Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 20 / No. 1 January/ Janvier ¼Ø{L ëíP_UÐ{dCÐ }xnfx ©nUÐëinT2014 There are just 2 years to go to achieve the MDGs; not all countries in the Region are on track to realize MDG 4 (reducing child mortality) and MDG 5 (improving maternal health). The Dubai Declaration marked the commitment of Member States of the Region to accelerate progress in maternal and child health in order to reach these health goals. V l m 2 0 N m b r 1 J n r 2 0 1 4 EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con- cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col- laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser-vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collabora- teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/ EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), CAB International, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). ©World Health Organization 2014 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 x{bUFfYwí phCn_UÐp[UÐpe^fe=HCÐçPUehdSüÐocCÐLÚ{[>UÐpheH}UÐpdCÐwphýn=UÐ Ónh]_CÐí hwnaCÐí ÊÐÚùÐ éØnUí ºn4 sxíGUÐí ph[UÐ ÓnY{#Ð ;Ò{x{!Ð ÓÐÚØnCÐí ÓnHnhUÐTOÎpg@Ywí HCÐ ç hdSl= ngfYd_x nY pÉnBíºÓnYd_CÐ YUÙEQíÔn=úÐsýnií~TÐ}CÐí ºphf_CÐ phYc"Ð EQÓ5^fCÐ Ð|Tíºphehd_UÐ {wn_CÐ }ýnHíph]UÐ ÓnhdcUÐí ºph[UÐ gCÐ Ên\LÌ @ÚnBíhdSüÐ;p[Un=NegCÐØÐ}RúÐíphCn_UÐp[UÐpe^fY Ypiín_CÐ GBÐçOTogZTÐocBÐ Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 20 No. 1 ¼Ø{LëíP_UÐ{dCÐr r Editorial -FTTUIBOEBZTUPHPGPS.%(TBOEXIFSFBSFXFBOEXIBUOFFETUPCFEPOF Flavia Bustreo .....................................................................................................................................................................................................................................................................................................3 Invited review 3FEVDJOHUIFCVSEFOPGNBUFSOBMBOEDIJMENPSCJEJUZBOENPSUBMJUZJOUIF&BTUFSO.FEJUFSSBOFBO3FHJPO :FT XFDBO M.F. Fathalla ...................................................................................................................................................................................................................................................................................................................... 5 Research articles $PNNVOJUZQBSUJDJQBUJPOFMVEFT1BLJTUBOTNBUFSOBM OFXCPSOBOEDIJMEIFBMUIQSPHSBNNF T. Akhtar, Z. Khan and S. Raoof ...............................................................................................................................................................................................................................................................10 &YQBOEJOHUIFDPNQSFIFOTJWFOBUJPOBMOFPOBUBMTDSFFOJOHQSPHSBNNFJOUIF6OJUFE"SBC&NJSBUFTGSPNUP H. Al Hosani, M. Salah, H.M. Osman, H.M. Farag , L. El-Assiouty, D.Saade and J. Hertecant .........................................................................................................................................17 1SFWBMFODFBOEGBDUPSTBTTPDJBUFEXJUIFYDMVTJWFCSFBTUGFFEJOHBUNPOUITPGMJGFJO5FISBOBQPQVMBUJPOCBTFETUVEZ Z.S. Noughabi, A. Baheiraei, S. Golian Tehrani, A.R . Foroushani and F. Nayeri ...................................................................................................................................................................... 1SFWBMFODFPGBOBFNJBJOQSFTDIPPMDIJMESFOJO,BSNB"MCBMBEBSFB /PSUIFSO4UBUF 4VEBO M.D. Hussein and S. Mohamed .................................................................................................................................................................................................................................................................33 "TTPDJBUJPOCFUXFFOEJFUBSZIBCJUTBOECPEZNBTTJOEFYPGBEPMFTDFOUGFNBMFTJOJOUFSNFEJBUFTDIPPMTJO3JZBEI 4BVEJ"SBCJB M.N. Al-Muammar, M. El-Shafie and S. Feroze.................................................................................................................................................................................................................................. $PNQBSJTPOPGUXPBTTBZTJOUIFEJBHOPTJTPGUPYPQMBTNPTJTJNNVOPMPHJDBMBOENPMFDVMBS D.A. Hashoosh and I.A. Majeed ............................................................................................................................................................................................................................................................... 1SFWBMFODFPGDPFMJBDEJTFBTFBNPOHBEVMUQBUJFOUTXJUIBVUPJNNVOFIZQPUIZSPJEJTNJO+PSEBO O.H. Farahid, N. Khawaja, M.M. Shennak, A. Batieha, M. El-Khateeb and K. Ajlouni ...................................................................................................................................................... 1IZTJDJBOTLOPXMFEHF BĨJUVEFBOEQSBDUJDFTSFHBSEJOHNBOBHFNFOUPGNFEJDBUJPOTJO3BNBEBO D. Jaber, A. Albsoul-Younes and M. Wazaify ......................................................................................................................................................................................................................................... Letter to the Editor 5FSNJOBUJPOPGTFDPOEBOEFBSMZUIJSEUSJNFTUFSQSFHOBODZDPNQBSJTPOPGNFUIPET J.A. Smith .......................................................................................................................................................................................................................................................................................................... Eastern Mediterranean Health Journal Reviewers’ list 2013 .................................................................................................................................................................................. Guidelines for authors................................................................................................................................................................................................................................................................................... Dr Ala Alwan, Editor-in-chief Editorial Board 1SPGFTTPS;VMėRBS#IVĨB 1SPGFTTPS.BINPVE'BINZ'BUIBMMB 1SPGFTTPS3JUB(JBDBNBO %S;JBE.FNJTI %S4BNFFO4JEEJRJ 1SPGFTTPS)VEB;VSBZL International Advisory Panel %S.BOTPVS."M/P[IB 1SPGFTTPS'FSFJEPVO"[J[J 1SPGFTTPS3BėL#PVLISJT 1SPGFTTPS.BKJE&[[BUJ %S;VIBJS)BMMBK 1SPGFTTPS)BOT7)PHFS[FJM 1SPGFTTPS.PIBNFE"(IPOFJN 1SPGFTTPS"MBO-PQF[ %S)PTTFJO.BMFLBG[BMJ 1SPGFTTPS&M4IFJLI.BIHPVC 1SPGFTTPS"INFE.BOEJM %S)PPNBO.PNFO Dr Sania Nishtar %S)JLNBU4IBBSCBG %S4BMNBO3BXBG Editors 'JPOB$VSMFU (VZ1FOFU &WB"CEJO "MJTPO#JDIBSE .BSJF'SBODF3PVY Graphics 4VIBJC"M"TCBIJ )BOZ.BISPVT %JBOB5BXBESPT Administration /BEJB"CV4BMFI :BTNFFO4FELZ HCÐçPUph[UÐpdCÐëíP_UÐ{dCÐ éíúÐØ{_UÐ 3 Editorial Less than 1000 days to go for MDGs 4 and 5: where are we and what needs to be done? 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EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 4 1. Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA and The World Bank estimates. Geneva, World Health Organization, 2012. (http://www.unfpa.org/webdav/site/ global/shared/documents/publications/2012/Trends_in_ maternal_mortality_A4-1.pdf, accessed 9 December 2013). 2. Levels and trends in child mortality. Report 2013. Estimates devel- oped by the UN Inter-agency Group for Child Mortality Estima- tion. Geneva, United Nations Children’s Fund, 2013 (http:// www.childinfo.org/files/Child_Mortality_Report_2013.pdf, accessed 9 December 2013). 3. Essential interventions, commodities and guidelines for reproduc- tive, maternal, newborn and child health. Joint press release: PMNCH, WHO and Aga Khan University. The Partnership for Maternal, Newborn and Child Health, 15 December 2011 [online press release] (http://www.who.int/pmnch/media/ press/2011/20111215_essential_interventions_pr/en/index. html, accessed 9 December 2013). 4. Accountability for maternal, newborn and child survival. The 2013 update. Geneva, World Health Organization/United Nations Children’s Fund, 2013 (http://countdown2015mnch.org/ documents/2013Report/Countdown_2013-Update_nopro- files.pdf, accessed 9 December 2013). References NJMMJPOXPNFOJOUIFXPSMETQPPS FTU DPVOUSJFTXJUIBDDFTT UPWPMVOUBSZ GBNJMZQMBOOJOHCZ ĉFTFHMPCBM JOJUJBUJWFT BSF JNQPS tant drivers for sustained action and DPNNJUNFOU GPS JNQSPWJOHNBUFSOBM BOEDIJMEIFBMUIBOESFEVDJOHNPSUBMJUZ ĉFZDBOOPUTUBOEBMPOF IPXFWFSĉF NPTU DSJUJDBM GBDUPS GPS TVDDFTT JT UIF FYUFOUUPXIJDIGPMMPXVQBOEBDUJPOJT IBQQFOJOHBUSFHJPOBMBOEDPVOUSZ MFW els. The WHO Eastern Mediterranean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die every year in the Region as a result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i4BWJOH UIF MJWFT PGNPUIFST BOEDIJMESFO SJTJOH UP UIF DIBMMFOHFu IFME JO%VCBJ 6OJUFE"SBC &NJSBUFTPOBOE+BOVBSZ XBT BĨFOEFECZQBSUJDJQBOUT JODMVEJOH NJOJTUFSTPGIFBMUI TFOJPSPđDJBMTBOE MFBEJOHėHVSFT GSPN.FNCFS4UBUFT BTXFMMBTLFZQBSUOFSTBOETUBLFIPMEFST ĉSPVHI UIF%VCBJ%FDMBSBUJPO DPVO USJFTFYQSFTTFEUIFJSDPNNJUNFOUUPEF WFMPQBOEFYFDVUFQMBOTGPSNBUFSOBMBOE DIJMEIFBMUI UP UBLFNFBTVSBCMF TUFQT UPTUSFOHUIFO UIFJSIFBMUITZTUFNT BOE UPNPCJMJ[FEPNFTUJDBOE JOUFSOBUJPOBM SFTPVSDFTUPFTUBCMJTITVTUBJOBCMFėOBOD JOHNFDIBOJTNT &ODPVSBHJOHMZ GPMMPXJOH UIJTIJHI MFWFMNFFUJOHJO%VCBJ BMMDPVOUSJFT IBWF EFWFMPQFE BDDFMFSBUJPO QMBOT GPS.%(TBOEXJUI TVQQPSU GSPN 8)0 6/*$&' 6/'1"BOEPUIFS QBSUOFSTĉFQMBOTWBSZ GSPNDPVOUSZ UPDPVOUSZ SFĚFDUJOHUIFJSEJĎFSFOUTJUV BUJPOTBOEDPOUFYUT)PXFWFS UIFQMBOT GPDVTPOJODSFBTJOHDPWFSBHFPGUIFLFZ DPTUFĎFDUJWFNBUFSOBMBOEDIJMEIFBMUI JOUFSWFOUJPOTBDSPTT UIFDPOUJOVVNPG DBSFXIJMFBEESFTTJOH JOFRVJUJFT JONB UFSOBMBOEDIJMEIFBMUI UPHFUIFSXJUIB DBMMGPSNPSFJOUFSTFDUPSBMDPMMBCPSBUJPO ĉF UJNF GPS JNQMFNFOUBUJPO PG UIF QMBOTJTOPX (FĨJOHDMPTFS UP SFBDIJOH.%(T BOEBOEUPSFBDIJOHUIFBNCJUJPVT UBSHFUT TFU CFZPOE XJMM SFRVJSF TVTUBJOFEDPNNJUNFOUCZBMMTUBLFIPME FST *UXJMM BMTP SFRVJSFB TUSFOHUIFOJOH PG IFBMUI TZTUFNT UISPVHI BMMPDBUJPO PG UIFOFDFTTBSZIVNBOBOEėOBODJBM SFTPVSDFT UPNPCJMJ[F CPUIEPNFTUJD BOEJOUFSOBUJPOBMGVOEJOH*NQPSUBOUMZ IPXFWFS UIJT TIPVMEOPUCFWJFXFEBT NFSFMZBOBEEJUJPOBMDPTUCVSEFOĉF IFBMUIPGXPNFOBOEDIJMESFOTIPVME CFTFFOBTBO JOWFTUNFOU JO UIF GVUVSF UIBUNBZBMTPMFBEUPXJEFSTPDJFUBMHBJOT BOETPDJPFDPOPNJDEFWFMPQNFOU HCÐçPUph[UÐpdCÐ 5 ëíP_UÐ{dCÐ éíúÐØ{_UÐ Invited review Reducing the burden of maternal and child morbidity and mortality in the Eastern Mediterranean Region? Yes, we can Mahmoud Fahmy Fathalla 1 ABSTRACT Maternal and child morbidity and mortality are a major public health, development and human rights challenge globally and in the WHO Eastern Mediterranean Region. The Region is diverse, with high-, middle- and low- income countries, many suffering from political instability, conflicts and other complex development challenges. Although progress has been made towards Millennium Development Goals 4 and 5, it has been uneven both between and within countries. This paper makes an analysis of the strengths, weaknesses, opportunities and threats to improving maternal and child mortality and morbidity with a focus on the Region. In answer to the question whether we can reduce the burden of maternal and child morbidity and mortality in the Region: yes, we can. However, commitment and collaboration are needed at the country, regional and international levels. 1Professor of Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, University of Assiut, Assiut, Egypt. TÙg\hº^hÈGBÐçgcRÎ9ém`IúÐíÓmfXúÐoÐ|XíÓmgQíÊnKÞmahÎ āÐyRØe7 :ëniüÐçbAíphefUÐíphYe_UÐp[UÐ@Ð>UÐÒEcUÐÓnx{UÐYHCÐç hdSÎ:énaJúÐíÓngYúÐpÐ}YíÓnhRíF_>oÉ°#Ð Ø{L©n_xíºB{UÐp\afYëÐ{d=íB{UÐp]HYî}BÌíB{UÐp_a>}YëÐ{d=hRºâfUÐ HÐíhdSünR phCn_UÐp[UÐpe^fCHCÐç hdSÎ YÐ}CÐY5í4 ÷Nóh óY}CÐÑÉê{´b>YìÛÐ}AÎ>nYQÚí phefUÐ:Ò{b_CÐÓnx{UÐYíÓnLÐWUÐYínhUÐÚÐ}bHøÐê{LYiÐ{d=Y Þ}aUÐíºÒbUÐYncYí_\UÐJÐC ðĆhdĻpSÚUÐì|wê{b>í Ò{ADL ò{d=TeøíëÐ{dUÐN=ðnxínYcx3ê{´bUÐUÙëlRºphaU±Uphý5iüÐ pÐ}YíÓnhRíÊoLÞnbiÎniÚí{be=ënTÐÙÎnYéAéÐkdUÑÐ!Ðí hdSüÐ:énaJúÐíÓngYúÐpÐ}YíÓnhRíNU_CÐ:ÓÐ{x{gUÐí <í{UÐíehdSüÐífJUÐ{h_[UÐDLën=d]Yëín_UÐíêÐ~UøÐëÌøκUÙ h]ii_iwhdSüÐ:énaJúÐíÓngYúÐ La réduction de la charge de la morbidité et de la mortalité maternelles et infantiles est effectivement possible dans la Région de la Méditerranée orientale RÉSUMÉ La morbidité et la mortalité maternelles et infantiles constituent un défi majeur en matière de santé publique, de développement et de droits de l’homme au niveau mondial ainsi que dans la Région OMS de la Méditerranée orientale. La Région est hétérogène et comprend des pays à revenus élevé, intermédiaire et faible, dont plusieurs connaissent une instabilité politique, des conflits ainsi que d’autres problèmes de développement complexes. Malgré les progrès accomplis vers la réalisation des objectifs du Millénaire pour le développement 4 et 5, des inégalités ont été observées aux niveaux régional et national. Le présent article analyse les forces, faiblesses, opportunités et menaces en matière d’amélioration de la mortalité et de la morbidité maternelles et infantiles dans la Région. La réponse à la question de savoir si nous pouvons effectivement réduire la charge de la morbidité et de la mortalité maternelle et infantile dans la Région est affirmative. Un engagement et une collaboration sont néanmoins nécessaires aux niveaux national, régional et international. 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Global Alert and Response (GAR), World Health Organization [online factsheet] (http://www. who.int/csr/don/2013_11_18/en/index.html, accessed 15 January 2014). 26. Summary report on the high-level meeting on saving the lives of mothers and children: rising to the challenge in the Eastern Medi- terranean Region. Dubai, United Arab Emirates 29–30 January 2013. Cairo, World Health Organization Regional Office for the Eastern Mediterranean, 2013 (WHO-EM/WRH/091/E. (http:// applications.emro.who.int/docs/IC_Meet_Rep_2013_ EN_14862.pdf, accessed 15 January 2014). EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 10 Community participation eludes Pakistan’s maternal, newborn and child health programme T. Akhtar,1 Z. Khan 2 and S. Raoof 1 ABSTRACT This study looked at the comprehensiveness of the primary health care approach being applied in Pakistan’s National Maternal, Newborn and Child Health (MNCH) Programme launched in 2005. The methods included a review of the programme’s guideline documents, in-depth interviews with managers/advisors and focus group discussions with community groups and service providers. The MNCH Programme is applying a selective primary care model. Programme advisors and managers were concerned about the quality of training, political interference and incomplete implementation. Service providers were not working together as envisioned. Community midwives complained about the community’s perceptions of them. Community members were unaware of MNCH Programme implementation in their areas. Pakistan’s primary health care programme needs to be reviewed and revised according current thinking on community participation and inter-sectoral collaboration to accelerate progress towards achievement of Millennium Development Goals 4 and 5. 1Consultant Research and Development; 2Directorate of Research and Development, Khyber Medical University, Peshawar, Pakistan (Correspondence to T. Akhtar: tasleem.akhtar@gmail.com). Received: 24/12/12; accepted: 09/04/13 ëmSm<9ëÐzTTÐíÓmfXúÐoÉrXmh|<Xp¬c`=og^dBÐo©mBÐ æLÚnhYnHºënBohwíÛºGBÌhd> d]iÐï|UÐíënTn=:énaJúÐíëÐ{UUÐíÓngYúÐpÉsYni}=:phUíúÐph[UÐpxnL}UÐÑdHÌphUeIî{YpSÚUÐì|wÜÚ{>oÉ°#Ð ÊÐ}@ÎíºxÚínZCÐíx}x{CÐ Ypbe_YÓĆ=nbYÊÐ}@ÎíºsYniFUÐ :pxØnIÚüÐýø{UÐ ýn?íßÐ}_HÐpHÐÚ{UÐ pbx}J e\>í 1997 ênL ºðÐÚn8ðnhUíÌðn@ÙeiënTn=:énaJúÐíëÐ{UUÐíÓngYúÐpÉsYni}=¬]xí ÓnY{#ÐY ¬{bYYíMCÐ eCÐYÓnLe6:ÓnZSnfY g\_=Ðde_x3pY{#ÐY ¬{bYëÌ5TÅecCÐEQ|hafUÐínhUÐB{UÐíoxÚ{UÐÒØ@éAgbdSìíÚnZYísYniFUÐí}x{Yï{xí dLDLMCÐ eCÐÊn\LÌcx3í wiÓÐÚ[>YMCÐ eCÐî{UnYYÓnh_eCÐÓĆ=nbUÐqcIÐí SYw5T_= Y ðnhUnAÜnfUÐn)}caxUÐpbx}]UÐRíyhbfdUíp_@Ð}edUënTn=:phUíúÐp[UÐsYni}=Õn²í nghRëZh_xUÐJnfCÐ:sYniFUÐ|haf= phaU±Uphý5iüÐYÐ}CÐY5í4 ÷Nóh óY}CÐãd=Ñ ÷ óÉê{´bUÐÒE>í x>@ÌYÓnLn]bUÐN=ëín_UÐí eCÐêngHÎî{YéA La participation communautaire absente du programme de santé de la mère, du nouveau-né et de l’enfant au Pakistan RÉSUMÉ La présente étude a examiné le caractère exhaustif de l’approche des soins de santé primaires actuellement appliquée au sein du programme national de santé de la mère, du nouveau-né et de l’enfant qui a été lancé en 1997 au Pakistan. La méthode employée comprenait un examen des lignes directrices, des entretiens approfondis avec des administrateurs et conseillers ainsi que l’organisation de groupes de discussions avec les groupes communautaires et les prestataires de services. Le programme de santé de la mère, du nouveau-né et de l’enfant applique un modèle de soins primaires sélectifs. Les conseillers et administrateurs du programme étaient inquiets au sujet de la qualité de la formation, de l’ingérence politique et de la mise en œuvre incomplète du programme. Les prestataires de services ne travaillaient pas ensemble, comme il avait été initialement prévu. Les sages-femmes communautaires se sont plaintes de la perception de la communauté vis-à vis de leur profession. Les membres de la communauté n’avaient pas connaissance de la mise en œuvre du programme de santé de la mère, du nouveau- né et de l'enfant dans leur région. Le programme de soins de santé primaires du Pakistan doit être examiné et révisé conformément à la pensée actuelle en matière de participation communautaire et de collaboration intersectorielle afin d'accélérer les progrès en vue de la réalisation des objectifs du Millénaire pour le développement 4 et 5. 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Popula- tion Policy 2002; Ten-Year Perspective Development Plan 2001–2011; Na- tional MNCH Communication Strategy Framework; and MNCH Programme Planning Commission 1 (PC-1) docu NFOU"ěFSEFWPMVUJPOPGIFBMUI UP UIFQSPWJODFTJOBOEJOUFHSBUJPO PG UIFOBUJPOBM./$)1SPHSBNNF JOUPUIFQSPWJODJBMIFBMUITFDUPSUIFTF EPDVNFOUT BSFOP MPOHFS BWBJMBCMF POMJOF BMUIPVHI BNJEUFSNFWBMV BUJPO PG UIF 1SPHSBNNF IBT CFFO QVCMJTIFE<> Data analysis ĉF DPODFQUVBM GSBNFXPSL HJWFO JO5BCMFXBTEFWFMPQFE UP HVJEF EBUBBOBMZTJTBTSFHBSETMFWFMTPGDPN NVOJUZQBSUJDJQBUJPOĉFGSBNFXPSL GPS EPDVNFOU BOBMZTJT JODMVEFE B TUBUFNFOU BCPVU UIF QFSDFJWFE OFFE GPS DPNNVOJUZ QBSUJDJQBUJPO DPODFQUVBMJ[BUJPO BOEEFėOJUJPOPG DPNNVOJUZQBSUJDJQBUJPO UIF MFWFM PGQBSUJDJQBUJPOBJNFEUPCFBDIJFWFE BOE UIF PCKFDUJWF UP CF BDIJFWFE UISPVHI QBSUJDJQBUJPO %BUB GSPN PUIFSTPVSDFTXFSFBOBMZTFEGPSPQJO JPOTBOEQFSDFQUJPOTPG UIF./$) Table 1 Objectives, methods and sample selected for the study to assess the effectiveness of the implementation of Pakistan’s Maternal, Newborn and Child Health (MNCH) Programme Objectives Data type Sample ō Determine the role assigned to the community in the CMW Programme policy, planning and implementation strategies ō Secondary data: document search and analysis ō Guiding documents identified in Research and Advocacy Fund document Maternal and newborn health—the policy context in Pakistan [13] ō Assess the perceptions of Programme policy- makers and managers towards the role of the community in the Programme ō Record managers’ views and suggestions for establishing the role of the community in the Programme ō Evaluate the criteria used for candidates’ selection for training as related to sociocultural norms and practices ō Determine community representation in the structures established for implementation of the CMW programme—selection methods, supervision and monitoring ō Determine the role assigned to the community in conflict resolution and accountability of CMWs ō Identify the different mechanisms in place for pay and incentives to CMWs ō Qualitative data: in-depth interviews with health and MNCH Programme managers and health and population professionals associated with MNCH Programme ō Available health and MNCH Programme managers. Other professionals associated with MNCH Programme were identified by Programme managers ō Planned to interview 18 people; interviewed 15 (national MNCH Programme managers became unavailable owing to devolution; provincial MNCH Programme managers were unavailable owing to an official inquiry) ō Get feedback from CMWs regarding community’s attitudes, acceptability and utilization of their services ō Record CMWs’ views and suggestions on community participation ō Qualitative: FGD with a group of 10–12 CMWs (not done) ō No group was selected owing to absence of CMWs in the study union councils ō Determine the status of CMWs in the community ō Record community’s perspectives on its role in the CMW programme ō Document community suggestions about institutionalization of the CMW programme ō Qualitative: FGD with community groups, LHWs and LHVs. ō 14 FGD done: 4 with women opinion-makers; 4 with male opinion-makers; 2 with poor mothers and mothers-in-law; 2 with non-poor mothers and mothers-in-law; 1 with LHWs; 1 with LHVs ō Compare the level of satisfaction of mothers with the care provided by CMWs and other MCH providers ō Get feedback from relevant stakeholders in the community on the quality and cost of care provided by the CMWs and other service providers ō Quantitative: women who had deliveries after CMWs were deployed. FGD with mothers and mothers-in-law. ō All women who delivered in the period 01/10–31/03/11 were identified and selected for interviews. Total 757 women CMWs = community midwives; LHWs = lady health workers; LHVs = lady health visitors; MCH = maternal and child health; FGD = focus group discussions. HCÐçPUph[UÐpdCÐ 13 ëíP_UÐ{dCÐ éíúÐØ{_UÐ 1SPHSBNNFBOEUIFSPMFPGUIFDPN NVOJUZJO1)$QSPHSBNNFT Results ĉF EBUB BOBMZTJT XBT FYQMPSFE JO UIFNFTHVJEFMJOFEPDVNFOUT ./$) 1SPHSBNNF BEWJTPST BOENBOBHFST QFSTQFDUJWFT TFSWJDFQSPWJEFSTQFSTQFD UJWFT BOEPQJOJPONBLFSTQFSTQFDUJWFT Theme 1: Commitment to and conceptualization of the PHC approach & community participation in MNCH Programme guideline documents ĉF./$)1SPHSBNNFHVJEFMJOF doc VNFOUT TIPXFEBEJTDPOOFDUCFUXFFO WJTJPO HPBMTBOETUSBUFHJFTĉFNational Health Policy 2001 UBLFT UIF)FBMUI GPS "MMHPBMBTJUTWJTJPOBOE1)$BOEHFOEFS FRVJUZBTNBKPSBSFBTPGGPDVTĉFQPMJDZ GBJMT UPEFėOFFJUIFSPG UIFTF DPODFQUT and its 10 target areas are focussed on technical strengthening of health services BU UIFQSJNBSZBOETFDPOEBSZ MFWFMT/P FYQMJDJU NFOUJPO PG DPNNVOJUZ QBS UJDJQBUJPO JTNBEF 5BCMF %JTTFNJ OBUJPOPG JOGPSNBUJPO EFWFMPQNFOUPG JOUFSQFSTPOBM TLJMMTPGDPNNVOJUZCBTFE XPSLFSTBOEQBSUJDJQBUJPOPGDJWJMTPDJFUZ PSHBOJ[BUJPOTBSFNFOUJPOFEBTTUSBUFHJFT GPSDSFBUJOHNBTTBXBSFOFTTPO iQVCMJD IFBMUINBĨFSTuĉFSF JTOPNFOUJPOPG BOZ DPMMBCPSBUJPOPG UIF./$)QSP HSBNNF EFWFMPQFEBOEJNQMFNFOUFECZ UIF.JOJTUSZPG)FBMUI XJUIUIFGVODUJPO BMMZSFMBUFE1PQVMBUJPO8FMGBSF.JOJTUSZ XIJDIIBEPWFSMBQQJOH SFTQPOTJCJMJUJFT UPXBSETSFQSPEVDUJWFIFBMUIBOEQPQVMB tion control. "OBMZTJTPG UIFEPDVNFOUPopula- tion Policy 2002TIPXFEUIBUUIFQPMJDZ JT iEFTJHOFE UPBDIJFWFTPDJBMBOEFDP OPNJD SFWJWBMCZDVSCJOH SBQJEQPQV MBUJPO HSPXUI BOE UIFSFCZ SFEVDJOH JUTBEWFSTFDPOTFRVFODFT GPSEFWFMPQ NFOUu *NQPSUBOU TUSBUFHJFT JODMVEF JOUFHSBUJPOPG SFQSPEVDUJWFIFBMUITFS WJDFTXJUIGBNJMZQMBOOJOH$PNNVOJUZ QBSUJDJQBUJPO JT MJNJUFE UP BXBSFOFTT creation. The MNCH Policy and Strategic FrameworkEPDVNFOUMJTUTiMBDLPGDPN NVOJUZ JOWPMWFNFOU JOQMBOOJOH JN QMFNFOUBUJPOBOEBDDPVOUBCJMJUZu BOE iFNQIBTJTPOCJPMPHJDBMEFUFSNJOBOUT BOEOPUPODVMUVSBMBOETPDJBMBTQFDUTu BTLFZHPWFSOBODFJTTVFTCVUUIFSFDPN NFOEFETUSBUFHJFT GBJM UPBEESFTTUIFTF DPODFSOT$PNNVOJUZQBSUJDJQBUJPO JT MJNJUFEUPBXBSFOFTTDSFBUJPO Table 2 Conceptual framework of levels of community participation in health programmes Level of participation Process Outcome Ownership (the ideal) Community takes full responsibility as owner and implementer. Government becomes facilitator Full community empowerment for decision-making/self-reliance Partnership/ contribution Community recognized as a partner. Community contributes to costs and infrastructure High level of empowerment. Community involved in decision-making Involvement Community recognized as facilitator involved in selection, monitoring, security and accountability Community empowered to a limited extent Awareness Community recognized as a utilizer of services only Community becomes “aware utilizer” of services Passive utilization No recognition of community role. Community is passive utilizer of services No community empowerment Table 3 Commitment to and conceptualization of community participation in Pakistan’s National Maternal, Newborn and Child Health (MNCH) Programme guideline documents Document Felt need for participation Concept and definition Level of participation envisioned Objective to be achieved through participation National Health Policy 2001 Nil Nil Awareness creation Behaviour change and enhanced utilization of services Population Policy 2002 Nil Nil Awareness creation Increased contraceptive use MNCH Policy and Strategic Framework 2005 Stated Nil Awareness creation Utilization of services National MNCH Communication Strategy Stated Nil Awareness creation and community involvement Utilization of services and behaviour change National MNCH Programme PC-1 Stated Nil Awareness creation and community involvement Utilization of services and behaviour change PC-1 = Planning Commission 1. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 14 The MNCH Programme Planning Commission 1 EPDVNFOU JOWPMWFT UIF DPNNVOJUZ JO UIFWFSJėDBUJPOQSPDFTT PG BQQMJDBOUTBOE TFMFDUJPO GPS$.8 USBJOJOHĉFEPDVNFOUBMTPQSFTDSJCFT UIFIPMEJOHEBZQMBOOJOHXPSLTIPQT BU EJTUSJDU MFWFM UPNPCJMJ[F UIF DPN NVOJUZ GPS FTUBCMJTIJOH SFGFSSBM BOE USBOTQPSUMJOLBHFT Theme 2: MNCH Programme advisors’ and managers’ perspectives on the adequacy of the MNCH Programme strategy and implementation mechanisms and on community participation "MM UIF./$)1SPHSBNNFBEWJTPST BOENBOBHFSTXFSFTBUJTėFEXJUIUIF SPMF HJWFO UP UIF DPNNVOJUZ JO UIF ./$) 1SPHSBNNF EPDVNFOUT and strategies. The 2 district level NBOBHFSTFYQSFTTFEDPODFSOTBCPVU QPMJUJDBM JOUFSGFSFODF RVBMJUZPG USBJO ing and issues related to the integra tion of MNCH services at the district level. They also revealed the issue of OPOQBZNFOUPG TBMBSJFT UPEFQMPZFE CMWs and delays in the release of GVOET GPS QSPHSBNNF JNQMFNFOUB tion. Theme 3: Service providers’ perspectives regarding MNCH Programme and community participation in the Programme 4FSWJDFQSPWJEFSTXFSFDPODFSOFEBCPVU UIF TFMFDUJPOQSPDFTT GPS$.8TBOE the integration of MNCH at the district MFWFM 5BCMF ĉFTFMFDUJPOQSPDFTT XBTSFQPSUFEUPCFJOWJPMBUJPOPGDSJUFSJB detailed in the MNCH Programme PC-1 EPDVNFOU-)8TFYQSFTTFEJHOPSBODF BCPVU UIF QSFTFODF PG $.8T BOE $.8T SFQPSUFE MBDLPG DPPQFSBUJPO GSPN-)8T Theme 4: Community awareness about MNCH Programme and views on their role in PHC programmes .PTU PQJOJPONBLFST FYQSFTTFE JHOPSBODF BCPVU UIF JNQMFNFOUBUJPO PG./$)1SPHSBNNF JO UIFJS BSFBT 0OFQBSUJDJQBOU XIPLOFXB$.8 SFQPSUFEUIBUTIFXBTXPSLJOHXJUIBO /(0BOEOPU JOIFSBTTJHOFEBSFB" XPNFOQBSUJDJQBOUIBEBHPPEPQJOJPO PGB$.8TIFLOFXBOEBDDPSEJOHUP IFS i$.8TEFBMLJOEMZXJUIBMM TPSUT PGQBUJFOUTXIFUIFS SJDIPSQPPS BOE UIFJSCFIBWJPVSJTHPPEXJUIFWFSZPOFu /PUNVDILOPXMFEHFPSQFSTQFDUJWF FNFSHFEBT SFHBSET UIF DPNNVOJUZT SPMF JO IFBMUI QSPHSBNNFTĉFQBS UJDJQBOUTNPTUMZFYQSFTTFE UIFJSOFFET Table 4 Implementation of Pakistan’s National Maternal, Newborn and Child Health (MNCH) Programme Planning Commission 1 (PC-1) strategies: selection of community midwives (CMWs) and coordination with lady health workers (LHWs) PC-1 strategies Implementation status Selection of CMWs CMWs shall be selected from rural areas ōCandidates are selected from urban areas based on: ō)DOVHGRFXPHQWV ō3ROLWLFDOLQĠXHQFH ō,QWHUHVWLQPRQHWDU\EHQHğWVE\SROLWLFDOO\VHOHFWHGFDQGLGDWHV Female, preferably married, will be selected ō There are few suitable candidates ō “There is no sincere effort” ō Politically selected candidates are unmarried ōUnmarried women leave assigned location after marriage Overall impression of the selection process ō Selection criteria are not followed ō There is political interference ō Stipend of Rs 3500 of trainee CMWs is the reason for political interference ō “If the provincial managers are politically appointed, how can it be expected that they will not to be influenced politically in the selection of CMWs?” Coordination between CMWs and LHWs LHWs will introduce the CMWs to the community and refer cases to them ō LHWs did not know the CMWs working in their assigned areas ōCMWs reported lack of cooperation from LHWs LHWs and CMWs will develop referral and transport networks in collaboration ō Professional jealousy reported between LHWs and CMWs ō LHWs wanted to become CMWs ō LHWs attended deliveries LHWs and CMWs will hold planning workshops supported by experts from MNCH Programme to mobilize the community for establishing referral and transport linkages ō These workshops were not held: ō0RQH\ZDVQRWUHOHDVHG ō'LVWULFWOHYHO01&+3URJUDPPHPDQDJHUVGLGQRWKDYH capacity to lead this community-oriented process PC-1 = Planning Commission 1. HCÐçPUph[UÐpdCÐ 15 ëíP_UÐ{dCÐ éíúÐØ{_UÐ BOEFYQFDUBUJPOTĉFTF JODMVEFE BD DFTTJCJMJUZ BĎPSEBCJMJUZ DPNQBTTJPO GSPNTFSWJDFTQSPWJEFSTBOESFTQFDU GPS QBUJFOUTQSJWBDZ Discussion ĉJT TUVEZ GPVOENBOZ JTTVFT JO1B LJTUBOT./$)1SPHSBNNFUIBUBSF MJLFMZ UP JNQFEF UIF BDIJFWFNFOUPG UIFQSPHSBNNFTPCKFDUJWFPGBDIJFW JOH.%(TBOEĉF1SPHSBNNF JTGPDVTTJOHPOJODSFBTJOHUIFOVNCFS PG TLJMMFECJSUIBĨFOEBOUT BWBJMBCJMJUZ PG UFDIOPMPHZBOENBOBHFNFOU JN QSPWFNFOU$PNNVOJUZQBSUJDJQBUJPO JT MJNJUFE UPBXBSFOFTTDSFBUJPO&WFO UIJT TFMFDUJWF 1)$ BQQSPBDI JT OPU CFJOH JNQMFNFOUFEFĎFDUJWFMZ *OUF gration of MNCH services has not IBQQFOFE" TJUVBUJPOPG DPNQFUJOH JOUFSFTUTIBTEFWFMPQFEBNPOH-)8T -)7TBOE$.8TĉF1SPHSBNNF QSFNJTF UIBU UIFTF TFSWJDFQSPWJEFST XJMMXPSL JODPPSEJOBUJPOIBTQSPWFE FSSPOFPVTCFDBVTFUIFZIBWFPWFSMBQ QJOH TLJMMT BOE SPMFTĉJT JTTVFXBT JEFOUJėFE JOBTUVEZ JO,BSBDIJXIJDI BEWJTFE UIBU DMFBSMZ EFėOFE SPMFT TIPVMEHVJEFUIFXPSLPGDPNNVOJUZ CBTFEXPSLFST<> ĉF JTTVF PG QBZNFOU PG TBMBSJFT UP$.8T JT FNFSHJOH BT B UISFBU UP UIF TVTUBJOBCJMJUZ PG UIF QSPHSBNNF 8IP TIPVME CF QBZJOH DPNNVOJUZ IFBMUIXPSLFST TVDIBT UIF$.8T JT BOVOSFTPMWFEJTTVF$PNNVOJUZIFBMUI XPSLFSTBSFVTVBMMZWPMVOUFFSTTFMFDUFE CZ UIF DPNNVOJUZ BOE BDDPVOUBCMF UP UIFDPNNVOJUZ *G UIFHPWFSONFOU QBZT UIFN UIFJS BDDPVOUBCJMJUZ UP UIF DPNNVOJUZ DBOOPUCF BTTVSFE)PX FWFSFWJEFODF GSPNPUIFS TPVUI"TJBO DPVOUSJFTTIPXTUIBUJGUIFZBSFOPUQBJE B SFHVMBS TBMBSZ UIFZBSF MJLFMZ UP TUPQ XPSLJOH <>0VS TUVEZ WFSJėFT UIJT concern. 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Acknowledgements ĉFBVUIPSTBSFHSBUFGVMUPUIFNBOBHF NFOUPG,IZCFS.FEJDBM6OJWFSTJUZ GPS GBDJMJUBUJOH UIF TUVEZ UIF.BSEBO EJTUSJDUIFBMUINBOBHFNFOU GPSDPPQ FSBUJPOBOETVQQPSU ,IZCFS.FEJDBM 6OJWFSTJUZ *OTUJUVUFPG1VCMJD)FBMUI BOE*OTUJUVUFPG$PNNVOJUZ0QIUIBM NPMPHZGPSQSPWJEJOHJOUFSWJFXFSTBOE CBTJDIFBMUIVOJUTJODIBSHFJOUIFTUVEZ BSFB GPS UIFJS TVQQPSUĉFEFEJDBUJPO BOE IBSE XPSL PG UIF JOUFSWJFXFST BOE,IZCFS.FEJDBM6OJWFSTJUZ%J SFDUPSBUFPG3FTFBSDI BOE%FWFMPQ NFOU TUBĎ.T.BSZBN,BVTFS .S 3FINBUVMMBI BOE.S"[NBU"MJ BSF BDLOPXMFEHFE Funding: ĉJTQBQFSJTBOPVUQVUGSPN B QSPKFDU GVOEFECZ UIF6,%FQBSU NFOU GPS *OUFSOBUJPOBM%FWFMPQNFOU %'*% BOE "VTUSBMJBO "HFODZ GPS *OUFSOBUJPOBM%FWFMPQNFOU "VT"*% GPS UIFCFOFėUPGEFWFMPQJOHDPVOUSJFT ĉFWJFXTFYQSFTTFEBSFOPUOFDFTTBSJMZ UIPTFPG%'*%"VT"*% Competing interests: None declared. References 1. Primary health care: report of the International Conference on Pri- mary Health Care. Alma Ata, USSR, 6–12 September 1978. Gene- va, World Health Organization, 1978 (http://whqlibdoc.who. int/publications/9241800011.pdf, accessed 13 October 2013). 2. Walsh J, Warren, K. Selective primary health care: an interim strategy for disease control in developing countries. Social Sci- ence and Medicine, 1980, 14:145–164. 3. Obimbo EM. Primary health care, selective or comprehensive, which way to go? East African Medical Journal, 2003, 80(1):7–10. 4. Magnussen L, Ehiri J, Jolly P. Comprehensive versus selective primary health care: lessons for global health policy. Health Affairs, 2004, 23(3):167–176. 5. World health report 1998. A vision of Health for All in the 21st century. Geneva, World Health Organization, 1998. 6. World health report 2008. Primary health care (now more than ever). Geneva, World Health Organization, 2008. 7. Nelson N, Wright S. Participation and power. In: Nelson N, Wright S, eds. Power and participatory development: theory EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 16 and practice. London, Intermediate Technology Publications, 1995:1–18. 8. Pérez D et al. Augmenting frameworks for appraising the praca- tices of community-based health interventions. Health Policy and Planning, 2009, 24(5):335–341. 9. Rifkin SB, Hewitt G, Draper AK. Community participation in nutrition programs for child survival and anemia. A report of the Centre for Public Health Nutrition. London, School of Integrated Health, University of Westminster, 2007. 10. Draper AK, Hewitt G, Rifkin S. Chasing the dragon: develop- ing indicators for the assessment of community participation in health programmes. Social Science and Medicine, 2010, 71(6):1102–1109. 11. Pakistan Millennium Development Goals report 2010. Develop- ment amidst crisis. Islamabad, Government of Pakistan, Plana- ning Commission, Centre for Poverty Reduction and Social Policy Development (http://www.undp.org/content/dam/ undp/library/MDG/english/MDG%20Country%20Reports/ Pakistan/mdgr2010.pdf, accessed 13 October 2013). 12. Pakistan National Maternal and Child Health Programme mid- term evaluation. Islamabad, Pakistan, Technical Resource Facility, 2012 (http://www.trfpakistan.org/LinkClick.aspx?filet icket=wrJZXuQPXJI%3D&tabid=2440, accessed 10 December 2013). 13. Golding S, Hall S, Shah F. Maternal and newborn health: the policy context in Pakistan. Islamabad, Pakistan, Research and Advocacy Fund, 2011 (http://rafpakistan.org/userfiles/MNH- PolicyContextPakistan.pdf, accessed 13 October 2013). 14. Islam A, Malik FA, Basaria S. Strengthening primary health care and family planning services in Pakistan: some critical issues. Journal of the Pakistan Medical Association, 2002, 52(1):2–7. 15. What works for children in South Asia community health workers. Kathmandu, Nepal, United Nations Children’s Fund Regional Office for South Asia, 2004 (http://www.unicef.org/rosa/ community.pdf, accessed 10 December 2103). 16. Kumar V. Strengthening governance of district health administra- tion. Munich, Germany, GRIN Verlag, 2010. 17. Lady health worker programme. External evaluation of the Na- tional Programme for Family Planning and Primary Health Care. Oxford, United Kingdom, Oxford Policy Management, 2009 (http://www.opml.co.uk/sites/opml/files/LHW.pdf, accessed 13 October 2013). HCÐçPUph[UÐpdCÐ 17 ëíP_UÐ{dCÐ éíúÐØ{_UÐ Expanding the comprehensive national neonatal screening programme in the United Arab Emirates from 1995 to 2011 H. Al Hosani,1 M. Salah,2 H.M. Osman,3 H.M. Farag,2 L. El-Assiouty,2 D. Saade 1 and J. Hertecant 4 ABSTRACT The national neonatal screening programme in the United Arab Emirates currently includes 16 disorders: congenital hypothyroidism, sickle-cell diseases, congenital adrenal hyperplasia, biotinidase deficiency and 12 amino acid, organic acid and fatty acid disorders. This paper reports data since the programme started in January 1995 up to December 2011 on the incidence of screened disorders and the molecular basis of positive screened cases. Screening used a combination of tandem mass spectrometry, molecular technologies and biochemical analysis. A total of 750 365 infants were screened and 717 babies saved from associated morbidity and/or mortality. The incidence of screened disorders were 1:1 873 for congenital hypothyroidism, 1:14 544 for phenylketonuria, 1:3 526 for amino acid, organic acid and fatty acid disorders, 1:9 030 for classical congenital adrenal hyperplasia, 1:8 300 for biotinidase deficiency, 1:2 384 for sickle-cell disease and 1:121 for sickle-cell traits. Coverage of neonatal screening in the population reached 95% in 2010. 1Central Department of Maternal and Child Health, Ministry of Health, Abu Dhabi, United Arab Emirates (Correspondence to H. Al Hosani: hager@emirates.net.ae). 2Department of Genetics; 3National Screening Laboratory, National Screening Centre, Abu Dhabi, United Arab Emirates. 4Department of Paediatrics, Tawam Hospital, Abu Dhabi, United Arab Emirates. Received: 09/02/12; accepted: 13/08/13 2011 1995ÒzBÐog<|^TÐÓÐÚmXüÐ9ëÐzTTÐï|TXmHeIírXmh|<çm\hgG= qfc>}wxÛ@ºÒØn_HøíغJhHúÐfUºÕ}RënfAºë5Lî{wºÖĆÉ{e7ºfH"Ð}@nw ßÐ}Y̺bd#ÐphSÚ{UÐÒ{`UÐÚ[Sðn=Ð}]Ð16ï}Ļ¦n"ÐqSUÐ:Ò{CÐph=}_UÐÓÐÚnYüÐ:ëÐ{UUÐï}UfJUÐsYniFUÐ e\xoÉ°#Ð LðÐ}x}b>pSÚUÐì|wê{b>í phfwØðn1íðnx\Lðn\1íðnhfhYÌðn\112Ón=Ð}]ÐíÛÐ{hfh>hUÐx~iÎÛLºbd#Ð}^cUÐsf>à}RºphdfCÐphd#Ð ºn0}Ļx UÐ Ón=Ð}]øÐÔí{Aé{_Yéínfxíº2011 FexØ éíúÐëinTAí1995 }xnfx ©nUÐ ëinT:ý{= |fYsYniFUÐ éAÓnh]_CÐ hdUÐíºphþx~!ÐÓnh@UfcUÐíºÉÐGCÐMcUÐh]UÐÜnhSYsx~Yï}UÐ:ê{xí n0}Ļ>UÐph=n«üÐÓøndUphþx~!ÐHúÐí >UÐÓn=Ð}]øÐÔí{Aé{_YëÌy\>Ðí pbRÐ}CÐÓnhRUÐíÌpÐ}CÐYgfYðĆaJ717ÙnbiÎ>íºðĆaJ750 365ï}Ļ>{Sí ïh"ÐýnhehcUÐ ße"ÐÓn=Ð}]øpfUn=3 526OÎ1ºéUÐ:ëhTéfhaUÐpdh=OÎpfUn=14 544OÎ1íÅbd#ÐphSÚ{UÐÒ{`UÐÚ[bUpfUn=1 873OÎ1n0}Ļ 2 384OÎ1íºÛÐ{hfh>hUÐx~iÎÛ_UpfUn=8 300OÎ1íÅbd#Ð}^cUÐsf>à}aUpfUn=9 030OÎ1íÅphfw{UÐße"Ðípx\_UÐße"ÐíphfhYúÐ 95%OÎ2010ênL:qdÉí{SíëncUÐN=ëÐ{UUÐye=ph]`UÐëÌy\>Ðí phdfCÐnxĆ#Ðpd óBOÎpfUn=121OÎ1íphdfCÐphd#Ðß}CpfUn= Extension du vaste programme national de dépistage néonatal aux Émirats arabes unis de 1995 à 2011 RÉSUMÉ Le programme national de dépistage néonatal aux Émirats arabes unis couvre actuellement 16 maladies ou troubles : l'hyperthyroïdie congénitale, la drépanocytose, l’hyperplasie congénitale des surrénales, le déficit en biotinidase ainsi que 12 troubles des acides aminés, organiques et gras. L’article présente les données collectées, depuis le commencement du programme en janvier 1995 jusqu’en décembre 2011, sur l’incidence des troubles dépistés ainsi que la base moléculaire des cas positifs dépistés. La spectrométrie de masse en tandem, les technologies moléculaires et l'analyse biochimique ont été utilisées pour les besoins du dépistage. Au total, 750 365 nourrissons ont été dépistés et la morbidité et/ou mortalité associée a pu être évitée pour 717 bébés. L’incidence des maladies ayant fait l’objet d’un dépistage était la suivante : 1 : 1873 pour l’hyperthyroïdie congénitale, 1 : 14 544 pour la phénylcétonurie, 1 : 3526 pour les troubles des acides aminés, organiques et gras, 1 : 9030 pour la forme classique de l’hyperplasie congénitale des surrénales, 1 : 8300 pour le déficit en biotinidase, 1 : 2384 pour la drépanocytose et 1 : 121 pour les traits drépanocytaires. En 2010, la couverture de la population par le dépistage néonatal avait atteint 95 %. 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Congenital hypothyroidism " UPUBM PG JOGBOUTXIP TDSFFOFE QPTJUJWF GPS$)XFSF GVSUIFS JOWFTUJ HBUFEBOE GPMMPXFEVQ UIFTF JODMVEFE JOGBOUTXJUIQFSTJTUFOUCPSEFSMJOF $) 54)mN6- BOEXJUI BCOPSNBM SFTVMUT 54) N6- 5BCMF 0GUIFCPSEFSMJOFDBTFT XFSF DPOėSNFE$) PG XIPNXFSFEFGBVMUFST0GUIFJOGBOUT XJUIBCOPSNBMUFTUSFTVMUT XFSF DPOėSNFE$)ĉFSF XFSF USBOTJFOU DBTFT UIBU XFSF OPSNBM PO GPMMPXVQ"NPOH UIF USBOTJFOU DBTFT UIFSFXFSFDBTFTXJUINBUFSOBMIJT UPSZPG BVUPJNNVOF UIZSPJEEJTFBTF QSFNBUVSFDBTFTBOEDBTFTXJUI VOJEFOUJėFEDBVTFT0GUIFCB CJFTTDSFFOFEGSPNUIFTUBSU +BOVBSZ UP%FDFNCFS XFSF DPOėSNFE$)DBTFT BO JODJEFODFPG $)BNPOH UIF TDSFFOFEOFPOBUFTPG Phenylketonuria 5BCMF TIPXT OFPOBUFT XIP TDSFFOFEQPTJUJWFGPS1,6 UIFTFXFSF XJUIQFSTJTUFOUCPSEFSMJOF1,6 QIFOZ MBMBOJOFmNHE- BOEBCOPSNBM CBCJFT QIFOZMBMBOJOF NHE- >0G UIF BCOPSNBM DBTFT XFSF DPO ėSNFEBTDMBTTJD1,6 QIFOZMBMBOJOF NHE- OPSNBMUZSPTJOFBOEOPSNBM CJPQUFSJO BOE DBTF BT1,6EVF UP CJPQUFSJOEFGFDU0GUIFCPSEFSMJOFDBTFT XFSFGBMTFQPTJUJWFTĉFJODJ EFODFPG1,6XBT Molecular DNA testing "UPUBMPGEJĎFSFOUNVUBUJPOT TQMJD JOHNVUBUJPOT BOENJTTFOTFNVUB UJPOT XFSFEFUFDUFECZBOBMZTJTPG UIF 1")HFOFGPS6"&OBUJPOBMCBCJFT ĉFGSFRVFODJFTPGUIFNVUBUJPOTXFSFBT GPMMPXT*74 ( $ 32 *74m( " *74m" ( 32 1- BOE-4 Amino acid, organic acid and fatty acid disorders 5BCMF TIPXT UIBUDBTFTPGBNJOP BDJE PSHBOJDBDJEPSGBĨZBDJEEJTPSEFST XFSFEFUFDUFECZ.4.4GSPN.BSDI VOUJM%FDFNCFSĉFSFXFSF DBTFTPGIZESPYZNFUIZMHMVUBSJD BDJ EVSJB OFXDBTFTPG1,6 EFUFDUFECZ .4.4OPUCZDPOWFOUJPOBMNFUIPET BOEDBTFTPGHMVUBSJDBDJEBFNJBUZQF* The total incidence of these disorders XBT Sickle cell haemoglobinopathies 5BCMFTIPXTUIBUPVUPGQPTJUJWF TDSFFOJOH SFTVMUT GPS TJDLMFDFMMIBFNP HMPCJOPQBUIJFTOFPOBUFTXFSF4$% '4 IBEOPOTJDLMFIBFNPHMPCJ OPQBUIZ XFSF TJDLMFIBFNPHMP CJOPQBUIZDBSSJFST '"4 BOEXFSF IBFNPHMPCJOPQBUIZ%DBSSJFST '"% ĉFEBUBTIPXFEUIBU UIF JODJEFODFPG 4$%XBT *U JTOPUFXPSUIZ UIBU PVUPG4$%DBTFTXFSFDPO ėSNFE BTIPNP[ZHPVTIBFNPHMPCJO )C 4 BOE POMZ DBTFTXFSF DPO ėSNFEBTTJDLMFCFUBUIBMBTTBFNJBĉF JODJEFODFPGTJDLMFDFMMUSBJUTXFSF 'PS UIFOPOTJDLMFIBFNPHMP CJOPQBUIJFT UIF JODJEFODFXBT GPS)C%USBJUBOEGPS)C$USBJU Congenital adrenal hyperplasia 5BCMF TIPXT UIBUPVUPGQPTJUJWF $")TDSFFOJOH SFTVMUTCBCJFTXFSF Table 1 Coverage of the neonatal screening programme in the United Arab Emirates (1998 to 2010) Year No. of live births % screened 1998 45 044 50 1999 49 075 61 2000 52 070 65 2001 53 485 67 2002 57 083 69 2003 60 249 89 2004 63 610 92 2005 66 192 94 2006 66 967 93 2007 67 789 94 2008 68 779 95 2009 76 366 95 2010 79 464 95 Data source: Department of Preventive Medicine, Ministry of Health, United Arab Emirates. 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TSH = thyroid stimulating hormone. Table 3 Follow up of newborns screening positive for phenylketonuria (PKU) (January 1995 to December 2011) Variable Borderline (PHA 3–4 mg/dL) Abnormal (PHA > 4 mg/dL) Total No. % No. % No. PKU – 0.0 52 91.2 52a Benign hyperplasia 11 15.1 5 8.8 16 Transient 3 4.8 – 0.0 3 False +ve 61 80.1 – 0.0 61 Total +ve screening 75 100.0 57 100.0 132 a51 cases were diagnosed as classical PKU and 1 case as PKU due to biopterin deficiency. PHA = phenylalanine. HCÐçPUph[UÐpdCÐ 21 ëíP_UÐ{dCÐ éíúÐØ{_UÐ DPVOUSJFTJOUIFSFHJPOTVDIBT0NBO BOE4BVEJ"SBCJB <> *O PVS SFTFBSDI XIJDI VTFE 54) BT BO JOEJDBUPS GPS UIF FWBMV BUJPOPG JPEJOFEFėDJFODZ UIFIJHI JODJEFODFPG$)XBTVOMJLFMZ UPCF FYQMBJOFE UISPVHI JPEJOFEFėDJFODZ NFDIBOJTNT <>0G UIF DBTFT UIBU TDSFFOFEQPTJUJWF USBOTJFOU DBTFTXFSFOPSNBMPO GPMMPXVQĉJT XBTFYQMBJOFECZNBUFSOBMIJTUPSZBOE JOWFTUJHBUJPOTPGBVUPJNNVOFUIZSPJE EJTFBTFT JODBTFTBOEUIFQSFTFODF PGQSFNBUVSJUZ JODBTFT)PXFWFS JO DBTFT OP TQFDJėD DBVTF XBT found. 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Hb = haemoglobin. 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Table 6 Follow up of newborns screening positive for congenital adrenal hyperplasia (CAH) from January 2007 to December 2011 Variable Term Preterm Total Screened population (no.) 367 436 11 836 379 272 Recalls (no.) 717 337 1 054 Recall rate (%) 0.2 2.9 0.28 CAH confirmed (no.) 41 1 42 False positive recalls (no.) 77 175 252 HCÐçPUph[UÐpdCÐ 23 ëíP_UÐ{dCÐ éíúÐØ{_UÐ References 1. American Academy of Pediatrics. Committee on Genetics: is- sues in newborn screening. Pediatrics, 1992, 89:345–349. 2. Chace DH, Kalas TA, Naylor EW. Use of tandem mass spec- trometry for multianalyte screening of dried blood specimens from newborns. Clinical Chemistry, 2003, 49:1797–1817. 3. Song F et al. Phenylketonuria mutations in Northern China. Molecular Genetics and Metabolism, 2005, 86:S107–S118. 4. Krone N et al. Multiplex minisequencing of the 21-hydroxylase gene as a rapid strategy to confirm congenital adrenal hyper- plasia. Clinical Chemistry, 2002, 48:818–825. 5. Hymes J, Stanley CM, Wolf B. Mutations in BTD causing bioti- nidase deficiency. Human Mutation, 2001, 18:375–381 6. Loeber G, Webster D, Aznarez A. Quality evaluation of new- born screening programs. Acta Paediatrica, Supplement, 1999, 88:3–6. 7. American Academy of Pediatrics. Update of newborn screen- ing and therapy for congenital hypothyroidism. Pediatrics, 2006, 117:2290–2303. 8. Al-Nuaim A et al. Neonatal screening for congenital hypo- thyroidism. Incidence, imaging, feasibility and difficulties of a nationwide programme. Annals of Saudi Medicine, 1992, 12:129–134. 9. Al-Hosani H et al. Prevalence of iodine deficiency disorders in the United Arab Emirates measured by raised TSH levels. Eastern Mediterranean Health Journal, 2003, 9:123–130 10. Abu-Osba YK et al. Comprehensive newborn screening pro- grammes: ARAMCO experience, the national need and rec- ommendations. Annals of Saudi Medicine, 1992, 12:235–240. 11. Holtzman NA, Meek AG, Mellits ED. Neonatal screening for phenylketonuria. I. Effectiveness. 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Haemoglobinopathies and glucose- 6-phosphate dehydrogenase deficiency in hospital births in Bahrain. Annals of Saudi Medicine, 1992, 12:536–539 17. Rajab A. Prevention of genetic disorders in Oman. Ambas- sadors, 1998, 1:5 [online magazine] (http://ambassadors.net/ archives/issue3/select-oman.htm, accessed 26 August 2013). 18. El-Hamzi M et al. Consanguinity among the Saudi Arabi- an population. American Journal of Medical Genetics, 1995, 32:623–626 19. Kösel S et al. Rapid second-tier molecular genetic analysis for congenital adrenal hyperplasia attributable to steroid 21-hy- droxylase deficiency. Clinical Chemistry, 2005, 51:298–304. 20. Lindner M et al. Implementation of extended neonatal screen- ing and a metabolic unit in the State of Qatar: developing and optimizing strategies in cooperation with the Neonatal Screening Center in Heidelberg. Journal of Inherited Metabolic Disease, 2007, 30:522–529. 21. Wolf B. Worldwide survey of neonatal screening for biotini- dase deficiency. Journal of Inherited Metabolic Disease, 1991, 14:923–927. 22. Cowan TM, Blitzer MG, Wolf B. Technical standards and guidelines for the diagnosis of biotinidase deficiency. Genetics in Medicine, 2010, 12:464–470. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 24 Prevalence and factors associated with exclusive breastfeeding at 6 months of life in Tehran: a population-based study Z.S. Noughabi,1 S. Golian Tehrani,1 A.R. Foroushani,2 F. Nayeri 3 and A. Baheiraei 4 ABSTRACT Exclusive breastfeeding is the best form of nutrition for infants in the first 6 months of life. The aim of this study was to determine the prevalence of exclusive breastfeeding in Tehran, Islamic Republic of Iran in the first 6 months of life, and the factors that influence it. In a population-based, cross-sectional study 538 mothers with children aged 6–24 months completed an interview questionnaire. Only 46.5% of mothers exclusively breastfed their infant in the first 6 months of life. In multivariate analysis formula supplementation in the hospital (OR = 0.41, 95% CI: 0.17–0.95) and mother receiving conflicting infant feeding advice (OR = 0.53, 95% CI: 0.37– 0.78) had a negative effect on exclusive breastfeeding. Mother’s intention to exclusively breastfeed (OR = 5.85, 95% CI: 2.88–11.9) and infant having first breast contact 6–30 minutes after delivery (OR = 2.35, 95% CI: 1.17–4.72) had positive effects on exclusive breastfeeding. 1Department of Maternal and Child Health; 2Department of Biostatistics, School of Public Health; 3Department of Neonatology, School of Medicine; 4Department of Reproductive Health, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to A. Baheiraei: baheiraei@tums.ac.ir). Received: 08/01/12; accepted: 06/11/12 }b=|=oGÐÚØëÐ|fI9|d^TÐXÜØmTÐ|fYTÐ@ïzTÐXâmÚüÐCKÚmZR°To@mZBÐXÐ^TÐíÚmYhøÐéz^X ëmbTÐCK xÐE=êÐ~LºïExnipeJnRº©nIí}RehAÚÜnLº©Ð}gJënhUQÛnfgIº-nbiì~HÊÐ}wÛ pHÐÚ{UÐì|wæ{*í *nhAYOíúÐpUÐ}gIúÐéĆB }UÐpx|`>éncIÌYcI\RÌï{UÐYânÚüÐDLÚn[SøÐF_xoÉ°#Ð DLíºÒnh"ÐYOíúÐpUÐ}gIúÐéĆBºphYĆHüÐëÐ}xÎpxÚg+ºëÐ}gJ:ï{UÐYpLn}UÐDLÚn[SøÐÚnZiÐé{_YDLæ}_UÐOÎ ðÐ}gI24-6N=4naJÌÚ5LÌÖíÐG>ºpd=nbCÐÓninh=decHÐðnYÌ538qdeIëncUÐDL~c>}>p}_YpHÐÚØwí hdL}?k>UÐYÐ_UÐ ÓÐ}xn`CÐØ{_CÐhdUÐ}gKÌ5T *nhAYOíúÐpUÐ}gIúÐéĆBï{UÐY4naJÌânÚÎDLëWSÐ{SbRgfY%46.5ëÌy\>Ðí éAp=Ún\Yyýn[fUÓngYúÐ ¬bd>íº0.95-0.17ÖíÐG>hb=íº%95pbUÐÒGRíº0.41ph@ÚúÐpiaZCÐ:ÓÐCn=hecUÐëÌ ĄcUënT{Sí ânÚüÐDLÚn[SøÐDLphdHÓÐE?j>n4ënT0.78-0.37ÖíÐG>hb=í%95pbUÐÒGRíº0.53ph@ÚúÐpiénaJúÐânÚÎ éíúÐ öÜ5UÐíº11.9í2.88N=ÖíÐG>hb=í%95pbUÐÒGRíº ph@ÚúÐpiï{UÐYânÚüÐDLÚn[SøÐDLÓngYúÐ õê ÷~ óLY DLÚn[SøÐDLph=n«ÎÓÐE?j>4.72í1.17N=ÖíÐG>hb=íº%95pbUÐÒGRíº2.35ph@ÚúÐpi>Øøí{_=pbhSØ30-6éĆB h}UÐ Y ï{UÐYânÚüÐ Prévalence et facteurs associés à l’allaitement maternel exclusif à six mois de vie à Téhéran : une étude en population générale RÉSUMÉ L’allaitement maternel exclusif est la meilleure forme d’alimentation pour les nourrissons dans les six premiers mois de vie. La présente étude visait à déterminer la prévalence de l’allaitement maternel exclusif à Téhéran (République islamique d’Iran) dans les six premiers mois de vie et ses facteurs d’influence. Au cours d’une étude transversale en population, 538 mères d’enfants âgés de 6 à 24 mois ont rempli un questionnaire en entretien. Seules 46,5 % des mères avaient allaité exclusivement leur nourrisson dans les six premiers mois de vie. D’après une analyse multivariée, le lait en poudre à l’hôpital (O.R. = 0,41 ; IC à 95 % : 0,17–0,95) et des conseils d’alimentation contradictoires prodigués à la mère (O.R. = 0,53 ; IC à 95 % : 0,37–0,78) avaient des effets négatifs sur l’allaitement maternel exclusif. En revanche, l’intention de la mère d’allaiter exclusivement (O.R. = 5,85 ; IC à 95 % : 2,88–11,9) et une première mise au sein entre 6 et 30 minutes après l’accouchement (O.R. = 2,35 ; IC à 95 % : 1,17–4,72) avaient des effets positifs sur l’allaitement maternel exclusif. 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Formula 25 4.6 Exclusive breastfeeding 250 46.5 Combination of formula and breastfeeding 126 23.4 Other 137 25.5 Total 538 100.0 EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 28 Table 2 Distribution of infants exclusively breastfed, by parental sociodemographic variables Variable No. of Exclusive breastfeeding χ2 (df) P-value mothers Yes No % % Maternal variables Mother’s age (years) 0.149 (2) 0.928 ≤ 25 155 47.7 52.3 26–30 208 46.2 53.8 ≥ 30 175 45.7 54.3 Mother’s education level 5.108 (3) 0.164 Illiterate/elementary 41 39.0 61.0 Secondary/high school 96 53.1 46.9 High school diploma 260 48.5 51.5 University 141 40.4 59.6 Mother’s employment 0.924 (1) 0.336 Employed 75 41.3 58.7 Unemployed 463 47.3 52.7 Mother’s ethnicity 0.785 (2) 0.675 Persian 297 45.5 54.5 Azari 144 45.8 54.2 Other 97 50.5 49.5 Mother’s return to work after delivery (months) a 2.723 (1) 0.256 < 6 23 47.8 52.2 ≤ 6 52 38.4 61.6 Parity 1.174 (2) 0.556 1 299 44.5 53.5 2 190 48.3 51.7 ≥ 3 49 51.0 49.0 Paternal variables Father’s age (years) 1.004 (2) 0.605 ≥ 29 121 43.8 56.2 30–35 245 45.7 54.3 ≥ 36 172 49.4 50.6 Father’s education level 5.858 (3) 0.119 Illiterate/ elementary 50 48.0 52.0 Secondary/ high school 104 56.7 43.3 High school diploma 237 43.9 56.1 University 147 42.9 57.1 Father’s employment 0.722 (2) 0.697 Unemployed 19 42.1 57.9 Government 176 44.3 55.7 Non-government 343 47.8 52.2 Father’s ethnicity 2.745 (2) 0.253 Persian 285 48.8 51.2 Azari 143 40.6 59.4 Other 110 48.2 51.8 HCÐçPUph[UÐpdCÐ 29 ëíP_UÐ{dCÐ éíúÐØ{_UÐ Table 2 Distribution of infants exclusively breastfed, by parental sociodemographic variables (concluded) Variable No. of mothers Exclusive breastfeeding χ2 (df) P-value Yes No % % Household variables Household income 0.186 (2) 0.911 Sufficient 131 48.1 51.9 Relatively sufficient 353 45.9 54.1 Insufficient 54 46.3 53.7 Area of residence 8.691 (4) 0.069 North 51 43.1 56.9 South 162 49.1 50.9 East 163 52.4 47.6 West 113 42.5 57.5 City centre 49 30.6 69.4 an = 75. df = degrees of freedom. Table 3 Distribution of infants exclusively breastfed, by childbirth and postpartum variables Variable No. of mothers Exclusive breastfeeding χ2 (df) P-value Yes No % % Childbirth variables Mode of delivery 0.204 (1) 0.651 Vaginal 214 47.7 52.3 Caesarean 324 45.7 54.3 Infant’s sex 0.559 (1) 0.254 Male 264 48.1 51.9 Female 274 44.9 55.1 Infant’s birth weight (g) 3.269 (2) 0.195 ≤ 2500 34 35.3 64.7 2500–4000 486 46.7 53.3 ≥ 4000 18 61.1 38.9 Infant’s birth age (week) 0.026 (1) 0.873 < 37 136 47.1 52.9 ≥ 37 402 46.3 53.7 Infant’s birth health 2.196 (1) 0.091 Healthy 491 47.5 52.5 Unhealthy 47 36.2 63.8 Postpartum variables Health problem in the 6 months after delivery 0.053 (1) 0.818 Yes 177 45.8 54.2 No 361 46.8 53.2 Postnatal depression 0.019 (1) 0.892 Yes 83 45.8 54.2 No 455 46.6 53.4 EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 30 Table 3 Distribution of infants exclusively breastfed, by childbirth and postpartum variables (continued) Variable No. of mothers Exclusive breastfeeding χ2 (df) P-value Yes No % % Postpartum variables Infant admitted to neonatal care unit 0.008 (1) 0.930 Yes 102 46.1 53.9 No 436 46.6 53.4 Infant put to the breast (time after birth) 14.71 (4) 0.005 0–5 min 115 57.4 42.6 6–30 min 119 52.9 47.1 30 min–2 h 200 42.0 58.0 2–12 h 59 32.2 67.8 > 12 h 45 40.0 60.0 Skin-to-skin contact 12.56 (4) 0.014 0–5 min 124 48.4 51.6 6–30 min 124 58.1 41.9 30 min–2 h 107 45.8 54.2 2–6 h 143 37.8 62.2 > 6 h 40 37.5 62.5 Infant breastfed on demand 6.00 (2) 0.050 Yes 361 44.0 56.0 No 105 57.1 42.9 Occasionally 72 43.1 56.9 Mother’s intention to breastfeed before childbirth 36.46 (1) < 0.001 Exclusive breastfeeding 465 51.6 48.4 Non-exclusive breastfeeding 73 13.7 86.3 Clinician help with breastfeeding 2.238 (1) 0.134 Yes 348 48.9 51.1 No 190 42.1 57.9 Clinician counselling on exclusive breastfeeding 0.007 (1) 0.936 Yes 399 46.4 53.6 No 139 46.8 53.2 Formula supplementation in hospital after birth 3.464 (1) 0.046 Yes 30 30.0 70.0 No 508 47.4 52.6 Husband’s support of exclusive breastfeeding 5.344 (1) 0.021 Yes 450 48.7 51.3 No 88 35.2 64.8 Family and friends’ support of exclusive breastfeeding 3.741 (1) 0.035 Yes 468 48.1 51.9 No 70 35.7 64.3 Mother received conflicting infant feeding advice 12.91 (1) < 0.001 Yes 216 37.0 63.0 No 322 52.8 47.2 HCÐçPUph[UÐpdCÐ 31 ëíP_UÐ{dCÐ éíúÐØ{_UÐ Table 3 Distribution of infants exclusively breastfed, by childbirth and postpartum variables (concluded) Variable No. of mothers Exclusive breastfeeding χ2 (df) P-value Yes No % % Postpartum variables Pacifier use during the first week of life 5.072 (1) 0.024 Yes 73 34.2 57.8 No 465 48.4 51.6 Having enough time for exclusive breastfeeding 10.89 (1) 0.001 Yes 475 49.1 50.9 No 63 27.0 73.0 Mother’s breastfeeding history 2.040 (1) 0.090 Yes 215 50.2 49.8 No 323 44.0 56.0 df = degrees of freedom. JOUFOEJOH UPCSFBTUGFFECFGPSF DIJME CJSUI BSFNPSF BCMF UPEFBMXJUI BOZ CSFBTUGFFEJOHQSPCMFNTUIBUNBZBSJTF ĉF SFMBUJPOTIJQCFUXFFOBNPUIFST JOUFOUJPO UPCSFBTUGFFEBOEFYDMVTJWF CSFBTUGFFEJOHTVQQPSUT UIFĉFPSZPG 3FBTPOFE"DUJPO"DDPSEJOH UPPOF QBSU PG UIJT UIFPSZ NPTU BDUJPOT BSF WPMVOUBSZBOEBQFSTPOT JOUFOUJPO UP do an action is a necessary factor for EPJOHJUBOEUIFJOUFOUJPOUPVOEFSUBLF TQFDJBMCFIBWJPVSJTJOĚVFODFECZUIBU QFSTPOT BĨJUVEFT BOE UIPVHIUT BOE PUIFSQFPQMFT BĨJUVEFT UPXBSET UIBU CFIBWJPVS <> *O FYDMVTJWF CSFBTU GFFEJOH POMZIBWJOH JOGPSNBUJPOBOE BQPTJUJWF BĨJUVEF BSFOPU TVđDJFOU BT UIF JOUFOUJPO UPCSFBTUGFFE JT BMTP OFFEFE GPS TVDDFTT XJUI FYDMVTJWF CSFBTUGFFEJOH<> ĉFQSFTFOU TUVEZXBT DSPTTTFD UJPOBM BOE UIF SFMBUJPOTIJQCFUXFFO BTTPDJBUFEGBDUPSTBOEFYDMVTJWFCSFBTU GFFEJOH JO UIF ėSTU NPOUIT PG MJGF XFSFOPU DBVTBMMZ SFMBUFE.PSFPWFS QPTTJCMF SFDBMMCJBTDPVMECFBOPUIFS MJNJUBUJPO/FWFSUIFMFTT UIF SFTVMUT PG UIJT TUVEZSFHBSEJOH UIFQSFWBMFODF PG FYDMVTJWFCSFBTUGFFEJOH JO UIFėSTU NPOUITPG MJGF BOE UIF BTTPDJBUFE GBDUPSTNBZNBLF BVTFGVM DPOUSJCV UJPO UP UIFEFWFMPQNFOUPG FđDJFOU JOUFSWFOUJPOT GPS UIF QSPNPUJPO PG CSFBTUGFFEJOH Acknowledgements Funding:ĉJT TUVEZXBT GVOEFEBOE TVQQPSUFE CZ 5FISBO 6OJWFSTJUZ PG .FEJDBM4DJFODFT HSBOU/P BTBO.4DUIFTJT Competing interests: None declared. Table 4 Backward logistic regression model for the associated factors and exclusive breastfeeding of infants at 6 months Variable Adjusted OR (95% CI) Infant put to the breast (time after birth) 0–5 min 1.76 (0.74–4.24) 6–30 min 2.35 (1.17–4.72) 30 min to 2 h 1.89 (0.95–3.78) 2–12 h 1.37 (0.71–2.63) > 12 h 1 Mother’s intention to breastfeed before childbirth Exclusive breastfeeding 5.85 (2.88–11.9) Non-exclusive breastfeeding 1 Formula supplementation at hospital after birth Yes 0.41 (0.18–0.96) No 1 Mother receiving conflicting infant feeding advice Yes 0.53 (0.37–0.78) No 1 OR = odds ratio; CI = confidence interval. References 1. Kramer MS, Kakuma R. The optimal duration of exclusive breastfeeding: Cochrane Database of Systematic Reviews, 2007, 1:CD003517. 2. The optimal duration of exclusive breastfeeding: report of an expert consultation. Geneva, World Health Organization, 2001. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 32 3. American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics, 2005, 11:496–506. 4. Olang B et al. Breastfeeding in Iran: prevalence, duration and current recommendations. International Breastfeeding Journal, 2009, 4:8. doi:10.1186/1746-4358-4-8. 5. Vafaee A et al. Prevalence of exclusive breastfeeding during the first six month of life its determinant factors on the refer- ring children to the health center in Mashhad, northeast of Iran–2007. Journal of Applied Sciences, 2010, 10:343–348. 6. Mohamadbeigi A, Salehi NM, Bayati A. [The pattern of exclu- sive breast feeding in referred neonatal to health centres of Arak]. Journal of Guilan University of Medical Sciences, 2010, 70:17–25 [in Farsi]. 7. Almasi H, Saberi HR, Moravveji AR. [The pattern of exclusive breast feeding in neonates under healthcares in health centres of Kashan city during 2006]. Journal of Kashan University of Medical Sciences, 2010, 14:163–168 [in Farsi]. 8. Eslami Z et al. [The relationship between types of delivery on breastfeeding success]. Journal of Pediatrics of Iran, 2009, 18 1(winter special issue):47–52 [in Farsi]. 9. Al-Sahab B et al. Prevalence and predictors of 6-month exclu- sive breastfeeding among Canadian women: a national survey. BMC Pediatrics, 2010, 10:20. doi:10.1186/1471-2431-10-20. 10. British national formulary 59. London, British Medical Associa- tion and the Royal Pharmaceutical Society, 2010. 11. Agho KE et al. Determinants of exclusive breastfeeding in Nige- ria. BMC Pregnancy and Childbirth, 2011, 11:2. doi:10.1186/1471- 2393-11-2. 12. Tan KL. Factors associated with exclusive breastfeeding among infants under six months of age in Peninsular Malaysia. In- ternational Breastfeeding Journal, 2011, 6:2. doi:10.1186/1746- 4358-6-2. 13. Rowe-Murray HJ, Fisher JRW. Baby friendly hospital practices: cesarean section is a persistent barrier to early initiation of breastfeeding. Birth, 2002, 292:124–131. 14. Nakao Y et al. Initiation of breastfeeding within 120 minutes after birth is associated with breastfeeding at four month among Japanese women: A self-administered question- naire survey. International Breastfeeding Journal, 2008, 3:1. doi:10.1186/1746-4358-3-1. 15. Global strategy for infant and young child feeding. Geneva, World Health Organization, 2003. 16. Fjeld E et al. No sister, the breast alone is not enough for my baby. International Breastfeeding Journal, 2008, 3:26. doi: 10.1186/1746-4358-3-26. 17. Rose VA et al. Factor influencing infant feeding method in an urban community. Journal of the National Medical Association, 2004, 96:325–331. 18. Morhason-Bello I, O’Adedokun B, Ojengbede AO. Social support during childbirth as a catalyst for early breastfeeding initiation for first time Nigerian mothers. International Breast- feeding Journal, 2009, 4:16. 10.1186/1746-4358-16. 19. Dashti M et al. Determinants of breastfeeding initiation among mothers in Kuwait. International Breastfeeding Journal, 2010, 5:7. doi:10.1186/1746-4358-5-7. 20. Semenic S, Loiselle C, Gottlieb L. Predictors of the duration of exclusive breastfeeding among first-time mothers. Research in Nursing and Health, 2008, 31:428–441. 21. Tarrant M et al. Breastfeeding and weaning practices among Hong Kong mothers: a prospective study. BMC Pregnancy and Childbirth, 2010, 10:27. doi:10.1186/1471-2393-10-27. 22. Scott JA et al. Factors associated with breastfeeding at dis- charge and duration of breastfeeding. Journal of Paediatrics and Child Health, 2001, 37:254–261. 23. Ajzen I, Albarracin D, Hornik R, eds. Prediction and change of health behavior: applying the reasoned action approach. Mahwah, New Jersey, Lawrence Erlbaum Associates, 2007. 24. Bai Y et al. Predicting intentions to continue exclusive breast- feeding for 6 months: a comparison among racial/ethnic groups. Maternal and Child Health Journal, 2010, 15(8):1257–1264. HCÐçPUph[UÐpdCÐ 33 ëíP_UÐ{dCÐ éíúÐØ{_UÐ Prevalence of anaemia in preschool children in Karma Albalad area, Northern State, Sudan M.D. Hussein 1 and S. Mohamed 2 ABSTRACT Anaemia is a major childhood health problem in developing countries. The aim of this cross-sectional study was to determine the prevalence of anaemia, and some of its determinants, in preschool children in a rural village in the Northern State of Sudan. All children aged 3–6 years attending the 4 village kindergartens on the day of the study were enrolled. Demographic and socioeconomic data were collected using a questionnaire completed by parents, and blood samples were taken for haemoglobin measurement. Out of 163 children, 131 had anaemia (haemoglobin level < 11 g/dL), a prevalence of 80.4%. This figure is comparable to data from other developing countries. The prevalence of anaemia was not significantly associated with any of the studied demographic and socioeconomic factors (sex, economic status of the family, mother’s literacy or family size) or health of the child (history of pica or number of attacks of malaria in the last year). A campaign to tackle this serious health issue is urgently needed. 1Department of Paediatrics, Dongola Police Hospital, Dongola, Sudan (Correspondence to M.D. Hussein: sararmohamed2000@yahoo.co.uk). 2Department of Paediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia. Received: 23/04/13; accepted: 24/04/13 ëÐØTÐ9ogT5YTÐowøTÐ9zcTÐoX|Soa\eX9oGÚzBÐGRém`IúÐîzTêzTÐ|aQÚmYhÐé ¬z^X {e7ÚкNAÑnxØ{e7 {x{Ļp}_CÐpHÐÚ{UÐì|wYæ{4ÐënT{bUí phYnfUÐëÐ{dUÐ:pUa]UÐpdA}Y:phHnHúÐph[UÐTnZCÐYê{UÐ}bRF_ôxoÉ°#Ð ,énaJúÐ h+ÕÐÚØÎ>í ëÐØUn=phU5ZUÐpxøUÐ:phaxÚpx}S:pHÚ{CÐSnYH:énaJúÐî{U>ÐØ{7_=íºê{UÐ}bRÚnZiÐé{_Y phRÐ}Qex{UÐÓninhUÐ he9>í pHÐÚ{UÐ:p_=ÚúÐénaJúÐßnxÚÜÚÐ{Y:rUÐÊÐ}@Î{fLpHØnUÐípUnUÐHN=wÚ5LÌÖíÐG>qinT N=Y131ëÌ{@íí N=dQeh4ÐÜnhSæ{)ê{UÐÓnfhL|BÌ>5TºU5cHn=Ên=ùÐênSï|UÐënhHøÐêÐ{Hn=pxØn[SøÐíphL5@øÐí ÓninhUn=S}UÐÐ|wpiÚnbYcexí %80.4 ÚnZiÐé{_e=GUØcUêÐ}Q11 YSÌN=dQeh4ÐîYëÌïÌêØ}bR0{UðĆaJ163 phL5@øÐíphRÐ}Qex{UÐ YÐ_UÐ Yïj=ðnhýn[AÎ= {_xðnJn>ÚÐ >}xøê{UÐ }bRÚnZiÐ é ö{_YëÌ{@íí phYnfUÐ ëÐ{dUÐ }ýnHYÒÙBjCÐ éínf>=ÐHa]UÐpÉíÌÒúÐAí̺p=ncUÐíÒÊÐ}bUn=êúÐênCκұUpxØn[SøÐpUn"кf!ÐngHÐÚØq/UÐpxØn[SøÐí ph[UÐpdcZCÐì|w YJn_dUpd1ÊÐ}@ÎOÎpHnYp@nAUnfwëÌDxí ĽnCÐên_UÐ:nxÚĆCn=p=nÉøÐÓÐ}YØ{LíÌpx}QØÐCa]UÐ pLUÐ@íDLÒE]#Ð Prévalence de l’anémie chez des enfants d’âge préscolaire dans la région de Karma Albalad dans l’État du Nord au Soudan RÉSUMÉ L’anémie chez l’enfant est une préoccupation de santé publique majeure dans les pays en développement. L’objectif de la présente étude transversale était de déterminer la prévalence de l’anémie ainsi que certains de ses déterminants chez des enfants d’âge préscolaire dans un village rural de l’État du Nord du Soudan. Tous les enfants âgés de trois à six ans fréquentant les quatre écoles maternelles du village le jour de l’étude ont participé. Les données démographiques et socioéconomiques ont été recueillies à l’aide d’un questionnaire rempli par les parents, et des échantillons de sang ont été prélevés pour le dosage du taux d’hémoglobine. Sur 163 enfants, 131 souffraient d’anémie (taux d’hémoglobine < 11 g/dl), une prévalence de 80,4 %. Ce chiffre est comparable aux données d’autres pays en développement. La prévalence de l’anémie n’était significativement associée à aucun des facteurs démographiques et socioéconomiques étudiés (sexe, statut socioéconomique de la famille, degré d’alphabétisme de la mère ou taille de la famille) ni à la santé de l’enfant (antécédents de syndrome de pica ou nombre d’épisodes de paludisme au cours de l’année précédente). Une campagne pour s’attaquer à ce problème de santé sérieux est nécessaire de toute urgence. 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Laboratory methods "N-CMPPETBNQMFXBT UBLFO GSPN BMMQBSUJDJQBUJOHDIJMESFOĉF)C MFWFM XBTNFBTVSFEXJUIJOIPVSTBěFSDPM MFDUJPOVTJOH UIF)FNP$VF¡ TZTUFN BOE%SBQLJOT SFBHFOUT *O UIJT TUVEZ BOBFNJBXBTEFėOFEBT)C HE- .JMEBOBFNJBXBT)C HE- NPEFSBUFBOBFNJBXBT)CmHE- XIJMFTFWFSFBOBFNJBXBT)C HE- < > Statistical analysis ĉFEBUBXFSFFOUFSFEBOEBOBMZTFE using SPSS WFSTJPOĉFEJĎFSFODF CFUXFFOQSPQPSUJPOT UFTUXBTVTFE UP UFTU TUBUJTUJDBM TJHOJėDBODF *UXBT DPOTJEFSFE TJHOJėDBOUXIFOPWBMVF #JOBSZ MPHJTUJD SFHSFTTJPO UFTUXBT VTFE UPEFUFSNJOF SJTL GBDUPST BTTPDJ BUFEXJUIBOBFNJBJOUIFTUVEZQPQVMB tion. Results 0G UIF DIJMESFO FMJHJCMF GPS UIF TUVEZ XFSFFYDMVEFEBT UIFQBSFOUT SFGVTFE UP QBSUJDJQBUF BOE GBJMFE UP BĨFOE GPS UFTUJOH2VFTUJPOOBJSFT XFSFEJTUSJCVUFEUPUIFQBSFOUTPG DIJMESFO PGXIPN GBJMFE UPėMM BOE SFUVSO UIFRVFTUJPOOBJSF2VFTUJPO OBJSF EBUB BOE CMPPE TBNQMFTXFSF UIFSFGPSF BOBMZTFE GPS DIJMESFO SFTQPOTFSBUF 5BCMF TIPXT UIFDIBSBDUFSJTUJDT PGUIFTUVEZHSPVQĉFSFXFSFHJSMT BOECPZT"NBKPSJUZPGUIFDIJMESFO XFSF GSPN MBSHF GBNJMJFT ɓ DIJMESFO XIJMF UIF SFTUXFSF GSPN TNBMM GBNJMJFT DIJMESFO 1JDBCF IBWJPVSXBT SFQPSUFE JODIJMESFO PG UIF TUVEZHSPVQ 'BUIFST PGPG UIF TUVEZ DIJMESFOXFSF JMMJUFSBUFXIJMFIBEJMMJUFSBUFNPUI FST'BUIFSTPGPGDIJMESFOXFSF GBSNFST"RVBSUFSPG UIFTUVEJFEDIJM ESFO XFSFGSPNQPPSGBNJMJFT SFDFJWJOHSFHVMBSBMMPXBODFTGSPNUIF social authority). 0VUPG TUVEJFE DIJMESFO IBE)C MFWFMT CFMPX UIF DVUPĎ GPS BOBFNJB BQSFWBMFODFPG"OBF NJBXBTHSBEFEBTNJME JO NPEFSBUF JO BOETFWFSF JO 5BCMF TIPXT UIBU UIFQSFWBMFODF PG BOBFNJB XBT OPU TUBUJTUJDBMMZ TJH OJėDBOUMZ SFMBUFE UPBOZPG UIFTUVEJFE EFNPHSBQIJDBOE TPDJPFDPOPNJD GBD UPST TFY FDPOPNJD TUBUVTPG UIF GBN JMZ NPUIFST MJUFSBDZPS GBNJMZ TJ[F PS IFBMUIPG UIF DIJME IJTUPSZPGQJDBPS OVNCFSPGBĨBDLTPGNBMBSJBJOUIFMBTU year). Discussion "OBFNJB JT B HMPCBMIFBMUIQSPCMFN BOEJTPOFPGUIFNBKPSDBVTFTPGDIJME IPPENPSUBMJUZBOENPSCJEJUZ<>"T UIFFQJEFNJPMPHJDBMEBUBPOBOBFNJB JO4VEBOFTFDIJMESFOBSFTDBSDF<> XFEFDJEFEUPTUVEZUIFQSFWBMFODFPG BOBFNJB JODIJMESFOBTBO JNQPSUBOU EFUFSNJOBOUPGXFMMCFJOH *OUIFQSFTFOUTUVEZUIFQSFWBMFODF PGBOBFNJBBNPOHQSFTDIPPMDIJMESFO JO,BSNB"MCBMBEWJMMBHFXBT ĉJT JT DPOTJTUFOUXJUI UIF SFTVMUTPG the household survey conducted JO4VEBO JO XIJDI SFQPSUFEB QSFWBMFODFPG BOBFNJB JOQSFTDIPPM DIJMESFOJO4VEBOBT<>ĉJT Table 1 Characteristics of the study group of preschool children in Karma Albalad, Northern State, Sudan (n = 163) Characteristic No. % Sex Male 81 49.7 Female 82 50.3 Family characteristics Large family 70 43.0 Poor family 40 24.5 Illiterate mother 12 7.4 Health history Frequent malaria attacks 55 33.7 History of pica 17 10.4 Asthma 13 8.0 Type 1 diabetes 1 0.6 Recurrent urinary tract infection 1 0.6 Tuberculosis 0 0.0 EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 36 BMBSNJOHMZIJHIQSFWBMFODFPGBOBFNJB JTDPNQBSBCMFXJUISFTVMUTGSPNTUVE JFT DPOEVDUFE JO PUIFS EFWFMPQJOH countries such as India and Nigeria <m>ĉF TJUVBUJPO IPXFWFS JT WFSZEJĎFSFOU GSPNUIBU JOEFWFMPQFE DPVOUSJFT < > 'PS JOTUBODF UIF QSFWBMFODF PG BOBFNJB JO DIJMESFO JO UIF6OJUFE4UBUFTPG"NFSJDBIBT CFFO SFQPSUFEBTPOMZ<> *U JT XFMM LOPXO UIBU UIFQSFWBMFODFPG BOBFNJB SJTFTXJUI JODSFBTJOHQPW FSUZ <m>ĉFIJHIQSFWBMFODF PGBOBFNJB JO UIJT TUVEZ JT UIFSFGPSF OPUTVSQSJTJOHBT4VEBOJTPOFPGUIF QPPSFTU DPVOUSJFT JO UIFXPSMEĉF SFDFOU 4VEBO QPWFSUZ BTTFTTNFOU QSFQBSFE CZ UIF8PSME #BOL BOE UIF4VEBO HPWFSONFOU TUBUFE UIBU PWFSBMMPG UIFQPQVMBUJPOXBT CFMPXUIFQPWFSUZ MJOFXJUIBIJHIFS SBUF BNPOHUIFSVSBMQPQVMB UJPO <>0UIFSQSPėMFT QSFTFOU B EFUBJMFEBOBMZTJTPGQPWFSUZ EFNP HSBQIJD MJWFMJIPPE FEVDBUJPO BOE FNQMPZNFOUJOUIFDPVOUSZ<m> 0VSTUVEZXBTDPOEVDUFE JOB SVSBM BSFBXIFSF UIFHSFBUNBKPSJUZPG UIF QBSFOUTXFSF GBSNFSTXJUI MJNJUFE JODPNFBOEFEVDBUJPO 1FPQMF MJWJOH JO SVSBM BSFBT PG 4VEBODPOTUJUVUFPGUIFQPQVMB UJPO BDDPSEJOH UP UIF DFOTVT <>ĉFSVSBMDPNNVOJUZJO4VEBO JTIPNPHFOPVTBOE UIFNBKPSJUZPG QFPQMFBSFGSPNUIFTBNFUSJCF XIJDI FYQMBJOTUIFTJNJMBSJUJFTJOUIFJSTPDJBM DIBSBDUFSJTUJDT8IFOXFBOBMZTFEUIF QPTTJCMF SJTL GBDUPSTBTTPDJBUFEXJUI BOBFNJB TVDIBTQBSFOUTFEVDBUJPO GBNJMZTJ[F GBNJMZ JODPNFBOEPUIFS TPDJPFDPOPNJDJOEJDBUPSTPGQPWFSUZ OPOFPG UIFTF SJTLT GBDUPSTXFSF TUB UJTUJDBMMZTJHOJėDBOUMZBTTPDJBUFEXJUI BOBFNJBĉJT TUVEZXBTDPOEVDUFE JO B SVSBM WJMMBHFDPNNVOJUZXIFSF GBNJMJFT BSF FYUFOEFE BOE TIBSF B TJNJMBSDVMUVSF UIFSFGPSFUIFMJGFTUZMFT PGUIFQFPQMF FTQFDJBMMZFBUJOHIBCJUT BSFFYQFDUFE UPCF SFMBUJWFMZ TJNJMBS EFTQJUFEJĎFSFODFTJOTPDJPFDPOPNJD TUBUVT 4P TPDJPFDPOPNJD GBDUPST XPVMEOPUIBWFBTHSFBUBOJNQBDUPO DIJMESFOTOVUSJUJPOBTDPNQBSFEXJUI VSCBO DPNNVOJUJFT *O DPOUSBTU UP PVSėOEJOHT "MBXBEZFUBM SFQPSUFE BIJHIQSFWBMFODFPGBOBFNJBBNPOH DIJMESFOXJUIVOFEVDBUFENPUIFST JO,VXBJU<>*OUIF64"UPP QBS FOUTFEVDBUJPOXBTSFQPSUFEBTBSJTL GBDUPS GPS UIFEFWFMPQNFOUPGDIJME IPPEBOBFNJB<> Most of the children in this study XFSFFYQPTFEUPNVMUJQMFBĨBDLTPGNB MBSJBJOUIFZFBSQSJPSUPUIFEBUFPGUIF TUVEZĉJTJTVOEFSTUBOEBCMFBTNBMBSJB JTFOEFNJD JO4VEBO)PXFWFS SFDVS SFOUBĨBDLTPGNBMBSJB ɓ UJNFTQFS ZFBS XFSFOPUTIPXOUPCFBSJTLGBDUPS GPSBOBFNJBJOUIJTTUVEZ.BMBSJBDBVTFT BOBFNJBCZTVCKFDUJOHSFECMPPEDFMMTUP IBFNPMZTJT <>4FWFSFNBMBSJBBTXFMM BTUIFQSFTFODFPGHMVDPTFQIPTQIBUF EFIZESPHFOBTFEFėDJFODZ (1%% BSFLOPXOSJTLGBDUPSTGPSEFWFMPQNFOU PGIBFNPMZTJTBTTPDJBUFEBOBFNJB<> .JMENBMBSJB IPXFWFS JTOPUVTVBMMZB DBVTFPGBOBFNJB BOENPTUPGUIFDIJM ESFOJOUIFDVSSFOUTUVEZIBENJMEBOBF NJB8IJMF(1%%JTDPNNPOJOUIF XFTUPG4VEBO JUJTOPUJOUIFOPSUI"MM UIFTF GBDUPSTNBZQPTTJCMZFYQMBJO UIF ėOEJOHUIBUNBMBSJBXBTOPUBTTPDJBUFE XJUIBOBFNJBJOUIJTTUVEZ 3FMBUJWFMZTNBMMOVNCFSTPGBOBF NJD DIJMESFO JO UIF DVSSFOU TUVEZ XFSF SFQPSUFE UPIBWFQJDB XIJDI XBTOPUTUBUJTUJDBMMZEJĎFSFOUGSPNUIF OVNCFSTPGOPOBOBFNJDDIJMESFO 1JDB JT B TPDJBM TUJHNB UIFSFGPSF B Table 2 Risk factors associated with anaemia in preschool children in Karma Albalad, Northern State, Sudan (n = 163) Risk factors Anaemic Hb < 11g/dL (n = 131) Not anaemic Hb ≥ 11g/dL (n = 32) OR 95% CI P-value No. % No. % Sex Male 63 48.1 18 56.3 1.19 0.54–2.60 0.54 Female 68 51.9 14 43.8 1.19 0.54–2.66 0.54 Family characteristics Large family 58 44.3 12 37.5 0.78 0.30–1.76 0.55 Poor family 33 25.2 7 21.9 1.06 0.49–2.80 0.90 Illiterate mother 11 8.4 1 3.1 2.63 0.30–22.7 0.38 Health historya Frequent malaria attacks 45 34.4 10 31.3 0.88 0.37–2.06 0.37 Pica 16 12.2 1 3.1 0.23 0.03–1.80 0.16 aOf the 13 children with asthma 6 had Hb ≥ 11 g/dL and 7 had Hb < 11 g/dL. The 1 child with type 1 diabetes had normal Hb and the 1 child with recurrent urinary tract infection had low Hb < 11 g/dL. Hb = haemoglobin; OR = odds ratio; CI = confidence interval. HCÐçPUph[UÐpdCÐ 37 ëíP_UÐ{dCÐ éíúÐØ{_UÐ RVFTUJPOOBJSFCBTFETUVEZNBZOPUCF UIFCFTUXBZ UPPCUBJOPCKFDUJWFEBUB PO UIFQSFWBMFODFPG QJDBĉJTNBZ CFPOFPG UIF MJNJUBUJPOTPG UIFTUVEZ 0UIFSMJNJUBUJPOTJODMVEFUIFSFMBUJWFMZ TNBMM TUVEZ TBNQMF BOE UIF MBDLPG B DPOUSPMHSPVQ'VSUIFS JOWFTUJHBUJPOT UPEFUFSNJOF UIFFUJPMPHZPGBOBFNJB JO UIFTF DIJMESFO XFSF CFZPOE UIF TDPQFPG UIJT TUVEZ)PXFWFS IBWJOH NPSFEBUBBT UP UIF UZQFBOEDBVTFPG BOBFNJBXPVME CF JOGPSNBUJWF8F SFDPNNFOEUIBUBNPSFDPNQSFIFO TJWF TUVEZPOBXJEFS TDBMFXPVMECF IFMQGVM UPWBMJEBUFPVSėOEJOHTBOE UP TUJNVMBUFUIFBVUIPSJUJFTUPBEESFTTUIJT JNQPSUBOUDIJMEIPPEIFBMUIQSPCMFN %BJMZJSPOTVQQMFNFOUBUJPO GPSFYBN QMF JTBWJBCMF JOUFSWFOUJPOUP JODSFBTF )C MFWFMT <>"DBNQBJHO UP UBDLMF UIJTEFUSJNFOUBMIFBMUIJTTVFJTVSHFOUMZ needed. Acknowledgements Funding: ĉJT TUVEZXBT GVOEFECZ %POHPMB1PMJDF)PTQJUBM BOEQBSUMZ CZ UIF$PMMFHFPG.FEJDJOF3FTFBSDI $FOUFS %FBOTIJQ PG 4DJFOUJėD 3F TFBSDI ,JOH4BVE6OJWFSTJUZ 4BVEJ "SBCJBĉFBVUIPSTXPVMEMJLFUPUIBOL UIFTF UXP JOTUJUVUFT GPS GVOEJOH UIJT XPSL Competing interests: None declared. References 1. De Benoist B et al. Worldwide prevalence of anaemia 1993- 2005: WHO global database on anaemia. Geneva, World Health Organization, 2008. 2. McLean E et al. Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System, 1993– 2005. Public Health Nutrition, 2009, 12:444–454. 3. Galloway R. Anemia prevention and control: what works? Geneva, USAID/World Bank/PAHO-WHO/Micronutrient Initiative/FAO/UNICEF, 2003. 4. Zimmermann MB, Hurrell RF. Nutritional iron deficiency. Lancet, 2007, 370:511–520. 5. Magalhães RJ, Clements AC. Mapping the risk of anaemia in preschool-age children: the contribution of malnutri- tion, malaria, and helminth infections in West Africa. PLoS Medicine, 2011, 8:e1000438. 6. Ghosh K, Ghosh K. Pathogenesis of anemia in malaria: a concise review. Parasitology Research, 2007, 101:1463–1469. 7. Soares Magalhães RJ, Clements AC. Spatial heterogeneity of haemoglobin concentration in preschool-age children in sub-Saharan Africa. Bulletin of the World Health Organiza- tion, 2011, 89:459–468. 8. Giha HA et al. Severe malaria in an unstable setting: clinical and laboratory correlates of cerebral malaria and severe malarial anemia and a paradigm for a simplified severity scoring. European Journal of Clinical Microbiology and Infec- tious Diseases, 2009, 28:661–665. 9. Dallman PR, Yip R, Oski FA. Iron deficiency and related nu- tritional anemias. In: Nathan DG, Oski FA, eds. Hematology of infancy and childhood, 5th ed. Philadelphia, WB Saunders Company, 1999. 10. Iannotti LL et al. Iron supplementation in early childhood: health benefits and risks. American Journal of Clinical Nutri- tion, 2006, 84:1261–1276. 11. García-Casal MN et al. A program of nutritional education in schools reduced the prevalence of iron deficiency in students. Anemia, 2011, 2011:284050. 12. Annual statistical report 2009. Khartoum, Sudan, Federal Ministry of Health, 2010. 13. Baumgartner J et al. Effects of iron and n-3 fatty acid sup- plementation, alone and in combination, on cognition in school children: a randomized, double-blind, placebo- controlled intervention in South Africa. American Journal of Clinical Nutrition, 2012, 96:1327–1338. 14. De-Regil LM et al. Intermittent iron supplementation for improving nutrition and development in children under 12 years of age. Cochrane Database of Systematic Reviews, 2011, 7:CD009085. 15. Health multiple indicators cluster survey 2006. Khartoum, Sudan, Federal Ministry of Health, 2006. 16. Omer A et al. Studies on the anaemia of kwashiorkor and marasmus in the Sudan. Journal of Tropical Pediatrics and Environmental Child Health, 1973, 19:91–97. 17. Rekart ML, Plastino J, Carr C. Health status of teenage school boys in eastern Sudan. East African Medical Journal, 1985, 62:54–59. 18. Population projections for Sudan 1993–2018. Khartoum, Sudan Ministry of Finance and National Economy, Central Bureau of Statistics, 1996. 19. Awasthi S. Anemia and undernutrition among preschool children in Uttar Pradesh, India. Indian Pediatrics, 2000, 40:985 –990. 20. Chaudhuri K. Anemia and nutritional status of preschool children in Kalara. Indian Pediatrics, 2000, 8:6–7. 21. Bamidele JO et al. Prevalence and determinants of anemia among primary school pupils of a peri-urban community in Osun State, Nigeria. International Journal of Adolescent Medicine and Health, 2010, 22:461–468. 22. Luo R et al. Anaemia among students of rural China’s el- ementary schools: prevalence and correlates in Ningxia and Qinghai’s poor counties. Journal of Health, Population, and Nutrition, 2011, 29:471–485. 23. Thane CW, Bates CJ, Prentice A. Risk factors for low iron intake and poor iron status in a national sample of British young people aged 4–18 years. Public Health Nutrition, 2003, 6:485–496. 24. Gwatkin D et al. Socio-economic differences in health, nutri- tion, and population within developing countries. Washington DC, World Bank, 2007. 25. Oliveira MA, Osório MM, Raposo MC. Socioeconomic and dietary risk factors for anemia in children aged 6 to 59 months. Jornal de Pediatria, 2007, 83:39–46. 26. Variyam JN et al. Mother’s nutrition knowledge and chil- dren's dietary intakes. American Journal of Agricultural Eco- nomics, 1999, 81:373–387. 27. A poverty profile for the Northern States of Sudan. Washington DC, World Bank, Poverty Reduction and Economic Man- agement Unit, African Region, 2011. 28. Haughton J, Khander S. Handbook on poverty and inequality. Washington DC, World Bank, 2009. 29. National baseline household survey2009. Khartoum, Sudan, Central Bureau of Statistics, 2009. 30. Human development report. The rise of the Sudan: human progress in a diverse world. New York, United Nations De- velopment Programme, 2013. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 38 31. Alawadi A. Nutritional status survey of preschool children in Kuwait. Eastern Mediterranean Health Journal, 1996, 2(3):386 –395. 32. Hassan MM. Glucose-6-phosphate dehydrogenase deficiency in the Sudan. Journal of Tropical Medicine and Hygiene, 1971, 74:187–188. 33. Thompson J, Biggs BA, Pasricha SR. Effects of daily iron sup- plementation in 2- to 5-year-old children: systematic review and meta-analysis. Pediatrics, 2013, 131:739–753. HCÐçPUph[UÐpdCÐ 39 ëíP_UÐ{dCÐ éíúÐØ{_UÐ Association between dietary habits and body mass index of adolescent females in intermediate schools in Riyadh, Saudi Arabia M.N. Al-Muammar,1 M. El-Shafie 1 and S. Feroze 1 ABSTRACT Obesity among Saudi youth is a growing public health challenge. This cross-sectional study measured body mass index (BMI) and determined the eating habits and lifestyle of 107 randomly selected female adolescent students (age 12–15 years) at schools in Riyadh. The students’ heights and weights were measured and a pre-tested questionnaire was used to collect data on diet and lifestyle. The majority of the students’ families had monthly income > 10 000 riyals (US$ 1 = 3.75 riyals). About half the students (53.3%) were within normal weight, 28.6% were underweight, 12.4% overweight and 5.7% obese. The majority of the students did not have healthy dietary or exercise habits. There were no significant differences between BMI category and dietary pattern and lifestyle. Increasing educational programmes with healthy dietary concepts to improve the dietary pattern of female adolescents is recommended. Department of Community Health Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia (Correspondence to M. El-Shafie: Melshafie@ksu.edu.sa). Received: 14/02/12; accepted: 30/07/12 owØ^TÐog<|^TÐobcdBкßmw|TÐ9o\GBÐÜÚÐzBÐ9ÓmavÐ|BÐîzT!ÐocSjXíogýÐ{_TÐÓÐØm^TÐM<<ÐFTÐ ÛíEReHº_RnZUÐ{e7fYº}e_CУniY ofYÜnhSp}_CÐpHÐÚ{UÐì|wß}_>í phYe_UÐp[UÐ@Ð>UÐphYnfCÐÓnx{UÐYïØ_UÐÑnZUÐN=pfeUÐF_>oÉ°#Ð :ðnYnL15í12N=wÚ5LÌÖíÐG>íphýÐZLÒÚ[=wÚnhBÐ>.ĆUÐÓnbwÐ}CÐY107ÒnhAà5iÌíºphýÐ|`UÐÓÐØn_UÐ{x{Ļ Yº!ÐpdT ënT{Sí Ònh"ÐeiíýÐ|`UÐên^fUÐéAÓninhUÐ heUðnbYìÚnBÐ>ënhHÐêÐ{HÐíºÓnUn]UÐëÛííéJÜnhS>í ßnx}UÐÜÚÐ{Y ðnx}b>ÓnUn]UÐ[iënTí ïØ_HénxÚ3.75éØn_xcx}YúÐÚøí{UÐïØ_HénxÚ10 000ÛínxÓnUn]UÐÌphUn`Uï}gZUÐB{UÐ phýÐ|QÓÐØnL0{Ucx3ÓnUn]UÐphUnQí ÓnfheH%5.7íºëÛUÐÓÐ{ýÐÛ%12.4íºëÛUÐÓn[Sni%28.6íºï UÐëÛUÐØí{A:%53.3 phahbUÐsYÐFUÐÒØnx~=¥x ?Yí Ònh"ÐÑdHÌíºýÐ|`UÐên^fUÐeiíº!ÐpdTo ó÷fYN=ETÓína>ènfwcx3í phÉphi{=íÌ ÓnbwÐ}edUphýÐ|`UÐà5iúÐNĻ@ÌYph[UÐphýÐ|`UÐhwnaCÐéA Association entre les habitudes alimentaires et l’indice de masse corporelle chez des collégiennes à Riyad (Arabie saoudite) RÉSUMÉ L’obésité chez les jeunes saoudiens est une préoccupation de santé publique croissante. La présente étude transversale a mesuré l’indice de masse corporelle puis a déterminé les habitudes alimentaires ainsi que le style de vie de 107 adolescentes sélectionnées aléatoirement (âgées de 12 à 17 ans) dans des collèges à Riyad. Le poids et la taille des collégiennes ont été mesurés et un questionnaire prétesté a été utilisé pour recueillir des données sur leur alimentation et leur style de vie. La majorité des familles des collégiennes disposait d’un revenu mensuel supérieur à 10 000 riyals (1 USD = 3,75 riyals). Environ la moitié des adolescentes (53,3 %) avaient un poids normal, 28,6 % souffraient d’insuffisance pondérale, 12,4 % présentaient une surcharge pondérale tandis que 5,7 % étaient obèses. La majorité des collégiennes n’avaient pas d’habitudes alimentaires ni sportives saines. Aucune différence significative n’a été observée entre la catégorie d’indice de masse corporelle, les habitudes alimentaires et le mode de vie. Une intensification des programmes d’éducation présentant des concepts sur une alimentation saine visant à améliorer les habitudes alimentaires des adolescentes est recommandée. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 40 Introduction %VSJOHBEPMFTDFODF IPSNPOBMDIBOHFT MFBE UP BDDFMFSBUFE HSPXUI XIJDI JT GBTUFSUIBOBUBOZPUIFSUJNFJOQPTUOBUBM EFWFMPQNFOU FYDFQUGPSUIFėSTUZFBSPG MJGF<>$PODFSOPWFSBEPMFTDFOUPCFTJ UZIBTNPVOUFEEVFUPJUTSBQJEJODSFBTF JOQSFWBMFODF JUTQFSTJTUFODFJOUPBEVMU IPPE BOEJUTBTTPDJBUFENPSCJEJUZBOE NPSUBMJUZ <>/VNFSPVT TUVEJFTIBWF EFNPOTUSBUFEBOBTTPDJBUJPOCFUXFFO CPEZXFJHIUBOEFBUJOHCFIBWJPVS<> BOE DVMUVSBM BOE TPDJPFDPOPNJD GBD UPSTBMTPQMBZBO JNQPSUBOU SPMF JO UIF EFWFMPQNFOUPGFBUJOHCFIBWJPVS<> "M)B[[BBFUBMDPODMVEFEUIBU PGNBMFBOEPGGFNBMF4BVEJBEP MFTDFOUTTQFOU IEBJMZPOTDSFFO BOE _PGCPZTBOE_PGHJSMTEJEOPU NFFUEBJMZQIZTJDBM BDUJWJUZHVJEFMJOFT <>ĉFNBKPSJUZ PG BEPMFTDFOUT EJE OPUIBWFBEBJMZJOUBLFPGCSFBLGBTU GSVJU WFHFUBCMFT BOENJML$PNQBSFEXJUI CPZT HJSMTXFSFTJHOJėDBOUMZNPSFTFE FOUBSZ NVDIMFTTQIZTJDBMMZBDUJWF FTQF DJBMMZGPSWJHPSPVTQIZTJDBMBDUJWJUZ BOE UIFSFXFSF GFXFSEBZTQFSXFFLXIFO UIFZ DPOTVNFE CSFBLGBTU GSVJU NJML BOEEBJSZQSPEVDUT TVHBSTXFFUFOFE ESJOLT GBTU GPPET BOE FOFSHZESJOLT )PXFWFS HJSMT JOUBLFPG'SFODI GSJFT BOEQPUBUPDIJQT DBLFTBOEEPVHIOVUT BOEDBOEZ BOEDIPDPMBUFXBT TJHOJė DBOUMZIJHIFSĉFSFXBT B TJHOJėDBOU JOWFSTFDPSSFMBUJPOCFUXFFOTDSFFOUJNF BOE JOUBLFPGCSFBLGBTU WFHFUBCMFTBOE GSVJU$POWFSTFMZ QIZTJDBMBDUJWJUZIBE B TJHOJėDBOUQPTJUJWF SFMBUJPOTIJQXJUI GSVJUBOEWFHFUBCMFJOUBLF &BUJOHCFIBWJPVSPGBEPMFTDFOUTDBO CF JOĚVFODFECZCPUIFYPHFOPVTBOE FOEPHFOPVT GBDUPSTĉFNPTU JNQPS UBOU FYPHFOPVT GBDUPST BSF QSPCBCMZ QBSFOUT QFFST BOEUIFNFEJB<>(FO EFS JOUFMMFDUVBMBCJMJUZ TFMGDPODFQU BOE QFSTPOBMJUZBSFBNPOHUIFFOEPHFOPVT GBDUPST UIBUNBZ JOĚVFODF UIF FBUJOH CFIBWJPVSPGBEPMFTDFOUT<> ĉFBEWFSTFIFBMUI DPOTFRVFODFT UIBUNBZSFTVMUGSPNFYDFTTJWFJOUBLFPG TPěESJOLT TVHBSFEESJOLTBOEGBTUGPPE JOBEFRVBUF JOUBLFPG GSVJU WFHFUBCMFT XIPMFHSBJO GPPET EBJSZQSPEVDUTBOE PUIFSDBMDJVNGPSUJėFE GPPET SFEVDFE MFWFMTPGFYFSDJTF BOEJODSFBTJOHPCFTJUZ rates indicate a need to revisit the diet and lifestyle characteristics of this age HSPVQ <>ĉFQSFTFOU TUVEZ JOWFTUJ HBUFEIPX UIFEJFUBSZIBCJUT PG BEP MFTDFOUHJSMT BĎFDUFECPEZNBTT JOEFY #.* XIJDINBZCFBO JOEJDBUPSPG GVUVSFXFJHIUHBJO BOEFTUJNBUFE UIF QSFWBMFODFPGPWFSXFJHIU BOEPCFTJUZ BNPOHTUVEFOUTBUJOUFSNFEJBUFTDIPPMT in Riyadh. Methods Study design and participants " DSPTTTFDUJPOBM TUVEZ XBT DBSSJFE PVUVTJOHBQSFEFTJHOFERVFTUJPOOBJSF UPBTTFTT UIF SFMBUJPOTIJQCFUXFFOEJ FUBSZIBCJUTBOE#.*JOSBOEPNMZ TFMFDUFE BEPMFTDFOU GFNBMF TUVEFOUT BHFEmZFBSTĉF TUVEFOUTXFSF FOSPMMFEBU JOUFSNFEJBUF MFWFMTPGHPW FSONFOU TDIPPMT JOEJĎFSFOU BSFBTPG 3JZBEI 4BVEJ"SBCJBĉFSFXFSF ėSTU MFWFM TFDPOE MFWFMBOE UIJSE level students. Data collection #PEZXFJHIUXBTSFDPSEFEUPUIFOFBSFTU LHPOB%JHJUBM1FSTPO4DBMF "%". &RVJQNFOU %BOCVSZ $5 64" XJUI PVUTIPFTBOEXJUIMJHIUDMPUIJOH#PEZ IFJHIUXBT SFDPSEFE UP UIFOFBSFTU DNVTJOHUIFTBNFTDBMF BOE#.*XBT DBMDVMBUFEBTLHN2#.* LHN2. 0UIFSQBUJFOUEBUBXFSF DPMMFDUFECZ BRVFTUJPOOBJSFDPOTJTUJOHPG GPVS TFD UJPOTBOE JUFNT4PDJPEFNPHSBQIJD data JODMVEFEBHF QBSFOUBM FEVDBUJPO MFWFM GBNJMZTJ[F UZQFPGIPVTF BOEBWFS BHF GBNJMZNPOUIMZ JODPNF%JFUBSZ EBUB JODMVEFENBJONFBM CSFBLGBTU XBUFSDPOTVNQUJPO EBJMZGSVJUBOEWFH FUBCMFJOUBLF EBJMZTOBDLDPOTVNQUJPO EBJMZNJML DPOTVNQUJPO TBUJTGBDUJPO XJUICPEZXFJHIU BĨJUVEF UPXFJHIU MPTT BOEHBJO FĎFDUPGNFEJBPO GPPE DIPJDFT GBWPVSJUF GPPEBU TDIPPM ESJOL QSFGFSFODFT BOEQSFGFSSFE GPPEXIFO XBUDIJOHUFMFWJTJPO Analysis %BUBXFSFBOBMZTFEVTJOHSPSS statisti DBM TPěXBSFĉFDIJTRVBSFE UFTUXBT VTFEUPBTTFTTUIFTUBUJTUJDBMTJHOJėDBODF PG UIF BTTPDJBUJPOCFUXFFO#.* DBU FHPSZBOEPUIFSWBSJBCMFTP < XBT DPOTJEFSFETUBUJTUJDBMMZTJHOJėDBOU Results Sociodemographic data 5BCMF TIPXT UIF TPDJPEFNPHSBQIJD DIBSBDUFSJTUJD BHF GBUIFS BOENPUIFS FEVDBUJPO OVNCFSPG UIFGBNJMZNFN CFST UZQFPG UIFIPVTFBOEBWFSBHFPG GBNJMZNPOUIMZ JODPNF ĉFNFBO BHFPGUIFTBNQMFXBTZFBST'PSUIF NBKPSJUZPGUIFQBSUJDJQBOUTUIFJSQBSFOUT XFSF VOJWFSTJUZ FEVDBUFE GPS GBUIFSTBOEGPSNPUIFST "CPVU IBMGPGUIFTBNQMF IBECFUXFFO BOEGBNJMZNFNCFSTĉFNBKPSJUZ MJWFEJOWJMMBT BOEUIFJSGBNJMJFT IBEBO BWFSBHFNPOUIMZ JODPNFPG SJBMT .PSFUIBOUIFIBMGPG UIFTBNQMFIBEBOPSNBM#.* XFSFVOEFSXFJHIU PWFS XFJHIUBOEXFSFNPSCJEMZPCFTF Adolescents’ dietary pattern 5BCMF TIPXT UIBU UIF NBJO NFBM GPS UIF NBKPSJUZ PG UIF QBSUJDJQBOUT XBT MVODI UIFSFXBT BOPO TJHOJėDBOU EJĎFSFODF CFUXFFO UIF #.* DBUFHPSJFTXJUI SFHBSE UPNBJO NFBM P > 0WFSIBMGPG UIF UPUBM OVNCFS PG QBSUJDJQBOUT BUF CSFBLGBTU XJUIOPTJHOJėDBOUSFMBUJPOTIJQ CFUXFFOUIF#.*DBUFHPSJFTBOEFBUJOH CSFBLGBTU P > .PSFUIBOIBMGPG UIFTUVEJFETBNQMF ESBOL MFTT UIBODVQTPGXBUFSQFSEBZ BHBJOXJUI OP TJHOJėDBOU WBSJBUJPOCFUXFFOEBJMZ JOUBLFPGXBUFSBOE#.*DBUFHPSZ P +VTUPWFSPGUIFBEPMFTDFOUT EJEOPUFBU GSVJUT BOEWFHFUBCMFTEBJMZ XJUIBOPOTJHOJėDBOUEJĎFSFODFBNPOH HCÐçPUph[UÐpdCÐ 41 ëíP_UÐ{dCÐ éíúÐØ{_UÐ UIF#.*DBUFHPSJFT P > ĉFSF XBTOPOTJHOJėDBOUEJĎFSFODFCFUXFFO #.*DBUFHPSJFTBOEESJOLJOHNJMLEBJMZ XJUIPG UIF UPUBM TBNQMFESJOL JOHNJMLEBJMZ" MBSHFNBKPSJUZPG UIF TBNQMF BUF TOBDLTEBJMZXJUI OPOTJHOJėDBOUEJĎFSFODFT P > CFUXFFO#.*DBUFHPSJFT 5BCMFTIPXTUIFEJTUSJCVUJPOPGUIF TUVEJFE TBNQMFBDDPSEJOH UP UIF GPPE BOEESJOLT UIFZ DPOTVNFEBU TDIPPM DIFFTF TBOEXJDI DIJQT DIPDPMBUFBOE KVJDF XFSF UIF GPPENPJTU GSFRVFOUMZ FBUFO BOE SFTQFDUJWFMZ XJUIBOPOTJHOJėDBOUEJG GFSFODF CFUXFFO #.* DBUFHPSJFT P 'J[[ZESJOLT BOE MPXDBMPSJF ė[[ZESJOLTXFSFUIFQSFGFSSFECFWFSBHF PG UIF TBNQMF SFTQFD UJWFMZ XJUIBOPOTJHOJėDBOUEJĎFSFODF CFUXFFOUIF#.*DBUFHPSJFT P > ĉFQSFGFSSFE GPPETDPOTVNFECZ UIF TUVEJFE TBNQMFXIFOXBUDIJOH UFMFWJ TJPOXFSF GBTU GPPET GPMMPXFECZEFT TFSUTė[[Z ESJOLT BOE SFTQFDUJWFMZ ĉFSFXBTOPTJHOJėDBOU WBSJBUJPOCFUXFFO#.*DBUFHPSJFT P > "QQSPYJNBUFMZ UXPUIJSET PG UIF BEPMFTDFOUT SFQPSUFE UIBU UIFZ XFSF OPU TBUJTėFE XJUI UIFJS XFJHIU 5BCMF ĉFNBKPSJUZPG UIF TBNQMF XBOUFE UP MPTFXFJHIUXIJMF TBJE UIFZEJEOPUXBOU UP HBJO XFJHIUĉFSFXBTTJHOJėDBOUEJĎFSFODF CFUXFFO#.*DBUFHPSZBOETBUJTGBDUJPO XJUICPEZXFJHIU BOEUIFTBNFQBĨFSO XBT GPVOE GPS JODSFBTJOHPSEFDSFBTJOH CPEZXFJHIU P 0VS SFTVMUT TIPX UIBU PG UIF TBNQMF UIPVHIU UIBUQFPQMFXFSF BĎFDUFECZ UIFNFEJB0OMZPG UIFTBNQMFFYFSDJTFEEBJMZ XIJMF FYFSDJTFEBCPVUPODFBXFFL Discussion 0VSTUVEZTIPXFEUIBUUIFBEPMFTDFOUJO UIJTTUVEZ JSSFTQFDUJWFPG#.*DBUFHPSZ IBETPNFCBEFBUJOHIBCJUT JODMVEJOH ESJOLJOH DVQTPGXBUFSQFSEBZ POMZ FBUJOH GSVJUTBOEWFHFUBCMF TPNFUJNFT TLJQQJOHNFBMT FTQFDJBMMZCSFBLGBTU FBU JOHTOBDLTEBJMZTVDIBTDIPDPMBUF TBOE XJDIFT DIJQT QBDLFE KVJDFT UIFZBMTP IBEMPXEBJMZNJMLDPOTVNQUJPO.PTU BMTPEJEOPUUBLFQBSUJOSFHVMBSFYFSDJTF ĉFTFTPSUTPGIBCJUTGPSUIFBEPMFTDFOUT DBOMFBEUPJODSFBTFTCPEZXFJHIUJOUIF GVUVSF BOEBSFMJLFMZUPCFDPNFSFHVMBS IBCJUT GPS UIFNBOEUIFJS GBNJMJFT0VS ėOEJOHT BSF JO BHSFFNFOUXJUIPUIFS TUVEJFT SFHBSEJOH VOIFBMUIZ EJFUBSZ FYFSDJTFBOETMFFQIBCJUTPGBEPMFTDFOUT %VSJOH BEPMFTDFODF IPSNPOBM DIBOHFT BDDFMFSBUF HSPXUI JOIFJHIU (SPXUIJTGBTUFSUIBOBUBOZPUIFSUJNFJO UIFJOEJWJEVBMhTQPTUOBUBMMJGFFYDFQUUIF ėSTUZFBSTPUIJTNBZOFHBUJWFMZPSQPTJ UJWFMZ BĎFDU UIF DPOTVNQUJPOPG GPPE BOEEJFUBSZIBCJUTXIJDINBZCFSFMBUFE Table 1 Distribution of the studied adolescent females in some intermediate schools in Riyadh according to their sociodemographic characteristics Sociodemographic characteristic % (n = 107) Age group (years) 12–13 29.9 14–15 58.9 > 15 11.2 Father’s education Illiterate 0.9 Primary 9.0 Secondary 7.5 University 90.7 Mother’s education Primary 2.9 Preparatory 5.7 Secondary 22.9 University 68.6 Number of family members < 3 1.9 4–6 39.3 7–10 53.3 10+ 5.6 Type of the house Villa 86.0 Apartment 3.7 Floor 3.7 Others 6.5 Family monthly income (Saudi rials) < 3000 1.0 3000–5000 5.0 5000–10 000 18.0 > 10 000 SR 76.0 BMI category Underweight 28.6 Normal weight 53.3 Over weight 12.4 Morbid obesity 5.7 BMI = body mass index. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 42 Ta bl e 2 D is tr ib ut io n of th e st ud ie d ad ol es ce nt fe m al es in s om e in te rm ed ia te s ch oo ls in R iy ad h ac co rd in g to a do le sc en ts e at in g pa tt er n A do le sc en ts ’ e at in g pa tt er n U nd er w ei gh t ( % ) (n = 3 0 ) N or m al w ei gh t (% ) ( n = 56 ) O ve rw ei gh t ( % ) (n = 15 ) M or bi dl y ob es e (% ) ( n =6 ) To ta l ( % ) (n = 1 0 7) C hi -s qu ar ed P- va lu e M ai n m ea l o f t he d ay 5. 37 3 > 0 .0 5 Br ea kf as t 10 .0 11 .1 0 .0 16 .7 9. 5 Lu nc h 83 .3 72 .2 76 .9 66 .7 76 .2 D in ne r 6. 7 16 .7 23 .1 16 .7 14 .3 Ea ti ng b re ak fa st 6. 97 6 > 0 .0 5 Ye s 60 .0 48 .2 46 .2 83 .3 53 .2 N o 0 .0 10 .7 15 .4 0 .0 7.5 So m et im es 40 .0 41 .1 38 .5 16 .7 39 .3 D ai ly w at er in ta ke 1.4 73 > 0 .0 5 Le ss th an 6 c up s / da y 56 .7 34 .0 7.0 4. 0 58 .9 6 to 8 c up s / da y 33 .3 15 .0 4. 0 2. 0 29 .9 M or e th an 8 c up s / da y 10 .0 7.0 2. 0 0 .0 11 .2 D ai ly fr ui t a nd v eg et ab le s c on su m pt io n 8. 37 8 > 0 .0 5 Ye s 16 .7 16 .1 7.7 16 .7 15 .0 N o 6. 7 23 .2 30 .8 50 .0 21 .2 So m et im es 76 .7 60 .7 61 .5 33 .3 63 .8 D ai ly m ilk c on su m pt io n 4. 36 7 > 0 .0 5 Ye s 36 .7 17 .9 33 .3 33 .3 26 .4 N o 26 .7 48 .2 33 .3 50 .0 39 .6 So m et im es 36 .7 33 .9 33 .3 16 .7 34 .0 D ai ly c on su m pt io n o f s na ck s 3. 46 8 > 0 .0 5 Ye s 93 .3 85 .7 92 .3 10 0 89 .5 N o 6. 7 8. 9 7.7 0 .0 7.6 >3 ti m es 0 .0 5. 4 0 .0 0 .0 2. 9 HCÐçPUph[UÐpdCÐ 43 ëíP_UÐ{dCÐ éíúÐØ{_UÐ UPUIFDPNNVOJUZ<>%VSJOHUIJTUJNF DIBOHFT JO BEPMFTDFOUT MJGFTUZMFNBZ BMTPBĎFDUFBUJOHIBCJUTBOEGPPEDIPJD FT*UIBTCFFOTIPXOUIBUEJFUBSZRVBMJUZ decreases throughout childhood and BEPMFTDFOUTIBWFBQPPSFSRVBMJUZEJFU DPNQBSFEUPZPVOHFSDIJMESFO<>ĉJT study also indicated that there are no TJHOJėDBOUEJĎFSFODFTCFUXFFOUIFTPDJ PEFNPHSBQIJDEBUBBOE#.*)PXFWFS /JMTFOFUBMSFQPSUFEUIBUUIFFEVDBUJPO PGNPUIFSTPGBEPMFTDFOUTBĎFDUFEBEP MFTDFOUTIFBMUISFMBUFEEJFUBSZIBCJUT <>"OPUIFS TUVEZ SFQPSUFEBOBTTP DJBUJPOCFUXFFOTPDJPFDPOPNJDGBDUPST BOEPCFTJUZBNPOHGFNBMFTDIPPMBHFE DIJMESFOBOEBEPMFTDFOUTJOQSJNBSZBOE JOUFSNFEJBUFTDIPPMT<> 0VSėOEJOHBCPVU TLJQQJOHNFBMT DPODVSTXJUIPUIFS TUVEJFT UIBU GPVOE UIBU BEPMFTDFOUT UFOE UP TLJQ SFHVMBS NFBMT BOE JOTUFBEPG FOKPZJOH B CBM BODFENFBM DPOTVNFGBTUGPPETEVSJOH UIFEBZ SFTVMUJOH JOXFJHIU HBJO <> .BOZBEPMFTDFOUTTLJQCSFBLGBTUJOQBS UJDVMBSPSFBUUIFXSPOHLJOEPGCSFBLGBTU <> 4BNVFM QPJOUT PVU UIBU BEPMFT DFOUTXIPTLJQCSFBLGBTUBSFNJTTJOHBO PQQPSUVOJUZ UPCPPTU UIFJSOVUSJFOU JO UBLF XIJDIIBTBOFHBUJWFFĎFDUPOUIFJS MFBSOJOH QFSGPSNBODF BOE BDBEFNJD BDIJFWFNFOU<> "TXFMM BT TLJQQJOHNFBMT OBUJPOBM TVSWFZEBUB JO UIF6OJUFE4UBUFT TIPX UIBU PG BEPMFTDFOUT DPOTVNF BU MFBTUPOFTOBDLQFSEBZ XJUIBSBOHFPG UP < >BOETOBDLTBDDPVOU GPS mPGEBJMZFOFSHZJOUBLFBNPOH BEPMFTDFOUT'VSUIFSNPSF GPPEDIPJDFT NBEF CZ BEPMFTDFOUTXIJMF TOBDLJOH UFOE UPCFIJHI JO TVHBS TPEJVN BOE GBU XIJMFSFMBUJWFMZ MPXJOWJUBNJOTBOE NJOFSBMT XIJDI JODSFBTF UIF SJTL GPS EFWFMPQJOHPCFTJUZ IFBSUEJTFBTF PTUFP QPSPTJT EFOUBMDBWJUJFTBOEWBSJPVTUZQFT PGDBODFS<> *U JT SFQPSUFE UIBUXBUDIJOH UFMFWJ TJPOEVSJOH GBNJMZNFBMT JT BTTPDJBUFE XJUIQPPSFSEJFUBSZRVBMJUZBNPOHBEP MFTDFOUTBOE JODSFBTFE UFMFWJTJPOWJFX JOH JTBTTPDJBUFEXJUI JODSFBTFEDBMPSJD JOUBLF DPOTVNQUJPOPGIJHIFSGBU GPPE BOE MPXFS JOUBLFPG GSVJUT BOEWFHFUB CMFT<m> XIJDI JT JO MJOFXJUIPVS Table 3 Distribution of the studied adolescent females in some intermediate schools in Riyadh according to their preferred food Preferred food Underweight (%) Normal weight (%) Overweight (%) Morbidly obese (%) Total (%) Chi- squared P-value Food at school Cheese sandwich 60.0 37.7 41.7 50.0 45.54 0.629 > 0.05 Burger 6.7 0.0 8.3 0.0 2.97 Chocolate 26.7 41.5 41.7 33.3 36.63 Biscuits 16.7 7.5 16.7 16.7 11.88 Ice cream 6.7 1.9 8.3 0.0 3.96 Fizzy drinks 10.0 11.3 25.0 0.0 11.88 Milk 0.0 1.9 0.0 0.0 0.99 Juice 30.0 32.1 58.3 50.0 35.64 Fruits or vegetables 3.3 0.0 0.0 0.0 0.99 Nothing 0.0 5.7 8.3 0.0 3.96 Chips and snacks 36.7 43.4 33.3 33.3 39.6 Favourite drink 0.228 > 0.05 Tea 13.3 5.7 .0 16.7 7.92 Power drinks 10.0 17.0 7.7 0.0 12.87 Fresh juice 13.3 28.3 23.1 0.0 21.78 Coffee 13.3 7.5 15.4 0.0 9.90 Fizzy drinks 86.7 71.7 69.2 100.0 78.22 Packet juice 10.0 30.2 30.8 33.3 24.75 Low-calorie fizzy drinks 76.7 50.9 53.8 50.0 59.41 Food preferred while watching television 0.531 > 0.05 Fast foods 89.7 85.5 84.6 80.0 86.28 Main meal 3.4 9.1 0.0 20.0 6.86 Coffee 0.0 0.0 7.7 0.0 0.98 Desserts and fizzy drinks 31.0 20.0 23.1 0.0 22.55 Fruits and vegetables 0.0 3.6 15.4 0.0 3.92 EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 44 results. Eating a diet rich in fruits and WFHFUBCMFTNBZCFQBSUJDVMBSMZ JNQPS tant during adolescence due to the high OVUSJFOUOFFET JO UIJT SBQJEQFSJPEPG HSPXUIBOEEFWFMPQNFOU'VSUIFSNPSF UIFEFWFMPQNFOUPGIFBMUIZFBUJOHQBU UFSOT EVSJOH BEPMFTDFODF JODMVEJOH BOBEFRVBUF GSVJUBOEWFHFUBCMF JOUBLF NBZ MFBE UPDPOUJOVFEIFBMUIZFBUJOH QBĨFSOTJOBEVMUIPPE<> " SFDFOU TUVEZ JO4BVEJ"SBCJB SF QPSUFE BQSFEPNJOBODFPGVOIFBMUIZ CFIBWJPVST <> "TJNJMBS TUVEZ JO3J ZBEIPCTFSWFE UIBU UIFQSPQPSUJPOPG PCFTF TUVEFOUT JOWFSTFMZ JODSFBTFECZ age and schooling grade (P /JOFUZėWFQFSDFOUPG UIFTUVEFOUT MJW JOH JOWJMMBTPSCJHIPVTFTXFSFPCFTF DMFBSMZ TIPXJOH UIBU UIF FYJTUFODFPG PCFTJUZQSPNPUJOH GBDUPST <>ĉVT PCFTJUZBOEQIZTJDBM JOBDUJWJUZBNPOH 4BVEJ DIJMESFOBOEZPVUI SFQSFTFOU B HSPXJOHQVCMJDIFBMUIDIBMMFOHF<> "MNPTU PG PVS TBNQMF XFSF OPUTBUJTėFEXJUIUIFJSXFJHIU)FJMNBO SFQPSUFEUIBUEVSJOHBEPMFTDFODFNBOZ UFFOBHFSTEFTJSFBO JEFBMXFJHIUXIJDI SFMBUFTUPUIFJSJNBHF<>ĉFNFEJBBOE BEWFSUJTFST SFJOGPSDFVOSFBMJTUJD CPEZ XFJHIUTBT UIFZDPOWFZ UPXPNFOBOE ZPVOHHJSMTUIBUCPEZGBUJTUIFJEFBM XIFOCPEZGBUJTJOGBDUDPOTJEFSFE IFBMUIJFS <>"U UIF TBNF UJNF NBOZ BEPMFTDFOUTXIPBSFPWFSXFJHIUEPOPU QBSUJDJQBUFJOTQPSUBOEQSFGFSUPEJFUJO PSEFSUPNBJOUBJOBTMJNėHVSFJOTUFBEPG EPJOHFYFSDJTFUPCVSODBMPSJFT<> Conclusion 0VS SFTVMUT TIPX UIBU UIFSF XBT OP TJHOJėDBOU WBSJBUJPO CFUXFFO #.* DBUFHPSZBOEEJFUBSZQBĨFSO CVUUIFEJ FUBSZQBĨFSOPG UIFBEPMFTDFOU GFNBMFT XBTVOIFBMUIZBOENPTUPGUIFNUFOEFE UP TLJQNFBMT *ODSFBTJOH FEVDBUJPOBM QSPHSBNNFTXIJDI JOUSPEVDFIFBMUIZ EJFUBSZDPODFQUTUPJNQSPWFUIFEJFUBSZ QBĨFSOPGGFNBMFBEPMFTDFOUTJTSFDPN NFOEFE Table 4 Distribution of the studied adolescent females in some intermediate schools in Riyadh according to their attitude to their body weight Attitude to weight % (n = 107) Affected by the media Yes 61.0 No 38.1 Some times 1.0 χ2 5.323 Daily exercise Yes 15.0 No 31.8 Some times 53.3 χ2 1.423 Satisfied with weight Yes 30.2 No 69.8 χ2 15.688 Would like to lose weight Yes 71.7 No 28.3 χ2 27.184 Would like to gain weight Yes 11.4 No 88.6 χ2 19.521 References 1. 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Preventive Medicine, 2003, 37:198–208. 21. Al Qauhiz NM. Obesity among Saudi Female University Stu- dents: Dietary Habits and Health Behaviors. Journal of the Egyptian Public Health Association, 2010, 85:45–59. 22. Alam AA. Obesity among female school children in North West Riyadh in relation to affluent lifestyle. Saudi Medical Journal, 2008, 29:1139–1144. 23. Hazzaa MH. Prevalence and trends in obesity and physical inactivity among Saudi children and adolescents: a growing public health challenge. International Journal of Pediatric Obe- sity; IJPO, 2009, 4 S3:6–14. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 46 Comparison of two assays in the diagnosis of toxoplasmosis: immunological and molecular D.A. Hashoosh 1 and I.A. Majeed 1 ABSTRACT Serological tests for Toxoplasma gondii are inadequate because antibody production either fails or is significantly delayed. This study in eastern Iraq investigated the IgG-avidity ELISA test for detecting recent T. gondii infections among pregnant women and compared immunological methods and PCR as molecular assays in the diagnosis of T. gondii. Serums samples were taken from 130 pregnant women at risk of toxoplasmosis and a control group of 25 women with normal pregnancy. Of 50 IgM- and/or IgG-positive samples, only 15 showed low IgG-avidity antibodies. PCR was performed on 25 selected samples. Toxoplasma DNA was detected in 15/15 IgM-positive with low IgG-avidity and 1/3 IgM-positive with high IgG-avidity. None of the IgM-negative with high IgG-avidity showed any Toxoplasma DNA. ELISA IgG-avidity when used in combination with ELISA IgG/IgM is a valuable assay for the exclusion of ongoing or recently acquired T. gondii infection in pregnant women. 1Department of Medical Laboratory Technology, College of Health and Medical Technology, Council of Technical Education, Baghdad, Iraq (Correspondence to I.A. Majeed: elhamalkawaz@yahoo.co.uk). Received: 11/11/12; accepted: 04/02/13 ÓmGaBÐÊÐØgY=9ogþw}!ÐowmaBÐíogKmeBÐowmaBÐM<ohÚmaX {h6{AÐUÐ{Lên4κÝInA{xnLênQ¦ qUínf>{Sí ETcZ=}BjxíÌZaxnYÎënTÓÐØn\CÐÕniÎëúðÐ}^iphRnTEQpx{i`UÐÓnHbedUphd[CÐÓÐÚnBøÐqinT{bUoÉ°#Ð ÓønAænZTÐph`=IgG LnfCÐNd=d`dUp=nQ}UÐÒ{ZUx~iún=>}CÐLnfCÐ~eCÐpxnbYÚnBÐçÐ}_UÐç :qx}@ÌUÐpHÐÚ{UÐì|w ÓnHbCÐhZ>:ÛÐEehUdU dCÐ LnaUÐíphLnfCÐ ç}]Un= ngiÚnbY YºYÐ"ÐÓÐ{hUÐ î{Upx{i`UÐ ÓnHbCn= px{"Ðîí{_UÐ Ò{wnIpLeeTðnh_hJðĆ1YnAÒÌ}YÐ25oin@OÎÓnHbCÐÊÐ{=g=nÉl=Zx,YnAÒ{hH130Yphd[CÐÓnfh_UÐ|BÌ>í px{i`UÐ LnaUÐ phfb> h]>>í p=nQ}UÐ p\afYIgG ØÐ{ÌnghR bRpfhL15 ëÌ ºph=n«ÎpfhL50 fUIgGíIgM {\dUp=nQ}UÐ Ò{IÚnBÐ}gKjR Ò{AÐííIgGp=nQ}UÐafCÐ{\UÐÓÐÙIgM{\dUph=n«ÐpfhL15ÉÌY15:ÓnHbCÐniØZTÐí ÒÚn8pfhL25DLÛÐEehUdUdCÐ {\UÐÓÐÙIgM{\dUpUnHÓnfhL:ðÐØ@YÓnHbCÐniØcx3NA: p=nQ}UÐ<nLIgG{\UÐÓÐÙIgM{\dUp@YÓnfhLÔĆ?ÉÌY phfb=IgMíIgG{\UÐÚnBÐ YYÐ~Un=ê{xnY{fLIgG{\dUp=nQ}UÐÒ{IÚnBÐêÐ{HÐëÌÕnfHÐcexê{b>n,í p=nQ}UÐ<nLIgG YÐ"Ðî{UÓnH bCn=ðÐ}BkYqôTÐUÐd>íÌpb=nUÐp=nÉüÐØn_HÐ:pehSpxnbY}öRxºx~iún=>}CÐp=nQ}dULnfCÐÛÐ~YøÐ Comparaison de deux dosages dans le diagnostic de la toxoplasmose : immunologique et moléculaire RÉSUMÉ Les tests sérologiques pour Toxoplasma gondii sont inadaptés car la production d’anticorps soit n’a pas lieu, soit se produit très tardivement. La présente étude menée dans la partie orientale de l'Iraq a examiné le test ELISA d'avidité des anticorps IgG pour dépister les infections à Toxoplasma gondii récentes chez les femmes enceintes, puis a comparé les méthodes immunologiques et la méthode PCR en tant que dosages moléculaires pour la pose du diagnostic de l'infection à T. gondii. Des échantillons de sérum ont été prélevés chez 130 femmes enceintes à risque de toxoplasmose et 25 femmes appartenant à un groupe témoin dont la grossesse était normale. Sur 50 échantillons positifs pour les IgM et/ou les IgG, seuls 15 ont présenté un faible degré d’avidité des anticorps IgG. La méthode PCR a été utilisée sur 25 échantillons sélectionnés. L’ADN de Toxoplasma a été détecté dans 15 échantillons positifs aux IgM sur 15 ayant une forte avidité des IgG et dans un échantillon positif aux IgM sur trois ayant une haute avidité des IgG. Aucun des échantillons négatifs pour les IgM et ayant une forte avidité des IgG ne contenait d’ADN de Toxoplasma. Le test ELISA d’avidité des IgG, en utilisation combinée à un test ELISA d’avidité des IgG/IgM, constitue un dosage valable pour l’exclusion des infections à T. gondii contractées récemment ou actives chez les femmes enceintes. HCÐçPUph[UÐpdCÐ 47 ëíP_UÐ{dCÐ éíúÐØ{_UÐ Introduction *OGFDUJPOXJUI UIF QSPUP[PBOToxo- plasma gondii JTPOFPG UIFNPTUDPN NPOQBSBTJUJD JOGFDUJPOT PG IVNBOT XPSMEXJEF <> *O HFOFSBM T. gondii JOGFDUJPOTBSFBTZNQUPNBUJDBOETFMG MJNJUJOH FTQFDJBMMZ BNPOH IFBMUIZ JNNVOPDPNQFUFOU IPTUT IPXFWFS UIF JOGFDUJPONBZDBVTF TFWFSF DPN QMJDBUJPOT JO QSFHOBOU XPNFO BOE JNNVOPDPNQSPNJTFEQBUJFOUT < > 'FUBM UPYPQMBTNPTJT QBSUJDVMBSMZ JO FBSMZQSFHOBODZDBODBVTFNJTDBSSJBHF TUJMMCJSUI BOECJSUIEFGFDUT <>&BSMZ ėSTUUSJNFTUFSNBUFSOBMJOGFDUJPOJTMFTT MJLFMZ UP SFTVMU JODPOHFOJUBM JOGFDUJPO CVUUIFTFRVFMBFBSFNPSFTFWFSF< > ĉFEFUFDUJPOPG SFDFOUMZBDRVJSFE JO GFDUJPOJOQSFHOBOUXPNFOJTUIFSFGPSF DSJUJDBM GPSDMJOJDBMNBOBHFNFOUPG UIF NPUIFSBOEIFSGFUVT<> ĉFEJBHOPTJTPG UPYPQMBTNPTJT JT SPVUJOFMZ CBTFE PO TFSPMPHJDBM UFTUT GPS UIFQSFTFODFPG JNNVOPHMPCVMJO *H .BOE *H(TQFDJėDBOUJCPEJFT UP ToxoplasmaCZFO[ZNFMJOLFE JNNV OPTPSCFOU BTTBZ &-*4" <>ĉFTF UFTUT IPXFWFS BSFOPU JEFBMCFDBVTF BOUJCPEZQSPEVDUJPOFJUIFS GBJMTPS JT TJHOJėDBOUMZEFMBZFEĉF *H(BWJEJUZ UFTUXBTEFWFMPQFEUPIFMQEJTDSJNJOBUF CFUXFFO QBTU BOE SFDFOUMZ BDRVJSFE JOGFDUJPO<>ĉFSFTVMUTBSFCBTFEPO UIFNFBTVSFNFOUPGUIFBWJEJUZ GVOD UJPOBMBđOJUZ PGToxoplasmaTQFDJėD *H(BOUJCPEJFT'PMMPXJOHBOBOUJHFOJD DIBMMFOHF UIF BOUJCPEJFT QSPEVDFE VTVBMMZIBWFBMPXBWFSBHFBđOJUZ%VS JOHUIFDPVSTFPGUIFJNNVOFSFTQPOTF UIFSF JTNBUVSBUJPOPGBOUJCPEZBđO JUZ UIBU JODSFBTFT QSPHSFTTJWFMZ PWFS XFFLTPSNPOUIT *H(BWJEJUZ PS UIF TUSFOHUIXJUIXIJDI *H(CJOET UPT. gondii VTVBMMZ TIJěT GSPN MPXBWJEJUZ UPIJHIBWJEJUZBUBCPVUNPOUITBěFS JOGFDUJPO<> MPTUDBTFTPGBDUJWFUPYPQMBTNPTJT are due to reactivation of latent infec UJPOT XIJDI JTXIZEJSFDUEFNPOTUSB UJPOPG UIFQBSBTJUF JO UJTTVFTPSPUIFS ĚVJET CZ QPMZNFSBTF DIBJO SFBDUJPO 1$3 BTTBZ JTBNBKPSCSFBLUISPVHI GPS UIFEJBHOPTJTPG UPYPQMBTNPTJT JO UIFTFQBUJFOUT < >1$3XBTėSTU EFWFMPQFE GPSEJBHOPTJTPGDPOHFOJUBM UPYPQMBTNPTJT JOBNOJPUJDĚVJE <> The detection of T. gondii %/" JO CMPPEIBTIJHIMJHIUFE UIFQPTTJCJMJUZ PGBOUJDJQBUJOHUIFEJBHOPTJTDPNQBSFE XJUI SBEJPMPHJDBMėOEJOHT BOEIJTUPM PHZ <>1$3BTTBZ JT BO JNQPSUBOU UFDIOJRVF UPFWBMVBUF UIFQSFWBMFODF of Toxoplasma SFBDUJWBUJPOXIFO UIF EFUFDUJPOPG DJSDVMBUJOH%/" JT UIF POMZDMVFUPJUTSFBDUJWBUJPO<> "DPNQBSJTPOCFUXFFO *H.BOE *H(BWJEJUZNFBTVSFNFOUT DBOIFMQ JOUIFEFUFDUJPOPGQBTUPSSFDFOUUPYP QMBTNPTJTBTWFSJėFECZ1$3ĉFBJN PGUIJTTUVEZXBTUPFWBMVBUFUIFVUJMJUZ PG&-*4"*H(BWJEJUZ UFTU GPSEFUFDU ing recent T. gondii JOGFDUJPOTBNPOH QSFHOBOUXPNFOBOEUPDPNQBSFJN NVOPMPHJDBMNFUIPET BOE 1$3 BT NPMFDVMBS BTTBZT JO UIFEJBHOPTJTPG T. gondii. Methods Study subjects ĉJTTUVEZXBTDBSSJFEPVUPOQBUJFOUT BĨFOEJOHQSJWBUFDMJOJDT JO"M4VXBJSB QSPWJODF 8BTTJUHPWFSOPSBUF JOFBTU FSO *SBR GSPN%FDFNCFS UP "VHVTU" UPUBMPGQSFH OBOUXPNFO XJUIBHFT SBOHJOH GSPN mZFBSTBOENFEJBOBHFZFBST XIPXFSF DPOTJEFSFE UPCF BU IJHI SJTLPGT. gondii JOGFDUJPO BCOPSNBM QSFHOBODZPVUDPNFT XFSFFOSPMMFE JOUP UIJT TUVEZ *OGPSNFEDPOTFOU UP QBSUJDJQBUFJOUIFTUVEZXBTUBLFOGSPN QBSUJDJQBOUT Data collection "N-WFOPVTCMPPETBNQMFXBTDPM MFDUFEGSPNBMMQBSUJDJQBOUT4FSVNXBT TFQBSBUFEGSPNIBMGPGFBDITBNQMFBOE LFQUBUm$ XIJMFUIFPUIFSIBMGPG UIF TBNQMFXBTQMBDFE JOB TUFSJMJ[FE &%5"UVCFBOETUPSFEBUm$ GPS BNQMJėDBUJPOCZ1$3ĉFFOUJSFTUVEZ HSPVQTXFSFTDSFFOFEGPSToxoplasma JOGFDUJPOXJUI B SBQJE MBUFY BHHMVUJ OBUJPO UFTU -BUFY5PYP LJU #JPLJU $PNQBOZ Determination of IgM and IgG by ELISA 1SFTFODFPG *H.BOE *H(BOUJCPEJFT XFSFEFUFSNJOFEVTJOH&-*4"5PYP QMBTNBLJUT &-*4"5PYP*H(BOE*H. *#-*OUFSOBUJPOBM Determination of avidity index of IgG anti-T. gondii antibodies .FBTVSFNFOU PG Toxoplasma *H( BWJEJUZXBTQFSGPSNFEBOE JOUFSQSFUFE according to the directions of the NBOVGBDUVSFS 5PYP*H(BWJEJUZ &6 30*..6/ VTJOHUIF&-*4"TZTUFN ĉFBWJEJUZJOEFYBMMPXTTQFDJNFODMBT TJėDBUJPOBTMPX BWJEJUZJOEFY JO EJDBUJOHBOBDVUFJOGFDUJPO CPSEFSMJOF BWJEJUZJOEFYm PSIJHI BWJEJUZ JOEFY BWJEJUZ"IJHIBWJEJUZJOEFY FYDMVEFTQSJNBSZ JOGFDUJPOXJUIJO UIF QSFWJPVTXFFLT Confirmatory testing for T. gondii by PCR 1$3BTTBZXBTQFSGPSNFEPO TF MFDUFE TBNQMFT BT B DPOėSNBUPSZ UFTU of Toxoplasma JOGFDUJPOCZ UBSHFUJOHB SFDFOUMZEJTDPWFSFE SFQFUJUJWFCQ %/" GSBHNFOU JOT. gondii. This se RVFODF JTNPSF SFQFUJUJWF UIBO UIF# HFOF BQQSPYJNBUFMZ UP UJNFT and is highly conserved. This region of the T. gondiiHFOPNFIBTCFFOSFQPSUFE UPCFBWFSZTQFDJėDBOETFOTJUJWFUBSHFU GPSUIFEJBHOPTJT<> %/" XBT FYUSBDUFE GSPN XIPMF CMPPE VTJOH B DPNNFSDJBM QVSJėDB UJPO TZTUFN "DDV1SFQ (FOPNJD %/"&YUSBDUJPO,JU #JPOFFS $PO WFOUJPOBM1$3XBTQFSGPSNFEPO BMM %/" TBNQMFT UP BNQMJGZ B GSBHNFOU PG SFTUSJDUJPOFOEPOVDMFBTF TFRVFODF ĉF TQFDJėD QSJNFST GPS VTFE GPS BNQMJėDBUJPO PG UIF TFRVFODF PG T. gondii%/"XFSF GPSXBSE QSJNFS Ƀ ""(($("(((5("(( "5 H Ƀ .8 NFMUJOH UFN QFSBUVSF $ SFWFSTF QSJNFS EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 48 Ƀ($(5$(5$5$(5$5( ("5 D Ƀ .8 NFMUJOH UFN QFSBUVSF$ 4BNQMFDSPTTDPOUBNJOBUJPOQSPC MFNTXFSFBWPJEFEGPMMPXJOHBOVNCFS PG QSFDBVUJPOT JODMVEJOH QFSGPSNJOH %/"FYUSBDUJPO JO MBNJOBSĚPXIPPE XJUI TVCTFRVFOU JSSBEJBUJPOCZVMUSB WJPMFUMJHIUBOEVTFPGTFQBSBUFEBSFBT GPSUIF%/"FYUSBDUJPO QSFQBSBUJPOPG 1$3NJYUVSF 1$3BNQMJėDBUJPOBOE running gels. Statistical analysis ĉFFYQFSJNFOUBMEBUBBSFQSFTFOUFE JO UFSNTPG PCTFSWFEOVNCFST BOE QFSDFOUBHFTĉF4UVEFOU tUFTUXBT VTFE GPSTUBUJTUJDBMBOBMZTJT"PWBMVF ɒ XBT DPOTJEFSFE TUBUJTUJDBMMZ TJHOJėDBOU Results 8JUI UIF SBQJE MBUFYBHHMVUJOBUJPO UFTU XPNFO TIPXFEB TF SPQPTJUJWFSFTVMU 0G UIFXPNFO UFTUFE GPS TQFDJėD BOUJToxoplasma*H.BOE*H(BOUJCPE JFTCZ&-*4" QSFHOBOUXPNFO XFSF QPTJUJWF GPS *H. BOE PS *H( VTJOH &-*4"Toxoplasma "C LJU IBEToxoplasma TQFDJėD*H.BOUJCPEJFT8IFOUIF*H( BWJEJUZ&-*4" UFTUXBTBQQMJFE UP TFSB GSPNUIFQPTJUJWF *H.BOEPS *H( JOEJWJEVBMT POMZPGUIFNTIPXFEMPX *H(BWJEJUZ ĉFTBNQMFTTFMFDUFE GPS1$3 JODMVEFE *H.QPTJUJWFXJUI MPX *H(BWJEJUZBOUJCPEJFT *H.QPTJUJWF XJUI IJHIBWJEJUZ BOUJCPEJFT BOE *H.OFHBUJWFXJUIIJHI *H(BWJEJUZ BOUJCPEJFT 5BCMF 1$3BOBMZTJT detected Toxoplasma%/" JOPG UIF TFMFDUFE TBNQMFT PG UIFTFXFSF*H.QPTJUJWFXJUIMPX*H( BWJEJUZ BOUJCPEJFTBOE XBT *H.QPTJUJWFXJUI IJHI *H(BWJEJUZ BOUJCPEJFT1$3XBTOFHBUJWFGPSPG UIFTBNQMFT/POFPGUIF*H.OFHB UJWFXJUIIJHI *H(BWJEJUZBOUJCPEJFT TIPXFEBOZToxoplasma%/" 5BCMF BOE'JHVSFT BOE Calculating the accuracy of the test BDDPSEJOH UP UIF1$3SFTVMUT TIPXFE UIBU UIF TFOTJUJWJUZPG *H.&-*4"XBT BOE TQFDJėDJUZXBT XIJMFGPS*H(BWJEJUZTFO TJUJWJUZXBT BOETQFDJėD JUZXBT Discussion Routine serological diagnosis of toxo QMBTNPTJTQSPWJEFTIJHI TFOTJUJWJUZ CVUUIFTQFDJėDJUZWBSJFTEFQFOEJOHPO UIFUFTUVTFE*OUIJTTUVEZ QSFHOBOUXPNFOIBEToxoplasma TQFDJėD*H.BOUJCPEJFT TVHHFTUJOHBO BDVUFJOGFDUJPOXBSSBOUJOHBQQSPQSJBUF UIFSBQFVUJD JOUFSWFOUJPO(FOFSBMMZ EFUFDUJPOPGBOUJToxoplasmaTQFDJėD *H.BOUJCPEJFT JT B TFOTJUJWF JOEJDB tor of an ongoing or recent infection. )PXFWFS GBMTFQPTJUJWF*H.BOUJCPEZ UFTUSFTVMUTIBWFCFFOSFQPSUFEQSFWJ PVTMZ<>*OTVDIDBTFT UIFEJBHOPTJT PG QSJNBSZ JOGFDUJPOXJUIT. gondii JOFBSMZQSFHOBODZDBOCF JNQSPWFE CZEFUFSNJOBUJPOPGBOUJToxoplasma *H(BWJEJUZ XIJDIIBT UIFBCJMJUZ UP EJTDSJNJOBUF CFUXFFO SFDFOU BOE QSJPSJOGFDUJPOT0OBWJEJUZUFTUJOH PVUPG UIF *H.QPTJUJWF Table 1 Comparison between enzyme-linked immunosorbent assay (ELISA) IgM and IgG-avidity results in the detection of past or recent toxoplasmosis according to polymerase chain reaction (PCR) results in samples from pregnant women at risk of toxoplasmosis (n = 25 samples) ELISA results Total PCR results IgG avidity IgM status DNA +ve (n = 16) DNA –ve (n = 9) No. No. No. Low –ve 0 0 0 +ve 15 15 0 High –ve 7 0 7 +ve 3 1 2 Total 25 16 9 +ve = positive; –ve = negative. Figure 1 Amplification of 529 bp from Toxoplasma gondii DNA in the blood of abnormal pregnancy. Lane M, molecular weight marker (100 bp ladder), Lane NC, negative control, Lane PC, positive control, Lane 5, positive sample. Running conditions: agarose gel (2%), 5 v/cm for 2 h, stained with ethidium bromide HCÐçPUph[UÐpdCÐ 49 ëíP_UÐ{dCÐ éíúÐØ{_UÐ XPNFOIBE MPXBWJEJUZ*H(BOUJCPE ies suggesting a recent T. gondii infec UJPO.PSF JNQPSUBOUMZ PG UIF *H.QPTJUJWFXPNFOIBE IJHIBWJEJUZ BOUJCPEJFT TVHHFTUJOH UIBUUIFJOGFDUJPOXBTBDRVJSFECFGPSF HFTUBUJPOĉFBQQBSFOUEJTDSFQBODZ JOEFUFDUJOH JOGFDUJPO TUBUVTCZ *H. TFSPMPHZBOEBWJEJUZUFTUTNBZCFEVF UP UIF GBDU UIBU *H.BOUJCPEJFTNBZ QFSTJTU GPSNPOUITPSFWFOZFBST GPM MPXJOHUIFBDVUFQIBTFPGBOJOGFDUJPO JOTPNFJOEJWJEVBMT UIVTUIFQSFTFODF PG *H. BOUJCPEJFT JT OPU BMXBZT BO JOEJDBUJPOPGB SFDFOU JOGFDUJPO<> ĉFQSFTFODFPGTQFDJėDT. gondii IgM BOUJCPEJFT JO UIFDISPOJD TUBHFPGBO JOGFDUJPO BT PCTFSWFE JO PG *H.QPTJUJWFDBTFT JO UIJT TUVEZ NBZ IBWFSFTVMUFEJOVOXBSSBOUFEDPODFSO BOEBNJTEJBHOPTJTQBSUJDVMBSMZJOFBSMZ QSFHOBODZ 1SFWJPVTMZJUIBTCFFOSFQPSUFEUIBU UIF&-*4"*H(BWJEJUZUFTUJTIJHIMZTFO TJUJWFBOETQFDJėDGPSEFUFDUJOHBSFDFOU T. gondiiJOGFDUJPOJO*H.QPTJUJWFDBTFT <>4VDISFTVMUTIBWFDPOėSNFEJOUIF QSFTFOU TUVEZCZB TFOTJUJWJUZPG XIJMFTQFDJėDJUZXBTGPVOEUPCF *U JTBMTPLOPXOUIBU UIFNBUVSBUJPOPG UIF *H( SFTQPOTF WBSJFT DPOTJEFSBCMZ CFUXFFOJOEJWJEVBMTBOEUIVTMPXBWJEJ UZBOUJCPEJFTNBZQFSTJTUGPSNPOUITUP NPSFUIBOZFBS<>*OTVDIQBUJFOUT BOBWJEJUZUFTUSFTVMU JGVTFEBMPOF XPVME IBWFCFFONJTJOUFSQSFUFEBTTVHHFTUJWF PG BO BDVUF JOGFDUJPO 1SFWJPVT TUVE JFT IBWF EPDVNFOUFE UIBU 1$3 DBO actually detect T. gondii JO UIFCMPPE PGXPNFOCFGPSFPSEVSJOHQSFHOBODZ < > #BTFE PO UIJT UIF QSFTFODF of Toxoplasma%/" JO UIFNBUFSOBM CMPPEQSPCBCMZJOEJDBUFTBSFDFOUJOGFD UJPOPS BQQBSFOUQBSBTJUBFNJB XIJDI JT MJLFMZ UPCFDMJOJDBMMZ TJHOJėDBOUĉF DMFBSBODF UJNF GPSToxoplasma%/" GSPNUIFCMPPEPGQBUJFOUTXJUIBDVUF UPYPQMBTNJD MZNQIBEFOPQBUIZXBTFT UJNBUFEUPCFmXFFLT<> Conclusions ĉF SFTVMUT EFTDSJCFE JO UIJT TUVEZ TIPXFEUIBUUIF&-*4"*H(BWJEJUZUFTU XIFOVTFEBTBDPOėSNBUPSZUFTUBMPOH XJUIUIF&-*4"*H(*H.UFTUTJOQSFH OBOUXPNFO XBTVTFGVM JOEJTUJOHVJTI JOHB SFDFOUMZBDRVJSFE JOGFDUJPO GSPN DISPOJDJOGFDUJPO$POėSNBUPSZUFTUJOH for ongoing or recent Toxoplasma infec UJPOXJUIUIF&-*4"*H(*H.BOUJCPEZ UFTU BOE UIF&-*4"BWJEJUZNFUIPE JO QSFHOBOUXPNFOIBT UIFQPUFOUJBM UP EFDSFBTFUIFOFFEGPSGPMMPXVQTFSBBOE GPSVOOFDFTTBSZ UIFSBQFVUJD JOUFSWFO UJPOT JOQSFHOBOUXPNFO%FTQJUF UIF FBTFPGVTFPG&-*4"UFTUT GBMTFQPTJUJWFT XFSF GPVOE BNPOH UIF IJHIBWJEJUZ *H.QPTJUJWFTBNQMFT BOE UIFSFGPSF JO XFMMFRVJQQFE MBCPSBUPSJFT UIFBQQMJDB UJPOPG1$3JTSFDPNNFOEFE Figure 2 Amplification of 529 bp from Toxoplasma gondii DNA in the blood of abnormal pregnancy. Lane M, molecular weight marker (100 bp ladder), Lanes 8, 10, 12 and 16, positive samples. Lanes 1, 2, 20, 22, 30, 38 and 47, negative samples. Running conditions: agarose gel (2%), 5 v/cm for 2 h, stained with ethidium bromide Figure 3 Amplification of 529 bp from Toxoplasma gondii DNA in the blood of abnormal pregnancy. Lane M, molecular weight marker (100 bp ladder), Lanes 17, 18, 26, 27, 28, 29, 34, 36, 40, 45, and 50, positive samples. Running conditions: agarose gel (2%), 5 v/cm for 2 h, stained with ethidium bromide EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 50 References 1. Remington JS, McLeond R, Desmonts G. Toxoplasmosis. In: Remington JS, Klein JO, eds. Infectious diseases of the fetus and newborn infant. Philadelphia, WB Saunders, 1995. 2. Holland GN et al. Toxoplasmosis. In: Peprose JS, Holland GN, Wilhelmus, KR, eds. Ocular infection and immunity. St. Louis, Missouri, Mosby, 1996:1183–1223. 3. Espinoza, L. Toxoplasmosis. 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HCÐçPUph[UÐpdCÐ 51 ëíP_UÐ{dCÐ éíúÐØ{_UÐ Prevalence of coeliac disease among adult patients with autoimmune hypothyroidism in Jordan O.H. Farahid,1 N. Khawaja,1 M.M. Shennak,2 A. Batieha,3 M. El-Khateeb 1 and K. Ajlouni 1 ABSTRACT The prevalence of coeliac disease among patients with autoimmune hypothyroidism has not been studied before in Jordan and other Arab countries. A cross-sectional record-based review was made of all adult autoimmune hypothyroidism patients who attended a referral centre in Jordan, during an 8-month period. Coeliac disease in these patients was diagnosed by the attending physician based on positive serological tests for anti-endomysial antibodies IgA and IgG followed by duodenal biopsy to confirm the diagnosis of coeliac disease. Of 914 patients recruited, 117 (12.8%) were seropositive for coeliac disease. Of 87 seropositive patients who underwent duodenal biopsy, 39 had positive histological findings of coeliac disease (44.8%). Extrapolating from these findings the overall rate of coeliac disease among autoimmune hypothyroidism patients was estimated to be 5.7%. In multivariate logistic regression coeliac disease was significantly associated with older age (> 40 years), presence of other autoimmune diseases, vitamin B12 deficiency and anaemia. 1National Centre for Diabetes, Endocrinology and Genetics, Amman, Jordan (Correspondence to K. Ajlouni: ajlouni@ju.edu.jo). 2Department of Gastroenterology and Liver Disease, Faculty of Medicine, University of Jordan, Amman, Jordan. 3Department of Community Medicine, Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan. Received: 03/05/12; accepted: 24/09/12 ëØÚúÐ9.Ð{TÐKmeBÐogRÚzTÐÚZRXëhm^w,M_TmTÐ|BÐM<e\TÐÊÐzTÐÚmYhÐéz^X ©d_UÐ{e7YnTºoh]#Ð{h_H{e7ºph]=Øe7Úi̺çnfZUÐØe7a][Yºp@Ð#ÐHYpd¹º{hwÐ}aUÐ=nAox}L ëÐ{dUÐ}ýnHíÌëØÚúÐ:ÊÐH.Ð|UÐLnfCÐphSÚ{UÐÚ[SYëin_x,}CÐN=f]UÐÊÐ{UÐÚnZiÐé{_YpHÐÚØSY>3oÉ°#Ð ÐíA,íº.Ð|UÐLnfCÐphSÚ{UÐÚ[SYëin_x,N`UnUÐ}CÐ he!ºÓĆUÐDLØ5Løn=p}_Yp_@Ð}YÊÐ}@Î>{Sí ph=}_UÐ DLØ5Løn=pUn"ÐDLæPCÐoh]UÐéĆBY}CÐÊøkwî{Uf]UÐÊÐ{UÐhZ>>{Sí }gIÌphi5?éĆBëØÚúÐ:pUnAüÐ~T}YOÎ bdUïPLnf?ĆUpL~BÊÐ}@Îngb_xëÌDLºGLnfCÐNd=d`UÐíALnfCÐNd=d`dUM\_UÐhdUÐ{e`UÒØn\CÐph=n«üÐphd[CÐÓÐÚnBøÐ [CÐ-n«Ððn\x}Y87N=Yíº%12.8pf=f]UÐÊÐ{dU[CÐh=n«Îwðn\x}Y914N=Yðn\x}Y117ëÌ{@íí f]UÐÊÐ{UÐhZ>Y ëÌ{isýnfUÐì|wYÊÐ}bHøn=í %44.8f]UÐÊÐ{dUph=n«Îph@Uhwsýni0{Uðn\x}Y39UnfwºïPLnf?øÐpL~BÐí}@Ìx|UÐí Ø{_CÐ @dUÐ æUÐ éĆBYq? {bUí %5.7 f= Ú{bx .Ð|UÐ LnfCÐ phSÚ{UÐ Ú[b= N=n[CÐ }CÐ î{U f]UÐ ÊÐ{dU ên_UÐ é{_CÐ ê{UÐ}bRíºB12NYnhaUÐÛ ó óLíºî}BÌph>ÐÙphLnfYßÐ}YÌØ@ííºN_=ÚúÐHçRº}e_UÐ:ê{bUÐAn[xnYðnUnQf]UÐÊÐ{UÐëÌÓÐE`CÐ Prévalence de la maladie cœliaque chez des patients adultes atteints d’hypothyroïdie auto-immune en Jordanie RÉSUMÉ La prévalence de la maladie cœliaque chez des patients atteints d’hypothyroïdie auto-immune n’a pas été étudiée auparavant en Jordanie, ni dans d’autres pays arabes. Un examen transversal à partir des dossiers de tous les patients adultes atteints d’hypothyroïdie auto-immune qui avaient consulté un centre d’orientation en Jordanie au cours d’une période de huit mois a été mené. Le diagnostic de maladie cœliaque de ces patients a été posé par le médecin traitant à partir des analyses sérologiques positives pour les anticorps anti-endomysium de classe IgA et IgG, puis d'une biopsie duodénale à visée de confirmation du diagnostic de maladie cœliaque. Sur 914 patients recrutés, 117 (12,8 %) étaient séropositifs pour la maladie cœliaque. Sur 87 patients séropositifs chez qui une biopsie duodénale a été réalisée, 39 ont eu des résultats histologiques positifs pour la maladie cœliaque (44,8 %). En extrapolant à partir de ces résultats, le taux global de maladie cœliaque chez les patients atteints d’hypothyroïdie auto-immune a été estimé à 5,7 %. Dans une analyse de régression logistique multivariée, la maladie cœliaque était significativement associée à un âge plus avancé (plus de 40 ans), à la présence concomitante d’autres maladies auto-immunes, à une carence en vitamine B12 et à une anémie. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 52 Introduction $PFMJBDEJTFBTF HMVUFOTFOTJUJWFFOUFS PQBUIZ JTBTZTUFNJDBVUPJNNVOFEJT PSEFSDIBSBDUFSJ[FECZJOĚBNNBUJPOPG UIFTNBMMCPXFMNVDPTB WJMMPVTBUSPQIZ BOEDSZQUIZQFSQMBTJBEVFUPFYQPTVSFUP HMJBEJOGSBDUJPOPGXIFBUHMVUFO IPSEFJO JOCBSMFZ TFDBMJOJOSZFBOEBWFOJOJOPBUT BOEPUIFSTJOHFOFUJDBMMZTVTDFQUJCMFJO EJWJEVBMT< >#BTFEPOUIFQSFTFODFPG BOUJFOEPNZTJBM BOUJCPEZ &." 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Methods Study population "DSPTTTFDUJPOBMTUVEZXBTDPOEVDUFE BU UIF/BUJPOBM$FOUSF GPS%JBCFUFT &OEPDSJOPMPHZBOE(FOFUJDT "NNBO +PSEBO"MMBEVMUQBUJFOUT BUPUBMPG XJUI"*)XIPBĨFOEFEUIF$FOUSFEVS JOH UIFQFSJPE0DUPCFS UISPVHI .BZ XFSF JODMVEFE JO UIFTUVEZ &YDMVTJPODSJUFSJBXFSFIZQPUIZSPJEJTN QPTUUIZSPJEFDUPNZPSQPTUSBEJPBDUJWF BCMBUJPOUIFSBQZ QSFHOBODZBOEUIZSPJE NBMJHOBODZ Data collection Clinical data ĉFEJBHOPTJTPG"*)XBTNBEFCZUIF BĨFOEJOHQIZTJDJBOCBTFEPOFMFWBUFE UIZSPJETUJNVMBUJOHIPSNPOF 54) MFWFMTXJUISFEVDFEUIZSPYJOFBOEQPTJ UJWF UIZSPJE BOUJCPEJFT BOUJUIZSPJE QFSPYJEBTF BOEPS BOUJUIZSPHMPCVMJO BVUPBOUJCPEJFT ĉFEJBHOPTJTPGDPF MJBDEJTFBTFXBTBMTPNBEFCZUIFBĨFOE JOHQIZTJDJBOCBTFEPOTFSPQPTJUJWJUZPG BOUJ&."JNNVOPHMPCVMJO *H "BOE *H(1BUJFOUTXIPXFSFTFSPQPTJUJWFGPS DPFMJBDEJTFBTFXFSF GVSUIFS TVCKFDUFE UPEVPEFOBMCJPQTZ UPDPOėSNUIFEJ BHOPTJT<>"OFYQFSJFODFEQBUIPMPHJTU FWBMVBUFE UIFCJPQTZBDDPSEJOH UP UIF .PEJėFE.BSTI$MBTTJėDBUJPO<>"MM EBUBXFSF DPMMFDUFE GSPN UIFNFEJDBM records. Laboratory measurement methods "OUJ&." *H" BOE *H( MFWFMT XFSF NFBTVSFECZHFOFSJDBTTBZT %BIMFXJU[ (NC) BO FO[ZNF JNNVOPBTTBZ GPS UIFRVBOUJUBUJWFEFUFSNJOBUJPOPG *H"BOE*H(BVUPBOUJCPEJFT UPIVNBO &."54) BOUJUIZSPJE QFSPYJEBTF BOE BOUJUIZSPHMPCVMJO MFWFMT XFSF NFBTVSFE CZ SEHFOFSBUJPO TZTUFN "YZTZN "CCPU BNJDSPQBSUJDMF FO [ZNFJNNVOPBTTBZGPSUIFRVBOUJUBUJWF EFUFSNJOBUJPOPG54)JOIVNBOTFSVN PSQMBTNB"MMPUIFSNFBTVSFNFOUTXFSF DBSSJFEPVUVTJOHTUBOEBSEUFDIOJRVFT Ethical considerations ĉFTUVEZQSPUPDPMXBT BQQSPWFECZ UIF FUIJDT DPNNJĨFFPG UIF/BUJPOBM $FOUSF GPS%JBCFUFT &OEPDSJOPMPHZ BOE(FOFUJDT"MMEBUBXFSFLFQUTUSJDUMZ DPOėEFOUJBMBOEVTFEGPSTDJFOUJėDQVS QPTFTPOMZĉFTUVEZDBSSJFEOPIBSN UPUIFQBUJFOUTBTBMMEBUBXFSFPCUBJOFE GSPNSPVUJOFNFEJDBM SFDPSETXJUIOP JEFOUJGZJOHJOGPSNBUJPO Statistical analysis ĉFQFSDFOUBHFPG"*)QBUJFOUTXJUI TFSPQPTJUJWJUZUPDPFMJBDEJTFBTFNBSLFST XBT PCUBJOFE BTXFMM BT UIF QFSDFOU BHFPGIJTUPMPHJDBMMZDPOėSNFEDPFMJBD EJTFBTF'PS UIFQVSQPTFPGPCUBJOJOH the overall rate of histologically con ėSNFEDPFMJBDEJTFBTF JO"*)QBUJFOUT TFSPQPTJUJWF"*)QBUJFOUTXIPXFSF OPUTVCKFDUFEUPEVPEFOBMCJPQTZXFSF BTTVNFE UP CF TJNJMBS UP UIPTFXIP VOEFSXFOUCJPQTZXJUI SFTQFDU UP UIF QFSDFOUBHFPGIJTUPMPHJDBMMZDPOėSNFE DPFMJBD EJTFBTFĉF DIJTRVBSFE UFTU XBTVTFE UPEFUFSNJOF UIFBTTPDJBUJPO PGDPFMJBDEJTFBTFTFSPQPTJUJWJUZXJUIEJG GFSFOUWBSJBCMFT.VMUJWBSJBUFMPHJTUJDSF HSFTTJPOBOBMZTJTXBTVTFEUPEFUFSNJOF GBDUPST BTTPDJBUFEXJUI TFSPQPTJUJWJUZ BěFSDPOUSPMMJOHGPSQPUFOUJBMDPOGPVOE FSTĉFNBHOJUVEFPG UIFBTTPDJBUJPOT XFSFFYQSFTTFEBTPEETSBUJPT 03 " UBJMFEPWBMVFPGXBTDPOTJEFSFE TUBUJTUJDBMMZTJHOJėDBOU Results Participants’ characteristics ĉJTTUVEZ JODMVEFEQBUJFOUTXJUI "*) GFNBMFTBOENBMFT BHFE mZFBSTXJUI BNFBOBHFPG ZFBST<TUBOEBSEEFWJBUJPO 4% > ĉFEFNPHSBQIJD DMJOJDBM BOEPUIFS relevant characteristics of the study QPQVMBUJPO BSFQSFTFOUFE JO5BCMF ĉFNFBOEVSBUJPOPG"*)XBT 4% ZFBST XJUIBMNPTUPGQBUJFOUT IBWJOH MPOHTUBOEJOHIZQPUIZSPJEJTN PGNPSFUIBOZFBSTĉFNFBOCPEZ NBTT JOEFY #.* XBT 4% LHN2 PGUIF"*)QBUJFOUTXFSF PCFTF BOE XFSF PWFSXFJHIU "SPVOE IBE UZQF EJBCFUFT NFMMJUVT UZQFEJBCFUFTNFMMJUVT BOBFNJB WJUBNJO # EFėDJFODZ WJUBNJO%EFėDJFODZ BOEPUIFSBVUPJNNVOFEJTFBTFT ĉFNFBOUIZSPYJOFEPTFXBT 4% HXFFL 5BCMF Prevalence of coeliac disease among adult patients with AIH ĉFTFSPQSFWBMFODFPG DPFMJBDEJTFBTF XBT PVUPGQBUJFOUT 0OMZ TFSPQPTJUJWFQBUJFOUTVO EFSXFOUEVPEFOBMCJPQTZ BOEPGUIFTF IBE QPTJUJWF IJTUPMPHJDBM ėOEJOHT HCÐçPUph[UÐpdCÐ 53 ëíP_UÐ{dCÐ éíúÐØ{_UÐ of DPFMJBDEJTFBTF ĉFIJTUP MPHJDBMėOEJOHTPGDPFMJBDEJTFBTFXFSF DPOTJTUFOUXJUI.BSTI * JO QBUJFOUT .BSTI**JOQBUJFOUT .BSTI ***B JO QBUJFOUT .BSTI***CJOQBUJFOUT BOE .BSTI ***D JO QBUJFOUTXJUI "*) "TTVNJOH UIBU UIF SFNBJOJOH TFSPQPTJUJWF"*)QBUJFOUTXIPXFSF OPU TVCKFDUFE UPEVPEFOBMCJPQTZIBE UIFTBNFSBUFPGDPFMJBDEJTFBTFBTUIPTF XIPVOEFSXFOUEVPEFOBMCJPQTZ UIF PWFSBMM SBUFPG DPFMJBDEJTFBTF BNPOH "*)QBUJFOUTXBTFTUJNBUFEUPCF 5BCMF Regression analysis 6TJOHNVMUJWBSJBUF MPHJTUJD SFHSFTTJPO BOBMZTJT JU XBT GPVOE UIBU BOBFNJB BEKVTUFE03 P WJUBNJO #EFėDJFODZ BEKVTUFE03 P BOEQSFTFODFPGPUIFSBVUPJN NVOFEJTFBTFT BEKVTUFE03 P XFSF TJHOJėDBOUMZ BTTPDJ BUFEXJUIDPFMJBDEJTFBTF 5BCMF *O BEEJUJPO PMEFSQBUJFOUT ZFBST XFSFTJHOJėDBOUMZUJNFTNPSFMJLFMZ UPIBWF DPFMJBDEJTFBTF BT DPNQBSFE XJUIQBUJFOUTBHFEmZFBST P = &BDIPG UIFTFWBSJBCMFTXFSF BEKVTUFETJNVMUBOFPVTMZ GPS UIFPUIFS WBSJBCMFT"MMPUIFSWBSJBCMFT TIPXO JO5BCMF OBNFMZ TFY #.* EVSB UJPOPG"*) UIZSPJEEPTF QSFTFODF PGEJBCFUFTBOEWJUBNJO%EFėDJFODZ XFSF OPU JOEFQFOEFOUMZ SFMBUFE UP DPFMJBDEJTFBTFTFSPQPTJUJWJUZBOEXFSF UIFSFGPSF SFNPWFE GSPN UIF MPHJTUJD SFHSFTTJPONPEFM Autoimmune diseases in the study population "UPUBMPGQBUJFOUTIBEPUIFSBTTPDJBU FEBVUPJNNVOFEJTPSEFST TVDIBTUZQF EJBCFUFTNFMMJUVT "EEJTPOEJTFBTFBOE WJUJMJHPBTTIPXOJO5BCMF Discussion 5IF QSFTFOU TUVEZ XBT UIF ėSTU JO +PSEBO UP BTTFTT UIF QSFWBMFODF PG DPFMJBDEJTFBTF JOQBUJFOUTXJUI"*) ĉFTBNQMFTJ[FXFVTFEXBTSFMBUJWFMZ MBSHF BT DPNQBSFEXJUINBOZQSFWJ ous studies conducted outside Jordan. 3FDFOUQPQVMBUJPO TDSFFOJOH TUVEJFT IBWF GPVOE UIBU UIF QSFWBMFODF PG coeliac disease in Western countries BQQSPBDIFT <> ĉF QSFTFOU TUVEZ TIPXFE UIBU UIFQSFWBMFODFPG IJTUPMPHJDBMMZDPOėSNFEDPFMJBDEJTFBTF BNPOHQBUJFOUTXJUI"*)XBT ĉJTėHVSF JT TMJHIUMZIJHIFS UIBO UIF FTUJNBUFE SBOHFPG HMPCBMQSFWBMFODF PGDPFMJBDEJTFBTFBNPOHBEVMUQBUJFOUT XJUI"*) m <>ĉFQSFWB MFODFT SFQPSUFECZ(VJMUFS FU BM JO B 5VSLJTIQPQVMBUJPO<> #FSUJFUBM JO *UBMJBOT<>BOE)BEJUIJFUBMJO%VUDI QBUJFOUT<>XFSF BOE SFTQFDUJWFMZ Table 1 Sociodemographic, clinical and other relevant characteristics of study participants with autoimmune hypothyroidism (AIH) (n = 914) Variable No. % Age (years) 20–40 199 21.8 41–60 472 51.6 61–82 243 26.6 Sex Female 806 88.2 Male 108 11.8 BMI (kg/m2) Normal (< 27) 114 12.5 Overweight (27–29) 245 26.8 Obese (30+) 555 60.7 Duration of AIH (years) ≤ 5 597 65.3 6–10 210 23.0 > 10 107 11.7 Anaemia Yes a 260 28.4 No 654 71.6 Thyroxine dose (μg/week) 350–650 311 34.0 651–1000 504 55.1 > 1000 99 10.8 Diabetes Yes 386 42.2 No 528 57.8 Vitamin B12 Deficiency b 202 22.1 Normal 712 77.9 Vitamin D deficiency Yes c 621 67.9 No 293 32.1 Other autoimmune diseases Present 34 3.7 Absent 880 96.3 aHaemoglobin level < 13 g/dL for males and < 12 g/dL for females [16]; bVitamin B12 level < 208 pg/mL; c25- hydroxy vitamin D level < 30 ng/mL. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 54 8JUISFTQFDUUPUIFTFSPQSFWBMFODFPG DPFMJBDEJTFBTFJOQBUJFOUTXJUI"*) TFW FSBMTUVEJFTSFQPSUFEIJHIFSėHVSFTUIBO UIBU GPSIJTUPMPHJDBMMZDPOėSNFEDPFMJBD EJTFBTF<m>)BEJUIJFUBMSFQPSUFEB TFSPQSFWBMFODFPGDPFMJBDEJTFBTFPG JOQBUJFOUTXJUI)BTIJNPUP UIZSPJEJUJT VTJOH BOUJHMJBEJO BOUJ&."BOEBOUJ U5(<> XIJMF *VPSJPFUBM SFQPSUFEB NVDIIJHIFSDPFMJBDEJTFBTFTFSPQSFWB MFODFPGVTJOHBOUJ&." CPUI*H" BOE*H(<>0VSEBUBTIPXFEBNVDI MPXFSTFSPQSFWBMFODFPGDPFMJBDEJTFBTF UIBO UIBU SFQPSUFECZ *VPSJP FUBM <>)PXFWFS *VPSJPFU BMTTUVEZXBTCBTFEPOBNVDITNBMMFS TBNQMFTJ[F "*)QBUJFOUT UIBOPVS TUVEZ "*)QBUJFOUT *OUIFQSFTFOUTUVEZ BHF ZFBST BOBFNJB WJUBNJO#EFėDJFODZ BOE QSFTFODFPGPUIFSBVUPJNNVOFEJTFBTFT XFSFJOEFQFOEFOUMZBTTPDJBUFEXJUIUIF TFSPQSFWBMFODFPGDPFMJBDEJTFBTF$PO TJTUFOUXJUIPVSėOEJOHT 3BWBHMJBFUBM SFQPSUFETJHOJėDBOUMZIJHIFSQSFWBMFODF PGDPFMJBDEJTFBTF JOQBUJFOUTXJUI"*) BHFEɓZFBST UIBO JOQBUJFOUT BHFE ZFBST P <>0VSEBUB TIPXFE UIBU"*)QBUJFOUT BHFE ZFBSTXFSFUJNFTNPSFMJLFMZUPIBWF DPFMJBDEJTFBTFUIBOQBUJFOUTBHFEɒ years (P = 0.02). 8JUISFTQFDU UPBOBFNJB PVSėOE ings of an association are consistent XJUI UIF ėOEJOHT PG6OTXPSUI FU BM XIPSFQPSUFE UIBUPGBOBFNJD WPMVOUFFSTIBEDPFMJBDEJTFBTF<> BOE ;BNBOJFUBMXIPSFQPSUFE UIBU PG BOBFNJD QBUJFOUT IBE DPFMJBD EJTFBTF<> 7JUBNJO#EFėDJFODZJTDPNNPO JO+PSEBO BTSFQPSUFECZ'PSB FUBM <> BOE UIJT SBUF JTIJHIFS UIBO UIFSFQPSUFEHMPCBMQSFWBMFODF SBOHJOH GSPN UPPG UIF BEVMUQPQVMB UJPO <>ĉJTEJĎFSFODFJTNBJOMZSF lated to ethnic variations and intestinal NBMBCTPSQUJPOQSPCMFNT<>5PPVS LOPXMFEHF UIF BTTPDJBUJPO CFUXFFO WJUBNJO#BOEDPFMJBDEJTFBTFIBEOPU CFFOSFQPSUFEQSFWJPVTMZ 0VSėOEJOHTBSF DPOTJTUFOUXJUIB IJHIFSSBUFPGDPFMJBDEJTFBTFJOQBUJFOUT XJUIPUIFSBVUPJNNVOFEJTFBTFTBTIBE CFFOQSFWJPVTMZ SFQPSUFECZ,BVLJOFO FUBM<>+JTLSBFUBM GPVOETJHOJėDBOUMZ IJHIFS TFSVN MFWFMTPG *H"BOUJHMJBEJO BOUJCPEJFTBNPOHQBUJFOUTXJUIBV UPJNNVOF UIZSPJEEJTFBTFT JFDISPOJD UIZSPJEJUJT BOE(SBWFTEJTFBTF USFBUFE XJUI B IJHI SFQMBDFNFOU EPTBHF PG MFWPUIZSPYJOFDPNQBSFEXJUIQBUJFOUT USFBUFEXJUIB MPXFSEPTBHF <>0VS EBUB IPXFWFS EJEOPU TIPXBO BTTP DJBUJPOCFUXFFOUIZSPYJOFSFQMBDFNFOU EPTBHFBOEDPFMJBDEJTFBTF TFSPQSFWB MFODFĉJTNBZCFBĨSJCVUFEUPUIFVTF PG BOUJ&."BOUJCPEJFT JO UIFQSFTFOU TUVEZ XIJDIIBWFIJHIFSTQFDJėDJUZBOE TFOTJUJWJUZUIBOUIF*H"BOUJHMJBEJOBOUJ CPEJFTVTFECZ+JTLBSBFUBM ĉFQSFTFOUTUVEZIBETPNFMJNJUB UJPOT'JSTU JUXBTBDSPTTTFDUJPOBMTUVEZ NBLJOH JU JNQPTTJCMF UP DPNQBSF UIF QSFWBMFODF PG DPFMJBD EJTFBTF BNPOH QBUJFOUTXJUI"*)BOEBDPOUSPMHSPVQ 4FDPOEMZ XFVTFEPOMZBOUJ&."BO UJCPEJFT*H"BOE*H(BTTFSPMPHJDBMUFTU for coeliac disease. *O DPODMVTJPO UIF QSFWBMFODF PG IJTUPMPHJDBMMZDPOėSNFEDPFMJBDEJTFBTF BNPOHQBUJFOUTXJUI"*) JOPVS TUVEZ XBT FTUJNBUFE UP CF DPNQBSFE XJUIBTFSPQSFWBMFODFPG"HF ZFBST BOBFNJB WJUBNJO#EFėDJFODZ BOEUIFQSFTFODFPGPUIFSBVUPJNNVOF EJTPSEFSTXFSF TJHOJėDBOUMZBTTPDJBUFE XJUIBIJHIFSTFSPQSFWBMFODFPGDPFMJBD EJTFBTFĉFTFėOEJOHTNBZQSPWJEF B CBTJTGPSTDSFFOJOHPGQBUJFOUTXJUI"*) GPSDPFMJBDEJTFBTF QBSUJDVMBSMZthe high FSSJTLHSPVQTJEFOUJėFEJOUIJTTUVEZ Table 2 Multivariate logistic regression analysis of factors associated with coeliac disease seropositivity among patients with autoimmune hypothyroidism Variable OR 95% CI P-value Anaemia 0.04 Yes 3. 7 0.63–16.9 Noa 1 Vitamin B12 0.01 Deficiency 3.0 0.91–17.1 Normala 1 Other autoimmune diseases 0.04 Present 3.1 0.47–30.7 Absent a 1 Age years 0.02 20–40a 1 > 40 4.3 1.04–28.1 Each variable in the table was adjusted for all other variables in the table. aReference group. OR = odds ratio; CI = confidence interval. Table 3 Autoimmune diseases in the study group of patients with autoimmune hypothyroidism (n = 914) Disease No. % Vitiligo 7 0.8 Addison disease 8 0.9 Systemic lupus erythematosus 2 0.2 Type 1 diabetes mellitus 15 1.6 Turner syndrome 1 0.1 Psoriasis 1 0.1 Normal 880 96.3 HCÐçPUph[UÐpdCÐ 55 ëíP_UÐ{dCÐ éíúÐØ{_UÐ References 1. Green PH, Cellier C. Celiac disease. New England Journal of Medicine, 2007, 357:1731–1743. 2. Sanders DS et al. Changing face of adult coeliac disease: experience of a single university hospital in South Yorkshire. Postgraduate Medical Journal, 2002, 78:31–33. 3. Collin P et al. Antiendomysial and antihuman recombinant tis- sue transglutaminase antibodies in the diagnosis of coeliac dis- ease: a biopsy-proven European multicentre study. European Journal of Gastroenterology and Hepatology, 2005, 17:85–91. 4. Kaukinen K et al. Celiac disease and autoimmune endo- crinologic disorders. Digestive Diseases and Sciences, 1999, 44:1428–1433. 5. Collin P et al. Endocrinological disorders and celiac disease. Endocrine Reviews, 2002, 23:464–483. 6. Valentino R et al. Prevalence of coeliac disease in patients with thyroid autoimmunity. Hormone Research, 1999, 51:124–127. 7. West J et al. Seroprevalence, correlates, and characteris- tics of undetected coeliac disease in England. Gut, 2003, 52:960–965. 8. Green PH, Jabri B. Coeliac disease. Lancet, 2003, 362:383–391. 9. Oberhuber G, Granditsch G, Vogelsang H. The histopathology of coeliac disease: time for a standardized report scheme for pathologists. European Journal of Gastroenterology and Hepa- tology, 1999, 11:1185–1194. 10. Guliter S et al. Prevalence of coeliac disease in patients with autoimmune thyroiditis in a Turkish population. World Journal of Gastroenterology, 2007, 13:1599–1601. 11. Hadithi M et al. Coeliac disease in Dutch patients with Hashi- moto’s thyroiditis and vice versa. World Journal of Gastroenter- ology, 2007, 13:1715–1722. 12. Iuorio R et al. Prevalence of celiac disease in patients with au- toimmune thyroiditis. Minerva Endocrinologica, 2007, 32:239– 243. 13. Jiskra J et al. IgA and IgG antigliadin, IgA anti-tissue transglu- taminase and antiendomysial antibodies in patients with au- toimmune thyroid diseases and their relationship to thyroidal replacement therapy. Physiological Research, 2003, 52:79–88. 14. Ravaglia G et al. Increased prevalence of coeliac disease in autoimmune thyroiditis is restricted to aged patients. Experi- mental Gerontology, 2003, 38:589–595. 15. Unsworth DJ, Lock RJ, Harvey RF. Improving the diagnosis of coeliac disease in anaemic women. British Journal of Haema- tology, 2000, 111:898–901. 16. Zamani F et al. Gluten sensitive enteropathy in patients with iron deficiency anemia of obscure origin. World Journal of Gastroenterology, 2008, 14:7381–7385. 17. Fora MA, Mohammad MA. High frequency of suboptimal se- rum vitamin B12 level in adults in Jordan. Saudi Medical Journal, 2005, 26:1591–1595. 18. Stabler SP, Allen RH. Vitamin B12 deficiency as a worldwide problem. Annual Review of Nutrition, 2004, 24:299–326. 19. Gümürdülü Y et al. Predictors of vitaminB12 deficiency: age and Helicobacter pylori load of antral mucosa. Turkish Journal of Gastroenterology, 2003, 14:44–49. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 56 Physicians’ knowledge, attitude and practices regarding management of medications in Ramadan D. Jaber,1 A. Albsoul-Younes 1 and M. Wazaify 1 ABSTRACT To evaluate knowledge, attitude and practices (KAP) of physicians regarding the management of medications in Ramadan we used a self-administered questionnaire on a target sample of 381 physicians at Jordan University Hospital, King Abdulla University Hospital and a number of private clinics in Amman, during September and October of 2008. A total of 297 questionnaires were returned. Physicians’ KAP about management of medications in Ramadan was generally insufficient. The main factors that affected KAP were age, nationality, specialty, and country and year of last qualification (P < 0.05). Female physicians scored better than males, and fellows scored better than other groups for knowledge. Most physicians’ attitudes and practices were in line with religious opinion in regard to which routes of drug administration can nullify fasting, indicating that physicians have adequate knowledge in this area. 1Department of Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, University of Jordan, Amman, Jordan (Correspondence to A. Albsoul-Younes: ablabsoul@yahoo.com, ablabsoul@ju.edu.jo). Received: 07/09/11; accepted: 12/12/11 ëm[XÚ9ogýÐízTÐo!m^BÐëiY<*mGÚm,íf`RÐXíÊmIúÐæÚm^X axnKíÒØnhYºix-é[UÐpdLº}=n@pexØ ëjZ=ðnh>ÐÙecxënhHÐêÐ{HÐNAnUÐYën\YÚ:phýÐí{UÐp!n_CÐëjZ=*nHÚn,ígaSÐYíÊnJúÐæÚn_Yhhb>ê~dHÐoÉ°#Ð ë5L:pÉn#ÐÓÐØnh_UÐYØ{Líº_Yn!ÐāÐ{LdCÐaZYíºphiØÚøÐp_Yn!ÐaZY:ðnhJ381nwØ{LUnUÐípR{gCÐÊnJúÐpfhL *nHÚn,ígaSÐYíÊnJúÐæÚn_YëÌq?íºðninhHÐ297ÒØnLÎ>_aUn=í 2008ênLY}=TÌ éíúÐxP>íFeH édxÌï}gIéĆB YP<0.05wkY}BËDLé["ÐpfHí{dUÐí[UÐíphf!ÐíUÐF_xí ênLcZ=phRnTEQën\YÚ:phýÐí{UÐ p!n_CÐëjZ= ë«}#ÐÊĆY~UÐH5TºÊnJúÐY\RÌsýniÓnh]UÐqdH{Síº*nHÚn,ígaSÐYíÊnJúÐæÚn_YDL}?k>UÐphhý}UÐYÐ_UÐ 5hRphfx{UÐÊÐÚùÐ Yp!n_CÐëjZ=*nHÚn,ígaSÐYíÊnJúÐ^_YæÚn_Yqb>Ð{Sí æÚn_Cn=d_x5hRÓnLeCÐ}ýnHY\RÌsýni Ú5\CÐÐ|w:Ò{h@pR}_Y0{UÊnJúÐëÌDLé{xn,ºênh[UÐ{a>UÐpxíØúÐÊn]LÎpbx}]=d_x Connaissances, attitudes et pratiques des médecins en matière de gestion des médicaments pendant le Ramadan RÉSUMÉ Afin d’évaluer les connaissances, les attitudes et les pratiques des médecins en matière de gestion des médicaments pendant le Ramadan, nous avons utilisé un autoquestionnaire dans un échantillon cible de 381 médecins dans un certain nombre de cliniques privées à Amman, ainsi que dans les établissements de soins Jordan University Hospital et King Abdulla University Hospital, en septembre et octobre 2008. Au total, 297 questionnaires ont été retournés. Les connaissances, attitudes et pratiques des médecins en matière de gestion des médicaments pendant le Ramadan étaient généralement insuffisantes. Les facteurs principaux qui affectaient les trois points analysés étaient l’âge, la nationalité, la spécialisation, ainsi que le pays et l’année de la dernière qualification (P < 0,05). Les médecins femmes ont obtenu de meilleurs résultats que les médecins hommes, et les boursiers ont obtenu de meilleurs résultats que les autres groupes pour les connaissances. La majorité des attitudes et des pratiques des médecins se situaient dans le droit fil des convictions religieuses pour identifier les voies d’administration des médicaments qui annuleraient le jeûne, indiquant que les médecins disposaient des connaissances adéquates en la matière. 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The MFBTU GSFRVFOUPQUJPO TVHHFTUFE OPU DIBOHJOH UIF EPTJOH BOE BTLJOH QBUJFOUTUPCSFBLUIFJSGBTU *O SFHBSE UPQIZTJDJBOTQSBDUJDF JO TFMFDUJOHXIJDIPGUIFJSQBUJFOUTTIPVME CFBEWJTFEOPU UP GBTU JO3BNBEBO UIF NBKPSJUZ BEWJTFE UIFJSQBUJFOUT UP GBTU JONPTUEJTFBTFTFYDFQU GPSVO DPOUSPMMFE IZQFSUFOTJPO TUBHF VO DPOUSPMMFEEJBCFUFT CPUI UZQFT BOE DISPOJDLJEOFZEJTFBTF TUBHFTBOE 5BCMF ĉJTQSBDUJDFXBT BĎFDUFE NBJOMZCZTFY OBUJPOBMJUZ DVSSFOUQPTJ UJPOBOEZFBSPGėSTURVBMJėDBUJPO'F NBMFQIZTJDJBOTIBEHSFBUFS UFOEFODZ UPJOTUSVDUUIFJSQBUJFOUUPGBTUUIBONBMF Table 1 Demographic details of participants (physicians) (n = 297) from Jordan University Hospital (JUH), King Abdulla University Hospital (KAUH) and private clinics Characteristic JUH KAUH Private clinics Total Age (years) Mean (SD) 27.1 (5.01) 28.6 (6.38) 40.4 (12.24) 33.45 (11.18) Range (min–max) 23–52 22–56 24–75 22–75 Sex No. % No. % No. % No. % Male 46 46.9 44 65.7 115 89.1 205 69.0 Female 52 53.1 23 34.3 14 10.9 90 30.3 Missing data 2 0.7 Total 98 100 67 100 129 100 295 99.3 Nationality Jordanian 85 86.7 56 83.6 117 90.7 259 87.2 Non-Jordanian 13 13.3 10 14.9 11 8.5 34 11.4 Missing data 1 1.5 1 0.8 4 1.3 Total 98 100 67 100 129 100 297 100 Current position Intern 39 39.8 15 22.4 0 0.0 55 16.8 General practitioner 0 0.0 0 0.0 4 3.1 4 3.1 1st year residency 20 20.4 14 20.9 14 10.9 48 16.2 2nd year residency 16 16.3 14 20.9 14 10.9 44 14.8 3rd & 4th year residency 16 16.3 12 17.9 17 13.3 45 15.2 Fellow 3 3.1 5 7.5 40 31.0 48 16.2 Consultant 2 2.0 5 7.5 39 30.2 47 15.8 Missing data 2 2.0 2 3.0 1 0.8 6 2.0 Total 98 100 67 100 129 100 297 100 SD = standard deviation of the mean. 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GFR = glomerular filtration rate. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 62 BOEDPNQMJBOUXJUIUIFJSEJFUBOEESVH JOUBLF<> ĉFFĎFDUPG GBTUJOHEVSJOH3BNB EBOPOQBUJFOUTXJUISFOBM JNQBJSNFOU JTTUJMMBNBĨFSPGDPOUSPWFSTZ<>,JE OFZEJTFBTFQBUJFOUTTIPVMECFBXBSFPG UIF JNQPSUBODFPGBEFRVBUFIZESBUJPO CFDBVTFEFIZESBUJPO JTBDPNNPOPD DVSSFODFEVSJOHB GBTU < >$ISPOJD LJEOFZ EJTFBTF QBUJFOUT FTQFDJBMMZ TUBHFT JOTJTUJOHPOGBTUJOHTIPVME CFBEWJTFEUPESJOLTVđDJFOUĚVJETCF UXFFO iftarBOETMFFQUPBWPJEEFIZESB UJPO< > $POTVMUBOUQIZTJDJBOTIBEBHSFBU FS UFOEFODZ UP JOTUSVDU UIFJSQBUJFOUT UP GBTU UIBO JOUFSOT EJĎFSFOU MFWFMT PG SFTJEFOUT BOE GFMMPXTQIZTJDJBOT *UNBZCF UIBU FYQFSJFODF HJWFT UIF EPDUPSHSFBUFS DPOėEFODFBCPVU UIF DPOTFRVFODFT UIBUQBUJFOUNBZIBWF CFDBVTFPGGBTUJOHĉJTėOEJOHDMFBSMZ IJHIMJHIUT UIFFĎFDUPGFYQFSJFODFPO UIFEPDUPShTBEWJDFPOXIFUIFSUPGBTU or not. Conclusion ĉFTUVEZSFWFBMFEUIBUUIFSFJTBTJHOJė DBOU MBDLPGLOPXMFEHFBNPOHQIZTJ DJBOT UPXBSET UIFQSPQFSNBOBHFNFOU PGNFEJDBUJPOTJO3BNBEBO *UJTQSFGFSBCMFGPSQBUJFOUTTVĎFSJOH GSPNDISPOJDEJTFBTFT UP UBLF BEWJDF SFHBSEJOH GBTUJOH JO 3BNBEBO GSPN their consultant. With regard to drug TDIFEVMF DIBOHFT UIFSF JT B OFFE UP BDUJWBUFUIFSPMFPGUIFDMJOJDBMQIBSNB DJTU JO HJWJOH BQQSPQSJBUF DPVOTFMMJOH BOETVHHFTUJOHBMUFSOBUJWFEPTBHFGPSNT GPS EJĎFSFOUNFEJDBUJPOT BMPOHXJUI QIZTJDJBOTJOPSEFSUPIFMQUIFQBUJFOUT EFBMJOHXJUIEJĎFSFOUESVHTQSPQFSMZ BOEGBTUJOH3BNBEBOTBGFMZ *ODPODMVTJPO HSFBUDBSFJTUBLFOUP JNQSPWF UIFRVBMJUZPG MJGFPGQBUJFOUT OFWFSUIFMFTT BIVHFBNPVOUPGSFTQFDU JTTUJMMTIPXOGPSUIFQJMMBSTPG*TMBN *OHFOFSBM MJĨMF SFTFBSDIIBTCFFO EPOFPO UIFLOPXMFEHF BĨJUVEFTBOE QSBDUJDFTPGQIZTJDJBOTBCPVU UIFNBO BHFNFOUPGNFEJDBUJPOT JO3BNBEBO TPGVSUIFSTUVEJFTBSFOFFEFEUPFYQMPSF this issue. Funding:ĉJTSFTFBSDIXBTGVOEFECZ UIF%FBOTIJQPG3FTFBSDI 6OJWFSTJUZPG +PSEBO)PTQJUBM Competing interests: None declared. References 1. 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HCÐçPUph[UÐpdCÐëíP_UÐ{dCÐ éíúÐØ{_UÐ 63 Letter to the Editor 4JS IBNXSJUJOHXJUISFHBSEUPBOBSUJDMFXSJU UFOCZ#BOJ*STIBJEFUBM JO UIFEastern Mediterranean Health Journal JO <> *U JTBOFOMJHIUFOJOHBSUJDMFPO UIF VTFPG'PMFZDBUIFUFST GPS UIF UFSNJOB UJPOPGQSFHOBODZĉFIJTUPSJDBMEJTDVT sion of devices related to the research unfortunately contains inaccuracies. ĉFBVUIPSTBĨSJCVUFUIF JOWFOUJPO PG UIF'PMFZDBUIFUFS UP"MCFSU,SBVTF JOĉJT JTOPUDPSSFDUĉF'PMFZ DBUIFUFS JTOBNFEBěFS'SFEFSJD'PMFZ XIP JOWFOUFE UIF JOĚBUBCMF MBUFY SVC CFS DBUIFUFSXJUI JOUFHSBUFE CBMMPPO ZFBST MBUFS UIBO,SBVTF<>8IJMF &NCSFZBOE.PMMJTPOEJETIPXIPXUP VTF UIF'PMFZDBUIFUFS GPS JOEVDUJPOPG MBCPVSJOUIFT<>UIFėSTUJOTUBO UJBUJPOTPG JOĚBUBCMF'PMFZMJLFEFWJDFT GPS JOEVDUJPOXFSF JOUSPEVDFECZ"O UPJOF.BĨFJ JO<>BOE)PSBUJP 4UPSFSJO<>.BOZBMTPDPOTJEFS UIFXPSLPG3PCFSU#BSOFTJOJNQSPWJOH TJNJMBS JOĚBUBCMF SVCCFSEJMBUPST JO UIF T<>BTLFZUPMBUFSEFWFMPQNFOUT CZ&NCSFZBOE.PMMJTPOBOEPUIFST *U JT JNQPSUBOU UP FOTVSF UIBU UIF IJTUPSJDBM SFDPSE JTBDDVSBUF)PXFWFS none of this discussion on historical FWFOUTTIPVMEEFUSBDUGSPNUIFTDJFOUJėD SFTVMUTPG#BOJ*STIBJEFUBMTXPSLĉFJS DPODMVTJPOTBCPVUUIFTBGFBOEFĎFDUJWF VTFPG UIF'PMFZBSF JOBHSFFNFOUXJUI SFTVMUT GSPNNBOZPUIFSQSBDUJUJPOFST and researchers. 1. Bani-Irshaid I et al. Termination of second and early third trin- mester pregnancy: comparison of 3 methods. Eastern Mediter- ranean Health Journal, 2006, 12(5):605–609. 2. Foley FEB. A hemostatic bag catheter—a one piece latex rubber structure for control of bleeding and constant drainage follow- ing prostatic resection. Journal of Urology, 1937, 38(1):134–139. 3. Embrey MP, Mollison BG. The unfavourable cervix and induco- tion of labour using a cervical balloon. International Journal of Obstetrics and Gynaecology, 1967, 74(1):44–48. 4. Mattei A. Essai sur l’accouchement physiologique. Paris, France, Victor Masson, 1855. 5. Storer HR. The uterine dilator. American Journal of the Medical Sciences, 1859, 38:107–113. 6. Barnes R. On the indications and operations for the induction of premature labour and for the acceleration of labour. Obstet- rical Transactions, 1861, 3:107–141. References +"4NJUI %FQBSUNFOUPG&MFDUSJDBMBOE$PNQVUFS&OHJOFFSJOH 3ZFSTPO6OJWFSTJUZ 5PSPOUP $BOBEB KBTNJUI!FFSZFSTPODB Termination of second and early third trimester pregnancy: comparison of 3 methods EMHJ r 7PM/P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 64 Eastern Mediterranean Health Journal reviewers’ panel, 20131 The Eastern Mediterranean Health Journal extends sincere thanks the following experts for their generous and invaluable assistance in the review of papers considered for publication during the year 2013. 1SPGFTTPS"MJ)BTTBO"CBEJ %S.PIBNFE"CEFM"[J[ 1SPGFTTPS4BOOB"CEFM"[J[ %S4BSBC"CEFMSBINBO 1SPGFTTPS:PVTFG"CEVMSB[[BR 1SPGFTTPS.PTUBGB"CEFMGBĨBI"CPMGPUPVI %S.BZB"CPV4BBE 1SPGFTTPS,BNJMJB"CPV4IBCCBOB 1SPGFTTPS.PIBNNBE"CV;BJOFI %S"CJPMB"EFOJZJ 1SPGFTTPS4BMJN"EJC %S3JNB"ėė %S.VIBNNBE"G[BM %S.VIBNNBE.BINPPE"G[BM %S5BTMFFN"LIUBS .T%FFOB"MBTGPPS %S"ZPVC"M+BXBMEFI %S+BXBE"M-BXBUJ %S8JEBE"M/BLJC %S.BOTPVS"M/P[IB %S"TZB"MJ"M3JZBNJ %S/BKFFC"M4IPSCBKJ %S#BTFM"M:PVTė %SĉBMJB"SBXJ %S4BJE"SOBPVU %S'B[BM"UIFS 1SPGFTTPS0TBNB.PIBNFE"INFE"XBE 1SPGFTTPS'FSFJEPVO"[J[J %S&M4IFJLI#BES %S)BOBO"M4BZFE#BES %S4BNJIB#BHIEBEJ %S&EVBSEP#BO[PO %S'BSBK#BSBI %S.BVSJ[JP#BSCFTDIJ %S,JEJTU#BSUPMPNFPT %S)ZBN#BTIPVS %S"OXBS#BUJFIB %S'BUFO#FO"CEFMB[J[ %S"CEVMMBI#FOBINFJE 1SPGFTTPS"CEVMCBSJ#FOFS %S3JZBEI#FO*TNBJM %S+JMM#FOTPO %S-VCOB#IBĨJ %S3VWFZEF#VOEBL %S*SUB[B"INBE$IBVEISJ Dr Leonard Cohen %S"MZB+BBGBS%BCCBHI 1SPGFTTPS%S'B[BM,BSJN%BS 1SPGFTTPS"EFLVOMF)%BXPEV %S3PTF$POTUBO[B7BMMFOBT#FKBS%F7JMMBS %S-BJMB%PSHIBN %S/BCJM%PXJEBS %S"CEFM)BEZ&M(JMBOZ %S"INFE3FGBU&M,BTINFSZ %S&NBO&MMBCBOZ .ST3JLV&EXBSE&MPWBJOJP 1SPGFTTPS'BSPVL.PIBNFE&M4BCCBO 1SPGFTTPS"JTIB"XBE&M4BZFE 1SPGFTTPS%S)BNEZ&M4BZFE 1SPGFTTPS(IBOFN&M4IFJLI 1SPGFTTPS.BINPVE.PIBNNFE&M4JCBFJ %S4BSBI#FBUSJDF&OHMBOE Dr Oya Ercan %S8BGBB&TTBN&MEJO %S(PSEPO"&XZ %S4IBEMFZ'BUBBS 1SPGFTTPS.BINPVE'BINZ'BUIBMMB %S)FCB'PVBE 1SPGFTTPS4BMNBO#BES&M%JO(BMBM %S1IJMJQQF(BVUSFU %S#SBE(FTTOFS %S.BJTPPO(IBMFC 1SPGFTTPS3JUB(JBDBNBO %S$ISJTUPQIFS(JMQJO Dr Gregory C. 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Research articles and Reports:1BQFSTSFQPSUJOHPSJHJOBMSFTFBSDI ėOEJOHTTIPVMEGPMMPXUIF*.Ć%GPSNBU*OUSPEVDUJPO .FUIPET 3FTVMUT "OBMZTJT BOE%JTDVTTJPOĉFUFYUPG3FTFBSDIBSUJDMFTBOE3FQPSUTTIPVMEOPUFYDFFE XPSET FYDMVEJOHUIFBDDPNQBOZJOHBCTUSBDU SFGFSFODFT UBCMFTBOEėHVSFT "OBCTUSBDU PGOPUNPSFUIBOXPSETTIPVMECFTVQQMJFE DMFBSMZBOECSJFĚZTUBUJOHUIFPCKFDUJWFT DPOUFYU SFTVMUTBOEDPODMVTJPOTĉFNBYJNVNOVNCFSPGSFGFSFODFTQFSNJĨFEJT ĉFOVNCFSPGUBCMFTBOEėHVSFTTIPVMEOPUFYDFFEPOFQFSXPSET Review articles JFDSJUJDBMBTTFTTNFOUTPGSFTFBSDIPOUPQJDTPGSFMFWBODFUP QVCMJDIFBMUIJOUIF3FHJPOĉFTFTIPVMEDPOUBJOTFDUJPOTEFBMJOHXJUIPCKFDUJWFT TPVSDFT NFUIPETPGTFMFDUJPO DPNQJMBUJPOBOEJOUFSQSFUBUJPOPGEBUBBOEDPODMVTJPOT ĉFUFYUTIPVMEOPUFYDFFEXPSET FYDMVEJOHUIFBDDPNQBOZJOHBCTUSBDU SFGFSFODFT UBCMFTBOEėHVSFT BOETIPVMECFBDDPNQBOJFECZBOBCTUSBDUPGOPUNPSF UIBOXPSETĉFOVNCFSPGUBCMFTBOEėHVSFTTIPVMEOPUFYDFFEPOFQFS XPSET Case reports:0OMZSFQPSUTPGDBTFTPGBOVOVTVBMOBUVSFBSFDPOTJEFSFEGPS QVCMJDBUJPO5FYUTIPVMEJODMVEFBO*OUSPEVDUJPO UIF3FQPSUPGUIFDBTF T BOEB %JTDVTTJPOĉFUFYUTIPVMEOPUFYDFFEXPSETBOEUIFOVNCFSPGSFGFSFODFTLFQU UPBNJOJNVN/PBCTUSBDUJTSFRVJSFE 10. Letters to the Editor:-FĨFSTDPNNFOUJOHPOQVCMJTIFEBSUJDMFTBSFXFMDPNF -FĨFSTXJMMCFTFOUUPUIFBVUIPSTPGUIFPSJHJOBMBSUJDMFGPSUIFJSDPNNFOUT BOEUIFTF XJMMCFQVCMJTIFEBMPOHXJUIUIFMFĨFSĉFUFYUPGMFĨFSTTIPVMECFLFQUBTTIPSUBT QPTTJCMF 11. Short communications:"SUJDMFTXIJDIEPOPUDPOTUJUVUFBDPNQMFUFSFTFBSDI TUVEZCVUBSFPGQBSUJDVMBSSFMFWBODFPSJNQPSUBODFUPQVCMJDIFBMUIJTTVFTJOUIF3FHJPO BSFPDDBTJPOBMMZDPOTJEFSFEGPSQVCMJDBUJPOĉFUFYUTIPVMEOPUFYDFFEXPSET FYDMVEJOHUIFBDDPNQBOZJOHBCTUSBDU SFGFSFODFT UBCMFTBOEėHVSFT BOETIPVMECF BDDPNQBOJFECZBOBCTUSBDUPGOPUNPSFUIBOXPSETĉFOVNCFSPGUBCMFTBOE ėHVSFTTIPVMEOPUFYDFFEPOFQFSXPSET 12. Ethical considerations:8IFSFBQQMJDBCMF BTUBUFNFOUNVTUCFJODMVEFE JOEJDBUJOHBQQSPWBMGPSUIFTUVEZXBTHSBOUFECZUIFFUIJDTDPNNJĨFFJOTUJUVUJPOBM SFWJFXCPBSEPGUIFSFMFWBOUJOTUJUVUJPO "VUIPSTTIPVMEWFSJGZXIFSFBQQSPQSJBUFUIBUBMMQFSTPOTPOXIPNSFTFBSDIIBTCFFO DBSSJFEPVUIBWFHJWFOUIFJSWPMVOUBSZ JOGPSNFE XSJĨFODPOTFOU BOEXIFSFQBSUJDJQBOUT MJWJOHPSEFBE XFSFVOBCMFUPHJWFTVDIDPOTFOU UIBUTVSSPHBUFDPOTFOUXBTPCUBJOFE "VUIPSTNBZCFBTLFEUPTVQQMZTVDIDPOTFOUGPSNT*ODBTFTXIFSFQBSUJDJQBOUTDBOOPU SFBEBOEXSJUF PSBMDPOTFOUJTBDDFQUBCMF 13. 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pbRÐe= ënh= R}x ºUÙ o@í Y phSĆBúÐ ÓÐÚnLøÐ ¼½ ÞnIúÐ h+ëÌ Ón?Î NaUkCÐ DL öN_xí pöhf_CÐ pHkCÐ :p_@Ð}CÐ d6í ëTÚnZCÐcex3ÐÙÎíºphLJíph=nTphLÐípbRÐYÐbRÐí{SºrUÐgdeIx|UÐ {Sí gýnhUíÌpbRÐYDLé["ÐxºpbRÐCÐì|wÊn]LÎYðn>ÐYÌêÌÐinTðÐÊnhAÌ ÒÊÐ}bUn=NTÚnZCÐênCÎê{LpUnA:Aíºì|wpbRÐCÐÕÙ5ix{b>NaUkCÐYod]x phgaZUÐpbRÐCÐb>{bRºp=ncUÐí yUn[CÐ : ÑÚn\> ïÌ yx ðninh= ëaUkCÐ ê ö{bx ëÌ `fx yUn[CÐ ÑÚn\> ¼¾ ÓĆCÐ ïÚ}C phUí{UÐ pfdU pxØnIÚüÐ ýø{UÐ OÎ â@}UÐ @}x h[aUn= ph]UÐ ØÚííqRHí}cxnYsYni}=êÐ{HÐ|ö²©íGcUÎcI:ÓnJ]CÐx{b> ¼¿ ÓnJ]edUpfUn=nYÌ A4pSÚUÐÜnbYëcxëÌí Ú]UÐN=NRnYè}> Y pSÚUÐAëcxëÌíºÚ]UÐN=NRnYè}> ðn\xÌohRSÚícI:ê {b>UÐ Óna[UÐY{AÐí@íDLpLn]UÐå>ëÌDLA4 @Ð}CÐ DLÒÚZfYé5LÌïÌÞ[iYØngZHøÐWbxëÌ`fx @Ð}CÐ ¼À ph=}LØÐ{LÎnghdx ëÌíºfUÐ:Ó}gK5dTº @Ð}CÐhS}>ê~dxí phHnHúÐpx{"Ð : ºpeS}Y peýnS : @Ð}CÐ ì|w xí{> `fx 5T [5-8 Ȇ1] Y p_=}Y ÜÐSÌ N= ºUkCÐHÐcYÌëÎphUnUÐÓnYd_CÐ öe\å>ëÌíºpSÚUÐpxn¹:ºpd[afYpaÉ :ÑncUÐíÌphUÐpSÚUÐëÐfLíºgý5HÌYOíúÐæ}AúÐíºNaUkCÐÊ5HÌíÌ YncUÐHøÐ}TÙxºphUÐÓønbedUpfUn=íÅng+}>OÎpRnκphdÉúÐp`dUÐ ºÞ[fUÐ}ýnHíocdUpfUn=íÅÓna[UÐØ{Líº{dCÐSÚOÎpRnün=pdedU ÅPfUÐzxÚn>ípHkCÐíÌïÚnUÐ nfUÐHÐípfx{CÐí{dUÐPfUÐëncY}TÙx =Ð}dU©íGcUüÐëÐf_UÐ}TÙxºqiGiüÐDLðÐWAPf>UÐÞ[fdUpfUn=í UÐÞ[fdUpfUn= n4éÉí}BËzxÚn>ín){gZCÐpa[Un=Þn#Ð(URL) "ýĆYÛí"pedT_xbRéíúÐUkCÐHÐ}T|xºNaUkYp?Ć?Y}TÌnghRèGZx x ëÌ HCÐ çPU ph[UÐ pdCÐ \a> ï|UÐ ÑdH±U pdYÌ Mx nY :í Book: Al Hamza B, Smith A. The fifth sign of identity. Cairo, American University Press, 1990. Journal article: Jones A et al. One day in Tibet. Journal of tautology, 1993, 13(5): 23-7 Document: Al-Itneen M, ed. The principles of uncertainty. Geneva, World Health Organization, 1985 (WHO/DOC/537) Web text: Child growth standards. 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Soudan . Soudan du Sud . Tunisie . Yémen Contents Editorial Less than 1000 days to go for MDGs 4 and 5: where are we and what needs to be done? .............................3 Invited review Reducing the burden of maternal and child morbidity and mortality in the Eastern Mediterranean Region? Yes, we can ..............................................................................................................................................5 Research articles Community participation eludes Pakistan’s maternal, newborn and child health programme .................... 10 Expanding the comprehensive national neonatal screening programme in the United Arab Emirates from 1995 to 2011 .................................................................................................................................................17 Prevalence and factors associated with exclusive breastfeeding at 6 months of life in Tehran: a population-based study ..................................................................................................................................24 Prevalence of anaemia in preschool children in Karma Albalad area, Northern State, Sudan ...................... 33 Association between dietary habits and body mass index of adolescent females in intermediate schools in Riyadh, Saudi Arabia .........................................................................................................................39 Comparison of two assays in the diagnosis of toxoplasmosis: immunological and molecular .....................46 Prevalence of coeliac disease among adult patients with autoimmune hypothyroidism in Jordan...............51 Physicians’ knowledge, attitude and practices regarding management of medications in Ramadan ...........56 Letter to the Editor Termination of second and early third trimester pregnancy: comparison of 3 methods ...............................63 Eastern Mediterranean Health Journal reviewers’ panel 2013 ...............................................................................64 Guidelines for authors ...............................................................................................................................................65