سويرفب ىودعلا نم ةياقولا دوهلج تاحارـتقا ةساردلا مدقتو .مهدلب هجاوت ةيرطخ ةيضق زديلإا نأ نوكردي مهو ،يشربلا يعانلما زوعلا سويرف .نميلا في ةيلبقتسم تاسارد ءارجإ نع ًاراكفأو ،زديلإا Connaissances en termes de VIH et stigmatisation associée au sida chez des étudiants en République du Yémen RÉSUMÉ La présente étude a analysé des informations recueillies auprès de 501 étudiants yéménites afin d’évaluer leurs connaissances sur le VIH et leur attitude vis-à-vis des personnes atteintes du VIH/sida. Les résultats montrent que les répondants présentaient de graves lacunes en termes de connaissances du VIH/sida et qu’ils réagissaient de manière négative envers les personnes infectées. Si les étudiantes étaient moins bien informées que les étudiants, elles adoptaient toutefois une attitude plus positive envers les personnes atteintes du VIH/sida. Un nombre considérable d’étudiants a exprimé le désir de bénéficier d’un test de dépistage du VIH et a admis que le sida représentait un grave problème auquel leur pays devait faire face. L’étude présente des propositions relatives aux efforts de prévention du VIH et des idées pour de futures études à réaliser en République du Yémen. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 902 Introduction HIV/AIDS prevention strategies aspire  to  reduce HIV  infection by  changing  the perceptions and behaviours that in- crease the likelihood of people becom- ing infected and altering the underlying  structural  arrangements  that  shape or  constrain people’s behaviours,  such as  poverty and gender inequality [1]. One  of  the  structural  factors  that has been  the  target of HIV prevention efforts  is  stigma [2–4]. Since the beginning of the  AIDS epidemic, AIDS-related  stigma  has  been  globally  acknowledged  as  detrimental to the well-being of people  living with HIV/AIDS (PLWHA) and  a significant obstacle to HIV prevention  programmes [2]. Stigma interferes with  individuals’  desire  to  seek  treatment,  disclose  their health  status,  adhere  to  antiretroviral  therapy or  seek  support.  Some  countries  have made  progress  towards understanding AIDS-related  stigma, its prevalence and its impact on  the  lives of PLWHA and  their  signifi- cant others. The  few  studies  available  on HIV/AIDS in countries of the Arab  world, however,  show the existence of  various misconceptions  about HIV/ AIDS and the pervasiveness of the stig- matization  of  individuals with HIV/ AIDS [5–7].  Although HIV/AIDS  prevalence  rates  in  the  Eastern Mediterranean  Region are  low,  the Region has one of  the fastest-growing HIV infection rates  in  the world  [8]. Djibouti  and Sudan  have the highest prevalence rates in the  Arab world and are facing a generalized  epidemic. Other countries, such as Mo- rocco and the Libyan Arab Jamahiriya,  are experiencing a  localized epidemic.  The main route of infection in the Arab  world  is unprotected heterosexual  in- tercourse. However,  in some countries  injecting drugs  is  the major  cause of  HIV infection.  Although considerable  success has  been achieved in slowing the spread of  AIDS, HIV rates continue  to  increase  rapidly  in  some  countries,  including  Yemen. Yemen  is  a  conservative  and  tribal  state of  23 million people with  a median  age  of  16.7  years  and high  rates of  illiteracy, poverty  and unem- ployment;  it  is one of  the poorest and  least-developed countries  in  the Arab  world [9]. The World Health Organiza- tion (WHO) has estimated  that  there  are approximately 24 000 HIV-infected  individuals  in Yemen [10]. During  the  1990s the majority of the infected peo- ple  in Yemen were men;  in 1995  for  every 4 HIV-infected men  there was  1 HIV-infected woman. However,  the  risk of HIV  infection  among Yemeni  women has increased and in 2005 it was  reported  that as many women as men  were infected [9].  Yemen  lacks  the basic  tools  to halt  the  spread of HIV. To  illustrate  this,  only 107 patients are  receiving antiret- roviral  therapy  [11],  and  testing  and  counselling  facilities  are  limited  [12].  With  this  in mind, we were able  to  lo- cate only 2 published empirical studies  about HIV/AIDS  in Yemen, one  that  examined  individuals’ knowledge and  perceptions of  individuals with HIV/ AIDS [13]  and another  that  assessed  Yemenis’  attitudes  toward  the use of  condoms as a means of HIV prevention  [14]. The purpose of the present paper  was  to assess Yemeni students’ knowl- edge of HIV/AIDS and the stigmatiza- tion of PLWHA. This  is  the first  study  to focus exclusively on young Yemenis,  who  represent 21.4% of  the country’s  population [15].  Methods Sample To determine  the  sample  size  for  the  study,  the proportion of  students who  held positive attitudes toward PLWHA  and  had  accurate  knowledge  about  HIV/AIDS was assumed to be 50%. The  sample size was estimated to be around  400  students. To minimize problems  associated with unusable questionnaires  we increased the sample size by 25%. A  convenience sample was selected con- sisting of 501 undergraduate  students  who attended a large public university in  Sana’a,  the capital of Yemen. Uninten- tionally,  the sample size was divided al- most equally between men and women  (251 males and 250 females).  Data collection The data were collected via a question- naire  that was distributed  to  students  in  psychology  classes. The  items  for  this  study were selected  from previous  studies conducted by the first author in  several countries  in the Arab world [5]  and from a study conducted in Yemen  to  develop  an  AIDS-related  stigma  scale [16]. The questionnaire contained  several items about HIV/AIDS knowl- edge, AIDS-related  stigma  and other  items related to HIV prevention.  For  the knowledge  index, 11 state- ments (e.g. “There is a cure for AIDS”)  were  generated  to  assess  students’  general knowledge about HIV and  its  transmission.  Students  could  choose  from 3 options for each question: “cor- rect”,  “wrong”  and  “don’t  know”. The  “don’t know” answers were  treated as  wrong answers in the analysis. An index  of AIDS knowledge was  created  that  ranged from 0 to 11, with higher scores  indicating greater knowledge of HIV.  AIDS-related stigma was measured  by 11  items  that  indicated  the beliefs  (e.g.  “AIDS  is  a  punishment  from  God”), emotional responses (e.g. “Peo- ple with AIDS make me angry”)  and  behavioural reactions towards PLWHA  (e.g. “People with AIDS should be fired  from  jobs”). Participants  responded  to  each  statement on a Likert-type  scale  with possible responses ranging from 1  (very strongly agree) to 6 (very strongly  disagree). Cronbach alpha was used to  assess  the  internal  consistency of  the  items of the AIDS stigma measure. The  coefficient of  reliability  indicated  that  the  11  items were  highly  consistent (α = 0.81).  Students  were  also  asked  about  their willingness  to  take  an HIV  test  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 903 and whether  they knew someone with  AIDS. To understand students’ percep- tions of  the AIDS situation  in Yemen,  we asked them if they thought that HIV  was an issue in Yemen and whether the  media had exaggerated its prevalence. Data analysis SPSS,  version 17 was used  to  analyse  the data  for  this  study. The mean and  standard deviation (SD) were used as  well as Student t-test, Spearman correla- tion and Cronbach alpha  to assess  the  reliability of  the stigma scale. The  level  of significance was P < 0.05. Results The students’ ages ranged from 17 to 29  years, mean 22 (SD 2.22) years, and the  majority (83.8%) were single. An over- whelming proportion of the participants  (82.6%) reported  that  they had grown  up in a middle-income family  The mean score of students’ knowl- edge  about HIV  transmission on  the  11-item  index  was  6.70  (SD  1.87)  (Table 1). Four out of 11  items were  answered  incorrectly by half or more  of  the  students.  Specifically,  69.2% of  the  participants  either  did not  know  or  thought  that  there was  a  cure  for  AIDS and 51.8% either did not know or  believed  that mothers cannot  transmit  HIV  through  breastfeeding.  Only  a   fraction  of  the  participants  (28.9%)  knew that mosquito bites cannot trans- mit HIV. A third of the students (36.3%)  knew that condoms are effective in pre- venting  sexually  transmitted diseases  such as HIV. Only a few students (8.2%)  knew  that  they  could  not identify  a  person with AIDS by  looking at him/ her,  and 33.9%  lacked  knowledge or  provided the wrong answer when asked  whether  the  HIV  virus  infects  only  homosexuals.  Female  students  were  less knowledgeable about HIV [mean  score 6.50 (SD 1.85)]  than were male  students [mean score 6.90 (SD 1.87)].  This gender difference was  statistically  significant (t = 2.40, P < 0.05).  Yemeni  students’  perceptions  of  PLWHA were slightly below  the mid- point of the scale [mean score 3.48 (SD  1.01)]. More than half the respondents  (52.1%) agreed that “people with AIDS  should be ashamed of themselves” and  56.5%  said  they would be  ashamed  if  one of  their  relatives got AIDS (Table  2). Similarly, 66.3% believed  that  it  is  shameful  to have people with AIDS  in  Yemen. Other AIDS-related emotional  statements  that  a  large proportion of  participants endorsed were about sym- pathy and anger: 48.5% agreed that they  find it personally difficult to sympathize  with people with AIDS, and 42.7% ex- pressed anger toward people with AIDS.  Although 60.3% of the students agreed  that “AIDS is a punishment from God”,  many also thought that individuals with  AIDS were  not  responsible  for  their  infection  (63.1%).  Statements  about  isolating PLWHA by dismissing  them  from  their  jobs or quarantining  them  were endorsed by 39.9% and 39.7% of  the students respectively.  Female  students overall  expressed  more  positive  attitudes  towards  PLWHA than did male students [mean  score 3.82 (SD 0.90) versus 3.14 (SD  0.99)] (t =7.87, P < 0.001) (Table 2).  Students who had greater knowledge  about HIV/AIDS also had higher  at- titude  scores  towards  PLWHA  than  students who  had  some misconcep- tions about HIV (r = 0.11, P < 0.05).  Just  over  85% of  the  participants  indicated  their willingness  to  take  an  HIV test. These students expressed more  positive attitudes toward PLWHA than  those who were not interested in taking  the  test  [score 3.55 (SD 1.00) versus  3.25  (SD 1.10)]  (t  = 2.36, P  < 0.05).  Twenty (20) students (4.0%) reported  knowing  someone with HIV/AIDS.  The majority of the students agreed that  HIV  is a problem  facing  their country  (84.3%) and that the issue is accurately  presented in the media (77.6%). Table 1 HIV/AIDS knowledge among students in Sana’a, Yemen (n = 501) AIDS-related knowledge item Correct response Incorrect responsea No. % No. % Can tell if someone has AIDS by looking at him/her 41 8.2 286b 57.1 Only homosexuals get AIDS 75 15.0 331b 66.1 HIV lives in human body for years without symptoms 383b 76.4 52 10.4 There is a cure for AIDS 149 29.7 154b 30.7 Pregnant women can transmit HIV to their unborn babies 426b 85.0 19 3.8 Can get HIV by touching someone with AIDS 59 11.8 392b 78.2 Can get HIV by using public phone 17 3.4 407b 81.2 HIV can be transmitted through breastfeeding 241b 48.1 94 18.8 Mosquito bites can transmit AIDS 183 36.5 145b 28.9 Condoms reduce the probability of getting HIV 182b 36.3 78 15.6 AIDS virus can be found in semen 410b 81.8 12 2.4 aDon’t know responses are not shown; bIndicates the expected answer. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 904 Discussion This  study  examined  the misconcep- tions  about HIV  and  the  stigmatiza- tion of PLWHA  in Yemen,  a  country  that  to date has been  largely outside  the realm of AIDS research. We found  specific deficiencies in Yemeni students’  knowledge about HIV. Most  students  erroneously believed  that HIV cannot  be  transmitted via breastfeeding,  that  mosquito bites can  infect people with  HIV,  that  condom  use  is  ineffective  in preventing HIV  infection and  that  there is a cure for AIDS. Al-Serouri et al.  noted similar findings  in  their  study  in  Yemen: 86% of the participants agreed  that one can get infected with the AIDS  virus  from mosquito bites  [13]. This  misconception  is probably due  to  the  high prevalence of malaria  in Yemen.  According to the WHO “approximately  60% of the population live in areas with  malaria transmission” [17]. Two knowledge items deserve close  examination because of  the significant  role  they play  in HIV prevention. The  first is about the effectiveness of condom  use  in preventing HIV  infection. Only  36.3% of  the participants were well  in- formed about the role of condoms in re- ducing the probability of HIV infection.  Unfortunately,  this figure  is  lower  than  that of Busulwa et  al., who  found  in a  household survey that 46% of Yemenis  knew  that  condoms  protect  against  sexually transmitted infections [14]. This  lack of knowledge among young college  students is disturbing because they are at  a stage in their  lives where they may be  tempted to experiment with extramarital  sex and drugs. One explanation for  this  deficiency  in our sample, which we did  not test directly, may be that our college  students do not consider  themselves at  risk of acquiring HIV; hence knowledge  about condoms  is  irrelevant. Although  they  acknowledge  the  seriousness  of  AIDS in Yemen, they might believe that  AIDS is an issue among older adults or  promiscuous individuals.  Another  interpretation, which we  believe is also applicable to the findings  of Busulwa  et  al.,  is  that most  public  health establishments in the Arab world  do not advocate the use of condoms as  a preventive measure in the fight against  AIDS  in  their educational and preven- tion programmes [14]. This attitude  is  motivated by  the misconception  that  promoting condom use  is  against  the  teaching of  Islam and would encour- age people  to  engage  in unlawful  sex  [18]. This attitude was  illustrated by a  female college student who stated, “No,  we  should  not  encourage  the  use  of  condom[s] or the spread of condom[s]  because this can cause the spread of dis- eases and other dangerous behaviour.  No,  it  is  forbidden.  It  is not  allowed.”  [14].  The  other  knowledge  item  was  about the availability of a cure for AIDS.  Al Serouri  et  al.  reported  that 17% of  the participants  in  their  study  in Yem- en assumed  that  there was  a  cure  for  AIDS [13]. Unexpectedly, in our study  a  larger  percentage  of  students were  either unsure (39.5%) or  thought  that  a  treatment did exist (29.7%). Perhaps  the students were not educated enough  about HIV  to  be  able  to  distinguish  between  antiretroviral  therapy  and  a  cure for AIDS. Another possible source  of confusion is the claim made by Abdul  Majeed Al-Zandani, a well-known Yem- eni religious figure, who said he can cure  people with AIDS. Such a  false  claim  being publicized by a figure well-known  in the country is dangerous to the public  health of Yemenis,  and  trivializes HIV  prevention efforts in Yemen.  Another  important finding of  this  study  is  the gender gap  in HIV knowl- edge, with Yemeni males being more  knowledgeable about HIV/AIDS than  Table 2 Sex differences in attitudes towards people with HIV/AIDS among students in Sana’a, Yemen Attitude item Males (n = 251) Females (n = 250) t-value P-value Mean scorea SD Mean scorea SD People with AIDS should be fired from their jobs 3.21 1.91 4.14 1.62 5.87 < 0.05 It is difficult to sympathize with people with AIDS 3.29 1.62 3.86 1.52 3.99 < 0.05 I would be ashamed if a relative of mine got AIDS 2.96 1.75 3.41 1.76 2.87 < 0.05 People with AIDS should be quarantined 3.21 1.88 4.25 1.63 6.61 < 0.05 If a friend of mine got HIV I would continue being friends with him/her 3.69 1.69 4.08 1.56 2.74 < 0.05 People with AIDS make me angry 3.33 1.70 3.93 1.61 4.01 < 0.05 People with AIDS should be ashamed of themselves 2.96 1.66 3.70 1.74 4.80 < 0.05 It does not bother me if my classmate has AIDS 3.27 1.63 4.01 1.49 5.32 < 0.05 People with AIDS are responsible for getting AIDS 3.54 1.85 4.30 1.69 4.80 < 0.05 It is shameful to have people with AIDS in Yemen 2.57 1.63 3.00 1.76 2.88 < 0.05 AIDS is a punishment from God 2.61 1.72 3.34 1.74 4.70 < 0.05 aHigher scores = more positive attitudes. SD = standard deviation. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 905 their  female counterparts. Although a  gender gap was noted in other studies in  Yemen [13] and the United Arab Emir- ates [19], our study pointed to 2 serious  misconceptions  that  Yemeni  female  college  students had about AIDS. We  found  that more males  (43.0%)  than  females  (29.6%) knew  that  condoms  are effective  in  reducing  the  likelihood  of  HIV  infection.  Also  more  males  (88.8%)  than  females  (74.8%)  knew  that HIV can be transmitted through se- men. This gap is grave and needs urgent  attention from public health officials  in  Yemen because  the  limited data  that  exist  suggest  that  the majority of HIV- positive Arab women have contracted it  from their husbands [20]. Yemeni  students’  overall  percep- tion of PLWHA was not encouraging.  The results  suggest  that  students were  divided  equally  in  their  emotional  reactions  and  negative  beliefs  about  PLWHA.  At  the  behavioural  level,  around 40% of  the  students endorsed  2 statements about the need to socially  isolate PLWHA. This tendency may be  motivated by  the students’ perception  that AIDS  is a punishment  from God.  Studies from around the world and the  Eastern Mediterranean Region  have  found  similar  attitudes  [21–24].  For  example, 23.2% of  those between  the  ages of 11 and 83 years from Eskisehir,  Turkey [22], 14% of those living in Te- hran, Islamic Republic of Iran [23] and  28% of high-school students in Tunisia  [24] supported such a statement.  One of most encouraging results of  this  study was  the finding  that correct  knowledge about HIV/AIDS was  as- sociated with holding a positive  image  of PLWHA. Another one was that most  students were willing  to get  tested  for  HIV,  although  such a desire may not  be  fulfilled because of  the  lack of  re- sources in Yemen. Students’ awareness  of the magnitude of the AIDS problem  in  their  country  is  a positive  step  that  would  facilitate HIV prevention efforts  in Yemen. Health  care  professionals  and nongovernmental organizations  in  Yemen should capitalize on these posi- tive orientations and try to provide test- ing and counselling for young Yemenis.  Only 4.0% of tudents reported that they  knew someone with AIDS. This  is  less  than the number reported by a sample  of rural and urban residents in Yemen in  which 15% of the 1400 participants said  they knew someone with AIDS [25].  Despite the valuable contribution of  this study, several limitations should be  mentioned. The findings cannot be gen- eralized to all college students in Yemen  because  the  sample was  conveniently  collected  from 1 university  in  1  city.  Furthermore, because no standardized  AIDS-stigma scale has been developed  exclusively for Yemenis or Arabs in gen- eral, we used a collection of  items  that  the first  author had used  in previous  studies. At this juncture, we believe that  there  is  a need  to  construct  an AIDS  stigma scale  that  is  appropriate  to  the  Arab culture.  Conclusion Our  findings demonstrate the benefit of  furnishing Yemeni students with accu- rate information about HIV/AIDS as a  strategy to eliminate the stigma of AIDS.  Educational campaigns in Yemen need  to present AIDS as a health issue rather  than a moral  failure and find a way  to  incorporate condom use into HIV pre- vention efforts.  Coates TJ, Richter L, Caceres C. Behavioural strategies to re-1. duce HIV transmission: how to make them work better. Lancet, 2008, 372:669–684. Heijnders M, Van Der Meij S. The fight against stigma: an 2. overview of the stigma-reduction strategies and interventions. Psychology, Health and Medicine, 2006, 11:353–363. Goffman E. 3. Stigma: notes on the management of a spoiled iden- tity. Englewoods Cliffs, New Jersey, Spectrum, 1963, Link B, Phelan JC. Conceptualizing stigma. 4. Annual Review of Sociology, 2001, 27:363–385. Badahdah AM. Saudi attitudes toward people with HIV/AIDS. 5. International Journal of STD and AIDS, 2005, 16:837–838. Musso S, Fanget D, Cherabi K. Religion and education for HIV/6. AIDS prevention: an Arab-Islamic view. Prospective, 2002, 32:207–213. Roudi-Fahimi F. 7. Time to intervene: preventing the spread of HIV/ AIDS in the Middle East and North Africa. Washington DC, Popu- lation Reference Bureau, 2007. AIDS epidemic update8. . Geneva, United Nations Joint Pro- gramme on HIV/AIDS, 2007. Akala FA, El-Saharty S. Public health challenges in the Middle 9. East and North Africa. Lancet, 2006, 367:961–964. References Yemen. HIV/AIDS treatment scale-up. Summary country profiles.10. World Health Organization, 2005 (http://www.who.int/hiv/ HIVCP_YEM.pdf, accessed 27 April 2010). Towards universal access. Scaling up priority HIV/AIDS interven-11. tions in the health sector: progress report 2008. Geneva, World Health Organization, 2008. Botswana: Champion of ART scale up in Africa. Country Sto-12. ries Fact Sheet for Media. World Health Organization, 2006 (http://www.who.int/hiv/countrystories.pdf, accessed 27 April 2010). AlSerouri AW et al. Knowledge, attitudes and beliefs about 13. HIV/AIDS in Sana’a, Yemen. Eastern Mediterranean Health Journal, 2002, 8:706–715. Busulwa R et al. Perpcetions of the condoms as a method of 14. HIV prevention in Yemen. Eastern Mediterranean Health Jour- nal, 2006, 12:64–77. Country profiles for population and reproductive health: policy 15. developments and indicators 2005. New York, United Nations Population Fund and Population Reference Bureau, 2005. Badahdah AM, Sayem N, Foote CE. Development of a Yemeni 16. AIDS stigma scale. AIDS Care, 2009, 21:1–6. Yemen: country profile.17. Overview of malaria control activities and programme progress. Geneva, World Health Organization, EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 906 International Conference on Opportunistic Pathogens, New Delhi, India, 27–30 September 2010 Topics of concern and interest which will be addressed at the International Conference on Opportunistic Pathogens  include: contracting opportunistic infections, resistance to anti-retroviral drugs, co-pathogens of HIV, receptor attachment,  neuropathology, tissue tropism, testing guidelines, universal testing strategies, and future vaccine candidates against HIV.  Further information on the conference can be found at: http://icopa-india.org/default.htm 2005 (http://rbm.who.int/wmr2005/profiles/yemen.pdf, ac- cessed 27 April 2010). Madani T et al. Epidemiology of the human immunodeficiency 18. virus in Saudi Arabia; 18-years surveillance results and preven- tion from an Islamic perspective. BMC Infectious Diseases, 2004, 4:1–8. Ganczak M et al. Break the silence: HIV/AIDS knowledge, at-19. titudes, and educational needs among Arab university students in United Arab Emirates. Journal of Adolescent Health, 2007, 40: 572.e1–572.e8 (doi:10.1016/j.jadohealth.2007.01.0112). Alrajhi A, Halim M, Al-Abdely H. Mode of transmission of HIV-1 20. in Saudi Arabia. AIDS, 2004, 18:1478–1480. Kopelman LM. If HIV/AIDS is punishment, who is bad? 21. Journal of Medicine and Philosophy, 2002, 27:231–243. Ayranci U. AIDS knowledge and attitudes in a Turkish popu-22. lation: an epidemiological study. BMC Public Health, 2005, 13:1–10. Montazeri A. AIDS knowledge and attitudes in Iran: results 23. from a population-based survey in Tehran. Patient Education and Counseling, 2004, 57:199–203. Tebourski F, Ben Alaya D. Knowledge and attitudes of high 24. school students regarding HIV/AIDS in Tunisia: does more knowledge lead to more positive attitudes? Journal of Adoles- cent Health, 2004, 34:161–162. Common misconceptions about HIV increase discrimination. 25. Yemen Times, 12 August, 2009 (http://yementimes.com/arti- cle.shtml?i=1180&p=health&a=2, accessed 27 April 2010). طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 907 Review Burden of HIV/AIDS infection before and during the civil war in Somalia B.H. Ahmed,1 M.R. Giovagnoli,1 H. Mahad 2 and G.G. Tarsitani 1 ABSTRACT Somalia has suffered a massive internal population displacement and exodus that began in 1988 and is still ongoing during the prolonged and intermittent civil war. This review looks at the burden of HIV infection in Somali and the impact of civil war on its epidemiology. Serosurveys have indicated that HIV was not present in Somalia before the civil war and to date Somalia has had an HIV prevalence markedly below that of its neighbours. However, due to the ongoing war HIV sentinel surveillance cannot reach most of the affected areas in Somalia and the current HIV infection problem may be greater than the figures indicate. 1School of Medicine, Sapienza University of Rome, Rome, Italy (Correspondence to: Gianfranco.tarsitani@uniroma1.it). 2Adolphus College, St Peter, Minnesota, United States of America. Received: 20/08/08; accepted: 24/12/08 لاموصلا في ةيلهلأا برلحا ءانثأو لبق زديلإا/يشربلا يعانلما زَوَعلا سويرفب ىودعلا ءبع نياتيسرت وكنارفنايج ،دهم نسح ،ليونافويج ايراسورايرام ،دحمأ نسحوهارب دملأا ةليوطلا ةيلهلأا برلحا للاخ ةرمتسم لازتلاو 1988 ماع في تأدب ةرجه عم ناكسلل ميسج ليخاد حوزن نم لاموصلا نياعت :ةـصلالخا .اله ةيئابولا تماسلا لىع ةيلهلأا برلحا رثأو ،لاموصلا في يشربلا يعانلما زَوَعلا سويرفب ىودعلا ءبع ةقرولا هذه في ناثحابلا سرديو .ةعطقتلماو راشتنا لدعم نأو ،ةيلهلأا برلحا لبق لاموصلا في ًادوجوم نكي لم يشربلا يعانلما زَوَعلا سويرف نأ لىإ )ةيلصلما( ةيجولويرسلا تاحوسلما يرشت ذإ د ُّصترلا نإف برلحا رارمتسلا ًارظن هنأ لاإ .ةرواجلما لودلا في هيلع وه امم ضفخأ ليالحا تقولا ىتح لازيلا لاموصلا في يشربلا يعانلما زَوَعلا سويرف يرشت امم ةروطخ رثكأ اذبه ىودعلا ةلكشم نوكت دقو ،لاموصلا في ةرضرتلما قطانلما مظعم لىإ لصي نأ نكمي لا يشربلا يعانلما زَوَعلا سويرفل رفالخا .ماقرلأا هيلإ Charge de l’infection par le VIH/sida avant et pendant la guerre civile en Somalie RÉSUMÉ Depuis 1988, la Somalie est confrontée à un déplacement massif de population à l’intérieur du pays et à un exode qui perdurent au cours de la guerre civile épisodique auquelle elle est confrontée de longue date. La présente analyse étudie la charge de l’infection par le VIH en Somalie et l’impact de la guerre civile sur son épidémiologie. Des enquêtes sérologiques ont révélé que le VIH n’était pas présent en Somalie avant la guerre civile et qu’à ce jour, la prévalence du VIH en Somalie était nettement inférieure à celle des pays voisins. Toutefois, en raison de la guerre qui sévit actuellement, la surveillance sentinelle du VIH ne peut accéder à la plupart des zones touchées en Somalie et le problème actuel relatif à l’infection au VIH pourrait être plus important que ce que les chiffres laissent entendre. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 908 Introduction Somalia, situated on the Horn of Africa,  has  suffered a massive  internal popu- lation displacement  and  exodus  that  began in 1988 with the rebellion in the  north of  the country,  causing  refugees  to flee to camps in Ethiopia and Kenya.  Other  refugees  from  the  north were  resettled  in Mogadishu,  the capitol of  Somalia, located on the central-southern  coast. In 1991, armed militia overthrew  the  Somali  central  government. The  population  shift has continued during  the ensuing prolonged and intermittent  civil war. The conflict was still ongoing  as of March 2008  [1].  In  this  review  we  look  at  the burden of human  im- munodeficiency virus (HIV)  infection  in Somalia and the impact of civil war on  its epidemiology.  Methods To  review  the HIV  epidemic  before  and during the civil war in Somalia, the  data in this article were identified from a  search using the PubMed search engine  and the keywords “East Africa”, “Soma- lia” “HIV” and “AIDS”. United Nations  (UN)  reports  and  articles  published  in  international  journals not  indexed  by PubMed  were  also  included. The  selection was based on original research  articles  and  critical  reviews by major  investigators. Key  issues  related  to  the  HIV epidemic  in Somalia  from early  studies collected  in different sites were  summarized,  including  a  serosurveil- lance  survey conducted by  the World  Health Organization (WHO) in 3 dif- ferent  zones: South-Central  Somalia,  Puntland and Somaliland. Results Before  the civil war,  some early HIV/ AIDS  surveys  were  carried  out  in  Somalia. Different population groups  were tested, using serum collected from  female  sex workers, patients attending  sexually  transmitted  disease  (STD)  clinics and patients with tuberculosis in  Mogadishu and 2 other southern cities.  Between 1978 and January 1987, anti- bodies against HIV were not detected  in any of these groups [2–5]. A seroepi- demiological  survey was conducted  in  1989 Mogadishu, the urban capital, and  the rural areas of Marko, Qoryoley and  Kismayo  [6]. There were 1269  study  subjects, including 57 female sex work- ers, 79 patients attending STD clinics  and 1133 others,  including hospital- ized patients, outpatients, people  from  rehabilitation camps, secondary-school  pupils  and  immigrants  from Ethiopia.  The people  tested were  suffering  from  leprosy,  tuberculosis  and other  infec- tious diseases. The results  showed that  none of them tested positive for HIV-1  and HIV-2.  Further studies were carried out  in  July and August 1985 and January 1986  on 471 serum samples, from 3 different  groups of women  aged 14–48  years,  including pregnant women admitted  to hospital  and  their newborn babies,  women with higher education (physi- cians, nurses,  university  students  and  administrative  staff)  and  sex workers.  All were negative  for HIV antibodies  [7].  The  first  HIV-antibody  positive  sample  in Somalia was  found  in 1987  among serum samples collected  from  287  female  sex workers  in Mogadishu  and  reported  first  by  Burans  at  the  IVth  International  Conference  on  AIDS,  Stockholm,  in  1988  and  later  published by Ahmed et al. [8]. Another  4 cases of HIV were reported in Somalia  in 1989. The numbers increased to 13 in  1991 [6,9].  A  follow-up  study  carried  out  in  1991  showed  that  the  seroprevalence  of HIV-1  antibodies was  3%  among  female  sex  workers  in  Mogadishu,  Merca  and Kisimayo  [10]. However,  HIV  infection was still  rare  in 1990  in  Somalia, perhaps due  to  the  low  level  of  trade activity between Somalia and  the  rest  of  Africa  [11].  By  2000,  the  figures  reported  for Somalia were  still  much  lower  than  those  reported  from  neighbouring  countries  [12,13].  In  Kenya, Ethiopia and Djibouti  the HIV  epidemic reached double-digit  rates of  infection, as  reported by  the UN Joint  Programme  on HIV/AIDS  in  2000  [14,15].  According  to  a WHO HIV  surveillance report in 2004 in 3 regional  zones  (South-Central  Somalia, Punt- land and Somaliland), out of a  total of  4732 people tested, 44 were positive for  HIV (0.9%). A follow-up report in 2007  indicated  that  the prevalence of HIV  had  increased  to 2.2%  in Bosaso,  and  2.7% in Berbera [16]. Based on the 2005  WHO estimate of the HIV status of So- malis,  there were 40 000 Somali adults  living with HIV infection and 4200 new  infections. The estimated death toll due  to AIDS was 970 [17].  Discussion Serosurveys have  indicated  that HIV  was not present  in Somalia before  the  civil war  started. Other  studies carried  out during  the war  indicated  that HIV  was  present  at  a  low  rate,  although  the prevalence has  subsequently  risen  steadily  to  reach a maximum of 2.7%,  the  latest figure  recorded  in  the north  of  the  country  in  2007  [16]. The  re- sults of  other  studies  emphasize  that  conflict is a risk factor for HIV transmis- sion  [1,16,18].  Somalia’s  population,  still  sporadically  at war,  is  vulnerable  to  further  exposure  to HIV  infection.  Factors such as promiscuity, polygamy,  high  incidence of STD, malnutrition,  poverty  and  the  continued  presence  of  some  traditional  practices  such  as  the use of  nonsterile  tools  for minor  surgery are high risk  for HIV transmis- sion. Longstanding conflict and  forced  displacement can change the behaviour  of a society and increase the risk of HIV  [17]. Surveys conducted on the Somali  population  indicate  that  there  is a  lack  of  understanding  and  awareness  of  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 909 basic information about HIV, including  mechanisms of prevention of transmis- sion. Added  to  this are  factors  such as  the widespread stigma attached to HIV  infection;  reluctance  to disclose  infor- mation  to  family and partners; gender  inequalities  that  increase  the  vulner- ability of women and girls;  transfusion  of  unsafe blood;  and  the widespread  use of qat which may be associated with  high-risk behaviour [18]. Because of  the ongoing war HIV  sentinel surveillance cannot reach most  of  the  affected  areas  in  Somalia. The  current HIV  infection  problem may  be higher  than  the figures  indicate. To  date, Somalia has had an HIV infection  rate markedly below  that of  its neigh- bours. This  is most  likely related to the  cultural  traditions  and  behavioural  norms practised  by  Somalis,  such  as  discouragement  of  extramarital  sex  and prostitution. This  is  in danger of  change due  the continued civil unrest  in the country. Another practice which  helped Somalis  avoid  the  scourge of  HIV may be male circumcision. Male  circumcision has been  suggested  as  a  reason  for  the  low prevalence of HIV  in many communities which practise it  in  sub-Saharan Africa [19–21]. WHO  has reported that male circumcision re- duces the risk of HIV by approximately  60%. The mechanism  is  thought  to be  that the HIV virus targets immune cells  such as Langerhan cells, CD4+, T-cells  and macrophages that are located in the  mucosal  side of  the  foreskin and  that  these are  reduced  in circumcised men.  Furthermore, circumcision, by forming  a thick layer of squamous epithelial cells,  may act as a barrier to HIV uptake in the  underlying target cells [22].  Special attention to HIV prevention  and education,  including more media  information,  is needed  for  the Somali  population, who are still being dispersed  by an ongoing war. Because of the lack  of  a  central  authority  in  the  country,  both surveillance programmes and pos- sible interventions should be addressed  in a decentralized way. 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Male circumcision for HIV 22. prevention: a prospective study of complications in clinical and traditional settings in Bungoma, Kenya. Bulletin of the World Health Organization, 2008, 86(9):669–677. EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 910 Short communication Public–private partnership scenario in the health care system of Pakistan F. Ahmed 1 and N. Nisar 2 ABSTRACT Public–private partnerships (PPP) in basic health services delivery aim to improve service provision, such as better coverage, quality and infrastructure of health care, as well as raising the demand for health by the community. This paper outlines some examples of public–private partnerships in Pakistan and examines barriers to further development of such initiatives. We argue that to meet the challenges of globalization and achievement of the Millennium Development Goals, Pakistan needs to improve the health status of its society by promoting and practising PPP in providing health care services. 1Institute of Health Sciences, Baqai Medical University, Karachi, Pakistan (Correspondence to F. Ahmed: fah_khan@yahoo.com). 2Department of Community Medicine, Dow University of Health Sciences, Karachi, Pakistan. Received: 28/12/08; accepted: 08/03/09 ناتسكاب في ةيحصلا ةياعرلا ماظن في صالخاو ماعلا عاطقلا ينب ةكاشرلا ويرانيس رازن تهجن ،دحمأ ميهف ،لضفأ ٍوحن لىع ةيطغتلا لثم ،تامدلخا ميدقت ينستح لىإ ةيساسلأا ةيحصلا تامدلخا ءاتيإ في صالخاو ماعلا عاطقلا ينب ةكاشرلا فدته :ةـصلالخا تاكاشرلا نع ةلثملأا ضعب ةقرولا هذه فصتو .ةحصلا لىع عمتجلما في بلطلا ةدايز بناج لىإ ،ةيحصلا ةياعرلل ةيتتح ةينب نمضو ،ةيلاع ةدوجبو ينستح ناتسكاب لىع يغبني هنأ ناثحابلا ىريو .تاردابلما هذله م ُّدقتلا نم ديزلما قيعت يتلا زجاولحا ضرعتستو ،ناتسكاب في صالخاو ماعلا عاطقلا ينب عاطقلا ينب تاكاشرلا زيزعتب كلذ نوكيو ،ةيفللأل ةيئمانلإا يمارلما قيقحتلو ةلموعلا اهضرفت يتلا تاي ِّدحتلل ي ِّدصتلل عمتجلما في ةيحصلا اهعاضوأ .ةيحصلا ةياعرلا تامدخ ءاتيإ في اتهاسراممو ،صالخاو ماعلا Projet de partenariat public-privé dans le système de santé du Pakistan RÉSUMÉ Les partenariats public-privé relatifs à la prestation de services de santé de base visent à améliorer les services fournis, notamment en développant la couverture et la qualité des soins de santé et les infrastructures correspondantes. Ils ont également pour objectif d’accroître la demande de la communauté en termes de santé. Cet article présente brièvement quelques exemples de partenariats public-privé au Pakistan et évalue les obstacles au développement futur de telles initiatives. Nous pensons que, pour relever les défis liés à la mondialisation et la réalisation des objectifs du Millénaire pour le développement, le Pakistan doit améliorer l’état de santé de sa population par la promotion et l’établissement de partenariats public-privé relatifs à la prestation de services de santé. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 911 Background The concept of co-operation between  public  and private provision of health  care was instituted in Pakistan in nation- al health policy in 1960 and started as a  model of corporate social responsibility  to serve the nation’s health needs. Pub- lic–private partnerships (PPP), as  they  are now called, are a health sector reform  to create  long-term,  task-oriented and  formal  relationships among  the public  and private sectors in sharing their core  competency and  resources,  including  some degree of  joint decision-making  and  innovative  interaction  to provide  sustainable improvements in the provi- sion and enhanced utilization of health  care services and also to address emerg- ing health challenges  for  the benefit of  society. A core set of objectives of PPP  in basic health  services delivery  relate  to  improving service provision, such as  coverage, quality and  infrastructure, as  well as raising the demand for health by  the community.  The 1973 Constitution of Pakistan,  Article 38(d), guarantees that the State  shall  provide  the  basic  necessities  of  life,  including  the provision of health  care. Yet,  the  apparent priority  given  national  security over human develop- ment means that the government seems  unable to fulfil its constitutional promise  to bring reforms to the health sector of  Pakistan. The provision of basic health  services  in Pakistan  is  inadequate and  is a major obstacle  to human develop- ment. Pakistan is facing a double burden of  disease. Not only  is  the country  failing  to overcome  infectious diseases  such  as poliomyelitis  that others have  tack- led, but it is also facing the challenge of  chronic noncommunicable diseases. As  far  as health  indicators  are concerned  the  infant and maternal mortality  rates  for Pakistan  are  very high  compared  even with other developing countries, at  around 100 per 1000 live births and 340  per 100 000 live births respectively. Barriers to public– private partnership Privatization policies in Pakistan remain  largely unexamined and  insensitive  to  the need  for basic health  services  that  are accessible, available, affordable and  of acceptable quality. This could be due  mainly  to downsizing of  social  capital  and  inadequate financial  resources or  to disparities in power and lack of trust  between the public and private sectors  that  inhibits collaboration at the policy  and operational  level  in  provision of  health care  in Pakistan. As a  result,  the  health  sector  in  Pakistan  is  far  from  developing a consistent form of interac- tion  between  the  public  and  private  sectors,  and  suffers  from a persisting  political  polarization  along  3 major,  intersecting  faultlines—bureaucrats,  technocrats  and  the  military—that  have been evident in Pakistan since the  partition of  the Indian subcontinent  in  1947. This  in turn is reflected in a high  burden of disease,  lack of health  care  staff, staff absenteeism and poor access  to health facilities for patients [1].  According to the Pakistan National  Health  Policy  2001,  primary  health  care in Pakistan is currently functioning  mainly  in  the  private  sector  through  contracting out of health services, which  means handing over of un- and under- utilized  government  health  facilities,  such as basic health units,  rural health  centres  and  hospitals  to  the  private  sector. This  is  supposed  to  provide  support  for  awareness  raising and  the  management of clinical and nonclinical  services in the community [2]. This was  implemented  through a  rural  support  programme.  Pilot programmes Pilot programmes were established in 8  districts of Punjab  in 2005. About 104  basic health units in one district, Rahim  Yar Khan, were handed over  to a  large  nongovernmental  organization  on  a  pilot initiative to provide primary health  care services to overcome the inability of  the health care services delivery system  to  tackle diseases at basic health units.  The World Bank has  been  a  catalyst  for  such contracting out  in Rahim Yar  Khan district, which includes providing  funds and technical  support. However,  the Sustainable Development Policy  Institute,  in cooperation with  the Uni- versity of Birmingham  in  the United  Kingdom,  recently  conducted a  study  and found that the PPP results in Rahim  Yar Khan district were disappointing,  due  to  lack of  a preventive  approach,  disparities  in power and other  factors.  While the overall utilization of facilities  had  increased,  insufficient numbers of  patients were  attending  basic  health  units. In this district—where the poor- est of the poor are still socially excluded,  live in inaccessible areas, lack confidence  and  information and are unable  to pay  for  services—the  services  provided  remain un-utilized [3]. The government  of Pakistan has decided to scale-up the  programme  to  the national  level  but  the benefits of this have not yet become  apparent  in  the general population  in  terms of improved public health.  Examples of public– private partnership The  goals  of  PPP  are  to  create  a  financially  sustainable  system,  capac- ity  reform and management  reform  in  the public–private  sector which may  lead  to  increased health  care delivery  and utilization, preventing unintended  outcomes of private  sector growth  in  health, control health care costs and cre- ate improvements in the health status of  society, thus facilitating socioeconomic  development.  In  Pakistan  there  are  some examples of  successful  public– private  collaborations  in  health  care  provision: a mobile doctors programme run by • a tobacco company since 1980 in the  tobacco cultivation areas and at their  EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 912 factories as a part of  their corporate  social  responsibility  strategy  (Paki- stan Tobacco Company, 2005);  the national programmes for malaria, • tuberculosis and HIV/AIDS control  implemented through a collaboration  of government and private health care  providers,  including  the Ministry of  Health and  the GreenStar Network,  the Asia Foundation and HealthNet  International;  the  World  Health  Organization (WHO), United Na- tions Development Programme and  World Bank support all providers  in  the services; the Ministry of Finance,  Government of Pakistan,  subsidizes  the insecticide-treated bednets.   a  public  sector mother  and  child • hospital  in  Shikarpur  district  in  Sindh province whose management  is  handed over  to  a private practi- tioner;  the Health  and Nutrition Develop-• ment Society (HANDS), an NGO in  partnership with Sindh government  to provide primary health care  serv- ices at basic health units in Karachi; the  Aga  Khan University  Karachi,  • Pakistan, a private sector partnership  with Sindh Government  to provide  primary health care  services  in  rural  and urban slum communities for dis- ease  surveillance,  vaccines and drug  trials; Heartfile, an NGO in partnership with • government,  the  International Vac- cine Institute (South Korea), WHO,  Save  the Children and UNICEF,  is  the  supporting  agency  in  a  policy  development  initiative  to  control  noncommunicable diseases;  a Ministry of Population Welfare and • United States Agency for Internation- al Development partnership  estab- lished a social marketing programme  from the GreenStar Network in Paki- stan to enhance contraceptive use;  a  private  company  that  educates • young  mothers   about  healthy  baby-care  practices  and  teaches  5–9-year-old  children  about  basic  hygiene habits using  these activities  in  the company’s marketing strategy  (Procter and Gamble) [4].  Challenges PPP are considered  to be a  successful  model of health  reform  in  the health  sector  of  other  countries  [5–7].  So  the challenge ahead  is  for Pakistan  to  facilitate  the  implementation of  vari- ous components of health  sector pro- grammes, including establishing norms,  tackling morality  and  accountability  issues, building a  legislative  framework,  defining operational strategies, as well as  safeguarding the Consumer Protection  Act to safeguard the interest of consum- ers. The issues we are facing to facilitate  implementation  of  partnerships  in  providing and encouraging utilization  of health care services  include a  lack of  appropriate monitoring and  reporting  mechanisms, a lack of clarity in policies  and  low efficiency of  the private sector  in  taking care of  the poorest  sectors of  society.  The research in the field of establish- ing effectiveness of PPP in providing and  raising demand of health care services in  the community in Pakistan is limited to  rare cases. Furthermore the data to pro- mote health  sector  reform  in Pakistan  are unavailable or unpublished. PPP  is  a multidisciplinary  and multi-sectoral  approach, which needs significant insti- tutional development, monitoring and  evaluations systems.  The government of Pakistan is com- mitted  to  achieving  the Millennium  Development  Goals  for  eradicating  poverty, providing health and education  facilities,  ensuring gender equality and  combating HIV by 2015 in partnership  with  the World Health Organization  and the World Bank. To meet the chal- lenges of globalization and achieving a  prosperous Pakistan in the 21st century  we need  to promote and practise PPP  in providing  health care services to im- prove the health status of our society. The state of the worlds’ children1. . New York, United Nations Chil- dren’s Fund, 2001. National Health Policy 2001. The way forward. Agenda for 2. health sector reform. Karachi, Ministry of Health, Government of Pakistan, 2001 (http://www.nacp.gov.pk/introduction/ national_health_policy/NationalHealthPolicy-2001.pdf, ac- cessed 26 May 2010). Siegmann KA, Shaheen N. Joining hands for better health care. 3. SDPI Research and News Bulletin, 2006, 13(4 & 5):10–15. Siegmann KA, Shaheen N, Shah S. 4. Collaboration between state and non-state providers of basic services in Pakistan. Islamabad, Pakistan, Sustainable Development Policy Institute, 2006. References Allen G. The private finance initiative. 5. House of Commons Library Economic Policy and Statistics Section Research Paper, 2001, 01/117. Nayani P, White F, Nanan D. Public–private partnership as 6. a success factor for health systems. Medicine Today, 2006, 4(4):135–142. Nikolic IA, Maikisch H. 7. Public–private partnerships and col- laboration in the health sector. An overview with case studies from recent European experience. Health, Nutrition, and Population Family discussion paper. Washington DC, World Bank Human Development Network, 2006. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما نماثلا ددعلا 913 Case report Primary hydatid cyst of the round ligament: case report M. Akinci,1 O. Yigitbasi,2 Z. Ergul,1 E. Olcucuoglu1 and H. Kulacoglu1 1Department of General Surgery; 2Department of Urology, Ankara Diskapi Teaching and Research Hospital, Ankara, Turkey (Correspondence to M. Akinci: melihakinci@yahoo.com). Received: 18/07/08; accepted: 11/09/08 Introduction Echinococcosis is a zoonotic infection in which the liver is the organ most fre- quently involved, followed by the lung and sometimes the heart, spleen, kidney and brain [1]. Hydatid cyst can be seen in almost every part of the human body [2–5]. Despite the common involve- ment of the liver in terms of location, only 2 cases of isolated hydatid cyst of the round ligament of the liver have been reported, first in 1985 in Italian [6] and then in 1993 in Spanish [7]. We present here the third case of round ligament hydatid cyst. Case report A 24-year-old male was admitted to the department of general surgery with an epigastric mass that he had noticed 3 months previously. He complained of abdominal fullness and vague pain. The patient had no other systemic disorder and no history of surgery or use of medi- cal drug therapy. Physical examination of the patient revealed a semifixed 6 cm mass on the abdominal epigastric area adjacent to the right inferior ribs. There were no other positive findings at physical examination. Abdominal ultrasound demon- strated a 6 × 4 cm cystic mass between the anterior abdominal wall and ante- rior surface of the left hepatic lobe. There were no vesicles or necrotic areas in the cystic mass. It was reported that the lesion could be originating from the left lobe of the liver. Ultrasound also revealed a left renopelvic dilatation. Abdominal com- puterized tomography showed a 7 × 4 cm capsulated cystic mass that was being compressed by the hepatic left lobe and abdominal wall. A clear border between the liver and mass was visualized. No other lesions were seen in any part of the abdominal cavity (Figure 1). The patient’s routine laboratory tests were normal and the echinococcosis immune haemagglutination test (Dade Behring, Margurg, Germany) was nega- tive. Before making a decision about the treatment of the cyst, the patient was referred to the department of urology. There he stated that he had recently started to experience left lumbar pain. In the urological evaluation an intrave- nous pyelogram confirmed dilatation of the left renal pelvis and calyx, and renal scintigraphy revealed left ureteropelvic stenosis. This ureteropelvic junction stenosis was considered to be symp- tomatic by the urologists and an open surgical treatment was planned. First, the urologists performed a dismembered pyeloplasty, then the cystic lesion was approached by the Figure 1 Hydatid cyst (6 × 4 cm) between the anterior abdominal wall and the liver. A clear border is seen between the cyst and the liver (R = right rectus abdominis muscle) EMHJ  •  Vol. 16  No. 8  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 914 general  surgery  team via a 10 cm  long  upper midline incision. The cyst was found to originate directly from the round ligament of the liver (ligamentum teres hepatis). The round ligament was ligated and divided and then the mass was totally excised from the abdominal wall with 1 cm free borders. It was a 6.5 × 4 × 4 cm cystic mass filled with serous fluid. The capsule was creamy-white in colour with a well-circumscribed shape. The histopathological examination con- firmed a hydatid cyst by demonstrating protoscolex within. The patient’s postoperative course was uneventful and he was discharged on the fourth postoperative day. Alben- dazole was prescribed with a dose of 2 × 400 mg/day.  Discussion Hydatid disease, caused by the larval stage of Echinococcus granulosus, is recognized as a public health problem [8]. Turkey is an endemic region for this disease. Besides the liver and lungs, hydatid cysts with unusual locations (e.g. pancreas, spleen, kidney, intra-abdominal cavity, ovary, breast, mediastinum, chest wall, muscle, adrenal, lung, thyroid gland, anterior abdominal wall, thigh, presacral space, brain, cavernous sinus, submandibular gland, heart, pleura, retrocrural tissue, inguinal canal, bone, bile duct, soft tissue and retroperitoneum) have previously been reported from this country [2–5]. When the present case presented with an anterior mass, the lesion was considered as a possible hydatid cyst since hydatid disease is very common in Turkey and anterior abdominal hydatid cysts have been reported several times [9–11]. However, the tomographic examination noted a deeper lesion beneath the anterior abdominal wall. Therefore a pancreatic cyst, parasitic or not, was a diagnostic possibility [12]. In 2003, the World Health Organiza- tion Informal Working Group on Echi- nococcosis  (WHO-IWGE) proposed  a standardized ultrasound classification based on the active–transitional–inac- tive status of the cyst as suggested by its sonographic appearance [13]. In our case, ultrasonography and tomography revealed a simple cyst with well-defined borders and uniform anechoic contents. This description,  according  to WHO- IWGE classification, is not pathogno- monic for echinococcal cysts because nonparasitic cysts may have the same appearance. In addition, the haemag- glutination test did not support a diag- nosis of hydatid disease. However, while haemagglutination displays a very good specificity with few false positive results, it has a low sensitivity of just 50% [14]. In fact hydatid cyst of the round liga- ment of the liver is a very rare presenta- tion of echinococcosis. Only 2 cases have  been reported to date [6,7]. There is no doubt that the ideal treatment of a cystic or solid mass is total excision. However, this choice is quite aggressive and rarely possible in hydatid cysts of the liver, and partial excision of the (peri)cyst with or without omentoplasty usually results in a better clinical response [15], while radical resections are still the treatment of choice for hepatic hydatid disease [16]. Unlike in hepatic hydatid cysts, total excision is technically easier for intra-abdominal nonhepatic hydatid cysts involving the omentam or free peritoneal cysts [17]. The present case was treated by perform- ing a total cystectomy. Surgery for hydatid cysts is rarely ac- companied by an unrelated abdominal surgery. Generally, surgeons are not will- ing to add an extra surgical procedure during a hydatid cyst operation because of its unclean nature. In our case, the hydatid cyst of the round ligament was totally excised without any spillage and no risk of infection was added to the elective urological procedure. Interestingly, a pal- pable abdominal lesion made it possible to diagnose and treat a hidden urinary pa- thology in an early stage. A Medline search found several reports using the keywords “ureteral obstruction” and “hydatid”, but those obstructions were secondary to renal hydatid disease [18]. Moreover, to the best of our knowledge, no reports have been found in the literature describ- ing such a combined surgery. Medical therapy in the form of ben- zimidazole carbamates, alone or in com- bination with praziquantel, has been advocated for the treatment of hydatid disease [19–21]. However, it is gener- ally accepted that systemic albendazole treatment is not an alternative to surgi- cal treatment [22]. Albendazole may be given as an adjuvant to surgery to avoid recurrence and to suppress subcenti- metre lesions not visible by ultrasound. Therefore, despite the fact that the first scan for any concomitant cysts was negative and that a total cyst excision was achieved, we put the patient on a prophylactic albendazole regimen with a dose of 2 × 400 mg/day.  We report here a very rare presenta- tion of hydatid disease that originated from the round ligament of the liver. Hydatid cysts should be considered in the differential diagnosis of intra- abdominal masses, particularly in endemic regions or in patients who have emigrated from endemic countries, even when serological tests are negative. 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Journal of Gastrointestinal Sur- gery, 2008, 12:867–871. طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ةيبيللا ةيبرعلا ةييرهمالجا . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . ةينميلا ةيروهملجا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما Subscriptions and Distribution Enquiries regarding subscriptions and distribution of the print edition of EMHJ should be addressed to: Printing and Marketing of Publications at: email: pam@emro.who.int; tel: (+202) 2276 5000; fax: (+202) 2670 2492 or 2670 2494 Permissions Requests for permission to reproduce or translate articles, whether for sale or non-commercial distribution should be addressed to EMHJ at: emhj@emro.who.int Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libyan Arab Jamahiriya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Republic of Yemen Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Jamahiriya arabe libyenne . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar République arabe syrienne . Somalie . Soudan . Tunisie . République du Yémen Correspondence Editor-in-chief EMHJ WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: sabrib@emro.who.int/emhj@emro.who.int EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con- cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col- laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser-vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. 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ISSN 1020-3397 Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تاسايسلا لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما طسوتلما قشرل ةيحصلا ةلجلما Cover 6.indd 2 5/24/2010 11:46:47 AM