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ISSN 1020-3397 Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تاسايسلا لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما طسوتلما قشرل ةيحصلا ةلجلما Cover 6.indd 2 5/24/2010 11:46:47 AM Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 16 No. 12 12 ددع شرع سداسلا دلجلما• 2010 • Letter from the Editor ............................................................................................................................................................................................................................................................................................................................1203 Research articles Assessment of core activities and supportive functions for the communicable diseases surveillance system in Khartoum state, Sudan, 2005–2007 N. Sahal, R . Reintjes, E.M. Eltayeb and A.R . Aro ...................................................................................................................................................................................................................................................1204 Clinical spectrum and cytogenetic analysis of Down syndrome patients attending a referral clinic in Jordan M. Kawar, M. Dahabreh and A. Hawamdeh ........................................................................................................................................................................................................................................................... 1211 Atopic profile of asthmatic children in Bahrain K.S. Tabbara, A. Ibrahim, R . Ajjawi and F. Saleh .................................................................................................................................................................................................................................................. 1214 Correction. Implementing the district health system in the framework of primary health care in Pakistan: can the evolving reforms enhance the pace towards the Millennium Development Goals? ..............................................................................................................................................................1220 Antimicrobial resistance of Staphylococcus species isolated from Lebanese dairy-based products O. Zouhairi, I. Saleh, N. Alwan, I. Toufeili, E. Barbour and S. Harakeh ..................................................................................................................................................................................................... 1221 Fluoroquinolone and macrolide co-resistance in clinical isolates of Campylobacter species: a 15-year study in Karachi, Pakistan S. Irfan, A. Ahmad, D. Guhar, E. Khan, F. Malik, S. Mahmood and A. Zafar....................................................................................................................................................................................... 1226 Multisectoral development for improved health outcomes: evaluation of community-based initiatives in the Islamic Republic of Iran M.R. Sheikh, M.M. Afzal, S.Z. Ali, A. Hussain and R . Shehzadi .................................................................................................................................................................................................................1231 Evaluation of capillary blood glucose versus a high-risk questionnaire for screening for undiagnosed diabetes mellitus in Eastern province, Saudi Arabia N.A. Al-Baghli, K.A. Al-Turki, A.J. Al-Ghamdi, K. Prasad, A.Z. Taha and S.M. Al-Almaie.........................................................................................................................................................1237 Prevalence of malocclusions in school-age children attending the orthodontics department of Shiraz University of Medical Sciences M. Oshagh, F. Ghaderi, H.R. Pakshir and A.M. Baghmollai .......................................................................................................................................................................................................................... 1245 Medical interns’ knowledge of tuberculosis and DOTS strategy in northern Islamic Republic of Iran A.R. Charkazi, G. Kouchaki, M. Soleymani Nejad and A.H. Gholizade .................................................................................................................................................................................................1251 Transfusion audit of blood products using the World Health Organization Basic Information Sheet in Qazvin, Islamic Republic of Iran H. Sheikholeslami, C. Kani, P. Fallah-Abed, F. Lalooha and N. Mohammadi ........................................................................................................................................................................................1257 Language barriers in medical education and attitudes towards Arabization of medicine: student and staff perspectives S.M. Sabbour, S.A. Dewedar and S.K. Kandil ......................................................................................................................................................................................................................................................... 1263 Difficulties facing first-year medical students at Umm Alqura University in Saudi Arabia H. Almoallim, S. Aldahlawi, E. Alqahtani, S. Alqurashi and A. Munshi .................................................................................................................................................................................................... 1272 Level of physical activity among teaching and support staff in the education sector in Dohuk, Iraq S.Y. Agha and S.A. Al-Dabbagh ....................................................................................................................................................................................................................................................................................... 1278 Reports Primary health care in the Eastern Mediterranean Region: from Alma-Ata to Doha S. Shawky ..................................................................................................................................................................................................................................................................................................................................... 1285 Experience of cyclone Gonu in the Islamic Republic of Iran: lessons learned F. Panahi, R . Asadollahi, M. Asadollahi and A. Hasani-Bafarani ................................................................................................................................................................................................................. 1290 Case report Abcès du psoas chez une femme enceinte : une observation à Bamako A. Togo, M. Traoré, B. Togo, G. Diallo et M. Keita ................................................................................................................................................................................................................................................ 1295 طسوتلما قشرل ةيحصلا ةلجلما شرع سداسلا دلجلما شرع نياثلا ددعلا 1203 ررحلما نم ةلاسر Letter from the Editor ،ليالحا دلجلما نم يرخلأا ددعلا اذه انل حيتيو .ةيرهشلا اهتعبطو يصرعلا اهرهظمو ،ديدلجا ابهوث في ،طسوتلما قشرل ةيحصلا ةلجلما رودص لىع ضىم ماع ةقرو 186 ـب ًةنراقم كلذو ،ناتسكاب لوح ًاقحلم تلمش ،ةلاقم 233 ةلجلما تشرن ،2010 ماع يفف .ةلجلما رّوـطت راسم راكذـتساو ضارعتسلا – ةصرفلا ينب ةينمزلا ةدلما طسوتم ضفخنا ذإ ،شرنلا رظتنتو لوبقلاب تيظح يتلا ثوحبلا مكارت نم ّدلحا في يربك وحن لىع اذه مهاس دقو .2009 ماع تشرُن ةيثحب انعضو دقف ،صلقتلا في ذخآ تقولا اذهو .2010 ماع ةيانه في رهشأ ةعبسو دحاو ماع لىإ ،2009 ماع ةيانه في رهشأ ةتسو ينماع نم اهشرنو ةلاقلما لوبق .للها ءاش نإ 2011 ماع في رهشأ ةينماث لىع ةدلما ديزت لا نأ اننيعأ بصن ةعجارم في نوثحابلا اهقرغتسي يتلا ةدلماب ًاضيأ رثأتي ،ةلجلما في اهشرن دعوم ينبو ةلاقلما ملاتسا دعوم ينب لصفي يذلا تقولا نأ لىإ انه ةراشلإا ُّدَوَنو ةلجلما تاسايس عم ةمدقلما ثوحبلا قباطت مدع ظحلان ام ًايرثك اننأ لىع ةولاع اذه .ينعجارلماو نيررحلما تاقيلعتو تاظحلام ءوض في متهلااقم صوصن ةطبترلما تاءارجلإا يرسيت ينثحابلا عسُو في نأ لىع ديكأتلا ماقلما اذه في ُّدَوَنو .عجارلما قيسنت ةقيرطو صنلا مجح ماَّيسلاو ،ابه ةصالخا ةيداشرلإا لئلادلا وأ ةولاع دلمج لك نم ددع لوأ في عبطُت لئلادلا هذهو ،طسوتلما قشرل ةيحصلا ةلجلماب ةصالخا ةيداشرلإا لئلادلاب ًاقيثو ًامازتلا اومزتلا ام اذإ ةم َّدقلما مهصوصنب :لياتلا نيورـتكللإا عقولما لىع اهرفاوت لىع http://www.emro.who.int/Publications/EMHJ/AuthorsGuidelines.htm بتكلما في عيزوتلاو ،ةعابطلاو ،ميمصتلا في ينلماعلاو ،ريرحتلا ةئيه ءاضعأو ،ينعجارلماو ،ينهماسلما عيجم لىإ ركشلا ءاجزلإ ةبسانلما هذه مانتغا ُّدَوَن ماك ىوتسم سفن ميدقت صخش لك لصاوي نأ لملأا انوديح ،قدصو ةنامأ لكب ،نحنو .ديدلجا ابهوث في ةلجلما رادصلإ ًادهج وأ ًاتقو اولأي لم نيذلا ،يميلقلإا ديزلماو ،شرنلاب عاسرلإاو ،ةدولجاب ءاقترلاا :في ةلثمتلماو ،طسوتلما قشرل ةيحصلا ةلجملل ةيلبقتسلما يمارلما غولب لىع انتدعاسلم لبقتسلما في لقلأا لىع معدلا دودلحا نم دعبأ وه ام لىإ لصتل ،ةلجلما للاخ نم ةرداصلا فراعلما ثبو شرن قاطن عيسوت عم ،ةيحصلا مظنلا ثوحبو ةيمومعلا ةحصلا لىع زيكرـتلا نم .ةدطوتلما ةيديلقتلا .دصقلا ءارو نم للهاو The redesigned EMHJ has now been running for one year with its new, fresh look and monthly publication. This final issue (no. 12) of the current volume provides us with an opportunity to look back and see how the Journal has further evolved. EMHJ published 233 articles in 2010, which included a supplement on Pakistan, as compared to 186 papers in 2009. This has helped to significantly reduce the backlog of accepted papers awaiting publication; time from acceptance to publication has gone from an average of 2 years 6 months at the end of 2009 to 1 year 7 months at the end of 2010. It is continuing to decrease and in 2011 we aim to bring it to no more than 8 months. The time from submission to publication of an article in EMHJ is, however, also affected by the time taken for authors to revise their manuscripts in the light of editorial and/or reviewers' comments. In addition, we commonly observe that submitted papers do not conform with the Journal policy/guidelines, in particular the size of the manuscript and formatting of the references! We would like to emphasize that authors can facilitate the processing of their submitted manuscripts if they strictly adhere to the EMHJ Guidelines. These are printed in the first issue of each volume as well on our website at http://www.emro.who.int/Publications/EMHJ/Authors- Guidelines.htm. We would like to take this opportunity to thank all our contributors, reviewers, Editorial Board members, as well as the graphics, printing and distribution staff of the Regional Office, who have all put substantial time and effort into producing this new look of the Journal. We sincerely hope that everyone will offer the same level of support in the future as this will help us fulfill the future goals of EMHJ: high quality, faster publication, more focus on public health and health systems research, and a greater reach and dissemina- tion of knowledge produced with the help of EMHJ beyond the established and conventional boundaries. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1204 Assessment of core activities and supportive functions for the communicable diseases surveillance system in Khartoum state, Sudan, 2005–2007 N. Sahal,1 R. Reintjes,2,3 E.M. Eltayeb 4 and A.R. Aro 1 ABSTRACT We conducted a descriptive, retrospective, cross-sectional study to assess the core activities and supportive functions of the communicable diseases surveillance system (CDSS) in Khartoum state, Sudan, for the period 2005–2007. This is the first assessment conducted for CDSS in Khartoum state. The CDSS was studied in terms of core activities and supportive functions. We found that knowledge of the system was 100% at all levels. Data reporting was over the recommended standard of 80% at all levels. Data analysis, epidemic preparedness and feedback were below the recommended standard. All assigned CDSS staff members were trained. Lower levels lacked modern technologies for data reporting and analysis. The CDSS system in Khartoum state is centralized; moreover, the system has not been updated, it is poorly documented and has a shortage of staff at lower levels. 1Unit for Health Promotion Research, Institute of Public Health, University of Southern Denmark, Esbjerg, Denmark (Correspondence to N. Sahal: nhsahal@health.sdu.dk). 2Department of Public Health, Faculty of Life Sciences, Hamburg University of Applied Sciences, Hamburg, Germany. 3Emerging Risks Unit, European Food Safety Authority, Parma, Italy. 4Acute Flaccid Paralysis Surveillance Programme, Federal Ministry of Health, Sudan. Received 13/03/09; accepted: 22/07/09 2007-2005 ،نادوسلا ،موطرلخا ةيلاو في ةيراسلا ضارملأا د ُّصرت ماظنل ةمعادلا فئاظولاو ةيسيئرلا ةطشنلأا مييقت ورأ ايرأ ،بيطلا بوجمح قداصلا ،زنتيجر فلار ،لهس مشاه ءلاجن ةيلاو في ةيراسلا ضارملأا د ُّصرت ماظنل ةمعادلا فئاظولاو ةيسيئرلا ةطشنلأا مييقتل ةَضِرْعَتْسُم ةيداعتسا ةيفصو ةسارد نوثحابلا ىرجأ :ةـصلالخا هفئاظوو هتطشنأ ثيح نم ماظنلا نوثحابلا سرد دقو .موطرلخا ةيلاو في ماظنلا اذله مييقت لوأ وهو ،2007 – 2005 ةرـتفلا في ،نادوسلا ،موطرلخا عيجم في %80 وهو هب صىولما رايعلما قوفي تايطعلما نع غلابلإا ناك ماك .%100 تايوتسلما عيجم في ماظنلا لوح فراعلما نأ اودجوو ،ةمعادلا ،ينب َّردم ماظنلا في ينلماعلا عيجم ناكو .ابه صىولما يرياعلما نم ىندأ تناك دقف تامولعلما عاتجراو ةئبولأل ب ُّهأتلاو تايطعلما ليلتح امأ .تايوتسلما نم نياعيو ،ث َّدمح يرغو ،ًايزكرم ماظنلا اذه نوثحابلا دجوو .اهليلتحو تايطعلما نع غلابلإل ةيصرعلا تاناقتلا دقتفي ىندلأا ىوتسلما ناك ينح في .تايوتسلما عيجم في ينلماعلا ددع ة َّلق نمو ،قيثوتلا فعض Évaluation des activités centrales et des fonctions d’appui du système de surveillance des maladies transmissibles dans l’État de Khartoum (Soudan) de 2005 à 2007 RÉSUMÉ Nous avons conduit une étude descriptive, rétrospective et transversale pour évaluer les activités centrales et les fonctions de soutien du système de surveillance des maladies transmissibles dans l’État de Khartoum (Soudan) de 2005 à 2007. Il s’agit de la première évaluation du système de surveillance des maladies transmissibles dans l’État de Khartoum. Le système de surveillance a été évalué en termes d’activités centrales et de fonctions de soutien. Nous avons observé que la connaissance du système atteignait 100 % à tous les niveaux. La notification des données était supérieure au pourcentage recommandé de 80 % à tous les niveaux également. L’analyse des données, la préparation aux épidémies et le retour d’information étaient insuffisants par rapport aux recommandations. Tous les membres du personnel du système de surveillance des maladies transmissibles en poste avaient reçu une formation. Aux niveaux inférieurs, les technologies modernes faisaient défaut pour la notifification et l’analyse des données. Le système de surveillance des maladies transmissibles de l’État de Khartoum est centralisé. En outre, il souffre d’un retard d’actualisation, d’une documentation médiocre et d’un manque de personnel aux niveaux inférieurs. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1205 Introduction Powerful disease surveillance is consid- ered a vital tool for a powerful response system, which is needed to achieve the goal of communicable diseases control [1]. An effective surveillance system has a major role in providing the necessary information for prevention and control of priority communicable diseases; it is considered an important instrument in public health decision-making [1]. The data provided by a surveillance system are important in monitoring the health status of the population and in detect- ing, preventing and controlling diseases in order to avert major public health problems. Strengthening the disease surveillance and response system is a globally recognized need [2]. Monitoring and evaluation are considered major components of the communicable disease surveillance and response systems; they assist in determining whether the system has achieved its target objectives. Moreover, the results of monitoring and evaluation in terms of outcomes and impact are important for better development of core capacities for the surveillance and response system [3]. Core activities and supportive func- tions are also considered major com- ponents of a communicable disease surveillance system [4]. Core activities are those dealing with case detection, registration, laboratory confirmation, data reporting, data analysis, feedback, and epidemic preparedness and re- sponse [4], while, supportive functions are coordination, supervision, training, and mobilization of resources [4]. The communicable diseases surveil- lance system (CDSS) in Khartoum State was established in 1994 for the collection, analysis and dissemination of communicable diseases data, and is part of the National Surveillance System, also launched in 1994. At first, the system placed emphasis only on malaria with weekly notification from all health fa- cilities using radio stations (n = 107). In January 1999 the system was changed to sentinel sites surveillance (150 sentinel sites), which included 24 hospitals, 91 health centres and dispensaries and 35 nongovernmental organization clinics [5]. The system depends on passive sur- veillance for communicable diseases, which changes to an active system during epidemics or outbreaks. Communicable diseases such as HIV/AIDS, sexually transmitted infections and tuberculosis have separate surveillance systems out- side the integrated CDSS. This leads to an overlap between the systems and to a waste of resources [5]. The data collected are used for plan- ning and monitoring. Hence, there was an urgent need to conduct this study to assess the CDSS and its response capacity to enable the development of a prioritized action plan. The aim of this paper is to assess the core activities and supportive functions of the CDSS in Khartoum state, Sudan, from 2005 to 2007. This is the first assessment con- ducted for CDSS in Khartoum state as an example for a developing country. Methods A descriptive, cross-sectional, retrospec- tive study design was used. The study population comprised all epidemiology departments/units (n = 177) from the 4 levels, state (n = 1), locality (n = 7), health area (n = 19), and health facilities (n = 150), participating in the CDSS. A pilot study was conducted in Omdur- man locality to test the reliability and validity of the survey. The CDSS core activities (case detection, case regis- tration, case confirmation reporting, data analyses and feedback) and CDSS supportive functions (communication, training, supervision and resources) were measured using World Health Organization (WHO) and Centers of Diseases Control (CDC) standards guide for integrated disease surveillance and response indicators in the African Region [6]. We used a records review survey for data collection for the period 1 Janu- ary 2005–31 December 2007. At the locality and health area levels, weekly surveillance reports submitted by all health facilities, report tracking tools, case investigation forms, outbreak re- ports, results of data analysis, epidemic preparedness plans, meeting minutes, schedules and reports for health educa- tion and other activities were reviewed. At the health facility level, patient reg- isters, copies of weekly reports, results of data analysis, schedules and reports for community outreach activities, case investigation forms, and standard case definitions were measured. At the state level, weekly reports submitted by all localities were included. The survey was conducted for all CDSS levels using 4 sets of modified generic WHO ques- tionnaires [6]. In 2008 a review of the records at the central CDSS level, locality and health area levels was conducted by a trained medical doctor and health officer, while 14 experts (7 medical doctors and 7 health officers) trained in research data collection conducted the review at the health facilities level. The first author, us- ing a sample of the health facilities ques- tionnaire, randomly checked the quality of the reviewers’ work. Data from the records review were collected using the standard WHO questionnaire [7]. The analysis was done using SPSS, version 10.0. We used 80% performance at all CDSS levels as the standard benchmark for each indicator, based on the WHO and CDC guide for Africa [6]. Results Presence and objectives of the communicable disease surveillance system The system assessed here, the main system for communicable diseases in the state, functioned on different CDSS levels, but there were also 4 parallel, special systems on these levels such as programmes for the prevention and EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1206 control of tuberculosis, leprosy, AIDS and sexually transmitted infections and poliomyelitis. These systems were not completely integrated; instead, they exchanged data with the poliomyelitis surveillance system. The CDSS had clear, specific, written objectives at the central level. However, the degree of clarity was lower moving down the lev- els of the system. Assessment of core surveillance and response functions Case detection, registration and confirmation Case definition is vital for the communi- cable diseases case detection. A manual of disease-specific case definitions has been distributed to the health facility staff in Khartoum. All staff working at the different CDSS levels knew the dis- eases under surveillance (Table 1). The capacity for transferring communicable disease specimens was 100% at lower levels. However, there were no standard written guidelines for specimen col- lection at any level. About 10% of the health areas had evidence of following- up or keeping specimen results (Table 1). Central hospitals had capacities to confirm by culture the cases of selected priority diseases. The majority of health facilities, district hospitals and health centres, were not able to perform cul- tures for any of the priority diseases. Almost all health facilities had a functioning laboratory, all of which had the ability to collect blood, urine, and stool specimens while less than a quar- ter were able to collect sputum and cer- ebrospinal fluid specimens. Almost all laboratories had all the recommended equipment for the collection of blood, urine and stool samples. Over half of the health facilities had the capacity to keep specimens, while less than a quarter were able to transfer the specimen to the reference laboratories (Table 1). Data reporting, analysis and management All health facilities had an outpatient register, and hospitals had an inpatient register for recording of the cases. Data on selected diseases were extracted and reported to the health area level. All CDSS levels had the recommended standard reporting form for the years 2005–2007 (Table 1). All CDSS per- sonnel agreed that reporting was easy and was not time consuming—the average time for preparing the weekly reports was 1 hour at all levels. All CDSS personnel at the lower levels, i.e. locality, health area and health facility levels, were trained in preparing the communicable diseases surveillance weekly reports. Existence of urgent notification for communicable diseases was found at nearly three quarters of the lower levels, however, there was no evidence that these notifications were sent in the rec- ommended time at all levels (Table 1). Further, there was no evidence of the zero reporting system at lower CDSS levels except in 1 health area. All levels used the standard format for weekly CDSS reports, made at the state level, and all lower levels kept copies of the weekly CDSS reports. No analysis of communicable dis- eases surveillance data was done at the health facilities level, and little was done at other lower levels. All lower levels except health facilities had computers for data management (Table 1). All health facilities recorded and processed their data manually. All localities had an epidemic threshold for the prior- ity diseases such as meningitis, malaria and measles, while health areas had a threshold only for meningitis, and none of the health facilities had an epidemic threshold for priority diseases such as meningitis, malaria and measles. Epidemic preparedness and response A case investigation sheet was used by almost all levels. However, there was no evidence on all recommended cases having a special investigation sheet, ex- cept for 1 area. None of the lower levels had reports for either the acute watery diarrhea outbreak in 2006 or the rift val- ley fever outbreak in 2007. The reports for these outbreaks were available at the state level only. None of the lower levels were aware of the number of cases during outbreaks or of the case fatality rates at their level. None of the lower levels had func- tioning epidemic management com- mittees for the years we studied as the outbreaks were managed centrally. There was no standard, regular rapid response team at any level; instead, it was activated when needed (Table 1). Feedback At the central CDSS level, all localities and health areas produced a regular feedback report to the lower level (Table 1). There was no standard for- mat for the feedback at lower levels, and none had well formulated feedback. Communicable diseases surveillance supportive functions System guidelines and supervision The CDSS had standard guidelines in the form of CDSS manuals, and these were found at the central (state) level and at some of the lower levels (Table 2). However, only about half the lower levels used these guidelines to direct their surveillance activities. The CDSS had a regular supervision system at all levels. About half of the lo- calities and health areas had performed the recommended supervision visits during the study years (Table 2). All CDSS levels used standard checklists for the supervision. On the other hand, no supervision feedback system existed at lower levels. The system existed from the central to local level in 2005. How- ever, none of the localities was there any evidence of this supervision feedback. Human resources and communication Professional, well-trained staff were available at the central level, whereas at the local level the staff consisted of a medical doctor and a health officer, and at the health area level 1 health of- ficer. Furthermore, the staff at these levels took care of the system as well as طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1207 other heavy duties for other preventive medicine departments. At the health fa- cility level the system had only 1 trained staff member conducting surveillance among other duties. Almost all CDSS staff at all levels were trained in commu- nicable diseases surveillance (Table 2). About 90 % of the health facilities had functioning communication methods (Table 2). The weekly epidemiological reports were sent manually/on paper from all levels except for 1 remote health facility, which sent them by phone. Discussion Objectives and guidelines of CDDS CDDS objectives in Khartoum were found to be clear and well documented at the central level only. None of the Table 1 Communicable diseases surveillance system (CDSS) core activities at different levels of CDSS in Khartoum state, 2005–2007 Core activity Locality (n = 7) Health area (n = 19) Health facility (n = 150) Standard benchmark No. % No. % No. % Case detection Knowledge of diseases under surveillance 7 100.0 19 100.0 150 100.0 80 Case confirmation Capacity to transport specimens to higher level 7 100.0 18 94.7 26 17.3 80 Presence of specimen collection guideline 0 0.0 0 0.0 0 0.0 80 Follow-up of specimen results 0 0.0 2 10.5 - NA 80 Keeps the specimen result 0 0.0 0 0.0 - NA 80 Data reporting Availability of CDSS reporting form 7 100.0 19 100.0 150 100.0 80 Average time to prepare the weekly CDSS report (1 hr) 7 100.0 19 100.0 150 100.0 80 Forward urgent notification for list A diseases - NE - NE - NE 80 Submission of urgent notification within 24 hr - NE - NE - NE 80 Presence of zero reporting system 0 0.0 0 0.0 0 0.0 80 Submission of case-based investigation reports for all recommended cases - NE - NE - NE 80 Data analysis Performing trend analysis 7 100.0 19 100.0 0 0.0 80 Use of appropriate source of denominators 0.0 0.0 0.0 80 Aggregate case data by demographic category 7 100.0 19 100.0 150 100.0 80 Epidemic preparedness and response Involved in an outbreak investigation 7 100.0 19 100.0 0 0.0 80 Implementation of community prevention and control measures based on local data 0 0.0 0 0.0 0 0.0 80 Presence of written epidemic preparedness and response plan 0 0.0 0 0.0 0 0.0 80 Presence of emergency stocks of drugs and supplies 0 0.0 0 0.0 0 0.0 80 Existence of epidemic management committee 0 0.0 0 0.0 0 0.0 80 Presence of health education material 0 0.0 0 0.0 - NA 80 Existence of vaccination strategy 7 100.0 19 100.0 - NA 80 Presence of epidemic rapid response team 0 0.0 0 0.0 - NA 80 Performance of mass vaccination campaign 7 100.0 19 100.0 - NA 80 Calculation of vaccination coverage 7 100.0 19 100.0 - NA 80 Feedback Received feedback from a higher level 7 100.0 19 100.0 150 100.0 80 Feedback seen as beneficial 1 14.3 12 63.2 10 10.0 80 NA = not applicable; NE = no evidence. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1208 localities or health areas had written objectives although most of the re- spondents at these levels were fully oriented about them. This shows that the system was well established but lacked documentation at the lower levels. In this respect the CDDS in Khartoum was functioning better than other systems (e.g. the Australian sys- tem) where the objectives were not clear [8]. Most of the CDSS personnel in Khartoum used the standard state guidelines, developed in 2001, to direct their activities. Case detection, registration and confirmation The lack of the manual for disease specific case definitions in the most of the studied health facilities implies that the case detection quality faces serious problems. On the other hand, con- tinuous supervision visits, which are regularly conducted at different levels, improve this situation. Khartoum state seems to be behind the other states in Sudan, where the CDSS manual was available in all health facilities [9], however, the situation in Khartoum was better than that of Uganda where the system lacked standard case defini- tions [10]. Another problem found in Khar- toum was that the CDSS case definition manual had not been updated since 2001. This means that it did not include new emerging diseases such as SARS and avian influenza. In this respect the situation is similar to that in Mozam- bique [6]. Although all health facilities had standard patient registries , in line with 8 other states in Sudan [9], in Khartoum it was not possible to check whether all cases were registered since no system for double checking of the registration was in place. Almost all sentinel sites had well functioning laboratories and health cen- tres. Whereas peripheral hospitals were capable of confirming only simple cases, the central hospitals were much better in confirming communicable diseases, but still viral diseases were not within their capability and confirmation was done at the state referral laboratory. Only half of the health facilities were capable of keeping the specimens; this affects case confirmation and leads to notification of more suspected cases as well as to overestimation of cases in the state. This was similar to the situa- tion in the other Sudanese states [9]. Table 2 Assessment of the communicable diseases surveillance system (CDSS) supportive functions at different levels of CDSS in Khartoum state, 2005–2007 Supportive functions Locality (n = 7) Health areas (n = 19) Health facility (n = 150) Standard benchmark No. % No. % No. % % CDSS manual Presence of the CDSS manual 5 71.4 14 73.7 20 13.3 80 Use of the CDSS manual to guide the surveillance activities 3 60.0 6 46.2 13 65.0 80 Training Training of the rapid response team - NA - NA - NA 80 Basic training on CDSS 7 100.0 19 100.0 131 87.3 80 Post basic training on CDSS 7 100.0 19 100.0 74.5 80 Supervision Presence of supervisory visits to the lower level 3 42.9 9 47.4 - NA 80 Review of CDSS activities during the supervisory visit 2 28.6 3 15.8 - NE 80 Existence of supervisory visit feedback system 0 0.0 0 0.0 0 0.0 80 Implementation of supervisory visit recommendation - NE - NE - NE 80 Resources Presence of office 7 100.0 16 84.2 150 100.0 80 Presence of functioning telephone 7 100.0 19 100.0 134 89.3 80 Presence of functioning means of transportation 7 100.0 14 73.7 NA 80 Availability of functioning computer 7 100.0 19 100.0 22 14.7 80 Availability of functioning photocopier 0 0.0 0 0.0 0 0.0 80 Availability of functioning spray pump 1 14.3 0 0.0 0 0.0 80 Availability of disinfection materials 1 14.3 0 0.0 98 65.3 80 Availability of protection materials 1 14.3 0 0.0 91 60.7 80 NA = not applicable; NE = no evidence. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1209 Surveillance data reporting and management The cornerstone of the surveillance system, registration and reporting of priority diseases, was well constructed since all CDSS levels in Khartoum state used the standard data reporting form. However, problems such as no update of the standard form since its estab- lishment and manual data reporting, especially at lower levels (as in other Sudanese states [9]), which leads to reduced data accuracy, weaken the sys- tem. On the other hand, the CDSS was concerned with reporting of important communicable diseases only and was not overloaded with unnecessary data as has been reported from the Armenian surveillance system [11]. In the integrated disease surveillance strategy the data collected should be analysed and used for action, especially at the health facility level [1]. Poor data analysis at the lower levels in Khartoum actually indicates a centralized system, which leads to the absence of proper scientific interpretation of the collected data. In this respect the situation resem- bles that of the other Sudanese states [9], South Africa [12] and Mali and Ghana [13]. Continuous, systematic and more detailed analysis of all data re- ported at lower levels should be done to keep track of the disease situation in the area and to maximize and strengthen CDSS effectiveness at lower levels. Another failure of the CDSS data analysis in Khartoum, lack of an ap- propriate denominator for data analysis, e.g. population per area in the lower levels, means that none of the localities or health areas had a clear idea about the true magnitude of the communicable diseases in their area (except for men- ingitis due to the special programme). This negatively affects the use of sur- veillance data to perform the recom- mended actions in time, and it might also affect early detection of epidemics. Similarly, proper and early action for epidemics is hindered by the fact that neither health areas nor health facilities had any epidemic threshold. Epidemic preparedness and response Khartoum state has experienced out- breaks of cholera and Hemorrhagic fe- ver in the period 2005–2007. However, neither regular epidemic management committees nor rapid response teams were found at any level as only during epidemics were meetings and teams ar- ranged, and in most cases there were no records of the meetings. Furthermore, the lower levels of CDSS had no writ- ten epidemic management plan, which affects the effectiveness of organized response to outbreaks. In this respect the Khartoum system was weaker than that in the other states of Sudan [9] but similar to those in Mozambique [6] and Ghana [14]. Monitoring and evaluation of the actions taken suffers from the absence of epidemic management documenta- tion at lower levels of the CDSS system. Further, not knowing the defects of the epidemic response system means that the defects cannot be corrected. The problem seems to be common also in other Sudanese states [9]. In addition, the central, state level stockpiling of drugs and vaccines might delay a quick response to epidemics at other levels. This seems to be a common problem in Sudan [9], Mozambique [6] and in most African countries [14]. Addition- ally, stopping of the regular vaccination campaign for communicable diseases such as meningitis in 2005 breaks the disease prevention chain and will lead to outbreaks in the coming years. This shows that the CDSS (in African coun- tries) lacks proper planning as the cost of epidemics will be much greater than the cost of campaigns. Feedback, supervision, human resources and training It seems that the absence of stand- ardization and regularity of feedback in the CDSS in Khartoum results in half of the CDSS personnel rating it as non-beneficial, as extra workload and a waste of time. In the absence of feed- back, regular standardized supervision provides quality checks and job training but it hampers achievement of the rec- ommended goals and is also a waste of resources within CDSS. The problems in this respect seems to be similar to those in other Sudanese states [9] and in Ethiopia [15]. The CDSS system in Khartoum as well as elsewhere in Sudan [9] has well- trained professional staff at the state level. However, in Khartoum the system is fac- ing shortages of staff at lower levels where the staff conduct surveillance activities along witho other preventive medicine activities. High work overload at those levels affects the quality of the CDSS activities. It has been pointed out that par- ticipants in the surveillance system should be properly trained for their surveillance tasks through both initial and ongoing in-service training [16]. In this respect the situation in Khartoum is better than in Tanzania [4] and Uganda [10]. Based on our findings, the CDSS in Khartoum state needs to strengthen the core and support functions of surveil- lance at all levels of the health system. Formulation of clear written objectives for CDSS at all levels should be the first priority. CDSS data are often not adequately analysed or used to evaluate the effectiveness of intervention pro- grammes. Thus, urgent intervention is needed to build an updated, advanced data analysis system, both for routine surveillance and for outbreaks, to make use of the large amount of data collected at different levels. Furthermore, the sys- tem should implement proper docu- mentation methods for all the CDSS data collected, mainly for the urgent notification of communicable diseases and outbreaks data as well as for zero reporting. In addition, the surveillance system needs to develop a standard, regular, effective feedback system. The challenge is to respond quickly and properly to epidemics, thus the forma- tion of a standard rapid response team at all levels is the very first step in build- ing effective epidemic preparedness in Khartoum state. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1210 Strengthening of CDSS supportive functions in Khartoum state is needed. Adequate human resources at lower levels of the surveillance system as well as the creation of an incentive system, which would maintain commitment to CDSS among the personnel, is needed. Provision of supported, documented supervisory visits to the different lev- els and timely feedback might create additional support to sustain an effec- tive CDSS that guides public health decision-making in Khartoum state. In conclusion, well-functioning core activities and supportive functions are the basis of the CDSS to achieve its aim in communicable disease prevention and control. The CDSS in Khartoum state is an old system that adopts the idea of integrated communicable diseases surveillance [17]. The system seems to be functioning well as it has clear objectives and guidelines at the state level but it still has many defects and is facing many challenges. Although the system appears decentralized, there are a number of items, such as data analysis and epidemic management, which are centralized. The Khartoum system was poorly documented at the lower levels, References Pan American Health Organization. An integrated approach 1. to communicable disease surveillance. Epidemiological Bul- letin, 2000, 21(1):1–4 (http://www.paho.org/English/SHA/ EB_v21n1.pdf, accessed 1 September 2007). Communicable disease surveillance and response systems, a 2. guide to planning. Geneva, World Health Organization, 2006 (WHO/CDS/EPR/LYO/2006.1). Technical review on monitoring and evaluation protocol for com-3. municable disease surveillance and response systems. Geneva, World Health Organization, 2004 (http://whqlibdoc.who. int/hq/2004/WHO_CDS_CSR_LYO_2004.15_eng.pdf, ac- cessed 18 October 2010). Nsubuga P et al. Structure and performance of infectious disease 4. surveillance and response, United Republic of Tanzania, 1998. Bulletin of the World Health Organization, 2002, 80(3):196–203 (http://www.who.int/bulletin/ archives/80(3)196.pdf, ac- cessed 1 September 2007). A report of strategic plan for National Communicable Disease 5. Surveillance in Sudan. Khartoum, Ministry of Health, Epidemi- ology Department, 1996. Guide for the use of core integrated disease surveillance and re-6. sponse indicators in the African Region. Geneva, World Health Organization, 2005 (http://www.cdc.gov/idsr/files/guide. pdf, accessed 1 September 2008). Protocol for the assessment of national communicable disease 7. surveillance and response systems, annex 12: Generic question- naires. Geneva, World Health Organization, 2001 (WHO/ CDS/CSR/ISR/2001.2) (http://www.who.int/csr/resources/ publications/surveillance/whocdscsrisr20012a.pdf, accessed 14 October 2010). Miller M et al. Evaluation of Australia’s National Notifiable 8. Disease Surveillance System. Communicable Diseases Interna- tional, 2004, 28:311–323. Mahdi TF. 9. An interventional study to strengthen the national com- municable disease surveillance and response systems in Sudan. Khartoum, Khartoum State Ministry of Health (research docu- ments), 2003. Assessment of Infectious Disease Surveillance Uganda. 10. Mor- bidity and Mortality Weekly Reports, 2000, 49:687–691. Tadesse W et al. Assessment of the infectious diseases sur-11. veillance system of the Republic of Armenia: an example of surveillance in the Republics of the former Soviet Union. BMC Public Health, 2002, 2(3) (http://www.biomedcentral. com/1471–2458/2/3, accessed 14 October 2010). Weber IB, Matjila MJ, Harris BN. Evaluation of the notifiable 12. disease surveillance system in Gauteng Province, South Africa. The Afrihealth post-conference information, 2007 (http://upetd.up.ac.za/thesis/available/etd-07302008- 141155/unrestricted/dissertation.pdf, accessed 18 October 2010). The implementation of integrated disease surveillance and 13. response in the African and Eastern Mediterranean Regions, 2003. Atlanta, Georgia, Centers for Disease Control and Prevention, 2003 (http://www.cdc.gov/idsr/focus/surv_ sys_strengthening/doc_idsr_implement.pdf, accessed 18 October 2010). Integrated Disease Surveillance and Response. Integrated Disease 14. Surveillance and Response Update Bulletin 2003. Washing- ton DC, Support for Analysis and Research in Africa (SARA) Project, 2003 (http://www.cdc.gov/idsr/focus/advocacy/ policy_briefsENG.pdf, accessed 17 October 2010). Assessment of the national communicable disease surveil-15. lance and response system, Ethiopia. Bulletin of the World Health Organization, 2001, 76:9–16. Integrated approach to communicable disease surveillance. 16. Ottawa, Public Health Agency of Canada, 2000 (http://www. phac-aspc.gc.ca/publicat/ccdr-rmtc/00vol26/dr2607eb. html, accessed 14 October 2010). Sahal N, Reintjes R, Aro AR. Communicable diseases sur-17. veillance lessons learned from developed and develop- ing countries. Scandinavian Journal of Public Health, 2009, 37(2):187–200. the system was not updated, and it lacked a proper feedback system for both data reporting and supervision. The system also faced the problem of staff shortages at lower levels. In addition, epidemic preparedness was centrally organized and was functioning poorly at lower levels. Laboratory capacity was poor at lower levels. Overall, the existing CDSS in Khar- toum state needs to be strengthened with more-effective coordination so that it can work at its optimum capacity to achieve the global goal of prevention and control of communicable diseases. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1211 Clinical spectrum and cytogenetic analysis of Down syndrome patients attending a referral clinic in Jordan M. Kawar,1 M. Dahabreh1 and A. Hawamdeh1 ABSTRACT The spectrum of medical conditions and the cytogenetic profile in all children with Down syndrome attending a referral clinic in Amman, Jordan over a 1-year period was described. A total of 33 patients (18 females, 15 males) attended, aged from day 1 to 14 years. Median maternal age at the time of delivery was 31.5 years. Eleven (33%) children had a mild to moderate conductive hearing loss, 5 (15%) had sensorineural hearing loss. 9 (27%) had refractive error and 3 (9%) showed Brushfield spots. Primary hypothyroidism was documented in 10 (30%) children. Congenital cardiac defects were found in 22 (67%) children; the most common was atrial or ventral septal defect. Cytogenetic testing results revealed that 28 (85%) had trisomy 21 (3 had translocation and 2 showed mosaic pattern). The clinical profile of Down syndrome patients at our centre varies from reports from other centres. 1Department of Paediatrics, King Hussein Medical Centre, Amman, Jordan (Correspondence to M. Dahabreh: munamd@gmail.com). Received: 23/03/09; accepted: 26/07/09 ندرلأا في ةلاحلإل ةدايع لىع نيددرـتلما نواد ةمزلاتمب ينباصلما ىدل ةيوللخا تايثارولاو يريسرلا فيطلا ليلتح ةدماولحا ليع ،ةرباحد لبقم ىنم ،راوعق ليمإ ىنم نيددرـتلما نواد ةمزلاتمب ينباصلما لافطلأا عيجم ىدل ةيوللخا تايثارولا مسترمو ةيريسرلا تلاالحا فيط ةقرولا هذه في نوثحابلا فصي :ةـصلالخا ينب حوارـتت رماعأ في ةدايعلا لىع اوددرت نمم )ًاركذ 15و ىثنأ 18( ًاضيرم 33 ةساردلا تلمشو .دحاو ماع للاخ ،ندرلأا ،ن َّاماع في ةلاحلإل ةدايع لىع ناكو ،طسوتم لىإ فيفخ ليقن عمس دقف )%33( ًلافط 11 ىدل ناكو .ًاماع 31.5 ةدلاولا تقو تاهملأل يطسولا رمعلا ناك دقو .ًاماع 14و ٍدحاو ٍموي قيثوت نكمأو .دليفشرب عَقُب )%9( مهنم 3 ىدلو ،ةيؤرلا في يراسكنا للخ )%27( مهنم 9 ىدل ناكو .سيح يبصع عمس دقف )%15( مهنم 5 ىدل زجالحا بيع ًاعويش اهرثكأ ناكو ؛)%67( مهنم 22 ىدل ةيبلق ةيدلاو بويع دوجو ظحول ماك .)%30( مهنم 10 ىدل ليولأا ةيقردلا روصق ثودح مهنم 3 ىدلو ،21 يغبصلا ث ُّلثت )%85( ًلافط 28 ىدل ترهظأ دقف ةيوللخا ةيثارولا تارابتخلاا جئاتن امأ . ْنينَنْنيَطُبلا ينب زجالحا بيعو ْنينَنْنيَذُلأا ينب يذلا زكرلما في نواد ةمزلاتمب ينباصملل يريسرلا مسترلما نأ نوثحابلا جتنتساو .يئافسيسف جذومن مهنم يننثا ىدلو )عقاولما في ًايرغت( ًايغبص ًءافزإ .ىرخلأا زكارلما نع تردص يتلا ريراقتلا نع فلتيخ هيف نولمعي Spectre clinique et analyse cytogénétique des patients atteints du Syndrome de Down en consultation dans une clinique de recours en Jordanie RÉSUMÉ Le spectre des affections médicales et le profil cytogénétique de tous les enfants atteints du Syndrome de Down consultant dans une clinique de recours à Amman (Jordanie), pendant un an, ont été décrits. Au total, 33 patients (18 filles, 15 garçons), âgés d’un jour à 14 ans, ont été vus en consultation. L’âge médian de la mère à l’accouchement était de 31,5 ans. Onze enfants (33 %) souffraient d’une surdité de transmission légère à modérée et cinq enfants (15 %) étaient atteints d’une surdité neurosensorielle. Neuf enfants (27 %) étaient porteurs d’un vice de réfraction et trois enfants (9 %) présentaient des taches de Brushfield. Une hypothyroïdie primaire a été observée chez dix enfants (30 %). Des malformations cardiaques congénitales ont été diagnostiquées chez 22 enfants (67 %), la communication interauriculaire ou interventriculaire étant la pathologie la plus fréquente. Les résultats des analyses cytogénétiques ont révélé que 28 enfants (85 %) étaient porteurs de trisomie 21 (trois cas par translocation et deux cas en mosaïque). Le profil clinique des patients atteints du Syndrome de Down dans notre centre diffère des rapports issus des autres centres. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1212 Introduction Down syndrome is one of the most common chromosomal disorders in children and is considered the leading cause of noninherited mental retarda- tion [1]. The prevalence has been re- ported in some studies to be 1/800 [1]. Down syndrome involves different body systems [1,2]. Not only do these children have characteristic physical features, they also have multiple medical conditions and malformations [3,4]. The occurrence of these malformations varies across different studies [4]. The genetics clinic at King Hussein Medical Centre was the first in Amman. It accepts patients from different centres and hospitals from all over Jordan. This study was important to check the pat- tern of referred cases and to compare it with that of other centres. The purpose of this case series was to describe the spectrum of medical conditions and cytogenetic profile of children with Down syndrome referred to a genetic clinic in Amman, Jordan. Methods A prospective study was conducted on all children with the diagnosis of Down syndrome who were referred to the genetics clinic at King Hussein Medical Centre, Amman, Jordan, from January 2004 to January 2005. A total of 33 patients were included, aged from 1 day to 14 years. The data collected included ma- ternal and paternal age at diagnosis. Thyroid function tests, ophthalmology examination and hearing assessment tests were performed for all patients. All children had a cardiac review and echocardiography examination. Chro- mosomal testing was done for all those included. Ethical committee approval for the study was obtained. Results There were 33 children with Down syndrome who attended the genet- ics clinic during the study period: 18 (55%) females and 15 (45%) males). The median maternal age at the time of delivery was 31.5 years; 10 (30%) mothers were aged 17–20 years, 15 (45%) were 20–35 years and 8 (25%) were 36–46 years. Normal hearing results were found in 17 (52%) children, 11 (33%) had mild to moderate conductive hearing loss, while 5 (15%) had sensorineural hearing loss. Eye examinations showed that 9 (27%) had refractive error and 3 (9%) had Brushfield spots. Primary hypothyroidism was docu- mented in 10 (30%) children; 2 of our patients developed hypothyroidism at an older age but none of them had autoimmune antibodies. Congenital cardiac defects were found in 22 (67%) children. Cyanotic congenital heart dis- ease was found in less than 5%: the most common was atrial or ventricular septal defect in 20/22 of these cases (90%). Cytogenetic testing results revealed that 28 (85%) had trisomy 21; 3 (9%) had translocation, 1 of which was a de novo 21,21 translocation, and 2 (6%) showed mosaic pattern. Discussion There is a well established relation- ship between older maternal age and increased incidence of Down syndrome in the offspring [5]. In our study the me- dian maternal age at the time of delivery was 31.5 years. This is consistent with a study in Dubai where the mean age was 33.5 years [6]. The mean maternal age in a study by Kava et al. in India was 26.8 years [5]. This may be explained by the higher fertility rate in this younger reproductive age group. A high propor- tion of the mothers in our case series (45%) were between 20 and 30 years of age. These mothers are considered to be at low risk and do not usually undergo antenatal screening. Mothers who would usually be considered as high risk (above 35 years of age) formed only 25% of our study group. Nondisjunction (trisomy 21) is the most common genetic defect found in Down syndrome [7] and we found this in 85% of cases; mosaic pattern was found in 2 patients (6%). This is higher than that reported worldwide (< 1%) [7,8]. This may be explained by the small number of patients studied. One of our patients had de novo 21,21 trans- location. There is a well known risk of auto immune diseases in these children, involving both the endocrine and the nonendocrine systems [3,4]. The most common autoimmune disease in Down syndrome is related to the thyroid gland [9]. The current recommendations are to screen annually for thyroid function in children with Down syndrome [9]. Congenital hypothyroidism has been reported to be about 30 times more common in Down syndrome [9] and 8/33 patients in our study had con- genital hypothyroidism, while 2 patients acquired hypothyroidism at an older age. In contrast to our findings, Karlsson in Sweden had no cases of congenital hypothyroidism in his study group of 85 patients [10]. He also demonstrated a gradual increase in the concentrations of thyroid autoantibodies from the age of 8 years. All children with Down syndrome, even if clinically asymptomatic, should undergo 2D echocardiography [11]. We found congenital cardiac defects in 22/33 (67%) of our children. Cyanotic congenital heart disease was found in less than 5%. The most common was atrial or ventricular septal defect in 20 of these cases. This is higher than figures reported worldwide (50%) [11]. Kava et al. in a study of 524 Down syndrome طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1213 patients in India reported an incidence of congenital heart disease of 18%, with 25% of these cases having ventricular septal defect [5]. In general most patients with Down syndrome have Brushfield spots during eye examination. In our case series 9% of patients had Brushfield spots. Interest- ingly, none of the patients with Down syndrome in a Hong Kong University study had Brushfield spots [12]. This is also consistent with the results in a Korean population [13]. This can be explained by the high prevalence of dark eyes in our population. Wallis has sug- gested that there is a low prevalence of Brushfield spots in blue or lightcoloured eyes that darken with age [14]. Refrac- tive errors have been demonstrated in 70% of Down syndrome patients [14]. We found such errors in 27% of cases, which is less than what was reported in Hong Kong (58%) [12]. Disorders of the ear, nose and throat may hinder children with Down syn- drome from reaching their develop- mental potential [8]. Mild to moderate conductive hearing loss was seen in 11 children (33%) in our study. This is less than the 50% reported in 26 patients screened in Saudi Arabia [15]. Hearing loss in Down syndrome patients may be due to recurrent otitis media, eustachian tube dysfunction or middle ear ciliary defects [15]. Balkany et al. reported that 78% of patients with Down syndrome had evidence of hearing loss [16]. Five (15%) of our studied group had sen- sorineural hearing loss. None of these patients showed other neurological deficits. Down syndrome is a predisposing factor for sleeprelated breathing dis- orders, and up to 80% of children were found to have sleep apnoea disorders [17]. Such disorders were not studied in our study group as we have limited access to sleep studies in addition to financial limitations. Conclusions The clinical profile of Down syn- drome patients at our centre varies, and is quite different from many other centres. The complexity of the medical condi- tions requires a multidisciplinary team approach and structured protocols. References Jorgenson RJ. 1. Down syndrome. Medicineonline. (http://www. medicineonline.com/topics/D/2/Down-Syndrome.html, ac- cessed 19 October 2010). Bianca S. Non congenital heart disease aspects of Down syn-2. drome. Images in Paediatric Cardiology, 2002, 13:3–11. Chen MH et al. Thyroid dysfunction in patients with Down 3. syndrome. Acta Paediatrica Taiwanica, 2007, 48:191–195. Dzurova D, Pikhart H. Down syndrome, paternal age and edu-4. cation: comparison of California and the Czech Republic. BMC Public Health, 2005, 5:69. Kava MP et al. Down syndrome: clinical profile from India. 5. Archives of Medical Research, 2004, 35:31–35. Murthy SK et al. Incidence of Down syndrome in Dubai, UAE. 6. Medical Principles and Practice, 2007, 16:25–28. Hindley D, Medakkar S. Diagnosis of Down syndrome in ne-7. onates. Archives of Disease in Childhood: Fetal and Neonatal, 2002, 87:F220–F221. Mitchell RMD, Call EMS, Kelly J. Ear, nose and throat disor-8. ders in children with Down syndrome. Laryngoscope, 2003, 113:259–263. Roizen NJ. The early interventionist and the medical problems 9. of the child with Down syndrome. Infants and Young Children, 2003, 16(1):88–95. Karlsson B et al. Thyroid dysfunction in Down’s syndrome: 10. relation to age and thyroid autoimmunity. Archives of Disease in Childhood, 1998, 79:242–245. Behrman RE, Kliegman R, Jenson B. 11. Nelson textbook of pediat- rics, 16th ed. Philadelphia, WB Saunders, 2000. Wong V, Ho D. Ocular abnormalities in Down syndrome: an 12. analysis of 140 Chinese children. Pediatric Neurology, 1997, 16:311–314. Kim JH et al. Characteristic ocular findings in Asian children 13. with Down syndrome. Eye (London, England), 2002, 16:710– 714. Wallis HRE. The significance of Brushfield’s spots in the diag-14. nosis of mongolism in infancy. Archives of Disease in Childhood, 1951, 26:495–500. Kattan HA, Jarrar RF, Mahasin ZZ. A pilot study of the relation-15. ship between Down’s syndrome and hearing loss. Saudi Medi- cal Journal, 2000, 21:931–933. Balkany T et al. Hearing loss in Down’s syndrome. A treatable 16. handicap more common than generally recognized. Clinical Pediatrics, 1979, 18:116–118. Fitzgerald DA, Paul A, Richmond C. Severity of obstructive 17. apnoea in children with Down syndrome who snore. Archives of Disease in Childhood, 2007, 92:423–425. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1214 Atopic profile of asthmatic children in Bahrain K.S. Tabbara,1 A. Ibrahim,2,3 R. Ajjawi 3 and F. Saleh 1,4 ABSTRACT This study aimed to define the profile of asthmatic children in Bahrain and the prevalence of sensitization to aeroallergens and foods. A total of 95 children who were clinically diagnosed with asthma were enrolled: 71.6% mild, 20.0% moderate and 8.4% severe asthma (NIH criteria). Serum IgE concentrations were elevated (> 200 kU/L) in 21.1% of patients and highly elevated (> 400 kU/L) in 9.5%. Absolute eosinophil counts were elevated (> 350 × 106/L) in 54.8%. Overall, 67.4% of children were atopic; 56.8% were sensitive to inhalant allergens and 39.0% to foods. The atopic profile was generally similar to asthmatic children in the region and worldwide. Conditions significantly associated with atopic asthma included food allergies, allergic rhinitis and eczema. 1Department of Microbiology, Immunology and Infectious Diseases; 2Department of Paediatrics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain (Correspondence to K.S. Tabbara: kst1@batelco.com.bh; khaledst@agu.edu.bh). 3Department of Paediatrics; 4Department of Pathology, Salmaniya Medical Complex, Ministry of Health, Manama, Bahrain. Received: 15/03/09; accepted: 27/05/09 نيرحبلا في وبرلاب ينباصلما لافطلأل يب ّـُ تأتلا مسترلما حلاص لضاف ،يواجع مير ،ميهاربإ ليع ،ةرابط ديعس دلاخ ةيئاولها تاجرؤتسملل سسحتلا راشتنا لّدعمو ،نيرحبلا في وبرلاب ينباصلما لافطلأا مَسَترم لىع فرعتلا ةساردلا هذه فدهتست :ةـصلالخا ىدلو ًاطسوتم مهنم %20 ىدلو ًافيفخ مهنم %71.6 ىدل وبرلا ناكو ؛ًايريسر وبرلا ميهدل ص ِّخُش نَّمم ًلافط 95 ةساردلا تلمش دقو .ةمعطلألو 200 نم رثكأ( ةعفترم اهودجوف ،لصلما في IgE يعانلما ينلوبولغلا زيكارت نوثحابلا ساق ماك .)ةحصلل ينطولا دهعلما يرياعم قفو( ًاديدش مهنم %8.4 تاينيزويلأل قلطلما دادعتلا نأ اودجو ماك .مهنم %9.5 ىدل )رـتل/ةدحو وليك 400 نم رثكأ( ًايرثك ةعفترمو ،ضىرلما نم %21.1 في )رـتل/ةدحو وليك تاجرأتسملل ينس ِّسحتم مهنم %56.8 ناكو ،ينبتأتم لافطلأا نم %67.4 ناك لاجملإا هجو لىعو .%54.8 ىدل )رـتل/6 10 × 350 نم رثكأ( ًاعفترم دقو .لماعلا قطانم ىتش فيو ميلقلإا في وبرلاب ينباصلما لافطلأل ًابهاشم ماع لكشب يب ّـُ تأتلا مَسَترلما ناكو .ةمعطلأل ينس ِّسحتم %39و ،ةقشنتسلما .ًايئاصحإ ابه ُّدَتْعُي ةبسنب ةيماعطلا تايجَرلأاو ةميزكلإاو يجَرلأا فنلأا باهتلاب يب ّـُ تأتلا وبرلا تلااح تقفارت Profil atopique des enfants asthmatiques à Bahreïn RÉSUMÉ La présente étude avait pour objectif de définir le profil des enfants asthmatiques à Bahreïn et la prévalence de la sensibilisation aux aéroallergènes et à certains aliments. Au total, 95 enfants ayant fait l’objet d’un diagnostic clinique d’asthme ont été inclus dans l’étude. Selon les critères du National Institute of Health, 71,6 % d’entre eux souffraient d’asthme léger, 20,0 % d’asthme modéré et 8,4 % d’asthme sévère. Les concentrations sériques d’IgE étaient élevées (> 200 kU/l) chez 21,1 % des patients et très élevées (> 400 kU/l) chez 9,5 % des enfants. Le nombre absolu d’éosinophiles était élevé (> 350 × 106/l) chez 54,8 % des patients de l’étude. Globalement, 67,4 % des enfants étaient atopiques ; 56,8 % présentaient une sensibilité aux allergènes inhalés et 39,0 % à certains aliments. Le profil atopique des enfants asthmatiques dans la région était généralement similaire au profil des enfants des autres pays dans le monde. Les affections fortement associées à un asthme atopique étaient les allergies alimentaires, la rhinite allergique et l’eczéma. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1215 Introduction Bronchial asthma is one of the com- monest multifactorial chronic diseases. The worldwide incidence of asthma has been increasing in frequency and sever- ity in recent years, particularly among children and young adults [1], and it has become a leading cause of emergency department admissions and school absenteeism in children. Atopy is the major predisposing factor for asthma in children. It seems likely that atopy results from a deviation of the immune response towards the activation of T- helper type 2 lymphocytes, resulting in a chronic inflammatory response associated with the induction of IgE class antibodies and eosinophilia [2]. The main route of allergen exposure in asthma is by inhalation. Common aeroallergens reflect both the indoor as well as the outdoor flora and fauna of a country. Substances that are gener- ally recognized as important inhalant allergens include pollens, mould spores, house dust mites and insect and animal proteins [3–5]. Food allergy, which has been shown to account for 2% to 8.5% of the underlying allergies in asthmatic children [6], is frequently overlooked in asthma. The prevalence of food al- lergies seems to have increased in the last decade and an accurate history is important in identifying food allergies in patients. Diagnostic tests for food allergies include skin testing and food- specific IgE assay, while oral challenge may be indicated in certain situations. Symptoms of food allergies vary from atopic dermatitis or gastrointestinal symptoms to violent anaphylaxis [7]. Foods that are often implicated in food allergies include egg, milk, nuts, wheat, soya and fish. Sensitization to these is usually acquired in childhood [8]. The desert nature of the Gulf region, coupled with the hot, humid weather predisposes the population to indoor living in an air-conditioned environ- ment for a major part of the year. Re- ported prevalence rates of asthma in the Gulf Cooperative Council (GCC) population range between 8% and 23% [9–12], higher than rates reported in the USA [1] or Europe [13]. Despite the desert environment, pollen is reported to constitute a major sensitizing allergen in several GCC countries [14,15], fol- lowed by indoor allergens, including house dust, animal dander and moulds [15–18]. There are no published studies defining the profile of asthmatic chil- dren in Bahrain and the contribution of aeroallergens and food allergy to the development of this condition in the residents of Bahrain. This study ex- plored the sociodemographic profile and the environmental living conditions of a sample of asthmatic children in Bahrain, including the prevalence of atopic asthma and its association with other atopic diseases in these patients. Methods Sample All 95 consecutive children referred to the Salmaniya Medical Complex (the principal government hospital in Bahrain with a capacity of 1300 beds) between January and December 2000 who were clinically diagnosed with asthma were enrolled in the study. Ethical approval for the study was ob- tained from the research committees of both the Arabian Gulf University and Salmaniya Medical Complex. Oral consent was obtained from the parents of children participating in the study. Data collection Demographic, clinical, allergic and therapeutic histories were collected from the records and the parents of all participants and a questionnaire check- list was filled by the interviewer. Two 5 mL samples of blood were collected from each patient by venepunc- ture. Total white blood cell count was carried out using a Coulter counter (Beckman Coulter). A differential count was carried out using routine procedures and absolute eosinophil counts were calculated. The cutoff for elevated eosi- nophils was > 350 × 106/L. Serum was separated and frozen at –80 °C until assayed for total and allergen-specific IgE. Total serum IgE concentrations were determined by sandwich enzyme-linked immunoassay (ELISA) using a commercial kit (Bethyl Laboratories). Allergen-specific IgE as- says were determined on the Pharmacia UniCap system (Pharmacia Diagnos- tics), a fully integrated and automated ELISA system for measurement of total and allergen-specific IgE. The cutoff for elevated IgE was > 200 kU/L. The determination of sensitivity to inhaled allergens was carried out by in vitro quantitative inhalant allergen- specific IgE test using Phadiatop® (ImmunoCAP), a balanced mixture of common allergens, while sensitivity to food allergens was carried out by a quantitative food allergen-specific IgE using fx5® (ImmunoCAP), a food aller- gen mixture which includes egg white, milk, fish, wheat, peanut and soy bean. The manufacturer’s recommended cut- offs were used. Asthma was defined according to National Institutes of Health (NIH) guidelines as mild (intermittent or persistent) asthma, moderate or severe [19]. Atopy was defined as positivity to either aero- or food allergens or both. Analysis Data compilation, tabulation, and sta- tistical analysis were performed using Windows Excel and SPSS, version 14. The mean values of atopy-positive and atopy-negative patients were compared (atopy being defined as positivity to either Phadiatop or fx5 or both) and significance was calculated using the Student t-test. Mean values of IgE/eosi- nophil counts for the various clinical groups were compared by ANOVA. Other variable were analysed using the chi-squared test. A P value of < 0.05 was considered significant. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1216 Results Background characteristics The 95 children included in this study had been clinically diagnosed with recurrent asthma. At the visit when blood was collected for this study 88% were seen at the pulmonary outpatient paediatric clinic, 9% were admitted for exacerbated asthma and 3% were seen at the accident and emergency depart- ment. The study group included 61 boys and 34 girls (ratio of 1.8:1) with a mean age of 6.8 (SD 3.8) years, range 6 months to 18 years. Most of the patients (82.1%) were Bahraini nationals and the majority were from low-income families (Table 1). Asthma profile Among the children 41.0% developed their first episode of asthma within the first 1 year of life, 58% within the first 2 years and 86% within the first 5 years. The majority of cases (71.6%) were classified as mild (intermittent or persistent) asthma, while 20.0% were moderate and 8.4% severe (Table 2). Asthma severity increased significantly with age (P = 0.001); the mean age of children with mild intermittent asthma was 4.78 (SD 2.97) years, moderate asthma was 8.63 (SD 4.63) years and severe asthma was 9.25 (SD 3.73) years. There were no differences between Bah- rainis and non-Bahrainis with respect to severity or prevalence of atopy (data not shown) (P = 0.751 and P = 0.46 respectively). Atopic profile Of the 95 asthmatic children studied, 56.8% were sensitized to aeroallergens and 39.0% to food allergens; 28.4% were sensitive only to aeroallergens and 10.6% only to foods but not aeroallergens. The overall rate of atopy (sensitization to aeroallergens or foods or both) in our sample was 67.4%. The rate of atopy ap- peared to be higher in girls (76.4%) than boys (62.2%), but this was not statisti- cally significant (P = 0.771), while the rate of food allergy was similar in both boys and girls (39.3% versus 38.2%) (Table 3). Risk factors for atopy We investigated various risk factors that are associated with atopy: 22.1% of asthmatic children were the product of consanguineous marriages and 81.1% had a family history of atopy (Table 4). Around half of the study children (51.6%) were exposed to animals at home, the majority (92.6%) lived in carpeted homes and one-third (31.6%) had a parent who smoked. Almost one-third (31.6%) had at least 1 other associated atopic disease (eczema, allergic rhinitis, allergic con- junctivitis) and 25.3% reported a history of known food allergies. (Table 4) Aller- gic rhinitis was the most prevalent atopy (24.2%), followed by eczema (15.8%), while allergic conjunctivitis (4.2%) was the least prevalent among our sample. Allergic rhinitis was significantly associated with laboratory-confirmed sensitivity to aeroallergens (P = 0.004), while eczema was significantly associated with both sensitivity to aeroallergens (P = 0.048) and to foods (P = 0.018). The only risk factors investigated that were significantly correlated with atopy (sen- sitivity to either food or aeroallergens or both) were history of known food allergies and allergic rhinitis (P = 0.015 and 0.021 respectively) (Table 4). Table 1 Demographic data of asthmatic children Variable Boys Girls Total No. % No. % No. % Total 61 64.2 34 35.8 95 100.0 Nationality Bahraini 49 51.6 29 30.5 78 82.1 Non-Bahraini 12 12.6 5 5.3 17 17.9 Household income (US$ /year)a < 10 000 – – 45 47.4 10–20 000 – – 28 29.5 > 20 000 – – 16 16.8 Mean (SD) age (years) 6.6 (3.8) 7.0 (3.9) 6.8 (3.8) aNo income data available for 6 families. SD = standard deviation. Table 2 Clinical classification of asthmatic children in Bahrain Severity of attacksa Boys (n = 61) Girls (n = 34) Total (n = 95) Age (years) No. % No. % No. % Mean (SD) Mild intermittent 24 39.3 7 20.6 31 32.6 4.78 (3.0) Mild persistent 21 34.4 16 47.0 37 38.9 6.92 (3.4) Moderate 10 16.4 9 26.5 19 20.0 8.63 (4.6) Severe 6 9.8 2 5.9 8 8.4 9.25 (3.7) aNational Institutes of Health criteria [19]. SD = standard deviation. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1217 Laboratory data Serum IgE concentrations were elevated (> 200 kU/L) in 21.1% of patients and highly elevated (> 400 kU/L) in 9.5%, with an overall mean of 113 [standard deviation (SD 171)] kU/L (range 0–1000 kU/L) (Figure 1A). Absolute eosinophil counts were elevated (> 350 × 106/L) in 54.8% of patients, with a mean absolute level of 432 (SD 364) × 106/L (range 0–1600 × 106/L) (Fig- ure 1B). There was a significant difference between the means of atopy-positivity and atopy-negative patients for both total serum IgE concentration and ab- solute eosinophil count (P < 0.001 and P = 0.037 respectively). When analysed separately (sensitization to aeroaller- gens or to food allergens), the differ- ence in means was significant for those who were sensitive to aeroallergens (P < 0.001 and P = 0.002 respectively) but not to food allergens (P = 0.07 and P = 0.302 respectively). There was no significant relationship between clinical severity of asthma and IgE concentra- tion or absolute eosinophil count (P = 0.966 and 0.793, respectively). Discussion This study was undertaken to define the profile of asthmatic children in Bahrain with respect to clinical presentation and allergen laboratory parameters and to determine the frequency of atopic asthma among our sample. Our sample included a predomi- nance of boys compared to girls (ratio of 1.8:1), a finding that agrees with in- ternational [20,21], as well as regional reports [22–24]. The age of onset of asthma in our patients was consistent with those reported from the region [22], but earlier than those reported in industrialized counties, as 58% of our pa- tients, as compared to one-third in Swe- den [25], developed their first episode within their first 2 years of life. Extended enclosed living in air-conditioned build- ings, living in carpeted homes (92.6% of our patients) and contact with animals at home (51.6% of patients) might be contributing factors. Severity of asthma in our patients followed worldwide trends [26,27], with r exseverity increasing with age (P < 0.001), although the percentage of affected children in each category decreased, and there were no significant differences between boys and girls or Bahrainis and non-Bahrainis, suggesting a greater role for environmental than genetic factors. Table 3 Distribution of sensitization to aeroallergens and foods among asthmatic children Sensitivity to: Boys (n = 61) Girls (n = 34) Total (n = 95) Aero-allergensa Foodb No. % No. % No. % – – 23 37.7 8 23.5 30 31.6 + – 14 22.9 13 38.2 27 28.4 – + 4 6.5 6 17.6 10 10.6 + + 20 32.8 7 20.6 27 28.4 aPhadiatop® positive; bfx5® positive. Table 4 Risk factors for atopy and the significance of their correlation with various sensitization groups for asthmatic children in Bahrain Risk factor Total Correlation (P-values) with sensitivity to: No. (n= 95) % Aero-allergensa (n = 54 ) Foodsb (n = 37 ) Either aero-allergens or foodsc (n = 64) Consanguinous marriage 21 22.1 0.975 0.166 0.653 Carpeted home 88 92.6 0.60 0.02 0.38 Exposure to animals at home 49 51.6 0.899 0.398 0.694 Smoker in house 30 31.6 0.169 0.78 0.674 Family history of atopy 77 81.1 0.685 0.473 0.062 Other atopic conditions Known food allergies 24 25.3 < 0.001 0.789 0.015 Allergic rhinitis 23 24.2 0.004 0.642 0.021 Eczema 15 15.8 0.048 0.018 0.256 Allergic conjunctivitis 4 4.2 0.454 0.548 0.739 aPhadiatop® positive; bfx5® positive; cPhadiatop® or fx5® positive. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1218 The majority of participants (81.1%) had a family history of atopy, which agrees with other international studies [20]. The overall rate of atopy (sensi- tization to aeroallergens or foods or both) in our sample was 67.4%, which is consistent with reports from industrial- ized countries such as the USA [20]. Of these, 56.4% were sensitized to aeroal- lergens and 39.0% to foods. Food allergy has been reported to be prevalent in asthmatic children [28,29], to be a risk factor for asthma [29] and to trigger or exacerbate bronchoconstriction in 2%–8.5% of children with asthma [6]. Although we observed a significant association between food allergy and atopic asthma, the actual impact of food allergies in triggering or exacerbating asthma was not assessed in this study. A high degree of consanguinity has been reported in the parents of asth- matic children in our region (52%) [23]. Although Bahrain is an island and marriage within families is common, our data showed a low rate of consan- guineous marriage among the parents of asthmatic children (22.1%). The rate of consanguinity in 1990 in a sample of 500 people was 39.4% [30] Figure 1 (A) Total serum IgE concentrations and (B) absolute eosinophil counts of children with atopic asthma 6 طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1219 Atopic diseases including allergic rhinitis and eczema, which are known to be highly associated with asthma in children [31–33], were similarly preva- lent in our study population. Allergic rhinitis was most prevalent, followed by eczema, while allergic conjunctivitis was least prevalent among our sample. Aller- gic rhinitis was significantly associated with sensitivity to aeroallergens, while eczema was significantly associated sen- sitivity to aeroallergens and to foods. Reference values for total IgE for non-atopic adults vary in different coun- tries [34–36], with high values being reported in the Gulf region [34] com- pared with Europe [34,36]. These val- ues are generally lower in children than adults and increase with age [37,38]. The range of serum IgE values of our patients was 0–1000 kU/L, mean 113 kU/L. A significant correlation existed between IgE concentrations and atopy, but not with severity of asthma. The range of absolute eosinophil count was 0–1600 × 106/L and was elevated in 54.8% of our patients. There was a positive relationship between increased absolute eosinophil count and atopy, particularly to aeroallergens; however this did not correlate with se- verity of asthma. Blood eosinophilia is seen in atopy and is influenced by several conditions including parasitic infections and corticosteroid therapy [39,40]. In many ways health provision in Bahrain shares many of the character- istics of health services in the advanced industrial countries. The infant mortal- ity rate is among the lowest in the Mid- dle East [41] and parasitic infections are uncommon. In conclusion, 67.4% of asthmatic children in Bahrain were atopic and a high proportion (58%) had their first episode of asthma within their first 2 years. A significant number were sen- sitized to foods and had other associ- ated atopic diseases, including allergic rhinitis and eczema, but their atopic profile was generally similar to other asthmatic children in the region and worldwide. The prevalence of asthma and the identity of specific allergens in asthmatics in Bahrain are still un- known. We are investigating these parameters. 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Allergy Proceedings, 1995, 16(2):63–66. 2010 world population data sheet41. . Population reference bureau [website] (http://www.prb.org/Publications/ Datasheets/2010/2010wpds.aspx, accessed 19 October 2010). Correction Implementing the district health system in the framework of primary health care in Pakistan: can the eveolving reforms enhance the pace towards the Millennium Development Goals? F. Sabih, K.M. Bile, W. Guehler, A. Hafeez, S. Nishtar and S. Siddiqi. Eastern Mediterranean Health Journal, 2010, 16(Suppl.):S132–S144. On page S136, column 3, under “Health workforce”, on lines 9 and 12, “Lady Health Visitors” should read “Lady Health Workers”. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1221 Antimicrobial resistance of Staphylococcus species isolated from Lebanese dairy-based products O. Zouhairi,1 I. Saleh,1 N. Alwan,1 I. Toufeili,2 E. Barbour 3 and S. Harakeh1 ABSTRACT The study evaluated the antimicrobial resistance of molecularly characterized strains of Staphylococcus aureus and S. saprophyticus isolated from 3 Lebanese dairy-based food products that are sometimes consumed raw: kishk, shanklish and baladi cheese. Suspected Staphylococcus isolates were identified initially using standard biochemical tests, then strains that were confirmed by polymerase chain reaction (29 S. aureus and 17 S. saprophyticus) were evaluated for their susceptibility to different antimicrobials. The highest levels of contamination with staphylococci were in baladi cheese. Resistance rates ranged from 67% to gentamicin to 94% to oxacillin and clindamycin. The results suggest that these locally made dairy-based foods may act as vehicles for the transmission of antimicrobial-resistant Staphylococcus spp. 1Department of Biology; 2Department of Nutrition and Food Science; 3Department of Animal and Veterinary Sciences, American University of Beirut, Beirut, Lebanon (Correspondence to S. Harakeh: sharakeh@gmail.com). Received: 31/03/09; accepted: 03/06/09 ةينانبللا نابللأا تاجتنم نم ةدرفتسلما تايدوقنعلا عاونأ في ميثارلجا تاداضلم ةمواقلما هكرح فيتس ،روبرب لييإ ،لييفط دماع ،ناولع نيسرن ،حلاص نمايإ ،ييرهز رمع تايدوقنعلاو ةيبهذلا تايدوقنعلا نم ةفورعم ةيئيزج تافصاوم تاذ يرارذ ىدل ميثارلجا تاداضلم ةمواقلما ةساردلا هذه في نوثحابلا مِّيقي :ةـصلالخا نوثحابلا ناكو .يدلبلا نبلجاو ،شيلكنشلاو ،كشكلا يهو ،ةئين كلهتست دق يتلا نابللأا نم ةينانبل ةيماعط تاجتنم ةثلاث نم ةدرفتسلما ةي ِّم ِّرلا د ِّكؤي يتلا يارذلا نومِّيقي مث ،ةيرايعم ةيويح ةيئايميك تارابتخا مادختساب يئدبم لكشب تايدوقنعلا نم انهوكب ةهبتشلما تادَرفتسلما لىع نوفّرعتي تاداضم فلتخلم اهتّيساسح ثيح نم )ةيمرلا ةيدوقنعلا يرارذ نم 17و ةيبهذلا ةيدوقنعلا يرارذ نم 29 يهو( زايرميلوبلل ليسلسلا لعافتلا ينسيماتنلجا هاتج %67 ينب ةمواقلما تلاّدعم تحوارت دقو .يدلبلا نبلجا في تناك تايدوقنعلاب ثولتلا تايوتسم لىعأ نأ نوثحابلا َّنينبتو .تابوركلما ةمواقلما تايدوقنعلا عاونلأ لقانلا رود ي ِّدؤت دق نابللأا نم ًايلمح ةَجَتنلما ةيذغلأا نأ لىع جئاتنلا ّلدتو .ينسيمادنيلكلاو ينليساسكولأا هاتج %94و .ميثارلجا تاداضلم Résistance aux antimicrobiens des espèces du genre Staphylococcus isolées dans des produits libanais dérivés du lait RÉSUMÉ La présente étude a évalué la résistance aux antimicrobiens, après caractérisation moléculaire, de souches de Staphylococcus aureus et S. saprophyticus isolées à partir de trois produits libanais dérivés du lait, parfois consommés crus : le kishk, le shanklish et le fromage baladi. Des isolats suspects de Staphylococcus ont d’abord été identifiés par l’analyse biochimique classique, puis les souches confirmées par amplification en chaîne par polymérase (29 isolats de S. aureus et 17 isolats de S. saprophyticus) ont été analysées pour déterminer leur sensibilité aux différents antimicrobiens. Les taux de contamination par staphylocoques les plus élevés ont été retrouvés dans le fromage baladi. Les taux de résistance allaient de 67 % pour la gentamicine, à 94 % pour l’oxacilline et la clindamycine. Les résultats suggèrent que ces denrées dérivées du lait et produites localement pourraient être des vecteurs de la transmission des espèces Staphylococcus résistantes aux antimicrobiens. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1222 Introduction Milk and milk-based food products are highly susceptible to microbial at- tack because of their rich composition, which provides a favourable medium for growth of a host of spoilage agents [1]. Unpasteurized milk may become contaminated with enterotoxigenic coagulase-positive Staphylococcus spp. [2], either through contact with the cow’s udder during milking or by cross- contamination during processing [3]. Symptoms such as nausea, vomiting, abdominal cramps and diarrhoea usually appear 1–6 hours after ingestion of the enterotoxins produced in contaminated milk [4]. Consequently, enumeration and identification of staphylococci in dairy products is a priority in developing public health measures to reduce food- borne disease outbreaks [5,6]. The uncontrolled application of antimicrobials in the environment is leading to a constant increase in the rate of antimicrobial resistance among community-acquired staphyloco- cci [7,8]. Staphylococcus spp. can rapidly acquire resistance to a broad range of antimicrobials, thereby posing a major concern in the treatment of staphylococcal infections [9]. Study- ing antimicrobial resistance in humans and animals is important for detecting changing patterns of resistance, imple- menting control measures on the use of antimicrobial agents and preventing the spread of multidrug-resistant strains of bacteria [10]. In Lebanon, Ministry of Public Health data showed an increase in the number of reported cases of food poi- soning, from 43 in 2002 to 373 in 2004. Some of these cases were related to the consumption of homemade cheese [11]. The Lebanese Bekaa valley is known for its production of a wide range of dairy products that are consumed all over Lebanon. Most of these foods are produced in “cottage industry” condi- tions using traditional techniques with little emphasis on hygiene practices. The most common Lebanese dairy prod- ucts are baladi cheese (white, semi-soft cheese), kishk (dried, fermented milk– wheat mixture) and shankleesh (cheese balls). The objective of this preliminary study was to assess the prevalence and antimicrobial resistance of S. aureus and S. saprophyticus in baladi cheese, kishk and shankleesh. Identification of these pathogens is important for surveillance, prevention and control of milk-borne diseases. Methods Baladi cheese, shankleesh and kishk were collected randomly from the Bekaa val- ley area of north-east Lebanon. Samples were collected on 4 trips between the months of August and December 2004. Target locations for sample collection included markets, houses and small family farms. In total, 164 samples were collected (83 kishk, 45 baladi cheese and 36 shankleesh). All samples were packaged in sterile bags and kept on ice in a refrigerator until brought to the laboratory. Samples were analysed within 24 hours. Samples were diluted and macerated in a stomacher for 3 minutes. Further se- rial dilutions of samples were inoculated on duplicate plate count agar (for aero- bic plate counts), McConkey agar or violet-red bile agar plates (Oxoid) (for total coliform counts) [12], and man- nitol salt agar (for Staphylococcus spp.) (Oxoid) [7]. Plates were incubated at 37 °C for 24 hours. Identification was carried out us- ing standard methods [13]. All purple colonies on McConkey agar were con- sidered as coliforms. Golden-yellow col- onies surrounded by a yellow halo and white mucoid colonies were considered possible S. aureus and S. saprophyticus respectively, and were selected for fur- ther biochemical and molecular testing. Positive controls were performed by inoculating sterile milk with S. aureus, and S. saprophyticus obtained from the American type culture collection (ATCC), cultured, plated and incubated for 24 hours at 37 °C. Based on Staphylococcus spp. counts, all samples were classified according to Public Health Laboratory Service guidelines [14] as satisfactory, accept- able, unsatisfactory and potentially hazardous. In the case of Staphylococcus spp., a sample was considered poten- tially hazardous if the bacterial count exceeded 103 colony forming units/g. Suspected colonies were character- ized biochemically. Presumptive sta- phylococcal colonies were confirmed by Gram staining. All Gram-positive cocci were divided into species on the basis of the type of haemolysis on blood agar. Colonies showing no haemolysis were suspected to be S. saprophyticus and subjected to PCR confirmation. Isolates showing α-haemolysis were further tested using a latex agglutina- tion test (Pastorex Staph-Plus, BioRad), which is indicative of the presence of S. aureus [15]. PCR was used for further molecular confirmation of the positive isolates [16]. Extraction of DNA from both spe- cies of Gram-positive staphylococci was performed using the GFX Genomic Blood DNA Purification Kit (Amer- sham Biosciences). Amplification was performed from purified genomic DNA. Two sets of primers were used for the detection of Staphylococcus spp. For S. aureus detection, the nucA primer pair, designed by Palomares et al. was used to amplify a 279-bp fragment within the nucA gene. For S. saprophyticus, a primer pair yielding a 380-bp product was used [17]. Negative controls (no DNA tem- plate added) and positive controls (con- taining template DNA from S. aureus, or S. saprophyticus) were included in each PCR reaction performed. An aliquot of 10 μL of each PCR-amplified sample was mixed with 2 μL of 6× loading dye (BioRad) and loaded onto a 1.5% aga- rose gel stained with 0.25 μg ethidium bromide. Electrophoresis of the ampli- fied DNA fragments was carried out in طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1223 0.04 M Tris-acetate/0.001 M EDTA at a constant voltage of 90 V for 100 minutes. The gel was visualized by UV illumination and photographed [8]. Positively identified Staphylococcus strains were tested for their susceptibil- ity to different antimicrobials using the disk diffusion method with incubation at 37 °C overnight [18]. Six different an- timicrobials were used: oxacillin (1 μg), teicoplanin (30 μg), gentamicin (10 μg), clindamycin (2 μg), vancomycin (30 μg) and methicillin (5 μg) (disks supplied by BioMerieux). Isolates were described either as resistant (not inhib- ited), or sensitive (appropriately inhib- ited) based on the size of the inhibition zone [18]. Statistical analysis Statistical analyses were carried out us- ing SPSS, version 11.0. The chi-squared test was used to compare the percent- ages of contamination of the 3 different dairy products tested. Results A total of 321 colonies were identi- fied morphologically as suspected Staphylococcus spp. and were subjected to Gram staining; 254 were identified as Gram-positive cocci. Of these, 78 iso- lates showed no haemolysis on blood agar and were presumed to be S. sapro- phyticus. A total of 146 isolates showed complete lysis on blood agar, which is a typical of S. aureus. Of these, 41 isolates were positive by latex agglutination test and were presumed to be S. aureus. Isolates showing partial haemolysis on blood agar were discarded. Presumed S. saprophyticus and S. aureus isolates were kept and subjected to PCR using specific primers. Of the 41 suspected S. aureus iso- lates, 29 were confirmed by PCR. All 29 isolates gave a clear 279 bp band, with the nucA primer pair (Figure 1). For S. saprophyticus, 17 of the 78 suspected isolates were confirmed using PCR. All 17 gave a 380 bp band with the sta-sap primer pair. Of the 46 PCR-confirmed staphy- lococci isolates, 45 (97.8%) showed resistance to 1 or more antimicrobials while 61.0%, mostly S. aureus, showed resistance to all 6 antimicrobials. The isolates showed highest resistance to oxacillin (93.5%) and clindamy- cin (93.5%), followed by methicillin (84.8%), teicoplanin (76.1%), vancomy- cin (71.7%) and gentamicin (67.4%). Microbiological quality of the tested dairy products Bacterial counts All the cheese, shankleesh and kishk samples had high aerobic plate counts; 76% of baladi cheese samples, 67% of shankleesh samples and 64% of kishk samples were contaminated with Sta- phylococcus spp. According to the guide- lines provided by the Public Health Laboratory Service (PHLS), a sample is considered unfit for consumption if it contains only 1 colony of Staphylo- coccus spp. in 25g of sample. Therefore, all baladi cheese, shankleesh and kishk samples that showed the presence of Staphylococcus spp. were graded as po- tentially hazardous. Cheese samples were of significantly lower microbio- logical quality compared with the other 2 dairy products (P < 0.05). PCR confirmation Out of the 45 baladi cheese samples, 19 (42.2%) were positive for S. aureus and 3 (6.7%) were contaminated with S. sapro- phyticus based on PCR analysis. Only 1 baladi cheese sample was contaminated with both Staphylococcus spp. With re- spect to the 36 shankleesh samples, 2 (5.6%) tested positive for S. aureus and 9 (25.0%) for S. saprophyticus. Only 8 (9.6%) of the 83 kishk samples were contaminated with S. aureus, whereas S. saprophyticus was isolated from only 5 samples (6.0%). Discussion Traditional handmade dairy products may be produced from raw milk heated for only a few minutes to temperatures that are not enough to kill many patho- genic bacteria. The continuous increase in food poisoning cases reported around Lebanon has highlighted the need to monitor the manufacturing of food products in order to avoid future health hazards [11]. Milking operations, 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 1000 bp 279 bp 100 bp Figure 1 Staphylococcus aureus-specific PCR products with the nucA primer pair as analysed on a 1.5% agarose gel. Lane 1: DNA ladder (EZ load 100 bp ruler); lane 2: S. aureus positive strain; lanes 3–4: positives with nucA primer taken from shankleesh samples; lanes 6–8, 12–16 and 19–21: positives with nucA primer taken from cheese samples; lane 22: negative control EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1224 including storage, handling and trans- port of milk to the consumer or the factory, are considered critical points where contamination may occur. The use of mechanical milking equipment and improved sanitary practices has reduced the opportunity for contamina- tion of milk by humans [19]. If raw milk is not rapidly refrigerated, then S. aureus can grow and produce a heat-stable enterotoxin that is usually not destroyed by pasteurization [20]. Staphylococci are halophilic bacteria and are able to survive in conditions of very low mois- ture content. This microorganism grows best on proteinaceous foods such as meat, poultry, milk and their products. With respect to the 3 dairy food types studied, contamination could have occurred at any step of production. One of the crucial steps in the produc- tion of kishk and shankleesh is drying in the open air. At this point, microbial contamination is likely to occur. Pro- duction of kishk involves rubbing of the mix by hand which provides ample op- portunity for bacterial contamination. The major sources of contamination in production of baladi cheese are the milk and manual handling at the different stages of processing. The 3 tested dairy products showed variability in their microbiological quali- ties that may be attributed to differences in their chemical and physical composi- tions. Shankleesh is usually coated with thyme, which has been demonstrated to show inhibitory effects against bacte- ria [21]. Moreover, shankleesh is stored in olive oil, which makes the medium anaerobic thus inhibiting the growth of all aerobic pathogens [22]. The low moisture content of kishk (< 10%), its acidic nature (pH ~ 3.8) and its high salt level (~ 2.8 g NaCl/100 g of the dried product) prevent the growth of most bacterial species [23]. Cheese, on the other hand, is highly susceptible to microbial attack due to its high moisture content and moderate levels of salt. Foodborne diseases, and espe- cially milk-related infections, are not limited to poorer countries. Even in industrialized countries it has been reported that around 2%–6% of the bacterial outbreaks in which the food vehicle is known were related to milk and dairy products [1]. In Lebanon, no previous studies were conducted to evaluate the contamination level of dairy-based foods. Most of the previous studies in Arab countries have investi- gated clinical isolates. However, recent research conducted in Egypt on 152 samples of dairy-based products result- ed in the identification of 16 Cronobacter strains, of which 3 showed resistance to trimethoprim and/or neomycin [24]. The results of that study together with our results show that dairy-based foods might act as sources of contamination for different bacterial strains. Therefore more studies and continuous evalua- tion of the microbiological quality of dairy products in the region are needed. The emergence of antimicrobial- resistant bacteria is common to areas where antimicrobials are carelessly ap- plied. One of the main reasons for the increase in environmental multi-drug resistant bacteria is the indiscriminate use of antimicrobials during animal husbandry. Because of the emergence of such bacteria, antimicrobials used in fighting infections are less effective. It is important to note that S. aureus can easily acquire resistance to most antimicrobials [9]. In Lebanon, the antimicrobial sus- ceptibility of Gram-negative bacteria has been largely determined for clini- cal isolates [25]. However, very little is known about antimicrobial resistance patterns of environmental isolates. In our study, it was striking to note that 97.8% of the tested staphylococcal isolates were resistant to at least 1 anti- microbial. Resistance patterns ranged from 67.4% for gentamicin and 93.5% for both oxacillin and clindamycin. The high resistance towards oxacillin can be explained by the fact that resistance to oxacillin might be either chromo- some- or plasmid-encoded; therefore, it can easily be acquired in nature by horizontal gene transfer [26]. The fact that resistance is high in environmental isolates is mainly because antimicrobi- als are frequently prescribed by veteri- narians as treatment for Gram-negative bacterial infections on farms. Thus, the indiscriminate use of those antimicro- bial agents might account, at least in part, for such a high resistance. This study provides some important baseline data about the contamination status of dairy-based food products in Lebanon and the patterns of resistance of Staphylococcus spp. towards common- ly used antimicrobials. The presence of multi-drug resistant strains is alarming, because such strains are considered a serious danger to public health. 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Cronobacter recov- ered from dried milk and related products. BMC Microbiology, 2009, 9:24. Araj GF. Available laboratory tests to guide antimicrobial 25. therapy. Lebanese Medical Journal, 2000, 48:199–202. Fluit AC, Verhoef J, Schmitz FJ. European SENTRY Participants. 26. Frequency of isolation and antimicrobial resistance of Gram- negative and Gram-positive bacteria from patients in intensive care units of 25 European university hospitals participating in the European arm of the SENTRY Antimicrobial Surveillance Program 1997–1998. European Journal of Clinical Microbiology and Infectious Diseases, 2001, 20:617–625. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1226 Fluoroquinolone and macrolide co-resistance in clinical isolates of Campylobacter species: a 15-year study in Karachi, Pakistan S. Irfan,1 A. Ahmad,1 D. Guhar,1 E. Khan,1 F. Malik,1 S. Mahmood 1 and A. Zafar 1 ABSTRACT Fluoroquinolone and macrolide antibiotics are generally considered as first-line drugs for the treatment of severe campylobacteriosis. This study was conducted to analyse the trend of erythromycin and ofloxacin resistance among Campylobacter spp. isolated from stool specimens over a period of 15 years (1992– 2007) at The Aga Khan University clinical laboratory in Karachi, Pakistan. A total of 83 396 stool specimens were processed, with a 14% isolation rate for enteric pathogens. The isolation rate of Campylobacter spp. was low during 1992–93 (6%–13%), peaked in 1996 (46%), then ranged from 20% to 40%. We report a rising trend in ofloxacin resistance, re-emergence of erythromycin resistance and indications of co-resistance to both drugs in clinical isolates of Campylobacter spp. 1Department of Pathology & Microbiology, Aga Khan University, Karachi, Pakistan (Correspondence to S. Irfan: seema.irfan@aku.edu). Received: 15/01/09; accepted: 05/03/09 ًاماع 15 تقرغتسا ةسارد :فئاطعلا عاونأ نم ةيريسرلا تادَرفتسلما في ديلوركالماو نولونيكورولفلا تابكرلم ةكرـتشلما ةمواقلما ناتسكاب ،شيتاراك في رفظ دهع ،دوممح داش ،كلام لصيف ،ناخ موريإ ،رهوج ناشخرد ،دحمأ ليدع ،نافرع مايس نع ةجمانلا ةيرطلخا ضارملأا ةلجاعلم لولأا طلخا ةيودأ ماع لكشب ديلوركالماو نولونيكورولفلا تابكرم نم ةيويلحا تاداضلما برتعت :ةـصلالخا نم ةدَرفتسلما فئاطعلا عاونأ ىدل ينساسكولفولأاو ينسيمورثيرلإل ةمواقلما هاتجا ليلحتل ةساردلا هذه نوثحابلا ىرجأ دقو .فئاطعلاب ىودعلا ةنيع 83 396 ةساردلا تلمش دقو .ناتسكاب في ،شيتاراك في ناخ اغأ ةعمالج يريسرلا برتخلما في )2007-1992( ًاماع 15 ىدم لىع ةيزارب تانيع لصوو ،)%13 - %6( ًاضفخنم 1993 – 1992 ْنينَماعلا للاخ فئاطعلا عاونأ دارفتسا لدعم ناكو ؛%14 يوعم ضرمم لماع دارفتسا لدعم ناك ،زارب ةمواقلما غوزب ةدوعو ،ينساسكولفولأل ةمواقلما هاتجا في عافترا نع نوثحابلا غ ِّلبيو .%40و %20 ينب حوارـتيل داع مث ،)%46( 1996 ماع هتورذ لىإ .فئاطعلا عاونأ نم تادَرفتسُمـلا في نْنيَءاودلا لاكل ةكرـتشم ةمواقم لىإ يرشت لئلادو ،ينسيمورثيرلإل Co-résistance aux fluoroquinolones et aux macrolides des isolats cliniques de Campylobacter : une étude sur 15 ans à Karachi (Pakistan) RÉSUMÉ Les antibiotiques tels que les fluoroquinolones et les macrolides sont généralement indiqués dans le traitement de première ligne des cas sévères de campylobactériose. La présente étude a été conduite pour analyser la tendance de la résistance à l’érythromycine et à l’ofloxacine des isolats des espèces du genre Campylobacter dans des échantillons de selles recueillis sur une période de quinze ans (de 1992 à 2007) au laboratoire clinique de l’Université Aga Khan à Karachi (Pakistan). Au total, 83 396 échantillons de selles ont été analysés, avec un taux d’isolement de 14 % pour les agents pathogènes intestinaux. Le taux d’isolement de l’espèce Campylobacter est resté faible entre 1992 et 1993 (de 6 % à 13 %), a atteint un pic en 1996 (46 %), puis s’est stabilisé de 20 % à 40 %. Nous avons observé une tendance à l’augmentation de la résistance à l’ofloxacine, une réémergence de la résistance à l’érythromycine et des indications de co-résistance des isolats cliniques de Campylobacter aux deux substances. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1227 Introduction Campylobacter spp. are the leading cause of enteritis in both developing countries and the developed world [1–3]. While a majority of Campylobacter infections are mild self-limiting diarrhoeal ill- nesses, in a proportion of cases severe infections occur, including prolonged enteritis, septicaemia and other extrain- testinal infections [4]. Milder cases of campylobacteriosis do not require an- timicrobial drugs but serious infections need therapy. In addition, immuno- compromised travellers might require prophylaxis and treatment for enteritis [5]. Erythromycin and fluoroquinolone are generally considered as first- and second-line drugs for the treatment of Campylobacter infections. Unfortunately antimicrobial resist- ance against these 2 groups of drug continues to rise throughout the world, especially against fluoroquinolone, resistance to which is rising at an alarming rate [6]. Fluoroquinolone- or macrolide-resistant Campylobacter strains are associated with increased risk of death and invasive disease as well as longer durations of illness in the immunocompetent population [7–9]. Data about the antimicrobial resist- ance of Campylobacter spp. is sparse in the developing world, especially from Pakistan. A study from The Aga Khan University reported Campylobacter spp. as the third most common pathogen in stool specimens [10]. The present study was conducted to analyse the rates of isolation of Campylo- bacter spp. isolated from stool specimens and the trend of fluoroquinolone and macrolide resistance over a period of 15 years at a referral laboratory in Karachi, Pakistan. Methods A retrospective study of stool culture data from January 1992 to June 2007 was conducted at the clinical microbiology laboratory of the Aga Khan University hospital, a tertiary referral centre based in Karachi, Pakistan. The laboratory re- ceives specimens from both inpatients and outpatients from all over the coun- try via its satellite collection centres. The American Society of Microbiol- ogy (ASM) guidelines were used for the culture of stool samples throughout the study period [11]. For the isolation of Campylobacter spp., stool samples were inoculated onto agar-based Campylo- bacter medium, supplemented with 40% haemolysed sheep blood with added antibiotics: trimethoprim, polymyxin B and vancomycin. Plates were incubated for 48 hours in a microaerophilic envi- ronment at 42 ºC for selective isolation of Campylobacter spp. Seagull-shaped Gram-negative rods with the ability to produce oxidase and catalase enzymes were identified as Campylobacter spp. and further tested for hippurate hydrol- ysis and cephalothin susceptibility. All isolated strains of Campylo- bacter spp. were tested for antimicro- bial susceptibility by the Kirby–Bauer disk diffusion method against 5 drugs: erythromycin (a macrolide), ofloxacin (a fluoroquinolone), ampicillin, gen- tamicin and tetracycline. The zone diameter breakpoints of each antimicro- bial agent were determined according to the Clinical and Laboratory Stand- ards Institute established guidelines for bacteria isolated from animals [12–15]. The same procedure for Campylobacter spp. isolation and antimicrobial suscep- tibility testing was followed throughout the study period. Campylobacter jejuni ATCC 33291 was used as a quality control strain for identification and sus- ceptibility testing. Results During the 15-year study period (Janu- ary 1992–June 2007) a total of 83 396 stool samples were processed, with a 14% isolation rate for enteric pathogens (n = 11 653). Vibrio cholerae was the most frequently isolated (32%) over this period, followed by Campylobacter spp. (30%). The isolation rates of Salmo- nella spp. and Shigella spp. were 18% and 15% respectively. Figure 1 shows the annual isolation rate of Campylobacter spp. from 1992 to 2007. The rate of isolation of Campy- lobacter spp. was low (6.3%) in 1993, peaked in 1996 (46%) and then for the next 10 years ranged from around 20% to over 40%. C. jejuni (89.5%) was the main spe- cies isolated, followed by C. coli (6.4%), C. laridis (3.2%) and other Campylo- bacter spp. (0.8%). The age distribution showed that the majority of the Campylobacter spp. isolates over the 15-year period (70%) came from children aged < 5 years (Fig- ure 2). The annual antimicrobial suscepti- bility data showed that ofloxacin resist- ance first emerged in 1994, rising to 25.4% in 2000 and continued to rise to reach a peak of 47.5% by 2004 (Figure 3). Ofloxacin resistance was highest in C. jejuni (21%), followed by C. coli (9%). Erythromycin resistance was 9.5% in 1993, gradually decreasing to 0% in 2000 but re-emerged in 2001 and gradually rose to reach 2.9% in 2005 (Figure 3). Erythromycin resistance was highest in C. coli (5%), followed by C. jejuni (3%). Co-resistance to both erythromycin and ofloxacin was 0.5%. The overall rates of resistance against ampicillin, tetracycline and gentamicin were 22%, 13% and 4% respectively. Discussion This study reviewed the isolation rate and trend of antimicrobial resistance of Campylobacter spp. in Karachi, Pakistan over a period of 15 years. To the best of our knowledge this is the longest pe- riod of reporting from this region. The isolation rate of Campylobacter spp. was lowest during the first 2 years, peaked in 1996 and since then has fluctuated EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1228 between 20% and 40%. A study from this centre has previously reported this organism to be the third most com- monly isolated organism (24%) after V. cholerae (31%) and Salmonella spp. (26%). However, current data showed a very similar isolation rate of this or- ganism as for V. cholerae over the study period, i.e. 30% versus 32%. The reason for the change in this epidemiology is not clear. A study published from Bang- ladesh also found Campylobacter spp. with the highest frequency among stool pathogens [16]. C. jejuni was the most common species found (89.5%), as reported in other studies [17]. In our study, the rate of isolation of Campylobacter spp. was highest among children aged < 5 years, which is consist- ent with a previous study reported from this region [18]. Our findings showed a gradual rise of fluoroquinolone resistance from its emergence in 1994 to 25.4% in 2000 and 47.5% in the year 2004. The rising trend is comparable with other studies published from different parts of the world [19,20]. Fluoroquinolones are among the most commonly used agents to treat Campy- lobacter enteritis in the community. However, since the early 1990s resist- ance against this group of drugs has been reported from several countries [20–22]. The prophylactic use of fluoroquinolo- nes in veterinary medicine as well as their use as a growth promoter in animal husbandry was recognized as a cause of resistance in the developed world [23]. A study published from Australia reported a significant fall in fluoroquinolone re- sistance after restricting its use in food- producing animals [24]. However, in a developing country such as Pakistan, the major issue is injudicious use of antibiot- ics in humans especially when there is a high rate of self-medication. Another important finding of this study is the re-emergence of macrolide resistance. The literature shows that resist- ance to macrolides is already high in Far East countries such as Singapore (51%), Figure 1 Annual Campylobacter spp. isolation rate from stool samples at a referral hospital in Karachi, January 1992–June 2007 Figure 2 Isolation of Campylobacter spp. in different age groups from stool samples at a referral hospital in Karachi, January 1992–June 2007 (n = 3384) طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1229 Thailand (31%) and Taiwan (18%) [25]. However, our rates are closer to the rates of developed countries [26]. An important finding of our study was the demonstration of co-resistance to the macrolide and fluoroquinolone agents tested by a few Campylobacter spp. isolates 0.5%). The emerging co- resistance must be considered alarming as these 2 classes are generally consid- ered as first- and second-line agents. Moreover, most of these isolates showed resistance to other groups of antibiotics, thus limiting the choice for treatment of life-threatening infections. Recent stud- ies have compared the clinical symp- toms, duration of illness and mortality rates between fluoroquinolone-/mac- rolide-sensitive and resistant isolates and concluded that drug-resistant strains had a significant relationship to disease severity and mortality [27]. As our study was laboratory-based, the clinical outcome of these cases could not be evaluated. However, the study highlights the need for future clinical studies based on clinical outcome, along with genetic analysis and epidemiologi- cal typing of these multidrug resistant Campylobacter spp. isolates. Conclusion In view of the minimum resistance of Campylobacter spp. against the mac- rolide group of antibiotics, they can be continued as empirical therapy for Figure 3 Annual rate of resistance to erythromycin and ofloxacin of Campylobacter spp. isolated from stool samples at a referral hospital in Karachi, January 1992–June 2007 severe campylobacteriosis in both the paediatric and adult population in Ka- rachi, Pakistan. However, the empirical use of fluoroquinolones is debatable due to rising resistance of Campylobacter spp. to this group of antibiotics. Acknowledgements This study was supported through a grant from the Joint Pakistan–US Aca- demic and Research Program HEC/ MoST/USAID. We would like to thank the faculty and staff of the clinical microbiology laboratory of the Aga Khan University hospital, Karachi for their support and help in this study. References Allos BM 2001: 1. Campylobacter jejuni infections: update on emerging issues and trends. 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Regional and seasonal differences in incidence 25. and antibiotic resistance of Campylobacter from a nationwide surveillance study in the Netherlands: an overview of 2000– 2004. Clinical Microbiology and Infection, 2007, 13:305–310. Engberg J et al. Quinolone and macrolide resistance in 26. Campy- lobacter jejuni and C. coli: resistance mechanisms and trends in human isolates. Emerging Infectious Diseases, 2001, 1:24–33. Mølbak K. Human health consequences of antimicrobial drug-27. resistant Salmonella and other foodborne pathogens. Clinical Infectious Diseases, 2005, 41:1613–1620. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1231 Multisectoral development for improved health outcomes: evaluation of community-based initiatives in the Islamic Republic of Iran M.R. Sheikh,1 M.M. Afzal,1 S.Z. Ali,2 A. Hussain 2 and R. Shehzadi 2 ABSTRACT Community-based initiatives (CBI) are based on integrated multisectoral socioeconomic development with community participation and intersectoral support to improve the health and quality of life of the people. During 2005–06 the World Health Organization supported an evaluation of CBI in the Islamic Republic of Iran by collecting information from intervention villages on social capital and other indicators, with validation of the findings. The data showed some positive changes in the intervention areas compared with control villages. The evaluation suggests that the CBI approach is a useful tool for improving health and social indicators and providing mechanisms for community-based participation and intersectoral collaboration for health and development at the local level. 1Global Health Workforce Alliance, World Health Organization, Geneva, Switzerland (Correspondence to M.R. Sheikh: sheikhm@who.int). 2Aga Khan Health Services, Karachi, Pakistan. Received: 01/03/09; accepted: 25/05/09 ةيملاسلإا ناريإ ةيروهجم في ةيعمتجلما تاردابملل مييقت :ةن َّس َ ُحم ةيحص لئاصح قيقحتل تاعاطقلا ةددعتلما ةيمنتلا يدازهش انامور ،ينسح ديبع ،ليع راقفلا وذ ديس ،لضفأ دوممح دممح ،خيش ضاير شربم تاعاطقلا ينب نواعتلاو ،عمتجلما ةكراشم عم ،تاعاطقلا ةد ِّدعتلما ةلماكتلما ةيعماتجلااو ةيداصتقلاا ةيمنتلا لىع ةيعمتجلما تاردابلما دنتست :ةـصلالخا ناريإ ةيروهجم في ةيعمتجلما تاردابلما مييقتل اهمعد ةيلماعلا ةحصلا ةمظنم تم َّدق 2006 – 2005 ةدلما فيو .اتهَدْوَجو سانلا ةايح ةحص ينستح ةَيْغُب نم ق ُّقحتلا عم ،تاشرؤلما نم هيرغو يعماتجلاا لالما سأر مييقتلا لوانتو ،تلاخدتلاب تَيظح يتلا ىرقلا نم تامولعلما عجم للاخ نم ةيملاسلإا بولسأ نأ لىع مييقتلا َّلدو .ةدهاشلا ىرقلاب ةنراقلماب تلاخدتلاب تيظح يتلا قطانلما في ةيبايجلإا تا ُّيرغتلا ضعب جئاتنلا ترهظأ دقو .جئاتنلا ةحص ينب نواعتلاو عمتجلما ةكراشم قيقحتل ةحجان تايلآ م ِّدقيو ،ةيعماتجلاا تا ِّشرؤلما رئاسو ةحصلا ينسحتل ةعفان ةليسو لِّثمي ةيعمتجلما تاردابلما .ليحلما ديعصلا لىع ةيمنتلاو ةحصلا لجأ نم تاعاطقلا Développement multisectoriel pour des résultats sanitaires améliorés : évaluation d’initiatives communautaires dans la République islamique d’Iran RÉSUMÉ Pour obtenir une amélioration de la santé et de la qualité de vie des populations, les initiatives communautaires s’appuient sur le développement socio-économique multisectoriel et intégré, la participation de la communauté et le soutien intersectoriel. En 2005 et 2006, l’Organisation mondiale de la Santé a soutenu une évaluation des initiatives communautaires en République islamique d’Iran, en collectant des informations sur le capital social ainsi que d’autres indicateurs, dans les villages bénéficiant d’interventions. Les données recueillies ont ensuite été validées. Elles ont révélé des changements positifs dans les zones d’intervention, par rapport aux villages témoins. Il ressort de cette évaluation que les initiatives communautaires constituent une approche utile pour améliorer les indicateurs sanitaires et sociaux ainsi que pour mettre en place des mécanismes permettant la participation communautaire et et la collaboration intersectorielle pour la santé et le développement au niveau local. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1232 Introduction The globally accepted definition of health—“a state of complete physi- cal, mental and social well-being and not merely the absence of disease or infirmity” [1]—highlights the need to address all the determinants of health in a comprehensive manner. Acknowl- edging this fact, the World Health Organization’s Regional Office for the Eastern Mediterranean (EMRO) has since the 1980s been advocating and actively supporting community-based initiatives (CBI) for health and human development in its Member States [2]. Improved quality of life has been recognized as the essential prerequi- site to attain optimum levels of health. CBI aims to achieve this through inte- grated socioeconomic developments that address the determinants of health collectively through community em- powerment rather than through a nar- row focus on health care services [2]. It is based on the principles of self- reliance, self-financing and self-man- agement by communities who are organized, empowered and actively participating, supported through coor- dinated intersectoral actions [3]. This approach facilitates access to essential social services, appropriate technolo- gies, information and financial credit, with the explicit aim of promoting fair distribution of resources to achieve equity at the grassroots level [4]. CBI represent a conceptual shift away from implementing conventional but isolated development activities towards a more holistic development where the com- munity itself assesses and prioritizes its needs, plans and implements feasible solutions and monitors and evaluates the outcomes, actively supported and assisted by the related government de- partments [5]. CBI encompass other initiatives such as basic development needs (BDN), the healthy city programme (HCP), the healthy village programme (HVP) and women in health and development (WHD). BDN and HVP are implemented primarily in rural areas with common objectives, structures and processes [6]. HCP operates in urban areas and aims to improve health and the environment by putting health on the local development agenda [7]. WHD are cross-cutting initiatives implement- ed through the existing structures of community-based programmes [8]. Currently in the Eastern Mediter- ranean Region, the BDN approach has been implemented in 14 countries, HCP in 16, HVP in 6 and WHD in 21; the programmes are at various stages of development [9]. The Islamic Republic of Iran initiated the HCP in Tehran dur- ing 1996 and established the National Coordination Council for Healthy Cit- ies and Healthy Villages Programme (NCCHCHVP) in 1999. The BDN approach was introduced during 2000 [10]. Currently, HCP is actively imple- mented in 16 cities, covering a com- bined population of around 4.2 million; HVP covers 39 areas with a population of around 73 000; and BDN operates in 34 areas with a population 58 000, with some overlap with HVP areas. EMRO has conducted evaluations of CBI in different countries, including Djibouti, Jordan, Pakistan, Sudan, Syr- ian Arab Republic and Yemen. With a view to further expansion of the pro- gramme in the Islamic Republic of Iran, especially its institutionalization in the health and development sectors, WHO commissioned an evaluation of CBI to assess the inputs, process, outputs and impact of the initiative. Methods Study design The evaluation and its validation were carried out in 3 stages: An evaluation of the development • of the CBI programme at national, district and grassroots levels through interviews with key stakeholders and a review of programme records. A cross-sectional survey of selected • social and health indicators compar- ing CBI programme and control sites, with the emphasis on social capital. Social capital refers to the connec- tions among individuals, social net- works and norms of reciprocity and trustworthiness [11]. Validation of the findings of the first • 2 stages through interviews with randomly selected key informants, on-site field visits and a review of pro- gramme documents. Evaluation framework The evaluation was carried out using the CBI guidelines developed by EMRO [12] with some adaptation of the in- dicators and questions. The guidelines include advice about the composition of evaluation teams, data collection tools and procedures to follow. For the assessment of social capital, instruments were used from the toolkit developed by the social development department of the World Bank [13]. Evaluation teams and study dates The multidisciplinary evaluation team was selected from relevant disciplines according to their roles and expertise and was led by an epidemiologist from Tehran University of Medical Sciences as the principal investigator. Team members were trained on the objec- tives, tools and methodology for 4 days during November 2005. Field visits and data collection were from November 2005 to February 2006. The validation of the findings was conducted during April 2006 by 2 international consult- ants from the Aga Khan Health Service, Pakistan to provide evidence-based confirmation of the evaluation results. Sampling of study sites and population According to the EMRO guidelines for evaluation of CBI [12], the evalua- tion was carried out only in areas with about 5 years’ experience of programme intervention. Among the list of suitable طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1233 programme areas, 5 were selected by stratified random sampling: Hammam- lar, Mohammadsalehi, Shole, Hureh and Savadjan. The study groups for the first stage— the evaluation of the development of the CBI programme—included repre- sentatives of community groups such as city and village Islamic councils, village development committees, cluster rep- resentatives (community representa- tives, 1 selected by the community from its residents in each cluster of 25–30 houses) and local or national non- governmental organizations (NGOs); members of the general public and beneficiaries of projects; policy-makers, government managers, health system officials, members of intersectoral teams (from health and related sectors and departments such as education, agri- culture, livestock, social welfare, local government/municipality, women and youth etc.), CBI programme managers and staff at national and local level; and representatives of international organi- zations engaged in similar programmes. In the second stage of the evalua- tion—the survey of selected social and health indicators—a comparative study was made between 5 selected interven- tion villages and 5 control villages, with 40 households chosen by systematic random sampling in each village (social capital indicators were evaluated only in 3 CBI and 3 control villages). Members of 401 households were interviewed by the evaluation team (240 households in the 3 CBI and control villages where so- cial capital indicators were studied). The sampling frames were obtained from the household records of health houses, which are present in almost all villages across the Islamic Republic of Iran. Data collection Data were collected by the evaluation teams by reviewing CBI programme documents at all levels, interviewing key informants and collecting data from available data sources such as: the health horoscope (a tool for compiling vital events of communities in the catchments area of each health house); surveillance data; and before and after surveys. Qualitative data on the develop- ment of the programme was collected in CBI areas through 47 focus group discussions (FGDs) and 58 indepth interviews with key stakeholders. The recordings of interviews and FGDs were transcribed by public health students. Available baseline data on selected social and health indicators for 2000 were compared with the relevant data for 2005 through a review of the pro- gramme documentation in CBI areas. The social capital assessment tool (SOCAT) [13] was extensively used to collect social capital data from a total of 240 households in 6 villages (118 households in 3 CBI areas and 122 households in 3 control villages). Con- trol villages were selected based upon the criteria of having similar demo- graphic, geographic and social condi- tions as the case villages. The percentage of household members affiliated with at least 1 local association and the frequen- cy with which they faced problems/ limitations accessing different public services were compared in CBI and control areas. For the validation stage various tools, including questionnaires, checklists and interviews, were used to assess the evaluation methodology and tools. A validation matrix was developed based on the programme evaluation standards of the Joint Committee on Standards for Educational Evaluation [14]. Analysis For the qualitative data analysis the written texts were carefully read and coded by the evaluation team. Statistical analysis of quantitative data was carried out using STATA, version 8.0 [15]. Evaluation findings The key findings of the CBI evaluation are presented as: qualitative findings of the interviews and FGDs; baseline and follow-up data; and quantitative data on social capital. Qualitative findings of interviews and FGDs Table 1 summarizes the qualitative evaluation of selected programme ele- ments based on the FGDs and indepth interviews with key stakeholders. Five important elements were addressed with key findings based upon selective indicators for each element, including links with national developmental plans, political commitment and intersectoral collaboration, community participa- tion, capacity building and needs-based developmental projects. Baseline and follow-up data in CBI areas Table 2 summarizes the findings of the review of programme documentation in the sample of 5 CBI villages, comparing baseline data from 2000 with the data from 2005 after 5 years of experience of the intervention. The average house- hold size ranged from 3.7 to 7.2 persons per household in 2000 and from 3.5 to 6.5 in 2005. The total population in these 5 villages declined 4%, from 8137 in 2000 to 7780 in 2005. The under-1- year-old population as a percentage of the total population of the CBI villages decreased from 1.9% in 2000 to 1.8% in 2005. After 5 years of implementation of CBI in the 5 villages, the percentage of households owning their own house increased from 86.0% to 94.3%, having a sanitary latrine from 79.7% to 97.1% and having a bathroom increased from 73.3% to 92.4%. Quantitative data on social capital in CBI and control villages As part of the evaluation of social capital the proportion of household members affiliated with at least 1 local association was assessed. Table 3 shows this indica- tor for 3 CBI and 3 control villages. The mean rate of affiliation in the CBI villages was 26.3% [95% confidence EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1234 interval (CI): 21.0%–31.7%] and in the control villages 22.7% (95% CI: 17.3%–28.2%). Respondents were asked if they or other household members had ever faced any limitations or problems in accessing essential public services. A smaller proportion of households in CBI villages compared with the control villages reported difficulty in access- ing employment, loans, drinking water, solid waste management and agricul- tural consultation (Figure 1). Discussion According to WHO “The right approach for attaining the target of optimum level of health for all lies in the totality of hu- man needs that can be achieved through integrated community development” [5]. This theme paved the way for the development of the innovative approach of CBI introduced by EMRO in its member states. The present evaluation of CBI in the Islamic Republic of Iran has shown some promising results. The continuity of activities of the national coordinating council, especially its ex- pert group and the district intersectoral committees, for about a decade is proof of strong positive political commitment Table 2 Key findings in randomly selected community-based initiatives (CBI) programme areas in the Islamic Republic of Iran in 2000 and 2005 Indicator Hammamlar Shole Mohammad Salehi Hureh Savadjan 2000 2005 2000 2005 2000 2005 2000 2005 2000 2005 No. of households 131 145 217 218 271 259 800 791 387 391 Total population 938 939 1236 1200 1433 1499 2971 2755 1559 1467 No. of children under 1 year old 33 22 7 10 28 27 59 59 26 21 No. of households with ownership of house 126 145 198 205 235 247 607 717 388 388 No. of houses with sanitary latrine 30 145 129 218 240 254 738 743 303 391 No. of houses with bathroom 26 135 110 210 253 254 639 699 296 367 Table 1 Key findings of selected programme elements in the community-based initiatives (CBI) programme areas in the Islamic Republic of Iran Serial no. Element Indicators Key findings 1 Links with national developmental plans CBI approach is linked with relevant programmes and partners Ministry of Welfare considering CBI approach in future programmes Fourth 5-year national plan has adopted CBI approach as one strategy for social justice 2 Political commitment and intersectoral collaboration Sufficient degree of political commitment is available. Intrasectoral support mechanisms are in place National council formed 1996 National expert groups from 15 ministries and organizations continuously provide support Intersectoral committees and teams are functionala at district levels 3 Community participation Community is organized, empowered, and participates in local development All CBI villages have functionala village development committees Communities voluntarily participate in different developmental activities 4 Capacity building Capacity building of concerned stakeholders on programme processes and essential skills Since 2001, around 50 training workshops, with almost 1500 participants were organized in 25 districts across the country Specialized training has been conducted on health, nutrition, environment, school health, life skills, social issues and income generation 5 Needs-based developmental projects Evidence-based planning and interventions carried out All CBI areas have had baseline surveys and determination of their priority needs All CBI areas have established a community development fund CBI areas have established various kinds of ‘pro-poor’ projects to address the development needs of the poor aFunctional means that committees or teams are performing CBI functions normally as planned in the programme. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1235 and ownership of the initiative. Estab- lishment of community organizations and the active participation of the com- munity in programme activities is the foundation of CBI. The rate of affiliation of household members with local asso- ciations was higher in CBI villages than control villages, suggesting that people in CBI areas in the Islamic Republic of Iran have become more proactive. This is one of the aims of CBI: for people to understand their priority needs and to strive for solutions through develop- mental activities. People in CBI areas also had better access to many public services. Our findings indicate positive changes in the intervention areas in many of the health, social and economic indicators. For example, although the data were not compared with control villages the rise in the proportion of households with sanitary latrines and bathrooms in CBI villages is indicative of an improved quality of life. Despite some positive shifts in the health and development indicators, there are various critical challenges and constraints that need to be addressed when consolidating the programme in existing areas and scaling up and ex- panding it into new areas. A common problem with CBI is that coordination mechanisms need to be formalized to ensure effective inter- and intrasectoral collaborations for planning, implemen- tation and monitoring. In addition to the institutionalization of the CBI ap- proach within health and development sectors, another issue for CBI in general is that partnerships with stakeholders need to be strengthened to reduce the financial burden that is at present main- ly in the health sector. The processes needs to be more decentralized with streamlining of supervision and moni- toring mechanisms, reforming informa- tion system to cater for the changing needs of programme areas and efficient Table 3 Percentage of household members in the community-based initiatives (CBI) villages and control villages affiliated with at least 1 local association Village type and name Mean % SD Percentile 25th 50th 75th CBI villages Hurrah 22 26 0 20 33 Savadjan 26 29 0 20 33 Mohammadsalehi 30 22 17 25 45 Control villages Garmdarreh 18 19 0 17 33 Shourab Saghir 27 26 0 25 50 Chahar Rousta 23 18 14 20 25 SD = standard deviation. Figure 1 Percentage of household members in the community-based initiatives (CBI) programme villages and control villages who faced problems/limitations accessing different public services % EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1236 documentation of success experiences. The health and social components of the programme need to be further emphasized, implementing core and essential interventions; complemented with continuous capacity building and skills development programmes. It is widely accepted that improved health is a fundamental input and out- come of socioeconomic development. Health for all cannot be achieved by the isolated interventions of the health sec- tor alone; rather it requires an integrated multisectoral development approach. This use of participatory mechanisms for both communities and related sectors is the central theme of the CBI concept. Considering the positive findings of this evaluation of CBI in the Islamic Repub- lic of Iran, it is strongly recommended that CBI should be strengthened, insti- tutionalized and expanded to new areas in this and other countries of the EMR. Acknowledgements Special appreciation to the following for their contribution during the evaluation of community-based initiatives and its validation in the Islamic Republic of Iran: Dr. Abbas Motivalian, Assistant Professor of Epidemiology, Iran Uni- versity of Medical Sciences; Dr Majid Tavakoli, National CBI Office, Ministry of Health and Medical Education; Mr Bagher Shoolaieh, CBI Official, Na- tional CBI Office, Ministry of Health and Medical Education; Mrs Zahra Salimi, National CBI Office, Ministry of Health and Medical Education; Dr Nazar Elfaki, former Short Term Profes- sional for CBI, WHO Country Office, Islamic Republic of Iran; Ms Sirous Shadrokh, Technical Officer, Health and Sustainable Development Unit, WHO Country Office, Islamic Repub- lic of Iran. References Constitution of the World Health Organization1. . Geneva, World Health Organization, 1946. Sheikh MR. Basic development needs approach in the Eastern 2. Mediterranean Region: from theory to practice. Eastern Medi- terranean Health Journal, 2000, 6(4):766–774. Motivalian A. 3. Proposal for evaluation of CBI. Tehran, Islamic Republic of Iran Country Office, 2005. Sheikh MR, Afzal MM. 4. Concepts and methods of community- based initiatives. Cairo, World Health Organization Region- al Office for the Eastern Mediterranean, 2003 (WHO-EM/ CBI/016/E/G). Training manual for community base initiatives. Apractical tool 5. for trainers and trainees. Community based initiatives series 1. Cairo, World Health Organization Regional Office for the East- ern Mediterranean, 2006. Sheikh MR, Afzal MM. 6. CBI training manual for midlevel man- agers. Module 2: health, health for all and primary health care. Cairo, World Health Organization Regional Office for the Eastern Mediterranean, 2003. Evaluation of the basic development needs programme in the 7. Republic of Yemen. Cairo, World Health Organization Re- gional Office for the Eastern Mediterranean, 2005 (WHO-EM/ CBI/048/E). Sheikh MR, Afzal MM. 8. Community-based initiatives. Cairo, World Health Organization Regional Office for the Eastern Mediterranean, 2003 (WHO-EM/CBI/017/E/G). CBI success stories. Islamic Republic of Iran9. . WHO Country Of- fice in Islamic Republic of Iran [website] (http://www.emro. who.int/iran/Media/PDF/CBI_SuccessStories_Iran.pdf, ac- cessed 24 August 2010). Country profile: Islamic Republic of Iran10. . WHO Country Office in Islamic Republic of Iran [website] (http://www.emro.who. int/iran/countryprofile.htm, accessed 24 August 2010). Putnam R. 11. Making democracy work: civic traditions in modern Italy. Princeton, New Jersey, Princeton University Press, 1993. Sheikh MR, Afzal MM. 12. Guidelines and tools for management of basic development needs. Tool 10: Programme evaluation. Cairo, World Health Organization Regional Office for the Eastern Mediterranean, 2002. Grootaert C, Chase R, van Bastelaer T. 13. The social capital assess- ment tool (SOCAT). Washington, DC, World Bank, 2002. Joint Committee on Standards for Educational Evaluation. 14. Program evaluation standards. Thousand Oaks, California, Sage Publications, 1994. Validation of the evaluation of community based initiatives in 15. Islamic Republic of Iran. Tehran, World Health Organization Country Office in Islamic Republic of Iran, 2006. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1237 Evaluation of capillary blood glucose versus a high- risk questionnaire for screening for undiagnosed diabetes mellitus in Eastern province, Saudi Arabia N.A. Al-Baghli,1 K.A. Al-Turki,1 A.J. Al-Ghamdi,2 K. Prasad,3 A.Z. Taha 4 and S.M. Al-Almaie 4 ABSTRACT This study compared 2 screening tests for detecting undiagnosed diabetes mellitus when applied in a mass-screening campaign in the Eastern province of Saudi Arabia in 2004–05. Of 15 082 individuals screened, 65.8% were positive by the American Diabetes Association risk-score questionnaire and 71.3% by determination of capillary blood glucose (CBG) using a portable glucometer. Type 2 diabetes mellitus was confirmed in 20.3% of participants and pre-diabetes in 33.9% using fasting venous blood testing. The risk-score questionnaire did not perform well versus fasting and random CBG. Optimal cut-offs for fasting and random CBG were 120 mg/dL and 160 mg/dL respectively. Fasting CBG had higher sensitivity, specificity and discriminating ability than random CBG for detection of diabetes and pre-diabetes in this population. 1Directorate of Health Affairs, Ministry of Health, Dammam, Saudi Arabia (Correspondence to N.A. Al-Baghli: nadiraa@windowslive.com). 2Ministry of Health, Riyadh, Saudi Arabia. 3Department of Medical Education, Collage of Medicine, Arabian Gulf University, Bahrain. 4Department of Family and Community Medicine, Collage of Medicine, University of Dammam, Dammam, Saudi Arabia. Received: 28/12/08; accepted: 01/03/09 ةكلمملل ةيقشرلا ةقطنلما في صخشلما يرغ يركسلل عفترلما راطتخلاا م َّلُِسل نايبتسا لباقم يرعشلا مدلا زوكولغ سايق مييقت ةيدوعسلا ةيبرعلا يعلملأا دممح حيمس ،هط نيدباعلا نيز ةيطع ،داساراب ريوشخم ،يدماغلا ناعجم ليقع ،يكترلا نحمرلا دبع دلاخ ،ليغبلا سابع ةيرضن ةكلمملل ةيقشرلا ةقطنلما في يعوملجا حسلما ةلحم في ماهقيبطت دنع صخشلما يرغ يركسلا ي ِّرحتل نيرابتخا ةساردلا هذه في نوثحابلا نراقي :ةـصلالخا رداصلا راطتخلاا زارحأ م َّلُس نايبتسلا ًاقفو ينيبايجإ مهنم %65.8 ناك ،ًادرف 15 082 ي ِّرحتلا لمش دقو .2005و 2004 يماع في ةيدوعسلا ةيبرعلا صيخشت د َّكأت دقو .مدلا زوكولغل لا َّقن سايقم مادختساب يرعشلا مدلا زوكولغ فشكب ينيبايجإ مهنم %71.3 ناكو ،يركسلل ةيكيرملأا ةيعملجا نع لىع يديرولا مدلا ركس رابتخا مادختساب %33.9 ىدل يركسلا لبق ام صيخشت د َّكأتو ،ةساردلاب ينكراشلما نم %20.3 ىدل نياثلا طمنلا نم يركسلا لصيفلا ةميقلا تناك دقو .يئاوشعلا وأ قيرلا لىع يرعشلا مدلا زوكولغ رابتخا ةدوج لىإ ىقري راطتخلاا زارحأ م َّلُس نايبتسا ءادأ نكي لم اذكهو .قيرلا رثكأ قيرلا لىع يرعشلا مدلا ركس سايق نأ ينبتو .لد/غم 160 يئاوشعلا يرعشلا مدلا زوكولغلو ،لد/غم 120 قيرلا لىع يرعشلا مدلا زوكولغل َىلىثلما .ةيدوعسلا ةيناكسلا ةعومجلما هذه في يركسلا لبق امو يركسلا فشكل يئاوشعلا يرعشلا مدلا ركس سايق نم زييمتلا لىع ًةردق رثكأو ًةيعون رثكأو ًةيساسح Évaluation de la mesure de la glycémie capillaire comparée à l’administration d’un questionnaire de dépistage destiné aux personnes à haut risque de diabète jamais diagnostiqué auparavant dans la province orientale d’Arabie saoudite RÉSUMÉ La présente étude a comparé deux méthodes de dépistage du diabète non diagnostiqué, utilisées pendant une campagne de dépistage de masse dans la province orientale d’Arabie saoudite entre 2004 et 2005. Parmi les 15 082 personnes dépistées, le diagnostic de diabète a été posé au moyen du questionnaire de risque de l’American Diabetes Association pour 65,8 %, et il a été effectué par détermination de la glycémie capillaire à l’aide d’un lecteur de glycémie portable pour 71,3 %. Le diabète de type 2 a été confirmé dans 20,3 % des cas et un état prédiabétique a été diagnostiqué chez 33,9 % des personnes dépistées au moyen d’une analyse de la glycémie à jeun par prélèvement veineux. Le questionnaire de risque était moins performant que l’analyse de la glycémie à jeun et l’analyse de la glycémie capillaire aléatoire. La valeur seuil optimale pour l’analyse de la glycémie à jeun était 120 mg/dl et celle de l’analyse capillaire aléatoire était 160 mg/dl. L’analyse de la glycémie à jeun avait une sensibilité plus élevée, une spécificité supérieure et une meilleure capacité de discrimination que l’analyse de la glycémie capillaire aléatoire pour le dépistage du diabète et des états prédiabétiques dans cette population. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1238 Introduction The debate whether to screen for diabetes mellitus (DM) continues in the medical community among those who recommend [1] and those who discourage it [2]. Although it seems intuitive that early detection improves outcome, lack of direct evidence from randomized controlled studies of the effectiveness of screening for type 2 DM is the main barrier to its widescale ap- plication. Nonetheless, type 2 diabetes may remain undetected for several years [3], and by the time of clinical diagnosis many people have developed one or more micro- or macrovascular diabetic complications [4]. The American Diabetes Associa- tion (ADA) has recommended regular screening for type 2 diabetes at 3-year intervals, beginning at age 45 years (or less if there are other risk factors) [1]. However, mass screening was not recommended. To save community resources, the ADA suggested using a screening questionnaire—“take the test, know the score”—whereby only those with high risk-factor scores would be tested [5]. While different diabetes risk questionnaires have been developed and evaluated [6–10], their validity has been mainly assessed in Caucasian populations, which raises doubts over their validity in other populations. When diabetes risk scores have been applied to other ethnic groups, e.g. in Caribbean and South Asian people liv- ing in the United Kingdom (UK) [11], the results vary, and the need to validate screening tests in other populations has been emphasized. The prevalence of DM is very high in the Saudi Arabian population [12], but the performance of screening tests has not yet been validated in this popu- lation. Capillary blood glucose (CBG) screening for type 2 DM, using a reflect- ance blood glucose meter, is less costly than other screening tests. The aim of the present study was to compare 2 screening tests for detecting undiagnosed diabetes when applied in a Saudi population through a mass screen- ing campaign in the Eastern province of Saudi Arabia. The study compared the performance of a diabetes risk-score questionnaire in a Saudi population with CBG testing by portable glucom- eter and determined which cut-off levels of random and fasting CBG yielded the best balance between sensitivity and specificity versus laboratory-confirmed fasting plasma glucose (FPG) testing. Methods Sample This study was part of a larger screen- ing campaign conducted in the Eastern province of Saudi Arabia between 28 August 2004 and 18 February 2005. The campaign and sampling has been described previously [13,14]. The target population was all Saudi residents of the Eastern province, aged 30 years and above, excluding pregnant women (650 000 subjects). They were invited to participate in a screening campaign for the early detection of DM and hy- pertension by attending one of the 300+ examination centres in the programme. A total of 15 082 individuals were in- cluded in the study reported here. Individuals with undiagnosed dia- betes who did screening of either fasting CBG or random CBG and underwent confirmatory testing were included in the study. Those with abnormal screen- ing results for blood pressure and/or FPG, pregnant women and those who had self-reported previously diagnosed diabetes were excluded from this study. Data collection At the mass screening participants underwent measurements of weight and height and completed a structured questionnaire to collect data for the risk- score questionnaire. CBG screening for undiagnosed DM was done with a port- able glucometer. Participants attended on another day for confirmatory testing for DM and pre-diabetes by fasting ve- nous glucose blood levels after ≥ 8 hours fast. The high-risk score questionnaire used in this study was the diabetes risk test recommended by the ADA [15] and studied by Rolka et al. [16]. The questionnaire provides a high-risk score based on age, body mass index (BMI), sedentary lifestyle, family history of DM and ever having delivered a macrosomic baby (> 4 kg). The maximum score was 22 and the cut-off score for a positive screening result was ≥ 10 points. Capillary blood samples were taken and whole blood glucose concentration was measured using a uniform portable glucometer with the Medisafe Reader (Terumo Co.). During the field study, instruments were calibrated every morning. Supervision of the technicians carrying out the blood tests was ensured. Quality control supervised teams were distributed in every sector to assure the quality of performance and accuracy of the devices. Screening was considered positive if fasting CBG was ≥ 100 mg/ dL or if random CBG was ≥ 140 mg/dL for those with undiagnosed diabetes. Venous blood specimens were col- lected and FPG concentrations were determined using glucose oxidase meth- odology in the central laboratory of the Dammam area or in other government and private hospitals. Type 2 DM was diagnosed when FPG level was ≥ 126 mg/dL and pre-diabetes when FPG was 100–125 mg/dL. Normal FPG was < 100 mg/dL. Laboratory personnel were blinded to the results of the screening test. In- dependent health team collected the questionnaires and the results of the screening tests, collated them with con- firmatory FBS tests and delivered them to the main primary health directorate centre for data collection and entry. Analysis Different cut-off points of random CBG and fasting CBG and the risk-score questionnaire were evaluated separately طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1239 against the diagnostic standard for diabetes (FPG ≥ 126 mg/dL). Sensi- tivity, specificity, positive and negative predictive values, likelihood ratio of positive and negative tests, and 95% confidence interval (CI) for all those were calculated using standard methods [17]. To select the optimal cut-off point for a positive test, a receiver operating characteristics (ROC) curve was con- structed by plotting sensitivity (true positive rate) against the false positive rate (1–specificity). The high-risk score questionnaire and fasting and random CBG were evaluated with respect to the area under the curve (AUC) in the ROC. All analyses were performed using SPSS for Windows, version 16. Results A total of 15 082 individuals aged 30+ years were included in the study. DM was confirmed by FPG ≥ 126 mg/dL in 3052 (20.3%) and pre-diabetes in 5108 (33.9%) (Table 1). The characteristics of the study group of undiagnosed cases of DM according to socioeconomic sta- tus are shown in Table 2. The mean age was 46.5 (SD 11.6) years, 55.6% were women and 47.9% had a first-degree relative with diabetes. A total of 9919 people (65.8%) had positive scores on the high-risk ques- tionnaire (at the cut-off score of ≥ 10) (Table 1). The sensitivity of the test at this cut-off was 71%, while the spe- cificity was 39% (Table 3). However, combining the risk score for the fasting CBG and random CBG increased the sensitivity to 83% and 75% and specifi- city to 86% and 77% respectively. Figure 1 shows the ROC curve for the high-risk questionnaire; the AUC was 0.55 (95% CI: 0.54–0.56). In the biochemical screening tests, 10 761 (71.3%) participants were posi- tive for either fasting CBG (at a cut-off of 100 mg/dL) or random CBG (at a cut-off of 140 mg/dL). Fasting CBG was done for 4961 (32.9%) participants, while random CBG was determined for 10 121 (67.1%). In Table 4 the diagnostic sensitivity, specificity and positive and negative predictive values of a positive test for both fasting and random CBS were compared with the FPG test at various cut-off points. Fast- ing CBG at 100 mg/dL had a sensitivity of 97% and specificity of 29%. When the cut-off point was increased to 140 mg/dL sensitivity dropped to 57% and specificity increased to 96%. Random CBG at 140 mg/dL had a sensitivity of 91% and specificity of 48%. When the cut-off point was increased to 200 mg/dL sensitivity dropped to 53% and specificity increased to 95%. The optimal cut-off point (high- est sensitivity with comparable high specificity) for fasting CBG was 120 mg/dL (Table 4). Sensitivity was 81%, specificity 86%, positive predictive value 76% and negative predictive value 90%. The likelihood ratio of a positive test was 5.88 and the likelihood ratio of a negative test was 0.22. For the random CBG, the optimal cut-off point was 160 mg/dL (Table 4). Sensitivity was 76%, specificity 77%, positive predictive value 58%, negative predictive value 89%. The likelihood of a positive test was 3.35 and likelihood ratio of a negative test was 0.31. Figure 2 shows the ROC curve of the performance of fasting and random CBG. The AUC for random CBG (0.87) was lower than that for fasting CBG (0.82). If only those with posi- tive high-risk scores were included, the AUC for fasting CBG increased to 0.87 and for random CBG dropped to 0.82 (Figure 3). Table 5 shows the optimum cut-off point for both types of CBG screening tests according to sex. The optimum cut-off for random CBG screening was 165.5 mg/dL in men, with both a sen- sitivity and specificity of 77%, and the cut-off for optimum random CBG in women was 159.5 mg/dL, with lower sensitivity and specificity. The sensi- tivity and specificity for fasting CBG screening were higher in both men and women at cut-offs of 119.5 mg/dL and 121.5 mg/dL respectively. Discussion There is an increasing interest in using non-invasive tools such as risk-score questionnaires to detect high-risk groups suitable for screening. Finding a good high-risk score to detect undiagnosed DM, which at the same time is simple enough not jeopardize compliance is difficult. This may be due to the overlap in the characteristics of DM types 1 and 2 [18] so that individuals do not always fit the typical pattern of type 2 DM [9]. Several multivariate equa- tion models have been constructed to predict undiagnosed DM, with variable rates of validity [6–10]. Spijkerman et al. found a different response to screen- ing tools—the Cambridge risk score versus FPG and glycosylated haemo- globin (HbA 1c )—among Caribbean and South Asian people living in the UK than the Caucasian population and rec- ommended assessing the performance Table 1 Number of participants positive for type 2 diabetes mellitus by the risk- score questionnaire and capillary blood glucose screening (CBG) compared with laboratory-confirmed fasting plasma glucose (FPG) (n = 15 082) Screening tool (cut-off) No. positive % ADA risk score (≥ 10 points) 9 919 65.8 CBG (fasting ≥ 100 mg/dL or random ≥ 140 mg/dL) 10 761 71.3 FPG (≥ 126 mg/dL) 3 052 20.3 FPG (100–125 mg/dL) 5 108 33.9 ADA = American Diabetes Association. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1240 Table 2 Characteristics of participants according to laboratory-confirmed fasting plasma glucose (FPG) results for diabetes mellitus (DM) Variable Alla (n = 15 082) FPG results Type 2 DMb (n = 3052) Pre-diabetesc (n = 5108) No. % No. % No. % Age (years) 30–40 4 603 30.5 725 23.8 1368 26.8 41–50 5 345 35.5 1104 36.2 1832 35.9 51–60 2 869 19.0 650 21.3 1093 21.4 > 60 2 254 15.0 570 18.7 813 15.9 Sex Male 6 673 44.4 1472 48.2 2121 41.5 Female 8 372 55.6 1580 51.8 2987 58.5 History Family history of DM 7 220 47.9 1587 52.1 2438 47.8 Family history of hypertension 6 606 43.9 1277 42.0 2239 47.8 History of gestational DM (women) 1 445 17.2 397 24.8 497 16.7 Marital status Single 429 2.9 77 2.5 126 2.5 Married 13 142 87.9 2652 87.8 4430 87.4 Widowed 1 142 7.6 243 8.0 425 8.4 Divorced 230 1.5 48 1.6 86 1.7 Occupation Self-employed 1 180 8.0 286 9.6 358 7.1 Housewife 7 103 48.0 1375 46.0 2578 51.5 Military 1 434 9.7 301 10.1 459 9.2 Professional 994 6.7 169 5.7 300 6.0 Technical 464 3.1 82 2.7 143 2.9 Non-technical 611 4.1 124 4.2 201 4.0 Administrative employee 1 709 11.6 332 11.1 522 10.4 Unemployed 1 288 8.7 318 10.6 448 8.9 Education Illiterate 5 824 39.3 1281 42.8 2162 43.1 Read & write 1 288 8.7 288 9.6 439 8.7 Primary 2 449 16.5 485 16.2 793 15.8 Intermediate 1 755 11.9 359 12.0 577 11.5 Secondary 2 029 13.7 352 11.8 604 12.0 University 1 373 9.3 206 6.9 425 8.5 Higher degree 83 0.6 19 0.6 22 0.4 Income (Saudi riyals) < 2000 4 051 30.0 873 32.2 1447 31.6 2000–< 5000 4 415 32.7 889 32.7 1465 32.0 5000–< 7000 2 365 17.5 461 17.0 835 18.2 > 7000 2 651 19.7 492 18.1 837 18.3 aTotal varies due to missing data. bFasting blood glucose ≥ 126 mg/dL; cFasting blood glucose 100–125 mg/dL. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1241 of screening methods in different ethnic groups [11]. The high-risk questionnaire used for our Saudi population was that recommended by the ADA and studied by Rolka et al. [16]. In the current study, the high-risk score identified 71.3% of previously undiagnosed diabetics. However, the specificity of the high-risk score in our sample was low (39%), even lower than in a Caucasian population for whom it showed a sensitivity of 69%–75% and specificity of 49%–50% for the criteria of diagnosed DM, which may constrain its reliability for detecting undiagnosed DM [18]. This may be related to the unique cultural and ethnic characteris- tics of the Saudi population [11]. While it is desirable to have both high sensitivity and specificity in a screening test, this is rarely achievable in practice. Therefore there should be a trade-off be- tween the two, according to the needs of the screening, taking into consideration the cost, convenience and reproduc- ibility in mass screening. In screening there is usually a requirement to detect a higher number of cases, so a higher sen- sitivity is required in diagnosis, although there is no uniform agreement on the cut-off point. However, CBG testing by portable glucometer has the lowest cost, followed by laboratory-confirmed FPG and HbA 1c testing [1]. The sensitivity of fasting CBG and random CBG were higher in our study when the cut-off point was lowered but their specificity was very low. Increas- ing the cut-off point of fasting CBG from 100 mg/dL to 120 mg/dL and of random CBG from 140 mg/dL to 160 mg/dL optimized the balance of sensi- tivity and specificity. On the other hand, an argument could be made for lower- ing the cut-off points to 110 mg/dL and 150 mg/dL for fasting and random CBG respectively and consequently reduce the chances of missing cases of diabetes and pre-diabetes with reason- able specificity. Zhang et al. studied the most ef- ficient cut-off point for CBG to iden- tify both pre-diabetes and undiagnosed diabetes in relation to both direct and indirect costs [19]. They chose a lower cut-off point (100 mg/dL) than in our study or Cervin et al.’s study [18], and found a sensitivity of 83% and specifi- city of 63%. Our study focused only on detecting undiagnosed DM. The main purpose, in addition to detection, was to follow patients through health care settings such as primary health care centres. So when focused on detecting undiagnosed DM the most efficient cut-off point for fasting CBG was higher, at 120 mg/dL. To study whether to use a lower cut-off and have a lower specificity or a Ta bl e 3 Pe rf or m an ce o f t he ri sk -s co re s cr ee ni ng q ue st io nn ai re a nd fa st in g an d ra nd om c ap ill ar y bl oo d gl uc os e (C BG ) s cr ee ni ng Sc re en in g te st a nd c ut -o ff Se ns it iv ity Sp ec ifi ci ty Po si ti ve p re di ct iv e va lu e N eg at iv e pr ed ic ti ve va lu e Po si ti ve li ke lih oo d ra ti o N eg at iv e lik el ih oo d ra ti o % 95 % C I % 95 % C I % 95 % C I % 95 % C I % 95 % C I % 95 % C I Ri sk sc or e ≥ 10 71 69 –7 3 39 38 –4 0 34 33 –3 5 75 74 –7 6 1.1 6 1.1 3– 1.2 0 0 .7 5 0 .7 0 –0 .8 0 Po si tiv e ris k sc or e + fa st in g C BG ≥ 12 0 m g/ dL 83 80 –8 51 86 84 –8 8 78 75 –8 1 89 87 –9 1 5. 80 5. 10 –6 .7 0 0 .2 0 0 .17 –0 .2 4 Po si tiv e ris k sc or e + ra nd om C BG ≥ 16 0 m g/ dL 75 73 –7 8 77 75 –7 8 60 58 –6 3 87 85 –8 8 3. 22 2. 99 –3 .4 6 0 .3 2 0 .2 9– 0 .3 5 C I = co nfi de nc e in te rv al . 1- Specificity Se ns it iv ity 0.0 0.2 0.4 0.6 0.8 1.0 1.0 0.8 0.6 0.4 0.2 0.0 Figure 1 Receiver operator characteristics curve for the high-risk screening questionnaire (diagonal segments are produced by ties) EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1242 higher cut-off and have lower sensitiv- ity, we used ROC curves to determine whether to use fasting or random CBG. The AUC for fasting CBG was higher (0.87) than for random CBG (0.82). Rolka et al. reported similar findings: CBG screening in participants who had not eaten for ≥ 8 hours had a higher sensitivity and specificity in both sexes compared with random CBG [16]. Figure 2 Receiver operator characteristics curve for (a) fasting capillary blood glucose screening test and (b) random capillary blood glucose screening test (diagonal segments are produced by ties) 1- Specificity Se ns it iv ity 0.0 0.2 0.4 0.6 0.8 1.0 1.0 0.8 0.6 0.4 0.2 0.0 (a) 1- Specificity Se ns it iv ity 0.0 0.2 0.4 0.6 0.8 1.0 1.0 0.8 0.6 0.4 0.2 0.0 (b) Table 4 Sensitivity, specificity, and proportion of individuals who tested positive for pre-diabetes and undiagnosed diabetes by fasting and random capillary blood glucose (CBG) screening test at different cut-off points Cut-off (mg/dL) Sensitivity Specificity Positive predictive value Negative predictive value Positive likelihood ratio Negative likelihood ratio % 95% CI % 95% CI % 95% CI % 95% CI % 95% CI % 95% CI Fasting 100 97 96–98 29 27–31 42 40–44 95 93–97 1.37 1.33–1.41 0.09 0.07–0.13 110 91 89–93 67 65–69 59 56–61 93 92–95 2.72 2.55–2.90 0.14 0.11–0.16 120 81 79–83 86 85–88 76 73–78 90 88–91 5.88 5.25–6.58 0.22 0.19–0.25 130 70 67–73 93 92–94 85 82–87 86 84–87 10.55 8.92–12.48 0.32 0.29–0.35 140 57 54–60 96 95–97 88 85–90 81 79–83 13.98 11.25–17.36 0.45 0.42–0.48 Random 140 91 90–92 48 47–50 42 40–43 93 92–94 1.76 1.70–1.81 0.18 0.16–0.21 150 84 83–86 65 64–66 50 48–51 91 90–92 2.41 2.30–2.51 0.24 0.22–0.27 160 76 74–78 77 76–79 58 56–60 89 88–90 3.35 3.16–3.55 0.31 0.29–0.34 170 69 70–71 86 85–87 66 64–68 87 86–88 4.77 4.43–5.14 0.36 0.34–0.39 180 63 61–65 90 89–91 72 70–74 86 85–87 6.35 5.79–6.95 0.41 0.39–0.44 190 57 55–60 93 92–94 77 75–79 84 83–85 8.29 7.43–9.26 0.46 0.43–0.48 200 53 51–55 95 94–96 81 79–84 83 82–84 10.75 9.43–12.24 0.50 0.47–0.52 CI = confidence interval. It was clear from our data that the high-risk questionnaire performed poorly when carried out alone, with a sensitivity of 71% and specificity of 39%. Even when a positive high-risk score was used in conjunction with portable CBG screening, sensitivity increased from 71% to 83%. However, other predic- tors did not change or were negatively affected, and this may be due to the high percentage of the study population who were obese or overweight. Three- quarters of the population of Eastern province of Saudi Arabia are obese or overweight [20]. Besides, the age of the study participants was ≥ 30 years. So, based on those factors, the ability to discriminate between those who had and those who did not have the disease was low. Our study had a number of strengths including the large size of the population طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1243 References enrolled in the campaign, the diversity of subgroups, and the study design, in which the laboratory personnel carry- ing out the confirmatory FPG testing were not aware of the previous results of CBG screening. FPG was selected for this study as the diagnostic standard because it is a convenient test to ensure compliance of the participants, espe- cially with large number of participants enrolled in this campaign. Conclusions The risk-score questionnaire did not perform well versus fasting and random CBG. The optimal cut-off points for fasting and random CBG were 120 mg/ dL and 160 mg/dL respectively. Fasting CBG had higher sensitivity, specificity and discriminating ability than random CBG for detection of diabetes and pre-diabetes in this population. Acknowledgements We thank all who participated in the campaign for their enthusiasm to ful- fil its objectives. Our thanks also go to the Ministry of Health, Al-Dawaa Pharmacy and Al-Qusaibi Com- pany for funding this study, and to Dr Mohamed Anwar Al-Yousef, Dr Ali Al-Atabani and Dr Jamal Al-Hamed for their active contribution in the campaign. Table 5 Optimal cut-off values of capillary blood glucose (CBG) screening test to predict diabetes mellitus according in males and female Saudi adults, Eastern province, 2004 Test/Sex No. tested AUC (95% CI) Cut-off (mg/dL) Sensitivity (%) Specificity (%) Random CBG Male 5104 0.85 (0.84–0.87) 165.5 77 77 Female 4991 0.79 (0.77–0.80) 159.5 70 71 Fasting CBG Male 1475 0.89 (0.87–0.91) 119.5 82 82 Female 3380 0.85 (0.83–0.87) 121.5 78 79 AUC = area under the curve; CI = confidence interval. 1- Specificity Se ns it iv ity 0.0 0.2 0.4 0.6 0.8 1.0 1.0 0.8 0.6 0.4 0.2 0.0 (a) 1- Specificity Se ns it iv ity 0.0 0.2 0.4 0.6 0.8 1.0 1.0 0.8 0.6 0.4 0.2 0.0 (b) Figure 3 Receiver operator characteristics curve of (a) fasting capillary blood glucose screening test and (b) random capillary blood glucose screening test if administered after positive high-risk score (Diagonal segments are produced by ties) American Diabetes Association. Standards of medical care in 1. diabetes–2008. 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Diabetes risk score: towards earlier detection 6. of type 2 diabetes in general practice. Diabetes/Metabolism Research and Reviews, 2000, 16:164–171. Baan CA et al. Performance of a predictive model to identify 7. undiagnosed diabetes in a health care setting. Diabetes Care, 1999, 22:213–219. Tabaei BP, Herman WH. A multivariate logistic regression 8. equation to screen for diabetes: development and validation. Diabetes Care, 2002, 25:1999–2003. Glümer C et al. A Danish diabetes risk score for targeted 9. screening: the Inter99 study. Diabetes Care, 2004, 27:727–733. Heikes KE et al. Diabetes risk calculator: a simple tool for de-10. tecting undiagnosed diabetes and pre-diabetes. Diabetes Care, 2008, 31:1040–1045. Spijkerman AMW et al. The performance of a risk score as a 11. screening test for undiagnosed hyperglycemia in ethnic mi- nority groups: data from the 1999 health survey for England. Diabetes Care, 2004, 27:116–122. Al-Nozha MM et al. Diabetes mellitus in Saudi Arabia. 12. Saudi Medical Journal, 2004, 25:1603–1610. Al-Ghamdi et al. A community-based screening campaign 13. for the detection of diabetes mellitus and hypertension in the eastern province, Saudi Arabia: methods and participa- tion rate. Journal of Family and Community Medicine, 2007, 14(3):91–97. Al-Baghli A et al. Control of diabetes mellitus in the Eastern 14. province of Saudi Arabia: results of screening campaign. East- ern Mediterranean Health Journal, 2010, 16(6):621–629. Diabetes risk test15. . American Diabetes Association [website] (http://www.diabetes.org/diabetes-basics/prevention/dia- betes-risk-test/, accessed 29 September 2010). Rolka DB et al. Performance of recommended screening tests 16. for undiagnosed diabetes and dysglycemia. Diabetes Care, 2001, 24:1899–1903. Stats calculator. Center for Evidence Based Medicine [website] 17. (http://cebm.utoronto.ca/practise/ca/statscal/, accessed 31 August 2010). Cervin C et al. Genetic similarities between latent autoimmune 18. diabetes in adults, type 1 diabetes, and type 2 diabetes. Diabe- tes, 2008, 57:1433–1437. Zhang P et al. Efficient cutoff points for three screening tests 19. for detecting undiagnosed diabetes and pre-diabetes: an eco- nomic analysis. Diabetes Care, 2005, 28:1321–1325. Al-Baghli AN et al. Overweight and obesity in the Eastern 20. province of Saudi Arabia. Saudi Medical Journal, 2008, 29:1319– 1325. Diabetes in the Eastern Mediterranean Region Diabetes mellitus is highly prevalent among both sexes in Member States of the WHO Eastern Mediterranean Region, ranging from 3.5% to 30.0% and it is highest among member countries of the Gulf Cooperation Council (GCC) at 11.5% to 30.0%. Many countries in the Region are now reporting the onset of type 2 diabetes mellitus at an increasingly young age. This is due to increasingly sedentary lifestyles, higher life expectancy and obesity. High blood pressure and cardiovascular diseases are also on the rise. In 2003, the 5 countries with the highest diabetes prevalence in the adult population were Nauru (30.2%), United Arab Emirates (20.1%), Qatar (16%), Bahrain (14.9%), and Kuwait (12.8%) (1). By 2025, the number of people with diabetes is expected to be more than double in Africa, the Eastern Mediterranean and South-East Asia regions. Further information on the Regional prevalence of this condition can be found on the noncommunicable diseases website at http://www.emro.who.int/ncd/diabetes.htm/ طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1245 Prevalence of malocclusions in school-age children attending the orthodontics department of Shiraz University of Medical Sciences M. Oshagh,1 F. Ghaderi,2 H.R. Pakshir 1 and A.M. Baghmollai 3 ABSTRACT To provide quantitative data about the prevalence of malocclusions in the Shiraz orthodontic population, we studied the records of 700 patients (391 girls and 309 boys) aged 6–14 years attending the undergraduate Department of Orthodontics at Shiraz University of Medical Sciences. The prevalence of Angle class I, II and III malocclusion of first molars was 52.0%, 32.6% and 12.3% respectively. Skeletal class I, II and III malocclusion was found in 18.0%, 70.0% and 12.0% respectively. There were no significant differences between the sexes in the prevalence of different types of skeletal malocclusion. Children with class III were significantly younger (mean age 8.9 years) than those with class I (9.6 years) or class II (9.7 years) malocclusions. Orthodontics students need more education and training in the management of class II malocclusion to improve the overall quality of care for patients. 1Orthodontic Research Centre, Department of Orthodontics; 2Department of Pedodontics, Faculty of Dentistry, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran (Correspondence to M. Oshagh: morteza_oshagh@yahoo.com). 3Dental Practice, Shiraz, Islamic Republic of Iran. Received: 14/03/09; accepted: 27/05/09 زايرش في ةيبطلا مولعلا ةعماج في نانسلأا ميوقت مسق لىع نيددرـتلما سرادلما بلاط ينب قابطلإا ءوس راشتنا لدعم ىيلامغاب يدممح هيسآ ،يرشكاپ اضر ديحم ،يرداق هزئاف ،قاشع ضىترم ةاتف 391( ًاضيرم 700 تلاجس اوسردف ،زايرش ناكس ىدل قابطلإا ءوس راشتنا لدعم نع ةيمك تايطعم ميدقت نوثحابلا فدهتسا :ةـصلالخا ىدلو .زايرش في ةيبطلا مولعلا ةعماج نم جرختلا لبق نانسلأا ميوقت مسق لىع اوددرت نممو ًاماع 14و 6 ينب مهرماعأ حوارـتت نمم ،)ىتف 309و )III )%12.3 ةئفلاو ،)II )%32.6 ةئفلاو )I )%52.0 ةئفلا في ليولأا ساضرلأا قابطإ ءوس راشتنا لدعم ناك ،لجنأ فينصت بسحب تائف لىإ مهعيزوت .)III )%12.0 ةئفلا فيو ،)II )%70.0 ةئفلا فيو )I )%18.0 ةئفلا في ليكيلها قابطلإا ءوس في لىولأا ساضرلأا قابطإ ءوس راشتنا لدعم نوثحابلا دجو ماك يطسولا رمعلا( III ةئفلا نم لافطلأا ناكو ،ليكيلها قابطلإا ءوسل ةفلتخلما طمانلأا راشتنا لدعم في ينسنلجا ينب ًايئاصحإ ابه ُّدتعي قورف كانه نكت لمو نانسلأا ميوقت صاصتخا بّلاط جاتيحو .)ماوعأ II )9.7 ةئفلا نمو ،)ماوعأ I )9.6 ةئفلا لافطأ نم ،ًايئاصحإ هب ُّدتعي رادقمب ًارمع رغصأ )تاونس 8.9 .ضىرلما ةياعرل ةيلاجملإا ةدولجا ينستح فدبه II ةئفلا نم قابطلإا ءوس ةلجاعم لىع بيردتلاو ميلعتلا نم ديزم لىإ Prévalence des malocclusions chez les enfants d’âge scolaire en consultation dans le service d’orthodontie de l’Université des Sciences médicales de Shiraz (République islamique d’Iran) RÉSUMÉ Pour fournir des données quantitatives sur la prévalence des malocclusions dans la population orthodontique de Chiraz, nous avons étudié les dossiers médicaux de 700 patients (391 filles et 309 garçons), âgés de six à quatorze ans ayant consulté dans le service d’orthodontie du premier cycle de l’Université des Sciences médicales de Shiraz. La prévalence des malocclusions des premières molaires correspondait respectivement à 52,0 % des patients pour la classe I, à 32,6 % pour la classe II et à 12,3 % du groupe étudié pour la classe III, selon la classification d’Angle. La prévalence des malocclusions squelettiques de classe I correspondait respectivement à 18,0 % des patients, celle de la classe II à 70,0 % et celle de la classe III à 12,0 % du groupe étudié. Il n’y avait pas de différences significatives entre les sexes pour la prévalence des types de malocclusion squelettique. Les enfants ayant une malocclusion de classe III étaient nettement plus jeunes (âge moyen 8,9 ans) que ceux qui présentaient une malocclusion de classe I (9,6 ans) ou de classe II (9,7 ans). Les étudiants en orthodontie ont besoin d’un enseignement et d’une formation renforcés pour la prise en charge des malocclusions de classe II afin d’améliorer la qualité globale des soins aux patients. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1246 Introduction The prevalence of malocclusion has been reported for different populations, but the figures can vary widely, even for the same population. Variables such as differences in the classification of malocclusions, age of the study sample, examiner differences in determining normal occlusion, and differences in sample sizes can affect the results [1]. Although several studies have in- vestigated the prevalence of dentofacial characteristics in a given population, few studies have been conducted among patients who seek or are referred for orthodontic care [1–10]. Danaei et al. reported that in Shiraz, Islamic Repub- lic of Iran, the prevalence of class I, II and III malocclusions in schoolchildren aged 7–9 years was 47.4%, 14.7% and 2.1% respectively [11]. Hedayati et al. found that almost half of the 11–14- year-old schoolchildren in Shiraz had a slight need or no need for orthodon- tic treatment according to the index of orthodontic treatment need [12]. In another study, however, they con- cluded that 70.1% of 12–15-year-old students in Shiraz had normal or minor malocclusions, indicating no need for orthodontic treatment [13]. No representative data on the prevalence of dentofacial characteris- tics are available for the orthodontic population in Shiraz. Because the number of orthodontists available to treat patients in Shiraz is only about 15, there is a high demand on each prac- titioner for treatment. Moreover, the establishment of a service usually leads to increased demand for treatment and there has been a steady increase in the number of patients being referred for treatment. Clearly the evaluation of referred patients and the distribu- tion of malocclusion types can provide valuable information for planning an orthodontic service. The present study was therefore designed to determine the frequency of malocclusions in a popula- tion of patients attending a university department of orthodontics in Shiraz for orthodontic treatment. Methods The orthodontic records of 700 patients (391 girls and 309 boys) attending the Department of Orthodontics at Shiraz University of Medical Sciences were selected randomly from 1200 patients and retrieved from the archives for evaluation. Patients with a history of previous orthodontic treatment or with system- atic disease, craniofacial deformities or syndrome and patients with incomplete records were excluded from this study. All patients were from the southern regions of the Islamic Republic of Iran and none of them had undergone previ- ous orthodontic treatment. Information about social class or ethnic origin was not recorded in the patient records at the department of orthodontics. Almost all patients were self-referred since there is no formal referral system for dental care through the Iranian health service. In addition, the insurance system in the country provides almost no special coverage for orthodontic treatment. Written case records, dental casts, panoramic and cephalometric X-rays and intraoral and extraoral photographs were studied. The following dentofacial characteristics were investigated from initial records: molar relation according to Angle’s classification and skeletal rela- tion according to ANB and Wit’s apprais- al, overjet, overbite, crossbite, growth pattern and oral habits [14,15]. Lateral cephalometric X-rays were retrieved and traced to establish skeletal relations. Skeletal malocclusion and growth pat- tern were determined by measuring SNA (saddle–nasion–A-point angle), SNB (saddle–nasion–B-point angle), ANB (A point–nasion–B-point angle), Wit’s distances, Go-Gn-SN (gonion– gnathion–saddle–nasion angle) and FMA (Frankfort plan–mandibular plan angle). Non-nutritional habits (thumb sucking, pacifier sucking, pen or nail biting, lip sucking or cheek biting) were determined by questioning children and their parents. Other characteristics were determined by clinical examination. The data were pooled and analysed with the chi-squared test and 1-way analysis of variance. All analyses were done using SPSS, version 8. Results The overall ratio of boys to girls was approximately 4:5. The age distribution of patients is shown in Figure 1. The age Figure 1 Age distribution of paediatric patients attending Shiraz University of Medical Sciences orthodontics department طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1247 at first consultation ranged from 6–14 years but almost all (97.9%) were in the age range 7–12 years. The prevalence of skeletal class I, II and III malocclusion was 18.0%, 70.0% and 12.0% respectively, and there was no significant difference between the sexes in the prevalence of skeletal malocclusion (P = 0.25) (Table 1). The mean age of patients with skeletal class III malocclusion [8.9 (SD 1.5) years] was significantly lower than patients with class I [9.6 (SD 1.5) years] or class II malocclusions [9.7 (SD 1.4) years] (P < 0.001). Table 1 also shows the distribution of malocclusion in both sexes according to Angle’s classification of first molars. The prevalence of Angle class I maloc- clusion was 52.0%, class II 32.6% and class III 12.3%. There were some dif- ferences in the prevalence of Angle malocclusion between the sexes but these were not statistically significant (P = 0.06). However, among all class III patients the percentage of girls (44.2%) was significantly lower than boys (55.8%) (P < 0.05) (Table 1). The growth pattern was normal in 24.0% of children, vertical in 56.6% and horizontal in 19.4%, and there was no significant difference in growth patterns between the sexes (P = 0.71). The prevalence of large overjet was 30.0% and negative overjet was 18.0%. The rate of overjet was significantly higher in boys than girls (P < 0.001) (Table 1). However, there were no sig- nificant differences in the prevalence of different overbites between the sexes (P = 0.46). Crossbite was found in 36.0% of the sample (17.0% anterior and 19.0% posterior crossbite). Oral habits were noted in 17.0% of patients, including thumb sucking in 9.2% and lip biting in 2.0%. No significant difference was found in the prevalence of crossbite (P = 0.17) or oral habits (P = 0.08) be- tween the sexes. Discussion In this study of Iranian children who sought orthodontic treatment, the prev- alence of class I, II and III malocclusion of first molars was 52.0%, 32.6% and 12.3% respectively. The reported preva- lence of dental malocclusion in a Co- lombian study of young patients varied from 39% to 93% [16]. The prevalence Table 1 Orthodontic profile of boys and girls attending Shiraz University of Medical Sciences orthodontics department Variable Total Boys Girls P-value (boys vs girls)(n = 700) (n = 309) (n = 391) No. % No. % No. % Malocclusion (skeletal) Class I 126 18.0 54 17.5 70 17.9 0.25 Class II 490 70.0 224 72.5 270 69.1 Class III 84 12.0 31 10.0 51 13.0 Malocclusion (Angle class) 0.06 Class I 364 52.0 147 47.6 217 55.5 Class II 228 32.6 105 34.0 123 31.5 Class III 86 12.3 48 15.5 38 9.7 End-to-end 22 3.1 9 2.9 13 3.3 Growth pattern 0.71 Normal 168 24.0 77 24.9 91 23.3 Vertical 396 56.6 169 54.7 227 58.1 Horizontal 136 19.4 62 20.1 74 18.9 Overjet < 0.001 Normal 364 52.0 – – – – Large 210 30.0 – – – – Negative 126 18.0 – – – – Bite type 0.46 Normal 252 36.0 102 33.0 160 40.9 Deep bite 371 53.0 170 55.0 215 55.0 Open bite 77 11.0 37 12.0 46 11.8 Cross bite 252 36.0 115 37.2 137 35.0 0.17 Other Oral habits 119 17.0 51 16.5 68 17.4 0.08 EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1248 of different types of malocclusion may show considerable variability, even in a population of the same origin. The criteria for normality vary from one examiner to another, and this affects the results of different studies. Our data are in agreement with Sari et al., who reported that 61.7% of the patients in Turkey had class I, 28.1% had class II and 10.2% had class III Angle dental malocclusion [17]. Small differences between different sets of results may be related to sample selection, ethnic origin and sample size. The sample ana- lysed by Sari et al. consisted of patients accepted for treatment, whereas our sample consisted of the total referred population [17]. Our results are also very similar to those of Jones, who investigated den- tal malocclusion in 132 Saudi Arabian patients referred for orthodontic treat- ment and reported that 53.8% had class I, 33.3% class II and 12.9% had class III Angle dental malocclusions [7]. How- ever, these results might not represent the prevalence of malocclusion in the reference population because the sam- ple size was insufficient. Our findings show less agreement with Sayin and Türkkahraman’s study, which found that the prevalence of class I, II and III Angle dental malocclusions in a Turkish population referred for orthodontic treatment was 64%, 24% and 12% respectively [1]. Although their reported frequency of class I and II malocclusions was different from our results, the frequency of class III maloc- clusion was similar. However, a study in Indonesia obtained different figures for class III frequencies, reporting a 2% incidence in the Indonesian sample compared to 4% in an English sample and 23% in a Chinese population [5]. The male:female ratio in our study was 4:5 ,which is similar to the 4:6 ratio in the studies by Willems et al. [18], Jones [7] and Sayin and Türkkahraman [1]. In our study 48.0% of the patients had abnormal (class II or III) molar in- terdigitation. This is in agreement with a 2007 study onstudents in Shiraz, which found deviation from the class I molar relation in about half the sample [13]. The data from our orthodontic population was affected by selection bias and cannot be extrapolated to the whole Shiraz population. Therefore, our patients would be expected to have a greater prevalence of malocclusion. Similarly, Ucuncu and Ertugay found that 83.2% of the Turkish patients re- ferred for treatment, but only 38.3% of the school-aged population, had a great need for orthodontic treatment [10]. In another study Danaei et al. found that in 7–9-year-old children in Shiraz, the prevalence of class I, II and III maloc- clusion was 47.4%, 14.7% and 2.1% respectively [11]. The lower prevalence of class II and III malocclusion in their study may be related to sample selec- tion, as noted above. Nevertheless, the orthodontic population can be a useful group for analyses related to specific orthodontic treatments, as others have previously reported [8,9,19,20]. Although Angle’s classification has been the topic of many discussions in the literature [21,22], it remains a fairly easy and accurate way of categorizing maloc- clusions, and is widely used in the dental profession. We therefore used Angle’s original classification in this study to categorize dental malocclusions. The results of this categorization are shown in Table 2, and compared with those of other surveys [8,9,19,20,23]. It is none- theless difficult to compare prevalence studies of dentofacial characteristics because the results represent different ethnic types [18]. The type of malocclusion is an im- portant factor that affects a patient’s motivation to seek treatment [1]. In our study, comparisons of the mean ages of the malocclusion groups indicated a sta- tistically significant difference between skeletal class III and other groups, and the lowest mean age was in the class III group (8.9 years). This contrasts with Wilmont et al.’s study, which reported that patients with a severe sagittal class II deformity had a higher motivation for orthodontic treatment [24]. This may be attributed to the fact that in Iranian society, a slightly convex profile in young children is more acceptable than concave profiles. Adolescence is often associated with increased self- consciousness, confusion about identity and acceptance by others, and concerns about recognition from adults and peers [25]. Accordingly, adolescents are more likely to be highly motivated to seek orthodontic treatment. According to our results, the majority of patients were 7–12 years old. Thus (and while ac- knowledging that external motivations may also play a role) we can conclude that the motivation for orthodontic Table 2 Prevalence of Angle classes in our Shiraz orthodontic population compared with other orthodontic populations Angle class Present study Willems et al. [18] Beresford [23] Sheiham et al. [19] Rose [8] Vig et al. [20] Yang [9] Islamic Republic of Iran Belgium England England England USA Korea % % % % % % % Class I 52.0 31 37.8 47.1 49.2 43.7 53.9 Class II 35.6 63 60.4 44.3 46.3 50.8 14.9 Class III 12.3 6 1.8 8.6 4.5 5.5 49.1 طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1249 treatment increased during early adoles- cence in our Iranian population sample. However, this interpretation must take into consideration the fact that at the Shiraz orthodontic department, most patients older than 12 years attend the postgraduate section of the department, and those records were not reviewed in the present study. In our study skeletal class II patients comprised the greatest percentage of cases, but in Danaei et al.’s study the prevalence of class II malocclusion in the Shiraz population was only 14.7% [11]. This suggests that more class II patients in our population were referred for orthodontic treatment. It therefore seems logical to reinforce education and training about class II malocclusion for Iranian dental students. Moreover, our results suggest that insurance system coverage for these patients would be appropriate. In our sample of children the prevalence of skeletal class I, II and III malocclusions was 18%, 70% and 12% respectively. These figures differ from those of Jones, who reported 46.4% for class I, 27.5% for class II and 26.1% for class III skeletal malocclusion in Saudi Arabian patients [7]. This difference may be attributed to ethnic differences and the small size of the Saudi Arabian study sample. In our study, 56.5% of the patients had a vertical growth pattern of the facial skeleton, compared with Willem’s study, which reported 29% vertical growth pat- tern at a Belgian university [18]. On the other hand our study showed that 19% of our sample had posterior crossbite, similar to the prevalence of this anomaly in Willem’s study (15%) [18]. The prevalences of large overjet (30.0%), negative overjet (18,0%) and open bite (11.0%) were higher than in a study by Danaei et al., which reported prevalences of increased overjet of 17%, reverse overjet of less than 2% and open bite of less than 3% [13]. These differ- ences can also be attributed to the fact that their sample consisted of a random selection of schoolchildren rather than referred patients and to the older age in general of the students in their study compared to our sample. Conclusions Most of the children attending the Department of Orthodontics at this Shiraz hospital had skeletal class II malocclusion. Since the number of or- thodontists available to treat patients in the city of Shiraz is limited, there is a high demand on each practitioner for treat- ment. Therefore current orthodontics students should receive more education and training in the management of class II malocclusion to improve the overall quality of care for patients. Acknowledgements This study was supported by the Office of the Vice Chancellor for Research of Shiraz University of Medical Sciences. We thank the Centre for Development of Clinical Research of Nemazee Hospi- tal in Shiraz for editorial assistance and K. Shashok (AuthorAID in the Eastern Mediterranean) for improving the use of English in the manuscript. References Sayin MO, Türkkahraman H. Malocclusion and crowding in an 1. orthodontically referred Turkish population. Angle Orthodon- tist, 2004, 74:635–639. Brunelle JA, Bhat M, Lipton JA. Prevalence and distribution 2. of selected occlusal characteristics in the U.S. population, 1988–91. 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A thousand cases: a survey. 8. British Journal of Orthodon- tics, 1974, 1:45–54. Yang WS. [The study on the orthodontic patients who visited 9. department of orthodontics, Seoul, National University Hos- pital]. Taehan Chikkwa Uisa Hyophoe Chi, 1990, 28:811–821 [in Korean]. Uçüncü N, Ertugay E. The use of the index of orthodontic treat-10. ment need (IOTN) in a school population and referred popula- tion. Journal of Orthodontics, 2001, 28(1):45–52. Danaie SM, Asadi Z, Salehi P. Distribution of malocclusion 11. types in 7–9-year-old Iranian children. Eastern Mediterranean Health Journal, 2006, 12(1–2):236–240. Hedayati Z, Fattahi HR, Jahromi SB. The use of index of ortho-12. dontic treatment need in an Iranian population. Journal of the Indian Society of Pedodontics and Preventive Dentistry, 2007, 25(1):10–14. Danaei SM, Amirrad F, Salehi P. Orthodontic treatment needs 13. of 12–15 year old students in Shiraz, Islamic Republic of Iran. Eastern Mediterranean Health Journal, 2007, 13(2): 326–234. Angle EH. Classification of malocclusion. 14. Dental Cosmos, 1908, 41:248–264. Proffit WR, Fields HWJr, Sarver DM, eds. 15. Contemporary ortho- dontics, 4th ed. St Louis, Missouri, Mosby, 2007:195–199. Thilander B et al. Prevalence of malocclusion and orthodontic 16. treatment need in children and adolescents in Bogota, Co- lombia. An epidemiological study related to different stages of EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1250 dental development. European Journal of Orthodontics, 2001, 23:153–168. Sari Z et al. Orthodontic malocclusions and evaluation of treat-17. ment alternatives: an epidemiologic study. Turkish Journal of Orthodontics, 2003, 16:119–126. Willems G et al. Prevalence of dentofacial characteristics in a 18. Belgian orthodontic population. Clinical Oral Investigations, 2001, 5: 220–226. Sheiham A et al. Orthodontic treatment in the general dental 19. service in England and Wales: a study. British Dental Journal, 1971, 131:535–538. Vig PS et al. The duration of orthodontic treatment with and 20. without extractions: a pilot study of five selected practices. American Journal of Orthodontics and Dentofacial Orthopaedics, 1990, 97:45–51. Brin I, Weinberger T, Ben-Choirin E. Classification of occlu-21. sion reconsidered. European Journal of Orthodontics, 2000, 22:169–174. Du SQ et al. Reliability of three methods of occlusion clas-22. sification. American Journal of Orthodontics and Dentofacial Orthopaedics, 1998, 113(4):463–470. Beresford JS. Tooth size and class distinction. 23. Dental Practice, 1969, 20:113–120. Wilmont JJ et al. Associations between severity of dentofacial 24. deformity and motivation for orthodontic–orthognathic sur- gery treatment. Angle Orthodontist, 1993, 63:283–288. Tung AW, Kiyak HA. Psychological influences on the timing of 25. orthodontic treatment. American Journal of Orthodontics and Dentofacial Orthopaedics, 1998, 113:29–39. Hidden cities: unmasking and overcoming health inequities in urban settings This global report is an important component of the overall World Health Organization strategy to strengthen the response of the local, national and global health communities to reduce health inequities in an increasingly urbanized world. The report exposes the extent to which the urban poor suffer disproportionately from a wide range of diseases and health problems, which can be traced back to inequalities in their social and living conditions. It also provides evidence- based information and tools to help municipal and health authorities tackle health inequities in their cities. The case for action is juxtaposed with personal stories and photos illustrating the issues of urban health equity in six countries. Stories of municipal and national authorities who are taking action to reduce inequities also are featured. Further information about this and other WHO publication is available at: http://www.who.int/publications/en/ طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1251 Medical interns’ knowledge of tuberculosis and DOTS strategy in northern Islamic Republic of Iran A.R. Charkazi,1 G. Kouchaki,2 M. Soleymani Nejad 1 and A.H. Gholizade 3 ABSTRACT The increasing incidence of tuberculosis (TB) is a major concern to public health policy-makers. To assess knowledge about TB and the DOTS strategy among medical students in a high incidence area of the Islamic Republic of Iran, a questionnaire designed around the national TB programme guidelines was given to 80 interns in Golestan and Mazandaran medical schools in December 2007. The overall mean knowledge score was 1.80 (SD 1.61) items correct out of 15. Knowledge about diagnosis, treatment and monitoring was especially poor. There were no significant differences between the knowledge of interns who had completed their internships in the infectious diseases or community health departments compared with those who had not. 1Department of Public Health; 2Department of Surgery, School of Paramedicine and Health, Golestan University of Medical Sciences, Gorgan, Islamic Republic of Iran (Correspondence to A.R. Charkazi: r.charkazi@gmail.com). 3Department of Public Health, School of Health, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran. Received: 09/02/09; accepted: 20/05/09 ناريإ ةيروهجم قشر في شرابلما فاشرلإا تتح دملأا ةيرصقلا ةلجاعلما ةيجيتارـتساو لسلا نع ينميقلما ءابطلأا فراعم ةيملاسلإا يدالها دبع هداز ليق ،دازن نمايلس ةيضرم ،يكجوك دممح نابرق ،يزكرج نحمرلا دبع ًانايبتسا نوثحابلا م َّمص دقو .ةيمومعلا ةحصلا في سيايسلا رارقلا باحصأ ىدل ةيسيئرلا لغاوشلا نم لسلا عوقول ديازتلما ل َّدعلما ُّدَعُي :ةـصلالخا ةيرصقلا ةلجاعلما ةيجيتارـتسا لوحو ضرلما اذه لوح بطلا بلاط فراعم مييقت فدبه ،لسلا ةحفاكم جمانبرب ةصالخا ةيداشرلإا لئلادلا لوح ينميقلما ءابطلأا نم يننماثل تانايبتسلاا تيطعأو ،ةيملاسلإا ناريإ ةيروهجم في لسلا عوقول عفترم ل َّدعم تاذ ةقطنم في شرابلما فاشرلإا تتح دملأا يرايعم فارحناب( ًادنب 1.80 ةيطسولا ةحيحصلا ةيلاجملإا زارحلأا تغلب دقو .2007 برمسيد/لولأا نوناك في نارادنزامو ناتسلُك في بطلا ْيَتيلك في ابه ُّدَتْعُي قورف كانه نكي لمو .صاخ لكشب ءوسلا ةغلاب دْص َّرلاو ةلجاعلماو صيخشتلا لوح فراعلما تناكو .فراعلما ملس لىع 15 لصأ نم )1.61 نيذلا ينميقلما ءابطلأا فراعم ينبو عمتجلما ةحص وأ ةيدعلما ضارملأا ماسقأ في مهتماقإ ةرـتف اولمكتسا نيذلا ينميقلما ءابطلأا فراعم ينب ًايئاصحإ .اهولمكتسي لم Connaissances des internes en médecine sur la tuberculose et sur la stratégie du traitement de durée brève sous surveillance directe dans la partie septentrionale de la République islamique d’Iran RÉSUMÉ L’incidence croissante de la tuberculose est une préoccupation majeure pour les responsables politiques de la santé publique. Pour évaluer les connaissances des étudiants en médecine sur la tuberculose et sur la stratégie du traitement de durée brève sous surveillance directe dans une zone d’incidence élevée de la République islamique d’Iran, un questionnaire élaboré à partir des directives nationales du programme de lutte contre la tuberculose a été administré à 80 internes des facultés de médecine de Golestan et Mazandaran, en décembre 2007. Le score moyen global était d’1,80 réponse exacte (E.T. 1,61) sur un total de 15 questions. Les connaissances concernant le diagnostic, le traitement et le suivi étaient particulièrement insuffisantes. Il n’y avait pas de différences significatives entre les connaissances des internes qui avaient effectué leur internat dans le service des maladies infectieuses ou dans les services de santé communautaires et les connaissances des internes d’autres services. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1252 Introduction The increasing incidence of tuberculosis (TB) is a major concern to public health policy-makers in both developing and developed countries [1–3]. Approxi- mately one-third of the world’s popu- lation is infected with Mycobacterium tuberculosis, and 3 million people die every year due to TB [4]. Today, in spite of M. tuberculosis screening, vaccines and effec- tive anti-TB drugs, it is still a major global public health problem [5,6]. Incorrect and insufficient treatment, the emer- gence of multi-drug resistant (MDR- TB) strains and the co-epidemic with HIV all contributed to the failure of TB control, prompting the World Health Organization (WHO) to pronounce TB a global emergency in 1993 [1]. In the Islamic Republic of Iran the incidence of TB decreased stead- ily from 34 per 100 000 population in 1993 to 13.2 per 100 000 population in 2006, after the introduction of the WHO recommended TB control strat- egy known as directly-observed treat- ment short-course (DOTS). In several regions such as Sistan va Baluchistan and Golestan provinces the incidence of TB is higher than in other regions [7]. Medical interns, as future specialist and general physicians (GPs), are the backbone of any health care system and are in a position to make an impact on TB control. Nevertheless, there is limited data about knowledge of TB and the DOTS strategy among medical interns. Previous studies conducted in the Islamic Republic of Iran showed poor knowledge about TB and DOTS among GPs in the public and private health sectors [8–10]. In view of the importance of phy- sicians’ collaboration in TB care to achieve control of the disease, we de- signed this study to evaluate knowledge of TB control and its management via the DOTS strategy among the medical interns of Golestan and Mazandaran medical schools in the northern part of the Islamic Republic of Iran. Methods A cross-sectional study was carried out in December 2007, simultaneously among interns of Golestan University of Medical Sciences in Gorgan city and Mazandaran University of Medical Sci- ences in Sari city. Participants To recruit participants for the study, a list of all interns resident in 7 hospitals (4 in Sari and 3 in Gorgan) were ob- tained from the medical schools. All departments and wards in the hospitals were visited to recruit the students to the study. Of the 103 eligible students 23 dropped out (15 in Gorgan and 8 in Sari), giving a final sample of 80 students. Interns gave verbal consent to participate after being given assur- ances of confidentiality and anonym- ity. A repeat visit was conducted on the subsequent 3 days to include interns who were absent during the first visit or could not be contacted as they were off-duty or busy at the time. Data collection Data were gathered using a self- administered questionnaire with a mix of open- and closed-ended questions. The first section recorded some back- ground information (age, sex, univer- sity and whether they had completed internships in departments where the subject of TB is taught routinely). The second section assessed TB knowledge based on the DOTS strategy includ- ing: meaning of the acronym DOTS, description of the DOTS concept, meaning of the term MDR-TB, usual mode of transmission of TB, most com- mon symptoms of pulmonary TB, the best tests for diagnosis of pulmonary TB and for monitoring of treatment, categories of TB treatment, the recom- mended anti-TB regimen in the initial and continuous phases, definition of failure of TB treatment, criterion for a cured person and the types of TB that need long-term treatment. The questionnaire was designed using the national tuberculosis pro- gramme guidelines and its validity was determined by assessing its content validity and testing its reliability by test– retest (r = 0.85). Statistics All data were entered into SPSS, version 13 for Windows, and double entry of data was used in order to check for data entry accuracy. Independent t-tests were performed to analyse any differences in mean knowledge. Values of P ≤ 0.05 were considered significant. All other measures were subject to descriptive statistics. Interns’ knowledge level was described as high if they scored > 75% correct answers, moderate if 50%–75% correct or low if < 50% correct. Results Background data of participants The participants comprised 44 (55%) men and 36 (45%) women. Their mean [standard deviation (SD)] age was 25.8 (SD 1.5) years, range 24–31 years. Of these, 28.8% had completed their intern- ship in the infectious diseases ward and 27.5% in the community health depart- ment. The participants’ demographic characteristics are shown in Table 1. DOTS strategy and MDR-TB Over 90% of the participants were un- able to define the DOTS acronym and 83.8% could not describe the DOTS concept; 57.5% were unable to define the term MDR-TB (Table 2). Transmission and symptoms A majority of interns (85.0%) correctly identified TB as a droplet infection, while some thought that sexual inter- course (8.7%) and digestion (5.0%) were routes of transmission (Table 3). Two-fifths (40.0%) mentioned coughing for 3 weeks or more as an important symptom of pulmonary طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1253 TB; other answers included chest pain (20.0%), dyspnoea (15.0%) and hae- moptysis (12.5%) (Table 3). Diagnosis and follow-up Only 17.5% considered sputum smears for acid-fast bacilli (AFB) as the best test for diagnosis of pulmonary TB, while 60.0% proposed chest X-ray (Table 3). Only 6.3% considered sputum mi- croscopy as the best test for follow-up of cases under treatment, while 85.0% thought it was chest X-ray. Treatment and management Only a few participants (7.5%) were able to define categories of TB treat- ment and duration of consumption of drugs in 2 categories (Table 4). Four- fifths (80.0%) were unable to recom- mended which anti-TB drugs should be used in each category. Asked to name the 4 types of TB that need long-term chemotherapy (miliary, CNS, menin- geal and skeletal TB), 58.8% could not identify even 1 type. Very few knew how to define TB treatment failure and only 2 respondents were able to give the definition of a cured case of TB. Knowledge assessment The overall mean knowledge score for the 80 interns was 1.80 (SD 1.61) cor- rect answers from a maximum of 15. Knowledge of all interns was poor: none of them achieved a moderate or high score. There was no significant differ- ence between the knowledge of interns who had completed their internships in the infectious diseases or community health departments and those who had not (data not shown). Discussion In this study interns working in 7 medi- cal centres in Gorgan and Sari had very weak knowledge of TB. Our results are consistent with the findings of studies in other regions and countries such as those of Shehzadi [11], Khan [12], Har- ries [13], Lotfi [8], Nojoomi [9] and Talaeei [10], in which most interns and GPs had insufficient knowledge. Our study also showed that poor knowledge of TB among interns was not affected by the type of ward they had worked in. Students who had completed their in- ternships in the infectious diseases and community health departments, where the subject of TB is taught routinely, had no better knowledge than those who had no experience in these fields. Our findings about knowledge of transmission of M. tuberculosis were con sistent with studies of medical students, residents and interns in Pakistan, the United States of America and Nigeria, although subjects there were somewhat better informed, with 96%, 95% and 88.1% knowing that droplet infection was the usual mode of transmission compared with 85.0% in our study [12,14,15]. A study among GPs in Pa- kistan showed that only 68% correctly identified TB as a droplet infection [11]. Two studies in India and the Philip- pines showed poor knowledge about the mode of transmission, with about 4% of interns and 21% of physicians aware that droplet infection was the only route of transmission [16,17]. Cough for 3 weeks or more is con- sidered to be the primary symptom of Table 1 Demographic profile of interns included in the study (n = 80) Variable No. % Sex Male 44 55.0 Female 36 45.0 Age (years) 23–24 15 18.8 25–26 44 55.0 27–28 16 20.0 29–30 4 5.0 30+ 1 1.2 Medical school Mazandaran, Sari 52 65.0 Golestan, Gorgan 28 35.0 Completed internship in: Infectious diseases 23 28.8 Community health 22 27.5 Table 2 Knowledge among interns about terminology related to the directly observed treatment, short-course (DOTS) strategy and multi-drug resistant tuberculosis (MDR-TB) (n = 80) Item Correct response Incorrect response No response No. % No. % No. % Define the acronym for DOTS 3 3.8 36 45.0 41 51.2 Describe the DOTS concepta 13 16.2 67 83.8 0 0 Define the term MDR-TBb 34 42.5 46 57.5 0 0 aStrategy to assure consumption of anti-TB drugs in the initial phase of pulmonary TB treatment when it is supported by health workers; bTB that is resistant to at least isoniazid and rifampicin. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1254 pulmonary TB according to WHO guidelines. Two-fifths of interns in our study were able to identify this symptom, although in a high prevalence region such as Golestan province this rate of knowledge was inadequate and should be higher. In contrast, in India, Pakistan, the Philippines and Somalia, physicians and medical interns were very knowl- edgeable about the presenting symp- toms of pulmonary TB [16–19]. We found that few interns indicated sputum smear microscopy for diagnosis of TB or as a follow-up test. Sputum mi- croscopy has a high specificity and low rate of false negatives. It is considered to be the most efficient method for diagnosis of pulmonary TB, and is advocated under the DOTS strategy worldwide. Interns in Pakistan and India were somewhat better informed about sputum smear microscopy [12,16]. Studies performed in other parts of world showed students’ and physicians’ knowledge ranging from 38% to 85% [12,14,19–23]. The interns had poor knowledge regarding treatment monitoring: a mere 6.3% were aware of AFB sputum mi- croscopy as a monitoring tool. Their counterparts in Pakistan were better informed with 43.5% aware [12]. A study in Ethiopia revealed similar levels of knowledge among physicians [24]. However, in a study of actual practices in Pakistan, no sputum smear tests were conducted during treatment [25]. A large proportion of our interns were unfamiliar with appropriate treat- ment regimens in the initial and continu- ation phases of the national tuberculosis control programme, which is based on WHO guidelines. Almost none of the respondents knew the meaning of the DOTS acronym. Their counterparts in Pakistan were slightly better informed with about 18% able to define it [12]. Similarly, most of the students in our study were unable to define the basic concept of the DOTS strategy. When asked to write the drugs and their dura- tion used in the initial phase (2 months Table 3 Knowledge among interns about transmission, symptoms, diagnosis and follow-up of tuberculosis (TB) (n = 80) Knowledge item for pulmonary TB No. correct responses % Usual mode of transmission Droplet infection 68 85.0 Sexual transmission 4 5.0 Digestion 3 3.8 No response 5 6.2 Most common symptom Coughing for 3 weeks 32 40.0 Chest pain 16 20.0 Dyspnoea 12 15.0 Haemoptysis 10 12.4 Fever 7 8.8 Weight loss 3 3.8 Best test for diagnosis Chest X-ray 48 60.0 Smear culture 18 22.5 AFB sputum microscopy 14 17.5 Treatment monitoring Chest X-ray 68 85.0 Smear culture 7 8.7 AFB sputum microscopy 5 6.3 AFB = acid-fast bacilli. Table 4 Knowledge among interns about treatment and management of pulmonary tuberculosis (TB) (n = 80) Question Correct response Incorrect response No response No. % No. % No. % Categories of TB treatment and duration of use of drugs 6 7.5 56 70.0 18 22.5 Drugs and doses used in both initial and continuous phase 16 20.0 52 65.0 12 15.0 Definition of failure of TB treatment 11 13.7 21 26.3 48 60.0 Criteria for cured case 2 2.5 12 15.0 66 82.5 Types of TB which need long-term chemotherapy (n = 79): 4 types 1 1.3 – – – – 3 types 1 1.3 – – – – 2 types 7 8.8 – – – – 1 type 23 28.8 – – – – None 47 58.8 – – – – طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1255 of isoniazid/rifampicin/pyrazinamide/ ethambutol) and the continuous phase (4 months of isoniazid/rifampicin) of treatment, only 20% of the interns were correct. This lack of knowledge about correct prescribing may lead to the spread of MDR-TB strains. In 2 surveys conducted among interns in India and Pakistan, the rates of correct knowledge of the recommended regi- men were 7.8% and 56.5% respectively [12,16]. Other studies conducted in various countries about the prescribing behaviour of GPs reported similar find- ings [18,20,24,26,27]. The definition of treatment failure, i.e. if a patient is AFB-positive for 5 months or more after treatment begins, was correctly answered only by 13.8% of respondents. Treatment failure is a sign that the TB management and control programme is inadequate and is a risk for MDR-TB in the community. Four types of TB need long-term treatment for 8 months: meningeal TB, miliary TB, CNS and skeletal TB. Only 1 of our participants knew all of these and 1 knew 3 types. Almost 60% ab- stained from responding, showing poor knowledge about this aspect of TB. Several limitations of this study re- strict the generalizability of the findings. Only 2 medical schools out of the 44 in the Islamic Republic of Iran were surveyed, and information about those who did not wish to participate was not collected. Conclusions In conclusion, this study demonstrated poor of knowledge about TB accord- ing to the WHO and national tuber- culosis programme guidelines among interns in Sari and Gorgan in 2007. We suggest that comprehensive, updated, in-service training is needed among undergraduates, with special emphasis on the DOTS strategy, and appropriate changes in the undergraduate medical teaching curriculum. Similar studies need to be conducted in other parts of country among interns, especially in regions with a high prevalence and incidence of TB such as Sistan va Balu- chistan and southern Khorasan. Acknowledgements This work received financial support from Golestan Medical Sciences University. We are very grateful to all interns who participated in this study and took time out of their busy lives to complete the questionnaire. 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International Jour- nal of Tuberculosis and Lung Disease, 1993, 3:74–78. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1257 Transfusion audit of blood products using the World Health Organization Basic Information Sheet in Qazvin, Islamic Republic of Iran H. Sheikholeslami,1 C. Kani,1 P. Fallah-Abed,2 F. Lalooha3 and N. Mohammadi4 ABSTRACT We assessed the practicality of using the transfusion Basic Information Sheet (BIS) for data collection, to determine the overall adequacy of physician documentation of blood product transfusion, and to make an audit of the appropriateness of blood product transfusion. The transfusion process and clinical indications for transfusions administered to adult hospitalized patients in 3 tertiary care teaching hospitals in Qazvin were prospectively reviewed. Adequate documentation was achieved in 62.6% of all transfusion episodes, range 41%–73%, depending on the medical specialty; 15.7% of red blood cells and whole blood requests, 40.8% of platelet requests and 34.1% of fresh frozen plasma requests were inappropriate. BIS-based information along with data collection can be used to provide feedback regarding the effectiveness of and compliance with local and national transfusion guidelines. 1Department of Internal Medicine, Boali Sina Hospital; 2Department of Surgery, Shahid Rajaei Hospital; 3Department of Obstetrics and Gynaecology, Kossar Hospital; Faculty of Medicine, Qazvin University of Medical Sciences, Qazvin, Islamic Republic of Iran (Correspondence to H. Sheikholeslami: bsrcqi@hotmail.com). 4Department of Community Medicine, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Islamic Republic of Iran. Received: 15/05/09; accepted: 17/08/09 ةحصلا ةمظنلم ةيساسلأا تامولعلما ةحيفص مادختساب ةيملاسلإا ناريإ ةيروهجم ،نيوزق في مدلا تاجتنم لقن لىع شيتفتلا ةيلماعلا يدممح ديون ،اهوللا ةمطاف ،دباع حلاف زيورب ،ينك ايلماك ،يملاسلإا خيش نوياهم ف ُّرعتلاو ،تايطعلما عجم في قيبطتلل ةيلباق نم مدلا لقن لوح ةيساسلأا تامولعلما ةحيفص هب عَّتمتت ام ىدم مييقت ةساردلا هذه تفدهتسا :ةـصلالخا عجار دقو .ةحيفصلا هذه مادختساب مدلا تاجتنم لقن ةمءلام ىدم لىع شيتفتلا ذيفنت مث ،مدلا تاجتنم لقنل ءابطلأا قيثوتل ةيلاجملإا ةيافكلا لىع في ةيثلاثلا ةياعرلل ةيميلعتلا تايفشتسلما اولخدأ نيذلا ينغلابلا ىدل اله ةيريسرلا يعاودلاو مدلا تاجتنم لقن َةيلمع ةيقابتسا ةعجارم نوثحابلا نم %62.6 ىدل ق َّقتح دق فياكلا قيثوتلا نأ لاجملإا هجو لىع نوثحابلا دجو دقو .مدلا لقن لوح ةيساسلأا تامولعلما ةفيحص اومدختساو ،نيوزق %15.7 ىدل ةمئلام نكت لم لقنلا تابلط نأ نوثحابلا دجو ماك .يبطلا صاصتخلال ًاعبت كلذو ،%73و %41 ينب حوارـتي ىدمبو ،مدلا لقن تا َّرم عيجم نوثحابلا جتنتساو .ةدمجلما امزلابلا لقن تابلط نم %34.1و تاحيفصلا لقن تابلط نم %40.8و ،مدلا لماكو ءارملحا تايركلا لقن تابلط نم لئلادلا ةيلاعف لوح ةيعاتجرا تامولعم ميدقت فدبه تايطعلما عجم عم ةيساسلأا تامولعلما ةحيفص لىع ةزكترلما تامولعلما مادختسا نكملما نم نأ .اله لاثتملاا ىدم لوحو مدلا لقنل ةينطولاو ةيلحلما ةيداشرلإا Audit de la transfusion des produits sanguins à l’aide de la fiche d’information de base de l’Organisation mondiale de la Santé, à Qazvin (République islamique d’Iran) RÉSUMÉ Nous avons évalué l’aspect pratique de l’utilisation de la fiche d’information de base relative à la transfusion et destinée au recueil des données, de déterminer l’adéquation générale de la documentation des médecins sur la transfusion des produits sanguins, et de conduire un audit sur la pertinence des épisodes de transfusion. Le processus de transfusion et les indications cliniques de transfusions sanguines administrées aux patients adultes hospitalisés dans trois hôpitaux universitaires de soins tertiaires à Qazvin ont été étudiés prospectivement. Globalement, une documentation adéquate a été obtenue dans 62,6 % des épisodes de transfusion. Ce pourcentage variait de 41 % à 73 % selon les spécialités médicales. Nous avons observé que 15,7 % des demandes de transfusion d’érythrocytes et de sang total, 40,8 % des demandes de plaquettes et 34,1 % des demandes de plasma frais congelé étaient contre-indiquées. Les données recueillies sur la fiche d’information de base associées aux autres données collectées peuvent être utilisées pour analyser l’utilisation efficace et conforme des directives nationales et locales des pratiques de transfusion. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1258 Introduction Clinical audit is a management tool for the appraisal and justification of appro- priateness and efficiency of transfusion therapy, and an important part of the quality assurance programme which can provide necessary information for improving transfusion medicine prac- tice [1]. Adequate documentation of evidence to support a rationale for blood transfusion is considered an essential part of transfusion medicine. More complete and appropriate documenta- tion allows more transfusion episodes to be assessed in an audit [2]. Transfu- sion is considered appropriate when it is used to treat conditions leading to significant morbidity and mortality and which cannot be prevented or managed effectively by other means [3]. Vari- ous strategies have been developed to reduce the inappropriate use of blood components. These include guidelines and consensus conferences as well as monitoring of transfusion practice, edu- cation, and self-audit by clinicians [4]. The World Health Organization (WHO) Regional Office for Europe developed a pan-European quality sys- tem using a basic information sheet (BIS) to improve the clinical use of blood products. The outcome of the pilot study indicated that the BIS for transfusion can serve as a tool for data collection and evaluation. Moreover, assessment of the impact of the transfu- sion BIS showed that BIS-based infor- mation can be used for measurement of performance against local guidelines, comparison of practices, improving per- formance and facilitating best transfu- sion practices [5]. The aims of the present study were to extend previous works on assessing the practicality of using the transfusion BIS for data collection, to determine the overall adequacy of physician documen- tation of blood product transfusion, and to carry out an audit of the appropri- ateness of blood products transfusion using the WHO BIS. Methods We prospectively reviewed the transfu- sion process using a WHO transfusion BIS [5], and clinical indications for red blood cell (RBC), platelet, and fresh frozen plasma (FFP) transfusions administered to adult (≥ 18 years) hospitalized patients in 3 tertiary care teaching hospitals in Qazvin (Depart- ment of Internal Medicine at Boali Sina Hospital, Department of Surgery at Shahid Rajaei Hospital, and Depart- ment of Obstetrics and Gynaecology at Kossar Hospital) in the 9-month period December 2007–August 2008. The appropriate use of platelet and FFP transfusions was assessed using the recommendations published by the British Committee for Standards in Haematology (BCSH) [6,7], and RBC transfusions were reviewed and compared with the current hospital guidelines. An internal medicine attending phy- sician used the BCSH and the hospital guidelines for each request within 48 h of transfusion to classify the transfusion as appropriate if the criteria were com- pletely fulfilled and inappropriate if the criteria were not completely covered. Doubtful assessments were judged by consensus after case review with a clini- cal haematologist. The following information was documented through a customized BIS for transfusion [5] (Farsi version, translated by a haematologist native to the study area) by internal medicine, surgery, and obstetrics and gynaecology resident physicians at the time a blood product was requested for any adult pa- tient: age, weight, date, transfusion start time, emergency or routine request, diagnosis, clinical indications, pre- and post-transfusion laboratory and clinical assessment, transfusion targets, blood components transfused, supporting therapies, transfusion outcome (clinical and/or laboratory improvement), and transfusion side-effects [5]. Documentation adequacy was judged independent of transfusion jus- tification. Transfusions were classified as adequately documented if, at least, the BIS included: documentation of a plan for transfu-• sion; documentation of pre- and post-• transfusion clinical or laboratory as- sessment; documentation of outcome of trans-• fusion (clinical and/or laboratory improvement) regardless of whether the transfusion episode was justified or not. All resident physicians responsible for prescribing in the study departments were asked for their consent to par- ticipate in the study, and were provided with guidance information for using the transfusion BIS. They were also asked to state any additional clinical condi- tions which may influence transfusion decisions but which were not included in the form. The study was approved by the Institutional Review Board of Qazvin University of Medical Sciences. SPSS, version 13.0, was used both at data entry and analysis. Results During the study period, 829 transfu- sion episodes were documented in 742 patients, who received a total number of 1994 units of blood components. The patient demographic data and trans- fusion episode information for each department are shown in Table 1. Of 829 transfusion episodes, 519 were identified as adequately docu- mented [43.4% (40/92) of whole blood transfusion episodes, 67.2% (361/537) of red cell transfusion episodes, 59.7% (52/87) of platelet transfusion episodes, and 58.4% (66/113) of FFP transfusion episodes]. This means adequate docu- mentation of at least a plan for transfu- sion, pre- and post-transfusion clinical طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1259 or laboratory assessment, and outcome of transfusion. Documentation adequacy of each part of the BIS was determined. Adequate documentation of patient identification required that patient’s name, age, sex, and weight were com- pleted. Transfusion targets, pre- and post-transfusion assessment, were judged adequately documented if, as a minimum, appropriate fields according to prescribed blood components were completed. Adequate documentation of the outcome of transfusion neces- sitated that minimally, the result and 1 of the therapeutic effects of transfusion (clinical or laboratory improvement) were included. Patient identification was adequate- ly documented in 64.6% of transfusion episodes, and the transfusion start time in 76.2% (Table 2). Documentation of the laboratory or clinical circumstances necessitating transfusion, and targets and outcome of transfusion reached the 80% minimum accuracy requirement for medical recording (Table 2). The volume of blood loss, the exist- ence of shock and the International Statistical Classification of Disease (ICD10) code were inadequately docu- mented in all departments. Improvement after transfusion ther- apy was achieved in 88.2% of transfusion episodes with a range of 84.8%–93.0%, depending on the department (Table 2). Although in 389 (58.6%)episodes the clinicians indicated that they had achieved the laboratory improvement, a review of outcome indicators com- paring the registered outcome with actual outcome showed that in 25% of episodes laboratory improvement was not actually achieved after transfusion Of 596 episodes of whole blood and RBC transfusion, 503 (84.3%) were considered appropriate according to the current hospitals guidelines (Table 3). Of 76 episodes of platelet transfusion, 45 (59.2%) were deemed appropriate according to the BCSH guidelines, and of 91 episodes of FFP transfusion 31 (65.9%) were deemed appropriate ac- cording to the same guidelines. Overall, of 763 blood product transfusions, 79.6% were judged appropriate. Table 1 Patient demographic data and transfusion episode information according to department Demographic data and transfusion episode information Department Internal medicine Surgery Obstetrics/ gynaecology Total Sex Males, No. (%) 234 (60) 107 (67) – 341 (46) Females, No. (%) 156 (40) 53 (33) 192 (100) 401 (54) Mean (SD) age (years) 56.7 (19.9) 50.5 (23.7) 33.4 (9.6) 49.6 (21.2) No. of transfusion episodes WB 19 15 58 92 RBC 281 147 109 537 PC 67 2 18 87 FFP 78 3 32 113 Total 445 167 217 829 Units/episode, mean (SD) median [range] WB 2.1 (1.4) 2 [1–7] 1.6 (1.1) 1 [1–4] 1.7 (0.9) 2 [1–6] 1.8 (1.0) 2 [1–7] RBC 1.6 (0.6) 2 [1–4] 1.8 (0.8) 2 [1–4] 1.8 (0.9) 2 [1–4] 1.7 (0.7) 2 [1–4] PC 7.5 (2.5) 7 [2–10] 6.0 (6)a 4.9 (2.5) 4 [2–10] 6.9 (2.6) 6 [2–10] FFP 2.8 (1.7) 2 [1–10] 2.0 (2) a 2.9 (1.6) 2 [2–9] 2.8 (1.7) 2 [1–10] No. of units transfused WB 42 24 102 168 RBC 461 258 193 912 PC 500 12 88 600 FFP 215 6 93 314 Total 1218 300 476 1994 Single unit transfusions RBC, No. (%) 119 (42.3) 53 (36.8) 51 (46.4) 223 (49.9) WB, No. (%) 7 (35) 10 (66.7) 23 (39.7) 40 (45.2) aThere was only 1 episode of PC transfusion and 1 episode of FFP transfusion in the Department of Surgery, thus, there is no standard deviation or range. SD = standard deviation; WB = whole blood; RBC = red blood cells; PC = platelet concentrate; FFP = fresh frozen platelets. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1260 Discussion Several lines of research have emerged that suggest the use of the transfusion BIS promotes self education in new staff, permits a further improvement in appropriate requests by acting as a checklist and promoting reflective prac- tice, and allows the audit of transfusion practice to be performed easily [5,8]. Although most departments (with the exception of obstetrics and gynae- cology) reached adequate documen- tation of greater than 80% in critical areas of the transfusion BIS (transfu- sion targets, pre- and post-transfusion outcome), the overall adequate docu- mentation (at least documentation of a reason for transfusion, pre- and post-transfusion clinical or laboratory assessment, and the transfusion out- come) was achieved only in 62.6% of all transfusion episodes. These items all are dynamic com- ponents of clinical decision-making [3]. The WHO BIS would support the clinical decision making, provided the collection of related information neces- sary to make a decision are documented as accurately and completely as pos- sible by clinicians, that highlights the importance of observing, training, and providing performance feedback on a regular basis particularly on the areas of poor compliance and performance to ensure achievement of compliance and performance standards necessary to support the efficiency and appropriate- ness of transfusion [9,10]. The finding that in 58.6% of cases, the clinicians indicated that they had achieved their laboratory results, but in only 33.6% did they meet the actual endpoints, while not inconsistent with WHO findings [5], is striking, and highlights the discrepancy between clinicians’ statements and actual per- formance. The study results showed that there was a significant correlation between this finding and inappropriate use within established clinical guide- lines. The volume of blood loss and the existence of shock were inadequately documented in the study departments. As the correct diagnosis of shock is criti- cal for proper management, an accurate history and assessment of the patient’s symptoms must be performed before commencing treatment. Including the degree of hypovolaemic shock (ac- cording to percentage of the blood loss and the associated clinical signs) in the WHO BIS is, therefore, more practical than global assessment of shock and leads to improved documentation. Moreover, in agreement with results of previous reports [5,8], the ICD10 code was often not recorded, probably because it was seldom avail- able for the clinicians at the bedside practice. Therefore the ICD10 code could be removed and replaced with Table 2 Number and percentages of transfusion episodes with adequate documentation in each part of the basic information sheet (BIS) and overall adequate documentation according to department Section of the transfusion BIS Department Internal medicine Surgery Obstetrics & gynaecology Total (n = 445) (n = 167) (n = 217) (n = 829) No. % No. % No. % No. % Patient identification 295 66.2 112 66.9 129 59.4 536 64.6 Start of transfusion 316 71.0 139 83.1 177 81.6 596 76.2 Assessment Pre-transfusion 432 97.1 158 94.6 209 96.3 799 96.3 Post-transfusion 366 82.2 139 83.1 116 53.4 621 74.9 Transfusion targets 387 86.9 156 93.4 187 86.1 730 88.1 Outcome 383 86.1 143 85.5 137 63.1 663 80.0 Overalla 307 69.2 121 72.3 91 41.9 519 62.6 Outcome of transfusion therapy (n = 383) (n = 143) (n = 137) (n = 663) Improvement 325 84.8 133 93.0 127 92.7 585 88.2 Both clinical & laboratory improvement 199 51.9 83 58.0 65 47.4 347 54.9 Clinical improvement 95 26.4 50 34.9 51 37.2 196 29.7 Laboratory improvement 31 8.1 0 0.0 11 8.0 42 6.3 Either clinical or laboratory improvement 126 32.9 50 34.9 62 45.3 238 35.9 No improvement 58 15.1 10 6.9 10 7.3 78 11.7 aAdequate documentation included at least a plan for transfusion, pre- and post-transfusion clinical or laboratory assessment, and outcome of transfusion. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1261 free text asking clinical indication for the transfusion as well as the patient-based conditions that may influence the deci- sion to transfuse a blood product (e.g. active bleeding in a patient with known cardiovascular or respiratory disease). Including the indications for transfu- sion would also improve adherence to transfusion guidelines and ensure ap- propriate blood transfusion practice. Although this study did not aim to assess the proportion of inappropriate use of blood components and the situ- ations in which the transfusions were considered inappropriate, the audit data using the WHO BIS showed that 15.7% of RBC and whole blood requests, 40.8% of platelet requests, and 34.1% of FFP requests, were inappropriate. The rate of inappropriate use of RBC, platelet, and FFP was within the ranges reported in previous studies [11–16]. However, our results are not directly comparable with these results because of differences in the guidelines used. Furthermore, of 629 transfusion episodes, 263 were for a single unit of whole blood or red cell transfusion and 62% of these were classed as inappropri- ate use. Skodlar et al. [8] and Metz et al. [12] also found a high proportion of inappropriate use of single-unit transfu- sion. Transfusion of a single unit of RBC should not be considered inappropriate by itself, however, its use without an appropriate clinical judgement is not acceptable [17,18]. Audits identify areas of problems in transfusion practice which can be cor- rected by education and formulation of Table 3 Appropriate and inappropriate blood products transfused according to hospital guidelines for red blood cell transfusions and according to British Committee for Standards in Haematology (BCSH) guidelines for platelet and fresh frozen platelet (FFP) transfusions [6,7] Indication Appropriate episodes Inappropriate episodes No. (sum of units transfused) Mean (SD) range No. (sum of units transfused) Mean (SD) range Contributory indications for RBC according to hospital guidelines (WB, RBC) (n = 596) 503 (881) 1.8 (0.82) 1–7 93 (142) 1.5 (0.63) 1–4 Acute blood lossa 176 (337) 1.9 (0.78) 1–4 35 (55) 1.6 (0.60, 1–4 Anaemia in critical care (target values as for acute blood loss) 64 (107) 1.7 (1.10) 1–6 9 (12) 1.3 (1.0) 1–4 Peri-operative transfusion (to maintain Hb concentration > 10g/dL) 82 (128) 1.6 (0.65) 1–4 24 (35) 1.4 (0.52) 1–2 Anaemiab 145 (256) 1.7 (0.72) 1–4 11 (18) 1.6 (0.87) 1–4 Anaemiac 36 (53) 1.4 (0.51) 1–2 14 (22) 1.5 (0.75) 1–4 Contributory indications for platelets (n = 76) 45 (327) 7.4 (2.6) 2–10 31 (201) 6.4 (2.7) 2–10 Bone marrow failured 27 (208) 8.0 (2.2) 3–10 6 (47) 7.8 (2.7) 4–10 Peri-operative or invasive proceduree 11 (69) 8.0 (2.2) 3–10 7 (41) 5.8 (2.0) 4–10 Massive haemorrhage/transfusionf 1 (10) 10.0g 5 (20) 4.0 (1.8) 2–6 Acute DIC in presence of bleeding & severe thrombocytopenia 1 (10) 10.0 2 (10) 5.0 (0.0) 5 Autoimmune thrombocytopenia in presence of major haemorrhage 5 (30) 6.0 (3.8) 2–10 11 (83) 7.5 (2.8) 3–10 Contributory indications for FFP (n = 91) 60 (172) 2.8 (1.4) 1–10 31 (71) 2.3 (1.7) 1–6 Single factor or coagulation inhibitor deficiency 5 (17) 3.4 (0.54) 3–4 – – Immediate reversal of warfarin effect in presence of life-threatening bleeding 10 (34) 3.4 (2.5) 1–10 9 (22) 2.4 (0.8) 1–4 Acute DIC in presence of bleeding and abnormal coagulation results 16 (53) 3.3 (1.4) 2–7 10 (21) 2.1 (1.2) 1–5 Liver disease 14 (31) 2.2 (0.80) 1–3 6 (18) 3.0 (2.0) 1–6 Active bleeding and PT > 1.5 × mean normal value 15 (37) 2.5 (0.64) 2–4 6 (10) 1.7 (0.51) 1–2 aTo maintain circulating blood volume and Hb concentration > 8g/dL in otherwise fit patients and > 10g/dL in elderly patients and those with known cardiovascular and respiratory diseases. bHb concentration < 8g/dL in otherwise fit patients. cHb concentration < 10g/dL in patients over 65 years and patients with cardiovascular or respiratory disease. dTo prevent spontaneous bleeding when the platelet count < 10 × 109/L or < 20 × 109/L in the presence of additional risk factors for bleeding. ePlatelet count < 50 × 109/L, or < 100 × 109/L before surgery in critical sites such as brain or eyes. fPlatelet count < 50, or < 100 × 109/L if micro-vascular oozing. gThere was only 1 episode of 10 units PLT transfusion, thus, there is no standard deviation or range. WB = whole blood; RBC = red blood cells; SD = standard deviation; Hb = haemoglobin; PT = prothrombin time; DIC = disseminated intravascular coagulation. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1262 practice guidelines [19]. To improve the effectiveness of the audit programmes, an audit must be simple, periodic, sys- tematic and documented. The WHO BIS includes transfusion measures for RBCs, platelets, and FFP and the reasons for transfusion for all blood components. These measures can be used for initial audits. Building on prior work [5,8], the au- thors predicted that the WHO BIS could be used in clinical settings as a practical data collection tool. The study findings support this prediction. Additionally, the WHO BIS will enable the transfu- sion service to improve patient care and outcome through the systematic review of the use of transfused blood compo- nents against transfusion guidelines. In addition to retrospective review of transfusion practice, the WHO BIS al- lows the transfusion service to evaluate product utilization by a prospective or concurrent review of ordering practices. In the prospective audit, reviewing and justifying the decision to use transfusion is provided prior to prescription and administration of blood, and the pa- tient receives the correct blood product or avoids an unnecessary transfusion, whereas a concurrent audit of requests is performed by reviewing all order forms within 12–24 hours after blood com- ponent administration and gives more timely feedback to clinicians about their individual guideline adherence [19]. Furthermore, the WHO BIS could be customized to ensure efficacy of audit processes by considering certain points, e.g. it could include the classification of the degree of hypovolaemic shock. A free text asking about some details re- garding the patient’s diagnosis and any relevant procedures to be undertaken References Audit measures for good practice in blood transfusion medicine1. . London, Royal College of Physicians Publications, 1995. Cheng G et al. The effects of a self educating blood component 2. request form and enforcements of transfusion guidelines on FFP and platelet usage. Clinical Laboratory Haematology, 1996, 18:83–87. The clinical use of blood handbook3. . Geneva, World Health Organization, Blood Transfusion Safety, 2002. www.who.int/ bloodsafety/clinical_use/en/Handbook_EN.pdf (accessed 8 August 2009). Hui CH, Williams I, Davis K.. Clinical audit of the use of fresh-4. frozen plasma and platelets in a tertiary teaching hospital and the impact of a new transfusion request form. Internal Medicine Journal, 2005, 35(5):283–288. Doughty HA. The Basic Information Sheet (BIS) for transfusion. 5. A new tool for data collection: interim report from pilot trials. In: Kalo I, ed. Development of quality systems to improve the clinical use of blood. Report on a WHO regional WORKSHOP, Groningen, the Netherlands, 29–31 October 2001. Copenhagen, World Health Organization, 2002. British Committee for Standards in Haematology. Blood Trans-6. fusion Task Force, Guidelines for the use of platelet transfu- sions. British Journal of Haematology, 2003, 122(1):10–23. British Committee for Standards in Haematology. Guidelines 7. for the use of fresh frozen plasma, cryoprecipitate and cryosu- pernatant. British Journal of Haematology, 2004, 126(1):11–28. Skodlar J et al. The use of a World Health Organization Transfu-8. sion Basic Information Sheet to evaluate transfusion practice in Croatia. Vox Sanguinis, 2005, 89:86–91. Garrioch M et al. Reducing red cell transfusions by audit, 9. education and a new guideline in a large teaching hospital. Transfusion Medicine, 2004,14:25–31. Goodnough LT et al. Transfusion medicine—blood transfusion. 10. New England Journal of Medicine, 1999, 340:438–447. Juárez-Rangel E et al. Auditoría transfusional retrospectiva 11. en el Centro Nacional de la Transfusión Sanguínea [Retros- pective transfusional audit at the Centro Nacional de la Transfusión Sanguínea]. Revista de investigación clínica, 2004, 56(1):38–42. Metz J et al. Appropriateness of transfusions of red cells, plate-12. lets and fresh frozen plasma: an audit in a tertiary care teaching hospital. Medical Journal of Australia, 1995, 162(11):564. Silverman JA et al. The appropriateness of red blood cells 13. transfusions in the peripartum patient. Obstetrics & Gynecology, 2004, 104(5 Pt 1):1000–1004. Schofield WN et al. Appropriateness of platelet, fresh fro-14. zen plasma and cryoprecipitate transfusion in New South Wales public hospitals. Medical Journal of Australia, 2003, 178(3):117–121. Kakkar N et al. Improvement in fresh frozen plasma transfusion 15. practice: results of an outcome audit. Transfusion Medicine, 2004, 14:231–235. Luk C et al. Prospective audit of the use of fresh-frozen plasma, 16. based on Canadian Medical Association transfusion guide- lines. Canadian Medical Association Journal, 2002, 166:1539– 1540. McClelland B. Effective use of blood components. In: Murphy 17. MF, Pamphillon DH, eds. Practical Transfusion Medicine. Ox- ford, Blackwell Science, 2001. Arslan O et al. Hb content-based transfusion policy success-18. fully reduces the number of RBC units transfused. Transfusion, 2004, 44:485–488. Joshi GP et al. Audit in transfusion practice. 19. Journal of Evalua- tion in Clinical Practice, 1998, 4:141–146. that may influence the transfusion deci- sion could also be included. In conclusion, the study findings suggest that the WHO BIS would be a practical tool for both data collection and auditing the transfusion practice. Further research, however, should be carried out to assess the feasibility, valid- ity and supporting role of the WHO BIS in effective local implementation and audit of guidelines. Acknowledgement The authors would like to acknowledge the support of all resident physicians at the participating hospitals for their contribution to the study. This research was supported by grants from Qazvin University of Medical Sciences Re- search Committee. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1263 Language barriers in medical education and attitudes towards Arabization of medicine: student and staff perspectives S.M. Sabbour,1 S.A. Dewedar 1 and S.K. Kandil 1 ABSTRACT Students and staff perspectives on language barriers in medical education in Egypt and their attitude towards Arabization of the medical curriculum were explored in a questionnaire survey of 400 medical students and 150 staff members. Many students (56.3%) did not consider learning medicine in English an obstacle, and 44.5% of staff considered it an obstacle only in the 1st year of medical school. Many other barriers to learning other than language were mentioned. However, 44.8% of students translated English terms to Arabic to facilitate studying and 70.6% of students in their clinical study years would prefer to learn patient history-taking in Arabic. While Arabization in general was strongly declined, teaching in Arabic language was suggested as appropriate in some specialties. 1Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt (Correspondence to S.M. Sabbour: sabbour_s@hotmail.com). Received: 27/12/08; accepted: 06/04/09 ةَّيميلعتلا ةئيلها ءاضعأو ةَبَلطلا رظن تاهجو :بطلا بيرعت هاتج فقاولماو يبطلا ميلعتلا في ةيوغللا قئاوعلا ليدنق ليلخ رَحَس ،راديود دحمأ رَحَس ،روبص دممح رَحَس بيرعت هاتج مهفقاوم لوحو ،صرم في يبطلا ميلعتلا في ةيوغللا قئاوعلا لوح ةيميلعتلا ةئيلهاو بلاطلا رظن تاهجو تاثحابلا تسرد :ةـصلالخا بلاطلا نم يرثكلا برعأ دقو .ةَّيميلعتلا ةئيلها ءاضعأ نم 150و بلاطلا نم 400 لمش ّيِحْسَم نايبتسا للاخ نم كلذو ،يبطلا سييردتلا جهنلما ةنسلا في ةَبَقَع هنوبرتعي منهأ نع ةَّيميلعتلا ةئيلها ءاضعأ نم %44.5 برعأ ينح في ،ةَبَقَع ةيزيلكنلإا ةغللاب بطلا م ُّلعت نوبرتعي لا منهأ نع )%56.3( نم %44.8 نإف ،رمأ نم نكي ماهمو .م ُّلعتلا هجو في ةيوغللا يرغ ىرخلأا قئاوعلا نم يرثك دوجو نع حسلما َرَفْسأ دقو .طقف بطلا ةيلك نم لىولأا نأ نولضفي ةيريسرلا مهتسارد تاونس في بلاطلا نم %70.6 نأو مهتسارد ليهستل ةيبرعلا ةغللا لىإ ةيزيلكنلإا تاحلطصلما نوجمرـتي بلاطلا ةغللاب ميلعتلا لىإ رظنُي هنإف ،ّماع هجوب ًاديدش ًاراسحنا بيرعتلا راسحنا نم مغرلا لىعو .ةيبرعلا ةغللاب ضيرملل ةيريسرلا ةصقلا ذخأ ةيفيك او َّملعتي .تاص ُّصختلا ضعب في مئلام هنأ لىع ةيبرعلا Les barrières linguistiques dans l’enseignement médical et l’état d’esprit concernant l’arabisation de la médecine : le point de vue des étudiants et du personnel médical RÉSUMÉ Dans une enquête par questionnaire, le point de vue de 400 étudiants en médecine et de 150 membres du personnel médical sur les barrières linguistiques dans l’enseignement médical en Égypte et leur opinion concernant l’arabisation du cursus médical ont été étudiés. De nombreux étudiants (56,3 %) ne considéraient pas l’apprentissage de la médecine en langue anglaise comme un obstacle, alors que 44,5 % du personnel médical percevaient cette pratique comme une difficulté uniquement pendant la première année d’études à la faculté de médecine. De nombreux obstacles à l’apprentissage de la médecine, autres que la barrière linguistique, ont été mentionnés. Toutefois, 44,8 % des étudiants traduisaient les termes anglais en arabe pour faciliter leur apprentissage et 70,6 % des étudiants auraient préféré apprendre à noter les antécédents des patients en langue arabe. Si l’idée de l’arabisation était fortement rejetée de manière générale, en revanche, l’enseignement dans cette langue était perçu comme approprié pour certaines spécialités. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1264 Introduction English has spread as the teaching lan- guage in the Arab world in many fields of higher education, prompting debate about the advantages and disadvantages of studying in English. The arguments in favour of teaching medicine in a stu- dent’s mother tongue have been stated before [1–5]. The use of the mother language in teaching medicine is seen as a way to free learners from the linguistic dualism imposed by thinking in one language and studying in another [6]. Many Arab countries teach medi- cine entirely in English (or French), others have certain medical subjects taught in Arabic, while in Syria all courses are taught in Arabic [5]. The rationale for continuing to teach medi- cine in English focuses on the fact that much of the scientific, technological and academic information in the world is expressed in English [7] and that medical students or doctors attending international conferences, courses or clerkships abroad need to be proficient in the English language [8]. However, in 2005, the Arabization Center for Medi- cal Science (ACMLS), together with the deans of medical schools in the Arab world, argued that learning medicine in Arabic does not hinder doctors from completing their education abroad or from staying up-to-date with medical advances worldwide [9]. The concept of medical Arabization does not mean abandoning English altogether; rather the aim is for the students to learn better in their native language while maintain- ing a good knowledge of English as the leading language of medical research today, as is the case in Japan, Germany, France, Scandinavia and some other European countries [6]. These different views are prompting medical educators to explore and iden- tify learning difficulties related to lan- guage. Previous studies have addressed the problem of English language for Arab medical students [10]. In Egypt elementary school education is mainly in Arabic, and while some students be- come proficient in English, others may experience difficulties with language when they progress to higher education. Yet, in the context of rapid globalization, there are concerns about accreditation of medical schools, including student qualifications, residency training and continuing education [11]. The Faculty of Medicine at Ain Shams University is one of the lead- ing medical faculties in Egypt and is progressing towards international ac- creditation. In order to provide language education support, it is essential that students’ learning needs are assessed and that useful feedback and advice are provided. The aim of the present study was to explore the language bar- riers encountered by students in some aspects of their medical education, such as studying from books, in lectures and in examinations, and to determine the attitude of medical students and Fac- ulty staff towards the Arabization of the medical curriculum. Methods The study was conducted in the Fac- ulty of Medicine, Ain Shams University, Cairo, Egypt at the beginning of the aca- demic year 2008. It was designed as an anonymous questionnaire survey to staff and students. Study tools Two questionnaire forms (1 for stu- dents, 1 for staff) were designed in Ara- bic. These explored language problems, obstacles to the medical education proc- ess and attitudes towards Arabization. Besides personal data, the questionnaire enquired about 3 aspects of language problems: university textbooks, lectures (academic and clinical) and examina- tions. We also explored barriers due to the language of instruction in the context of other issues in the medical education process in order to identify its actual weight relative to other obstacles. The questionnaires included a section on the consequences and expectations about the Arabization of medical education from the perspectives of both students and staff. Response to questions were dichotomous (yes/no, agree/disagree) or a Likert-type scale (attitudes towards Arabization). Two open-ended ques- tions were used for other comments or suggestions. Subjects This study included 326 medical stu- dents and 110 faculty staff members. Staff members were enrolled from dif- ferent departments to get a broad view. This was achieved through distributing questionnaires to all attendees during the preparatory meetings organized by the Faculty of Medicine for the work plan needed for accreditation. Other staff members were surveyed at the ex- amination hall where the written exams are corrected. The Dean and vice-deans of the Faculty were contacted at their offices. Questionnaires were distributed to students, without regard to grade or sex, during the Faculty orientation day for accreditation of Ain Shams Medical School held on 18 February 2008. All learning activities were cancelled on that day to allow many students to attend. We also distributed questionnaires in later meetings with students. Ethical considerations Ain Shams University Faculty of Medicine research ethics committee approved the protocol for this study. The questionnaires were anonymous and when they were distributed it was emphasized that participation was vol- untary. Statistical analysis SPSS, version 13 was used for analysing the results. Simple frequency analysis was used to describe demographics and opinions. Percentages were calculated for each question from those who an- swered. The chi-squared test was used to test for associations. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1265 Results Background characteristics of sample The response rate was 81.5% (326/400) among students and 73.3% (110/150) among staff members. Three-quarters (74.9%) of the students had graduated from schools where Arabic was the first language; only 15.8% had studied at English lan- guage schools (Table 1). Of the staff members recruited in the study, 19.4% had leading positions in the faculty. Problems in medical education The major problem in medical educa- tion as a whole reported by a majority of students (61.9%) was the high (and increasing) numbers of students in class (Table 2). Moderate problems were identified as: the tutors, content of the curriculum and teaching and assess- ment methods. Teaching medicine in a foreign language (English) was not viewed as a problem by 56.3% of stu- dents. Problems with English language Of the faculty staff 35.8% agreed that a gap was caused by the difference between the language of instruction in medical teaching and the actual practice of medi- cine, and a similar proportion agreed that teaching in the mother tongue was more appropriate for students to create a harmony between thinking and speak- ing (data not tabulated). While 44.5% of staff members con- sidered that teaching medicine in Eng- lish was a barrier for students in the 1st year only, 12.8% considered it not to be a problem at all (Figure 1). Only 3 staff members (2.7%) believed that it was a barrier to the learning process. As for the 139/318 students (43.7%) who mentioned that the Eng- lish language was a major/moderate problem in their medical education, 1st year (26.3%) and 2nd year (22.2%) students complained more than those in the other years (17.8%). When they were asked whether they found any difficulty in lectures, university textbooks, oral or written exams and patient communication due to being taught in English, 160 (49.1%) students reported difficulty in patient communication and 124 (38.0%) in the oral exams (data not tabulated). Language barriers We enquired about language barriers in the context of other defects in the current university textbooks (produced by the university staff) (Figure 2) and medical lectures (Figure 3). Obstacles mentioned included books were writ- ten in English (13.7%), had summa- rized information (14.3%), contained chapters that were unrelated (49.7%), used complicated wording and phrases Table 1 Description of the sample of medical students and faculty staff members Item No. % Medical students Sex (n = 326) Male 124 38.0 Female 202 62.0 Grade (n = 326) 1st year 102 31.3 2nd year 27 8.3 3rd year 10 3.1 4th year 88 27.0 5th year 43 13.2 6th year 56 17.2 School type & language of tuition (n = 323) a Private school, English language 51 15.8 Government experimental school, English language 30 9.3 Government school, Arabic language 242 74.9 Type of school certificate (n = 324) a General secondary certificate 304 93.8 Other 20 6.2 Faculty staff Sex (n = 110) Male 39 35.5 Female 71 64.5 Academic degree (n = 110) Assistant lecturer 12 10.9 Lecturer 19 17.3 Assistant professor 25 22.7 Professor 54 49.1 Department (n = 98) a Clinical 31 31.0 Academic 69 69.0 Leadership position (n = 110) Yes 22 19.4 No 88 80.6 aMissing data. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1266 (56.1%), were not logically arranged (67.7%) and had too much unnecessary information (69.8%). Students reported finding lectures inefficient as a learning tool due to in- competent tutors (74.1%) (the reasons were not probed further) (Figure 3). The least mentioned problem with lec- tures was English language (18.3%). In an open-ended question, other lecture defects pointed out by students were the crowdedness of the lecture halls, poor ventilation (25.5%), too much information in a short time (22.2%) and poor use of audiovisual aids (18.0%). Regarding details about language difficulties encountered by students in university textbooks, lectures and ex- ams, 73.2% of students found that the language used in the university books made it difficult for them to obtain the information they needed, 44.8% said that they translated most words in books into Arabic so that they could understand the meaning and facilitate studying, while 39.1% thought that foreign-produced English language textbooks had easier and clearer lan- guage than the university books. More than half of students (56.8%) found difficulty in following the lectures that were totally delivered in English and 31.3% of students had difficulties with language in the written exam questions. Around one-third of students (32.0%) preferred that tutors use only English in lectures while 34.0% preferred a mixture of Arabic and English in the same lecture. Around 70% of students agreed that they preferred learning pa- tient history-taking in clinical medicine in Arabic but 70% also believed that doc- tors and students should talk in English in front of patients (bedside teaching). Many students (61.8%) in the years of clinical practice in medicine (4th–6th years) agreed that learning medicine in English created a gap in their deal- ing with patients (Table 3). Regarding exams, 55.2% of students preferred to be allowed to answer in Arabic language in written and oral exams. Language difficulties in exams Asked about language difficulties in exams that should been answered only in English, nearly 8% of students admit- ted to answering some parts of the written questions in Arabic. Regarding the multiple choice questions exam, Table 2 Students’ views of obstacles in the learning process (n = 326) Item No. % Teaching medicine in a foreign language is: A major problem 29 9.1 A moderate problem 110 34.6 Not a problem 179 56.3 Content of the curriculum is: A major problem 79 24.8 A moderate problem 160 50.3 Not a problem 79 24.8 Teaching methods are: A major problem 120 37.9 A moderate problem 150 47.3 Not a problem 47 14.8 Tutors’ level (as an educator) is: A major problem 93 29.6 A moderate problem 162 51.6 Not a problem 59 18.8 Methods of assessment are: A major problem 115 37.2 A moderate problem 133 43.0 Not a problem 61 19.7 High numbers of medical students are: A major problem 197 61.9 A moderate problem 82 25.8 Not a problem 39 12.3 Major problem = more than 50% as an obstacle for students in the learning process. Moderate problem = less than 50% as an obstacle for students in the learning process. Figure 1 Faculty staff views of language barriers for students in their medical education (n = 110) – طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1267 43.7% of students had difficulty in understanding the language used in some parts of it. Half the staff (50.9%) were aware of students’ complaints about language difficulties in univer- sity medical exams. The majority of staff members (89.9%) insisted that students must know and use English terminology in their exams. Expectations and consequences of Arabization of medicine The expected consequences of the Ara- bization of medicine revealed similar responses among students and staff (Table 4). Most agreed that Arabi- zation would create a new language with difficult Arabic terminology far removed from people’s everyday lan- guage (this was identified by 80.8% of students and 74.6% of staff). Also 60.0% of staff and 53.9% of students agreed that Arabization was logical only if we have sufficient translated textbooks. However, more students (40.7%) than staff members (28.7%) expected that Arabization would result in a harmony between student’s think- ing and speaking and hence lead to better performance (P < 0.05). Attitudes towards Arabization of medicine Opposition to Arabic teaching of medi- cine was apparent from both staff and students (Figure 4). At present, 39.1% of staff and 31.5% of students were op- posed to the idea of Arabization and only 5.5% of staff and 8.6% of students strongly agreed with Arabization. The difference between staff and students opinions was not significant (χ² = 5.35, P > 0.05). The language used by tutors in lectures, whether purely English or a mixture of Arabic and English, had no relation to their attitude towards Ara- bization; nearly three-quarters of both groups (73.0% who use English only and 75.5% who used a mixture) disagreed with Arabization (P > 0.05), although 28.6% of staff members admitted that lectures taught in Arabic would be more easily communicated to students. Nearly one-third of staff members (33, 30.3%) and students (103, 31.6%) agreed that Arabic teaching was needed in some branches of medicine. The main branches suggested were public health and community medicine by 7 (21.2%) staff and 29 (28.2%) students, communication skills and health educa- tion by 10 (30.3%) staff and 12 (11.6%) students. Other subjects where it was suggested that Arabic could be used were medical ethics, psychiatry and in- ternal medicine. Regarding factors affecting staff and students’ attitudes towards Arabizing medicine, male staff showed more ac- ceptance for Arabization than female staff (χ²= 5.78, P = 0.05). No significant difference was found between staff working in leadership positions and others, nor between those in clinical versus academic departments. As for students’ attitude, those who had gradu- ated from Arabic language schools and those whose (self-perceived) English level was inadequate showed more ac- ceptance for Arabization (P < 0.01). Sex and study year were not significant factors (data not tabulated). Figure 2 Student views of barriers to learning due to university medical textbooks (n = 326) Figure 3 Student views of barriers to learning due to university lectures (n = 326) Lecture problem EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1268 Opinions concerning Arabization of medicine Through open-ended questions, other opinions and suggestions about Arabiz- ing medicine were raised. The main ar- guments against Arabization from staff members were that graduates would not be able to compete internationally. They also mentioned that there were other important problems concerning medi- cal education than the language barrier. Suggestions to overcome difficulties with teaching in English were: improv- ing language proficiency in school years before joining college; ensuring that stu- dents have access to English textbooks; and supplying students with a medical dictionary of Arabic terminology. Discussion In the present study, students were able to criticize and identify various barriers in the current medical education specific to the language of instruction. Over 50% of students mentioned that the teaching medicine in a foreign language was not a problem in the learning process. The same applied to the university textbooks and lectures, for which the use of a for- eign language was the least drawback. English has been the main teaching language in Egyptian medical schools for many years and most students in our survey did not propose any alterna- tive to the teaching language. However, about 44% of students mentioned that learning in a foreign language was a problem in understanding the scientific knowledge, while 9% considered it a major problem. The students were asked about detailed problems related to univer- sity textbooks, lectures and methods of assessment. Only 13.7% thought that language was one of the problems with university textbooks; however, 56.8% agreed that they had difficulty in following lectures totally delivered in English and 31.3% found difficulty in understanding exam questions written in English. These results suggest that teaching in a foreign language actually affects several different aspects of the learning process. Many staff members (44.5%) be- lieved that the language barrier that some medical students experienced was just a transient problem in the 1st year of study. They expected that students would overcome it as they advanced in learning. This opinion may be correct as three-quarters of the sample of students in the present study had graduated from Arabic language schools where English was a second language. Medical students are able to differ- entiate between effective and ineffective teaching methods in lectures. An earlier study showed that students regarded having lectures by properly qualified teachers as particularly important [12]. In Kuwait, students evaluating the teaching characteristics of their lectur- ers stated that well-delivered, organized and logical lectures were the most effec- tive [13]. This result of the Kuwait study is consistent with the present study as among the most important problems with lectures for students in our present study were incompetent tutors, disor- ganized lectures and being a one-way channel without interaction. A study in Saudi Arabia emphasized the impor- tance of good lectures and lecturers in Table 4 Expectations about the consequences of Arabizing medicine: staff and students’ perspectives Consequences of Arabization of medicine Staff (n = 110) Students (n = 326) No. % No. % Arabization will result in a strange language with difficult Arabic terminology which will be different from patients’ everyday language 50 74.6 227 80.8 Arabization can only be applied if translated textbooks are available 48 60.0 146 53.9 Arabization will create harmony between students’ thinking and speaking 31 28.7 118 40.7* Arabization will hinder scientific development and will result in isolation 79 72.5 217 74.8 Arabization will affect negatively students’ medical level 72 66.7 173 61.1 *P < 0.05 staff versus students. Table 3 Students’ perspectives on lectures and clinical rounds (n = 326) Lectures No. % Language used in lecture (in both presentations and explanations) (n =294) Prefer lectures given totally in English 94 32.0 Prefer lectures given in both English and Arabic 100 34.0 Prefer lectures given totally in Arabic 100 34.0 Clinical rounds Prefer learning patient history-taking in Arabic 168 69.4 During bedside teaching doctors and students should speak in English 178 70.6 Learning medicine in English created a gap in my dealing with patients (n = 170)a 105 61.8 aStudents in their clinical practice years (4th–6th grades). طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1269 encouraging students’ attendance at lectures [14]. Since incompetent tutors were identified as a problem by so many students in the present study, exact rea- sons for this need to be studied further. Was this because their English was poor, they did not prepare their lectures, they do not know their subject or simply they do not know how to teach? Nearly one-half of students translat- ed most of the words in medical books into Arabic to facilitate studying. A glos- sary of translated terminology could be prepared and offered to students because almost 90% of staff members insisted that students should know the medical terminology in English. In other countries such as in Latin America, most of the leading US medical textbooks have been translated into Spanish and Portuguese [15]. There was a revival of Arabization in the beginning of the 19th century in Egypt. Following this, medi- cal sciences were taught in Arabic for about 70 years and during this period about 72 textbooks were translated and many books were published [16]. The present study revealed that some students answered parts of written exams in Arabic although they should have answered only in English. This sug- gests that thinking, understanding and expressing using their mother tongue may be easier for some students. Previ- ous studies have appreciated learning with the mother tongue for this reason [5,6]. Many students (61.8%) felt there was a gap between their medical studies and their clinical practice with patients and they attributed this to learning medicine in a foreign language. This should be investigated in further studies. Students requested that learning how to take a patient’s history in clinical rounds should be in Arabic. Communication skills and health education were identi- fied as aspects of medicine that might be taught in Arabic. Students need to understand the various Arabic collo- quial dialects and idioms of patients who may come from different regions. Harmsen et al. recommended that medical students and physicians should be trained to become aware of patients’ cultural backgrounds so as to bridge language barriers [17]. Books in the medical specialties that were suggested as suitable for Arabization should be available for students to use besides the English copies. A previous study recommended that students at colleges of medicine, pharmacy, science and computer science be taught the Arabization proc- ess [18]. Students at those colleges must study the Arabic equivalents to English technical terms in their major area of specialization and it must be part of their course grades. The choice of the language of medi- cal teaching, whether English or Arabic, should not be considered as all-or-none. Previous studies highlighted that in undergraduate and postgraduate learn- ing, students with the greatest need for language support should be properly helped [19,20]. Although about 40% of staff mem- bers were strongly against the idea of Arabizing medicine, 28.6% believed that lectures given in Arabic would be communicated more effectively to stu- dents and 40.7% of them expected that Arabization would result in a harmony between students’ thinking and speak- ing. This shows that we need to use the Arabic language in medical education; but how, when and in what fields? This should be discussed by decision-makers in medical education. Previous researchers have stated that it is far better for students to learn in their mother tongue as the time taken by students to understand information in English is about twice as long as it takes to understand it in Arabic, the mother tongue [5,21]. By contrast, in Gezira University in Sudan, an experiment with Arabization of medicine showed no difference between the performance of students learning medicine in Arabic and those learning it in English [22]. Other studies have also explored the effect on performance of teaching medi- cal students in their mother tongue. In the United Arab Emirates, undergradu- ate students performed better in com- munication skills using their mother tongue (Arabic) than in English [23]. Other studies have also found that lan- guage barriers add new anxieties and worries for health professionals in their dealing with patients with a different language [24,25]. Figure 4 Staff (n = 110) and student (n = 326) views about Arabization of medicine View EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1270 References Drouin J. 1. Educating future physicians for a minority popula- tion: a French–language stream at the University of Ottawa. Academic Medicine, 2002, 77(3):217–221. Haidinger G, Frischenschlager O, Mitterauer L. Reliability of 2. predictors of study success in medicine. Wiener Medizinische Wochenschrift, 2006, 156(13–14):416–420. 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(http://faculty.ksu.edu.sa/aljarf/default.aspx, accessed 1 July 2010). Letelier LM et al. Exploring language barriers to evidence-19. based health care (EBHC) in post-graduate medical students: a randomised trial. Education for Health (Abingdon, England), 2007, 20(3):82. Chur-Hansen A. Language background, proficiency in English, 20. and selection for language development. Medical Education, 1997, 31 (5):312–319. Al-Ahmad N. 21. ةيبرعلا تاعمالجا ضعب فى بيرعتلا براتج نم[From the ex- periences of Arabization in some Arab universities]. 1993.برمسيد سداسلا ددعلا ؛بيرعتلا ةلمج . [Journal of Arabization, 1993, Dece - ber, No. 6]. In Saudi Arabia, a study showed a positive attitude towards teaching medicine in Arabic by students, and that Arabization was welcomed pro- vided it was approached gradually and with adequate planning [26]. One of the reasons behind the resistance of medical staff towards Arabization in the current study was the fear that it would have a negative impact on the student’s education level. Medical professionals need continuing profes- sional development to keep up-to-date and many of the resources for this are in English. The possibility that students who learn medicine in Arabic will not be competent enough in English to be able to use English scientific resources efficiently has been previously stated [6]. Currently, several activities concern- ing the Arabization of health sciences are being implemented by the Arabization of Health Sciences Network in collabo- ration with the World Health Organi- zation Regional Office for the Eastern Mediterranean. These include training courses for translators, editors and pub- lishers and production of educational materials in health subjects [27]. Though the official language in uni- versity textbooks and in examinations in the faculty of medicine is currently the English language, however, the ac- tual language used by faculty members in delivering the lectures and in Oral exams is a combination of Arabic and English language. In addition, the ac- tual language used in patient commu- nication is Arabic (the mother tongue) though the teaching is in English. In the clinical rounds students use the Arabic language in elaborating the complaints of patients, in explaining the condition the patient has, and in prescribing the medications he needs. Most of the official reports offered by the hospital are also in Arabic lan- guage so we are facing a situation where we teach in a language and we practise in a different language. . Although this study was exploratory, it demonstrates that the idea of teaching some medical courses in Arabic is not out of the question and that teaching interventions are necessary for students whose English language is not adequate. Further studies would help us to explore this in more detail طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1271 Mahmadani AA, Abdel Rahman SH. 22. ليصتح لىع بيرعتلا رثأ مييقت ةحصلا ةمظنم طسوتلما قشرل ةيحصلا ةلجلما نادوسلا ةريزلجا ةعماج ,بطلا بلاط مقر شرع ىناثلا دلجملل فىاضأ ددع ةيلماعلا [Evaluating the impact of Arabization on medical students’ acquisition, Gezira Uni- versity, Sudan]. Eastern Mediterranean Health Journal, 2006, 12(S2):S223–229. Swadi H The impact of primary language on the performance 23. of medical undergraduates in communication skills. Medical Teacher, 1997, 19(4):270–274. Al-Naseri H. Found in translation. 24. Student BMJ, 2005, 13:133– 176. Al-Shahadat S. 25. ىبرعلا ضيرلما و بيبطلا ينب لصاوتلا ةغل [Language of communication between Arab doctor and patient]. Medical Arabization, 2008, 12(2):87–89. Albar AA, Assuhaimi SA. Attitude of medical students and 26. postgraduate residents at King Faisal University towards teach- ing medicine in Arabic. Saudi Medical Journal, 1996, 17(2):230– 234. Sara K. Arabization27. of Health Sciences Network (AHSN): cur- rent issues, problems, trends and the role of the Regional Of- fice. Saudi Medical Journal, 2004, 25(1):S47. Essential health technologies Health technologies are developed to solve a health problem and improve quality of lives. They form an indispensable component of the services health systems can offer in the prevention, diagnosis and treatment of disease and in alleviating disability and functional deficiency. Access, including in primary health care, to safe and effective health technologies relies on policies for selection and management based on scientific evidence and best practice for organization of their management and use. Further information on technical areas such as blood transfusion safety, diagnostic imaging, transplantation and medical devices can be accessed at: http://www.who.int/eht/en/ EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1272 Difficulties facing first-year medical students at Umm Alqura University in Saudi Arabia H. Almoallim,1,2 S. Aldahlawi,3 E. Alqahtani,4 S. Alqurashi 5 and A. Munshi 6 ABSTRACT This study investigated medical students’ study habits and perceptions of learning difficulties during their first year of study. A specially-designed questionnaire was answered by 165 second-year medical and medical science students at Umm Alqura University in Saudi Arabia. Out of the 7 difficulties listed in the questionnaire, students ranked peer competition first, followed by poor English language skills. Male students ranked peer competition as the top difficulty whereas females ranked it fourth. A majority of students were dissatisfied with the passive, lecture-based method of teaching and wanted the English language curriculum to be improved by more emphasis on conversation skills. Early introduction of the concept of active learning and effective studying habits is needed. 1Department of Medicine, Medical College, Umm Alqura University, Saudi Arabia (Correspondence to H. Almoallim: hanialmoallim @hotmail.com). 2Department of Medicine, King Faisal Specialist Hospital, Jedda, Saudi Arabia. 3Department of Dentistry, International Medical Center, Jedda, Saudi Arabia 4Department of Radiology; 6Department of Family Medicine, National Guard Hospital. Jedda, Saudi Arabia. 5Department of Internal Medicine, Al-Hada Armed Forces Hospital, Taif, Saudi Arabia. Received: 30/03/09; accepted: 17/06/09 ةيدوعسلا ةيبرعلا ةكلملما في ىرقلا مأ ةعماج في لىولأا ةنسلا في بطلا بلاط هجاوت يتلا تابوعصلا شينم جيرأ ،شيرقلا ىذش ،نياطحقلا نمايإ ،يولهدلا ىولس ،ملعلما نياه في ًابلاط 165 باجأ دقو .مهتسارد نم لىولأا ةنسلا للاخ م ُّلعتلاو ةساردلا ةبوعصل بطلا بلاط كرادمو تاداع ةساردلا هذه صيقتست :ةـصلالخا تابوعص 7 ينب نمو .ةساردلل ًاصيصخ دعأ نايبتسا لىع ةيدوعسلا ةيبرعلا ةكلملما في ىرقلا مأ ةعماج في ةيبطلا مولعلاو بطلا ةيلك نم ةيناثلا ةنسلا سفانت روكذلا بلاطلا َجَرْدأ دقو .ةيزيلكنلإا ةغللاب متهاراهم فعض هلاتو ،ءلامزلا سفانت ةمدقلما في بلاطلا َجَرْدأ ،نايبتسلاا في ةمئاقلا اهتنمضت ،ةيلعافلالاب مستت يتلا سيردتلا ةقيرط نع ينضار يرغ بلاطلا مظعم ناكو .ةعبارلا ةبترلما في تابلاطلا هْتَجردأ ينح في ،تابوعصلا ةمدقم في ءلامزلا لاخدإ لىإ ةسام ةجالحا نأ اوركذ ماك.ةثداحلما تاراهم لىع ديكأتلا عم ةيزيلكنلإا ةغلل يميلعتلا جهنلما ينستح في اوبغرو ،تاضراحلما ءاقلإ لىع ز ِّكرتو .ةلا َّعفلا ةساردلا تاداعو لعافلا ملعتلا موهفلم ركاب Difficultés rencontrées par les étudiants en première année d’études de médecine à l’Université Umm Al- Qura (Arabie saoudite) RÉSUMÉ Le présent travail de recherche a analysé les habitudes d’étude des étudiants en médecine et leur perception des difficultés d’apprentissage pendant leur première année d’étude. Un questionnaire spécialement conçu a été administré à 165 étudiants de deuxième année de la faculté de médecine et de sciences de l’Université Umm Al-Qura, (Arabie saoudite). Sur les sept difficultés répertoriées dans le questionnaire, les étudiants ont classé la compétition entre étudiants en premier, puis de médiocres compétences linguistiques en anglais en second. Les étudiants de sexe masculin ont classé la compétition entre étudiants comme la première difficulté, alors que les étudiantes ne l’ont classée que quatrième dans la liste. Pour la majorité, les étudiants n’étaient pas satisfaits de la méthode d’enseignement passive reposant sur les cours magistraux et souhaitaient que le programme d’enseignement en langue anglaise soit amélioré, en mettant davantage l’accent sur le développement des compétences à l’oral. Il est nécessaire d’introduire tôt dans le cursus le concept d’apprentissage actif et des habitudes d’étude efficaces. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1273 Introduction The relevance of an educational pro- gramme is a concern for curriculum designers. Lack of interest and increased stress levels are typical problems faced by students when they perceive courses as lacking in relevance to their studies. Learning interventions that are directly based on students’ needs, promote student participation, and are largely student-driven have been shown to enhance students’ performance [1]. Students enter the medical college of Umm Alqura University in Saudi Arabia directly from high school at an average age of 18 years. The school system relies mainly on teacher-based activities, examinations based on re- gurgitation of memorized information and norm-referenced tests to evaluate students. As a result, most of the stu- dents acquire passive learning habits. The secondary school system in Saudi Arabia uses the Arabic language as the primary language for education; English is taught as a second language, starting in grade 7. As the medical school cur- riculum is taught in English, all first-year students, regardless of their language proficiency level, receive an intensive course in English along with their other premedical requirements. When they join university students are faced with increased academic de- mands and quickly realize that they need to develop appropriate learning skills. Many capable medical students experi- ence frustration and failure [2]. While introductory learning skills courses are common in many international medical schools, few medical schools in the Mid- dle East have such courses. At Umm Alqura University we planned to design a learning skills course for our first-year students of medicine and medical sci- ences to introduce the principles of ac- tive learning. To inform the design of the course, we surveyed second-year medical and medical science students about the difficulties they faced during their first year and their study habits. Methods All second-year medical and medical sciences students (graduation class 2009) in Umm Alqura University, Mecca, Saudi Arabia were asked to an- swer a questionnaire designed by the authors. A total of 270 students were surveyed in October 2006 (128 males and 142 females), comprising 153 medical students and 117 medical sci- ence students. In the first part of the questionnaire, students were presented with a list of 7 common difficulties faced by students and asked to rank them according to the degree of difficulty they faced in their first year, from 1 (most difficult) to 7 (least difficult). The items were based on the results of interviews with a group of medical students from different classes carried out by the authors. The second part was divided into questions about learning styles and study habits: their own beliefs about the difficulty and workload of the first-year course (3 items); difficulties they experienced with aspects of the first-year course (8 items); how they communicated with instructors during teaching sessions (4 items); what self-study strategies would facilitate their learning (3 items); and ways in which the university could or- ganize courses to facilitate learning (9 items). Students were asked to answer each statement as yes, no or don’t know. Two open-ended questions about ad- ditional difficulties were included. All questions were in English. A pilot sample of medical students evaluated the simplicity of the ques- tionnaire language and the time needed to answer it and adjustments were made based on their recommenda- tions. The questionnaire was distrib- uted to second-year students after their classes. Students were asked to answer and return it immediately to one of the supervisors. Most students needed around 30 minutes to complete the questionnaire. The data were entered in Microsoft Excel software and the Student t-test was used to assess significant differences based on sex. P value < 0.05 was consid- ered significant. Results Of the 270 students surveyed, 165 responded (89 females and 76 males; 119 medical students and 46 medical science students). The overall response rate was therefore 61% (62% among females and 59% among males). More students of medicine responded (78%) than medical science students (39%). A majority of students considered peer competition to be the greatest difficulty facing them in the first year (mean rank 4.28 out of 7) (Figure 1). English language skills were rated sec- ond (mean rank 3.95). Difficulty of the subjects was ranked third (mean rank 3.78), followed by lack of information resources (mean rank 3.76) and the large amount of academic work (mean rank 3.70). Lack of time for social life (mean rank 3.13) and stress related to courses (mean rank 2.77) were the lowest ranked items. When analysing the data by sex, peer competition was ranked first as a difficult faced by male students (mean rank 5.17) whereas female students ranked it fourth (mean rank 3.52) (P < 0.05) (Figure 2). On the other hand, English language was ranked first as a difficulty by female students (mean rank 4.09). More female students than male students felt they were facing a high academic workload (mean ranks 4.01 and 3.33 respectively) (P < 0.05). Furthermore, more male students than female students thought the subjects were too difficult (mean ranks 4.16 and 3.45 respectively) (P < 0.05). Half of the students (51%) agreed that the courses taught in the first year were hard, 61% that the courses were time-consuming and 47% that their results did not reflect the amount of EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1274 M F Figure 1 Mean ranking of 7 difficulties facing medical and medical sciences students during first-year medical school (n = 165 students) Figure 2 Mean ranking of difficulties facing male and female medical and medical sciences students in first-year of medical school (n = 76 males; n = 89 females). *Statistically significant differences were found between males and females regarding peer competition, increased academic demands and subjects are too hard (P < 0.05) Difficulty Difficulty طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1275 effort they put into their study. There were no statistical differences between the sexes (data not shown). Regarding problems they faced during teaching sessions including lectures, 62% of the students agreed that they had difficulty following the instructors and taking notes and 50% did not know what they were expected to learn by the end of teaching sessions. Concerning their assessments, 60% of the students had difficulty remembering information and writing essays and 40% had problems with answering multiple choice ques- tions. More female students than male students reported difficulty in keeping up with the required reading and in remembering information (P < 0.05) (data not shown). Just over half of the students (52%) had problems with communicating and explaining their ideas during teaching sessions, 52% did not ask questions or interact with instructors, 53% consid- ered themselves shy, while 46% asked instructors if they did not understand something. Male students were signifi- cantly more likely than females to ask for help from instructors when they faced difficulties (P < 0.05) (data not shown). Regarding the strategies that stu- dents followed to facilitate their learn- ing, 59% reported that they did not prepare for teaching sessions by reading about the subject in advance and 56% did not search for information to sup- plement teaching sessions. However, 86% would use the library resources to facilitate learning. More male students than females would prepare for teaching sessions by reading about the subject (P < 0.05) (data not shown). The majority of the students (85%) agreed that they would like an introductory course prior to the start of first year medical school and 80% would welcome a mentor assigned to each student. A majority also wanted instructors to give more time for discus- sion and answering questions (80%) and to clarify the learning outcomes of each teaching session (80%). Many wanted more feedback on their own performance (75%) and 74% wanted to be divided into smaller groups dur- ing teaching sessions. More than half of the students wanted a different ap- proach to teaching than lectures (60%) and more help with using library and online services (55%); 60% agreed that extracurricular activities would help to bond students and instructors. Several suggestions resulted from analysing open-ended questions. A majority of students thought that the English language curriculum should be improved, with more emphasis on conversation skills. First-year course instructors should speak both Arabic and English languages. A majority of students were dissatisfied with the pas- sive, lecture-based and traditional way of teaching; they wanted to be involved in the learning process and to have more chance to ask questions during teaching sessions. Discussion Needs analysis can be used to identify problems in the educational process. Learners remain a valuable resource that should be utilized by curriculum planners to diagnose problems in course design and delivery. The findings of this study will help us to design a learning skills course that should meet the needs of our students. Learning skills courses are intended to prepare students to cope with the new learning environment in medical colleges and its challenges. Significant numbers of first-year medical students report little experience, particularly in IT skills and library research [3]. Es- say writing and oral presentation are also rarely practised [3]. Students in the majority of medical schools in the Middle East are left alone to face this new, challenging environment. Inability to cope with these changes leads to a high drop-out rate from courses. Even at higher levels, the causes of academic failure are widespread and range from deficient learning skills to financial, do- mestic and emotional problems [4]. A great majority (85%) of our students recognized the importance of introduc- ing a learning skills course that would help in the transitional phase to meet the challenges of university life. Most of them (80%) also recognized the need to provide a proper mentoring programme in the college to help students overcome their academic problems. Students in this study considered peer competition to be the top difficulty facing them in the first year. The assess- ment process in their schools was prob- ably focused on comparisons between students rather than specific achieve- ment levels. This has resulted in the overwhelming concern of our students being the performance of their peers. In contrast, a review of stress in under- graduates noted that peer competition was one of the least common sources of stress among undergraduates [5]. Our medical college therefore needs to implement strategies to solve this problem. Developing valid and reliable assessment methods and enhancing the educational environment [6] are probably initial steps. Lack of fluency in the language of instruction can form a barrier to medical education [7]. It has been reported that many nurses from non-English speaking backgrounds are at high risk of failure in university programmes [8]. Few studies have investigated clinical experiences of students from non-English speaking backgrounds and strategies to support their learning. In an Australian university unsatisfactory spoken language fluency was associated with poor performance in medical communication skills under examination conditions [9]. English was considered one of the top difficulties facing our students during their first year. Students clearly felt the need for an improved English language curriculum in our college with more focus on con- versation skills. They also suggested that EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1276 first-year instructors must speak both Arabic and English languages. In an- other Australian study, medical students experiencing English language difficul- ties were allocated to a faculty-based language development programme for up to 2 years [10]. Similar approaches can be adopted in our college. Stress is common among medical students. The one-month prevalence of mental distress among medical students in one college in Ethiopia was found to be 32.6% [11]. The same study showed that the risk of mental distress decreased in the students’ later years of medical school. Other studies suggested that stress and anxiety are major causes of cognitive dysfunction and poor aca- demic performance in university stu- dents [12,13]. Another study linked anxiety in medical students to the medi- cal curriculum [14]. Students with high test anxiety are compromised in their performance and emotional wellbeing [15]. It was shown that mental health worsens after students begin medical school and remains poor throughout training [16,17]. Great care should be taken to avoid any factors that may in- crease students’ stress levels. Our students experienced substan- tial problems with the traditional teach- ing methods at this college, including lectures. A majority of them had diffi- culty in following instructors and taking notes during lectures. This could partly be explained on the basis of deficiencies in basic learning skills such as listening and note-taking. However, the fact that half of students did not understand the objectives of their lectures is clearly likely to compromise the effectiveness of these lectures. It is not surprising therefore that more than 60% of our stu- dents thought that the subjects taught in the first year were time-consuming. As long ago as the 1970s there was evidence of students’ dissatisfaction with unchallenging lectures [18] and that student concentration in lectures rose sharply to reach a maximum after 10–15 minutes and fell steadily there- after [19]. Nevertheless many medical colleges still use traditional methods of teaching. An interesting finding in our study was that a majority of our students considered themselves to be shy: 53% reported never asking questions or inter- acting with instructors during lectures. Only 46% would interact if they did not understand something. Passive learning is an expected outcome with large-group teaching formats [20]. Active participa- tion of learners in any learning interven- tion is a key factor for effective learning. Our students’ perceptions of the learning process needs to be changed. They need to be oriented to the concepts of deep and superficial approaches to learning. A majority of our students did not prepare in advance for their lectures and tended not to seek information beyond what was mentioned during lectures. These are classic examples of a superficial ap- proach to learning. The results of studies on gender dif- ferences in the experiences of medical students vary. A study in India conclud- ed that stress did not vary significantly based on sex [21]. In an Iranian study, stress was associated with female sex [22] and in a study in Austria male sex was one of the factors that contributed to academic success in medical students [23]. In our study, significantly more female students were concerned about the academic workload than were males. They found more difficulties in keeping up with the required reading and in remembering information. Males on the other hand were more concerned about peer competition. In one study, academic factors were the highest per- ceived cause of stress in medical stu- dents regardless of sex [21]. There are some limitations to our study. It was based on self-reporting which may be a source of bias in the responses. The study was carried out in only one medical college in Saudi Ara- bia so the results cannot be generalized to other medical colleges. Nevertheless the study does shed some light on issues related to first-year medical students studying medicine in English language. Medical colleges in Saudi Arabia should consider needs analysis studies to inform changes in educational strate- gies. Learning skills courses are clearly desired by our students. These courses should prepare Saudi medical students to overcome difficulties facing them such as peer competition. These courses should also build active study skills and develop a deep approach to learning. Based on our findings, the English language curriculum requires revision and new teaching methods should be employed. References Beckert L, Wilkinson TJ, Sainsbury R. 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English to medical students from non-English speaking back- grounds. Medical Education, 1996, 30:412–417. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1277 Operational research in tropical and other communicable diseases: final report summaries 2007-2008 Operational research is crucial for identifying ways to increase access to timely diagnosis and effective treatment. It involves the evaluation of programme implementation, leading to improved policy-making, better design and operation of health systems, and more efficient methods of service delivery. The Regional Office for the Eastern Mediterranean supports operational research in tropical and other diseases through the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) supported Small Grants Scheme. The scheme encourages collaboration between national control programmes and researchers from academia. The aim of the series is to disseminate the results of the operational research projects supported by the scheme with the ultimate goal that they are translated into the policies and practices of national control programmes The report is available in English and can be downloaded at: http://www.emro.who.int/publications/Book_Details. asp?ID=1040. Rogan F et al. ‘You find yourself.’ Perceptions of nursing stu-8. dents from non-English speaking backgrounds of the effect of an intensive language support program on their oral clinical communication skills. Contemporary Nurse, 2006, 23:72–86. Chur-Hansen A, Vernon-Roberts J, Clark S. Language back-9. ground, English language proficiency and medical commu- nication skills of medical students. Medical Education, 1997, 31:259–263. Chur-Hansen A. Language background, proficiency in English, 10. and selection for language development. Medical Education, 1997, 31:312–319. Alem A et al. Mental distress in medical students of Addis Aba-11. ba University. Ethiopian Medical Journal, 2005, 43:159–166. Akgun S, Ciarrochi J. Learned resourcefulness moderates the 12. relationship between academic stress and academic perform- ance. learned resourcefulness moderates the relationship between academic stress and academic performance. Educa- tional Psychology, 2003, 23:287–294. McKenzie K, Schweitzer R. Who succeeds at university? Factors 13. predicting academic performance in first year Australian uni- versity students. Higher Education Research and Development, 2001, 20:21–33. Smith CK et al. Depression, anxiety, and perceived hassles 14. among entering medical students. Psychology, Health and Medicine, 2007, 12:31–39. Schaefer A et al. Seelische Gesundheit und Studienerfolg von 15. Studierenden der Medizin mit hoher und niedriger Prufung- sangstlichkeit [Mental health and performance of medical students with high and low test anxiety]. Psychotherapie, Psy- chosomatik, Medizinische Psychologie, 2007, 57:289–297. Dyrbye LN, Thomas MR, Shanafelt TD. Medical student dis-16. tress: causes, consequences, and proposed solutions. Mayo Clinic Proceedings, 2005, 80:1613–1622. Dutta AP, Pyles MA, Miederhoff PA. Stress in health professions 17. students: myth or reality? A review of the existing literature. Journal of National Black Nurses’ Association, 2005, 16:63–68. Shephard RJ, Ashley MJ. Attitudes of health science students 18. towards teaching practices, examinations, and other related issues. Medical Education, 1979, 13:111–116. Stuart J, Rutherford RJ. Medical student concentration during 19. lectures. Lancet, 1978, 2:514–516. Cantillon P. Teaching large groups. 20. British Medical Journal, 2003, 326:437. Supe AN. A study of stress in medical students at Seth G.S. 21. Medical College. Journal of Postgraduate Medicine, 1998, 44:1–6. Shariati M, Yunesian M, Vash JH. Mental health of medical stu-22. dents: a cross-sectional study in Tehran. Psychological Reports, 2007, 100:346–354. Frischenschlager O, Haidinger G, Mitterauer L. Factors associ-23. ated with academic success at Vienna Medical School: pro- spective survey. Croatian Medical Journal, 2005, 46:58–65. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1278 Level of physical activity among teaching and support staff in the education sector in Dohuk, Iraq S.Y. Agha 1 and S.A. Al-Dabbagh1 ABSTRACT Sedentary lifestyle is a major underlying cause of death, disease, and disability worldwide. This survey in 2006 aimed to estimate the current level of physical activity among 293 school and university teaching staff and 246 support staff working in the education sector in Dohuk city, Iraq. The short form of the international physical activity questionnaire (IPAQ) was used to estimate physical activity. Using the higher IPAQ cutoff point (i.e. high, not moderate, level of activity) the prevalence of physical activity beneficial to health among all participants was 39.5%. Small but nonsignificant differences in physical activity were found among sex, age and BMI categories. Teachers reported significantly higher physical activity levels than support staff, and individuals with longer average sitting times per day reported significantly lower levels of physical activity. 1Department of Family and Community Medicine, College of Medicine, University of Dohuk, Dohuk, Iraq (Correspondence to S.Y. Agha: saadagha13@yahoo.com). Received: 08/04/09; accepted: 02/08/09 قارعلا ،كوهد في يميلعتلا عاطقلا في معدلا فيو ميلعتلا في ينلماعلا ينب نيدبلا طاشنلا ىوتسم غابدلا دحمأ ميمص ،اغأ سنوي دعس ماع يرجأ يذلا حسلما اذه فده دقو .لماعلا ءاجرأ عيجم في زجعلاو ضرلماو توملل ةنماكلا ةيسيئرلا بابسلأا نم لوملخا ةايح طمن دعُي :ةـصلالخا يميلعتلا عاطقلا في معدلا ميدقت في ينلماعلا نم 246و تاعمالجاو سرادلما في ينلماعلا نم 293 ينب نيدبلا طاشنلل نهارلا ىوتسلما ريدقت لىإ 2006 ؛نيدبلا طاشنلا ريدقتل ةيندبلا ةطشنلأا لوح ليودلا نايبتسلاا نم ةصرتخلما ةغيصلا ةساردلا هذه في نوثحابلا مدختساو .قارعلا في كوهد ةنيدم في نيديفتسلما راشتنا لدعم نأ )طسوتلما سيلو عفترلما نيدبلا طاشنلا ىوتسم لىع يأ( نايبتسلاا اذه في ايلعلا لصْيَفلا ةطقنلا مهمادختسا دنع اودجوو ينب نيدبلل طاشنلا في ًايئاصحإ ابه ُّدتعي لا ةفيفط تافلاتخا نوثحابلا دجو ماك .%39.5 ةساردلا في ينكراشلما عيجم ينب نم نيدبلا طاشنلا نم ًايحص ينلماعلا ىدل امم لىعأ نيدبلا طاشنلل تايوتسم نع اوغلبأ دق ينسردلما نأ نوثحابلا دجوو .مسلجا ةلتك بَسْنَمو رمعلاو سنلجا قفو ةع َّزولما تائفلا .نيدبلا طاشنلا نم ضفخأ تايوتسم نع اوغلبأ دق مويلا ءانثأ ليوط دملأ سوللجا صصح نم ددع ميهدل نيذلا دارفلأا نأو ،معدلا في Niveau d’activité physique du personnel enseignant et administratif dans le secteur de l’éducation à Dohuk (Iraq) RÉSUMÉ Le mode de vie sédentaire est l’une des principales causes sous-jacentes de mortalité, de morbidité et d’incapacité dans le monde. La présente enquête, réalisée en 2006, avait pour objectif d’estimer le niveau d’activité physique d’alors de 293 enseignants en écoles secondaires et en universités et de 246 membres du personnel administratif dans le secteur de l’éducation à Dohuk (Iraq). La version courte du questionnaire international sur l’activité physique a été utilisée pour mesurer cet élément. En utilisant la valeur seuil la plus élevée du questionnaire, (c’est-à-dire une activité physique intense et non modérée), la prévalence d’une activité physique bénéfique pour la santé a été estimée à 39,5 % pour tous les participants. Des différences minimes non significatives ont été retrouvées en fonction du sexe, de l’âge et de l’indice de masse corporelle. Les enseignants ont déclaré des niveaux d’activité physiques supérieurs à ceux du personnel administratif et les individus passant en moyenne le plus de temps en position assise par jour ont déclaré avoir des niveaux d’activité physique nettement plus faibles. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1279 Introduction Regular participation in physical activ- ity is associated with a reduced risk of premature mortality, coronary heart disease, hypertension, cancer, diabetes mellitus, obesity, emotional stress and musculoskeletal disorders. Sedentary lifestyles or physical inactivity, on the other hand, are a major underlying cause of death, disease and disability [1,2]. Approximately 2 million deaths every year are attributable to physical inactiv- ity. The world is witnessing a significant increase in the burden of noncommu- nicable diseases such as cardiovascular diseases, cancer, diabetes and chronic respiratory diseases. These relate closely to changes in lifestyle, mainly in tobacco use, physical inactivity and unhealthy diets. Meanwhile, the burden of non- communicable diseases is shifting to poorer countries. [3]. Obesity/overweight rates are increasing among young people and middle-aged adults [2–4]. This is re- lated in part to lack of leisure time physi- cal activity, but is more likely the result of increasing hours spent in sedentary behaviours, e.g. watching television, using computers and passive modes of transport such as cars and buses. Decreasing physical activity and reduc- tions in physical education programmes in schools is an alarming trend world- wide. An assessment of current levels of physical activity and inactivity is critical for defining the extent of the problem, guiding public health efforts and evalu- ating progress toward national health objectives [5]. This survey in Dohuk city, Iraq aimed to estimate the cur- rent level of physical activity among the teaching and nonteaching staff of the primary, secondary and higher educa- tion institutions. The study will provide background data for improving the level of physical activity among the studied population. Methods The survey was conducted in Dohuk city, the centre of Dohuk governorate. The city is in a semi-mountainous area in northern Iraq and has a population of around 400 000. Data were collected over 3 months from 15 February to 30 April 2006 during moderate weather conditions and from 15 June to 30 June 2006 during hot weather. Sample At the time of the survey, the city had 114 primary and secondary schools and a university with 10 colleges. Multistage quota sampling was used to obtain balanced subsamples from the various education offices. In the first stage, the directorate of education and the uni- versity presidency offices (each around 150 staff) were surveyed to represent nonteaching staff, e.g. supervisors, ad- ministrators, engineers and others. To represent the teaching staff, the second stage included 2 randomly selected sub- samples each with around 150 staff from 8 primary and secondary schools and 3 university colleges. Two colleges were surveyed during the hot season in June, because university holidays do not start until July, while school holidays start in June. Thus, the total sample planned to be surveyed was 600. Data collection The international physical activity • questionnaire (IPAQ) short form was used in the current survey for estima- tion of physical activity level. This is an instrument designed primarily for population surveillance of physical activity among adults aged 15–69 years [6]. An Arabic version of IPAQ was taken from the IPAQ website [6] and translated into the local Kurdish language. To ensure similarity to the original English version, both ver- sions were back-translated, and then used to train the one physician who conducted the survey. During the survey, the physician briefly explained the purpose of the survey, obtained verbal consent for participation and completed the questionnaire by di- rect interview. The IPAQ short form asks about specific types of physical activity dur- ing the 7 days preceding the interview, under the following 4 domains: leisure time; domestic and gardening; work- related; and transport-related physical activities. The 3 types of activity assessed are: walking; moderate-intensity activi- ties (e.g., gardening, washing the car or clothes by hand, or bicycling at normal speed); and vigorous-intensity activi- ties (e.g. heavy weightlifting, running or swimming). The items in the short IPAQ form are structured to provide separate scores on these activities. Computation of the total score requires summation of the duration (in minutes) and frequency (days) of these activities. The volume of activity can then be com- puted by weighting each type of activity by its energy requirements defined in metabolic equivalents (METs) to yield a score in MET-minutes. METs are multiples of the resting metabolic rate. Physical activity can then be reported as a categorical variable and 3 levels have been proposed [6]. Low: No activity reported or some • activity reported but not enough to meet categories 2 or 3. Moderate: Any of the following 3 • criteria: ≥ 3 days of vigorous activity of at least 20 minutes/day or ≥ 5 days of moderate-intensity activity and/or walking of at least 30 minutes/day or ≥ 5 days of any combination of walk- ing, moderate-intensity or vigorous- intensity activities achieving at least 600 MET minutes/week. High: Any of the following 2 criteria: • vigorous-intensity activity on at least 3 days and accumulating at least 1500 MET-minutes/week or ≥ 7 days of any combination of walking, moder- ate- or vigorous-intensity activities accumulating at least 3000 MET- minutes/week. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1280 Weight was measured using an electronic scale to the nearest 0.5 kg. Height was measured with a stadiom- eter to the nearest 1.0 cm. Body mass index (BMI) was categorized as: below normal weight (< 18.5 kg/m2); normal weight (18.5–24.9 kg/m2); overweight (25.0–29.9 kg/m2); and obese (≥ 30.0 kg/m2) [7]. Age was grouped into 3 categories: 15–29 years (youth); 30–44 years; and 45–64 years [8]. Data analysis Continuous variables were categorized and frequency distribution tables organ- ized to describe them. Because the phys- ical activity score in MET–minutes was found largely positively skewed, physical activity was displayed as a categorical variable and then cross-tabulated with demographic and physical factors; the chi-squared test was used to test the as- sociation between physical activity level and those factors. The significance level was set at P < 0.05. Analysis of data was performed using SPSS, version 15. Results Of the 600 staff members planned to be surveyed, 543 were available on survey days and 539 agreed to participate in the study, 269 males and 270 females. As Table 1 shows, teaching staff comprised 54.4% of the study popula- tion. All respondents were surveyed during February, March and April, ex- cept for 67 (12.4%) university teachers who were surveyed in June. The age of respondents ranged from 18–64 years (Table 2). Over 80% of the respondents were below age 45 years; more males than females were aged 45–64 years. Two-thirds of the study population were sedentary for 5 hours or more. The prevalence of overweight was 36.2% and of obesity was 14.8%; men tended to be more overweight than obese compared with women. Three-quarters of all staff (74.0%) were classified as highly or moderately active using the IPAQ cutoffs, while 39.5% of staff were highly active. Table 3 shows more than half of schoolteachers (56.8%) reported high physical activity compared with around one-third of other staff (P < 0.001). When the teaching staff were compared with the support staff, again the former were significantly more active than the latter (P < 0.001). Women seemed to be more active than men, with 41.5% of women reporting high physical activity compared with 37.5% of men, although the difference did not reach statistical significance. Those aged 15–29 years were more active (42.3% in the high physical activity category) than those aged 30–44 and 45–64 years (37.0% and 37.8% in the high physical activ- ity category, respectively), but again the differences did not reach statistical significance. Table 3 confirms that highly active persons had significantly fewer sitting hours than less active ones; half of the highly active individuals reported < 5 sitting hours per day compared with about one-quarter of the less active. Among the various BMI categories, small nonsignificant differences existed, but, interestingly, a high proportion of obese people reported high physical activity (42.5%). High physical activity was significantly more often reported by the staff surveyed during the moderate weather season than by those surveyed in hot summer (40.9% versus 29.9%). Discussion Although physical inactivity is a global concern, the diversity of physical activ- ity measures currently in use prevent national and international comparisons. Most studies have focused on leisure time physical activity, while physical activity at work, home and during transport has not been assessed [9,10]. Progress has been made recently in developing an international measure of physical activity—the IPAQ—as a sim- ple instrument to assess overall physical activity and to provide information for use in population health surveillance systems. This was followed by extensive reliability and validity testing worldwide [11–15]. The use of a standard measure allows comparisons within a country, between neighbouring countries and at a regional and global level. The final results of those studies recommended the use of the IPAQ short “last 7 days” form, as used in our study, in national and regional prevalence studies [11]. Recognizing that virtually no data are available on the prevalence of physical activity in Iraq [16], we at- tempted to estimate the current level of physical activity among the teaching Table 1 Distribution of the study population according to type and place of work, by sex Type and place of work Total (n = 539) Males (n = 269) Females (n = 270) No. % % % Nonteaching (support) staff Office of directorate of education 128 23.7 24.8 22.6 Office of university president 118 21.9 16.4 27.3 Subtotal 246 45.6 41.3 49.9 Teaching staff School 155 28.8 20.8 36.7 University 138 25.6 37.9 13.4 Subtotal 293 54.4 58.7 50.1 طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1281 and nonteaching staff of the primary, secondary and higher education institu- tions in Dohuk city. Using the conven- tional classification of moderate or high physical activity—i.e. the cutoff point at moderate physical activity—three- quarters of our respondents (74.0%) would be classified as physically active. This is a higher than levels reported for the USA (45.9%) [17], Australia (57%) [18] or the world (15%–40%) [4]. This may be explained as follows. The criteria for physical activity levels mentioned in the methods section of this study were set taking into account that IPAQ asks questions in all domains of daily life, resulting in higher median MET-minutes estimates than would have been estimated from leisure time participation alone. Given that meas- ures such as IPAQ assess total physical activity in all domains, the public health recommendation for “leisure time physical activity” based on 30 minutes on most days will be achieved by most adults in a population. Although widely accepted as a goal, in absolute terms, 30 minutes of moder- ate intensity activity is low and broadly equivalent to the background or basal levels of activity adult individuals would accumulate in a day. Therefore, a higher cutoff point—i.e. high rather than mod- erate or high physical activity level as clas- sified by the IPAQ scoring system—has been proposed to describe the levels of physical activity associated with health benefits [6]. According to this new cut- off point, only 39.5% of the study popu- lation would be considered physically active and meeting health requirements. This level is similar to developed coun- tries such as Switzerland (37%) [19], but is still high compared with Saudi Arabia (23.5%, 19.1%) [20,21], South Korea (16.6%) [22], Taiwan (14%) [23] and Brazil (3.3%) [24]; the latter 4 surveys are similar to the current study in using self-reports of physical activity, but they only measured leisure time or recreational physical activity. We need to wait for local or regional surveys that use this stricter IPAQ cutoff to make better comparisons. It is also possible that respondents in the current survey overestimated their physical activity, an observation that was made in IPAQ’s 12 countries study [11]. Overreport- ing of physical activity in population samples has been found to be a serious problem, and a need exists to develop the IPAQ further to solve the apparent overreporting by sedentary individuals [25,26]. Apart from methodology issues, other possible explanations for the high physical activity level reported in this survey include the favourable season during which most of participants were surveyed. The tradition of families in Dohuk is to spend spring in picnics where opportunities for physical activity and sports are high. Another explana- tion could have been the high price of fuel at the time of the survey, which might have reduced the use of private cars, replacing it by walking. It should be emphasized that high levels of physical activity are not necessarily achieved by being vigorously active; in fact most people in the high physical activity category in the current study achieved this by walking and/or doing moderate activities of sufficient duration to classify them as such. Physical activity does not need to be vigorous to provide health benefits; moderate intensity physical activity is considered a vital component of a healthy lifestyle for people of all ages and abilities, being more readily adopted and maintained than vigorous physical activity [2]. Teachers, in particular schoolteach- ers, reported significantly higher physical activity in the current survey compared with the support staff. This could be due to the clerical desk-bound nature of work for many support staff. Many teachers mentioned that they walked several hours while teaching. This agrees with the finding that individuals with longer average sitting times per day reported significantly less physical activ- ity than those with shorter sitting times. Table 2 Distribution of the study population according to age and physical factors, by sex Variable Total (n = 539) Male (n = 269) Female (n = 270) No. % % % Age (years) 15–29 241 44.7 31.7 57.7 30–44 208 38.6 43.5 33.7 45–64 90 16.7 24.8 8.6 Level of physical activitya High 213 39.5 37.5 41.5 Moderate 186 34.5 35.3 33.7 Low 140 26.0 27.3 24.8 Sitting time (hours per day) 0.5–4.5 178 33.0 29.7 36.3 5.0–9.5 289 53.6 58.3 48.9 ≥ 10.0 72 13.4 12.0 14.8 BMI (kg/m2) < 18.5 16 3.0 2.6 3.4 18.5–24.9 248 46.0 44.9 47.1 25.0–29.9 195 36.2 38.7 33.7 ≥ 30.0 80 14.8 13.6 16.0 aInternational physical activity questionnaire short form cutoffs [6]. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1282 The desk-bound nature of support staff work could have contributed to this inverse relation. The problem of seden- tary working populations has been well recognized and desk-based exercises and on-site physical activities have been recommended as useful solutions [27]. Support staff, including administrators and engineers, need to be involved in physical activity programmes for the sake of their own health, and in order to be convinced of the importance of promoting and sustaining a safe envi- ronment for physical activity for chil- dren and adolescents. With increased opportunities for physical activity, e.g. playgrounds and playtime, students may opt to selectively engage in these activities instead of more inactive be- haviours [28]. Weather or the time of year appar- ently impacts all socioeconomic groups as a barrier to physical activity [29]. Cold weather has been found to have modest impeding effects on physical activity [30]. Another study which used self- reports of physical activity found no asso- ciations with weather [31]. While these studies done in industrialized countries have taken into account the effect of low temperature, rain, snow or wind, the current study found significantly fewer people were physically active during hot weather. Environmental temperatures up to 45 ºC during summer in Dohuk usually prompt an increase in the use of private cars and a decrease in physical activity. This is especially the case when fuel becomes available and cheap, as occurred in June 2006 when a subsam- ple of the study population was being surveyed. Environmentally conditioned playgrounds and sport facilities should be made available in schools and univer- sities in our country. Contrary to several reports of less physical activity among women [17,32–34], our study found women to be more active than men, though this Table 3 Association of physical activity level with demographic and physical factors Variable Total No. Physical activity levela P-value Low % Moderate % High % Place of work < 0.001Office of directorate of education 128 28.1 39.8 32.0 Office of university president 118 32.2 39.0 28.8 School 155 11.6 31.6 56.8 University 138 34.8 29.0 36.2 Type of work < 0.001Nonteaching 256 30.1 39.4 30.5 Teaching 293 22.5 30.4 47.1 Sex 0.634Male 269 27.1 35.3 37.5 Female 270 24.8 33.7 41.5 Age (years) 0.578 15–29 241 23.7 34.0 42.3 30–44 208 26.4 36.5 37.0 45–64 90 31.1 31.1 37.8 Sitting time (hours per day) < 0.001 0.5–4.5 178 16.3 34.3 49.4 5.0–9.5 289 26.6 34.3 39.1 ≥ 10.0 72 47.2 36.1 16.7 BMI (kg/m2) 0.750 < 18.0 16 31.3 31.3 37.5 18.0–24.9 248 25.0 35.9 39.1 25.0–29.9 195 24.6 36.4 39.0 ≥ 30.0 80 31.3 26.2 42.5 Season of survey Spring 472 23.3 35.8 40.9 < 0.001 Summer 67 44.8 25.3 29.9 aInternational physical activity questionnaire short form cutoffs [6]. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1283 References Health and development through physical activity and sport1. . 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Centers for Disease Control and Prevention (CDC). Adult par-17. ticipation in recommended levels of physical activity–United States, 2001 and 2003. Morbidity and Mortality Weekly Report, 2005, 54:1208–1212. Armstrong T, Bauman A, Davies J. 18. Physical activity patterns of Australian adults: results of the 1999 national physical activity survey. Canberra, Australian Institute of Health and Welfare, 2000:22–31. Martin B et al. Physical activity in the Swiss population: preva-19. lence data and associations with health. Sportmedizin und Sporttraumatologie, 2000, 48(2):87–88. Al-Shahri M, Al-Almaei S. Promotion of physical exercise by 20. primary health care physicians in Riyadh city. Saudi Medical Journal, 1998, 19:67–69. Al-Refaee S, Al-Hazzaa HM. Physical activity profile of adult 21. males in Riyadh City. Saudi Medical Journal, 2001, 22:784–789. Cho MH. The strength of motivation and physical activity level 22. during leisure time among youth in South Korea. Youth and Society, 2004, 35:480–494. Ku PW et al. Prevalence of leisure-time physical activity in 23. Taiwanese adults: results of four national surveys, 2000–2004. Preventive Medicine, 2006, 43:454–457. Monteiro CA et al. A descriptive epidemiology of leisure-time 24. physical activity in Brazil, 1996–1997. Revista Panamericana de Salud Pública, 2003, 14:246–254. Rzewnicki R, Auweele YV, De Bourdeaudhuij I. Addressing 25. overreporting on the International Physical Activity Question- was not statistically significant. Working women also appeared to have fewer sitting hours than men. This may be explained by the younger age of women in the current study, and the customs of the local society, where women carry out most of the household requirements of the family. A major improvement in questionnaire assessment of physical activity in IPAQ was the inclusion of household sources of activity, which may be the primary context for physical activity among women in our culture. A study in a rural county in the United States also found women to be more active than men [35]. We found young people to be more active than the older age groups. The difference was statistically not significant, but it does follow the worldwide pattern [2]. Irwin et al. found that the trend for overestimat- ing energy expenditure increases with ageing and obesity and that the trend for underestimating energy expendi- ture increases as physical activity level increases [36]. This might have ob- scured a significant association in the current study between physical activity on the one hand, and age and low BMI on the other. Half of our respondents were either overweight or obese. Overweight and obesity levels were similar to those of developed countries [17,18,37], sup- porting the idea that Dohuk city is advanced in the spectrum of epide- miological transition [38]. Differences among various BMI categories were not statistically significant in the cur- rent study; it is possible that obese individuals who reported high activ- ity had overestimated their activity, which agrees with Irwin et al.’s findings [36]. Maintaining ideal body weight is important in preventing a decline in overall health and physical functioning. Regular exercise can reduce the risk of health decline even among individuals who cannot achieve ideal weight [39]. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1284 Physical inactivity is the fourth leading risk factor for global mortality Globally, 6% of deaths are attributed to physical inactivity. This follows high blood pressure (13%), tobacco use (9%) and is equal to high blood glucose (6%). Moreover, physical inactivity is the main cause for approximately 21–25% of breast and colon cancers, 27% of diabetes and 30% of ischaemic heart disease burden. WHO developed the Global Recommendations on Physical Activity for Health with the overall aim of providing national and regional level policy makers with guidance on the dose-response relationship between the frequency, duration, intensity, type and total amount of physical activity needed for the prevention of noncommunicable diseases. The recommendations address 3 age groups: 5–17 years old; 18–64 years old; and 65 years old and above. The recommendations for each age group can be downloaded at: http://www.who.int/dietphysicalactivity/factsheet_ recommendations/en/index.html naire (IPAQ) telephone survey with a population sample. Pub- lic Health Nutrition, 2003, 6:299–305. Fogelholm M et al. International Physical Activity Question-26. naire: validity against fitness. Medicine and Science in Sports and Exercise, 2006, 38:753–760. Schneider S, Becker S. Prevalence of physical activity among 27. the working population and correlation with work-related factors: results from the first German National Health Survey. Journal of Occupational Health, 2005, 47:414–423. Gordon-Larsen P, McMurray RG, Popkin BM. Determinants of 28. adolescent physical activity and inactivity patterns. Pediatrics, 2000, 105:e83. Burton NW, Turrell G, Oldenburg B. Participation in recrea-29. tional physical activity: why do socioeconomic groups differ? Health Education and Behavior, 2003, 30:225–244. Chan CB, Ryan DAJ, Tudor-Locke C. Relationship between 30. objective measures of physical activity and weather: a longi- tudinal study. International Journal of Behavioral Nutrition and Physical Activity, 2006, 3:21. King AC et al. Personal and environmental factors associated 31. with physical inactivity among different racial-ethnic groups of U.S. middle-aged and older-aged women. Health Psychology, 2000, 19:354–364. Gomes VB, Siqueira KS, Sichieri R. Atividade fisica em uma 32. amostra probabilística da população do Municipio do Rio de Janeiro [Physical activity in a probabilistic sample in the city of Rio de Janeiro]. Cadernos de Saude Pública, 2001, 17:969–976. Muntner P et al. Prevalence of physical activity among Chinese 33. adults: results from the International Collaborative Study of Cardiovascular Disease in Asia. American Journal of Public Health, 2005, 95:1631–1636. Belander O, Torstveit MK, Sundgot-Borgen J. Er unge norske 34. kvinner aktive nok? [Are young Norwegian women sufficiently physically active?]. Tidsskrift for Den Norske Laegeforening, 2004, 124:2488–2489. Eaton CB et al. Self-reported physical activity in a rural county: 35. a New York county health census. American Journal of Public Health, 1994, 84:29–32. Irwin ML, Ainsworth BE, Conway JM. Estimation of energy 36. expenditure from physical activity measures: determinants of accuracy. Obesity Research, 2001, 9:517–525. Colucciello M et al. Prevalenza dei fattori di rischio per le 37. malattie ischemiche del cuore in una popolazione adulta del Nord Italia [Prevalence of risk factors for ischemic heart disease in a northern Italian adult population]. Annali d’Igiene, 2006, 18:23–30. Agha SYA, Mohamad JB, Abdullah QH. Registered mortality 38. and cardiovascular mortality in Dohuk province. Zanco Journal for Medical Sciences, 2001, 5:1–13. He XZ, Baker DW. Body mass index, physical activity, and 39. the risk of decline in overall health and physical functioning in late middle age. American Journal of Public Health, 2004, 94:1567–1573. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1285 Report Primary health care in the Eastern Mediterranean Region: from Alma-Ata to Doha S. Shawky 1 ABSTRACT The celebration in Doha of the 30th anniversary of the Alma-Ata Declaration at the International Conference on Primary Health Care renewed the commitment of the Eastern Mediterranean Region to primary health care as the tool for better health. The principles agreed at Alma-Ata in 1978 apply as much now as they did before. The event provided an opportunity for the Eastern Mediterranean countries to define future directions to steer the health systems to integrate primary health care and harness the intersectoral approach. 1Social Research Center, American University in Cairo, Cairo, Egypt (Correspondence to S. Shawky: shshawky@aucegypt.edu). Received: 25/03/09; accepted: 03/06/09 ةحودلا لىإ اتآ المأ نم :طسوتلما قشر ميلقإ في ةيلولأا ةيحصلا ةياعرلا يقوش نييرش قشر ميلقإ مازتلا د َّدتج ،ةحودلا في ميقأ يذلا ةيلولأا ةيحصلا ةياعرلا لوح ليودلا رتمؤلما في اتآ المأ نلاعلإ ينثلاثلا ىركذلاب لافتحلاا في :ةـصلالخا ماك مويلا قبَطْنَت 1978 ماع اتآ المأ في اهيلع قافتلااب تيظح يتلا ئدابلما لازتلاو .لضفأ ةحص قيقحتل ةليسولا اهرابتعاب ةيحصلا ةياعرلاب طسوتلما ةيحصلا ةياعرلا جامدإ وحن ةيحصلا مظنلا هيجوتل ةيلبقتسلما تاه ُّجوتلا ديدحتل طسوتلما قشر ميلقإ نادلبل ةصرف رتمؤلما اذه م َّدق دقو .لبق نم تناك .تاعاطقلا ددعتلما لمعلا بولسأ عابتاو ،ةيلولأا Les soins de santé primaires dans la Région de la Méditerranée orientale : d’Alma-Ata à Doha RÉSUMÉ À l’occasion de la célébration à Doha du trentième anniversaire de la Déclaration d’Alma-Ata, lors de la Conférence internationale sur les soins de santé primaires, la Région de la Méditerranée orientale a renouvelé son engagement en faveur des soins de santé primaires en tant qu’outils pour l’amélioration de la santé. Les principes adoptés à Alma-Ata en 1978 restent, aujourd’hui comme hier, d’actualité. L’événement a fourni une occasion pour les pays de la Méditerranée orientale de convenir de nouvelles orientations pour guider les systèmes de santé, intégrer les soins de santé primaires et mettre en oeuvre l’approche intersectorielle. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1286 Introduction On 1–4 November 2008 in Doha, the capital of Qatar, the countries of the Eastern Mediterranean Region (EMR) celebrated the 30th anniversary of the Alma-Ata Declaration with the International Conference on Primary Health Care: The foundation for health and wellbeing [1]. The event was an important occasion, assembling numer- ous health professionals to share their global and regional experiences and plan future directions. The main goal of the conference was to develop action- oriented recommendations to harness the potential of the primary health care (PHC) approach in safeguarding health and wellbeing. The Doha conference reaffirmed the World Health Organi- zation’s (WHO) definition of health and renewed the health community’s commitment to the Alma-Ata vision [2] which shifted health care away from a focus on hospital care and the biomedi- cal model. The event underlined the importance of looking at regional needs in order to steer health systems towards better performance and greater equity and ensuring the role of PHC as the tool for achieving the goal of “health for all”. PHC was adopted as an ideal to strive for in most EMR countries soon after the Alma-Ata Declaration, with the aims of limiting health sector expenditure, using resources more efficiently, im- proving health care and reducing health inequities. The past few decades have seen increasing political attention in the Region on PHC, with an active focus on health sector reforms that integrate PHC within national health systems and a push for broader economic structuring, with countries implementing health sec- tor reforms and looking for mechanisms to increase their health system’s financ- ing and strategies to mobilize financial resources. The evidence, however, paints a different picture of PHC in the Region: as a vision that did not fully achieve its goals. Recent statistics reveal that the EMR countries are still lagging behind other countries in achieving health eq- uity, in facing the new health threats and in reducing expenditure on health through building insurance systems [3,4]. Despite notable improvements in the overall health of people in the Region, the health indicators are skewed towards the most favoured groups in the population. The Region suffers from new health threats, among which HIV infection is one of the most concern- ing [5]. The cost of health services are mounting, health insurance systems are in their infancy and many people are at risk of catastrophic payments. The regional and international com- mitment to revitalize the role of PHC and support health and wellbeing in EMR provide a unique opportunity to review the evolution of health concepts and the Alma-Ata vision [1,6]. These aim to highlight the issues and challenges facing the development of PHC in the EMR in an attempt to map out future directions for supporting population health and well-being in the Region. Evolution of health concepts In the past, “health” referred to the absence of disease. Progress in health since the early years of the 20th century alerted the scientific community to the idea that health needs to be thought of as much broader than just absence of disease. WHO called for a shift from this focus on curing disease towards the concept of health balance through pre- serving health for the healthy and restor- ing health for the unhealthy. WHO has defined 2 main dimensions to maintain- ing the health balance: building health potential and health protection. The new direction liberated the concept of health from the narrow con- tinuum of disease and medicine to the WHO broader definition of health in 1946 as: “a state of complete, physi- cal, social and mental well-being and not merely the absence of disease or infirmity”. The definition was a revolu- tion from earlier concepts that spelt out health in a social context. However, this new vision was challenged by break- throughs in health technology during the 1950s that produced an array of new antibiotics, vaccines and other medi- cines, instilling the belief among health professionals and the general public that technology held the answer to all the world’s health problems. This was cou- pled with a global trend towards the re- alization that the medical model was not meeting the most urgent needs of the poor and disadvantaged populations. It was clear that the advanced curative technologies were distorting the health systems in many countries, especially those in the developing world. The new health perspective was revitalized by the landmark WHO and UNICEF international conference in Alma-Ata in 1978. The main goal was to discuss the urgent problem of providing people with the right to life and health. The participants stressed the respon- sibility that governments have for the health of their people. The conference underlined the importance of social and economic development, as well as the political independence for completely realizing the mission of health develop- ment. The triumph of the event was the adoption of the Alma-Ata Declaration: the 20th century’s key health charter [2]. The Alma-Ata Declaration had two major achievements: defining the goal “Health for All by the year 2000” and identifying PHC as its tool. The Health for All policy ushered in a new era in health and a new vision of the disease panorama. The redefinition of health removed the focus on hospitals and the biomedical model of health care. It called for a broader sociopolitical ori- entation for health policy, encompassing a broad social and economic develop- ment context. It gave prominence to the need for action from many other social and economic sectors in addition to the health sector. The core idea of the Alma- Ata Declaration was to administer the طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1287 Health for All policy under the concept of PHC. PHC was viewed as a major tool in implementing the WHO strat- egy and the key for achieving the goal of Health for All, thus, contributing to health development in an integrated comprehensive, intersectoral and partic- ipatory approach through efficient and equitable health systems. The Health for All framework set the ground for reform in the national public health policies of WHO member states. The reference to the year 2000 meant that, as of that date, all the countries would have developed the appropriate political strategies and be enacting concrete measures towards achieving the goal of Health for All. WHO saw clearly the value of PHC and began to promote it around the world. The 1990s saw increasing scien- tific advances in understanding the so- cial determinants of health. In 2000, the United Nations Millennium Summit set ambitious targets to tackle the root causes of ill health and the Millennium Development Goals were adopted by the 189 member states [7]. In the same context, the Commission on Social De- terminants of Health was founded in 2005 as an attempt to revive the founda- tion for health equity, the efficiency of health systems and intersectoral action for health [8]. All these initiatives agreed on the need for an integrated PHC sys- tem within a comprehensive national health system as the best way to tackle health problems in communities and for people to access health care. Primary health care concepts and mission The definition of PHC proposed 30 years ago rests on 3 pillars (Figure 1). First, care must be essential, providing comprehensive, continuous and quality care that meets the actual health needs of the community. Secondly, care should be accessible through geographical, so- cial and functional accessibility. Thirdly, care needs to be affordable within the available resources. PHC aimed to be context-specific to meet the actual priority community needs, the stage of socioeconomic and health development and the available re- sources in a community or a country. In this context, 6 strategies and 8 elements were defined to shape the PHC mission (Figure 1). The strategies of PHC and the delivery of its elements are organized on the basis of equity in distribution, appropriate technology, intersectoral ap- proaches and community participation. The mission of PHC is completed by its instruments, including community sur- veys and diagnosis, family health records, plans of action, the team approach and health information systems. This emphasis on PHC has reshaped health systems worldwide to cope with their new broader role. Within any health system, the PHC concept has several responsibilities that are linked to the medical and non-medical sectors. Within PHC there is a responsibility to provide individual diagnosis and health care services through primary medi- cal care, focusing on minor illness and prevention of diseases. It has a screen- ing function for the early detection of patients who need a higher level of medical care, thus acting as a referral system. PHC involves a community responsibility to provide a diagnosis of community needs and services through surveillance systems, surveys, outreach programmes, community empower- ment programmes and building health databases. PHC also includes a respon- sibility to mobilize intersectoral actions and oversee the services provided by other non-health sectors for promotion of health and wellbeing. Primary health care issues in the EMR It is apparent that there is an active movement towards PHC in the EMR. The Region can point to many suc- cess stories. However, an in-depth look at the Region reveals a common issue. While the mission of PHC is to target health and wellbeing, PHC in the Region is still skewed towards the biomedical model. The intersectoral approach is lagging behind, with many PHC instruments blocked and several elements lacking. The PHC package in this case acts only as primary medical care with a patient–doctor approach and disease focus. This half-finished development of PHC is illustrated by 3 main issues. Firstly, most PHC settings are only ap- plying a family health model. It is true that the family model has a broad health vision that looks at an individual within the family. Integration of a family health model within a PHC setting is an asset that can effectively and efficiently reduce the need for, and relieve the burden on, referral systems. Nevertheless, the fam- ily approach does not encompass all components of PHC. For example, the family health approach is not applicable to initiatives such as surveillance sys- tems, community surveys and diagno- sis, control of endemic diseases, health information systems and community empowerment, all of which require a community approach with intersectoral action. Secondly, the role of PHC in moni- toring population health and controlling emerging diseases is hampered by the numerous disease-specific programmes running independently outside of PHC settings in the Region. Thirdly, recent years have seen the setting up of huge number of different initiatives in the Region, for example maternal and child health, reproductive health, community-based, women’s em- powerment and poverty alleviation pro- grammes. Although these programmes represent important elements of PHC, each is working on its own, detached from the PHC context. This risks de- priving the PHC system of its respon- sibilities and functions, encouraging weak and fragmented health systems, and delays the initiation of intersectoral actions. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1288 Health care challenges in the EMR The 3 major challenges concerning PHC in the EMR countries are how to stimulate an intersectoral approach, how to utilize human capacities and how to secure funding. A common feature in all EMR countries is the lack of an intersectoral approach to PHC. The blame for this can be attributed to both the national and international communities. On a national level, government sectors are accustomed to working independently. The ministries of health are still believed to be uniquely responsible for popula- tion health. The other non-health sec- tors rarely pay attention to the health outcomes of their policies and interven- tions. NGOs and civil society are strug- gling for population health; however, they are rarely engaged in intersectoral actions. On the international level, each international organization has links with a specific sector, whether government sector or civil society. The international aid programmes are directed to a single sector and there are no international aid investments or programmes that have an intersectoral model with a mecha- nism for budget sharing. The countries of the Region lack the health professionals who can lead a health system integrated with PHC [9–12]. Integrated PHC systems need 3 main types of professional: public health professionals to plan, manage and organize the health system; com- munity health professionals to work on community diagnosis and manage PHC with a community-based approach; and family health professionals to provide primary care. There are several reasons for this. First, education in public health Definition: Primary health care is “…essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their develop- ment in the spirit of self-reliance and self-determination. It forms an integral part both of a country’s health system, of which it is the central and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system, bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.” Strategies: Expansion of health services and ensuring efficiency;• Development of better relations with the community;• Progressive improvement towards comprehensive health care for all; • Integration of preventive and curative service;• Promotion of health awareness;• Coordination with academic institutes for primary health care• development; Multi-sector approach and at-risk approach.• Elements:• Education concerning the prevailing health problems and the methods of preventing and controlling them; • Promotion of food supply and proper nutrition; • Provision of comprehensive maternal and child health care; • Immunization of children against major communicable diseases; • Prevention and control of locally endemic diseases; • Provision of adequate supply of safe water and basic sanitation; • Appropriate treatment of common diseases and injuries;• Provision of essential drugs. • Rehabilitative services could be included if decided on and when required. • Figure 1 Primary health care: definition, strategies and elements طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1289 References The foundation for health and wellbeing1. . International Confer- ence on Primary Health Care, Doha, Qatar, 1–4 November 2008. International Conference on Primary Health Care: Declaration of 2. Alma-Ata. Alma-Ata, USSR, 6–12 September 1978. WHO Statistical Information System3. (WHOSIS). Geneva, World Health Organization [website] (http://www.who.int/whosis/ en/index.html, accessed 29 August 2010). The state of the world’s children 2008: child survival4. . Geneva, United Nations Children’s Fund, 2008. AIDS epidemic update 2007. 5. Geneva, Joint United Nations Program on HIV/AIDS and the World Health Organization, 2007. The world health report 2008. Primary health care: now more 6. than ever. Geneva, World Health Organization, 2008. The millennium development goals report, 20077. . New York, United Nations, 2007. Commission on Social Determinants of Health, 2005–2008.8. Ge- neva, World Health Organization [website] http://www.who. int/social_determinants/thecommission/en/ The world health report 2006. Working together for health.9. Ge- neva, World Health Organization, 2006. A snapshot of the world’s public health schools. 10. Bulletin of the World Health Organization, 2007, 85:910–911. Public health schools: six portraits. 11. Bulletin of the World Health Organization, 2007, 85:907–909. Health professions education directory12. . Cairo, World Health Organization Regional Office for the Eastern Mediterranean [website] (http://www.emro.who.int/hped/, accessed 29 August 2010). is deficient in most countries of the Re- gion, and in countries where it does exist the number of public health profession- als is inadequate for the size and health needs of the population. Second, while community health education is availa- ble in most medical schools and schools of health sciences, PHC education is rarely integrated into the community health curriculum. Even though there are many community health profession- als, their role is ill-defined or is confused with public health or family health and there is a limited labour market. Third, in several countries of the Region, family health education does not exist. To solve this problem in settings where the family model leads PHC, some countries have trained general practitioners on family health for a few months, although there are many doubts about the success of this experience. PHC funding is a function of govern- ment subsidies and beneficiary’s contri- butions. Government inputs to PHC in the Region are limited as ministries of health give priority to hospital care and curative technology. The beneficiaries pay their share, either as service fees or through membership of a family fund, or a package of both. The PHC out-of- pocket cost overburdens the people, especially the poor, who are forced to seek health care in public hospitals at lower cost. Although PHC is a global responsibility, international aid invest- ments are mainly allocated to detached, disease-specific vertical programmes or community programmes, thus depriv- ing PHC of a likely funding source. Future directions in the EMR Integrated PHC health systems remain a key goal of health policy. It is time that EMR countries steered their health systems towards this goal with well- planned steps that build on positive achievements and mitigate the short- comings in the implementation of PHC. Three broad future directions are recommended to nurture the role of PHC: defining an operational model for intersectoral action, generating human resources and securing financing for PHC. First, the EMR countries are invited to initiate a vigorous dialogue among all relevant stakeholders to reach a consensus on strategies to support and organize intersectoral action. Strate- gies designed with the focus on equity, working within the framework of social determinants of health and a budget- sharing mechanism will provide the best base for defining an operational intersectoral model. The Region can go further and test the model on a country level, identify success stories that can be improved on and used on a wider scale as a model for the Region. Second, the EMR countries need to strengthen their health education programmes and direct them towards meeting community health needs. The Region needs to set up more schools of public health independent from the medical schools. Schools of public health are distinct from medical schools in offering multidisciplinary education to students from diverse disciplines. Coun- tries need to build capacity in family health through enforcing family health education in schools of medicine and allied health sciences. Countries need to revisit the community health curriculum in schools of medicine and allied health sciences in order to integrate PHC as a key component and define the true role of community health education. Third, there is a need for stakehold- ers to take action towards institutional- izing vertical programmes, outreach activities and community-based initia- tives within PHC. On the one hand this will support the PHC system to fulfil its responsibilities and on the other it will offer more funding opportunities for PHC. This action is best complemented by developing a workable social health insurance structure that guarantees uni- versal coverage and risk pooling. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1290 Report Experience of cyclone Gonu in the Islamic Republic of Iran: lessons learned F. Panahi,1 R. Asadollahi,2 M. Asadollahi 3 and A. Hasani-Bafarani 4 ABSTRACT Gonu, the second tropical cyclone of the 2007 northern Indian ocean cyclone season, affected Oman, Pakistan, the United Arab Emirates and the Islamic Republic of Iran. This report examines the effects of cyclone Gonu in the Islamic Republic of Iran where it approached on its path on 6 June 2007 and reviews the actions taken before, during and after the cyclone. The incident highlighted the need for a special protocol to be prepared for all types of natural disasters. Responsible organizations should train their personnel according to the prepared protocols and service packages. Among the important lessons learned were the need for early warning, proper community involvement, access to essential data for risk analysis, special attention to safety of infrastructures, coordination and command integrity. 1Emergency Management Centre; 4Secretariat for Health Risk Management in Disasters, Ministry of Health and Medical Education, Tehran, Islamic Republic of Iran (Correspondence to F. Panahi: farzadpanahi@yahoo.com). 2Iran Helal Institute of Applied Science and Technology, Tehran, Islamic Republic of Iran. 3Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran. Received: 27/02/09; accepted: 18/06/09 ةيملاسلإا ناريإ ةيروهجم في ونوغ راصعإ نم ةدافتسلما سوردلاو تابرلخا نيارفاب ينسح هدازآ ،يهللا دسأ ىفطصم ،يهللا دسأ اضر ،يهانب دازرف ناتسكابو نماُع لىإ هيرثأت دتما دق ،2007 ماع يدنلها طيحلما لماش في يرصاعلأا مسوم في نياثلا يرادلما راصعلإا وهو ونوغ راصعإ ناك :ةـصلالخا يتلا ةيملاسلإا ناريإ ةيروهجم لىع راصعلإا اذه راثآ ةقرولا هذه في نوثحابلا سَرَد دقو .ةيملاسلإا ناريإ ةيروهجمو ةدحتلما ةيبرعلا تاراملإاو ةثدالحا هذه تحضوأ دقو .هدعبو هءانثأو راصعلإا لبق ةذخَّتلما تاءارجلإا اوضرعتساو ،2007 وينوي/ناريزح نم سداسلا في هراسم اهنم برـتقا تلاوكوتوبرلل ًاقفو اهيف ينلماعلا بيردتب ةلوؤسلما تماظنلما موقت نأ لىإو ،ةيعيبطلا ثراوكلا طمانأ عيمجب صاخ لوكوتورب دادعإ لىإ ةجالحا ىدم تايطعلما ةحاتإو ،عمتجلما لَبِق نم ةبسانم ةكراشمو ،ركبم راذنإ لىإ ةجالحا ةمالها ةدافتسلما سوردلا نم نأ نوثحابلا دجوو .تامدلخا مَز َُحو ة َّدعلما لماكتلا نماضو ،قيسنتلاو ،ةيساسلأا ةينبلاو ،ةيحصلا ةياعرلا زكارمو ،تايفشتسلما ةملاسب صاخ مماتها ءلايإ عم ،رطاخلما ليلتح لجأ نم ةيساسلأا .رماولأا ذيفنتو ءاطعإ ةيلمع في طابضنلااو Passage du cyclone Gonu dans la République islamique d’Iran : enseignements tirés de cette expérience RÉSUMÉ Gonu, le deuxième cyclone tropical de la saison des cyclones de l’année 2007 du nord de l’océan Indien, a frappé les Émirats arabes unis, la République islamique d’Iran, le Pakistan, et le Sultanat d’Oman. Le présent rapport étudie les effets du cyclone Gonu en République islamique d’Iran, qu’il approcha dans sa course le 6 juin 2007, et analyse les actions entreprises avant, pendant et après le passage du cyclone. L’incident a mis en lumière le besoin d’un protocole spécial pour la préparation à tous les types de catastrophes naturelles. Les organisations concernées devraient former leur personnel en suivant les protocoles et les ensembles de services préparés. Parmi les enseignements importants tirés de cette expérience, nous pouvons citer les suivants : le besoin d’une alerte précoce, d’un engagement adéquat de la communauté, d’un accès aux données essentielles pour l’analyse des risques, d’une attention particulière à la sécurité des hôpitaux et des centres de soins de santé, mais aussi le besoin d’infrastructures, de coordination des niveaux hiérarchiques et d’intégrité à ces niveaux. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1291 Introduction Cyclones, hurricanes and typhoons are intense low-pressure weather systems arising in the tropics that produce strong winds and heavy rain. These storms are the most damaging large-scale weather systems in the world and cause massive destruction and loss of life [1]. Tropical cyclones occur in the south-west Pacific, south-east Indian, north Indian, south Pacific or South Atlantic oceans [1]. Gonu, the second named tropical cyclone of the 2007 northern Indian Ocean cyclone sea- son, developed from a persistent area of convection in the eastern Arabian Sea on 1 June before rapidly intensifying to reach peak winds of 240 km/h (150 mph) on 3 June according to the In- dian meteorological department. Late on 5 June, it crossed the land on the easternmost tip of Oman [2]. Reports say cyclone Gonu was the strongest to hit the Arabian Peninsula since records started in 1945 [3]. The cyclone caused about US$ 4 billion damage and about 50 deaths with 14 people missing in Oman, where the cyclone was consid- ered the nation’s worst natural disaster. Gonu dropped heavy rainfall near the eastern coastline, reaching up to 610 mm (24 inches), which caused flooding and heavy damage [4,5]. After affecting Oman (especially Muscat), the United Arab Emirates and Pakistan (Sindh and Baluchistan) [6], Gonu was the first cyclone to affect the Islamic Republic of Iran in almost 100 years [7]. Cyclone Gonu in the Islamic Republic of Iran Cyclone Gonu hit the Islamic Republic of Iran on 6 June 2007, causing sea waves up to 5.8 metres and moderate to heavy rain. Gonu affected 3 provinces, Sistan va Baluchestan (especially Chabahar and Konarak), Hormozgan (Bandar Ab- bas, Jask, Bashagard) and southern parts of Kerman. Winds reached 111 km/h (69 mph) and heavy monsoon rainfall (part of the seasonal pattern in the area) caused some of the rivers to overflow. The cyclone and the consequent heavy rain continued until 8 June [8,9]. The cyclone affected an estimated 560 000 people in 28 cities and 2900 villages. Throughout the affected ar- eas the cyclone caused 23 deaths (20 from drowning) and more than 20 000 houses were flooded. The death toll of domesticated animals was estimated to be about 6500. The total damage in the Islamic Republic of Iran was estimated at 2 billion Iranian riyals (US$ 216 million) [10]. Other major effects of cyclone Gonu included disconnection of electricity, piped water and telecom- munications to more than 2200 popu- lation units, destruction of transport routes to more than 2000 population units, destruction of several dams [11] and damage to the shrimp-breeding industry, one of the most important industries of Chabahar and Konarak, at an estimated cost of about US$ 6 million [12]. Climate change and increases in the incidence of storms and floods through- out the world highlights the need for a comprehensive emergency planning system capable of responding to such events. This report examines the effects of cyclone Gonu in the Islamic Republic of Iran and the measures which were taken before, during and after the cy- clone. Review of the emergency response During the emergency response to cyclone Gonu in the Islamic Republic of Iran written logs documenting the initial actions that were taken were kept by the Natural Disaster Management Task Force of the Ministry of Interior, the Secretariat for Health Risk Manage- ment in Disasters of the Ministry of Health and Medical Education, the Sec- retariat of the Task Force on Meteoric Disasters and the Iran Red Crescent So- ciety. These log entries were reviewed for this report. Rosters of staff who initially assisted or were deployed in the field opera- tion were obtained. Team leaders who managed or coordinated these teams were interviewed using structured and unstructured questions. Copies of correspondence, includ- ing health alerts, messages and situation reports were collected and reviewed for relevant content. The first author was the coordinator between the health authorities of the 3 affected provinces in charge of the health sector response and his notes and reports were also used. A Google search was conducted for reports of different news agencies and newspapers. Additional anecdotal in- formation or experiences were obtained from presentations at the “International meeting on Gonu cyclone: lessons learned” held on 18–19 February 2008 in Chabahar, Islamic Republic of Iran by the Secretariat for Health Risk Man- agement in Disasters in collaboration with the World Health Organization Regional Office for the Eastern Medi- terranean. Pre- and post- incident measures for management The experiences of the Bam earthquake, which struck the Islamic Republic of Iran in 2003, highlighted the need to improve disaster preparedness and disaster management in the country. This prompted the preparation of pre- disaster guidelines, some of which were utilized in the next event, the Lorestan earthquake in 2006. Thus there was a better level of preparedness for respond- ing to upcoming emergencies (includ- ing cyclone Gonu). Actions taken for the management of cyclone Gonu can be reviewed in 2 parts: pre-incident and post-incident measures. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1292 Pre-incident measures In view of the fact that Oman and Paki- stan were affected by cyclone Gonu be- fore it passed over the Islamic Republic of Iran, the relevant organizations were in a state of alert after receiving writ- ten warnings from the Iranian weather bureau on 5 June. The recipient organi- zations of this alert included: Ministry of Health and Medical Education, the governorships of Sistan va Baluchestan, Hormozgan and Kerman provinces; Iran Red Crescent Society; general staff of the Iranian armed forces; civil aviation department; fire department; naviga- tion and ports authorities; Ministry of Foreign Affairs; and all related agencies of the United Nations. The first stage—the evacuation of people from the coastlines to higher and safer places—started quickly. Mosques, sports clubs and schools were prepared to accommodate local residents who had been evacuated or lost their homes. The other major measures comprised: Obtaining updated information • minute-by-minute about the storm conditions through Internet websites and satellite images. Dissemination of early warning mes-• sages through the media and local information networks. Transfer of passenger boats, tugboats • and light and heavy rafts to safe places as well as a halt to any kind of fishing. Ensuring readiness of fire trucks and • provincial ambulances. Announcing the alert phase for all • reinforcement agents such as Red Crescent volunteers. Ensuring readiness of all hospitals, • health centres and health posts in the high-risk provinces. Preparation of food, water and food • rations for those already evacuated or those who may be in need later. Evacuation of Chabahar hospital (in • the high-risk zone) and provision of some essential medical and general equipment in nearby safe places. Post-incident measures Due to proper preparation and good coordination with the general staff of the armed forces, several flights were dispatched to the region soon after the incident based on an initial assessment of personnel shortages in distributing the necessary equipment. Food, medi- cine and tent packages were sent to the region by the Red Crescent Society and other relevant organizations. Reconstruction and repair of water systems, electricity, telecommunica- tions and roads began immediately. All the main roads were opened 3 days after the incident and during this time elec- tricity, water and telecommunication networks were reconstructed in 80% of the damaged regions. About 2500 families were accom- modated in the prepared areas and in emergency tents. Injured people were treated in the hospitals, health centres and mobile hospitals provided [11,13]. Necessary policies were considered by the Iranian Center of Disease Con- trol for prevention of the waterborne diseases (cholera, non-specific diar- rhoea, rotavirus, typhoid and paraty- phoid) and the vectorborne diseases (leptospirosis and malaria). Disease control and prevention prior to the cyclone Attention to weather bureau warn-• ings to predict the features of the storm and to design an appropriate, comprehensive disease control plan. Recruitment of all human resources • relevant to disease control and appli- cation of service guidelines. Evaluation of the regional equipment • stores required for disease control. Assessing the training requirements • and availability of health sector staff. Risk assessment of public health is-• sues, considering local conditions. Predicting potential risks due to loss • of facilities and resources (e.g. spoil- ing of biological products such as vac- cines due to electricity loss). Disease control and prevention during and after the cyclone Establishment of an active disease • surveillance and data collection system for daily assessment of dis- eases. Implementation of a specific surveil-• lance system for cholera. Supplying safe (bottled) water in the • early days after the storm to control waterborne diseases. Constructing hygienic toilets.• Drying superficial ponds and swamps • to prevent outbreaks of cholera and malaria. Face-to-face education of the pub-• lic and distribution of educational pamphlets. Starting larval eradication 2–3 weeks • after the flood. Hygienic burial of animal carcasses.• Disinfection of the environment via • debris removal and insecticide fog- ging. Identification of patients with diar-• rhoea [14]. Lessons learned Appropriate and timely early warning Appropriate and timely warnings before the occurrence of a disaster can reduce human and financial losses. Both civil- ians and responsible government or- ganizations should be warned. During cyclone Gonu, the warnings resulted in the vacuation of the population of Chabahar and Konarak areas, and the preparation of local authorities. Managing what really happens in the field In the immediate aftermath of a disaster, the severity of its impact and extent of the damage should be evaluated by طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1293 teams of experts. This assessment is essential for the prediction of needs. During the cyclone, the extent of the af- fected areas and inaccessibility of many villages and human settlements led to lack of accurate information about the damages and resulted in the wrong type and incorrect amount of resources be- ing mobilized to the affected areas. Training of personnel A specific protocol should be prepared for all known types of natural disaster. Responsible organizations should train their personnel according to the prepared protocols and service pack- ages. Each responsible person should be given a description of his/her own duties. The role of volunteers should be defined too. During cyclone Gonu, confusion over duties and incorrect ac- tions by personnel were the result of the lack of a clear written protocol. Regular training, annual exercises and public education are necessary in the disaster preparedness phase. Staying operational so that you can help In disaster conditions, there is always the possibility of damage to and malfunc- tion of important infrastructures such as water supplies, electricity, telecom- munication and transport routes. Thus provision of backup systems for energy and communications is a must. Cylone Gonu again highlighted the need for electricity generators, communication devices, water tanks and mobile health facilities following a natural disaster. A rescuer should not be in need of rescue Many health centres in the affected areas were not resilient enough to be completely operational after the cy- clone. The price we pay for the failure of hospitals or health facilities in a disaster is too high; in comparison, the cost of making hospitals safe from disasters is small. Disaster damage to health systems is a human tragedy, resulting in huge economic losses, devastating blows to development goals and dam- age to social confidence. Ensuring that hospitals and health facilities are safe from disasters is not only an economic requirement, but also a social, moral and ethical necessity. Integrated disaster management: a repetitive experience Multiple lines of command that lack coordination and command integrity and limited resources are typical prob- lems of disaster management. Ensuring the integration of disaster management systems increases their efficiency and prevents waste of time and of human and financial resources. Strengthening the health network A unique feature of the health system of the Islamic Republic of Iran that facilitates an efficient response to emer- gencies is the network of health posts and health centres. They act as censors at the community level and help gather in- formation and provide early warning and surveillance [15]. The efficiency of this network in accessing affected people, fast response to health issues and providing services was a key factor in the response to cyclone Gonu, especially at the areas where access was initially a problem. Conclusions Every country should have a national policy for the management of disasters and emergencies. This policy should be documented by the government and mandated to all organizations having responsibilities in disaster management to enable them to develop their own disaster management plan as a part of the national disaster management plan. Key points which should be high- lighted in these plans include the duties and responsibilities of the organization, human resources and logistics, prepara- tion of suitable guidelines, secretariat or coordination unit, coordination mechanisms between key ministries and special attention to improvements in communications, transport and the health infrastructure. Public education for appropriate community involvement in different phases of disaster management should not be forgotten. References Coenraads R. 1. Natural disasters and how we cope. Elanora Heights, Australia, Millennium House, 2006:179–217. Tropical cyclone Gonu. 2. Earth observatory, NASA [website] https://earthobservatory.nasa.gov/NaturalHazards/quar- terly.php?cat_id=10&y=2007&q=2, accessed 20 September 2010). Cyclone hits Gulf state of Oman3. . BBC news [website] (http:// news.bbc.co.uk/2/hi/6722749.stm Cyclone Gonu4. . Wikipedia [website] (http://en.wikipedia.org/ wiki/Cyclone_Gonu, accessed 20 September 2010). Azhar Haroun A. L-Kindi. Gonu: lessons learnt. 5. Presentation to the International meeting on Gonu Cyclone: lessons learned, 18–19 February 2008, Chabahar, Islamic Republic of Iran. Federal Ministry of Health, Government of the Islamic Repub-6. lic of Pakistan. Warning phase activities and lessons learned. Presentation to the International meeting on Gonu Cyclone: Lessons Learned, 18–19 February 2008, Chabahar, Islamic Re- public of Iran. Gonu cyclone reached Iran coasts7. [in Farsi]. Roshangari [website] (www.roshangari.net/as/ds.cgi?art=20070715032601.html, accessed 20 September 2010). Cyclone Gonu kills 158. . Gulfnews.com [website] (http://archive. gulfnews.com/region/oman/10130666.html, accessed 20 September 2010). Iran evacuates thousands as cyclone strikes9. . ABC news online [web- site] (http://www.abc.net.au/news/newsitems/200706/ s1944500.htm, accessed 20 September 2010). EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1294 Death toll in Iran from cyclone climbs to 2310. . Reuters [website] (http://www.alertnet.org/thenews/newsdesk/L10319787. htm, accessed 20 September 2010). Iran Weather Bureau.11. [Super cyclonic storm Gonu]. Final report of the Secretariat of the Task Force on Meteoric Disasters, July 2007 [in Farsi]. [12. Gonu cyclone damage to shrimp breeding]. Farmiran [website] (www.farmiran.ir/news/?id=3415, accessed 20 October 2010) [in Farsi]. [13. Comprehensive report of the Secretariat for Health Risk Manage- ment in Disasters about the Gonu cyclone]. Tehran, Ministry of Health and Medical Education, 2007 [in Farsi]. Soroush M. A report of the learnt lessons from Gonu flood 14. regarding disease control and prevention aspects. Presentation to the International meeting on Gonu Cyclone: Lessons Learned, 18–19 February 2008, Chabahar, Islamic Republic of Iran. Bristol N. US region to model health service on Iranian system. 15. Lancet, 2010, 375(9715):625. Natural Hazards, UnNatural Disasters: The Economics of Effective Prevention According to this joint report from the World Bank and the United Nations, annual global losses from natural disasters could triple to $185 billion by the end of this century, even without calculating the impact of climate change. Climate change could then add $28-$68 billion more in damages each year from tropical cyclones alone. The report also says that the number of people exposed to storms and earthquakes in large cities could double to 1.5 billion by 2050. The report outlines a number of measures to prevent death and destruction from natural hazards such as earthquakes, hurricanes, and flooding. For example, governments can make information about hazards and risks easily accessible. Providing land titles reduces the possibility of eviction or demolition, and encourages individuals to invest in safer structures; removing rent controls restores incentives for landlords to maintain buildings; and reorienting existing public spending to prioritize day-to-day operations and maintenance would increase prevention. Undertaking these measures does not necessarily require governments to spend more, says the report, but to spend better. The report emphasizes that it is the vulnerable, not the rich, who face the brunt of natural hazards There were 3.3 million deaths from natural hazards in the 40 years to 2010. Damages are disproportionally high in middle-income countries. One area where the report calls for more spending is on early warning systems, particularly weather forecasting. There have been many advances in predicting weather, with three-day accuracy now over 95 per cent and more than half the seven-day forecasts correct. Few countries, however, have taken full advantage of this progress since many governments do not fund their hydro-meteorological services adequately. The report can be accessed at: http://www.gfdrr.org/gfdrr/sites/gfdrr.org/files/nhud/files/NHUD-Report_Full.pdf طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شرع نياثلا ددعلا 1295 Rapport de cas Abcès du psoas chez une femme enceinte : une observation à Bamako A. Togo,1 M. Traoré,2 B. Togo,1 G. Diallo -1 et M. Keita 2 1CHU Gabriel Touré, Bamako (Mali) (Correspondance à adresser à A. Togo : ap.togo@yahoo.fr ; pierretogo@yahoo.fr). 2Centre de santé de référence de la commune V, Bamako (Mali). Reçu : 30/03/09 ; accepté : 16/06/09 Introduction L’abcès du psoas est une suppuration profonde du muscle psoas-iliaque. Ce- tte pathologie est rare et de diagnostic clinique difficile, surtout au cours de la grossesse [1]. Nous rapportons un cas d’abcès de psoas traité au cours d’une grossesse menée à terme au centre de santé de référence de la commune V à Bamako. Observation Mme C. M., âgée de 28 ans, sans antécédent médical a été admise à la ma- ternité du centre de santé de référence de la commune V le 26 avril 2007 pour douleur du flanc droit irradiant dans la fosse iliaque droite et évoluant depuis 12 jours. L’examen physique a retrouvé une température à 38,9 °C, une tension artérielle à 120/70 mmHg et un pouls à 95 battements par minute. L’examen de l’abdomen a retrouvé une douleur provoquée dans le flanc droit et dans la fosse lombaire droite. L’utérus à 29 cm de hauteur était souple sans contraction, les bruits du cœur fœtal étaient réguliers au stéthoscope de Pinard à 136 battements par minute. Au toucher vaginal, le col long postérieur était fermé. Le reste de l’examen retrouve une tuméfaction du membre inférieur droit avec impotence fonctionnelle et un psoïtis. L’échographie abdominopelvienne a objectivé un abcès du psoas droit dont le volume a été estimé à 679,7 cc sur une grossesse de 26 semaines d ’ a m é n o r r h é e ( S A ) é v o l u t i v e . L’hémogramme a révélé une hyperleu- cocytose à 28 000 éléments/mm3 et un taux d’hémoglobine à 9 g/dL. Nous avons retenu le diagnostic d’abcès du psoas droit sur grossesse évolutive de 26 SA. La culture du pus a montré le sta- phylocoque doré sensible à l’association amoxicilline + acide clavulanique. Le traitement a consisté en un drainage chirurgical de l’abcès par voie lom- baire associé à l’administration per os d’amoxicilline + acide clavulanique à raison de 2 grammes par jour pen- dant 21 jours. Les suites opératoires ont été simples et le séjour hospitalier a été de 12 jours. Trois mois plus tard, Mme C. M. a accouché par voie basse d’un nouveau-né normal. Discussion L’abcès du psoas en général est rare. Sa fréquence varierait entre 1,5 à 3 cas/ an [2,3], sa survenue au cours de la grossesse est encore plus rare. Gezer et al. [1] rapportaient 1 cas traité. Pour nous, en 5 ans d’activité, il s’agit de notre premier cas. Le diagnostic reste difficile. Les signes retrouvés par les auteurs [2-4] ont été : fièvre, douleur du flanc irradiant au membre inférieur avec impotence fonctionnelle, psoïtis. Notre unique ob- servation non représentative a présenté ces signes. La localisation plus fréquente de l’abcès à droite a été rapportée par les auteurs [3,5], et le siège était le psoas droit dans notre cas. Le diagnostic est facilité par le scanner et l’échographie abdominale. Comme plusieurs auteurs [2-5], nous n’avons pas effectué de scanner car l’échographie a permis de poser le di- agnostic, de quantifier l’abcès et de pré- ciser l’évolutivité de la grossesse. Dans les abcès non tuberculeux, le germe le plus fréquemment retrouvé dans la lit- térature a été Staphylococcus aureus [2-4]. Ce germe a été retrouvé dans notre observation avec une sensibilité à l’association amoxicilline + acide clavu- lanique. Le traitement de l’abcès repose sur le drainage chirurgical associé a une antibiothérapie adaptée [3-5]. Pour la prise en charge de la grossesse, certains auteurs ont effectué une césarienne associée au drainage de l’abcès en un temps [1]. Compte tenu de l’âge de la grossesse de notre patiente et des moy- ens de réanimation de néonatologie limités dans notre pays, nous n’avons pas adopté cette attitude. Une surveil- lance prénatale nous a permis de mener la grossesse à terme. Conclusion L’abcès du psoas associé à la grossesse est une entité rare. L’échographie ab- dominopelvienne est importante pour le diagnostic de l’abcès et l’évolutivité de la grossesse. Cette observation nous permet d’espérer qu’un drainage chirur- gical de l’abcès avec une antibiothérapie adaptée suivi d’une surveillance préna- tale amélioreraient le pronostic mater- nel et fœtal. EMHJ • Vol. 16 No.12 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1296 Références Gezer A et al. Primary psoas muscle abscess diagnosed and 1. treated during pregnancy: case report and literature review. Infectious Diseases in Obstetrics and Gynecology, 2004, 12(3–4): 147–149. Echarrab M 2. et al. Les abcès du psoas à pyogènes. À propos de 21 cas. Médecine du Maghreb, 2000, 79: 1–4. Diakité I. 3. Abcès du psoas au CHU Gabriel Touré, Bamako (Mali) : à propos de 11 cas [Mémoire]. Bamako, Université de Bamako, 2006 (M 34). Dahami Z 4. et al. Traitement de l’abcès primitif à pyogène du muscle psoas : étude rétrospective à propos de 18 cas. Annales d’Urologie, 2001, 35(6):329–334. Mounkoro M. 5. Étude de l’abcès du psoas dans le service de chirurgie A du CHU du Point G [Thèse]. Bamako, Université de Bamako, 2007. Statistiques sanitaires mondiales 2010 Les Statistiques sanitaires mondiales 2010 présentent les statistiques sanitaires les plus récentes disponibles des 193 États Membres de l’OMS et un résumé des progrès accomplis vers les objectifs et les cibles du Millénaire pour le développement (OMD) liés à la santé. Cette édition comprend également une nouvelle partie consacrée aux cas notifiés de maladies infectieuses sélectionnées. 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ISSN 1020-3397 Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تاسايسلا لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما طسوتلما قشرل ةيحصلا ةلجلما Cover 6.indd 2 5/24/2010 11:46:47 AM
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Eastern Mediterranean Health Journal [2010; Vol.16, Issue 12]
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