Eastern Mediterranean Health Journal [2010; Vol.16, Issue 1]

Contents Healthy newborn baby, Syrian Arab Republic: global progress in achieving Millenium Development Goal 4 (two-thirds reduction by 2015 of the 1990 mortality rates among children under 5 years) is contingent upon improvements in neonatal health. Eastern Mediterranean Health Journal La Revue de Santé de le Méditerranée orientale Letter from the Editor ...............................................................................................................................................................................................................................................3 Research articles Case–control study to evaluate risk factors for acute hepatitis B virus infection in Egypt ................................................................................4 Hepatitis B and C viral infection: prevalence, knowledge, attitude and practice among barbers and clients in Gharbia governorate, Egypt .............................................................................................................................................................................................................................................10 HIV/AIDS knowledge, attitudes and beliefs among a group of Iraqis ........................................................................................................................18 Seroprevalence of Toxoplasma gondii in unmarried women in Qazvin, Islamic Republic of Iran .............................................................24 Comparison of pregnancy and implantation rates in zygote intrafallopian transfer and uterine embryo transfer for nontubal infertility .....................................................................................................................................................................................................................................29 Perinatal outcomes of singleton term breech deliveries in Basra ......................................................................................................................................34 Nosocomial infections in a neonatal intensive care unit in south-western Saudi Arabia ................................................................................40 Antibiotic resistance trends in paediatric community-acquired first urinary tract infections in the United Arab Emirates ...45 National survey of the oral health of 5-year-old children in the United Arab Emirates ....................................................................................51 Pattern and prevalence of smoking among students at King Faisal University, Al Hassa, Saudi Arabia ...............................................56 Diabetes mortality and causes of death in Benghazi: a 5-year retrospective analysis of death certificates ..........................................65 Ketosis-onset diabetes in Tunisian adults: immunological markers and β-cell function ................................................................................70 Corrected QT dispersion improves diagnostic performance of exercise testing in diagnosing coronary artery disease .........75 Biological activity resulting from exposure to aquatic environmental genotoxic pollutants in northern Egypt.............................82 Evaluation of intralesional 0.2% ciprofloxacin as a treatment for cutaneous leishmaniasis ...........................................................................89 Musculoskeletal disorders among bank office workers in Kuwait ..................................................................................................................................94 An analysis of carbon monoxide poisoning cases in Bursa, Turkey ............................................................................................................................101 Les nouveaux critères et la qualité des services de soins de santé dans le gouvernorat de Monastir (Tunisie) ............................107 Review Gender inequity in Saudi Arabia and its role in public health .........................................................................................................................................113 Report Supporting the Saudi e-health initiative: the Master of Health Informatics programme at KSAU-HS .............................................119 Eastern Mediterranean Health Journal reviewers’ panel, 2009 .................................................................................................................................125 Guidelines for authors .......................................................................................................................................................................................................................................127 Volume 16 / Number 1 January / Janvier 2010 1 ددع / شرع سداسلا دلجلما رياني / لولأا نوناك Volum e 16 N um ber 1 January / Janvier 2010 طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ةيبيللا ةيبرعلا ةييرهمالجا . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . ةينميلا ةيروهملجا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما Subscriptions and Distribution Enquiries regarding subscriptions and distribution of the print edition of EMHJ should be addressed to: Printing and Marketing of Publications at: email: pam@emro.who.int; tel: (+202) 2276 5000; fax: (+202) 2670 2492 or 2670 2494 Permissions Requests for permission to reproduce or translate articles, whether for sale or non-commercial distribution should be addressed to EMHJ at: emhj@emro.who.int Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libyan Arab Jamahiriya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Republic of Yemen Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Jamahiriya arabe libyenne . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar République arabe syrienne . Somalie . Soudan . Tunisie . République du Yémen Correspondence Editor-in-chief EMHJ WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: sabrib@emro.who.int/emhj@emro.who.int EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con- cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col- laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser-vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collabora- teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line) and the ExtraMed-Full text on CD-ROM, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), CAB International, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). ©World Health Organization 2010 All rights reserved Disclaimer The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. ISSN 1020-3397 Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تاسايسلا لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما طسوتلما قشرل ةيحصلا ةلجلما Cover 6.indd 2 5/24/2010 11:46:47 AM Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 16 No. 1 1 ددع شرع سداسلا دلجلما Letter from the Editor ..........................................................................................................................................................................................................................................................................3 Research articles Case–control study to evaluate risk factors for acute hepatitis B virus infection in Egypt M. Talaat, E. Radwan, N. El-Sayed, T. Ismael, R . Hajjeh and F.J. Mahoney .........................................................................................................................................................................4 Hepatitis B and C viral infection: prevalence, knowledge, attitude and practice among barbers and clients in Gharbia governorate, Egypt S. Shalaby, I.A. Kabbash, G. El Saleet, N. Mansour, A. Omar and A. El Nawawy .......................................................................................................................................................... 10 HIV/AIDS knowledge, attitudes and beliefs among a group of Iraqis A.H. Hayyawi, A.Y. Al-Marayaty, W.S. Salman and W. Hamed ........................................................................................................................................................................................... 18 Seroprevalence of Toxoplasma gondii in unmarried women in Qazvin, Islamic Republic of Iran H. Jahani Hashemi and M. Saraei ................................................................................................................................................................................................................................................. 24 Comparison of pregnancy and implantation rates in zygote intrafallopian transfer and uterine embryo transfer for nontubal infertility M. Agha-Hosseini, A. Aleyaseen, S. Peyvandi and L. Kashani ................................................................................................................................................................................................ 29 Perinatal outcomes of singleton term breech deliveries in Basra H. Alshaheen and A. Abd Al-Karim.............................................................................................................................................................................................................................................. 34 Nosocomial infections in a neonatal intensive care unit in south-western Saudi Arabia A.A. Mahfouz, T.A. Al-Azraqi F.I. Abbag , M.N. Al-Gamal, S.Seef and C.S. Bello .......................................................................................................................................................... 40 Antibiotic resistance trends in paediatric community-acquired first urinary tract infections in the United Arab Emirates H. Narchi and M.A.M. Al-Hamdani ........................................................................................................................................................................................................................................... 45 National survey of the oral health of 5-year-old children in the United Arab Emirates M.A.I. El-Nadeef, H. Hassab and E. Al-Hosani ......................................................................................................................................................................................................................... 51 Pattern and prevalence of smoking among students at King Faisal University, Al Hassa, Saudi Arabia H.I. Al-Mohamed and T.T. Amin ................................................................................................................................................................................................................................................... 56 Diabetes mortality and causes of death in Benghazi: a 5-year retrospective analysis of death certificates R.B. Roaeid and A.A. Kablan ........................................................................................................................................................................................................................................................ 65 Ketosis-onset diabetes in Tunisian adults: immunological markers and β-cell function F. Harzallah, A. Ben Brahim, L. Laadhar, M.Feki, M. Zitouni, S. Makni, N. Kaabachi and H. Slimane ................................................................................................................... 70 Corrected QT dispersion improves diagnostic performance of exercise testing in diagnosing coronary artery disease H. Hasan-Alia, M.H. Maghraby, D.A. Fouad and A.A. Abd-Elsayed ................................................................................................................................................................................. 75 Biological activity resulting from exposure to aquatic environmental genotoxic pollutants in northern Egypt A.A. Saad, A.M. El-Sikaily, S.F. Kholeif, E.S. Khalil, H.S. Mahrous, E.M.S. Al-Zabedi and H.A. Kassem ............................................................................................................... 82 Evaluation of intralesional 0.2% ciprofloxacin as a treatment for cutaneous leishmaniasis K.I. Al Hamdi, A.H. Awad and H.M. Moker ............................................................................................................................................................................................................................ 89 Musculoskeletal disorders among bank office workers in Kuwait Q.A.S. Akrouf, J.O. Crawford, A.S. Al-Shatti and M.I. Kamel ................................................................................................................................................................................................ 94 An analysis of carbon monoxide poisoning cases in Bursa, Turkey Ş. Akköse, N. Türkmen, M. Bulut, S. Akgöz, R . İşcimen and B. Eren ................................................................................................................................................................................. 101 Les nouveaux critères et la qualité des services de soins de santé dans le gouvernorat de Monastir (Tunisie) S. El Mhamdi, M.S. Soltani, A. Haddad, M. Letaief et K. Ben Salem ............................................................................................................................................................................... 107 Review Gender inequity in Saudi Arabia and its role in public health A.E.H. Mobaraki and B. Söderfeldt............................................................................................................................................................................................................................................ 113 Report Supporting the Saudi e-health initiative: the Master of Health Informatics programme at KSAU-HS M.M. Altuwaijri .............................................................................................................................................................................................................................................................................. 119 Eastern Mediterranean Health Journal reviewers’ panel, 2009 ................................................................................................................................................................. 125 Guidelines for authors ................................................................................................................................................................................................................................................................... 127 •  2010  • Belgacem Sabri MD MPA, MA (Econ), Editor-in-chief Muhammad Afzal MSc, MPhil, PhD, Executive Editor Editorial Board Mohammad Abdur Rab MBBS, DTM&H, MPH&TM, PhD Mohamed M. Ali BSc, MSc, PhD, DTMH Abdulla S. Assaedi MBBS, MPH Mounir Farag MD, DGS, DEmS, DPH Abdul Ghaffar MD, MPH, MHA, PhD Malekafzali Hossein MK, MPH, PhD Jaouad Mahjour MD, MPH Mamunur Rahman Malik MBBS, Dip (Health Economics), MSc, MPhil Kassem Sara MD International Advisory Panel Dr S. Aboulazm. Professor of Orthodontics. Egypt Dr Abdul Rahman Al-Awadi BSc, MD, MPH, Honorary FRCM, Ireland Dr Law, Korea, Honorary FRCS & P, Glasgow, FRCP, Edinbugh. Kuwait Dr Fariba Al-Darazi RN, MSc, PhD. Bahrain Dr M. Al-Nozha, MD, FRCP, FACC, FESC. Professor of Medicine and Consultant Cardiologist. Saudi Arabia Dr Ala’din Alwan MD, FRCP, FFPHM. Iraq Dr F. Azizi. Professor of Internal Medicine and Endocrinology. Islamic Republic of Iran Dr K. Bagchi BSc, MD, PhD. India Professor K. Dawson BA, MD, PhD, FRCP, FRACP, FRCPCH, DObst, RCOG. New Zealand Professor Kaussay Dellagi MD. Tunisia Dr R. Dybkaer MD. Denmark Dr M. Aziz El-Matri. Professor of Medicine. Tunisia Professor F. El-Sabban BSc, MS, PhD. United States of America Dr A.H. El-Shaarawi MSc (Stat), PhD (Stat). Canada Professor N. Fikri-Benbrahim PhD (Pub health) (SocSci). Morocco Professor A.T. Florence BSc (Pharm), PhD, DSc, FRSC, FRPharmS, FRSE. United Kingdom Professor Cheherezade M.K. Ghazi BS (Nursing), MS (Nursing), DPH, MPA. Egypt Professor M.A. Ghoneim MD, MD (Hons). Egypt Dr J.A. Hashmi DTM&H, FRCP. Pakistan Professor J. Jervell MD, PhD. Norway Professor G.J. Johnson MA, MD, BChir, FRCS (C), FRCOphth, DCEH. United Kingdom Dr M. Kassas. Emeritus Professor of Plant Ecology. Egypt Professor M.M. Legnain MBBS, MRCOG, FRCOG. Libyan Arab Jamahiriya Professor El-Sheikh Mahgoub DipBact, PhD, MD, FRCPath. Sudan Professor A.M.A. Mandil MSc (Paediatr), MPH, DrPH. Egypt Professor A.B. Miller MB, FRCP. Canada Professor S.S. Najjar MD. Lebanon Dr Abubaker A. Qirbi BSc, MD (Edin), FRCPC (Can), FRCP FRCPath (UK). Republic of Yemen Professor O.S.E. Rasslan MD, PhD. Egypt Professor W.A. Reinké MBA, PhD. United States of America Professor I.A. Sallam, MD, Dip High Surgery Cairo, Honorary FRCS, PhD (Glasgow), LRCP, MRCS, FRCS (London), ECFMG. Egypt Dr C.Th.S. Sibinga FRCP (Edin), FRCPath. The Netherlands Mr Taoufik Zeribi Eng BSc, MSc. Tunisia Editors Fiona Curlet, Eva Abdin, Alison Bichard, Guy Penet Graphics Suhaib Al Asbahi, Hany Mahrous, Diana Tawadros Administration Nadia Abu-Saleh, Nagwan Behairy, Yasmine El Sakhawy طسوتلما قشرل ةيحصلا ةلجلما شرع سداسلا دلجلما لولأا ددعلا 3 ررحلما نم ةلاسر As revealed earlier, with this issue of the Eastern Mediterranean Health Journal (EMHJ), we are very pleased to announce the launch of the Journal with a new and fresh look. The newly-formed Editorial Board of EMHJ decided in its first meeting in September 2009 that from January 2010 the Journal will be published monthly in a new design and size. The new format of EMHJ was selected by the Board from a number of designs received in response to an announcement for open competition for the design of the Journal as approved by the Regional Director. Publication of EMHJ was initiated by the WHO Regional Office for the Eastern Mediterranean in 1995 to provide a forum for the publication of research papers on a diverse range of medical topics, to present and promote new policies and initiatives in health services, and to exchange ideas, concepts, epidemiological data, research findings, and other information with special reference to the WHO Eastern Mediterranean Region. Additionally, the Journal seeks to enable health professionals in all fields to remain informed of developments in the many areas of medicine and public health. The target audience of EMHJ includes health professionals, medical and other health educational institutes, governmental and nongovernmental organizations in the area of public health, and interested individuals within and outside the Region. Papers published by the Journal should pertain to public health-related biomedical or technical subjects within the field of work of WHO, with particular relevance to the Eastern Mediterranean Region. Since its inception, EMHJ has gone from 2 issues per year to 6, and from very few submissions to over 500 hundred per year in recent years. The Journal has been published in single issues, combined issues and special issues. In the past several years, 170–180 papers have been published per year in 6 bi-monthly issues. However, since its first issue, the Journal had not changed at all in format and only minimally in content in order to accommodate more papers. In its new form, EMHJ will continue its distinct role in bringing a multitude of health research fields together, with a common focus on research for health. Owing to a high submission rate and in order to assure good quality, EMHJ has made its peer-review process more stringent, with rigorous initial screening of the articles and expert review by at least by two qualified referees. Therefore, future acceptance of articles submitted to EMHJ will depend strictly on the vision, quality of research, creativity and collaborative nature of the research topics. EMHJ welcomes innovative, interdisciplinary research for health that is reliable as well as useful. Furthermore, the Journal envisages new sections for advocacy and policy papers, as strongly recommended by the Editorial Board. Letter from the Editor ريرتح سلمج ر َّرق دقف .ديدلجا اهلكشب ةلجلما قلاطإ نع نلعن نأ ،ًافلس انحضوأو قبس ماك ،طسوتلما قشرل ةيحصلا ةلجملل ةرادصلإا هذه عم اندعسي ًايرهش ةلجلما شرنُتس ،2009 رياني/نياثلا نوناك نم ًارابتعا هنأ ،2009 برمتبس /لوليأ في دقُع يذلاو لولأا هعماتجا في ًارخؤم ل َّكشُمـلاو ديدلجا ةلجلما لىع يميلقلإا ريدلما ةقفاوم لىع ًءانب ةاقلتلما تمايمصتلا نم ددع ينب نم ةلجملل ديدلجا لكشلا اذه لىع سلجلما رايتخا عقو دقو .ديدج مجحو ديدج لكشب ماع في طسوتلما قشرل ةيحصلا ةلجلما شرن في ةيلماعلا ةحصلا ةمظنلم طسوتلما قشرل يميلقلإا بتكلما أدب دقو.ةلجلما ميمصتل ةحوتفم ةسفانم نع نلاعلإا تامدلخا لامج في ةديدلجا تاردابلماو تاسايسلا زيزعتو ضرع ةيغب ةيبطلا تاعوضولما نم عونتم فيط لوح ةيثحبلا قارولأا شرنل ىدتنم يرفوتل ،1995 ةمظنلم طسوتلما قشر ميلقإب صاخ لكشب ةقلعتلما ىرخلأا تامولعلما نم اهيرغو ،ةيثحبلا جئاتنلاو ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،ةيحصلا تلاامج لىع أرطت يتلا تاروطتلاب ةرمتسلما ةطاحلإا نم تلااجلما لك في ينـِّيحصلا ينـِّينهلما ينكتم لىإ ةلجلما ىعست كلذ لىإ ةفاضلإاب .ةيلماعلا ةحصلا ،يحصلا ميلعتلا دهاعم رئاسو ،ةيبطلا تاسسؤلماو ،ينـِّيحصلا ينـِّينهلما ةيحصلا ةلجملل فدهتسلما روهملجا لمشيو .ةد ِّدعتلما ةيمومعلا ةحصلاو بطلا ةروشنلما قارولأا طبترت نأ َّينعتيو .هجراخو ميلقلإا لخاد اياضقلا هذبه ينمتهلما دارفلأا رئاسو ،ةيمومعلا ةحصلا لامج في ةيموكحلالاو ةيموكلحا تماظنلماو قشر ميلقلإ صاخ مماتها ءلايإ عم ةمظنلما لمع لاجمب ةصالخا ةينقتلا تاعوضولما وأ ةيمومعلا ةحصلاب ةطبترلما ةيجولويبلا ةيبطلا تاعوضولماب ةلجلما في 500 لىع وبري ام لىإ ةليلق تاعوضوم ميدقت نمو ،دادعأ 6 لىإ ماعلا في نيددع نم اهقلاطإ ذنم طسوتلما قشرل ةيحصلا ةلجلما دادعأ تداز دقو.طسوتلما متي ناك ،ةمصرنلما ةيرخلأا تاونسلا فيو .ةصاخ دادعأو ،ةعممج دادعأو ،ةيدرف دادعأ لكش في ةلجلما ردصتو .ةيرخلأا تاونسلا في ماعلا في عوضوم فلأ تايريغت دهش يذلا نومضلما كلذكو لكشلا ثيح نم يريغت يأ اهيلع أرطي لم انهأ ديب ،نيرهش لك دادعأ ةتس ىدم لىع ماع لك ةقرو 180و 170 ينب ام شرن نم ددع لىإ ق ُّرطتلا في زِّيمتلما اهرودب علاطضلاا ديدلجا اهلكش في ةيحصلا ةلجلما لصاوتسو.ةيثحبلا قارولأا نم ديزلما بعوتستل اهرودص ءدب ذنم ةفيفط ةدولجا ديكوت في ًةبغرو ،ةم َّدقلما تلااقلما نم يربكلا لدعملل ًارظنو .ةيحصلا ثوحبلا لىع صاخ لكشب زيكترلا عم ًايوس اهطبرو ةيحصلا ثوحبلا تلاامج متت ماك ،تلااقملل ةقدلا غلاب يئدبم رتح ءارجإ متي ثيح ،ةماصر رثكأ ايهدل نارقلأا ةعجارم ةيلمع لعج لىع طسوتلما قشرل ةيحصلا ةلجلما تصرح ،ةيلاعلا لىع ةدشب لبقتسلما في دمتعيس طسوتلما قشرل ةيحصلا ةلجملل ةم َّدقلما تلااقلما لوبق نإف َّم َـ ث نمو .لقلأا لىع ينلهؤم يننثا ينمكمح لَبِق نم ءابرلخا ةعجارم تلاجلما نم يأ نأش انهأش ةضيرع ًلاامآ طسوتلما قشرل ةيحصلا ةلجلما دقعتو.ةيثحبلا تاعوضوملل ةينواعتلاو ةيراكتبلاا ةعيبطلاو ،ثحبلا ةدوجو ،ةيؤرلا لىإ ةفاضلإاب .اهيلع ليوعتلا نكمي يتلاو ةحصلا لجأ نم تاصصختلا ةددعتلما ةديفلما ةركتبلما ثوحبلاب ب ِّحرت يهف ،ص ُّصختلا ةددحلماو ًاديج ةفورعلما .رملأا اذه لىع ةدشب دكأ يذلاو ريرحتلا سلمج تايصوتل ًاقفو تاسايسلاب ةقلعتلما قارولأاو ،ةيعوتلل ةديدج ماسقأ ةفاضلإ ًاروصت عضت ةلجلما نإف كلذ EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 4 Case–control study to evaluate risk factors for acute hepatitis B virus infection in Egypt M. Talaat,1 E. Radwan,2 N. El-Sayed,2 T. Ismael,1 R. Hajjeh3 and F.J. Mahoney3 ABSTRACT Hepatitis B virus (HBV) infection is a significant health problem in Egypt. To better define risk factors associated with HBV transmission, we conducted a case–control study among patients admitted with acute hepatitis to an infectious disease hospital in Cairo. A total of 60 cases and 120 controls were interviewed about various exposures within 6 months prior to admission. Univariate analysis revealed HBV case-patients were more likely to report providing injections to relatives or friends, injecting drug use, exposure to a household contact with hepatitis, exposure to invasive medical procedures and being in the military. Efforts should be made to implement strict infection control standards in Egypt. 1US Naval Medical Research Unit, No.3, Cairo, Egypt (Correspondence to M. Talaat: Maha.talaat.ctr.eg@med.navy.mil). 2Ministry of Health and Population, Cairo, Egypt. 3Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America. Received: 19/07/07; accepted: 26/09/07 صرم في دالحا يئابلا يدبكلا باهتللاا ىودع راطتخا لماوع مييقتل دهاوشلاو تلااحلل ةسارد نيوهام سماج كنارف ،يجاح انر ،ليعماسإ تورث ،ديسلا صرن ،ناوضر نمايإ ،تعلط اهم ىودعلا لاقتناب ةطبترلما راطتخلاا لماوعل ةقد رثكأ ديدحتلو .صرم في ىبرك ةيمومع ةيحص ةلكشم يئابلا يدبكلا باهتللاا ىودع لكشت :ةصلالخا في اولخدأ نيذلا دالحا يدبكلا باهتللااب ينباصلما ضىرلما ينب دهاوشلاو تلااحلل ةسارد نوثحابلا ىرجأ ،يئابلا يدبكلا باهتللاا سويرفب للاخ مله ترج يتلا تاض ُّرعتلا فلتمخ نع ملهاؤسل ًادهاش 120 و ةلاح 60 ـل تلاباقم تيرجأو .ةرهاقلا في ةيدعلما ضارملأا تايفشتسم ىدحإ ىودعلا لاقتنا نع ةيضرلما يئابلا يدبكلا باهتللاا تلااح غلبت نأ احيجرت رثكلأا نأ يداحلأا يرغتلما ليلتح رهظأو .ىفشتسلما ملهاخدإ لبق روهش 6 ،ةعضاب ةيبط تاءارجلإ ض ُّرعتلاو ،يدبكلا باهتللااب ينباصملل ةيلزـنلما ةطلاخلماو ،ًانقح تاردخلما يطاعتو ،ءاقدصلأا وأ براقلأا قيرط نع اهيلإ .صرم في ةماصرب ىودعلا ةحفاكم يرياعم قيبطتل دوهلجا لذب ينعتيو .ةحلسلما تاوقلا في ةمدلخاو Étude cas-témoin visant à évaluer les facteurs de risque d’infection aiguë par le virus de l’hépatite B en Égypte RÉSUMÉ L’infection par le virus de l’hépatite B (VHB) est un important problème sanitaire en Égypte. Afin de mieux définir les facteurs de risque associés à la transmission du virus de l’hépatite B, nous avons réalisé une étude cas- témoin parmi des patients admis pour une hépatite aiguë dans un hôpital pour maladies infectieuses du Caire. Au total, 60 patients atteints par la maladie et 120 témoins ont été interrogés sur les différents types d’exposition au cours des six mois précédant l’hospitalisation. L’analyse univariée a révélé que les sujets contaminés par le VHB avaient davantage tendance à déclarer avoir administré des injections à des parents ou à des amis, être consommateurs de drogues injectables, avoir été exposés à un contact avec une personne atteinte d’hépatite au domicile ou à des procédures médicales invasives et à servir dans l’armée. Des efforts devraient être faits pour mettre en œuvre des normes strictes de lutte contre les infections en Égypte. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 5 Introduction Hepatitis B virus (HBV)  infection  is a  serious  global  public health problem  with  an  estimated  2  billion  people  infected worldwide  and  350 million  persons with  chronic HBV  infection.  The World Health Organization esti- mates that 500 000 to 1.2 million deaths  occur  each  year  due  to HBV-related  chronic  liver disease, and  that cirrhosis  of  the  liver and primary hepatocellular  carcinoma associated with HBV  infec- tion  is  the 10th  leading cause of death  worldwide [1,2].  The epidemiology of HBV transmis- sion is complex. Transmission occurs in  all age groups associated with percuta- neous and permucosal exposure  to  in- fectious body fluids  from persons with  acute or  chronic HBV  infection. The  highest  concentrations of HBV occur  in blood and serous fluids, and infection  most  frequently occurs  through direct  inoculation of the virus through unsafe  injections  or  reuse  of  contaminated  medical  equipment. Other  common  modes of  transmission  include  sexual  contact with infected persons and births  from HBV-infected mothers [3,4].  The epidemiology of HBV infection  in Egypt has not been well  character- ized. Cross-sectional  studies  indicate  that HBV  is of  intermediate endemic- ity, with 3%  to 5% of  the population  having  chronic HBV  infection  [4,5].  Hospital-based data indicate that HBV  is a common cause of disease, account- ing  for  approximately 30% of patients  with acute viral hepatitis [6]. Most stud- ies characterizing  risk  factors  for HBV  infection  in Egypt  are  cross-sectional  studies among patients with prevalent  disease. These studies have  implicated  a variety of  exposures  associated with  infection,  including unsafe  injections,  unsafe medical  care,  community-ac- quired practices and others. For patients  with acute HBV disease,  there  are no  published studies to identify risk factors  to help define  intervention  strategies.  During 2002–03, we conducted a case– control study to determine current pre- ventable  risk  factors  associated with  transmission of acute HBV infection in  Egypt, and to explore the epidemiologi- cal characteristics of patients with acute  disease.  Methods Selection of cases and controls Case-patients  and  controls  were  recruited  from  Abbassia  Infectious  Disease Hospital,  the  largest  infectious  disease hospital  in Cairo, Egypt. Cases  enrolled  in  the study  included patients  evaluated  in  a  sentinel  surveillance  system  for  acute viral hepatitis. Cases  of  acute hepatitis were defined as pa- tients > 12 months of age, with discrete  onset of  jaundice  (or  elevated  serum  aminotransferase  levels,  if performed),  and no underlying medical conditions  associated with acute or  chronic  liver  disease. Cases of acute HBV  infection  were defined as cases of acute hepatitis  with detection of  IgM-class  antibody  to hepatitis B core antigen (anti-HBc)  following  serological  testing. Controls  were  identified  from  the hospital  log  books of patients admitted to the same  hospital with any diagnosis other  than  hepatitis  and with no  jaundice on  the  same day of confirmation of diagnosis  of  the HBV case patients. Cases were  recruited consecutively and no patients  refused to participate in the study. Two  controls were selected for each case and  were matched by age (to within 5 years)  and sex.  The  Institutional Review Board of  the US Naval Medical Research Unit  No. 3 (NAMRU-3) approved the study  procedures. The attending physicians  explained the study procedures and ob- tained  informed consent/assent  from  all study subjects or their guardians. Data collection Sample  size  calculations used  to  esti- mate  the appropriate  size of  the  study  population suggested 60 cases and 120  controls  to achieve a confidence  level  of 95% and a power of 80%. The risk of  exposure to injections among cases was  calculated as 28%, whereas  the  risk of  exposure  to  injections among controls  was estimated as 10%.  Cases  and  controls  were  inter- viewed by  trained social workers using  a  standard questionnaire.  Information  was  collected  on demographic  char- acteristics,  history of  vaccination  and  risk  factors  for  exposure  to HBV  that  occurred within 6 months prior  to  the  onset  of  disease,  including  invasive  health care procedures, blood  transfu- sions, frequency and types of injections,  injecting drug use, contact with infected  persons and sexual practices. In addition,  community-acquired  risk  factors were  explored,  such as sharing  toothbrushes  or  razors and household contact with  hepatitis patients. Information on other  community exposures, such as circum- cision,  tattooing and acupuncture, was  also collected. Laboratory tests Acute HBV  infection was  identified  by  the presence of hepatitis B  surface  antigen  (HBsAg)  in  serum  and  the  development of  anti-HBc [7]. HBsAg  antibodies  to  hepatitis  B  surface  an- tigen  (anti-HBs)  and  anti-HBc  (im- munoglobulin  IgM) were detected by  enzyme-linked  immunoassay (ELISA)  (Abbott Murex Biotech, UK).  Data analysis Risk  factors were grouped  into 4 cate- gories based on exposure patterns. The  first group  included exposures associ- ated with health  care,  such as  visiting  an outpatient clinic,  receiving a blood  transfusion, receiving an injection, visit- ing a dentist and exposure to any  inva- sive procedure during the last 6 months,  including surgery, dialysis,  insertion of  EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 6 intravenous (IV) cannula, wound and  abscess  treatment  and  stitches. The  second  group of  exposures  included  personal practices that might be associ- ated with  infection,  such as providing  injections, being shaved at a community  barber, having household contacts with  hepatitis  and using  recreational drugs.  The third group of risk factors included  high-risk  sexual  practices,  defined  as  having multiple  sexual partners or en- gaging in homosexual activity. The final  group of  risk  factors  included military  service or being imprisoned during the  previous 6 months.  The  data  were  entered  into  an  inhouse computerized database. Uni- variate and multivariate analyses were  conducted and  logistic  regression was  performed to  identify  risk  factors  inde- pendently  associated with  the  risk of  acquiring disease. The model  included  variables significant on univariate analy- sis. For  variables  that might  influence  the occurrence of acute HBV, we calcu- lated odds ratios (OR) and the P-value.  P  <  0.05 was  considered  statistically  significant. Results Among  2416  patients  with  acute  hepatitis evaluated during  the  sentinel  surveillance at  the Abbassia  Infectious  Disease Hospital  from 2002  to 2004,  515 (21.3%) were diagnosed with acute  HBV infection based on the case defini- tion above. The mean age of patients  with acute disease was 32 years with a  range of 2–85 years;  62% of patients  were males. Among  the 515 patients  with  acute HBV  infection,  497 were  born after  integration of HBV vaccine  into  the Expanded Programme on Im- munization (EPI) in Egypt. From these  515 patients,  60 were  recruited  from  the 2002–03 time period to participate  in  the  case–control  study  and  were  matched with 120 controls. Demographic characteristics Case-patients with  acute HBV  infec- tion were matched with controls with  respect  to  age  (median  25  years  for  cases versus 27 years  for controls) and  sex. They were also similar with  regard  to job category, marital status,  illiteracy  and history of hepatitis B vaccination  (Table 1). Risk factors Health care-related risk factors Of  the various health care-related  risk  factors  explored,  the only one  found  to be associated with  increased  risk of  disease was exposure to  invasive medi- cal  procedures  (insertion  of  IV  line,  surgery, wound or  abscess  treatment  and suturing) [odds ratio (OR) = 2.2]  (Table 2). Health care exposures not  associated with  acute HBV  infection  included  receiving blood  transfusions,  visiting  a  dentist,  being  hospitalized,  receiving injections and visiting a physi- cian clinic.  Personal behaviour and household exposures Personal  behaviour  and  household  exposures significantly associated with  infection  included  injecting drug use  (OR = 9.2),  exposure  to a household  contact with hepatitis (OR = 3.9) and  providing  injections  to  relatives  or  friends (OR = 5.4) (Table 2). A number  of  personal  behaviours were  not  as- sociated with  infection,  such as being  shaved by  a  public  barber,  receiving  tattoos, having pierced ears and sharing  toothbrushes. Cases were more  likely  to report high-risk sexual activity (OR =  2.5), incarceration (OR = 3.9) and mili- tary service (OR = 3.5) in the 6 months  prior  to  admission when  compared  with  the control group, although only  the association with military service was  statistically significant. Table 1 Demographic characteristics of case-patients with acute hepatitis B virus (HBV) infection and controls attending Abbassia Infectious Disease Hospital, Egypt Demographic characteristic HBV cases (n = 60) Controls (n = 120) No. % No. % Median age (years) 25.5 27.5 Sex Male 49 81.7 98 81.7 Female 11 18.3 22 18.3 Marital status Married 27 45.0 70 58.3 Single 33 55.0 50 41.7 Education Illiterate 24 40.0 35 29.9 Basic education 36 60.0 82 70.1 Occupation Housewife or not working 10 16.9 23 19.2 Handicraft 15 25.4 20 16.7 Government employee 3 5.1 21 17.5 Manual labourer 27 45.7 54 45.0 Health professional 4 6.8 2 1.7 History of HBV vaccination Vaccinated 2 3.3 3 2.5 Not vaccinated 58 96.7 117 97.5 Data were not recorded in some categories. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 7 Multivariate analysis The multivariate model  included vari- ables  significant on univariate analysis:  military  service,  providing  medical  injections,  injecting drug use, exposure  to invasive procedures and contact with  a  household member with  hepatitis.  Three  factors  remained  independently  associated with  increased  risk of HBV  infection: military  service (OR = 19.2;  95% CI: 2.7–135.6), providing  injec- tions (OR = 8.7; 95% CI: 1.1–72.1) and  exposure to invasive medical procedures  (OR = 5.6; 95% CI: 1.1–27.2).  of public health  importance  is  a  chal- lenging but  important  step  in  the de- velopment  of  prevention  strategies.  Epidemiological  studies  suggest  that  the prevalence of HIV  infection  is  low  in Egypt and there are few studies char- acterizing behaviours  associated with  transmission. HCV  infection  on  the  other hand  is highly endemic  in Egypt  where 10%–15% of the population has  evidence  of  chronic HCV  infection  [8]. Chronic  liver  disease  associated  with HCV infection is one of the major  causes of  death  in Egypt. Numerous  studies have  identified diverse  risk  fac- tors  associated with HCV  transmis- sion [9,10]; however, none of these has  evaluated patients with acute disease. It  is challenging  to  identify patients with  acute HCV  infection due  to  the  lack  of a diagnostic marker (IgM antibody)  that can differentiate patients with acute  versus chronic infection. Similar to HIV  and HCV,  there are  few studies evalu- ating  the  risks  associated with HBV  transmission in Egypt.  Table 2 Univariate analysis for risk factors of acute hepatitis B virus (HBV) infection, Abbassia Infectious Disease Hospital, Egypt Risk factor HBV cases Controls OR (95% CI) P-value No. % No. % Health care-related Receiving blood transfusion 5/58 8.6 4/118 3.4 2.7 (0.6–12.5) 0.1 Exposure to invasive medical procedurea 16/60 26.7 17/120 14.2 2.2 (0.9–5.1) 0.04 Visiting a dentist 12/59 20.3 27/120 22.5 2.7 (1.1–6.9) 0.3 Receiving injections 40/60 66.7 81/120 67.5 0.9 (0.5–2.0) 0.9 Hospitalization 6/60 10.0 16/120 13.3 0.7 (0.2–2.1) 0.7 Visiting a doctor 22/59 37.3 53/119 44.5 0.7 (0.3–1.5) 0.4 Personal behaviour Injecting drug use 8/59 13.6 2/119 1.7 9.2 (1.7–65.0) 0.003 Contact with hepatitis case in household 13/59 22.0 8/120 6.7 3.9 (1.4–11.3) 0.005 Providing injections 8/42 19.0 4/95 4.2 5.4 (1.3–22.9) 0.007 Shaving at barber (for males) 36/47 76.6 61/97 62.9 1.9 (0.8–6.4) 0.1 Unsafe sexual practices Multiple partners/homosexuality 11/60 18.3 10/120 8.3 2.5 (0.9–6.8) 0.08 Other exposure Being imprisoned 5/44 11.4 3/93 3.2 3.9 (0.8–21.6) 0.07 Military service (for males) 9/48 18.8 6/97 6.2 3.5 (1.1–12.0) 0.04 aIncludes surgery, insertion of intravenous cannula, wound or abscess treatment and stitches; injections were excluded. OR = odds ratio; CI = confidence interval. Table 3 Multivariate analysis for risk factors of acute hepatitis B virus (HBV) infection, Abbassia Infectious Disease Hospital, Egypt Risk factor OR (95%CI) Military service 19.2 (2.7–135.6) Providing injections 8.7 (1.1–72.1) Exposure to invasive medical procedure 5.6 (1.1–27.2) Injecting drug use 6.9 (0.5–83.4) Contact with household hepatitis case 3.8 (0.9–14.6) Unsafe sexual practices 1.2 (0.2–6.1) OR = odds ratio; CI = confidence interval. Discussion Prevention  of  bloodborne  pathogen  transmission  is  a high priority  for  the  Ministry  of  Health  and  Population  (MOHP)  in Egypt. While  the modes  of  transmission of human  immunode- ficiency virus (HIV), hepatitis C virus  (HCV) and HBV infection are similar,  the  contribution  of  different  expo- sures  to overall disease burden varies  significantly  in different countries and  regions.  Identifying specific risk  factors  for bloodborne pathogen transmission  EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 8 HBV exists  in high  titres  in blood  and  infectious body fluids among per- sons with chronic infection and is more  easily  transmitted  than  other  blood- borne pathogens [11]. With  the  intro- duction of  the hepatitis B  vaccine  in  1992, it is unlikely that early childhood  transmission continues  to  contribute  to overall disease burden.  Indeed,  the  sentinel  surveillance  system  identified  few cases who were born since the intro- duction of vaccines and found that most  transmission occurred  among young  adult males. This  age  coincides with  the onset of high-risk behaviours,  such  as unsafe sexual practices and  injecting  drug use. Thus, we hypothesized  that  these high-risk behaviours are key  risk  factors for infection. The findings of our  study suggested that military service, ex- posure  to  invasive medical procedures,  injecting  drug  use,  contact  with  an  infected household member and pro- viding  injections  to others contributed  to the transmission of acute HBV infec- tion  in Egypt. Few of  these exposures  were  identified  in  a  large proportion  of patients with acute HBV  infection,  thus making  the  identification of  risk  groups for prevention difficult. The lack  of  a  significant  association with high- risk  sexual behaviours was  somewhat  surprising and may reflect difficulties in  eliciting information on these exposures  within the cultural context of Egypt. The finding that exposure to unsafe  invasive medical procedures contributes  to HBV transmission is consistent with  other studies,  indicating deficiencies  in  standard  infection control precautions  in  the  local health care setting [8–10].  The MOHP  started  to  implement  a  national  infection control programme  in 2001 and has adopted a comprehen- sive strategy  to  implement practices  to  prevent  transmission  of  bloodborne  pathogens  in health care settings [12].  However, performance of  some  inva- sive procedures  through  the  informal  sector  remains  a  risk,  and  awareness  campaigns directed  towards  the public  need to be launched to raise public de- mand for safety. The  lack  of  association  between  HBV  and  receipt  of  injections,  with  the exception of injecting drug use, was  surprising,  based on data  from other  studies suggesting that reuse of needles  is  relatively common  in Egypt  [13].  It  is estimated that unsafe  injections may  cause  8–16 million HBV  infections  each  year worldwide, most  of which  occur in developing countries [14]. The  similar proportions who received injec- tions among cases and controls might  be  the  reason  for  this  lack of  associa- tion. Community-based studies  reveal  a much lower frequency of receiving in- jections in the general population when  compared  to our  control population,  thus it is possible that the control popu- lation (hospitalized patients) may have  introduced a bias against demonstrating  an association of unsafe  injections and  HBV infection. The  association  of  serving  in  the  military with HBV  infection has  not  been  reported  in other  studies. Mili- tary  recruits  in  Egypt  are  housed  in  compounds where sharing of personal  hygiene materials,  such  as  razors  or  toothbrushes,  is  relatively  common.  Presumably such unapparent exposures  would promote HBV transmission that  has been observed among household  contacts of persons with acute or chron- ic HBV infection.  Our findings also revealed that those  imprisoned within the last 6 months had  higher odds of being  infected by HBV  than controls,  consistent with  studies  in  other  countries  [15,16],  although  it was not  statistically  significance on  univariate or multivariate analysis. For  example, Macalino et al.  reported  that  the prevalence of HBV infection among  prisoners was 20.2% and was  associ- ated with injecting drug use (OR = 10).  Their study revealed that high-risk prac- tices, such as injecting drug use, homo- sexuality or unsafe medical procedures,  might be  risk  factors  associated with  transmission. The restrictive nature of  the prison environment and  the prob- able reuse of syringes heighten the haz- ards associated with high-risk activities  [16]. General disease prevention efforts  must  include prevention within high- risk  facilities,  such as prisons, military  facilities and others.  While it is likely that risk factors for  HIV, HCV  and HBV  infection may  vary, particularly  in  relation to attribut- able risk, it is anticipated that the identi- fication of risk factors and development  of prevention  strategies based on  the  findings of  this  study  and others  can  form the basis for developing a compre- hensive prevention strategy  to prevent  bloodborne pathogen  transmission  in  Egypt. The  strategy  should  include  a  programme targeting HBV prevention  efforts,  including vaccination  for high- risk groups and raising public awareness  and demands for safety and promotion  of  infection  control  standards  in  the  health care setting. Acknowledgements The authors would  like  to  thank with  great appreciation the support provided  by Dr Yehia Sultan, the Director of Ab- bassia Infectious Disease Hospital, and  the hepatitis coordinators who partici- pated in enrolling the patients. This work was  supported  by US- AID, Work Unit  no.  80000.000.000. E0022. The  views  expressed  in  this  article  are  those  of  the  authors  and  do  not  necessarily  reflect  the  official  policy or position of  the Department  of  the Navy, Department of Defense,  the US Government or  the Egyptian  Ministry of Health and Population. The  study protocol was approved by the US  Naval Medical Research Unit No.  3  Institutional Review Board (Protocol  # NAMRU3.2003.003) and work was  conducted  in  compliance with all US  Federal  regulations governing  the pro- tection of human subjects. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 9 This article fits the description stipu- lated by the new US Copyright Act of a  “United States Government work.” The  authors are employees of  the US Gov- ernment and this work was prepared as  part of their official duties. Title 17 USC  105 provides  that  “Copyright protec- tion under  this  title  is not available  for  any work  of  the United  States Gov- ernment work as a work prepared by a  military service member or employee of  the United States Government as part  of that person’s official duties.” Hepatitis B.1. Geneva, World Health Organization, 2008 (WHO Fact sheet, No. 204) (http://www.who.int/mediacentre/ factsheets/fs204/en/index.html , accessed 18 May 2009). Lavanchy DJ. Hepatitis B virus epidemiology, disease burden, 2. treatment, and current and emerging prevention and control measures. Viral hepatitis, 2004, 11:97–107. Mahoney FJ. Update on diagnosis, management, and preven-3. tion of hepatitis B virus infection. Clinical microbiology reviews, 1999:351–66. Qirbi N, Hall AJ. Epidemiology of hepatitis B virus infection in 4. the Middle East. Eastern Mediterranean health journal, 2001, 7:1034–45. Kamal M, Aoun S. 5. Natural history of hepatitis C: factors contrib- uting to the evolution and outcome of infection. Cairo, Egypt, Ministry of Health and Population, 1999. Azab MA et al. Epidemiology of acute viral hepatitis in Egypt, 6. 2001–2003. Abstract in the Proceedings of the International Conference on Emerging Infectious Diseases (ICEID). Atlanta, Georgia, 29 February 2004 to 3 March 2004. Chau K et al. Serodiagnosis of recent hepatitis B virus infection 7. by IgM class anti-HBc. Hepatology, 1983, 3:142–9. Frank C et al. The role of parenteral antischistosomal therapy 8. in the spread of hepatitis C virus in Egypt. Lancet, 2000, 11:887–91. References Habib M et al. Hepatitis C virus infection in a community in 9. the Nile Delta: risk factors for seropositivity. Hepatology, 2001, 33:248–53. Medhat A et al. Hepatitis C in a community in Upper Egypt: risk 10. factors for infection. American journal of tropical medicine and hygiene, 2002, 66:633–8. Margolis HS et al. 11. Viral infections of humans: epidemiology and control, 4th ed. New York, Plenum, 1997. Talaat M et al. Evolution of infection control in Egypt: achieve-12. ments and challenges. American journal of infection control, 2006, 34(4):193–200. Talaat M et al. Overview of injection practices in two governo-13. rates in Egypt. Tropical medicine and international health, 2003, 8:234–41. Kane A et al. Transmission of hepatitis B, hepatitis C and human 14. immunodeficiency viruses through unsafe injections in the developing world: model-based regional estimates. Bulletin of the World Health Organization, 1999, 77:801–7. Khan AJ et al. Ongoing transmission of hepatitis B virus infec-15. tion among inmates at a state correctional facility. American journal of public health, 2005, 95:1793–9. Macalino GE et al. Prevalence and incidence of HIV, hepa-16. titis B virus, and hepatitis C virus infections among males in Rhode Island prisons. American journal of public health, 2004, 94:1218–23. Note from the Editor We wish to draw the kind attention of our potential authors to the importance of applying the editorial requirements of  EMHJ when preparing their manuscripts for submission for publication. These provisions can be seen in the Guidelines  for Authors, which are available online at http://www.emro.who.int/emhj.htm, and are published at the end of the first  issue of each volume. We regret that we are unable to consider papers that do not conform to the Guidelines. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 10 Hepatitis B and C viral infection: prevalence, knowledge, attitude and practice among barbers and clients in Gharbia governorate, Egypt S. Shalaby,1 I.A. Kabbash,1 G. El Saleet,1 N. Mansour,1 A. Omar 1 and A. El Nawawy 2 ABSTRACT A study in Egypt determined the prevalence of hepatitis B and C virus infections among barbers (n = 308) and their clients (n = 308) in Gharbia governorate, and assessed knowledge, attitude and practices during hair-cutting and shaving. HBsAg was detected among 4.2% of barbers and 3.9% of clients (more urban than rural). Anti-HC antibodies were detected in 12.3% of barbers and 12.7% of clients. HCV-RNA prevalence was 9.1% among both barbers and clients (more rural than urban). Knowledge was high among the majority of participants and good practices during shaving and hair-cutting were observed for the majority of barbers. Barbers appeared to have no job-related risk of acquiring viral hepatitis. 1Sepahan Green-Thou Plant Pathology and Medical Entomology Centre, Isfahan, Islamic Republic of Iran (Correspondence to M.M. Emami: motovaliema@yahoo.com). 2Kerman University of Medical Sciences, Kerman, Islamic Republic of Iran. 3Communicable Diseases Control, Prevention and Eradication, World Health Organization, Geneva, Switzerland. Received: 14/02/08; accepted: 09/04/08 صرم ،ةيبرغلا ةظفامح في نئابزلاو ينقلالحا ينب تاسرمالماو ،تاهجوتلاو ،ةفرعلماو ،راشتنلاا :C سويرفب ىودعلاو B يدبكلا باهتللاا يواونلا ليع ،رمع ءماسأ ،روصنم ةريدن ،طيلسلا تلااجم ،شابك ليع ميهاربإ ،يبلش زان فياص مهددعو( مهنئابزو ،)308 مهددعو( ينقلالحا ينب C سويرفب ىودعلاو B يدبكلا باهتللاا راشتنا ديدحتل صرم في ةساردلا تيرجأ :ةصلالخا سويرفلل يحطسلا دضتسلما فِشتكاو .ةقلالحاو رعشلا صق ءانثأ تاسرمامللو ،تاهجوتللو ،ةفرعملل مييقت ىرجو ،ةيبرغلا ةظفامح في )308 %12.7و ،ينقلالحا نم %12.3 في C سويرفلل دضلا فشتكاو .)فايرلأا نم رثكأ ندلما في( نئابزلا نم %3.9و ،ينقلالحا نم %4.2 ينب HBsAg يدبكلا ظحولو ةفرعم ينكراشلما ةيبلاغ ىدل ناكو .)فايرلأا نم رثكأ ندلما فيو( نئابزلاو ينقلالحا نم لك ينب %9.1 وه HCV-RNA لدعم ناكو .نئابزلا نم ةباصلإل ضرعتلاب يفيظولا رطلخا نم ينمأت ميهدل سيل ينقلالحا نأ ودبيو .رعشلا صقو ةقلالحا ءانثأ ةديج تاسرامم عابتا ينقلالحا ةيبلاغ لىع .يدبكلا باهتللااب Infection par les virus de l’hépatite B et de l'hépatite C : prévalence, connaissances, attitudes et pratiques chez les coiffeurs pour hommes et leurs clients dans le gouvernorat de Gharbia (Égypte) RÉSUMÉ Une étude réalisée en Égypte a déterminé la prévalence des infections par les virus de l’hépatite B (VHB) et de l'hépatite C (VHC) chez les coiffeurs pour hommes (n = 308) et leurs clients (n = 308) dans le gouvernorat de Gharbia, et évalué les connaissances, les attitudes et les pratiques pendant la coupe de cheveux et le rasage. L’antigène de surface (Ag HBs) du VHB a été détecté chez 4,2 % des coiffeurs et 3,9 % des clients (plutôt citadins que ruraux). Des anticorps anti-HC ont été trouvés chez 12,3 % des coiffeurs et 12,7 % des clients. La prévalence de l’ARN du VHC était de 9,1 % chez les deux groupes (plutôt ruraux que citadins). Les connaissances étaient élevées chez la plupart des participants et de bonnes pratiques ont été observées lors du rasage et de la coupe des cheveux chez la plupart des coiffeurs. Ceux-ci ne semblaient pas courir de risque de contracter une hépatite virale dans le cadre de leur travail. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 11 Introduction Bloodborne  diseases  impose  heavy  burdens  on  national  economies  and  individual  families due  to costs arising  from acute and chronic morbidity and  mortality. Globally, 2 billion people are  infected with hepatitis B virus (HBV).  An estimated 170 million persons are  chronically  infected with  hepatitis C  virus (HCV) and 3–4 million persons  are newly infected each year [1,2].  The highest HCV prevalence in the  world  is  in Egypt, where the prevalence  of  infection  increases steadily with age.  High  rates  of  infection  are  observed  among all age groups although there are  regional differences in the average overall  prevalence [3–5]. The prevalence ranges  from 10% to 20% of the general popula- tion, and rural populations show a higher  prevalence than urban ones. This differ- ence has been attributed to past infection  and treatment of schistosomiasis [6–8].  The barber shop is a place where hair- cutting,  shaving and hair  reforming  for  men are practised. Negligence during the  use of  sharp  instruments may be a  risk  factor  for bloodborne  infections,  caus- ing serious health problems for both the  barber and the clients [9]. Razor sharing  and  shaving  in barber  shops has been  identified as a key  risk  factor  for HBV  infection  in  Italy  [10].  It has also been  identified as a risk factor for HCV among  institutionalized patients [11]. The objectives of  this  study were  to  determine  the prevalence of both HBV  and HCV infections among barbers and  a sample of  their clients  in Gharbia gov- ernorate, Egypt, and to assess the knowl- edge and attitude of the study population  regarding viral hepatitis and their practices  during hair cutting and shaving. Methods Study setting This  study was carried out during  the  year 2007 in Gharbia governorate, one  of  the governorates of  the Nile Delta  area. Two out of 8  administrative  ar- eas of  the governorate were  randomly  chosen  as  the  study  location  (Tanta  and Mahalla El-Koubra). The 2 cities  (Tanta and Mahalla El-Koubra) were  included  to  represent urban  localities,  while 3 villages (from 42 villages related  to Tanta and 55 villages related to Ma- halla) were selected randomly from the  list of  total  villages  to  represent  rural  localities. Gharbia  governorate  has  a  population of nearly 3 million, with an  urban to rural ratio of residents of 1:2. Sample The target population of  the study was  people working  in  barber  shops  and  practising hair-cutting and shaving and  1 regular client from each shop who had  attended for at least 1 year.  Based  on  the  lowest  reported  prevalence of 3% for hepatitis B surface  antigen (HBsAg),  the sample  size  that  could detect a prevalence ranging from  1%–5%, at a 95% confidence level, was  estimated as 280 in each group (barbers  and clients).  In  fact 616 subjects (308  barbers and 308 clients) were enrolled  as  follows. All barbers  in  the chosen 6  villages who agreed to participate in the  study were included (a total of 147 bar- bers out of 159 barbers) and  the same  number of  clients,  plus  a  total of 161  barbers from urban areas in both Tanta  and Mahala cities and the same number  of clients. The proportion of individuals  who refused to participate ranged from  4%  to 8% at different  localities of  the  study. Efforts were made to explain the  objectives  of  the  study  and  its  bene- fits  to  the participating person and the  whole community in order to minimize  refusals, which were mainly due to fears  about discovering  their  serostatus or  giving a blood sample.  A block  sampling  technique with  a map was used. Regarding  the urban  areas,  a  multistage  random  sample  was used. Both Tanta and Mahalla El- Koubra cities were classified into 2 large  strata,  based  on  the  socioeconomic  standard  of  the  dwellings  (high  and  medium-low). Each stratum was further  divided into clusters and 5 clusters were  chosen  randomly  from each  stratum.  A list of barber shops in the study areas  was prepared with  the help of  senior  barbers  living  in  the study area. Direct  personal communication with barbers  in  their working shop was made  to get  their  consent  and cooperation before  being enrolled  in  the study. While col- lecting data from the barber, one of the  attending clients  at  that  time was  ap- proached and  invited  to participate  in  the study after the purpose of the study  was explained.  In case of  refusal by  the  client another person was chosen in the  same setting.  Data collection A pre-designed,  structured question- naire  sheet was filled  inside  the barber  shop through direct personal  interview  with  both  the  barber  and  the  client.  Direct observation of the place and the  practice of  the barber during his work  were  also  carried  out. The  question- naire sheet included the following data:  sociodemographic  data;  know ledge,  awareness and beliefs  related  to HBV  and HCV  infection;  attitude  to HBV  and HCV; risky behaviours  that might  contribute to infection with both types  of  hepatitis;  and  an  observational  checklist  for barbers’  practice during  hair-cutting/shaving. The  cut-off  for  a high  level knowledge was defined as > 50% of questions correct. Before  starting data  collection  the  research team reviewed thoroughly the  questionnaire and received an orienta- tion  training on communication skills  and were  trained on  the methods of  data collection. The validity of the ques- tionnaire was tested by expert and peer  review and the reliability was  tested by  the  test–retest method  in a pilot  study  including 30 barbers and 30 clients not  included in the study sample. A blood  sample  (5 mL) was  tak- en  from  each  study  subject  through  EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 12 venepuncture using a vacutainer device.  The sample was  allowed  to clot natu- rally  to separate  the serum for analysis  and was  stored upright  in an  ice box/ refrigerator at a temperature of 2–8 °C  (for up to 3 days) until it was sent to the  laboratory for analysis.  For diagnosis of HBV infection, an  in vitro diagnostic kit  for  the detection  of HBsAg  in human  serum was used  (Biorex Diagnostics, UK). This  test  is  an  enzyme-immunoassay based on  a  “sandwich” principle.  For diagnosis of HCV, a 3rd-genera- tion enzyme-linked immunosorbent as- say (ELISA) kit for qualitative detection  of antibodies to HCV in human serum  or plasma was used (Biorex Diagnos- tics, UK). Samples  found  to be nega- tive on  the preliminary screening were  considered HCV-seronegative. Initially  positive  and borderline  samples were  confirmed by qualitative HCV-RNA  detection assays using classic polymer- ase chain  reaction using a commercial  kit  (HEPA-Check-C, Nuclear  Laser  Medicine, Italy).  Standard  techniques were applied  according to the manufacturer’s guide- lines. Laboratory  investigations were  carried out in a specialized private labo- ratory (Al-Ahram Laboratory, Tanta).  Ethical considerations The people recruited to the study were  informed about  the objectives of  the  study and that  they were  free  to refuse  participation. A verbal witnessed con- sent was obtained from each study par- ticipant. Clients or barbers < 18 years  old were not  included  in  the  study as  they were unable  to give  legal consent.  The  confidentiality  of  collected  data  and for the results of investigations was  assured. Only  the principal  investiga- tor held  the  results of blood  samples  tested. The participants were  informed  about  their HBV/HCV  test  results  if  they expressed a desire to be informed.  These  results were delivered  in person  in a sealed envelope.  Statistical analysis The  collected  data  were  organized,  tabu lated and statistically analysed us- ing SPSS,  version 12. The chi-squared  test was used for testing the significance  of differences between the study groups.  When the chi-squared test was not ap- propriate,  Fisher  exact  test was used.  The level of significance was 5%. Results A  total  of  616  subjects  (308 pairs  of  barbers and clients) were included: 322  from urban areas (161 pairs) and 294  from rural settings (147 pairs). The majority of  the  study  subjects  (64.3% of barbers and 59.4% of clients)  were aged 20–40 years. Nearly one-half  of barbers (49.7%) and 41.2% of clients  had  intermediate  education.  About  one-third of clients (36.7%) were highly  educated compared with only 7.8% of  barbers. HBsAg  was  detected  in  25  indi- viduals (13 barbers and 12 clients), an  overall prevalence of 4.1%. The rate was  similar among barbers and clients (4.2%  versus 3.9%) (Table 1). The prevalence  of HBsAg  among urban barbers  and  clients was higher than that among rural  ones (6.2% versus 2.0%), although not  significantly  so. Anti-HCV antibodies  were detected  in 77  individuals with  an overall prevalence of 12.5%. Again,  the  rate was  almost  the  same  among  barbers and their clients (12.3% versus  12.7%). The  infection rate was highest  among rural clients (13.6%) followed by  rural barbers (12.3%). The prevalence  of  anti-HCV was equal  among urban  barbers and  their clients (11.8%). De- tection of HCV-RNA revealed similar  figures among both barbers and clients  (9.1%). The prevalence in rural subjects  was higher  than  that of urban subjects  (10.2% and 8.1% respectively). Double  infection was detected  in 3 subjects (1  barber and 2 clients). There was no sta- tistically significant difference between  barbers and clients  in  the  rate of HBV  or HCV infection (Table 1). The level of knowledge about modes  of  transmission was  high  among  the  majority of the study participants (over  80%  for most questions). Knowledge  about the existence of protective drugs  and  vaccines was  to  low;  about  40%  knew about the presence of an HBV vac- cine and around one-quarter claimed to  know  about  a  protective  vaccine  for  HCV. Friends  and  relatives were  the  main  source of  information  for  both  barbers  (46.1%) and clients  (49.7%),  followed by television, newspapers and  doctors (Table 2). About  two-thirds  of  the  barbers  (67.9%) and more  than half of  the cli- ents  (55.5%) were  concerned  about  the  status  of  shaving  blades  used  (P = 0.002) (Table 3). Positive  attitudes  towards antiseptic use after shaving and  safe injections was found among 55.8%  and 49.0% of barbers  compared with  70.5% and 66.9% of clients respectively  (P < 0.001). It was also found that 217  (70.5%) of the barbers would not mind  being  tested  for viral hepatitis and 145  (47.1%) would be willing  to have pe- riodic  screening  for viral hepatitis  and  other bloodborne diseases. The practice of barbers during shav- ing  showed  that  changing  the  blade  for each client was  the practice of 291  barbers  (94.5%); 93.2% of urban and  95.9% of rural ones. Disinfection of used  instruments  was  practised  by  76.9%  and washing hands by 63.0% of  them.  Wearing protective clothes,  especially  gloves, was practised by 52.8% of urban  barbers  and only  9.6% of  rural  ones.  The difference between rural and urban  barbers  regarding  these practices was  not  statistically  significant,  except  for  wearing protective clothes/gloves and  washing used  instruments (P < 0.001)  (Table 4). The shaving practices of  the clients  revealed  that  the practice of urban cli- ents was better  than  that of  rural ones  regarding  verification of  the  status of  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 13 used  instruments before shaving (P < 0.001), bringing their  own instruments (P = 0.019) and asking the barber to wash his  hands before shaving (P = 0.012). The practice of rural clients  was better regarding refusing shaving with used  instruments  (P < 0.001) and asking  the barber  to disinfect used  instru- ments (but not statistically significant) (Table 5).  On observing barber’s  shops and  their practice during  shaving it was found that, in general, the majority of shops were  well-equipped, clean and neat. Rural shops were significantly  better  than urban  shops  regarding  the electric  supply  and  ventilation while urban shops were better regarding the pres- ence of washing facilities and good decoration. Observations  during shaving revealed that using a razor machine, throwing  used blades  in  the waste bin and disinfection of  skin  cuts  were practised by more  than  three-quarters of barbers with  a  significantly higher  rate of use of a  razor machine among  urban compared with rural barbers (P < 0.001). Using alum as  antiseptic for skin cuts was practised by a higher percentage of  urban than rural barbers, while rural clients were more likely  to change the blade for each client (P < 0.001) (Table 6). Discussion The prevalence of HBV and HCV infection has been widely  investigated  in many occupational groups, but  few data are  available on  the prevalence  in barber  shops. Therefore,  this  study may fill a gap. The prevalence of HBs Ag has been  reported  to  range  from 3% to 11% in Egypt [12]. In the present study, the total  prevalence of HBsAg detected was 4.1%, which  is near  the  lower limit of the recorded national range. This rate is lower  than  that  reported among barbers  in Turkey (8.5%) [13],  but higher than among barbers in Morocco where HBV was  found in only 2% of 150 barbers [14].  Qirbi et al.  stated  that HBV is generally associated with  poor socioeconomic conditions [15]. However,  the present  study revealed that HBsAg was more prevalent among urban  barbers  and clients, who may be assumed  to be of higher  social  class,  than  rural  subjects.  In  contrast,  our  study  re- vealed a higher prevalence of HCV infection among barbers  and clients of  rural areas  than urban ones. These results are  similar to the findings of previous studies among the general  population that attribute the higher figures in rural areas to the  endemicity of schistosomiasis and the use of glass syringes for  parenteral  treatment  in  the past decades.  In addition,  these  studies observed that the seroprevalence rates of HCV were  much higher  in villages  in  the Nile Delta  region compared  with Upper Egypt and this was correlated with the difference  in  schistosomiasis  infection  rates  in both  regions  [16,17].  Other workers assume that schistosomiasis-induced immune Ta bl e 1 Pr ev al en ce o f h ep at it is B (H BV ) a nd C v ir us (H C V ) i nf ec ti on a m on g ba rb er s an d th ei r c lie nt s H ep at it is in fe ct io n Ba rb er s C lie nt s To ta l ( n = 61 6) St at is ti cs U rb an (n = 1 61 ) Ru ra l ( n = 14 7) To ta l ( n = 30 8) U rb an (n = 1 61 ) Ru ra l ( n = 14 7) To ta l ( n = 30 8) N o. % N o. % N o. % N o. % N o. % N o. % N o. % U ni nf ec te d 13 3 82 .6 12 5 85 .0 25 8 83 .8 13 3 82 .6 12 6 85 .7 25 9 84 .1 51 7 83 .9 χ2 = 0 .0 0 0 In fe ct ed 28 17 .4 22 15 .0 50 16 .2 28 17 .4 21 14 .3 49 15 .9 99 16 .1 χ2 = 1.0 0 0 χ2 = 0 .18 ; P = 0 .6 73 χ2 = 0 .3 50 ; P = 0 .5 56 H BV + ve (H Bs A g) 10 6. 2 3 2. 0 13 4. 2 9 5. 6 3 2. 0 12 3. 9 25 4. 1 χ2 = 0 .0 4; P = 0 .8 38 χ2 = 3. 30 8; P = 0 .16 9 χ2 = 2. 58 5; P = 0 .10 8 H C V + ve (a nt i-H C V ) 19 11 .8 19 12 .9 38 12 .3 19 11 .8 20 13 .6 39 12 .7 77 12 .5 χ2 = 0 .0 1; P = 0 .9 0 3 χ2 = 0 .0 90 ; P = 0 .7 64 χ2 = 0 .2 26 ; P = 0 .6 34 H C V + ve (H C V- RN A ) 13 8. 1 15 10 .2 28 9. 1 13 8. 1 15 10 .2 28 9. 1 56 9. 1 χ2 = 0 .0 4; P = 0 .8 39 χ2 = 0 .4 22 ; P = 0 .5 16 χ2 = 0 .4 22 ; P = 0 .5 16 1 b ar be r a nd 2 c lie nt s w er e in fe ct ed w ith b ot h ty pe s o f h ep at iti s. H Bs Ag = h ep at iti s B su rf ac e an tig en . EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 14 Table 2 Knowledge of barbers and clients about hepatitis B (HBV) and C virus (HCV) infection Knowledge item Barbers (n = 308) Clients (n = 308) Total (n = 616) χ2-value P-value No. % No. % No. % General awareness Ever heard about liver diseases 268 87.0 284 92.2 552 89.6 3.92 0.048* Ever heard about viral hepatitis B & C 265 86.0 250 81.2 515 83.6 2.32 0.128 Knew modes of transmission Blood transfusion 285 92.5 290 94.2 575 93.3 0.42 0.518 Reusing needles 279 90.6 289 93.8 568 92.2 1.83 1.176 Dental procedures 261 84.7 275 89.3 536 87.0 2.43 0.119 IV drug use 271 88.0 262 85.1 533 86.5 0.89 0.345 Scissors/surgical instruments 256 83.1 271 88.0 527 85.5 2.57 0.109 Barbers shaving instruments 239 77.6 254 82.5 493 80.0 1.99 0.158 Ear/body piercing 205 66.6 230 74.7 435 70.6 4.51 0.034* Sexual contact 203 65.9 217 70.5 420 68.2 1.26 0.261 Tattooing 196 63.6 223 72.4 419 68.0 5.04 0.025* Sharing utensils 150 48.7 167 54.4 317 51.5 1.66 0.197 Food 114 37.0 126 40.9 240 39.0 0.83 0.363 Water 78 25.3 104 33.8 182 29.5 4.87 0.027* Others 103 33.4 56 18.2 159 25.8 17.94 0.001* Complications/treatment of viral hepatitis On liver 43 14.0 64 20.8 107 17.4 4.52 0.033* On general health 32 10.4 33 10.7 65 10.6 0.02 0.895 Presence of HBV treatment 55 17.9 57 18.5 112 18.2 0.01 0.917 Presence of vaccine for HBV 125 40.6 138 44.8 263 42.7 0.96 0.328 Presence of HCV treatment 111 36.0 89 28.9 200 32.5 3.27 0.071 Presence of vaccine for HCV 81 26.3 73 23.7 154 25.0 0.42 0.515 Source of information Friends & relatives 142 46.1 153 49.7 295 47.9 0.650 0.420 Television 148 40.1 117 38.0 265 43.0 5.960 0.014* Newspapers 99 32.1 127 41.2 226 36.7 5.090 0.024* Doctors 76 24.7 109 35.4 185 30.0 7.910 0.005* Radio 61 19.8 74 24.0 135 21.9 1.370 0.245 Health care workers 16 5.2 44 14.3 60 9.7 13.46 0.001* Others 47 15.2 15 4.9 62 10.1 17.12 0.001* *P < 0.05. More than 1 answer was reported. IV = intravenous. Table 3 Attitude of barbers and clients towards risk factors for hepatitis Attitude item Barbers (n = 308) Clients (n = 308) Total (n = 616) χ2-value P-value No. % No. % No. % Concerned about status of used blades 209 67.9 171 55.5 380 61.7 9.40 0.002* Concerned about using antiseptics 172 55.8 217 70.5 389 63.1 13.51 0.001* Concerned about using disposable syringes 151 49.0 206 66.9 357 58.0 19.43 0.001* *P < 0.05. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 15 suppression could increase the persist- ence of viraemia following acute  infec- tion with both HBV and HCV and this  could partly explain the high prevalence  of HCV  infection  in  Egypt  [18,19].  However, no association was observed  between HCV and Schistosoma man- soni infection in endemic areas in either  Egypt or Brazil [20,21].  Many  workers  consider  infec- tion  with  HBV  and HCV  to  be  an  occupational  hazard  for  barbers  [10,22]. Other  researchers  consider  barbers  a  source of  infection  to  their  clients, especially when there is reuse of  razor blades that may transmit infection  through micro-trauma [23,24]. How- ever, others found no relation between  shaving by community barbers and in- fection with viral hepatitis [5]. Özdemir  et  al.  concluded  that HBV and HCV  infections  are not occupational  risks  for barbers and hairdressers  [24]. The  same can be concluded from the results  of the present study, as the rate of viral  hepatitis  infection among barbers was  the  same as  that  among  their  regular  clients  and was  similar  to  the preva- lence in the general population in Egypt  [4,5,16]. This  is  consistent with  our  finding  that barbers  and  their  clients  were not  generally  being  exposed  to  risk factors for HBV and HCV infection  Table 4 Shaving practices of barbers in their shops by residence Practice item Barbers’ residence Total (n = 308) χ2-value P-value Urban (n = 161) Rural (n = 147) No. % No. % No. % Changes the blade for each client 150 93.2 141 95.9 291 94.5 0.650 0.420 Disinfects the instruments 117 72.7 120 81.6 237 76.9 2.990 0.084 Only washes the used instruments 103 64.0 69 46.9 172 55.8 8.370 0.004* Washes hands 104 64.6 90 61.2 194 63.0 0.240 0.621 Wears prote ctiveclothes/or gloves 85 52.8 14 9.6 99 32.1 64.00 0.001* Disinfectant used Perfume 82 50.9 46 31.3 128 41.6 11.41 0.001* Savlon® 79 49.1 47 32.0 126 40.9 8.60 0.003* Alcohol 61 37.9 50 34.0 111 36.0 0.35 0.556 Talcum powder 34 21.1 7 4.8 41 13.3 16.42 0.001* Povidone/iodine 14 8.7 15 10.2 29 9.4 0.07 0.797 Hydrogen peroxide 17 10.6 2 1.4 19 6.2 9.70 0.002* Dettol® 8 5.0 9 6.1 17 5.5 0.04 0.847 Water 4 2.5 5 3.4 9 2.9 FE 0.741 Alum crystals (shaba) 1 0.6 4 2.7 5 1.6 FE 0.196 None 3 1.9 3 2.0 6 1.9 FE 1.000 Changes disinfectant frequently 91 56.5 89 60.5 180 58.4 0.36 0.549 *P < 0.05. More than 1 answer was reported. FE = Fisher exact test. Table 5 Shaving practices of clients at barber shops by residence Practice item Clients’ residence Total (n = 308) χ2-value P-value Urban (n = 161) Rural (n = 147) No. % No. % No. % Verifies the status of instruments 130 80.7 89 60.5 219 71.1 14.29 0.001* Asks if the instruments has been disinfected 58 36.0 65 44.2 123 39.9 1.82 0.177 Asks barber to disinfect the instruments 72 44.7 74 50.3 146 47.4 0.76 0.383 Refuses shaving with used instruments 53 32.9 106 72.1 159 51.6 45.70 0.001* Brings his own instruments 44 27.3 23 15.6 67 21.8 5.49 0.019* Asks barber to wash his hands before shaving 30 18.6 12 8.2 42 13.6 6.29 0.012* *P < 0.05. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 16 and that knowledge and practices were  good among a considerable percentage  of barbers. In our study, the level of knowledge  among barbers  and  their  clients was  relatively  high,  especially  regarding  modes of  transmission. But  there were  information  deficits  about  the  com- plications and  treatment of hepatitis,  perhaps because  friends  and  relatives  were an  important  source of  informa- tion. Studies  carried out  in Morocco,  Ethiopia and Pakistan showed that  the  level  of  knowledge  and  awareness of  barbers about the concept of infectious  risk associated with blood was generally  very low, especially for HBV and HCV  [14,25,26]. Poor knowledge and lack of  awareness of  the general public about  HBV and HCV  is  the main  cause of  the  rapid  spread of  these  infections  in  developing  countries  compared with  developed ones [26,27].  In previous studies, it was found that  the proportion of barbers with a positive  attitude to the risk of virus transmission  was greater than the proportion of those  with good knowledge and good practice  [22,25]. The present study showed that  there were positive  attitudes  towards  safe  injections  and use of  antiseptics,  especially among clients. The practices  of barbers were  also generally  sound,  as  similarly  documented  in  Pakistan  [27]. However,  the practice of  throw- ing used blades  in  the waste bin poses  a major  risk  to  garbage handlers  and  waste  scavengers,  who  in  Egypt  and  other developing countries commonly  search  the waste  dumps  for  valuable  items and metals and are also  likely  to  be children. The majority  of  barber  shops  in  Gharbia governorate had good hygiene  conditions, whereas Zahraoui-Mehadj  et al.  reported  that hygienic conditions  were deficient among barbers  in Mor- occo [15]. There were some  limitations to the  study. The sample  size of barbers was  chosen  to be  representative of  all bar- bers  in the studied areas. However,  the  sample size of clients was small and not  fully  representative of  all  clients. Thus  the study gives only a general picture of  the situation among clients. Conclusions This  study  revealed  a  very  similar  in- fection  rate of HBV and HCV among  barbers and their clients to that reported  nationally. The prevalence of HBV and  Table 6 Observations of conditions in barber shops and barbers’ shaving practices Observation items Urban ( n = 161) Rural ( n = 147) Total ( n = 308) χ2-value P-value No. % No. % No. % Barber shop Has adequate electric supply 116 72.0 127 86.4 243 78.9 8.65 0.003* Has adequate ventilation 112 69.6 130 88.4 242 78.6 15.15 0.001* Has ceiling fans/airconditioning 112 69.6 123 83.7 235 76.3 7.70 0.005* Is clean and neat 110 68.3 110 74.8 220 71.4 1.29 0.256 Has adequate sinks for washing hands and face 109 67.7 110 74.8 219 71.1 1.57 0.210 Has good washing facilities 89 55.3 65 44.2 154 50.0 3.33 0.068 Is decorative/attractive 97 60.2 56 38.1 153 49.7 14.21 0.001* Situated on main road 67 41.6 61 41.5 128 41.6 0.01 0.924 Situated in internal market area 44 27.3 31 21.1 75 24.4 1.30 0.253 Barber’s practices during shaving Uses razor machine 154 95.7 119 81.0 273 88.6 15.06 0.001* Throws used blades in waste bin 137 85.1 126 85.7 263 85.4 0.02 0.877 Properly disinfects skin cuts 123 76.4 119 81.0 242 78.6 0.70 0.404 Washes razor with antiseptic 122 75.8 95 64.6 204 66.2 4.07 0.044* Sterilizes the razor before use for each client 85 52.8 89 60.5 174 56.5 1.58 0.209 Causes cuts from razor machine 118 73.3 56 38.1 174 56.5 37.31 0.001* Uses alum as antiseptic for skin cuts 99 61.5 61 41.5 160 51.9 11.52 0.001* Uses new razor for each client 86 53.4 118 80.3 135 43.8 23.59 0.001* Puts used blades in the box 62 38.5 33 22.4 95 30.8 8.55 0.003* Washes razor with tapwater only 23 14.3 16 10.9 39 12.7 0.53 0.468 *P < 0.05. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 17 HCV  among  barbers  was  similar  to  that  among clients. Barbers  appeared  to have no  job-related  risk of  acquir- ing viral hepatitis. This may be due  to  the  relatively good knowledge among  barbers  about modes of  transmission  and positive attitude towards protecting  themselves  and  their  clients  and  also  due to good practices by the majority of  the  studied barbers and good hygiene  conditions in barber shops. 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Pakistan journal of medical sciences quarterly, 2007, 23(4):514–7. (EMRO), Division of Communicable  diseases (DCD) and the WHO Special  Programme  for Research  and Train- ing  in Tropical Diseases  (TDR):  the  EMRO/TDR Small Grants  Scheme  for Operational Research  in Tropical  Medicine  and  other Communicable  Diseases. طسوتلما قشرل ةيحصلا ةلجلما شرع سداسلا دلجلما لولأا ددعلا 18 HIV/AIDS knowledge, attitudes and beliefs among a group of Iraqis A.H. Hayyawi,1 A.Y. Al-Marayaty,1 W.S. Salman1 and W. Hamed2 ABSTRACT This study aimed to build a baseline profile of knowledge, attitudes and beliefs of Iraqis toward HIV/AIDS. Questionnaire interviews were conducted in 2006 with 335 people attending HIV testing centres in Baghdad. Most respondents (82.7%) had heard about AIDS, mainly from the mass media (71.0%), and 91.9% knew that AIDS is an infectious disease, most commonly via sexual relationships (74.9%). There was no association between knowledge level and acceptance of caring for an HIV-positive relative or marrying an HIV-positive partner, but there was a significant association between low knowledge level and negative attitudes towards sharing food, sitting on the bus and working at the same place with an HIV-positive individual. 1Al-Risafa Directorate of Health, Primary Health Care Division, HIV/AIDS Control Department, Baghdad, Iraq (Correspondence to A.H. Hayyawi: hayawi2004@yahoo.com). 2AIDS Research Centre, National AIDS Programme, Baghdad, Iraq. Received: 06/05/07; accepted: 02/09/07 ينيقارعلا نم ةعوممج ينب هسويرفل ينشياعلماو زديلإا ضىرمب ةصالخا تادقتعلماو تاهجوتلاو ةفرعلما دوبع دماح حاضو ،نمالس ركاش ماسو ،تيايارلما فسوي ءارفع ،يوايح نسح ليع .هسويرفل ينشياعلماو زديلإا ضىرم لوح ينيقارعلا ينب تادقتعلماو تاهجوتلاو ةفرعملل يدعاقلا مسترلما ءانب لىإ ةساردلا هذه فدته :ةصلالخا دقو .دادغب ةنيدم في زديلإا سويرف صحف زكارلم ينعجارلما نم ًاصخش 335 عم 2006 ماع في نايبتسا ةرماتسا مادختساب تلاباقم تيرجأ دقو فرعيو ،)%71.0 ةبسنب( ةماعلا ملاعلإا لئاسو قيرط نع اهيلع اولصح يتلا تامولعلما بلغأو ،زديلإا نع )%82.7 ةبسنب( ينعجارلما بلغأ عمس ةياعر لوبقو ةفرعلما ىوتسم ينب طابترا دجوي لمو .)%74.9( ةيسنلجا تاقلاعلا قيرط نع لقتني ام ًابلاغ هنأو ،دعم ضرم زديلإا نأب مهنم %91.9 سوللجا وأ ،ماعطلا ةكراشم وحن ةيبلسلا تاهجوتلاو ةفرعلما ىوتسم ينب ًايئاصحإ هب دتعي طابترا كانه ناك نكلو ،مهنم جاوزلا وأ زديلإل ينشياعلما .زديلإا سويرفل ينشياعلما عم عقولما سفن في لمعلا وأ ،تلافالحا في Connaissances, attitudes et croyances en matière de VIH/sida dans un groupe d’Iraquiens RÉSUMÉ Cette étude visait à élaborer un profil de référence des connaissances, des attitudes et des croyances des Iraquiens concernant le VIH/sida. Des entretiens par questionnaire ont été réalisés en 2006 auprès de 335 personnes fréquentant des centres de dépistage du VIH à Bagdad. La plupart des personnes interrogées (82,7 %) avaient entendu parler du sida, principalement par le biais des médias (71,0 %), et 91,9 % d’entre elles savaient que le sida est une maladie infectieuse qui se transmet le plus souvent lors de relations sexuelles (74,9 %). Il n’existait pas d’association entre le niveau de connaissances et le fait d’accepter de s’occuper d’un membre de la famille séropositif ou de se marier avec une personne séropositive, mais il existait une association significative entre un faible niveau de connaissances et des attitudes négatives concernant le fait de partager la nourriture d’une personne séropositive, de s’asseoir dans un bus avec elle ou de travailler au même endroit qu’elle. EMHJ  •  Vol. 16     No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 19 Introduction Acquired immunodeficiency syndrome  (AIDS)  is  one  of  the most  complex  health problems of the 21st century [1].  The AIDS epidemic is in its 3rd decade  and has become  a pandemic disease  that  threatens  the world  population  [2]. Moreover,  it  continues  to  spread  at an alarming rate [3]. Human immu- nodeficiency virus (HIV)  is present  in  the blood and body fluids of  infected  individuals, whether  symptomatic or  asymptomatic. The  main  modes  of  transmission are  sexual contact,  expo- sure to infected blood or blood products  and perinatal transmission [4]. In  the absence of a vaccine or cure  for HIV/AIDS, public health education  is still the best means of combating the  pandemic [5]. Public understanding of  the virus  is growing but many behav- ioural aspects of  the epidemic  remain  incompletely documented and poorly  understood. The  impact of prevention  programmes  on  behaviour  remains  uncertain because  they  frequently  lack  complementary information on chang- es in behaviour or because behavioural  data are not collected or are incomplete  [6].  Several studies conducted in coun- tries  in  Asia  and North  Africa  have  evaluated HIV/AIDS knowledge,  at- titudes  and practice of  certain  target  populations such as university students  [3,5,7], army students [8], soldiers [9],  street children/youth [10] and nurses  [11].  Young  people  are  particularly  at  risk of HIV  infection because  they  are  in  the  transition phase of  their  life,  experimenting with sexual experiences  and drug use  [3]. The present  study  in Baghdad,  Iraq  covered  a  non-ho- mogenous  sector  of  the  community  (people attending HIV testing centres)  and aimed to build a baseline profile of  knowledge, attitudes and beliefs regard- ing HIV/AIDS among the study group.  The study was also seen an opportunity  to distribute correct  information and  to  correct misconceptions  about dif- ferent  aspects  of HIV/AIDS  among  this group. Methods Setting and sample A cross-sectional study was conducted  in  the Al-Risafa area of Baghdad. The  area  has  4 HIV  testing  centres  that  perform  premarital  counselling  and  testing, testing for Iraqis returning from  other countries and voluntary counsel- ling and testing. One centre also issues  international  health  certificates  on  request. A convenience sample of 335 sub- jects  from both  sexes  attending  the 4  HIV testing centres from April to June  2006 constituted the study group.  Questionnaire A questionnaire was  constructed  to  meet the purpose of the study based on  similar  studies of knowledge and atti- tudes in different countries [1,3,12,13].  The questions were modified according  to  Iraqi culture and social norms. The  questionnaire  included data  related  to  personal  information, knowledge and  beliefs  about HIV/AIDS,  sources of  knowledge, and attitudes  toward HIV  patients. The questionnaire was filled  through a direct interview.  The  possible  responses  to  each  question were yes, no or don’t know,  and  items were  scored as 2 (correct),  1 (don’t know) or 0 (incorrect), with  a maximum score of 17. The median  score (14) was calculated and the sub- jects were categorized into high knowl- edge  level  (> 14) and  low knowledge  level (≤ 14) groups.  A pilot study was done on a sample  of 25 individuals drawn from the same  testing centres. According  to  their  re- sponses, some questions were modified  to make  them more  applicable. The  pilot  sample was not  included  in  the  study.  Ethical issues Written permission  for  the  study was  obtained  from  the  appropriate  local  authority health manager. The ques- tionnaire was  administered  to  those  who gave  their  verbal  consent  to par- ticipate.  Participation was  voluntary  after explaining the purpose of the study  to each  individual. The questionnaire  was anonymous and participants were  assured of  the confidentiality of  their  responses. Statistical analysis The data were  analysed  using SPSS,  version 12. The data were expressed as  frequencies and percentages. The chi- squared test was used and a P-value of ≤  0.05 was considered as significant. Results A  total  of  335  respondents were  in- cluded in the study: 196 (58.5%) males  and 139 (41.5%) females. The mean age  was 28 (standard deviation 9) years and  94.0% of the respondents were aged 44  years or less (Table 1). Of the study group 79.1% were un- married, 83.0% had secondary or higher  education and 36.4% were employees.  The proportion of  respondents with  high knowledge  increased significantly  with increasing educational status (P < 0.001) (Table 2). There was no signifi- cant  association between knowledge  level and marital  status (P = 0.16) but  the  association with occupation was  significant (P = 0.021);  employees had  the greater knowledge  than other oc- cupation groups. Couples attending for  premarital  testing  constituted 69.0%  of  the  study group,  followed by  those  attending  for  international health cer- tificates (19.7%) and people  returning  from  travel  abroad  (11.3%). Higher  knowledge was significantly associated  with attending for travel-related reasons  compared with premarital  testing (P = 0.012) (Table 2). طسوتلما قشرل ةيحصلا ةلجلما شرع سداسلا دلجلما لولأا ددعلا 20 A  high  proportion  of  the  study  group  (277,  82.7%)  reported having  heard about HIV/AIDS. Mass media  was  the main source of knowledge  for  238  respondents (71.0%), principally  local  television and  satellite  channels  (49.3%),  followed by newspapers and  magazines  (7.2%),  folders/leaflets  (3.6%),  radio broadcasts (3.0%) or all  of these (8.1%). People were the second  source of  information  (145,  43.3%),  mainly medical staff (28.7%), followed  by  friends (7.5%),  relatives  (6.3%) or  all  of  these  (0.9%). Educational  pro- grammes were  the  lowest  source  of  information (31, 9.3%). The majority  of  the  study  group  (308, 91.9%) knew  that AIDS was an  infectious  disease  (Table  3). A high  proportion (72.7%) reported  the pos- sibility of transmission of the virus from  the infected mother to her infant, while  11.5% denied this possibility while only  37.5% reported the possibility of trans- mission of HIV through breastfeeding  with 26.0% denying this as a method of  transmission (Table 3).  Just over half  of  the  respondents  (54.9%)  thought  that AIDS was not  a  curable disease  while 26.6%  thought  that  it was  cur- able and 18.5% did not know. Similar  proportions had  incorrect and correct  knowledge about the existence of a vac- cine  (34.9% and 39.4%  respectively)  and 25.7% admitted they did not know  about  the  presence  of  a  vaccine.  A  majority of  the study group knew that  sexual  relationships were a method of  transmission (251, 74.9%) and a high  percentage  gave  a  correct  response  about blood  transfusion (71.6%) and  sharing syringes and sharp instruments  (68.7%) as methods of  transmission.  On  the other hand, more  than half of  the  sample  believed  incorrectly  that  HIV was  transmitted by  sharing  food  (56.7%),  shaking  hands  and  social  Table 1 Age and sex distribution of respondents attending an HIV testing centre in Baghdad Age group (years) Female Male Total No. % No. % No. % 15–24 76 54.7 52 26.2 128 38.2 25–34 47 33.8 91 46.4 138 41.2 35–44 10 7.2 39 19.9 49 14.6 45–54 4 2.9 10 5.1 14 4.2 55+ 2 1.4 4 2.0 6 1.8 Total 139 41.5 196 58.5 335 100.0 Table 2 Distribution of HIV/AIDS knowledge level according to marital status, educational level, occupation and reason for attendance at centre among respondents attending an HIV testing centre in Baghdad Variable HIV/AIDS knowledge level Statistical tests Low (n = 173) High (n = 162) Total (n = 335) No. % No. % No. % Marital status Single 144 83.2 121 74.7 265 79.1 χ2 = 1.96, df = 1, P = 0.16 Married 28 16.2 37 22.8 65 19.4 Separated 1 0.6 4 2.5 5 1.5 Educational status Illiterate 10 5.8 1 0.6 11 3.3 χ2 = 19.65, df = 3, P < 0.001 Primary 29 16.8 17 10.5 46 13.7 Secondary 82 47.4 62 38.3 144 43.0 Higher 52 30.1 82 50.6 134 40.0 Occupation Housewife 41 23.7 27 16.7 68 20.3 χ2 = 9.72, df = 3, P = 0.021 Employee 48 27.7 74 45.7 122 36.4 Manual worker 60 34.7 41 25.4 101 30.2 Student 24 13.9 20 12.3 44 13.1 Reason for attendance Premarital test 131 56.7 100 43.3 231 69.0 χ2 = 8.82, df = 2, P = 0.012International health certificate 24 36.4 42 63.6 66 19.7 Back from travel 18 47.3 20 52.7 38 11.3 df = degrees of freedom. EMHJ  •  Vol. 16     No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 21 relationships  (56.1%),  sharing a bath- room  and  toilet  (54.0%)  and  insect  bites (50.4%).  Table 4  shows  the  attitude of  the  individuals  in  the  study group  toward  HIV-positive  relatives and shows  that  there was no significant association be- tween knowledge level and acceptance  of  caring  for  an HIV-positive  relative  (P  = 0.11) or not  changing marriage  plans  if  the  partner was  found  to  be  HIV positive (P = 0.53). However,  re- spondents with a lower knowledge level  were  significantly more  likely  to have  negative attitudes towards sharing food  with an HIV-positive individual, sitting  beside an HIV-positive  individual  in a  bus or working with an HIV-positive  individual in the same work place (P = 0.003, P < 0.001 and P < 0.001 respec- tively) (Table 4). Discussion The majority  of  the  study  group  at- tending  for HIV  testing were  in  the  reproductive age group,  showing  that  the  surveillance activities are properly  targeting the at-risk group who are sexu- ally active [3,14,15].  main  source of  information  for males  and booklets for females [13]. A  majority  of  respondents  gave  correct  responses about  the methods  of  transmission of HIV, especially  re- garding  sexual  relationships,  sharing  of  syringes and sharp  instruments and  blood transfusion. There were miscon- ceptions about the risk from insect bites  and routine daily activities, such as shar- ing  food with HIV/AIDS patients or  sharing  toilets  and bathrooms, which  agrees with the findings of other studies  [13,18,19].  The majority  of  the  study  group  accepted being a care provider  for  an  HIV-positive relative, which can be ex- plained by the strong family and social  links  in our society. The results of  this  study agree with  those of  a Ugandan  study in 2000 which showed that 86.2%  would provide  care  for  relatives with  HIV/AIDS  [20],  but  disagrees with  a  study  conducted  in Kuwait  during  1995  in which 72% were unwilling  to  take  care of AIDS patients  [21],  and  another  study  conducted  in  Sana’a,  Yemen, which  showed  that only 21%  thought  that  family members  should  provide  care  for HIV/AIDS  patient  and 51% thought that this care should  be the responsibility of specialized staff  in specialized centres [22].  In our study high educational  level  was associated with higher knowledge  about  AIDS,  which  agrees  with  the  findings of a  study  in Turkey  in 2005  [12], presumably as  those with higher  education can utilize written mass me- dia channels  that are not accessible  to  those with  lower  educational  status.  The  significant  association  between  non-manual  occupation  and  knowl- edge level can be explained by the rela- tionship that exists between occupation  and educational status.  Mass media, especially the visual, is  an accessible, widespread and effective  means  of  knowledge  dissemination.  Local  television and satellite channels  represented  the main  source of  infor- mation about HIV/AIDS in this study,  while people,  including medical  staff,  ranked  second. The  role of  television  channels should be emphasized in dis- tributing accurate,  active and effective  messages  to  the population, especially  the younger age groups, about sexually  transmitted diseases. These messages  should match  our  social  norms  and  religious values. Our results agree with  the  findings of  studies  conducted  in  Bangladesh and Thailand [16,17], but  disagree  with  a  study  conducted  in  Saudi Arabia in which friends were the  Table 3 Knowledge and beliefs about HIV and its modes of transmission among respondents attending an HIV testing centre in Baghdad (n = 335) Item Yes No Don’t know No. % No. % No. % AIDS is infectious 308 91.9 27 8.1 0 0.0 Possible to transmit AIDS from mother-to-child 249 72.7 34 11.5 52 15.8 Possible to transmit AIDS through breastfeeding 125 37.5 89 26.0 121 36.5 AIDS is curable 89 26.6 184 54.9 62 18.5 Vaccine against AIDS exists 117 34.9 132 39.4 86 25.7 Modes of transmission of HIV Sexual relationship 251 74.9 84 25.1 – – Blood transfusion 240 71.6 95 28.4 – – Sharing syringes & sharp instruments 230 68.7 105 31.3 – – Sharing food 190 56.7 145 43.3 – – Shaking hands & social relations 188 56.1 147 43.9 – – Sharing bathroom & toilet 181 54.0 154 46.0 – – Insect bite 169 50.4 166 49.6 – – طسوتلما قشرل ةيحصلا ةلجلما شرع سداسلا دلجلما لولأا ددعلا 22 Over  a  quarter  of  the  study  group  (26.6%) thought that AIDS was a cur- able disease, which is close to the results  of  a Turkish  study (30%) conducted  during 2005 [12]. More than one-third  of  the  respondents  (34.9%)  thought  that  there was  a  vaccine  against  the  disease which is higher than the results  of  an  Iranian  study (11%) conducted  during 2004 [3]. These false beliefs re- flect  risky misconceptions which need  to be corrected by effective educational  information.  Respondents’ knowledge  level was  associated with negative  attitudes  to- wards HIV-positive individuals in pub- lic places and at work,  since  the group  with higher knowledge level were more  accepting  towards contact with HIV- positive  individuals  than  those with  low knowledge  level. This agrees with  the  results of  the Turkish study where  people with  good  knowledge  about  AIDS were more  tolerant  of  people  with AIDS [12]. However, more  than  half of our study sample overall would  avoid HIV-positive individuals at work  or in public.  Conclusion The  sample  in  this  study  may  not  necessarily  represent  the  population  of  Baghdad  but  it  does  represent  an  important  subgroup  of  Baghdadis  for  evaluating  knowledge  and  attitudes  towards  HIV/AIDS  individuals. The  study  identified  many  misconcep- tions  and negative  attitudes  that need  to  be  addressed. A  nationwide  health  education  programme  through mass  media  campaigns  and  introduction of HIV/AIDS education into the secondary  school curriculum are recommended to  overcome misconceptions, spread aware- ness and, hopefully, modify behaviour. Acknowledgements The authors would like to greatly thank  Professor Nada Al Ward  for her kind  efforts in the revision of the work. Table 4 Distribution of HIV/AIDS knowledge level according to attitudes towards HIV-positive individuals among respondents attending an HIV testing centre in Baghdad Variable HIV/AIDS knowledge level Statistical tests Low (n = 173) High (n = 162) Total (n = 335) No. % No. % No. % Agree to care for HIV-positive relative Yes 119 68.8 125 77.2 244 72.8 χ2 = 4.303, df = 2, P = 0.116No 21 12.1 19 11.7 40 11.9 Don’t know 33 19.1 18 11.1 51 15.2 Continue with marriage plan if partner is found to be HIV positive Yes 59 34.1 46 28.4 105 31.3 χ2 = 1.274, df = 2, P = 0.529No 83 48.0 85 52.5 168 50.1 Don’t know 31 17.9 31 19.1 62 18.5 Eating with an HIV-positive individual Continue eating 35 20.2 56 34.6 91 27.2 χ2 =11.79, df = 2, P = 0.003 Shift to other table 35 20.2 38 23.5 73 21.8 Leave the place 103 59.5 68 42.0 171 51.0 Sitting beside an HIV-positive individual in a bus Stay in place 39 22.5 58 35.8 97 29.0 χ2 = 16.66, df = 2, P < 0.001Change place 37 21.4 49 30.2 86 25.7 Leave the bus 97 56.1 55 34.0 152 45.4 Working with an HIV-positive individual Stay in work 36 20.8 59 36.4 95 28.4 χ2 = 13.57, df = 2, P < 0.001 Ask to shift to another department 71 41.0 66 40.7 137 40.9 Leave work 66 38.2 37 22.8 103 30.7 df = degrees of freedom. 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Knowledge, attitude, beliefs and practices 22. of the population in Kuwait about AIDS—a pilot study. Eastern Mediterranean health journal, 1995, 1(2):235–40. Note from the Editor We wish to draw the kind attention of our potential authors to the importance of applying the editorial requirements of  EMHJ when preparing their manuscripts for submission for publication. These provisions can be seen in the Guidelines  for Authors, which are available online at http://www.emro.who.int/emhj.htm, and are published at the end of the first  issue of each volume. We regret that we are unable to consider papers that do not conform to the Guidelines. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 24 Seroprevalence of Toxoplasma gondii in unmarried women in Qazvin, Islamic Republic of Iran H. Jahani Hashemi1 and M. Saraei2 ABSTRACT In a cross-sectional study, we evaluated the seroprevalence of Toxoplasma gondii among 400 women referred to Qazvin community health centre laboratory for pre-marriage examinations. Indirect immunofluorescent antibody test was used to detect IgG anti-toxoplasma. Titres ≥ 1: 20 were considered positive. The overall seropositivity was 34%. Mean age was significantly higher in seropositive women (P < 0.05). Seropositivity was highest among unemployed women (38.3%) and lowest among students (22.6%), and was significantly higher in women with less than high-school education (P < 0.05). With two-thirds of these unmarried women seronegative, they represent a high-risk group in pregnancy. Such women need to be educated to prevent congenital toxoplasmosis. 1Department of Community Medicine; 2Department. of Medical Parasitology and Mycology, Faculty of Medicine, Qazvin University of Medical Sciences, Qazvin, Islamic Republic of Iran (Correspondence to H. Jahani Hashemi: jahanihashemi@qums.ac.ir; jahanihashemi@yahoo.com). Received: 21/02/07; accepted: 02/09/07 ةيملاسلإا ناريإ ةيروهجم ،ينفزاق في تاجوزتلما يرغ ءاسنلا ينب Toxoplasma gondii ةيدنوعلا ةسوقملل ليصلما راشتنلاا يياسر دازرهم ،يمشاه نياهج نسح برتمخ لىإ نهتلاحإ ىرج ةأرما 400 ينب Toxoplasma gondii ةيدنوعلا ةسوقملل ليصلما راشتنلاا ناثحابلا مّيق ،ةيضرع ةيعطقم ةسارد في :ةصلالخا ينبولغلا فاشتكلا كلذو ،دادضلأل شرابلما يرغ يعانلما قلأتلا رابتخا نله يرجأو .جاوزلل ةقباسلا صوحفلا ءارجلإ عمتجلما ةحصل ينفراق زكرم لىعأ ناك رمعلا طسوتمو .%34 ةيلاجملإا ةيلصلما ةيساسلحا تناكو .ةيبايجإ ةجيتن 20:1 نع ديزي وأ يواسي رايعلا برتعاو .ةسوقملل داضلما G يعانلما )%38.3( تلاماعلا يرغ ءاسنلا ينب نوكت ام لىعأ ةيلصلما ةيساسلحا تناكو .)0.05 نم لقأ p( لصملل تايبايجلإا ءاسنلا في ًايئاصحإ هب ُّدَتْعُي وحن لىع في راطتخلاا ةيلاع ةعوممج نلّكشي نهف ،لصملل تايبلس نك تاجوزتلما يرغ ءاسنلا يثلث نأ ثيحو .)%22.6( تاذيملتلا ينب نوكت ام لقأ تناكو .يقللخا تاسوقلما ءادب ةباصلإا عنلم فيقثتلا لىإ ءاسنلا ءلاؤه جاتتحو ،لملحا Séroprévalence de Toxoplasma gondii chez les femmes non mariées à Qazvin (République islamique d’Iran) RÉSUMÉ Dans une étude transversale, nous avons évalué la séroprévalence de Toxoplasma gondii chez 400 femmes adressées au laboratoire du centre de santé communautaire de Qazvin en vue d’examens prénuptiaux. La détection des anticorps anti-toxoplasmose de type IgG a été réalisée grâce à la technique de l’immunofluorescence indirecte. Les titres supérieurs ou égaux à 1/20 ont été considérés comme positifs. La séropositivité globale s'élevait à 34 %. L’âge moyen était significativement plus élevé chez les femmes séropositives (P < 0,05). La séropositivité la plus élevée se trouvait chez les femmes sans emploi (38,3 %) et la plus faible, chez les étudiantes (22,6 %) ; elle était significativement plus élevée chez les femmes qui avaient arrêté leur scolarité avant le secondaire (P < 0,05). Les deux tiers de ces femmes non mariées étant séronégatives, elles pourraient représenter un groupe à haut risque au moment de la grossesse. Une action éducative doit être menée auprès d'elles afin de leur éviter de contracter une toxoplasmose congénitale. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 25 Introduction When seronegative women are infected  with Toxoplasma gondii  during  preg- nancy, the parasite may be congenitally  acquired through the placenta. The rate  of  fetal  transmission during first  infec- tion  is 10%–25%  in  the first  trimester,  30%–54% in the second and 60%–65%  in  the  third  [1]. Congenital  toxoplas- mosis  can have  serious consequences  and may  result  in mental  retardation,  blindness and death [2].  Seroepidemiology of T. gondii  has  been reported in many countries. A high  seroprevalence has been found in devel- oped countries,  such as France, where  undercooked meat  is commonly eaten  [3],  and  in  tropical  areas where  cats  are  abundant  and  the climate  favours  survival of oocysts [4]. In  the  Islamic Republic of  Iran,  at  least 30% of people are seropositive for  T. gondii  immunoglobulin G (IgG)  in  most regions, with the highest reported  prevalences being  in Gilan  and Maz- andran provinces (north of  the coun- try) [5,6]. Since seronegative pregnant  women are at high  risk  for  congenital  toxoplasmosis, studies on T. gondii have  focused on such women [7]. However,  the°re is no national programme for the  prevention of congenital toxoplasmosis  in the Islamic Republic of Iran. The aim of this study was to conduct  a toxoplasmosis serosurvey among pre- marriage women  to provide data  for  an educational programme that will be  designed  to prevent T. gondii  infection  in women of childbearing age. Methods Climatic conditions of the studied area The study was  carried out  in Qazvin  province, which is located about 120 km  north-west of Tehran. The average tem- perature  is 24–27 °C with a maximum  of 40 °C in summer and a minimum of  –10° C  in winter. Rainfall  varies  from  zero mm  rainfall  in August  to  106.2  mm  in December. The mean  relative  humidity  is 16%–65%  in  summer and  from 40%–86% in the winter. Sample size determination Using the formula:  2 2 2 )1()( d PPZZ n −+ = βα where α = 0.05, β = 0.2, P = 0.4, d = 0.07,  the  sample  size was determined  to be  384, so 400 women who referred to the  laboratory were selected. Subjects and collection of sera The  400 women were  selected  from  those  referring  to  the  laboratory of  the  Qazvin  community medicine  centre  between  January and March 2004  for  screening  for  thalassaemia  prior  to  marriage (a  requirement  in  the  Islamic  Republic of  Iran). All  the women who  referred  to  the  laboratory over  this pe- riod were  included  in  the  study;  there  were no exclusions. The sera were kept at  –20 °C until testing. The age range of the  women was 13–39 years with a mean of  20 years (the legal age of marriage in the  country  is 18 years;  for marriage under  this age a court certificate is required). Data on age, occupation and educa- tion of  the women were obtained by  interview questionnaire. Preparation of antigen The  antigen  was  prepared  according  to  the method  of Goldman  [8]  used  by Ghorbani  et  al.  [5]  using T. gondii RH strain. Smears with  approximately  30–40  tachyzoites  per  power  field  of  microscope  (× 400) were dropped on  a glass  slide  and air dried (12 uniform  thick smears). The slides were stored at  –20 °C until testing and used as antigen. Immunofluorescence test The immunofluorescence  test  (IgG- IFA) tests of sera samples were carried  out according  to  the procedure used  by Ghorbani, Edrissian and Assad [5].  Briefly,  each  serum sample was first  examined  at  dilutions  of  1:20  and  1:400; if the latter dilution gave a posi- tive result, 2-fold serial dilutions were  made  in order  to determine  the end  point.  Fluorescein  isothiocyanate- conjugated rabbit anti-human IgG im- munoglobulin (Daru Pakhash, Islamic  Republic of Iran) was used at dilution  of 1:50  in phosphate buffered  saline  with 1% Evans blue. The slides were  examined under a Leitz fluorescence  microscope,  equipped with  a  Phil- lips CS 200 W-4 mercury lamp, and a  combination of exciter filters BG12 and  BG3 and 570 mμ barrier filter. Statistical analysis Statistical  analysis was performed us- ing chi-squared  test,  t-test and analysis  of  variance  (ANOVA) with P  < 0.05  considered statistically significant. Results The overall, T. gondii  seropositive  rate  (SPR)  was  34%.  IgG  titres  <  1:20,  1:20, 1:400, 1:800, 1:1600, 1:3200 and  1:6400 were observed  in 264 (66%),  63  (15.8%),  39  (9.8%),  27  (6.8%),  3  (0.8%), 3  (0.8%) and 1 (0.3%) of  the  women respectively. IgG titres ≥ 1:1600  were observed in 1.9% of the women. With  regard  to occupation, no sig- nificant difference in SPR was observed  between  unemployed women  living  with  their  families  (38.3%)  and  gov- ernment employees (32.6%), but SPR  in  students  (22.6%) was  significantly  lower  than  the  unemployed women  (P < 0.05) (Table 1). Mean ages of the  unemployed women, government em- ployees and students were 20 [standard  deviation  (SD) 0.6],  25.14  (SD 3.8)  and 17.4  (SD 2.2)  years  respectively.  Difference of mean ages was significant  between  the groups  (P  < 0.001) and,  on post hoc comparison,  this was due  EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 26 to  the student and government officer  groups. As shown in Table 2, SPR of T. gon- dii in women with less than high-school  education was significantly higher than  in women with higher education (P < 0.05). The mean  age of women with  less  than high-school  education, high- school  and  higher  than  high  school  were 19.8 (SD 5.1), 20.6 (SD 2.9) and  23.1  (SD 3.7)  years  respectively. The  difference  in mean ages was significant  between the 3 groups (P < 0.001) and,  on post hoc comparison,  this was due  to subjects with higher than high-school  education. The SPR was not significantly differ- ent between urban and rural  residents;  SPR was 32% and 39.4%  respectively.  Mean age of urban  residents was 20.7  (SD 4.1) years which was significantly  higher  than  that of  rural women [19.1  (SD 4)] years (P < 0.001). Discussion In the present study, 66% of pre-marriage  women were seronegative. This figure is  very  close  to  the Daryani  and Saghar  study [9]  that  reported 65.3%  in same  group  in  Ardabil  (north-west  of  the  Islamic Republic of Iran). Such women  will usually become pregnant  early  in  marriage in our country. Therefore, they  are  considered  a  high-risk  group  for  congenital  toxoplasmosis,  if  they sero- convert in the pregnancy period. Traditionally,  screening  for  toxo- plasmosis has been carried out in France  [3]  and Austria  [10]  as  a mandatory  part of prenatal  care. Prenatal  screen- ing has  also been  carried out  in pilot  projects  in  countries  such  as Finland  [11], Sweden [12] and Brazil [13]. The  screening programmes have  revealed  congenital  toxoplasmosis  prevalence  values  varying  from 1 per  1000  [10] to 1 per 10 000 [14] live births in Aus- tria  and  the United States of America  (Massachusetts)  respectively.  In  the  Islamic Republic of  Iran,  frequency of  susceptible pregnant women in the first  prenatal consultation (being seronega- tive)  is not known. However, pregnant  women at high risk of fetal transmission  of  toxoplasmosis  at  the beginning of  pregnancy  could be  identified during  this consultation. It is generally accepted that the prev- alence of antibodies  in human popula- tions depends on geographic, climatic,  hygiene and socioeconomic conditions,  as well as on the lifestyle of the popula- tion  [15]. Studies have  indicated  that  the prevalence of T. gondii varies greatly  in different areas of the Islamic Republic  of Iran. The highest prevalence has been  reported  from Gilan  and Mazandran  provinces (in the north of the country)  [5,6] where  the environmental  condi- tions are more  favourable  for matura- tion and survival of oocysts  than other  regions. Qazvin is a southern neighbour  of Gilan and Mazandran provinces and  it  is  a  region with moderate T. gondii seroprevalence in comparison to them. In  our  study,  mean  ages  of  the  sero positive women were  significantly  higher  than  the seronegative ones. Se- roprevalence of T. gondii  is  known  to  increase by age [2,15]; we assume that  the increase is a reflection of increasing  exposure years of women  to T. gondii.  Infection with T. gondii  starts with  a  short  acute  phase  and proceeds  to  a  latent  phase when  cysts  are  formed;  these survive for the rest of the host’s life,  mainly  in neural and muscular  tissues.  Data suggest that toxoplasma infection  in humans  is  life-long, namely:  there  is  a slow decrease in specific antibodies to  T. gondii  in an infected individual [16];  the  frequency of  seroconversion (loss  of specific antibodies) among seroposi- tive subjects is extremely low [17]; and  there is a high frequency of reactivation  of  toxoplasmosis  in  seropositive AIDS  patients [18]. IgG antibodies to T. gondii usually  appear within 1  to 2 weeks of  acquisition of  the  infection  and peak  within 1 to 2 month, then fall at variable  rates, and usually persist for life [1]. Our  results  show  that SPR  in  the  unemployed women was  significantly  Table 1 Distribution of IFA antibodies to Toxoplasma gondii in women referred for pre-marriage examinations according to occupation Occupation IgG < 1:20 IgG ≥ 1:20 Total No. % No. % No. % Unemployed out side the home 153 61.7 95 38.3 248 100 Government officer 29 67.4 14 32.6 43 100 Student 48 77.4 14 22.6 62 100 Other 26 68.4 12 31.6 38 100 Total 256a 65.5 135b 34.5 391 100 aWith 8 missing; bwith 1 missing. IFA = immunofluorescence. Table 2 Distribution of IFA antibodies to Toxoplasma gondii in women referred for pre-marriage examinations according to education Education IgG < 1:20 IgG ≥ 1:20 Total No. % No. % No. % < High school 80 56.7 61 43.3 141 100 High school 139 72.0 54 28.0 193 100 > High school 45 68.2 21 31.8 66 100 Total 264 66.0 136 34.0 400 100 IFA = immunofluorescence. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 27 higher  than students. The difference  is  probably due  to age; mean ages of  the  unemployed women were significantly  higher  than  the  students. Toxoplasma  prevalence  in women with  less  than  high-school education was significantly  higher  than  in  women  with  higher  education. Lower  levels of  education  are usually associated with lower socio- economic status and may be related to  employment  in  jobs with greater  soil  exposure. We  found no significant dif- ference  in  seroprevalence  between  urban and rural residents. Some studies  showed higher T. gondii  seropositivity  among people who  live  in  rural  areas,  but other  studies have  failed  to  show  any difference [15,19–22]. Predicting future trends in T. gondii prevalence  in  the  Islamic Republic of  Iran is difficult because we do not have  a national estimate of what proportion  of T. gondii  infections  are  attributable  to undercooked meat exposure, cat fae- ces,  soil or water exposure. Currently,  there are no tests that can discriminate  between oocyst  ingestion  and  tissue  cyst  ingestion  as  the  infection  route.  Considering  the abundance of domes- tic  and  stray  cats  in  the  country,  the  consumption of uncooked vegetables  and the suitable climatic conditions for  sporulation of T. gondii oocysts, it seems  that exposure to cat faeces is the princi- pal route for Toxoplasma infection in the  most parts of  the country. Consump- tion  of  undercooked meat  (kebabs)  could be a  second possible means  for  acquiring Toxoplasma  infection  in  the  area studied. These data  suggest  that  two-thirds  of pre-marriage women  in Qazvin are  Montoya JC, Remington JS. 1. 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Journal of communicable diseases, 2002, 34(1):15–22. susceptible  to acute  toxoplasma  infec- tion. For this reason, it is important that  women of childbearing age,  especially  pregnant women, be  educated  about  the  risk  factors  for T. gondii  infection  such as the danger of eating raw or un- dercooked meat,  soil-related hygiene  and handling of cats. Acknowledgements The authors would like to thank Dr H.  Keshavarz, Professor of Parasitology,  School of Health, Tehran University of  Medical Sciences and Mrs S. Shojaei for  kindly providing the RH strain. We also  thank Mrs M. Damircheli  for technical  assistance and Dr GH-R. Dargahi  for  sera preparation. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 28 Kawashima T et al. Prevalence of antibodies to 21. Toxoplasma gondii among urban and rural residents in the Philippines. South-east Asian journal of tropical medicine and public health, 2000, 31(4):742–6. Allain JP, Palmer CR, Pearson G. Epidemiological study of latent 22. and recent infection by Toxoplasma gondii in pregnant women from a regional population in the UK. Journal of infection, 1998, 36(2):189–96. Regional workshop on the implementation of best practices in family planning The World Health Organization (WHO) organized the Regional Workshop on the Implementation of Best Practices in  Family Planning, in Amman, Jordan, from 27 to 30 September 2009 The objective of the Workshop is to build capacity in data collection and analysis. Experts from all countries of the  Region, as well as from the United States and the United Kingdom, representatives of UNRWA, IPPF, UNFPA,  UNICEF, USAID and the Population Council in Jordan, as well as WHO concerned staff, participated in the  Workshop. The Workshop covered, inter alia: Implementing best practices initiative for improving family planning; Reproductive  health programme in the Eastern Mediterranean Region; Commodity security for ensuring sustainable family planning  service delivery; Information, education and communication for promoting family planning practices; The ten  elements of successful family planning; Mapping the implementation of best practices in family planning in the Eastern  Mediterranean Region; Promoting family planning through community-based interventions; and Successful national  family planning programme experiences in Egypt, Iran and Tunisia. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 29 Comparison of pregnancy and implantation rates in zygote intrafallopian transfer and uterine embryo transfer for nontubal infertility M. Agha-Hosseini,1 A. Aleyaseen,1 S. Peyvandi 2 and L. Kashani 1,3 ABSTRACT We carried out a prospective randomized trial on 220 couples with nontubal factor infertility to compare pregnancy rates and implantation rates after zygote intrafallopian transfer (ZIFT) and uterine embryo transfer (UET). The zygote was transferred by laparoscopy into the fallopian tube 24 hours after oocyst retrieval. UET was performed 72 hours after retrieval with abdominal sonography guide. Transfer was performed in 102 cycles in the ZIFT and 100 cycles in the UET group. The pregnancy and implantation rates were significantly higher in the ZIFT group (42.1% and 11.7%) than in the UET group (21.0% and 7.8%) (P < 0.05). ZIFT could be considered for couples who have limited time and adequate financial support. 1Infertility Centre, Dr. Shariati Hospital; 3Infertility Ward, Arash Hospital, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to L. Kashani: kashani_ladan@yahoo.co.uk). 2IVF Unit, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran. Received: 10/04/07; accepted: 02/09/07 يننلجا لقنو ،بولاف بوبنأ لىإ )ةحقلالا( تويجزلا لقن ينب بيوبنلأا يرغ مقعلا في ةضيوبلا سارغنا تلاّدعمو لملحا ةنراقم محرلا لىإ نياشاك ندلا ،يدنويب هديبس ،ينساي لآ فشرأ ،ينيسح اقآ هيضرم دعب ةضيوبلا سارغنا تلادعمو لملحا تلادعم ةنراقلم بيوبنلأا يرغ مقعلا نم نوناعي ًاجوز 220 لىع ةيقابتسا ةاشعُم ةبرتج نوثحابلا ىرجأ :ةصلالخا قيرط نع بولاف بوبنأ لىإ )ةحقلالا( تويجزلا لقن ىرجو .(UET) محرلا لىإ يننلجا لقن دعبو (ZIFT) بولاف بوبنأ لىإ )ةحقلالا( تويجزلا لقن طيطختلا ةدعاسمب هيلع لوصلحا نم ةعاس 72 دعب محرلا لخاد يننلجا لقن ىرجو .ةسيكتلما ةضيبلا لىع لوصلحا نم ةعاس 24 دعب نطبلا يرظنت سارغناو لملحا تلادعم تناك .ةرود 100 في محرلا لىإ يننلجا لقن ىرج مانيب ،ةرود 102 في بولاف بوبنأ لىإ تويجزلا لقن يرجو .ينطبلا تيوصلا )%7.8و UET) )%21.0) محرلا لىإ يننلجا لقن ةعومجمب ةنراقم )%11.7و ZIFT) )%42.1) بولاف بوبنأ لىإ تويجزلا لقن ةعوممج في لىعأ ةضيوبلا ميهدلو دودمح تقو ميهدل نيذللا ينجوزلل بولاف بوبنأ لىإ تويجزلا لقن ءارجإ رابتعلاا في ذخلأا نكمي كلذبو .)0.05 نم لقأ P ةقثلا ةلصاف( .ٍفاك ليام معد Comparaison des taux de grossesse et d’implantation après un transfert intra-tubaire de zygote et un transfert intra-utérin d’embryon en cas de stérilité non tubaire RÉSUMÉ Nous avons réalisé un essai prospectif randomisé sur 220 couples présentant une stérilité due à un facteur non tubaire afin de comparer les taux de grossesse et les taux d’implantation après un transfert intra- tubaire de zygote ZIFT) et un transfert intra-utérin (TIU) d’embryon. Le zygote a été transféré par cœlioscopie dans l’une des trompes de Fallope 24 heures après le prélèvement d’ovocytes, tandis que le transfert intra- utérin d'embryon a été réalisé 72 heures après le prélèvement par voie vaginale avec guidage échographique. Le transfert a été effectué sur 102 cycles dans le groupe ZIFT et sur 100 cycles dans le groupe TIU. Les taux de grossesse et d’implantation étaient significativement plus élevés dans le groupe ZIFT (42,1 % et 11,7 %) que dans le groupe TIU (21,0 % et 7,8 %) (P < 0,05). La méthode ZIFT pourrait être envisagée pour les couples disposant d’un temps limité et de ressources financières suffisantes. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 30 Introduction The ability of tubal transfer of an embryo  to produce pregnancy and live birth was  first demonstrated in a non-human pri- mate model [1]. Soon afterwards the first  successful zygote intra fallopian transfer  (ZIFT)  in humans was described [2].  Initial  reports  showed superior  results  using ZIFT rather than uterine embryo  transfer (UET) [3–6].  Subsequent  prospective  clinical  trials  failed  to  support  the  improved  efficacy  in nontubal  infertility  [7–10].  Nevertheless, due  to heterogeneity of  study populations  and differences  in  sample  size  and  treatment  protocols  in  these  clinical  trials,  the  efficacy  of  ZIFT over UET has not been evaluated  critically.  Each technique has advantages and  disadvantages. Clinical experience has  shown that transcervical UET is a rela- tively simple and safe procedure which  does not have  the  risks and complica- tions associated with general anaesthe- sia and laparoscopy. It is a cost-effective  technique and permits the selection the  best cleaving embryo for transfer.  ZIFT allows confirmation of  ferti- lization before transfer as well as exclu- sion of polyploid  embryos. There  are  several  additional advantages of ZIFT  over UET. Early cleavage and develop- ment occur  in  the natural  and physi- ological  environment of  the  fallopian  tube. The  tubal  environment may be  potentially  superior  to  the  suboptimal  conditions  in  artificial  culture media  and  incubators. With ZIFT,  there  is  better synchronization between embry- onic and endometrial development.  In  addition,  the highly  favourable clinical  pregnancy and live birth rates per cycle  commenced and per embryo  transfer,  all in the range of 40%, show ZIFT to be  a powerful clinical tool for management  of  patients with  repeated  IVF  failure  [11]. Embryos  have  been  found  in  the  vagina  after UET  and  some  transfer  procedures are more frequently associ- ated with  ectopic pregnancy  [11,12].  However, the ZIFT procedure requires  general  anaesthesia  and  laparoscopy,  increasing the cost and the risk of com- plications.  The aim of  this  study was  to com- pare pregnancy and  implantation rates  after ZIFT and UET for  the  treatment  of nontubal factor infertility. Methods This study was approved by Research  Committee  of  Tehran University  of  Medical Sciences.  Study design This was  randomized clinical  trial con- ducted  in  the  infertility  centre  of Dr  Shariati Hospital, Tehran University of  Medical Sciences from January 2005 to  February 2006.  Participants Women with  normal  hysterosalpin- go graphy and/or normal  laparoscopy  who been candidates for embryo trans- fer (ET) and had easy mock ET were  invited to participate in this prospective  randomized trial of ZIFT versus stand- ard UET. Exclusion criteria were: con- traindications for laparoscopy; repeated  implantation  failure  in previous cycles;  azoospermia;  and difficult  transfer  in  mock ET.  Informed  consent  was  obtained  from all the couples and the advantages  and  disadvantages  of  each  protocol  were fully explained to the couple before  entering  the  study. The protocol was  approved by  the  ethics  committee of  Tehran University of Medical Sciences.  Sample size calculations were based  on a previous  report  [6]  that  the clini- cal pregnancy rate in tubal transfer was  40% and in UET was 20%. Considering  these pregnancy rates, and with α = 0.05  and β = 20%, a sample size of 90 patients  in each group was calculated. As some  patients  do  not  respond  to  ovarian  stimulation or  fertilization  failure may  occur, we  increased  the sample  to 110  patients  in  each  group. The  patients  knew that they would be randomized to  either  tubal  transfer or uterine  transfer  of embryo. Randomization was performed af- ter  the decision to enter  into  the study  was made and mock ET was done. A  woman’s age is the most important fac- tor  influencing  pregnancy  rates  after  transfer [4]. Therefore, to obtain similar  demographic  characteristics  in  the 2  groups, women were  stratified by age  < 35 or 35–40 years. After  this,  rand- omization was carried out by opening a  sequentially numbered sealed envelope  to allocate women  into  the  treatment  protocol groups.  Treatment protocol Ovarian  stimulation  was  achieved  with  long-luteal GnRH-agonist down- regulation  and  human  menopausal  gonadotrophin  (HMG)  or HMG +  metrodine from day 3 of the menstrual  cycle. For  all  patients oral  contracep- tion was  administered on days 3–23  of the cycle preceding stimulation with  doxycycline 100 mg twice per day from  day 3 for 10 days only.  The GnRh-agonist buserelin acetate  (Suprefact) 500 µg  subcutaneous was  administered  from day  21 of  the  cy- cle preceding  stimulation until  day 3  of  the menstrual  cycle. The dose was  then  reduced  to 250 µg/day until  the  day of human chorionic gonadotropin  (HCG) administration.  Follicular development was  stimu- lated with HMG or metrodine + HMG  from day 3 of  the menstrual cycle. The  starting dose  for  gonadotrophins was  determined by  age,  body mass  index  and ovarian response in previous stimu- lation  cycles.  Cycle monitoring  was  achieved by  transvaginal  sonography  from day 10 of the stimulation cycle and  repeated every 48–72 h until the day of  HCG administration.  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 31 Human  chronic  gonadotropin  (10 000 U) was given when at  least 2  follicles were > 18 mm and other  fol- licles were > 15 mm. The oocytes were  aspirated using  an ultrasound guided  transvaginal  approach  34–36  hours  after HCG administration. Preparation  of  sperm  for oocyte  insemination was  carried  out  using  the  swim-up  tech- nique.  Intracytoplasmic  sperm  injec- tion was achieved  for all patients. The  ovarian  stimulation protocol,  criteria  for HCG administration and laboratory  handling in ZIFT and UET groups were  similar.  Fertilization of  recovered oocytes  was assessed 14–18 hours after insemi- nation with  visualization  of  a  2-pro- nuclear  stage embryo. We performed  ZIFT under general  anaesthesia 24 h  after oocyte retrieval using a 3 puncture  video laparoscopic technique.  After introducing the umbilical tro- cor and optical equipment the abdomi- nal cavity was surveyed. After aspirating  sanguineous fluid from the pelvic cavity  a maximum of 5 2-pronuclear embryos  were placed 4–5 cm  into  the most ac- cessible fallopian tube (Cook catheter). In  the  UET  cycles,  transfer  was  performed 72 h after retrieval of the em- bryo at the 4–8-cell stage (grade I, grade  II) using a Wallace catheter guided by  transabdominal  sonography  to place  the tip 1.5 cm proximal to the fundus.  The  luteal phase was  supported  in  all  cycles  by  cyclogest  suppositories  400 g  every  8–12 h.  Serum  level  of  β-human chorionic gonadotropin was  determined 12–14 days  after ET and  if positive, measured again after 48 h. If  the  titre had  increased,  the use of cycl- ogest was continued until 12 weeks of  pregnancy.  At 5 weeks after  transfer,  the  intra- uterine gestational  sac  and  fetal heart  beat  were  demonstrated  by  vaginal  sonography. The patients were followed  until 12 weeks pregnancy. Clinical preg- nancy was defined by  the presence of  gestational sac 5–6 weeks after transfer.  Ongoing pregnancy was defined as  a  pregnancy of > 12 weeks gestation. The  implantation  rate  was  calculated  by  dividing  the  total number of gestation  sacs by the total number of  transferred  embryos.  Statistical analysis Statistical comparisons were performed  with  the unpaired Student  t-test  and  chi-squared test.  Results There were 110 couples in each group:  with  78  women  < 35  years  and  32  women 35–40 years in each. There was  no  significant difference between  the  2  groups  regarding  baseline  data  in- cluding duration of  infertility, etiology,  body mass index or number of previous  assisted reproduction technology cycles  (Table 1).  Clinical  data  and  treatment  cycle  characteristic were similar  in  the ZIFT  and UET  groups  and  are  presented  in Tables 1 and 2.  In  the ZIFT group,  6 patients did not  respond  to ovarian  stimulation and  in 2 patients  fertiliza- tion failure occurred. In the UET group  5 patients were poor responders and in  5 patients  fertilization  failure occurred.  So analysis was performed in 102 cycles  in the ZIFT and 100 cycles in the UET.  There was no significant difference  between  the 2 groups  regarding  treat- ment protocol,  stimulation duration,  number of HMG ampoules,  number  of oocytes retrieved and number of em- bryos transferred. Serum estradiol  level  and endometrial  thickness on  the day  of HCG injection was  similar  in  the 2  groups.  Clinical pregnancy rate per transfer,  42.1% (43/102); ongoing pregnancy  rate per  transfer, 35.3% (36/102); and  Table 1 Clinical characteristics of women undergoing zygote intrafallopian transfer (ZIFT) and uterine embryo transfer (UET) Characteristic ZIFT UET P No. % No. % Number of patients 110 110 History of: Previous ART cycle 47 53 IVF or ICSI + ET 21 44.7 31 58.5 NS ZIFT 26 55.3 22 41.5 Type of infertility Primary 94 85.3 92 83.6 NS Secondary 16 14.7 18 16.4 Infertility diagnosis Anovulation 14 12.7 24 21.8 NS Male factor 53 48.2 38 34.5 NS Unexplained 8 7.3 7 6.4 NS Endometriosis 4 3.6 5 4.5 NS Male factor + anovulation 31 28.2 36 32.7 NS Mean SD Mean SD Age (years) 30.9 5.3 30.4 4.8 NS BMI (kg/m2) 22.9 2.3 22.8 2.5 NS Duration of infertility (years) 8.3 4.4 8.6 4.7 NS No. of previous ART cycles 1.29 0.54 1.30 0.46 NS ART = assisted reproduction technology; IVF = in vitro fertilization; ICSI = intracytoplasmic sperm injection; BMI = body mass index; SD = standard deviation. NS = not significant (P > 0.05). EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 32 implantation rate, 11.7% (57/488) were  significantly higher  in  the ZIFT group  than  the UET group [21% (21/100),  20%  (20/100)  and  7.8%  (27/343)  respectively]  (P < 0.05). Abortion oc- curred in 7 (6.9%) women in the ZIFT  group and 1 (1%) woman  in  the UET  group.  In  those  in whom abortion oc- curred, 2 had  triplet pregnancy and 5  had twin pregnancy.  Ectopic  pregnancy  occurred  in  1  patient  in  the ZIFT group; no ectopic  pregnancy occurred in the UET group.  The  data  regarding  pregnancies  that  went  to  term are presented  in Table 3.  No triplet pregnancies went  to  term  in  the either group. There was no significant  difference between the 2 groups in terms  of multiple pregnancies (Table 3).  Discussion This  prospective  randomized  study  demonstrated higher  rates  for  clinical  pregnancy, ongoing pregnancy and im- plantation with ZIFT  than with UET.  These findings agree with those of Pool  et al. [6]. In our study, clinical pregnancy  rate per transfer was 42.1% in ZIFT and  21%  in UET. Ongoing pregnancy rate  per  transfer was 35.3%  in ZIFT versus  20%  in UET.  In  the first  prospective  study of  this  issue,  reported pregnancy  rate per  transfer was 47.7%  for  in vitro fertilization  and 37.9%  for ZIFT  [7].  The  difference  between  their  results  and ours may be  related  to differences  in sample size and  treatment protocol.  [7].  A Canadian  study  failed  to  dem- onstrate  any obvious benefit of  tubal  transfer  compared  to uterine  transfer  [8]. Clinical pregnancy per retrieval was  12% with ZIFT and 26.5% with UET  [8]  although  the  treatment  protocol  was  not  comparable  for  all  patients.  Ovarian stimulation was achieved with  clomiphen + HMG, HMG or GnRH- agonist in short protocol. Meta-analysis  of  prospective  clinical  trials  did  not  demonstrate any differences  in clinical  pregnancy rate per transfer and implan- tation  rate  between ZIFT  and UET  (36.5%, 15% in ZIFT versus 31.4%, 12%  in UET), although there was a tendency  towards  a higher pregnancy  rate with  ZIFT [10]. In our  study,  there were no differ- ences between  the 2 groups  regarding  demographic and baseline data.  Our findings  suggest  that  the dif- ference  in clinical pregnancy between  the 2 groups is due to differences in the  transfer  techniques. One of  the  factors  that most affected UET cycles was qual- ity of  transfer. Clinical pregnancy and  implantation  rates were  significantly  higher with ZIFT than with UET.  It has been reported that UET with a  transabdominal sonography guide  is  su- perior  to blind catheter placement [13].  With sonography we can ensure that the  catheter passes the internal os and place- ment is 1–1.5 cm under the fundus.  Clinical  experience demonstrates  that UET  is a  safe  technique but a  re- port of mock ET showed that in 23% of  transfers, expulsion of catheter contents  occurred or  increased  junctional  zone  contraction may decrease the pregnan- cy  rate  [14]. Transmission of  vaginal  microorganisms  to  the uterus  via  the  transfer catheter may also decrease  the  pregnancy rate. All of these factors may  be prevented by tubal transfer.  In  the  Van  Voorhis  et  al.  study  comparing pregnancy  rates after  tubal  and uterine  transfer of  cryopreserved  embryos,  tubal  transfer  improved  the  pregnancy  rate. They  reported clinical  pregnancy  rate  of  68%  and  ongoing  pregnancy  rate  of  58%  per  transfer  with  ZIFT  compared with  24%  and  19% respectively with UET [15]. They  Table 2 Stimulation cycles characteristic in the zygote intrafallopian transfer (ZIFT) and uterine embryo transfer (UET) groups Characteristic ZIFT UET P No. of patients 110 110 No. of cycles with transfer 102 100 No. (%) of cycles cancelled 8 (7.2) 10 (9.0) NS Mean SD Mean SD No. gonadotropine ampoules 16.38 7.13 36.88 12.06 NS Stimulation duration (d) 10.7 1.79 10.8 1.78 NS Serum E2 on HCG day (pg/ml) 2279.1 1199.0 2296.5 7209.0 NS Endometrial thickness on HCG day (mm) 10.59 2.07 10.48 2.25 NS No. oocytes retrieved 7.22 3.00 6.65 3.17 NS No. oocytes fertilized 4.07 2.30 3.82 2.14 NS No. embryos transferred 4.06 2.02 3.87 1.61 NS E2 = estradiol; HCG = human chorionic gonadotrophin; SD = standard deviation. NS = not significant (P > 0.05). Table 3 Pregnancies that went to term and multiple pregnancies in the zygote intrafallopian transfer (ZIFT) and uterine embryo transfer (UET) groups Variable ZIFT UET P No. % No. % Pregnancies that went to term 25/36 69 13/20 65 NS Multiple pregnancies 20/43a 46 9/21b 42 NS aTwin 15; triplet 5. bTwin 7; triplet 2. NS = not significant (P > 0.05). طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 33 suggested  that  tubal  transfer  of  the  cryopreserved embryo mimics a natural  conception cycle  in  terms of early em- bryo development and implantation. It  has  been  reported  that  zygote  intra fallopian  transfer  is  a  beneficial  mode  for  treatment  for patients with  repeated  failure of  implantation  in  IVF  and UET  [16].  Pregnancy  rates  and  implantation  rates were  significantly  higher  in  the ZIFT group  than  in  the  UET group. They showed that patients  in whom only  low quality embryos are  achieved  in repeated IVF attempts can  also benefit from the ZIFT procedure].  The limitations of this study include  the small sample size and the fact that it  was carried out in a single centre. In  summary,  our  results  demon- strate  a  significant  advantage of  tubal  over  uterine  transfer.  Although  the  ZIFT approach  involves  greater  cost  and complexity,  the greater pregnancy  rate per  cycle  is  one of  the most  im- portant  reasons  for  suggesting ZIFT  to couples who have  limited  time and  adequate financial support. Balmaceda JP et al. Successful in vitro fertilization and embryo 1. transfer in cynomolgus monkeys. Fertility and sterility, 1984, 42:791–5. Devroey P et al. Pregnancy after translaparoscopic zygote in-2. trafallopian transfer in a patient with sperm antibodies. Lancet, 1986, 1:1329. Asch R. Uterine versus tubal embryo transfer in the human. 3. An- nals of the New York Academy of Science, 1991, 626:461–6. Yovich JL et al. The relative chance of pregnancy following 4. tubal or uterine transfer procedure. Fertility and sterility, 1988, 49:858–64. Hammitt DG et al Comparison of concurrent pregnancy rates 5. for in vitro fertilization—embryo transfer, pronuclear stage embryo transfer and gamete intra-fallopian transfer. Human reproduction, 1990, 5:947–54. Pool TB et al. Zygote intrafallopian transfer as a treatment for 6. nontubal infertility a 2-year study. Fertility and sterility, 1990, 54:482–8. Tanbo T, Dale PO, Abyholm T. Assisted fertilization in infertile 7. women with patent fallopian tubes. A comparison of in-vitro fertilization, gamete intra-fallopian transfer and tubal embryo stage transfer. Human reproduction, 1990, 5:266–70. Fluker MR, Zouves CG, Bebbington MW. A prospective ran-8. domized comparison of zygote intrafallopian transfer and in vitro fertilization embryo transfer and in vitro fertilization–em- bryo transfer for nontubal factor infertility. Fertility and sterility, 1993, 60:515–9. References Preutthipan S et al. A prospective randomized crossover 9. comparison of zygote intrafallopian transfer fallopian trans- fer and in vitro fertilization embryo transfer in unexplained infertility. Journal of the Medical Association of Thailand, 1994, 77:599–604. Habana AE, Palter SF. Is tubal embryo transfer of any value, a 10. meta analysis and comparison with the Society for Assisted Reproductive Technology database. Fertility and sterility, 2001, 76:286–92. Levran D et al. Prospective evaluation of blastocyst stage 11. transfer vs. zygote intrafallopian tube transfer in patients with repeated implantation failure. Fertility and sterility, 2002, 77:971–6. Schulman JD. Delayed expulsion of transfer fluid after IVF/ET. 12. Lancet, 1986, 1:44. Woolcott R, Stanger J. Potentially important variables identi-13. fied by transvaginal ultrasound—guided embryo transfer. Hu- man reproduction, 1997, 12:963–6. Mansour RT et al. Dummy embryo transfer using methylene 14. blue dye. Human reproduction, 1994, 9:1257–9. Van Voorhis BJ et al. Tubal versus uterine transfer of cryopre-15. served embryo. Fertility and sterility, 1995, 63:578–82. Levran D et al. Zygote intrafallopian transfer may improve preg-16. nancy rate in patients with repeated failure of implantation. Fertility and sterility, 1998, 69:26–30. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 34 Perinatal outcomes of singleton term breech deliveries in Basra H. Alshaheen1 and A. Abd Al-Karim2 ABSTRACT This study aimed to assess the perinatal morbidity and mortality in breech deliveries, to study the correlation of parity and birth weight with perinatal mortality by mode of delivery. Of 210 women in labour in Basra maternity and child hospital, 97 underwent vaginal breech deliveries and 113 delivered by caesarean section. Birth trauma was restricted to vaginal deliveries. The perinatal mortality was significantly higher in vaginal deliveries (8.2%) compared with caesarean deliveries (0.9%). A higher perinatal mortality was recorded among infants > 3500–4000 g birth weight in vaginal deliveries. Caesarean section reduced the perinatal mortality in both nulliparous and parous women in term breech infants. 1Department of Obstetrics and Gynaecology, Basra Maternity and Child Hospital, Basra, Iraq (Correspondence to H. Alshaheen: hayfa_alshaheen@yahoo.com). 2Department of Paediatrics, Medical College, University of Basra, Basra, Iraq. Received: 14/06/07; accepted: 02/09/07 ةصربلا في ةيدعقلما تادلاولل ةدلاولاب ةطيحلما ةترفلا جئاتن حايلما رثنم ميركلا دبع ةدئاع ،ينهاشلا ةعجم ردوهم ءافيه ملأا تادلاو ددع ينب ةقلاعلا ةساردو ،ةيدعقلما تادلاولا في ةدلاولاب ةطيحلما ةترفلا في تايفولاو ةضارلما مييقت لىإ ةساردلا هذه فدته :ةصلالخا 97 ترجأ ،لافطلأاو ةدلاولل ةصربلا ىفشتسم في تدلو ةأرما 210 ينب نمو .ةدلاولا زارطو ةدلاولاب ةطيحلما ةترفلا في تايفولا عم دولولما نزوو ةيصريقلا تادلاولاب ةنراقم )%8.2( ةيلبهلما تادلاولا لىع ةدلاولا حوضر تصرتقاو .ةيصريق ةدلاو ةأرما 113 تدلوو ،ةيدعقم ةيلبهم ةدلاو ةأرما ةدلاولا تللقو .مارغ 4000-3500 ةدلاولا نزو نم بركأ لافطلأا ينب ةدلاولاب ةطيحلما ةترفلا في ةيلبهلما تادلاولا في رثكأ تايفو تلجسو .)%0.9( .لبق نم ندلو تيلالا ءاسنلل ةيدعقلما تادلاولا فيو ،لبق نم ندلي لم تيلالا ءاسنلا في ةدلاولاب ةطيحلما ةترفلا في تايفولا نم ةيصريقلا Issue périnatale d’accouchements par le siège d’enfants uniques nés à terme à Bassora (Iraq) RÉSUMÉ Cette étude visait à évaluer la morbidité et la mortalité périnatales associées aux accouchements par le siège afin d’étudier la corrélation entre d’une part, le nombre d’enfants nés vivants et le poids à la naissance et d’autre part, la mortalité périnatale selon le type d’accouchement. Sur 210 femmes en travail à la maternité-hôpital pour enfants de Bassora, 97 ont eu un accouchement par voie basse par le siège et 113 ont accouché par césarienne. Les traumatismes obstétricaux étaient limités aux accouchements par voie basse. La mortalité périnatale était significativement plus élevée pour les accouchements par voie basse (8,2 %) que pour les accouchements par césarienne (0,9 %). Une mortalité périnatale plus élevée a été enregistrée chez les nourrissons nés par voie basse et pesant plus de 3,5 kg à 4 kg à la naissance. La césarienne réduisait la mortalité périnatale des nourrissons nés à terme par le siège chez les femmes nullipares et multipares. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 35 Introduction It has  long been  thought  that  vaginal  delivery of breech  infants  is associated  with  increased neonatal morbidity and  mortality compared with elective cae- sarean delivery  [1]. This observation  has been a topic of considerable debate  over  the past  few years, and retrospec- tive studies of  the subject have yielded  conflicting data  [2–6]. The  frequency  of breech presentation is approximately  3% of term all term deliveries, according  to a large population-based study in the  United States [7]. The controversy over  appropriate  management  of  breech  presentation,  as well  as  considerable  disagreement  regarding  appropriate  candidates  for a  trial of vaginal breech  delivery, has made it a difficult phenom- enon to study prospectively.  Only  3  prospective,  randomized  controlled  studies  have  examined  maternal  and newborn outcomes  as- sociated with breech vaginal delivery  [8–10]. The first 2 were published more  than 20 years ago and  found minimal  increased risk to the fetus  in a carefully  selected  group of  vaginal  breech de- liveries  [8,9].  In  these 2 older  studies,  however, maternal morbidity was  sig- nificantly increased (49%) with caesar- ean delivery, thus influencing decisions  to undergo a  trial of  labour  for breech  presentation  [8,9]. More  recently,  in  the Term Breech Trial, Hannah et  al.  conducted  a  large, multicentre,  pro- spective,  randomized  controlled  trial  of vaginal breech delivery as compared  with planned caesarean delivery  [10].  They found a lower rate of perinatal and  neonatal mortality and serious neonatal  morbidity (1.6% for planned caesarean  delivery compared with 5.0% in planned  vaginal birth) with no significant differ- ences in maternal morbidity or mortal- ity. This study prompted the American  College of Obstetricians and Gynecolo- gists to recommend planned caesarean  delivery for term singleton breech pres- entation [11]. Some workers, however,  have argued that the design of the Term  Breech Trial  is flawed, and  the debate  continues [12].  The aim of  this  study was  to assess  the perinatal outcome in singleton term  infants delivered in breech presentation  in Basra maternity  and child hospital  and  to  study  the  correlation of parity  and birth weight with perinatal mortal- ity by mode of delivery.  Methods This prospective  study was conducted  over a 12-month period (from 1 Sep- tember 2005  to 31 August 2006) on  women  attending  the  delivery  room  with a  live singleton  term breech pres- entation  at  the  maternity  and  child  hospital  in Basra,  Iraq. Of  the 10 215  deliveries during  the study period, 259  were breech presentation. Only women  who delivered during  the  researchers’  visits  (3–4  times per week) were  in- cluded in the study (n = 210). Women  with obstetric problems  and medical  illnesses were excluded from the study.  All women were  examined by  the  same  obstetrician,  and medical  and  neonatal data were obtained,  including  maternal age, parity,  educational  level,  date of  last menstrual period, previous  caesarean  section, previous admission  to neonatal intensive care unit (NICU),  history of  infertility  and maternal  ill- nesses. All women were informed about  the  study before  they gave consent  to  participate. All of the women who were  eligible  for  the study consented to par- ticipate.  Abdominal  examination was per- formed  for  fetal presentation, engage- ment and  fetal size. Pelvic examination  was  performed  under  full  aseptic  techniques, to assess cervical dilatation,  type of  breech  and  state of  amniotic  membranes,  to exclude cord prolapse  or presentation and  to assess  the pel- vis. Ultrasound was done  to  confirm  gestational  age,  estimate  fetal weight,  exclude  congenital malformations of  the  fetus,  exclude  twin pregnancy and  locate  the placenta. Abdominal X-ray  was  performed  only  to women who  were  in  the early  stages of  labour (n = 156)  to diagnose extended head. This  was standard practice in our hospital. All women chose trial of labour, no  woman  requested  caesarean  section.  When caesarean section was performed  it was clinically  indicated by the  judge- ment of the attending obstetricians and  after discussion with the patient. A trial  of breech vaginal delivery was done only  for  those patients who had  the  inclu- sion criteria for breech vaginal delivery.  Those who did not meet  these criteria  delivered by caesarean section without  trial of labour.  The  inclusion  criteria  for  a  trial  breech delivery were:  a  clinically  ade- quate pelvis, a frank or complete breech  with estimated fetal weight < 4 kg with  a flexed head and the informed consent  of  the mother. Labour was allowed  to  progress  and  the  fetal  heart  rate was  continuously monitored by electronic  fetal heart monitoring with  regular ab- dominal  and pelvic  examination. The  method of delivery was assisted or spon- taneous breech delivery by  the most  experienced obstetrician. Conversion  to  caesarean  section was  considered  appropriate whenever  the need arose,  e.g.  lack of progress of  labour and  fetal  distress. The  indications  for caesarean  section were: primigravida  aged > 35  years, conception after  infertility, previ- ous  difficult  vaginal  delivery, macro- somia, cephalopelvic disproportion and  breech with footling presentation. All neonates were examined follow- ing delivery by  the paediatric  resident.  Body weight was  recorded and gesta- tional age was assessed using Dubowitz  criteria  [13].  Perinatal  outcome was  assessed  including Apgar  scores  at  1  minute  and 5 minutes,  admissions  to  NICU,  as  well  as  birth  traumas  and  deaths.  EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 36 The overall perinatal mortality  rate  was calculated according to the formu- la:  [no. of  still births + no. of 1st-week  neonatal deaths)/no. of  total births] ×  100. Perinatal mortality  in  relation  to  parity and birth weight were compared  by route of delivery. Statistical  analysis was done using  the chi-squared test, with P-value < 0.05  considered  to be significant.  It was not  used in samples of less than 5. Results A total of 210 women were included in  this  study, 97  (46.2%) who delivered  vaginally and 113 (53.8%) who had an  emergency caesarean section.  The maternal  and birth  character- istics  of  the women  are presented  in  Table 1. There were 104 nulliparas and  106 paras. There were  statistically  sig- nificant differences in the age and parity  of women who delivered vaginally and  those who delivered by caesarean sec- tion. There was higher incidence of cae- sarean deliveries among the nulliparous  group (P < 0.05). A significantly higher  percentage of caesarean deliveries were  among  well-educated  women  (P  <  0.05). There was a significant difference  in  infant’s birth weight between  the 2  groups, with a higher  rate of caesarean  deliveries  among  women  who  gave  birth to infants weighing 3500–4000 g.  Neonates of vaginal deliveries had a  higher incidence of Apgar score < 7 at 1  and 5 minutes (both P < 0.05). NICU  admittance was  significantly higher  in  the vaginal compared with  the caesar- ean delivery group (P < 0.05) (Table  2). All the cases of birth trauma were in  vaginally-delivered  infants. There were  3  (3.1%)  infants with brachial  plexus  lesion,  2  (2.1%) with  birth  asphyxia  and 1 (1.0%) with a  fractured clavicle (Table 3).  The overall perinatal mortality  rate  was  4.3%  (9/210). Neonatal  deaths  in  the first week occurred significantly  more  often  among  infants  delivered  vaginally  (8/97,  8.2%)  than  by with  caesarean  delivery  (1/113,  0.9%) (P  <  0.05). There were  no  stillbirths  in  either  group  (Table 4). The cause  of 1st-week neonatal death was birth  asphyxia  in both vaginal and caesarean  deliveries.  Neonatal mortality was higher  in  both nulliparous  and parous women  Table 1 Maternal and infant characteristics by mode of delivery P-valueTotal (n = 210) Caesarean section (n = 113) Vaginal delivery (n = 97) Maternal factors %No.%No.%No. Age (years) < 0.0159.0 12465.5 7451.5 5017–30 41.0 8634.5 3948.5 4731–45 Parity < 0.0149.5 10473.58321.6 21Nulliparous 50.5 10626.5 3078.4 76Parous Educational level < 0.01 28.6 6017.7 2041.2 40Illiterate 31.4 6625.7 2938.0 37Primary 33.0 6947.8 5415.5 15Secondary 7.0 158.8 10 5.2 5Higher Occupation > 0.0585.7 18082.3 9389.7 87Housewife 14.3 3017.7 2010.3 10Employed Infant’s birth weight (g) < 0.0177.6 16372.6 8283.5 812500–3500 22.4 4727.4 3116.5 16> 3500–4000 n = number of women/births. Table 2 Apgar scores and neonatal intensive care unit (NICU) admittance by mode of delivery P-valueTotal (n = 210) Caesarean section (n = 113) Vaginal delivery (n = 97) Variable No.%No.%No.% < 0.056.2132.7310.310Apgar score < 7 at 1 min < 0.055.7121.8210.310Apgar score < 7 at 5 min < 0.054.8101.828.28NICU admittance Table 3 Fetal morbidity by mode of delivery Caesarean section (n = 113) Vaginal delivery (n = 97) Variable %No.%No. –03.13Brachial plexus lesion –02.12Birth asphyxia –01.01Fracture clavicle 0.91–0Meconium aspiration 0.916.26Total طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 37 when comparing vaginal and caesarean  deliveries  (Table 5). Among  the nul- liparas, a higher rate of neonatal mortal- ity was  recorded  for vaginal deliveries  (23.8%) compared with caesarean de- liveries (1.2%). For the paras, there were  3/76  neonatal  deaths  in  the  vaginal  delivery group (3.9%) while there were  no  neonatal  deaths  in  the  caesarean  delivery group. Among the infants with  birth weight 2500–3500 g,  there were  6 neonatal deaths (7.4%)  for  those de- livered  vaginally while  there were no  neonatal deaths among caesarean deliv- eries (Table 6). In the infants with birth  weight 3500–4000 g, the neonatal death  rate was 12.5% for vaginal deliveries and  3.2% for those delivered by caesarean.  Discussion According to Cheng and Hannah who  reviewed 24  studies  in  1993,  vaginal  delivery  is associated with higher peri- natal morbidity and mortality rates than  planned caesarean delivery [14]. They  suggested that, until more evidence was  available,  a planned caesarean delivery  should be strongly considered  for per- sistent breech presentation at  term. A  study by Bingham et al. concluded that a  policy of selected vaginal delivery will re- sult in 4 perinatal deaths for every 1000  patients delivered  [15]. Other  studies  suggested a potential  increased  risk of  neonatal morbidity and mortality after  a trial of labour and vaginal delivery and  that there was greater neonatal survival  in  association with  caesarean  section  [16–18].  Although  there  is  a  growing  ten- dency worldwide  to perform elective  caesarean section for infants presenting  in  the breech position,  a  trial  of  vagi- nal delivery  is  still  allowed  in  selected  breech cases in our main maternity cen- tre  in Basra.  In  this prospective  study  the perinatal outcomes of 113 women  delivered by emergency caesarean sec- tion were compared with  those of 97  women delivered vaginally. We  found  that,  even applying appropriate  inclu- sion criteria for a trial of labour, vaginal  breech deliveries  seemed  to be associ- ated with significantly greater neonatal  risks. The overall  neonatal  outcomes  were  better  in  the  caesarean  section  group compared with the vaginal deliv- ery group. In  this  study,  the  rate of  caesarean  section  for  term breech presentation  was 53.8%;  this  finding  is  lower  than  that reported by Diro et al. [19]. Mater- nal educational level was inversely pro- portional  to  the  rate of vaginal breech  birth. This  study  has  confirmed  that  illiterate women were more  likely  to  deliver  a breech  infant  vaginally  than  were  educated  women. This  finding  is  similar  to  that of Gilbert  et  al.  [1].  This may indicate that illiterate women  have inadequate information about the  adverse perinatal  outcome of  vaginal  breech delivery due  to  inadequate or  no antenatal  care. Mothers who were  better  educated were more  likely  to  have caesarean section for their breech  birth. It should be noted that caesarean  section was clinically indicated and not  on  the patient’s  request. This  can be  explained by better  educated women  having  adequate  antenatal  care  and  Table 4 Perinatal mortality by mode of delivery Variable Vaginal delivery (n = 97) Caesarean section (n = 113) Total (n = 210) P-value No. % No. % No. % Stillbirths 0 – 0 – 0 – – 1st-week neonatal deaths 8 8.2 1 0.9 9 4.3 < 0.05 Overall perinatal deaths 8 8.2 1 0.9 9 4.3 < 0.05 Table 5 Perinatal mortality by mode of delivery and parity ParousNulliparousVariable Caesarean section (n = 30) Vaginal delivery (n = 76) Caesarean section (n = 83) Vaginal delivery (n = 21) %No.%No.%No.%No. –0–0–0–0Stillbirths –03.931.2123.851 st-week neonatal deaths –03.931.2123.85Overall perinatal deaths Table 6 Perinatal mortality by mode of delivery and birth weight Birth weight 3500–4000 gBirth weight 2500–3500 gVariable Caesarean section (n = 31) Vaginal delivery (n = 16) Caesarean section (n = 82) Vaginal delivery (n = 81) %No.%No.%No.%No. –0–0–0–0Stillbirths 3.2112.52–07.461st-week neonatal deaths 3.2112.52–07.46Overall perinatal deaths EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 38 being  assigned  to planned  caesarean  section by their obstetrician. Therefore,  when labour started earlier with persist- ent breech,  the caesarean  section was  performed immediately on admission.  Parity  and birth weight were  also  evaluated. There were more nulliparas  in  the caesarean section (73.5%)  than  the  vaginal  delivery  (21.6%)  group,  which is similar to the results of Gilbert  et al.  [1]. Birth weight  is  an  important  factor  affecting  the  caesarean  section  rate  in breech delivery, with more  in- fants weighing > 3500–4000 g  in  the  caesarean section (27.4%) than vaginal  delivery (16.5%) groups  in our  study.  This finding  is  in  agreement with  the  studies of Doyle  et  al.  and Koo et  al.  [20,21]. The  present  study  confirmed  that  Apgar  score < 7  at 5 minutes occurred  significantly more often among vaginal  deliveries. This finding  is  in  contrast  to  that of Doyle et al.  [20]. Also, our  study  documented a significantly higher rate in  NICU admission for vaginal breech deliv- eries (8.2% versus 1.8%). This rate is lower  than that of Koo et al. which may be due to  the large sample in their study [21]. Our  results  indicate  that  major  neonatal morbidity was  increased with  vaginal breech deliveries. The most strik- ing was risk of brachial plexus injury; this  was a major cause of  injury associated  with breech  vaginal  deliveries  in  our  study (3.1%). This  is  in  agreement  to  that reported by Collea et al. who found  that 3.3% of births with brachial plexus  injury in the vaginal delivery group [8].  Clearly  our  study  supports  the  view  that  vaginal breech delivery  is  associ- ated with birth trauma more often than  caesarean deliveries [22]. When  comparing  vaginal  and  caesarean deliveries,  the present  study  has confirmed a significant association  between mode  of  delivery  and  neo- natal mortality. A  significantly higher  neonatal  death was  reported  among  vaginal breech deliveries. Our neonatal  mortality rate of 8.2% for vaginal breech  delivery  is greater  than  that previously  reported  in a meta-analysis by Cheng  and Hannah [14].  Our  study  sustains  the  general  opinion  that nulliparous women are  at greater  risk  than parous women  in  vaginal breech delivery.  In  those who  delivered vaginally,  the neonatal mor- tality  rate was  higher  in  nulliparous  women compared with that  in parous  women. This  is  in agreement Diro et  Gilbert WM et al. Vaginal versus cesarean delivery for breech 1. presentation in California: a population-based study. Obstet- rics and gynecology, 2003, 102:911–7. Sanchez-Ramos L et al. Route of breech delivery and maternal 2. and neonatal outcomes. International journal of gynaecology and obstetrics, 2001, 73:7–14. Irion O et al. Planned vaginal delivery versus elective caesarean 3. section: a study of 705 singleton term breech presentations. British journal of obstetrics and gynaecology, 1998, 105:710–7. Thorpe-Beeston JG, Banfield PJ, Saunders NJ. Outcome 4. of breech delivery at term. British medical journal, 1992, 305:746–7. Roman J, Bakos O, Cnattingius S. Pregnancy outcomes by 5. mode of delivery among term breech births: Swedish experi- ence 1987–1993. Obstetrics and gynecology, 1998, 92:945–50. Confino E et al. The breech dilemma: a review. 6. Obstetrics and gynecology, 1985, 40:330–7. Hickok DE et al. The frequency of breech presentation by ges-7. tational age at birth: a large population-based study. American journal of obstetrics and gynecology, 1992, 166:851–6. References Collea JV et al. The randomized management of term frank 8. breech presentation, a study of 208 cases. American journal of obstetrics and gynecology, 1980, 137:235–44. Gimovsky ML et al. Randomized management of the nonfrank 9. breech presentation at term: a preliminary report. American journal of obstetrics and gynecology, 1983, 146:34–40. Hannah ME et al. Planned caesarean section versus planned 10. vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lan- cet, 2000, 356:1375–83. Mode of term singleton breech delivery. 11. Washington DC, Ameri- can College of Obstetricians and Gynecologists, 2001 (ACOG Committee Opinion No. 265). Hauth JC, Cunningham FG. Vaginal breech delivery is still justi-12. fied. Obstetrics and gynecology, 2002, 99:1115–6. Stoll BJ, Kleigman RM. The fetus and the neonatal infant. 13. In: Behrman RE et al., eds. Nelson textbook of pediatrics. Philadelphia,WB Saunders, 2000:463–4. Cheng M, Hannah M. Breech delivery at term: a critical review 14. of the literature. Obstetrics and gynecology, 1993, 82:605–18. al.  [19].  It  suggests  that  the firmer  tis- sues of primigravidas present greater  hazards of trauma and asphyxia to the  fetus. It is important to inform nullipa- rous patients who refuse elective cae- sarean section and undergoing a  trial  breech vaginal delivery  that morbidity  and mortality  seems  to be  increased  in women in their first pregnancy. The  neonatal mortality  following  vaginal  breech delivery  increased when  fetal  weight was  3500–4000  g. This  is  in  agreement  to  that of  Jones et al.  [23].  This  is  explained  that macrocosmic  baby is more liable to birth trauma and  asphyxia  and  such  infants  should be  delivered by caesarean section to avoid  these adverse perinatal outcomes. In  conclusion,  vaginal breech de- livery  is  associated with  significantly  increase  in  perinatal  morbidity  and  mortality (more evident  in nulliparous  women  and  in  infants with  expected  birth weight 3500–4000 g), when com- pared with caesarean breech delivery.  Caesarean  section  for  singleton  term  breech  is  recommended as a mode of  delivery  in all nulliparas and  for  those  infants  with  expected  birth  weight  3500–4000 g. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 39 Bingham P, Lilford RJ. The management of the selected term 15. breech presentation: assessment of the risks of selected vaginal delivery versus cesarean section for all cases. Obstetrics and gynecology, 1987, 69:965–8. Krebs L, Langhoff-Roos J, Weber T. Breech at term: mode of 16. delivery? A register-based study. Acta obstetricia et gynecologica scandinavica, 1995, 74:702–6. Gifford DS et al. A meta-analysis of 1995 infant outcomes after 17. breech delivery. Obstetrics and gynecology, 1995, 85:1047–54. Kiely JL et al. Mode of delivery and neonatal death in 17 587 18. infants presenting by the breech. British journal of obstetrics and gynaecology, 1991, 98:898–904. Diro M et al. Singleton term breech deliveries in nulliparous 19. and multiparous women: a 5-year experience at The University of Miami/Jackson Memorial Hospital. Discussion. American journal of obstetrics and gynecology, 1999, 8(2):247–52. Doyle NM et al. Outcomes of term vaginal breech delivery. 20. American journal of perinatology, 2005, 22(6):325–8. Koo MR, Dekker GA, van Geijn HP. Perinatal outcome of sin-21. gleton term breech deliveries. European journal of obstetrics and gynecology and reproductive biology, 1998, 78(1):19–24. Gimovsky ML, Paul RH. Singleton breech presentation in labor: 22. experience in 1980. American journal of obstetric and gynecol- ogy, 1982, 143:733–9. Jones WR et al. Breech presentation. In: Studd G eds. 23. Progress in obstetrics and gynecology. Volume 2. London, Churchill Liv- ingstone, 1982:78–82. Monitoring emergency obstetric care Monitoring emergency obstetric care is an update of an earlier publication on monitoring the availability and use of obstetric  services, issued by UNICEF, WHO and UNFPA in 1997. The indicators defined within the publication have been used  by ministries of health, international agencies and programme managers in over 50 countries around the world. This  revision incorporates changes based on monitoring and assessment conducted worldwide and the emerging evidence  on the topic over the years, and has been agreed by an international panel of experts. It includes two new indicators and  an additional signal function, with updated evidence and new resources.  This handbook aims to describe the indicators and to give guidance on conducting studies to people working in the  field. It includes a list of life-saving services, or signal functions, that define a health facility with regard to its capacity  to treat obstetric emergencies. The emphasis is on actual rather than theoretical functioning. The emergency obstetric  care indicators described in this handbook can be used to measure progress in a programmatic continuum: from the  availability of and access to emergency obstetric care to the use and quality of those services. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 40 Nosocomial infections in a neonatal intensive care unit in south-western Saudi Arabia A.A. Mahfouz,1,2 T.A. Al-Azraqi1,3 F.I. Abbag,4 M.N. Al-Gamal,1,5 S.Seef 1,5 and C.S. Bello1,6 ABSTRACT A cohort study measured the occurrence and risk factors of nosocomial infections in the neonatal intensive care unit of Abha general hospital, Saudi Arabia. Of 401 neonates who stayed at least 48 hours in the unit, 77 developed infections, a period prevalence of 19.2% and an incidence of 13.7 infections per 1000 patient- days. The most frequent infections were: pneumonia (50.0%), primary bloodstream (40.9%) and skin and soft tissues (6.5%). In logistic regression analysis, mechanical ventilation (OR = 2.69, 95% CI: 1.39–5.19) and total parenteral nutrition (OR = 5.62, 95% CI: 2.78–11.35) were identified as significant risk factors. Neonates suffering from nosocomial infections had more than 3 times the risk of dying compared to neonates free of infection. 1Asir Regional Committee for Nosocomial Infection Control; 5Asir General Directorate of Health Affairs, Asir, Saudi Arabia. 2Department of Family and Community Medicine; 3Department of Internal Medicine; 4Department of Child Health; 6Department of Clinical Microbiology, College of Medicine, King Khalid University, Asir, Saudi Arabia (Correspondence to A.A. Mahfouz: mahfouz2005@gmail.com). Received: 04/07/07; accepted: 02/09/07 ةيدوعسلا برغ بونج في نادلولل ةزكرلما ةياعرلا ةدحو في تايفشتسلما ىودع ولليب سولينروك ،فيس دعس ،لملجا صرن دممح ،قابع سيردإ داؤف ،يقرزلأا قراط ،ظوفمح نحمرلا دبع دحمأ ةكلملماب ،ماعلا ةحابلا ىفشتسم في نادلولل ةزكرلما ةياعرلا ةدحو في تايفشتسلما ىودعل راطتخلاا لماوع عوقو ةيبارتأ ةسارد تساق :ةصلالخا ،%19.2 ةترفلا في راشتنلاا لدعم ناكو ،ىودعلاب مهنم 77 بيصأ ،لقلأا لىع ةعاس 48 ةدحولا في اوقب دولوم 401 ينب نمو .ةيدوعسلا ةيبرعلا مدلاب ةلوقنلما ةيلولأا ىودعلاو ،)%50( يوئرلا باهتللاا :يه ًاراشتنا ىوادعلا رثكأ تناكو .مايأ-ضيرم 1000 لكل ىودع 13.7 عوقولا لدعمو :%95 ةقث ةلصافو ،2.69 = ةيحجرأ ةبسنب( ةيكيناكيلما ةيوهتلا ديدتح ىرج ،يتسجول فوتح ليلتح فيو .)%6.5( ةوخرلا ةجسنلأاو دللجاو ،)%40.9( نادلولا ضرعتيو .ًايئاصحإ مابه ُّدَتْعُي راطتخا ليماعك )11.35 – 2.78 :%95 ةقث ةلصافو ،5.62 = ةيحجرأ ةبسن( نقلحاب ةلماكلا ةيذغتلاو )5.19 – 1.39 .تايفشتسلما ىودعب ينباصلما يرغ نادلولاب ةنراقم تولما رطخ فاعضأ ةثلاثل تايفشتسلما ىودعب نوباصلما Infections nosocomiales dans un service de soins intensifs néonatals du sud-ouest de l’Arabie saoudite RÉSUMÉ Une étude de cohorte a mesuré la fréquence des infections nosocomiales et leurs facteurs de risque dans le service de soins intensifs néonatals de l’hôpital général d’Abha (Arabie saoudite). Sur 401 nouveau-nés ayant séjourné au moins 48 heures dans le service, 77 ont contracté des infections, avec une prévalence de 19,2 % au cours de la période et une incidence de 13,7 infections pour 1 000 jours-patient. Les infections les plus fréquentes étaient la pneumonie (50,0 %), les bactériémies primaires (40,9 %) et les infections de la peau et des tissus mous (6,5 %). Dans l’analyse de régression logistique, la ventilation artificielle (OR = 2,69, IC 95 % : 1,39- 5,19) et l’alimentation parentérale totale (OR = 5,62, IC 95 % : 2,78-11,35) ont été identifiées comme facteurs de risque significatifs. Les nouveau-nés souffrant d’infections nosocomiales avaient plus de 3 fois plus de risques de mourir que les autres. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 41 Introduction Neonatal deaths account for over a third  of  the global burden of child mortality  [1]. In many developing countries neo- natal mortality rates (deaths in the first  28 days of life) are as high as 40–50 per  1000  live births  [2,3], with  infections  being  the major  cause of death  [4,5].  Unfortunately, hospitals  in developing  countries  are  at high  risk of  infection  transmission,  and  improvements  in  neonatal  outcomes  are  subverted by  hospital-acquired  infections and  their  associated morbidity, mortality and cost  [6–9]. These  infections can be attrib- uted to  lack of knowledge and training  about basic infection control processes,  coupled with inadequate infrastructure,  systems of care and resources. This has  serious  consequences  when  devices  such as intravenous catheters and venti- lators are introduced without sufficient  attention to the substantial risk of infec- tion they entail [10–12]. The  Asir  region  (population  of  1 200 000) is located in the south-west  of Saudi Arabia covering an area of more  than 80 000 km2. Primary health care  (PHC) services in Abha health district,  the capital of Asir, are provided through  a widespread network of 36 urban and  rural health centres, providing services  to a population of 129 465. Each PHC  centre has well-defined catchment area  and population. Secondary care  is pro- vided at Abha general hospital where  almost all deliveries are performed.  Our objective was  to study  the oc- currence and risk factors of nosocomial  infections (NIs) at Abha general hospital  neonatal intensive care unit (NICU). Methods Abha  general  hospital  is  a  100-bed  general hospital with an average of 300  births  a month  and  a 15-bed NICU.  The NICU consists  of  4  rooms with  a capacity of 15–30 hospital-born ne- onates. The NICU was staffed with 22  registered nurses/nurse assistants, 5 per  shift,  a  ratio of nurses/nurse assistants  to NICU patients of 1:5. The registered  nurses  supervised  the  team and were  directly  responsible  for  the care of  the  most  severely  ill patients. The medical  staff  included neonatologists, 1 on call  every 24 hours and 4 who worked on  a daily basis. One of  these neonatolo- gists was responsible  for the NICU for  24-hour periods. A chief physician and  a  registered nurse were responsible  for  the neonatal unit as a whole. Consultant  support was available when necessary  from nearby Asir central tertiary hospital.  A physical therapist was also present in  the unit for 8-hour periods. There were  5 hand-washing sinks in the NICU, 1 at  the entrance, 1 at the nurse’s station, and  1 sink for each 10 m2. Six conventional  ventilators provided assisted ventilation  on a conventional basis. A cohort of  all neonates attending  Abha NICU from 1 January 2004 to 31  March 2005 and who remained at least  48 hours were  followed up and evalu- ated. All  neonates were  examined  at  the time of admission and the following  information was  recorded: gestational  age, birth weight, Apgar score at 1 and  5 minutes, maternal predisposing  fac- tors, mode of delivery,  length of  stay  and  exposure  to  vascular  catheter,  endotracheal  intubation, mechanical  ventilation, antibiotic  therapy and total  parenteral  nutrition.  Surveillance  for  development of NI, death and  transfer  to other units was conducted 2–3 times  a week  and recorded using  a manual  spreadsheet. The outcome variable was  acquisition of a NI, assessed and classi- fied using Centers  for Disease Control  and Prevention definitions [13]. Data were analysed using SPSS, ver- sion 12.0. Univariate  analysis methods  were  used  at  5%  level  of  significance.  Multivariate  logistic  regression analysis  was used to identify potential risk factors. Results During  the study period, 401 neonates  were admitted  to Abha NICU and  re- mained  at  least  48 hours. There were  233 males  (58.1%)  and  168  females  (41.9%). The  5  primary  reasons  for  admission  to  the NICU were preterm  and hyaline membrane disease (50.5%),  transient  tachypnoea  of  newborn  (8.2%), meconium asphyxia  syndrome  (6.2%) and birth asphyxia (4.1%). There  were  54  neonates  with  a  congenital  anomaly  (13.7%). Half  the  neonates  were born  through unassisted vaginal  delivery (50.3%) and half by caesarean  section (47.7%) or  instrumental deliv- ery (2.0%). The mean length of stay was  14.0 (SD 19.5) days and median 8 days.  In all, 77 neonates developed a NI, a  period prevalence of 19.2% and incidence  of 13.7 NIs per 1000 patient-days obser- vation. The commonest  sites of  infec- tion were:  lungs (pneumonia) (50.0%),  blood (primary bloodstream  infection)  (40.9%), skin and soft tissues (6.5%) and  urinary  tract (2.6%). Table 1 shows  the  Table 1 Distribution of isolated pathogens related to nosocomial infections in Abha neonatal intensive care unit (n = 77 infants) Isolated organisms No. of infants % Coagulase-negative Staphylococcus spp. 18 23.4 Klebsiella spp. 17 22.1 Enterobacter cloacae 16 20.8 Methicillin-resistant Staphylococcus aureus 8 10.4 Group B Streptococcus 1 1.3 Serratia spp. 5 6.5 Escherichia coli 6 7.8 Staphylococcus aureus 1 1.3 Other Gram-negative bacilli 5 6.5 EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 42 distribution of isolated pathogens related  to NIs. The most  frequently  isolated  organisms  were  coagulase-negative  Staphylococcus spp.  (23.4%), Klebsiella spp.  (22.1%) and Enterobacter cloacae (20.8%). Using  logistic  regression  analysis  to  identify  risk  factors associated with  NIs (Table 2) the following significant  risk factors were identified: mechanical  ventilation (adjusted OR = 2.69, 95%  CI:  1.39–5.19)  and  total  parenteral  nutrition (adjusted OR = 5.62, 95% CI:  2.78–11.35). Sex, birth weight, method  of delivery,  gestational  age  and  intra- venous  line were not  associated with  development of NIs. During the study period 87 neonates  died (21.7%). Mortality among neonates  suffering  from NIs (40.3%) was signifi- cantly higher compared with neonates  free  from NIs (17.3%) (χ2 = 19.33, P < 0.05). Neonates suffering from NIs had  3 times the risk of dying compared with  neonates  free  from NIs  (crude OR =  3.23, 95% CI = 1.80–5.70). Table 2 Multivariate analysis of potential risk factors determining nosocomial infections in Abha neonatal intensive care unit (n = 401 infants) Variable Nosocomial infections Adjusted OR 95% CI No. % Sex Male 44 18.9 0.80 0.45–1.42 Female 33 19.9 Mode of delivery Caesarean 39 19.5 1.02 0.58–1.80 Vaginal 38 19.0 Presence of congenital anomalies Yes 9 18.0 1.06 0.45–2.46 No 68 16.8 Low birth weight (< 1500 g) Yes 25 27.8 0.68 0.43–1.17 No 52 16.7 Gestational age Preterm 62 27.4 0.58 0.32–1.03 Term 15 8.6 Mechanical ventilation Yes 39 35.8 2.69* 1.39–5.19 No 38 13.0 Intravenous line Yes 70 18.1 0.07 0.18–2.52 No 7 50.0 Total parenteral nutrition Yes 31 57.4 5.62* 2.78–11.35 No 46 13.3 Endotracheal intubation Yes 2 33.3 0.96 0.14–6.84 No 75 19.0 *P < 0.05 OR = odds ratio; CI = confidence interval. Discussion Babies are born without an endogenous  microbial  flora  and  rapidly  become  colonized with microbes encountered  in  the maternal genital  tract  and  their  immediate postnatal environment [14].  Since  their  immature  immune systems  are unable  to provide a  robust defence  against  virulent  pathogens,  neonates  are at high  risk of developing  invasive  infections  if  exposed  to  pathogenic  microorganisms. Premature neonates  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 43 Lawn JE et al. Why are 4 million newborn babies dying each 1. year? Lancet, 2004, 364:399–401. Saving Newborn Lives. 2. The state of the world’s newborns: a report from Saving Newborn Lives. Washington DC, Save the Children, 2001. Hyder AA, Wali SA, McGuckin J. The burden of disease from 3. neonatal mortality: a review of South Asia and Sub-Saharan References Africa. British journal of obstetrics and gynaecology, 2003, 110:894–901. Mother–baby package: a road map for implementation in coun-4. tries. Geneva, World Health Organization, 1993. Stoll BJ. Neonatal infections: a global perspective. In: Reming-5. ton JS, Klein JO, eds. Infectious diseases of the fetus and newborn infant, 5th ed. Philadelphia, WB Saunders, 2001:139–68. are  at  especially high  risk of  infection  because  of  their  lack  of  protective  maternal  antibodies,  underdeveloped  innate  immunity and  their  fragile, eas- ily damaged  skin. However, while  the  newborn intrinsically faces an increased  risk of infection, failures at critical points  in the system of care can greatly increase  this  risk. The  rapid  development  of  medical  technology has enhanced our  ability to improve the quality and length  of  life of neonates, particularly  infants  born with congenital defects or extreme  prematurity. This growing population  of fragile patients is often dependent for  survival  on  therapeutic  interventions  that are associated with complications  of infections that can result in neonatal  morbidity and mortality [15,16]. The present  study  showed  a  rela- tively high prevalence of NIs  in Abha  NICU of 19.2% with an incidence rate  of 13.7 infections per 1000 patient-days  observation. Previous studies have doc- umented widely varying  infection rates  between  individual  institutions. A pro- spective multicentre  study conducted  by the European Study Group found an  infection  rate of 7%  in 7 NICUs [17].  The USA national point prevalence sur- vey, a collaborative study in 29 hospitals  representing 19 states,  found a NICU  infection rate of 11.4% [18]. In Spain a  study found an incidence rate of 1.6 NIs  per 100 patients-day observation in the  NICU [19].  In developing  countries,  investigators  in Brazil  and  Indonesia  have reported rates of hospital-acquired  infections  to be  as high  as 51%–52%  among all NICU admissions  [12,16].  Although  the  Centers  for  Disease  Control and Prevention definitions are  usually used  in  these studies,  it may be  difficult  to make  direct  comparisons  with  these data because of  inconsist- encies  in  surveillance or  study meth- ods,  such  as  intensity of  surveillance,  prospective  versus  retrospective data  collection, infection detection methods  and the populations included.  Bacteraemia,  pneumonia,  urinary  tract infections and sensory organ infec- tions  are  the most  common NIs  re- ported in the literature, with 40% to 70%  for  bacteraemia  and 15%  to 30%  for  respiratory  infection [16,19,20]. These  are in agreement with our results. The present study showed that  the  most frequently isolated organisms were  coagulase-negative Staphylococcus spp.,  Klebsiella spp. and Ent. cloacae. In devel- oping  countries Gram-negative  rods  are major pathogens of NIs  in NICUs.  Gram-negative rods were isolated from  at  least 60% of positive blood cultures  in developing regions of the world [16].  K. pneumoniae  is  the major pathogen,  responsible  for  16%–28%  of  blood- culture-confirmed  sepsis  in  different  regions of  the world. Africa and South  Asia also have high rates of Sta. aureus in- fections, whereas Latin America, South- East Asia and the Middle East have high  reported  rates  of  coagulase-negative  staphylococcal infections that might be  due  to  their adoption of  sophisticated  tertiary neonatal care with a high rate of  invasive device use [16]. Neonates  in Abha NICU on me- chanical  ventilation had  significantly  2.7  times  higher  risk  of  developing  NIs  compared  with  other  neonates.  Similarly,  in Riyadh, Saudi Arabia  the  mean ventilator-associated pneumonia  rate in the paediatric ICU was 8.87 per  1000 ventilation-days with a ventilation  utilization rate of 47% [21]. Neonates  in Abha NICU on  total  parenteral nutrition had a significantly  5.6  times  greater  risk  of  developing  NIs  compared with  other  neonates.  Similarly,  in Riyadh,  a  study  showed  that  in paediatric  ICUs, patients who  had  total parenteral nutrition  infused  through  the  line had 8.6  times greater  risk of developing NIs [22]. This may  be due to the severity of illness or a de- ficiency  in adhering  to parenteral fluid  infusion guidelines. Standard infection- control practices—hand hygiene, isola- tion,  aseptic  techniques,  cleaning and  disinfection or  sterilization of  reused  equipment  and  elimination of  point  sources of contamination—minimize  many  such  hazards.  Alcohol-based  antiseptics for hand hygiene are an ap- pealing  innovation because of  their ef- ficacy in reducing hand contamination  and  their ease of use,  especially when  sinks and supplies for hand-washing are  limited [23]. The results of this study will assist in  developing  intervention  strategies  for  the prevention of NIs in NICUs in the  region.  Interventions should  target  the  use of total parenteral nutrition (indica- tions, preparation,  storage,  administra- tion and  time of use) and mechanical  ventilation. More continuing medical  education programmes are needed  for  the health care  team  to  improve  their  competence. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 44 Nejjari N et al. Infections nosocomiales a Acinetobacter experi-6. ence du service de neonatologie de Casablanca. [Nosocomial infections caused by Acinetobacter: experience in a neonatal care unit in Casablanca.] La Tunisie médicale, 2003, 81:121–5. Yalcin AN. Socioeconomic burden of nosocomial infections. 7. Indian journal of medical science, 2003, 57:450–6. Raza MW et al. Developing countries have their own char-8. acteristic problems with infection control. Journal of hospital infection, 2004, 57:294–9. Richards C et al. 9. Klebsiella pneumoniae bloodstream infections among neonates in a high-risk nursery in Cali, Colombia. Infec- tion control and hospital epidemiology, 2004, 25:221–5. Ho JJ. Late onset infection in very low birth weight infants in 10. Malaysian level 3 neonatal nurseries. Pediatric infectious disease journal, 2001, 20:557–60. Martinez-Aguilar G et al. Outbreak of nosocomial sepsis and 11. pneumonia in a newborn intensive care unit by multiresistant extended-spectrum beta-lactamase producing Klebsiella pneu- moniae: high impact on mortality. Infection control and hospital epidemiology, 2001, 22:725–8. Nagata E, Brito AS, Matsuo T. Nosocomial infections in a neo-12. natal intensive care unit: incidence and risk factors. American journal of infection, 2002, 30:26–31. Garner JS et al. CDC definitions for nosocomial infections. 13. American journal of infection, 1988, 16:128–40. Harris J, Goldmann D. Infections acquired in the nursery: 14. epidemiology and control. In: Remington JS, Klein JO, eds. Infectious diseases of the fetus, newborn and infants, 5th ed. Philadelphia, WB Saunders, 2001:1371–418. Klein JO. Bacterial sepsis and meningitis. In: Remington JS, 15. Klein JO, eds. Infectious diseases of the fetus, newborn and in- fants, 5th ed. Philadelphia, WB Saunders, 2001:943–84. Zaidi A et al. Hospital-acquired neonatal infections in develop-16. ing countries. Lancet, 2005, 365:1175–88. Raymond J, Aujard Y. Nosocomial infections in pediatric pa-17. tients: a European, multicenter prospective study. European Study Group. Infection control and hospital epidemiology, 2000, 21:260–3. Sohn A et al. Prevalence of nosocomial infections in neonatal 18. intensive care unit patients: results from the first national point- prevalence survey. Journal of pediatrics, 2001, 139(6):821–7. Urrea M et al. A prospective incidence study of nosocomial 19. infections in a neonatal care unit. American journal of infection, 2003, 31(8):505–7. Kilani RA, Basamad M. Pattern of proven bacterial sepsis in a 20. neonatal intensive care unit in Riyadh—Saudi Arabia: a 2-year analysis. Le journal médical libanais, 2000, 48(2):77–83. Almuneef M et al. Ventilator-associated pneumonia in a pedi-21. atric intensive care unit in Saudi Arabia: a 30-month prospec- tive surveillance. Infection control and hospital epidemiology, 2004, 25(9):753–8. Almuneef M et al. Rate, risk factors and outcomes of catheter re-22. lated blood stream infection in a pediatric intensive care unit in Saudi Arabia. Journal of hospital infection, 2006, 62(2):207–9. Brown SM et al. Use of an alcohol-based hand rub and quality 23. improvement interventions to improve hand hygiene in a Rus- sian neonatal intensive care unit. Infection control and hospital epidemiology, 2003, 24:172–9. Note from the Editor We wish to draw the kind attention of our potential authors to the importance of applying the editorial requirements of  EMHJ when preparing their manuscripts for submission for publication. These provisions can be seen in the Guidelines  for Authors, which are available online at http://www.emro.who.int/emhj.htm, and are published at the end of the first  issue of each volume. We regret that we are unable to consider papers that do not conform to the Guidelines. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 45 Antibiotic resistance trends in paediatric community- acquired first urinary tract infections in the United Arab Emirates H. Narchi1 and M.A.M. Al-Hamdani2 ABSTRACT We analysed the trend of antibiotic resistance of community-acquired uropathogens over a 4-year period in a cohort of children with a first episode of culture-proven urinary tract infection presenting to the department of paediatrics at a large general secondary care hospital in the United Arab Emirates. Comparisons were made between 2 time periods: 2003–04 versus 2005–06 for 145 children aged 2 months to 12 years of age. Although some changes in resistance were observed for some antibiotics between the 2 time periods, the differences were not significant, nor were the trends, except for a significant increase in resistance to nitrofurantoin (from 5.4% to 35.6%), with a significant increasing trend over the 4 years. 1Department of Paediatrics, Faculty of Medicine and Health Sciences, Al Ain, United Arab Emirates (Correspondence to H. Narchi: hassib.narchi@ uaeu.ac.ae). 2Department of Paediatrics, Al Ain Hospital, Al Ain, United Arab Emirates. Received: 03/07/07; accepted: 11/09/07 ةدحتلما ةيبرعلا تاراملإا ةلود في عمتجلما في ةبستكلما ليوبلا زاهجلل ةيلولأا ىوادعلا في ةيويلحا تاداضلما ةمواقم تاهاتجا نيادملحا دنهم ،شيران بيسح عبرأ ةترف للاخ ًايعمتمج ةبستكلما ةيلوبلا ضارملأل ةببسلما ميثارجلل ةبسنلاب ةيويلحا تاداضملل ةمواقلما ةأشن هاتجا ليلحتب نوثحابلا ماق :ةصلالخا ىفشتسم في لافطلأا مسق لىإ اومدق نيذلاو ،ميثارلجا هذه ةعارزب ةدكؤلما ليوبلا زاهلجا ىودع نم ةبون لوأب اوبيصأ لافطلأ ةيبارتأ ةسارد في تاونس في ًلافط 145 ـل 2006/2005و 2004/2003 اهم ينتينمز ينتترف ينب تانراقلما تيرجأو .ةدحتلما ةيبرعلا تاراملإا ةلود في ةيوناثلا ةياعرلل يربك ماع ُّدَتْعُي ةدايز ثودح ادعام ،تاهاتجلاا كلذكو ،ًايئاصحإ ابه ُّدَتْعُي لا انهأ لاإ ةمواقلما في تايرغتلا ضعب دوجو نم مغرلابو .ًاماع 12 لىإ نيرهش رمع .تاونس عبرلأا للاخ ابه ُّدَتْعُي ةمواقلما هاتجا في ةدايز عم ،)%35.6 لىإ %5.4 نم تداز( نيوتنارويفوترينلل ةمواقلما في ابه Tendances de la résistance aux antibiotiques chez des patients pédiatriques lors d’un premier épisode d’infection urinaire communautaire aux Émirats arabes unis RÉSUMÉ Pendant quatre ans, nous avons analysé l’évolution de la résistance aux antibiotiques d’agents pathogènes urinaires communautaires dans une cohorte d’enfants connaissant un premier épisode d’infection urinaire confirmé par culture et dirigés vers le service pédiatrique d’un grand hôpital général de niveau secondaire aux Émirats arabes unis. Des comparaisons ont été effectuées entre deux périodes, de 2003 à 2004 et de 2005 à 2006, sur 145 enfants âgés de 2 mois à 12 ans. Bien que l’on ait observé quelques changements sur le plan de la résistance à certains antibiotiques pendant les deux périodes, ni les différences ni les tendances n’étaient significatives, à l’exception d’une nette augmentation de la résistance à la nitrofurantoïne, qui est passée de 5,4 % à 35,6 % et a montré une importante tendance à la hausse sur la période de quatre ans. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 46 Introduction Urinary tract infections (UTI) are com- mon in the paediatric age group and may  be associated with a risk of renal scarring  which may lead to hypertension and/or  renal damage [1]. To minimize this risk,  prompt and appropriate antibiotic ther- apy is imperative, and is usually initially  started empirically before the results of  urine culture and bacterial susceptibility  are available. Many guidelines exist  to  recommend  the  choice  of  empirical  antibiotic  treatment, usually based on  the knowledge of which organisms are  commonly  involved  and on  their  an- tibiotic  susceptibility. However,  as  the  latter is known to change over time with  the development of antimicrobial resist- ance, a regular evaluation of the pattern  of antibiotic sensitivities is imperative to  facilitate the choice of treatment [2–4]. This study assessed the trend of an- tibiotic  resistance of urinary pathogens  over  a 4-year period  in  an unselected  cohort of children with a first episode of  community-acquired UTI, with the aim  of improving the choice of initial empiri- cal therapy. We believe that the findings,  whether showing a positive or negative  or no trend at all in antibiotic resistance,  will be of interest to the physician decid- ing how to treat such infections. Methods The study was undertaken in the depart- ment of paediatrics  at  a  large general  secondary care hospital  in  the United  Arab Emirates. Sample size Based on prior audit  in our  institution,  the resistance of uropathogens to com- monly  used  antibiotics  ranged  from  10% to 70%. As we planned to study sev- eral antibiotics with different patterns of  resistance, we estimated that  for a 95%  confidence  level, 5% significance  level  and 80% power  to detect  an  average  change  of  antibiotic  resistance  from  an average of 30%–50%  to 60%–75%  (or vice versa) between  the 2 periods,  a minimum  a  sample  size  of  49  to  a  maximum of 66 urine samples  in each  period (minimum of 98 to a maximum  of 132  in  total) was needed (Epi-Info statistical  software).  Assuming  that  incomplete data may occur  in 10% of  these episodes, we decided to analyse a  total of 145 UTIs. Patients The inclusion criteria were all children  between  the  age of 2 months  and 12  years who had a first episode of culture- proven UTI between 1  January 2003  and 31 December 2006, diagnosed  in  our  institution. The absence of a prior  UTI (documented by culture or not),  whether  in or outside our  institution,  was  specifically  ascertained  from  the  child or the parents by history. The patients were  identified  from  the  log books  in  inpatient wards  and  outpatient clinics, as well as  the micro- biology laboratory log book. As per de- partment guidelines,  the data collected  from all  children with UTI (and  their  parents) is entered on a specifically de- signed UTI  form. This  form contained  detailed  information on  the past his- tory, current symptoms and signs, prior  relevant  investigations or  therapy and  comorbidity.  We  excluded  comorbidity  or  un- derlying factors shown to be associated  with different resistance patterns to an- tibiotics or a predisposition to recurrent  infections which may be associated with  a modified resistance profile  in view of  multiple and/or prolonged courses of  antibiotics. Thus  the exclusion criteria  were:  recurrent UTIs (documented or  by history, whether  in our  institution  or  any other),  urine  collected by bag  specimen,  nosocomial UTI,  primary  or  secondary  immunosuppression,  glucocorticoid  therapy, diabetes mel- litus, malnutrition,  recent  urological  surgery (within 1 month) or presence of  indwelling urinary catheter.   The children were  treated with ap- propriate antibiotics as per anti microbial  sensitivities and underwent appropriate  imaging studies as defined in our hospi- tal clinical guidelines. Urine collection The  standard departmental  protocol  for urine  collection  to diagnose UTI  was  followed  for  this  study. The mode  of  urine  collection was  documented  in  the microbiology  request  form and  also  in  the  report of urine  culture  for  interpretation purposes. In  children of  either  sex,  under  2  year of age or not yet continent, urine  was collected by suprapubic aspiration  or  catheterization  if  immediate  anti- biotic  therapy was deemed necessary.  Otherwise,  or  if  the  parents  refused  the procedure, 2 samples of urine were  collected aseptically by  the clean-catch  method which, when  performed  ad- equately,  is  as  reliable  as  suprapubic  aspiration  or  catheterization.  After  cleansing of the genitalia and perineum,  the clean catch was collected either by  a  trained  and  experienced paediatric  nurse,  or  by  the  child’s mother  after  appropriate  explanation  and  training  by the nurse. UTI was diagnosed by the  clean-catch method only  if both  sam- ples had  significant  colony  counts  as  defined below. For older and continent  children of  either  sex,  urine was  col- lected by  the midstream method. The  child  and/or parents were  instructed  how  to clean  the genitalia,  retract  the  foreskin  in boys and allow urination to  start prior  to collecting  the midstream  in an aseptic manner.  Microbiology UTI was defined as the growth of a single  pathogen of > 105 colony-forming units  (CFU)/mL of urine collected by clean  catch  in  infants or  from midstream  in  older children with bladder control, or  > 103 CFU/mL if obtained by bladder  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 47 catheterization, or any growth  in urine  obtained by suprapubic aspiration. Antimicrobial  susceptibility of  the  isolates was tested by the disk diffusion  technique,  according  to  the National  Committee  for  Clinical  Laboratory  Standards [5]. For the purpose of analy- sis  in  this  study, organisms with  inter- mediate susceptibility were considered  resistant. Data collection The information analysed  in  the study  was derived from the specific UTI form,  the  case  notes  and  included  demo- graphic data, mode of presentation,  re- sults of urine cultures and antimicrobial  susceptibility. As, for several years, these  forms  have  been  prospectively  filled  on all  children with a UTI when  they  first presented, with excellent complete- ness of information shown in audits, we  believe  that  their  retrospective  review  for  the purpose of  this  study  remains  associated with a high level of complete- ness.  Once  the  data were  entered  in  a  computer  file  and  after  checking  for  completeness and consistency, any  in- formation which could allow identifica- tion of the participants was removed. Ethical  approval  was  granted  by  the Al Ain medical district human  re- search ethics committee (protocol No.  07/116) and no patient  consent was  required as it was a retrospective obser- vational case notes review. Analysis As  the  antibiotic  resistance  pattern  was  identical between ampicillin  and  amoxicillin,  they  were  analysed  as  a  single group (aminopenicillins), so too  for  cefotaxime  and  ceftriaxone  (3rd- generation cephalosporins). The data were divided into 2 time pe- riods for analysis: period 1 (years 2003  and 2004)  and period 2  (years 2005  and 2006). We used  the  chi-squared  test or Fisher exact  test  for small num- bers  (when appropriate)  to  compare  the  resistance  for  each  antibiotic  be- tween the 2 periods and to look for any  association with clinical  factors such as  age, sex or presence of fever. In addition,  we also  tested  for  trend  in  that change  throughout the 4 years of the study. For  all the results, statistical significance was  defined as P-value < 0.05.  Results Clinical descriptive data A  total  of  145  episodes of UTI were  diagnosed during  the study period. All  the  information  required  for  the study  was present  in  the UTI  form and case  notes and there were no relevant miss- ing data. Children under  the age of 4  years developed 67.6% of  the episodes  (38.6% under 1 year and 15.2% between  1 and 2 years of age) and 71.0% of all  infections occurred in females. In period  1, there were significantly more females  (84.0% versus 61.0%, P < 0.001) than in  period 2, and there were more younger  children aged < 4 years (61.9% versus  71.9%)  but  this  was  not  statistically  significant. Fever  was  present  in  97.2%  of  episodes with no difference  in  the  rate  between  periods  1  and  2,  between  the sexes or between  the 2 age groups (< 4 and 4+ years). Of all the episodes,  94.0% were managed as inpatients, with  a significantly higher proportion in chil- dren < 4  years old  (97% versus 86%, P  < 0.05), but no difference between  the sexes.  Urine was collected by clean catch  in 46%, midstream in 41%, suprapubic  aspiration in 8% and bladder catheteriza- tion in 5%. Midstream and catheteriza- tion were significantly more  frequently  performed in females (P < 0.01). There  was no significant difference in the rates  of different collection methods between  periods 1 and 2. Only 2 children (1.4%) had received  antibiotics (amoxicillin) within 30 days  of  the diagnosis of UTI;  cultures  in 1  child were resistant to the same medica- tion while  in  the other child  they  still  showed sensitivity. Bacteriology Escherichia coli were  found  in 86.0% of  urine cultures overall (87.3%  in period  1 and 85.4% in period 2), Klebsiella spp.  in 6.2% (4.7%  in period 1 and 7.3%  in  period 2);  the  remainder were other  organisms. There was no significant dif- ference  in the proportion of organisms  between the 2 periods, nor by age group  or  sex, nor between first and recurrent  episodes (data not shown). Bacteraemia  (with the same organism as in the urine)  occurred in 2 of the episodes (both with  E. coli) and all in children under 1 year of  age (1 male and 1 female). Antibiotic resistance and trends In the study of the association between  clinical data  and antibiotic  resistance,  only resistance to gentamicin was found  to be significantly lower (P = 0.05) in the  absence of fever (5/133, 4%) compared  with febrile episodes (1/4, 25%). Resist- ance  to  the other  antibiotics was not  associated with age, sex or the presence  of fever.  The  specific  resistance  pattern  to  each organism is shown in Table 1. There  was no significant change in the overall  antibiotic  resistance between periods  1 and 2,  except  for a  significant 6-fold  increase  in  resistance  to nitrofurantoin  (from 5.4% to 35.6%, P < 0.001) with a  significant increasing trend (P < 0.001).  There was also a significant decrease in  resistance  to nalidixic  acid (P < 0.05)  but the test for trend was not significant  over  the 4 years. Some changes  in  re- sistance were observed  for some other  antibiotics, such as a decrease  in resist- ance  to aminopenicillins (from 78.0%  to 72.0%),  co-amoxiclav (from 62.0%  to  48.6%),  cefalexin  (from  50.0%  to  40.6%),  and an  increase  in  resistance  EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 48 to cefuroxime (from 13.5% to 22.6%), 3rd-generation  cephalosporins (from 11.1% to 16.7%) and gentamicin  (from 3.3% to 5.2%); however, the differences were not  significant, nor were the trends. The strains resistant to  3rd-generation cephalosporins were sensitive  to peni- cillins, 1st-generation cephalosporins, ceftazidime and  aztreonam, and were not considered  to be extended- spectrum beta lactamase (ESBL) producers. Discussion As most microbiological  surveillance systems  lack epi- demiological and clinical data  to differentiate between  first  or  recurrent  episodes  of UTI,  community-  or nosocomially-acquired UTI,  complicated or uncom- plicated UTI and presence or absence of comorbidity,  they may incorrectly estimate the rates of resistance of  uropathogens in the community [6]. We aimed to rem- edy this difficulty by selecting exclusively symptomatic  children with a bacteriologically proven community- acquired UTI, excluding all children with asymptomatic  bacteriuria or indwelling bladder catheters, all hospital- acquired UTIs  and all  urine  specimens  collected by  bag where  the  risk of contamination  is very high. The  proportion of  isolated organisms was  similar  to other  studies,  suggesting  that  the profile of uropathogenic  flora in our region is not unusual [7]. Another strength  of our study was  the completeness of  the  information  available for analysis since we prospectively used stand- ardized data collection  forms;  this  is  reflected by  the  absence of missing data. The study period was restricted  to 4 years  to coincide with  the use of our prospective  standardized data collection form for children with UTI  (which started in 2003) in order to maximize complete- ness  and accuracy of  the data  to be analysed.  In our  community the majority of first UTI in young children  are  referred  to hospital  for management  and  further  evaluation;  therefore,  although  the  study was carried  out  in one centre, we believe  it  to be representative of  the general population  in  this  region. However, as we  cannot entirely exclude the possibility that some cases of  community-acquired UTI may not have been referred,  we caution  that our  results, although representative of  hospital data, may not necessarily be generalized to the  community. It  is  reassuring  that  resistance  to antibiotics of uri- nary pathogens  in community-acquired first UTI has  not  increased significantly over  the 4-year  study, with  the  exception of  resistance  to nitrofurantoin which  has  increased 6-fold. As none of  these children with a  first UTI had ever been on nitrofurantoin prophylaxis, Ta bl e 1 A nt ib io ti c re si st an ce p ro fil e of u ri na ry p at ho ge ns c ol le ct ed fr om c hi ld re n in p er io d 1 (2 0 0 3– 0 4) a nd p er io d 2 (2 0 0 5– 0 6) A nt ib io ti c Es ch er ic hi a co li K le bs ie lla s pp . A ll or ga ni sm s Pe ri od 1 Pe ri od 2 P- va lu e Pe ri od 1 Pe ri od 2 P- va lu e Pe ri od 1 Pe ri od 2 P- va lu e P- va lu e fo r t re nd % % % % % % (n = 8 7 (n = 1 22 ) (n = 6 ) (n = 8 ) (n = 1 0 3) (n = 1 47 ) A m in op en ic ill in sa 82 .7 85 .4 N S 10 0 .0 75 .0 N S 78 .0 72 .0 N S N S C o- am ox ic la v 66 .7 51 .7 N S 33 .3 16 .7 N S 62 .0 48 .6 N S N S C ef al ex in 60 .0 41 .4 N S 0 .0 0 .0 N S 50 .0 40 .6 N S N S C ef ur ox im e 12 .2 20 .8 N S 0 .0 25 .0 N S 13 .5 22 .6 N S N S 3r d- ge ne ra tio n ce ph al os po rin sb 14 .3 25 .0 N S 0 .0 0 .0 N S 11 .1 16 .7 N S N S G en ta m ic in 3. 6 5. 9 N S 0 .0 0 .0 N S 3. 3 5. 2 N S N S C o- tr im ox az ol e 55 .5 52 .4 N S 33 .3 50 .0 N S 52 .5 50 .7 N S N S N itr of ur an to in 3. 8 35 .8 < 0 .0 0 1 0 .0 20 .0 N S 5. 4 35 .6 < 0 .0 0 1 < 0 .0 0 1 N al id ix ic a ci d 25 .5 23 .5 N S 10 0 .0 0 .0 < 0 .0 5 27 .8 21 .0 N S N S a A m pi ci lli n an d am ox ic ill in ; b Ce fo ta xi m e an d ce ftr ia xo ne . N S = no t s ig ni fic an t; n = nu m be r o f i so la te s. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 49 long-term exposure to it cannot explain  the  increase  in  resistance.  In addition,  as nitrofurantoin  is  almost exclusively  used in paediatrics for UTI prophylaxis,  acquired  resistance cannot be blamed  on its use in other paediatric conditions.  Furthermore, when we analysed the rate  of its use as a prophylactic antibiotic for  another group of  children with  recur- rent UTI,  it was used  in  less  than 5%  of  them (the majority were  either on  co-trimoxazole  or  a  cephalosporin).  We therefore could find no support for  the  theory of  an  association between  antibiotic  susceptibility  and antibiotic  prescribing  for  the  treatment of UTIs,  nor can we provide an explanation  for  the  increase  in  resistance  for  that  an- tibiotic  [8–10]. Reassuringly, we also  found a marked decrease  in  resistance  to nalidixic acid  in  the  second period.  The  reasons are not clear but  it  could  be speculated  that  the very  rare use of  that particular antibacterial in our com- munity  could  explain  the  increasing  sensitivity of uropathogens to it. The study results differ  from a pre- vious  study where  a  tendency  for  in- creased resistance to several antibiotics  was demonstrated [7]. However,  that  study compared  the  resistance pattern  between 2 years, 1991 and 1999,  and  focused exclusively on oral antibiotics,  while our  study covers  a more  recent  period, which started 4 years later, com- pared the  trend over 4 years  instead of  8, and included parenteral as well as oral  antibiotics. It is interesting that the rate of  resistance to aminopenicillins, cefalexin,  nitrofurantoin and nalidixic acid in that  study was  fairly  similar  to our  results,  except  that  resistance  to co-amoxiclav,  cefuroxime  and  co-trimoxazole were  higher in our study and others [11,12]. We  found no significant difference  in resistance to a specific antibiotic and  risk  factors  such as young age (below  4  years),  sex or  the presence of  fever  at  presentation,  except  for  resistance  to gentamicin which was  significantly  lower in the absence of fever (P < 0.05).  This  is unlike other  studies where  fe- male sex was associated with resistance  to  co-trimoxazole  [7]. This may  also  be explained by  the differences  in  the  design of  the 2  studies  as mentioned  above. In our  setting,  the most  common  empirically  prescribed  antibiotics  for  UTI (prior to the laboratory sensitivities  results) were 1st-, 2nd- and 3rd-genera- tion cephalosporins,  co-amoxiclav and  co-trimoxazole. Although  it  is  reassur- ing that resistance to the 3 generations  of  cephalosporins  and  to  gentamicin  remained  below  50%  on  average,  it  was  above  50%  to  aminopenicillins  and co-amoxiclav  and around 50%  to co-trimoxazole, similar to other reports  [12,13]. If these latter antibiotics are em- pirically selected to treat a UTI instead  of  cephalosporins,  our  findings  con- firm that addition of gentamicin  is  still  required  [14]. Empirical  therapy with  gentamicin, when parenteral  treatment  is required, is associated with the lowest  resistance (less than 5%). For empirical  oral  therapy,  except  for nitrofurantoin  and nalidixic  acid which  still have  the  lowest resistance (below 50%), all other  choices  are  associated with  resistance  above 50%, including co-trimoxazole, as  shown in other studies [14,15]. For the treatment of UTI, our find- ings reinforce the recommendation that  cephalosporins  (any of  the 3  genera- tions) or gentamicin (alone or in com- bination with aminopenicillins) should  be the first choice for empirical therapy  [13,14,16]. The choice of which of these  antibiotics and  its  route of administra- tion would of course depend on the age  of  the child,  the presence of  toxicity or  the suspicion of pyelonephritis. For oral  antibiotic prophylaxis, ni- trofurantoin and nalidixic acid  remain  the antibiotics with the lowest resistance  rate, while,  similar  to other  studies, we  found co-trimoxazole, aminopenicillins,  co-amoxiclav  and  cephalosporins  to  have more than 50% resistance [14]. As this study only included children  with a first UTI, its findings may not be  applicable  to  recurrent urinary  infec- tions, where underlying urinary  tract  anomalies  and  the  role  of  antibiotic  prophylaxis may lead to different results.  This should be studied separately before  any recommendations can be made for  the  choice of  empirical  antibiotics  in  children with recurrent UTIs. Conclusion There has been no significant  increase  in antibiotic resistance to urinary patho- gens in community-acquired infections  presenting to our hospital between 2003  and  2006,  except  for  nitrofurantoin.  There was a decrease  in  the  resistance  to nalidixic  acid. Continuing  surveil- lance of  antibiotic  resistance  remains  essential and requires the incorporation  of epidemiological and clinical data into  the analysis [6,17,18]. Vernon SJ et al. New renal scarring in children who at age 3 and 1. 4 years had had normal scans with dimercaptosuccinic acid: follow up study. British medical journal, 1997, 315:905–8. Hannan M, Cormican M, Flynn J. A comparison of antimicro-2. bial sensitivities of urinary pathogens for the years 1980 and 1990. Irish journal of medical science, 1993, 162:499–501. References Dyer IE, Sankary TM, Dawson JA. Antibiotic resistance in bac-3. terial urinary tract infections, 1991 to 1997. Western journal of medicine, 1998, 169:265–8. Shigemura K et al. Pathogen occurrence and antimicrobial 4. susceptibility of urinary tract infection cases during a 20-year EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 50 period (1983–2002) at a single institution in Japan. Japanese journal of infectious diseases, 2005, 58:303–8. Performance standards for antimicrobial susceptibility testing. 5. Twelfth informational supplement. Wayne, Pennsylvania, Na- tional Committee for Clinical Laboratory Standards, 2002 (Ap- proved Standard. M100–S12). Lopardo G et al. Uropathogen resistance: are laboratory-gen-6. erated data reliable enough? Journal of chemotherapy (Florence, Italy), 2007, 19:33–7. Prais D et al. Bacterial susceptibility to oral antibiotics in com-7. munity acquired urinary tract infection. Archives of disease of childhood, 2003, 88:215–8. Tan TY et al. Laboratory antibiotic susceptibility reporting and 8. antibiotic prescribing in general practice. Journal of antimicro- bial chemotherapy, 2003, 51:379–84. Christiaens TC, Digranes A, Baerheim A. The relation between 9. sale of antimicrobial drugs and antibiotic resistance in uropath- ogens in general practice. Scandinavian journal of primary health care, 2002, 20:45–9. Hillier SL et al. How strong is the evidence that antibiotic use 10. is a risk factor for antibiotic-resistant, community-acquired urinary tract infection? Journal of antimicrobial chemotherapy, 2002, 50:241–7. Hernández-Porras M, Salmerón-Arteaga G, Medina-Santillán R.11. Microbial resistance to antibiotics used to treat urinary tract infections in Mexican children. Proceedings of the Western Phar- macology Society, 2004, 47:120–1. Mehr SS, Powell CV, Curtis N. Cephalosporin resistant urinary 12. tract infections in young children. Journal of paediatrics and child health, 2004, 40:48–52. Lu KC et al. Is combination antimicrobial therapy required for 13. urinary tract infection in children? Journal of microbiology, im- munology, and infection, 2003, 36:56–60. Yüksel S et al. Antibiotic resistance of urinary tract pathogens 14. and evaluation of empirical treatment in Turkish children with urinary tract infections. International journal of antimicrobial agents, 2006, 28:413–6. Goldraich NP, Manfroi A. Febrile urinary tract infection: Es-15. cherichia coli susceptibility to oral antimicrobials. Pediatric nephrology (Berlin, Germany), 2002, 17:173–6. Haller M, Brandis M, Berner R. Antibiotic resistance of urinary 16. tract pathogens and rationale for empirical intravenous thera- py. Pediatric nephrology (Berlin, Germany), 2004, 19:982–6. Gordon KA, Jones RN. Susceptibility patterns of orally admin-17. istered antimicrobials among urinary tract infection pathogens from hospitalized patients in North America: comparison report to Europe and Latin America. Results from the SENTRY Antimicrobial Surveillance Program (2000). Diagnostic micro- biology and infectious disease, 2003, 45:295–301. Zhanel GG et al. Antibiotic resistance in Escherichia coli out-18. patient urinary isolates: final results from the North American Urinary Tract Infection Collaborative Alliance (NAUTICA). In- ternational journal of antimicrobial agents, 2006, 27:468–75. Handbook: Good Laboratory Practice (GLP). Second Edition Good laboratory practices (GLP) are the recognized rules governing the conduct of non-clinical safety studies. They  ensure the quality, integrity and reliability of the study data.  This handbook is designed as an aid for those countries wishing to upgrade their laboratories to GLP status. Based on  the Organisation for Economic Cooperation and Development (OECD) principles of GLP, the aim of the handbook  is to provide laboratories and trainers in disease-endemic countries with the necessary technical information for  implementing GLP programmes. The material in the handbook is presented in a clear and informative way. The introduction reviews the need for quality  standards in drug research and development, and gives a history of GLP. Chapter 2 covers GLP training, and chapter 3,  the stepwise introduction of GLP. The OECD principles of GLP and compliance monitoring are reprinted, with kind  permission, in the annex section. Further information about this and other WHO publications can be found at: http://www.who.int/bookorders/ anglais/home1.jsp?sesslan=1 طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 51 National survey of the oral health of 5-year-old children in the United Arab Emirates M.A.I. El-Nadeef,1 H. Hassab2 and E. Al-Hosani2 ABSTRACT A total of 1340 5-year-old children were examined as part of the first national survey of the oral health of children in the United Arab Emirates. The objective was to determine dental caries status and compare variations in caries experience in all 9 medical districts. Sampling and examination for caries was done following World Health Organization guidelines and criteria. Only 17% of the children were caries-free. The mean decayed/missing/filled teeth (dmft) index was 5.1, ranging from 3.8 in Ajman to 6.6 in Dubai. More than half (52%) had > 4 dmf teeth. Overall, caries is highly prevalent in the primary dentition of 5-year-old children and mostly untreated. 1Preventive Dentistry Section, Ministry of Health, Dubai, United Arab Emirates. 2General Authority for Health Services for the Emirate of Abu Dhabi, Abu Dhabi, United Arab Emirates (Correspondence to M.A.I. El-Nadeef: nuraini@emirates.net.ae). Received: 14/03/07; accepted 02/09/07 ةدحتلما ةيبرعلا تاراملإا في تاونس سخم رمع نم لقأ لافطلأل مفلا ةحصل ينطولا حسلما ينسولحا ىسيع ،باسح ةبه ،فيضنلا يم .ةدحتلما ةيبرعلا تاراملإا في لافطلأا مف ةحصل لولأا ينطولا حسلما نم ءزجك تاونس سخم نم لقأ رمع في ًلافط 1340 صحف ىرج :ةصلالخا سوستلا صحفو ةنيعلا رايتخا يرج دقو .عستلا ةيحصلا قطانلما ينب سوستلا في نيابتلا ةنراقمو ،نانسلأا سوست تلااح ديدتح وه فدلها ناكو شرؤم طسوتم ناكو ،نانسلأا سوستب ينباصم يرغ اوناك لافطلأا نم طقف %17 نأ ينبتو .ةيلماعلا ةحصلا ةمظنم يرياعمو ةيداشرلإا لئلادلا بسح شرؤم )%52( لافطلأا فصن نم رثكأ ىدل ناكو .بيد ةرامإ في 6.6 لىإ ،نماجع ةرامإ في 3.8 ينب حوارتو ،5.1 نانسلأا وشحو نانسلأا دقفو رخنلا ،تاونس سخم رمع نم لقأ لافطلأل ةيلولأا نانسلأا في راشتنلاا عساو سوستلا ناك ،ًايلاجمإو .4 نم بركأ نانسلأا وشحو نانسلأا دقفو رخنلا .اولجاعي لم مهبلغأو Enquête nationale sur la santé bucco-dentaire des enfants de cinq ans aux Émirats arabes unis RÉSUMÉ Une population de 1 340 enfants âgés de cinq ans a été examinée dans le cadre de la première enquête nationale sur la santé bucco-dentaire des enfants aux Émirats arabes unis. L’objectif était de constater la situation des caries dentaires et de comparer les différentes expériences en la matière dans la totalité des neuf districts médicaux. L’échantillonnage et l’examen des caries ont été réalisés sur la base des directives et des critères de l’Organisation mondiale de la Santé. Seuls 17 % des enfants ne présentaient pas de caries. L’indice CAO moyen (nombre de dents cariées, absentes ou obturées) était de 5,1, avec des valeurs allant de 3,8 à Ajman à 6,6 à Dubaï. Plus de la moitié (52 %) des enfants avaient un indice CAO supérieur à 4. Dans l’ensemble, la prévalence des caries sur les dents de lait des enfants de cinq ans est élevée ; ces caries sont rarement traitées. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 52 Introduction Over  the  past  20  years,  information  on dental caries among children  in the  United Arab Emirates (UAE) has been  collected  from pathfinder  surveys but  these did not  represent all 7 Emirates.  Reports  on  dental  caries  experience  in  the primary dentition were mainly  from Abu Dhabi. In 1991 there were 3  reports on caries  in  the primary denti- tion of  5–6-year-olds: mean number  of  decayed, missing or  filled primary  teeth (dmft) was  reported  as  5.1  for  5-year-old children  in Abu Dhabi city  [1]; the second study reported 6.3 dmft  for 6-year-olds  in 3  cities  in  the UAE  [Unpublished  report,  K.  Cowles,  E.  Beltran, 1991]; and  the  third  reported  an average dft of 6.8, 4.0, 3.0 and 6.2 for  Abu Dhabi, Dubai, Sharjah and Fujairah  respectively  [Unpublished  report,  P.  Leous,  1991].  In  1998,  a mean dmft  of 7.7  for was  reported 5-year-olds  in  Abu Dhabi [2]. These reports suggested  an  increasing  trend of dental  caries  in  the primary dentition of children in the  UAE. Primary  teeth begin  to  shed  from  about  the  age  of  5  years  onwards.  If  children are examined after this age, the  record of primary  teeth will be  incom- plete. For countries  such as  the UAE,  where  children  are mostly  attending  school at 5 years of age,  this  is a better  age group to survey than 6 years, which  is  commonly used  in  surveys  in  some  countries.  Three  age  groups  of  children,  5,  12  and 15 years, were  covered  in  the  national  survey  of  the  oral  health  of  children  in  the UAE. Recognizing  the  importance of  reliable  information on  the oral  health problems  and  trends,  the Preventive Dentistry Section or the  Ministry of Health took the initiative in  conducting  the first national  survey of  the oral health of 5-year-old children  in  the UAE. The findings  for  the other  2 age groups have been described else- where [3]. The objective of  this  survey was  to  determine  the  status of  dental  caries  in  the primary dentition of 5-year-old  children and  to compare variations  in  caries experience among the 7 Emirates  as well  as differences according  to  sex  and nationality. Methods Approval for conducting the survey was  obtained  from the Ministry of Health,  Ministry of Education and appropriate  authorities in each medical district. Writ- ten consent was  sought  from parents  prior  to  the child’s examination. Only  children whose parents consented were  examined. The dental  survey was con- ducted during 2001/2002.  Sampling The  sampling methods  followed  the  guidelines  for oral health surveys pub- lished by  the World Health Organiza- tion (WHO) [4]. The size of the sample  was determined according to the guide- lines which  state  that  the  smallest  cell  size  should be ≥ 40.  It was decided  to  sample about 150 children  in each of  the 9 medical districts to allow for some  non-participation. Thus the sample size  was 1350  children  altogether. As  the  size of the population within each of the  medical districts differs,  the proportion  of children who were sampled differed  accordingly. Therefore, the mean scores  for each district had to be weighted ap- propriately.  Five-year-old children in private and  state schools in all medical districts were  included. Only a few community schools  were excluded. Sampling was done  in  2  stages:  by  school within  the medi- cal district and by child within schools.  Schools were  selected using  random  number  tables  unless  the number of  schools in a district was small, in which  case all  schools were  included. Within  each  school,  children were  randomly  selected with  frequency  according  to  the size of  the school. This meant  that  each child within each district had an  equal  chance of being chosen. No  re- placement was made  for children who  were not examined.  Standardization of examiners Nine dentist examiners, 1  in each dis- trict,  examined  the children. Training  sessions  were  conducted  and  each  examiner  re-examined  a 10%  sample  of children  in order  to assess examiner  reproducibility;  this was  expressed as  the  reliability  coefficient  for  the dmft  index [5]. This was calculated  for each  examiner.  Examination of children The children were examined in a supine  position on a flat table. All examinations  were carried out under natural and arti- ficial room light, but without a spotlight.  No  special  tooth-cleaning was  done  before  examination.  A  plane mouth  mirror (number 4) and a blunt explorer  (0.5 mm diameter  tip) were used. The  examination was principally visual. The  explorer was used for removal of plaque  and debris,  and as a diagnostic  aid  for  proximal and fissure sites. Diagnosis of  dental  caries  followed WHO criteria  and the recording was done on a modi- fied WHO form [4]. Data handling The numeric  information  entered on  the  recording  form was  checked  for  completeness  before  being  entered  into a computer file. SPSS,  version 7.5,  data files were  created  and data were  subjected  to checks  for completeness.  Missing data were recorded as such. We  calculated decayed  teeth (dt), missing  teeth  (mt),  filled  teeth  (ft)  and dmft  for  each  child.  Descriptive  statistics  expressed as percentage prevalence of  dental caries and mean number of teeth  affected by dental caries per mouth (as  a measure of caries severity) were calcu- lated according  to sex, medical district  and nationality.  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 53 Results The  total  number of  children  aged 5  years at school in the UAE was 20 942.  The total number of children examined  was 1382 (Table 1),  representing 6%  of  5-year-olds  in  school. There was  a  high  response  rate, 96.7% of  those  se- lected were examined;  the number of  boys and girls was approximately equal.  Non-nationals constituted 14% of  the  number of  children examined (Table  1),  and  the most  common countries  of origin were Egypt, Palestine, Syrian  Arab Republic and Jordan. Examiner  reproducibility  was  measured by  the  reliability coefficient  calculated for re-examination of 10% of  children. The data obtained  indicated  high reliability (average 0.97). The proportion of 5-year-olds who  had  caries  experience  in  the primary  dentition was 83% overall; this varyied  from 71% in Ajman to 93% in the West- ern Region (Table 2). A high propor- tion (52% overall) had > 4  teeth with  decay experience; 10% had had  teeth  extracted due  to  caries  and 13% had  had teeth filled. Most of the teeth with  decay, however, were unfilled (Table  3). The mean dmft was 5.1, varying from  3.8 dmft in Ajman to 6.6 dmft in Dubai  (Table 3). The filled component of the  dmft values was only 0.3 ft overall, high- est  in Abu Dhabi medical district  (0.6  dmft). Caries experience was similar  in  boys (5.1 dmft) and girls (4.9 dmft) both  overall and within each medical district.  There was also little difference between  the sexes in the mt and ft components.  Likewise,  there was  little difference  in  dmft values between nationals and non- nationals,  although  non-nationals  in  Ras Al Khaima medical district had very  high caries experience (10.0 dmft) with  no teeth extracted or filled. For UAE na- tionals, caries experience was highest in  Dubai (6.6 dmft) and Western Region  (6.5 dmft).  In our sample of 5-year-olds, the first  permanent molars had erupted in 18%  of the children and 11% of these already  had dental caries experience.  Discussion In our  study,  the mean dmft was 5.1,  which varied from 3.8 dmft in Ajman to  6.6 dmft in Dubai; there was no signifi- cant difference between boys and girls in  dmft values. Although previous studies  Table 1 Distribution of the sample of children aged 5 years in each medical district in the United Arab Emirates (UAE) Medical district Total Examined Males Females UAE nationals Non- nationals No. No. % No. % No. % No. % No. % Abu Dhabi 6 639 150 2 75 50 75 50 119 79 31 21 Al Ain 5 432 149 3 79 53 70 47 123 83 26 17 Western Region 444 151 34 77 51 74 49 85 56 66 44 Dubai 1 339 151 11 65 43 86 57 151 100 0 0 Sharjah 2 014 151 7 69 46 82 54 151 100 0 0 Ajman 1 713 161 9 86 53 75 47 110 68 51 32 Umm Al Quwain 488 150 31 73 49 77 51 137 91 13 9 Ras Al Khaima 1 640 150 9 79 53 71 47 149 99 1 0 Fujairah 1 233 127 10 75 59 5 41 127 100 0 0 Total 20 942 1340 6 678 51 662 49 1152 86 188 14 Table 2 Caries status of 5 year old children in each medical district in the United Arab Emirates Medical district Caries status of children (%) Free (dmft 0) Moderate (dmft 1–4) High (dmft > 4) Abu Dhabi 18 36 46 Al Ain 22 39 39 Western Region 7 28 65 Dubai 11 27 62 Sharjah 15 27 58 Ajman 29 39 32 Um Al Quwain 21 29 50 Ras Al Khaimah 19 25 56 Fujairah 13 30 57 dmft = delayed, missing and filled teeth. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 54 in the UAE were limited in size (sample  size < 500) and geographical coverage,  it  appears  that  that  caries  experience  in  the primary dentition has been high  (> 5 dmft)  for at  least 12 years [1,2, K.  Cowles, E. Beltran, unpublished report,  1991]. In other countries in the region,  caries experience  is also reported to be  high. For example, over  the same  time  period, in Kuwait, values of 6.2 dmft and  4.6 dft in 6-year-olds have been reported  [6,7]; in  Saudi Arabia,  a  value of  7.3  dmft in 6–7 year olds [8];  in Bahrain,a  value of 7.1 dmft in 5-year-olds [WHO  Data Bank];  in Oman,  a  value of  4.6  dft  in 6-year-olds has bee  reported [9] and in Iraq, values of 4.8  in 6-year-olds  and 2.3 dmft in 7-year-olds [10]. These  values are much higher than those now  recorded (of under 2 dmft) in Northern  Europe [11].  The value of dmft has been reported  to range from 0.94 to 2.55 in the United  Kingdom [12]. However, dmft values  were  just  as  low  in  Sudan,  1.68  [13] and Tunisia, 0.1 [14] and in the Libyan  Arab  Jamahiriya dft was 1.1 and 2.7  in  children of comparable age [15] (Table  4). In  spite of  remarkable progress  in  the  provision  of  dental  health  serv- ices  in  the UAE, dental caries remains  a considerable public health problem  in young children. To avoid a  further  Table 3 Distribution of 5-year-old children in each medical district in the United Arab Emirates with experience of decayed, missing or filled teeth Medical district dt mt ft Mean dmft Abu Dhabi 77 9 22 4.9 Al Ain 78 9 9 4.4 Western Region 91 0 19 6.4 Dubai 88 11 9 6.6 Sharjah 83 23 7 6.1 Ajman 68 14 14 3.8 Um Al Quwain 77 5 19 5.3 Ras Al Khaimah 80 13 5 6.2 Fujairah 86 7 9 6.1 dt = decayed teeth; mt = missing teeth; ft= filled teeth. increase  in  the  prevalence  of  decay,  we  recommend  treatment  be  given  in parallel with  intensive promotion  of oral health and disease prevention,  targeting young children and expectant  mothers.  The current mother and child pre- ventive programme should be encour- aged  and  reinforced  in  all maternity  health centres. There  is a  large body of  evidence  that supports  the  importance  of the implementation of caries preven- tive and management measures as early  as possible before birth as well as during  postnatal  care  [13]. Fluoride use  and  dietary  counselling  for mothers  dur- ing pregnancy and after birth  for  their  young children have been shown to be  effective  in  preventing  and  reducing  the  risk of dental  caries  in  infants and  preschool children [11,16].  Acknowledgement This study was conducted by  the Pre- ventive Dentistry Section of the Dental  Department, Ministry of Health, United  Arab Emirates and is a result of a team  effort of  a  large group of people. Our  special thanks go to the project supervi- sors and the staff members of the survey  teams. Table 4 Caries experience in primary dentition for children in the Middle East Survey year Age (years) Country No. Mean dmft Reference 1993 6 Kuwait – 6.2 [6] 2001 6 Kuwait – 4.6 dft [7] 2002 6–7 Saudi Arabia (Riyadh) 602 7.3 [8] 1994 6 Oman – 4.6 dft [8] 1989 6–7 Iraq – 4.8 [10] 1995 6–7 Iraq 1047 2.3 [10] 1990 4–5 Sudan 275 1.68 [13] 1994 6 Tunisia 600 0.1 [14] 1994 6 Libyan Arab Jamahiriya, rural – 1.1 SVD dft [15] 1994 6 Libyan Arab Jamahiriya, Benghazi – 2.7 dft [15] dmft = delayed, missing and filled teeth; dft = delayed and filled teeth. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 55 Al-Mughery AS, Attwood D, Blinkhorn AS. Dental health of 1. 5-year-old children in Abu Dhabi, United Arab Emirates. Com- munity dentistry and oral epidemiology, 1991, 19:308–9. Al-Hosani E, Rugg-Gunn AJ. Combination of low parental edu-2. cational attainment and high parental income related to high caries experience in pre-school children in Abu Dhabi. Com- munity dentistry and oral epidemiology, 1998, 26:31–6. El-Nadeef M et al. National survey of the oral health of 12- and 3. 15-year old schoolchildren in the United Arab Emirates. Eastern Mediterranean health journal, 2007, 15(4):993–1004. Oral health surveys: basic methods4. , 4th ed. Geneva, World Health Organization, 1997. Rugg-Gunn AJ, Holloway PJ. Methods of reliability of caries 5. prevalence and incremental data. Community dentistry and oral epidemiology, 1974, 2:287–94. Vigild M et al. Dental caries and dental fluorosis among 4-, 6. 6-, 12- and 15-year-old children in kindergartens and public schools in Kuwait. Community dental health, 1996, 13:47–50. Al-Mutawa SA et al. Dental caries experience of Kuwaiti 7. schoolchildren. Community dental health, 2006, 23:31–6. Al-Wazzan KA. Dental caries prevalence in 6–7-year-old 8. schoolchildren in Riyadh region: comparative study with the 1987 oral health Survey of Saudi Arabia Phase I. Saudi dental journal, 2004, 16:54–60. 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International dental journal, 2004, 54(Suppl. 1):389–94. Hawew RM et al. Dental caries in children from two Libyan 15. cities with different levels of fluoride in their drinking water. Community dental health, 1996, 13:175–7. Beiruti N. Views on oral health care strategies16. . Eastern Mediter- ranean health journal, 2005, 11(1/2):209–16. Milk fluoridation for the prevention of dental caries Around the globe, dental caries is a public health problem and the disease burden is particularly high among under- privileged groups. In several low-income countries, the WHO anticipates that the incidence of dental caries will increase  as a result of growing consumption of sugars and inadequate exposure to fluorides. The good news is that dental caries is preventable through the effective use of fluoride. WHO emphasizes the  importance of automatic administration of fluoride as part of public health programmes. Substantial research has  provided evidence of the effectiveness of milk fluoridation in the prevention of dental caries. As milk fluoridation mostly  targets the child population, such schemes have been established within the context of school health programmes and  programmes for healthy diet and nutrition. This publication, Milk fluoridation for the prevention of dental caries, describes  the justification of milk fluoridation as an effective public health measure and experiences from community health  programmes are highlighted. Further information about this and other WHO publications can be found at: http://www.who.int/bookorders/ anglais/home1.jsp?sesslan=1 EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 56 ABSTRACT The study describes the prevalence of different forms of smoking, and the correlates of current smoking, by male students of King Faisal University, Saudi Arabia. A random sample of 1382 students at 9 colleges answered a self-administered questionnaire based on the Global Youth Tobacco Survey plus the modified Fagerström Test for Nicotine Dependence. The prevalence of current smoking was 28.1% (21.6% for cigarettes, 14.6% for waterpipe). Of current smokers, 41.4% were living in homes where others smoke and 17.0% initiated smoking below age 12 years. In logistic regression analysis older age, living away from home, smoking by family and close friends and exposure to tobacco promotion were predictors of current smoking status. 1Department of Biomedical Science; 2Department of Family and Community Medicine, College of Medicine, King Faisal University, Al Hassa, Saudi Arabia (Correspondence to T.T. Amin: amin55@myway.com). Received: 29/05/07; accepted: 09/09/07 ةيدوعسلا ،ءاسحلأا ،لصيف كللما ةعماج ةبلط ينب ينخدتلا راشتناو طمن ينمأ قيفوت قراط ،دمحلما ميهاربا نادحم دقو .ةيدوعسلا ،لصيف كللما ةعماج في روكذلا ةبلطلا ينب ،ليالحا ينخدتلا تاقلاعو ،ينخدتلل ةفلتخلما طمانلأا راشتنا ةساردلا تفصو :ةصلالخا لىإ ةفاضإ بابشلا ينب ينخدتلل يلماعلا حسلما لوح ًايتاذ رادي نايبتسا لىع اوبيجيل ،تايلك عست في ،ًابلاط 1382 نم ةنوكم ةيئاوشع ةنيع تيرتخا يننخدلما ينب نمو .)ةشيشلل %14.6 ؛رئاجسلل %21.6( %28.1 ليالحا ينخدتلا راشتنا لدعم ناكو .ينتوكينلا لىع دماتعلال لّدعلما مروتسرغاف رابتخا يتسجول فوتح ليلتح فيو .ةنس 12 نم لقأ رمع في ينخدتلا مهنم %17 أدبو ،نورخآ نونخدم مهعم شيعي ثيح لزانم في نوشيعي %41.4 ناك ينيلالحا ض ُّرعتلاو ،ينبرقلما ءاقدصلأا ينبو ةسرلأا في يننخدم دوجوو ،ملهزانم نع ًاديعب نوشيعي نيذلاو ،ًانس بركلأا :ليالحا ينخدتلا تائبنم تنمضت .غبتلا تانلاعلإ Pattern and prevalence of smoking among students at King Faisal University, Al Hassa, Saudi Arabia H.I. Al-Mohamed 1 and T.T. Amin 2 Caractéristiques et prévalence du tabagisme chez les étudiants de l’université Roi Fayçal d’Al Ahsa (Arabie saoudite) RÉSUMÉ Cette étude décrit la prévalence des différentes formes de tabagisme et les corrélats du tabagisme au moment de l’étude chez des étudiants de sexe masculin de l’université Roi Fayçal (Arabie saoudite). Un échantillon aléatoire de 1 382 étudiants inscrits dans 9 facultés a répondu à un autoquestionnaire fondé sur l’enquête mondiale sur le tabagisme chez les jeunes et sur le test de Fagerström modifié sur la dépendance à la nicotine. La prévalence du tabagisme au moment de l’étude était de 28,1 % (21,6 % pour les cigarettes ; 14,6 % pour la pipe à eau : parmi ces fumeurs, 41,4 % vivaient avec d’autres fumeurs et 17,0 % avaient commencé à fumer avant l’âge de 12 ans. Dans l’analyse de régression logistique, l’âge, le fait de vivre loin de chez soi, le tabagisme chez les membres de la famille et les amis proches, et l’exposition à la publicité en faveur du tabac étaient des facteurs prédictifs du tabagisme au moment de l’étude. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 57 Introduction Smoking  has  been  identified  as  the  single most important cause of prevent- able morbidity  and premature  death  [1].  Although  many  of  the  adverse  health effects of  tobacco occur  later  in  life,  smoking has health  implications  for young people [2] and  is associated  with other high-risk behaviours among  young people  including abuse of other  drugs,  fighting  and  high-risk  sexual  behaviour  [3]. Each day, nearly 4800  adolescents  smoke  their first cigarette;  of  these,  nearly  2000  will  become  regular  smokers  [4]. Smoking-related  health problems are  a  function of  the  duration (years of smoking) and inten- sity (number of cigarettes/day); most  adult smokers began to smoke or were  already addicted before  the age of 18  years [5]. While many adolescents want  to quit smoking, only a small number of  them succeed [6].  There has been a dramatic  increase  over the past decade in the numbers of  college-age smokers [7]. Several studies  report  that  the prevalence of  smoking  increases from the first year to the final  year among university  students, which  underlines  the  fact  that  the early years  at university are important for targeting  anti-smoking activities  [8,9]. Students  who enter college as non-smokers are  40% less likely to begin smoking if they  live in a smoke-free campus [10]. The World Health Organization has  reported widely differing prevalences  of  smoking  among  young  people  in  the Arab countries: 7%  in Oman, 18%  in Kuwait,  23%  in  Iraq,  25%  in Saudi  Arabia and Jordan, 31% in Syrian Arab  Republic,  43%  in Yemen and 53%  in  Lebanon [11]. However, the trend and  pattern of smoking as well as the quitting  rate especially among college students  are  largely unknown  in many of  these  countries. The objectives of the present  study were  to describe  the pattern and  prevalence of different  forms of  smok- ing among male students at King Faisal  University, Al Hassa, Saudi Arabia and  to explore  the possible correlates and/ or predictors of current smoking status. Methods This was  a  cross-sectional descriptive  study. Setting and sample King Faisal University  in Al-Hassa  is  located at the Eastern province of Saudi  Arabia. The campus contains 9 colleges  and the total population enrolled in the  University according to registries for the  academic year 2006–07 was 12 400; the  male population was 8200.  A  sampling  frame  of  all  students  at  the different  colleges,  of  all  grades  and with male  sex only was used  for  the purpose of sampling. Females were  not  included due  to  the  traditions of  Saudi Arabian  society which  restricts  access  to  females by male  researchers  and the lack of female researchers at the  time of  the study. Using Epi-Info 2002  software,  a  total  population of  8200,  assuming  the prevalence of  smoking  from a similar study of 18% [12] and the  worst acceptable prevalence was 16%,  applying a confidence level of 95%, the  total number of  subjects  required  for  our  study was 1209;  taking  into  con- sideration a non-response rate of about  15%, the final sample size was estimated  as 1390 students (16.9% of the enrolled  students at the University).  A multistage  proportionate  sam- pling method was applied. The colleges  were  stratified according  to  the  scope  of  specialty  and  number  of  enrolled  students. A  sampling  fraction was cal- culated to select participants in relation  the population in each college. For each  college the students were chosen using a  systematic random sampling technique  from the available registries. Data collection Data were  collected using  an  anony- mous  self-administered,  modified  Arabic  version  of  the Global  Youth  Tobacco Survey  questionnaire  [13],  with  the addition of  the modified Fag- erström Test for Nicotine Dependence  [14]. The final form of the questionnaire  was field  tested on 100 students  from  the medical college who were not part  of the sample.  The  questionnaire  included  the  following  items:  sociodemographic  data (age in years, college, year, current  and permanent  residence,  living with  parents  or  not);  smoking within  the  household (who smoked, for how long,  extent of smoking and quitting, if any);  current smoking status; opinions about  smoking  behaviour;  previous  smok- ing experience; and pattern of smoking  (type, age at initiation, duration in years,  frequency of smoking and average cost  per month). The modified Fagerström  test is a widely used and validated 6-item  questionnaire to assess severity of nico- tine dependence [14], with scores rang- ing from 0 to 10. A score ≤ 4 suggests a  low  level of nicotine dependence, and  a  score ≥ 6 usually  indicates high de- pendence. Those who had not smoked  in  the previous 12 months or  longer  were asked  to consider  themselves  as  ex-smokers. For  each  college,  a  series of  visits  was carried out by the  investigators  for  selection of participants  and orienta- tion  regarding  the objectives, contents  and confidentiality of data  collection.  Lecture halls in each college were used  to deliver the necessary orientation ses- sion on  the objectives and contents of  the  questionnaire while  assuring  the  participants of  the anonymity of  their  responses. The confidentiality of data  was preserved according to the Helsinki  declaration of bioethics.  Data processing and analysis The data were  revised  and  validated  according  to  certain  pre-determined  EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 58 criteria. Questionnaires with more than  2  items missing were discarded, a  total  of 69 forms. The response rate was 100%  in the different colleges with the excep- tion of the college of education (84.3%),  agriculture  (89.8%) and management  science (96.5%). A pre-designed SPSS,  version 12.0, file was used for data entry  and data  analysis. The  following  tests  of  significance were used as appropri- ate: chi-squared  test of  independence,  Kruskall–Wallis and analysis of variance  and Spearman  rank order  correlation  coefficient. A  logistic  regression model  was applied  to determine  the possible  predictors and/or correlates of current  smoking status of the respondents. P ≤  0.05 was considered statitically  signifi- cant. Results A  total  of  1382 male  students  were  included, with age  range 18–29 years  and mean age 20.9 [standard deviation  (SD) 2.0] years (Table 1). Nearly one- quarter of  the  students  (23.5%) were  living away from home, the reasons for  which were: education (95%), marriage  (4%) or social reasons (1%). Smoking prevalence and sociodemographics The prevalence of  smoking among the  students  is  shown  in Table 2. For any  type of  tobacco 28.1% of  respondents  were  current  smokers,  37.4%  ever  smokers and 62.6% never smokers. For  cigarettes,  21.6% were  current  smok- ers and 28.4% ever  smokers, while  for  sheesha  (traditional Arabic waterpipe)  the  corresponding  prevalences were  14.6% and 16.7%. Of the current smok- ers, 77.1% smoked cigarettes and 52.1%  waterpipes.  Table  1  shows  the  sociodemo- graphic characteristics of  the  respond- ents in relation to their current smoking  status. Significantly more current smok- ers were  in older age groups 20–< 24  years  (67.5%) and 24+ years  (15.7%)  compared with  the  total  sample  and  with the never smokers and ex-smokers  (P < 0.001). Students at the colleges of  education, community services and ag- riculture had  the highest prevalence of  smoking compared with those at other  colleges;  the  lowest prevalences were  at  the colleges of medicine and clinical  pharmacy (P < 0.001). A  significantly  higher proportion of ever smokers (cur- rent and ex-smokers) (30.0%) were liv- ing away  from their parents compared  with  the never  smokers  (19.7%) (P <  0.001). Environmental tobacco smoke Of  the  total  respondents, 41.4%  lived  in homes where others smoked (Table  1); this was higher for current smokers  (57.5%)  compared with  ex-smokers  (42.6%) and never smokers (34.0%) (P < 0.001). Over half of  all  respondents  (58.2%) were  exposed  to  tobacco  in  places  other  than  home  such  as  col- leges, cafés and social gatherings (76.3%  among current  smokers, 33.6% of  ex- smokers and 26.2% of never  smokers)  (P < 0.001). The prevalence of smoking  among any parents or relatives was also  different  (57.5%  of  current  smokers  versus 41.1% and 33.6% for ex-smokers  and  never  smokers  respectively)  (P < 0.001). Current  smokers had more  close family members (father or broth- ers  or  both) who  smoked  (205/388  (53.4%) than did ex-smokers (53/129,  41.1%) and never  smokers (274/865,  31.7%) (P < 0.001).  Smoking among close  friends was  also different as 63.9% of current smok- ers  reported  that  all  or most of  their  friends were  smokers  compared with  24.8%  and  15.8% of  ex-smokers  and  never smokers respectively (P < 0.001). Patterns of smoking The duration  of  smoking  among  re- spondents  ranged  from 2  to 19 years,  with a mean of 7.45 (SD 3.17) years. As  regards the  age of initiation of smoking  among current smokers, 17.0% started  below  age  12  years  (4.6%  at  10–11  years, 6.7% at 8–9 years and 5.7% at 7  years), 13.9% at 12–13 years, 23.2% at  14–15 years  and 45.9% at 16+ years.  The age of  initiation was  significantly  lower  for  those  who  smoked  only  cigarettes  compared with  those who  smoked both cigarettes and waterpipe;  9.9% of them started at age 12–13 years,  24.0% at 14–15 years and 76.1% at 16+  years (P = 0.012).  For  cigarette  smokers  the  mean  monthly  cost  was  165.7  (SD  75.1)  Saudi Arabian riyals (SR) (median 150  SR) and  for waterpipe  smokers  it was  104.3  (SD  69.9)  SR  (median  100.0  SR). Home and college were the usual  places  for cigarette  smokers  to  smoke  (46.0%),  while  waterpipe  smokers  smoked at  special places  such as cafés  and restaurants. Nicotine dependence Of the current cigarette smokers, 47.0%  had a nicotine dependence score of ≥ 6  (high), 33.8% scored 4–6 (moderate)  and 19.2% scored < 4 (minimal). The  overall mean score on the modified Fag- erström Test for Nicotine Dependence  out of a maximum of 10 was 4.13 (SD  2.55)  [95% confidence  interval  (CI):  3.84–4.39] (Table 3, available in online  version).  Students  at  the  colleges  of  computer  science, community services  and agriculture had the highest nicotine  dependence  scores, while  the  college  of medicine  students  had  the  lowest  score (Table 3). The mean number of  cigarettes smoked per day was the high- est among students of computer science  and  veterinary  colleges  (P  =  0.029).  There were  significant differences be- tween students in the different colleges  in  all  the questions  except  about  the  item  for  the most difficult  cigarette of  the day to give up.  Quitting behaviour Among the current smokers, about 60%  had  tried quitting, with a median of 3  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 59 Ta bl e 1 So ci od em og ra ph ic c ha ra ct er is ti cs o f t he s tu de nt s by c ur re nt s m ok in g st at us Va ri ab le To ta l ( n = 13 82 ) C ur re nt s m ok in g st at us St at is ti cs Sm ok er (n = 3 88 ) Ex -s m ok er (n = 1 29 ) N ev er s m ok er (n = 8 65 ) N o. % N o. % N o. % N o. % C ol le ge χ2 = 3 8. 24 ; d f = 14 ; P < 0 .0 0 1 Ed uc at io n 42 9 31 .0 15 1 39 .0 48 37 .2 23 0 26 .6 A gr ic ul tu re 26 8 19 .4 78 20 .1 26 20 .2 16 4 19 .0 M an ag em en t 19 1 13 .8 51 13 .1 20 15 .5 12 0 13 .9 Sc ie nc e 16 2 11 .7 35 9. 0 13 10 .1 11 4 13 .2 C om m un ity se rv ic es 10 0 7.2 31 8. 0 7 5. 4 62 7.2 M ed ic in e 94 6. 8 11 2. 8 8 6. 2 75 8. 7 Ve te rin ar y 60 4. 3 16 4. 1 5 3. 9 39 4. 5 C om pu te r 54 3. 9 14 3. 6 1 0 .8 39 4. 5 Ph ar m ac y 24 1.7 1 0 .3 1 0 .8 22 2. 5 A ge g ro up (y ea rs ) χ2 = 3 3. 62 ; d f = 4 ; P < 0 .0 01 < 20 37 1 26 .8 65 16 .8 42 32 .6 26 4 30 .5 20 –< 2 4 82 0 59 .3 26 2 67 .5 73 56 .6 48 5 56 .1 24 + 19 1 13 .8 61 15 .7 14 10 .9 11 6 13 .4 M ea n ag e (y ea rs ) ( SD ) 20 .8 9 (2 .0 3) 21 .5 0 (2 .10 ) 20 .6 0 (2 .2 0 ) 20 .7 4 (1. 93 ) F = 22 .0 5; P < 0 .0 0 1 Ye ar o f e nr ol m en t χ2 = 2 9. 54 ; d f = 8 ; P = 0 .0 0 2 1s t y ea r 37 1 26 .8 11 4 29 .4 48 37 .2 20 9 24 .1 2n d ye ar 37 4 27 .1 93 24 .0 27 21 .0 25 4 29 .4 3r d ye ar 38 5 27 .9 10 6 27 .3 39 30 .2 26 1 30 .2 4t h ye ar 19 5 14 .1 63 16 .2 12 9. 3 13 6 15 .7 5t h ye ar 20 1.4 12 3. 1 3 2. 3 5 0 .6 C ur re nt re si de nc e χ2 = 3 6. 0 1; d f = 4 ; P < 0 .0 0 1 U rb an 87 3 63 .2 26 5 68 .3 71 55 .0 53 7 62 .1 Ru ra l 31 7 22 .9 63 16 .2 24 18 .6 23 0 26 .6 H os te l/ ot he r 19 2 13 .9 60 15 .5 34 26 .4 98 11 .3 Pe rm an en t r es id en ce χ2 = 6 .6 3; d f = 2 ; P = 0 .0 41 U rb an 97 9 70 .8 29 3 75 .5 93 72 .1 59 3 68 .6 Ru ra l 40 3 29 .2 95 24 .5 36 27 .9 27 2 31 .4 EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 60 Ta bl e 1 So ci od em og ra ph ic c ha ra ct er is ti cs o f t he s tu de nt s by c ur re nt s m ok in g st at us (c on cl ud ed ) Va ri ab le To ta l ( n = 13 82 ) C ur re nt s m ok in g st at us St at is ti cs Sm ok er (n = 3 88 ) Ex -s m ok er (n = 1 29 ) N ev er s m ok er (n = 8 65 ) N o. % N o. % N o. % N o. % Li vi ng w it h pa re nt s χ2 = 2 4. 18 ; d f = 2 ; P < 0 .0 0 1 Ye s 10 57 76 .5 28 1 72 .4 81 62 .8 69 5 80 .3 N o 32 5 23 .5 10 7 27 .6 48 37 .2 17 0 19 .7 Sm ok er s a t h om e χ2 = 6 0 .9 9; d f = 2 ; P < 0 .0 0 1 Ye s 57 2 41 .4 22 3 57 .5 55 42 .6 29 4 34 .0 N o 81 0 58 .6 16 5 42 .5 74 57 .4 57 1 66 .0 Sm ok er s a m on g re la ti ve s χ2 = 11 2. 87 ; d f = 10 ; P < 0 .0 0 1 Fa th er o nl y 23 9 17 .3 68 17 .5 14 10 .9 15 7 18 .2 Br ot he rs o nl y 16 3 11 .8 73 18 .8 22 17 .1 68 7.9 Fa th er + b ro th er s 13 2 9. 6 66 17 .0 17 13 .2 49 5. 7 Fa th er + b ro th er s + o th er s 23 1.7 14 3. 6 0 0 .0 9 1.0 O th er s o nl y 10 0 .7 2 0 .5 0 0 .0 8 0 .9 N on e 81 5 59 .0 16 5 42 .5 76 58 .9 57 4 66 .4 Sm ok er s a m on g cl os e fr ie nd s χ2 = 3 47 .2 8; d f = 6 ; P < 0 .0 0 1 A ll 74 5. 4 48 12 .4 6 4. 7 20 2. 3 M os t 34 2 24 .7 20 0 51 .5 25 19 .4 11 7 13 .5 So m e 61 6 44 .6 13 3 34 .3 69 53 .5 41 4 47 .9 N on e 35 0 25 .3 7 1.8 29 22 .5 31 4 36 .3 df = d eg re es o f f re ed om . Ta bl e 2 Pr ev al en ce o f c ur re nt s m ok in g, e ve r s m ok in g an d ne ve r s m ok in g am on g th e st ud en ts (n = 1 38 2) Ty pe o f t ob ac co C ur re nt s m ok er Ev er s m ok er N ev er s m ok er N o. % (9 5% C I) N o. % (9 5% C I) N o. % (9 5% C I) A ny 38 8 28 .1 (2 5. 8– 30 .5 ) 51 7 37 .4 (3 4. 6– 39 .7 ) 86 5 62 .6 (6 0 .0 –6 5. 1) C ig ar et te s 29 9 21 .6 (1 9. 5– 23 .9 ) 39 2 28 .4 (2 6. 1– 30 .8 ) – – – W at er pi pe 20 2 14 .6 (1 2. 9– 16 .6 ) 23 4 16 .7 (1 5. 0 –1 9. 0 ) – – – C I = co nfi de nc e in te rv al . طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 61 attempts,  and 78% planned  to quit  in  the near  future. The primary motives  for  quitting were health,  family  pres- sure and  restrictions,  and other  social  reasons. Out of 388  current  smokers  138 (35.6%) had  stopped smoking  in  the past, 76.1%  for a period  from 1–3  months,  16.0%  for 4–11 months  and  7.9% for 1 year or more. Knowledge and beliefs There were  significant differences be- tween smokers and non-smokers as re- gards their knowledge about the harms  of both smoking and passive  smoking  and  the  effect  of  smoking  on  body  weight (P < 0.001) (Table 4, available  in online  version).  In  addition,  there  was  a  significant  difference  between  smokers  and non-smokers  as  regards  receiving advice  from  family members  on  the  harms  of  smoking. Concern- ing  the participants’ beliefs,  there were  significant differences between smokers  and non-smokers  that  smokers  have  more  friends and  that  smoking should  be banned in public places (P < 0.001),  but no difference  in  the belief  that  it  was easy  to quit  smoking (P = 0.061);  only about 25% of participants  in both  groups thought it was not easy to quit. There were  statistically  significant  differences between smokers and non- smoker as  regards having received  free  cigarettes or gifts during  tobacco com- pany promotions  (P  < 0.001). As  re- gards students exposure to anti-smoking  messages or  smoking advertisements,  27.5% had seen anti-smoking messages  in  the media  in  the previous 30 days,  while 54.2% had  seen posters  against  smoking on several occasions at cultural  and  sports  activities. However, 24.6%  had seen cigarette promotion advertise- ments  in newspapers  and magazines  during the previous month.  Smoking predictors Table 5 illustrates the logistic regression  model of current smoking status against  the  possible  correlates.  The  model  explained 79.9% of cases. Older age was  a  risk  factor  for current  smoking (OR  = 2.57  for  age 20–< 24 years). Urban  residence was also a  risk  factor. While  residing  in  hostels/other  residence  was significant on univariate analysis  it  became insignificant in the multivariate  model. Living with parents was protec- tive  against  the  adoption of  smoking  (OR = 0.53); so too was having received  parental  and  family advice against  the  hazards of smoking (OR = 0.07). Hav- ing parents and other  family members  who smoked was a risk factor for smok- ing  (OR = 2.52), while  having  all  or  most  close  friends as  smokers was an  even greater  risk (OR = 6.86). Receiv- ing free cigarettes through promotional  campaigns of cigarettes companies was  associated with smoking (OR = 2.82);  so  too was receiving gifts with  tobacco  company  logos  (OR = 2.28). Finally,  exposure  to high  intensity media mes- sages against smoking was protective of  current smoking (OR = 0.59). Discussion Although Saudi Arabia does not grow  tobacco or manufacture cigarettes, an av- erage of 600 million SR (approximately  US$ 150 millions) are  spent annually  on tobacco [15]. No nationwide studies  on the prevalence of tobacco have been  performed and this, coupled with a lack  of data regarding the pattern of smoking,  may  conceal  serious  tobacco-related  problems [16]. The prevalence of cur- rent  tobacco  smoking  in our  students  (28.1%) was higher than rates reported  in a previous study of students in Saudi  Arabia  (13.6%  among  medical  and  17.5% among  students of  education)  [12], while a study conducted on male  secondary school students in the central  region of Saudi Arabia reported a similar  prevalence (29.8%) [17]. The reported  prevalence  among university/college  students  was  34.4%  in  Kuwait  [18],  24.8% (males) in Syrian Arab Republic  [19] and 22.1% (males) in Turkey [8].  These  figures  can be  compared with  prevalences ranging  from 5.5% to 20%  among adolescents  in  some countries  of  the European Union  and Canada  [20].  Many people consider  that water- pipe  smoking  is  less  harmful  than  cigarettes because they believe that the  water  filters  out  harmful  substances.  Waterpipes do not contain less nicotine  than  cigarette  smoke  and have more  carbon monoxide [21]. Our  study  re- vealed a higher percentage of  current  smokers used waterpipes (52.1%) than  male students in other countries in the  region  (43.6%  in  Saudi Arabia  [12],  24.6% in Kuwait [22] and 25.5% in Syr- ian Arab Republic [23]). This could be  explained by  the  increasing popularity  of waterpipe smoking. The widespread  attention  focused  on  the  dangers  of  cigarette  smoking,  coupled with  the  stigma associated, might unintentional- ly encourage waterpipe smoking [22].  Data  show  that  the proportion of  adolescents who smoke  increases with  age [24,25]. Also, adolescents who start  to smoke early are more  likely  to con- tinue smoking as adults [26]. We found  a negative association between smok- ing  status  and  age which  contradicts  the first  statement,  probably because  the age  range of  the study sample was  too  narrow  to  demonstrate  such  an  association.  Age  at  initiation  in  our  study  (66.5%  initiated below  age 16  years) was lower than in another similar  study in Saudi Arabia where about 59%  started  smoking  at  or  above  the  age  of  18  years  [12], whereas  in  another  study  in  secondary  schools 83.7% of  the current  smokers  started at  age 15  years or below [17]. A study in the USA  reported the mean age of initiation to be  18.3 years among medical and nursing  students [27].  Our  results  show  that  the  preva- lence of smoking varied across students  at  different  colleges within  the  same  university,  which  is  consistent  with  other studies  in Saudi Arabia [12] and EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 62 Table 5 Logistic regression model between the current smoking status and possible predictors of current smoking among the students Covariates Smoking status Multivariate logistic regression model Current smoker (n = 388) Non- smokera (n = 994) β SE OR (95% CI) P-value Age group (years) < 20 65 306 1b < 0.001 20–< 24 262 558 0.945 0.260 2.57 (1.56–4.28) < 0.001 24+ 61 130 0.406 0.224 1.50 (0.97–3.38) 0.070 Current residence Urban 265 608 1b 0.004 Rural 63 254 –0.735 0.293 0.48 (0.27–0.86) 0.013 Hostel/other 60 132 –0.236 0.315 0.61 (0.31–0.80) 0.454 Living with parents Yes 281 776 –0.632 0.237 0.53 (0.33–0.85) 0.008 No 107 218 Smokers at home Yes 223 344 –0.923 0.147 2.52 (1.89–3.36) < 0.001 No 165 650 Smokers among close friends All/most 248 150 1.926 0.147 6.86 (5.14–9.16) < 0.001 Few/none 140 826 Received parental advice against smoking Yes 285 634 –0.358 0.158 0.70 (0.51–0.95) 0.024 No 103 360 Received free cigarettes from tobacco company promotion Yes 156 40 1.038 0.157 2.82 (2.12–3.76) < 0.001 No 232 954 Received gift with tobacco company logo (wallet, pens, shirts) Yes 252 315 0.824 0.266 2.28 (1.35–3.84) 0.002 No 136 679 Exposed to media messages against smoking Many 120 261 –0.534 0.158 0.59 (0.43–0.80) < 0.001 Few or did not follow 268 733 aEx-smokers + never smokers; bReference group. SE = standard error; OR = odds ratio; CI = confidence interval. the USA [27]. Gliksman et al. found that  students in arts and social sciences pro- grammes were 2–3 times more likely to  be current daily smokers than were stu- dents enrolled in a science programme  [28]. We found higher rates of smoking  by students at the colleges of education,  community  services  and  agriculture.  The  intensity of physical  addiction  to  nicotine as measured by the Fagerström  test [28]  also  showed higher depend- ency among students at  these colleges.  The mean Fagerström score among all  medical students in our study [2.90 (SD  1.97)] was higher than among medical  students in a study in the USA [2.3 (SD  0.8)] [27]. Smoking  by  parents  and  sibling  seems to be  important  in  the  initiation  as well as the continuation of smoking.  Bauman et al.  found  that 12–14-year- olds whose parents  currently  smoked  were almost twice as likely to smoke as  those whose parents had never smoked  [29]. Kandel and Wu  found  that both  maternal  smoking  and  the quality of  parent–child interaction influenced the  current  smoking status among adoles- cents [30]. These finding are consistent  with our study as current smokers had  twice  the risk when relatives, especially  parents and siblings, were smokers.  Friends’  behaviour  and  attitudes  have also been shown in a large number  of  studies  to be a particularly powerful  force  in  shaping behaviour  [31]. Peer  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 63 Rigotti et al. found that the distribution  of  free cigarettes and attendance of  to- bacco company sponsored events was  strongly associated with current smok- ing after adjusting for demographic fac- tors (OR = 1.75) [40].  There were some  limitations to the  study. Only male students were includ- ed in the study as the access to females  was difficult. Although anonymity was  guaranteed for data collection, smoking  is  socially  unacceptable  in  the  Saudi  Arabian community, and  therefore  the  prevalence of smoking by self-reporting  may have been underestimated. Conclusion Smoking  among  students  in  Saudi  Arabia  seems  to be higher  in  terms of  prevalence and  intensity as compared  to  those  in developed countries. Most  of  the  current  smokers  in  our  study  were highly nicotine dependent with  significant variation across colleges. Par- ents,  siblings and peers were  the most  important predictors of  smoking be- haviour among the students. Concerns  are  raised  about  role of  promotional  strategies and the media in the initiation  and progression of  smoking behaviour  among this group.  smoking seemed to be the most impor- tant  factor  influencing smoking behav- iour of our  respondents. Bawazeer  et  al.  [32] and Botvin et al.  [33]  reported  similar findings in younger populations.  A  study  in  the  Syrian Arab Republic  demonstrated  that  about half of male  current  smokers were  introduced  to  smoking by a  friend and  they  smoked  because their friends did so [23]. Hahn  et al. found that 60% of adolescent aged  11–17 years had first smoked, and 72%  had most recently smoked, with a close  friend [34]. Mohammed et al. in Kuwait  found that about half of male waterpipe  smokers and 70% of  female waterpipe  smokers reported that waterpipe smok- ing was either accepted or very much ac- cepted by their friends, and both males  and  females  tended  to  have  friends  whose behaviour and attitudes reflected  their own behaviour [22].  Parental  guidance  and  living with  parents was protective  against  taking  up  smoking  in our  study. Gfroerer  et  al. also showed that among a sample of  USA college students,  those who  lived  with their parents were less likely to have  smoked  in  the  last month  compared  to  students who did not  [35]. These  findings are further supported by Adlaf  et  al. who  found  that post-secondary  students who resided off campus with- out their family had a higher rate of daily  smoking than those  living  in university  housing and those living with their par- ents [36].  It has been hypothesized  that  the  tobacco  industry’s  targeted marketing  strategies have contributed  to  the ob- served  increase  in cigarette use among  post-secondary  students  [37].  In  Saudi Arabia,  tobacco advertising and  promotion are prohibited  in  the  local  media  and  smoking  is not  allowed  in  government buildings or on domestic  flights. However, there is no close moni- toring of  compliance  [38]  and  in our  study 24.6% of  respondents had  seen  cigarette  promotion  advertisements  in newspapers  and magazines during  the  previous month.  Another  study  among  secondary-school  students  in  Saudi Arabia  revealed  that about 66%  had  seen pro-cigarette advertisements  on billboards, 73% had seen advertise- ments in magazines or newspaper, 12%  had an object with cigarette  logo and  28% had been offered free cigarettes by  company representatives [17]. Promo- tional events  reinforce brand visibility,  allow the industry to reach specific tar- get groups and generate names  for  fu- ture marketing efforts [39]. In addition,  1. 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Note from the Editor We wish to draw the kind attention of our potential authors to the importance of applying the editorial requirements of  EMHJ when preparing their manuscripts for submission for publication. These provisions can be seen in the Guidelines  for Authors, which are available online at http://www.emro.who.int/emhj.htm, and are published at the end of the first  issue of each volume. We regret that we are unable to consider papers that do not conform to the Guidelines. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 65 ABSTRACT A retrospective study of death certificates from 2000 to 2004 was made to estimate the contribution of diabetes to total mortality in Benghazi, Libyan Arab Jamahiriya, and to study the causes of death among diabetics (coded using the International Classification of Diseases). Of 12 237 death certificates, 1482 (12.1%) mentioned diabetes. Of these, diabetes was recorded as the underlying cause in 5.1% of deaths and a contributory cause in 94.9%. The most frequent single causes of death for diabetics were: coronary artery disease (32.7%), cerebrovascular accident (20.1%), infections (14.0%), malignancies (7.7%), acute complications of diabetes (7.3%) and chronic renal failure (6.6%). Among multiple causes of death, circulatory diseases were mentioned on 46.2% of death certificates. 1Department of Medicine, Faculty of Medicine, University of Garyounis, Benghazi, Libyan Arab Jamahiriya (Correspondence to R.B. Roaeid: roaeid@yahoo.com). Received: 04/03/07; accepted: 27/09/07 تاونس سخم ةدلم ةافولا تاداهشل يداعتسا ليلتح :يزاغنب في ةافولا بابسأو يركسلا نع ةجمانلا تايفولا تلادعم نلابك ليع ديملحا دبع ،ضيعرلا ةليجع وبأ بجر ،يزاغنب ةنيدم في تايفولا لممج لىع يركسلا ءاد يرثأت ريدقتل 2004 ىتح 2000 ماع نم ةافولا تاداهشل ةيداعتسا ةسارد تَيرجأ :ةصلالخا ةافولا تاداهش عيجم نم .)ضارملأل ليودلا فينصتلا دوك مادختساب( يركسلا ضىرم ىدل ةافولا بابسأ ةساردلو ،ةيبيللا ةيبرعلا ةييرهمالجاب %5.1 في ًانيفد ًاببس ناك يركسلا ءاد نأ لجُس ،تاداهشلا هذه نمو .)%12.1( ةافو ةداهش 1482 في ركذ دق يركسلا ءاد نأ دجو ،12237 اهددعو ،)%32.7( يجاتلا نايشرلا ضرم :يه يركسلا ضىرلم ةبسنلاب ًاراركت ةافولل ةيدرفلا بابسلأا رثكأ تناكو .%94.9 في ًاكراشم ًاببسو تايفولا نم يولكلا لشفلاو ،)%7.3( يركسلل ةدالحا تافعاضلماو ،)%7.7( ةيناطسرلا مارولأاو ،)%14.0( ىوادعلاو ،)%20.1( ةيئاعولا ةيغامدلا تاباصلإاو .ةافولا تاداهش نم %46.2 في نارودلا ضارمأ تركذ ،ةافولل ةددعتلما بابسلأا ينب نمو .)%6.6( نمزلما Diabetes mortality and causes of death in Benghazi: a 5-year retrospective analysis of death certificates R.B. Roaeid 1 and A.A. Kablan1 Mortalité due au diabète et causes des décès à Benghazi : une analyse rétrospective des certificats de décès sur cinq ans RÉSUMÉ Une étude rétrospective des certificats de décès délivrés entre 2000 et 2004 a été réalisée afin d’estimer la part du diabète dans la mortalité totale à Benghazi (Jamahiriya arabe libyenne) et d’examiner les causes de décès chez les sujets diabétiques (sur la base des codes de la Classification internationale des maladies). Sur 12 237 certificats de décès, 1 482 (12,1 %) mentionnaient le diabète. Parmi ceux-ci, le diabète figurait comme cause initiale dans 5,1 % des décès et comme cause ayant contribué au décès dans 94,9 % d’entre eux. Les causes de décès uniques les plus fréquentes chez les diabétiques étaient : les coronaropathies (32,7 %), les accidents vasculaires cérébraux (20,1 %), les infections (14,0 %), les cancers (7,7 %), les complications aiguës du diabète (7,3 %) et l’insuffisance rénale chronique (6,6 %). Parmi les causes de décès multiples, les maladies circulatoires figuraient sur 46,2 % des certificats de décès. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 66 Introduction Despite improvements in the prognosis  of  individuals with diabetes, mortality  is still 2 to 4 times higher for this group  compared with the general population,  with  life expectancy  reduced by up  to  one-third [1]. They have a significantly  higher mortality  than  controls  both  from  all  causes  and  from  circulatory  diseases [2]. The excess global mortal- ity  attributable  to diabetes  in  the year  2000 was estimated  to be 2.9 million,  equivalent  to  5.2%  of  all  deaths  [3].  Yet mortality attributable to diabetes is  underestimated due to under-reporting  of  diabetes  on  death  certificates  [4].  Although figures obtained  from death  certificates have limited use in research  or health planning [5], they do provide  comprehensive data, making them use- ful for studying long-term trends [6].  Benghazi  is  the  second  largest  city  in  the  Libyan Arab  Jamahiriya,  situ- ated along the Mediterranean seaboard,  with a population  that  increased  from  575 900  in 1991  to 803 300  in 2000  [National Census and Statistics Depart- ment, personal  communication]. The  prevalence of diabetes  in a community  study in Benghazi in 2001 was found to  be 14.1% [7]. A 5-year study of diabetes  mortality was carried out in Benghazi in  1986–90 [8], but since then no further  studies have been undertaken. The aim  of this study was to update the data on  diabetes mortality and causes of death  in Benghazi. Methods Benghazi municipality  covers  all  51  districts  (communes) of  the  city. All  home deaths and all deaths in Benghazi  hospitals are registered in the Benghazi  central office  for deaths. Non-Libyans  have a separate register.  All death certificates of Libyan citi- zens registered during the 5-year period  1  January 2000 to 31 December 2004  were  examined  and  data  on  age,  sex  and cause(s) of death were  collected  from certificates  that mentioned dia- betes. For analysis,  the causes of death  recorded on  the death certificate were  coded to the nearest code of the Inter- national Classification of Diseases, 10th  revision (ICD-10) [9]. Diabetes as an  underlying cause of death was defined if  death was due to diabetic ketoacidosis,  hypoglycaemia, or hyperosmolar non- ketotic hyperglycaemia. Total mortality  during  the  study period was obtained  from the register of deaths. Results During  the  study  period  there  were  12 237 deaths  recorded  in Benghazi:  7071 males and 5166  females. A  total  of 1482 (12.1%) death certificates men- tioned diabetes: 758 (51.1%)  females  and 724 (48.9%) males. The mean age  at death of  this  group was 63.8  years  (65.4 years for males and 62.3 years for  females), and 82 (5.5%) were < 45 years  old at death.  Of  all  death  certificates mention- ing diabetes,  1038  (70.0%)  recorded  a  single  cause of  death,  153  (10.3%)  2  causes  and 291 (19.7%) 3 or more  causes. Diabetes  (ICD-10: E10–E14)  as  the underlying  cause of death was  recorded  in 76 certificates (5.1%) and  as a contributory cause of death in 1406  (94.9%).  Coronary artery disease was record- ed on 32.7% of 1038 death certificates  with a single cause of death (Table 1):  25.1% due  to acute myocardial  infarc- tion and 7.5% due  to  ischaemic heart  disease. Cerebrovascular diseases were  the next most common cause of death  (20.1%). Therefore circulatory diseases  (ICD-10:  I00–I99) were  the most  fre- quently  reported single cause of death  in people with diabetes (52.8%).  Infections (excluding tuberculosis)  (14.0%) were  the next most common  single cause of death (Table 1). Acute  metabolic  complications  of  diabetes  (diabetic ketoacidosis, hypoglycaemia  and hyperosmolar nonketotic hyperg- lycaemia) accounted  for 7.3% of  total  deaths due  to a  single  cause. Chronic  renal failure was mentioned on 6.6% of  death certificates with a single cause of  death, malignancies on 7.7% and tuber- culosis on 0.5%. Circulatory diseases were  also  in- cluded  as  the  cause of  death on 136  death certificates for the 444 cases with  2 or more causes. Aggregating the multi- ple causes of death, circulatory diseases  were mentioned on 684/1482 (46.2%)  of death certificates.  Among  the 82 diabetics aged < 45  years at death, acute diabetic complica- tions  accounted  for  35.1% of deaths,  chronic renal failure for 18.9%, coronary  artery disease for 8.1% and infections for  13.5%. Discussion Diabetes accounted  for 12.1% of  total  deaths in Benghazi from 2000 to 20004,  which  is  almost  double  the  figure  of  6.4% recorded  in  the previous study  in  Benghazi 14 years  earlier  (1986–90)  [8]. This  increase might be  explained  by  the high prevalence of diabetes  in  the Libyan Arab  Jamahiriya  (14.1%)  [7]  or  because  certifying  physicians  have become more  aware of  the  im- portance of reporting diabetes on death  certificates. However, in view of the fact  that  diabetes  is  known  to  be  under- reported on death certificates  [10,11],  the magnitude of  the problem might  be even greater than this. Certainly, our  figure  is  considerably  lower  than  that  of 38% reported from France [12] and 24% from Western Australia [13].  It  is  comparable  to  9.3%  from Singapore  [10] but higher than figures from other  developing countries: 2.7% from north  India [14], 2.8% from Kashmir [15] and 6.5% from Jamaica [16]. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 67 The mean  age  at  death of  people  with diabetes  (63.8  years) was  lower  than  in New Zealand (78 years) [17].  In our study, a single cause of death was  mentioned on 70.0% of death  certifi- cates, 2 causes on 10.3%, and 3 or more  causes on 19.3%, compared with 60.2%,  26.4% and 6.0% respectively from Kash- mir [15]. Considering  the  cases of multiple  causes of death, circulatory diseases were  recorded  in 46.2% of death certificates  of  diabetics, which  is  comparable  to  50% reported from the 1986–90 Beng- hazi study [8], 48.0% from north India  [14], 50% from Otago [17], 35.0% from  Japan  [18],  49.1% and 46%  from  the  United Kingdom (UK) [19,20]. Higher  rates have been  reported  in Western  Australia  (63%)  [13]  and  in  another  UK study (71%) [21], while lower rates  were  found  in Kashmir  (30.1%)  [15] and among Oklahoma Indians (38%)  [22]. Libyans now have a more seden- tary lifestyle, with consumption of high  fat, high carbohydrate  foods  and  lack  of exercise, mimicking  the  lifestyles of  more developed countries. Among  the 1038 death certificates  with a  single cause of death,  coronary  artery disease was  the most  frequently  mentioned  cause of  death  in  diabet- ics  (32.7%),  compared with 34%  in  a  hospital-based study  in Benghazi  [23] and 36% in the United States of Amer- ica  (USA)  [24],  but  higher  than  the  13.8%  for  aboriginal Australians  [25],  17.4%  from north  India  [14],  16.4%  from Kashmir  [15]  and  20.5%  from  Japan [18]. Among those with vascular  diseases, 261 (38.2%) deaths were due  to myocardial infarction compared with  28%  from Benghazi  in  the  1986–90  study of death certificates [8], and 19%  from a 1-year hospital  study  in Beng- hazi in 2002 [23]. Diabetes is known to  accelerate  the onset of  cardiovascular  disease. Changes  in diet  and physical  activity  in  the Libyan Arab  Jamahiriya  (the  traditional  Libyan  nomadic  life  no  longer exists) may contribute  to an  increased  incidence of  cardiovascular  disease. Increased life expectancies and  improved health care facilities for acute  Table 1 Single causes of death recorded on death certificates of 1038 Libyan diabetics, coded by International Classification of Diseases, 10th revision (ICD-10) Cause of death (ICD-10 code) Males Females Total No. No. No. % Coronary artery disease 175 164 339 32.7 Acute myocardial infarction (I21) 137 124 261 – Ischaemic heart disease (I25) 38 40 78 – Cerebrovascular diseases (I60–I69) 106 103 209 20.1 Infection 70 75 145 14.0 Septicaemia (A02.1) 34 42 76 – Pneumonia (J15) 30 26 56 – Meningitis (G00) 8 5 13 – Malignancy 46 34 80 7.7 Lung (C34) 23 0 23 – Gastrointestinal tract (C16, C18) 10 18 28 – Prostate (C61) 5 0 5 – Other 8 16 24 – Diabetes mellitus 46 30 76 7.3 Diabetic ketoacidosis (E10) 25 14 39 – Hypoglycaemia (E16.0) 20 13 33 – Hyperosmolar nonketotic hyperglycaemia (E11) 1 3 4 – Chronic renal failure (N18) 38 31 69 6.6 Chronic obstructive pulmonary disease (J40–J46) 25 15 40 3.9 Liver cirrhosis (K72.1) 18 20 38 3.7 Acute renal failure (N17) 5 9 15 1.4 Gastrointestinal haemorrhage (K92) 6 5 11 1.1 Other endocrine disease (E03.5, E05.5, E23, E27.2) 2 9 11 1.1 Tuberculosis (A15) 3 2 5 0.5 Total 540 497 1038 100.0 EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 68 diabetic complications may add  to  in- creasing  life expectancy among diabet- ics  and hence  a  greater  risk  of  dying  from cardiovascular disease. Acute cerebrovascular accident was  the second leading single cause of death  in 20.1% of cases, compared with 22%  from the hospital study in Benghazi [23] and 38.6%  from  the 1986–90  record  study from Benghazi [8]. This is higher  than  the14.5%  from Japan [18], 13.8%  from Kashmir [15] and 6% in Mexican,  Puerto Rican  and Cuban Americans  [26], 10.5% from Taiwan [27] and 6%  in the USA [24], but lower than 30.6%  from north India [14].  We found that infections, excluding  tuberculosis, are still an important cause  of death among diabetics (14.0%), a fig- ure that is comparable to earlier reports  from Benghazi of 12.0% and 11% [8,23].  However, much higher figures have been  reported among aboriginal Australians  (20.8%) [25], in Kashmir (33.8%) [15] and in north India (46.5%) [14]. Tuber- culosis was  reported on 0.5% of death  certificates  compared with  1.7%  [8],  and 1% [23] from Benghazi.  Malignancies were  recorded on 80  (7.7%) death certificates with a  single  cause  of  death,  similar  to  8.4%  from  the Benghazi 1986–90 study  [8],  and  8% among Mexican, Puerto Rican and  Cuban Americans [24], but lower than  18.5% from Taiwan [27], 12.0% among  Oklahoma  Indians  [22],  and 21%  in  the TRIAD study  [24]. This  is  prob- ably related to a lack of proper diagostic  facilities for malignancies so many cases  might have been missed. Chronic  renal  failure was  reported  on 6.6% death certificates of diabetics  with a  single cause of death,  a decline  from the figure of 14.5% in 1986–90 in  Benghazi [8]. This is probably due to the  recently developed nephrology centres  in Benghazi. Studies  in other countries  show 9.7% from north India [14], 22.3%  among aboriginal Australians [25] and 30.9% from Kashmir [9].  Diabetes was recorded as the cause  of death for 5.1% of deaths. This is com- parable  to  the  rate  from death certifi- cates in Benghazi 14 years earlier (6.4%)  [8], but  lower  than  the hospital-based  study in Benghazi (9%) [23]. Other in- ternational figures are: 6.2% from north  India [14], 10% from USA [16], 16.7%  from Kashmir [15], 24% from Western  Australia [10], 28.8% from Taiwan [25],  and  44%  in Cuban Americans  [26].  Low diabetes-related mortality  agrees  with our previous  report  and may be  related to earlier diagnosis and the avail- ability of treatment facilities  Among  those diabetics  aged < 45  years at death, acute diabetic complica- tions  accounted  for  35.1% of deaths,  compared  with  32%  from  Sweden  [28], 32% from Norway [29], 9% from  Ukraine [30] and 2% from France [4].  Mortality due  to chronic  renal  failure  in  this age group was 18.9% compared  with  69%  from Ukraine  [30].  Infec- tions were the cause of death in 13.5%.  Coronary artery disease was  the cause  of death in 8.1% compared to 9% from  Ukraine [30]. The high mortality among  those aged < 45 years due to metabolic  complications of diabetes and chronic  renal  failure  reflects poor control. This  is not due to lack of treatment, which is  free of charge in our country, but prob- ably due to lack of health education and  of certain specific diagnostic  tools  that  help  in detecting  those who are at  risk  and  educating  them properly. These  facilities are now becoming available. The study had some limitations. No  distinction between  type 1 and  type 2  diabetes was  recorded; however,  since  3.7% of diabetics  in Benghazi were as- sessed as having type 1 diabetes [31], we  can assume that the majority of deaths  in this study occurred in type 2 diabet- ics. Since underreporting of diabetes on  death certificates is well known, ranging  from 35%  to 55% [10,11], we can as- sume that many cases were not report- ed. Finally many undiagnosed diabetics  might have been missed.  Conclusions Diabetes  is  a major health problem  in  Benghazi and an important cause of mor- tality. The mortality from diabetes appears  to have nearly doubled over almost 15  years. Deaths  from chronic renal  failure  have declined in this period. Circulatory  diseases were still the main causes of death  in diabetics, with acute myocardial infarc- tion at the top of the list.  Acknowledgements We give  special  thanks  for Professor  Samir Helmy Assaad Khalil, Professor  of Medicine,  Alexandria  University,  Egypt, for his valuable comments.  1. Brown LJ, Scott RS, Moir LM. All-cause mortality in the Canter- bury (New Zealand) insulin-treated diabetes registry popula- tion. Diabetes care, 2001, 24:56–63. 2. Gatling W et al. Mortality rates in diabetic patients from a community-based population compared to local age and sex matched controls. Diabetes medicine, 1997, 14:316–20. References 3. Roglic G et al. The burden of mortality attributable to diabe- tes: realistic estimates for the year 2000. Diabetes care, 2005, 28(9):2130–5. 4. Penman A. Excess mortality due to diabetes in Mississippi and the estimated extent of underreporting on death certificates. Journal of the Mississippi State Medical Association, 2003, 44(10):319–25. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 69 5. Bhurgri A et al. Mortality statistics in South Karachi. Journal of the Pakistan Medical Association, 2001, 51(12):446–9. 6. Adelstein AM. Death certification and epidemiological re- search. British Medical Association, 1978, 2:1929–30. 7. Kadiki OA, Roaeid RB. Prevalence of diabetes mellitus and impaired glucose tolerance in Benghazi Libya. Diabetes & me- tabolism, 2001: 27:647–54. 8. Roaeid RB, Kadiki OA. Mortality of diabetes mellitus from death certificates in Benghazi–Libya. Egyptian journal of diabe- tes, 1996, 1:47–8. 9. Manual of the international statistical classification of diseases, in- juries and causes of death, 10th revision. Geneva, World Health Organization, 1992. 10. Cutter JL. Diabetes mortality in Singapore, 1991: a preliminary study. Singapore medical journal, 1998, 39:311–8. 11. Chen F et al. Death certification and New Zealand health in- formation service (NZHIS) statistics for diabetes mellitus: an under-recognized health problem. Diabetes research and clini- cal practice, 2004, 63:113–8. 12. Jougla E et al. Analysis of diabetes-related mortality in France. Diabetes & metabolism, 1991, 17:337–45. 13. Whittall DE et al. Deaths from diabetes are under-reported in national mortality statistics. Medical journal of Australia, 1990, 152:598–600. 14. Bhansali A, Chattopadhyay A, Dash RJ. Mortality in diabetes: a retrospective analysis from a tertiary care hospital in North India. Diabetes research and clinical practice, 2003, 60:119–24. 15. Zargar AH et al. Mortality in diabetes mellitus—data from a developing region of the world. Diabetes research and clinical practice, 1999, 43:67–74. 16. Alleyne SI et al. Mortality from diabetes mellitus in Jamaica. Bulletin of the Pan American Health Organization, 1989, 23:306– 14. 17. Coppell K, McBride K, Williams S. Under-reporting of diabetes on death certificates among a population with diabetes in Otago Province, New Zealand. New Zealand medical journal, 2004, 17:1207–17. 18. Sasaki A et al. A 15-year follow-up study of patients with non- insulin dependent diabetes mellitus (NIDDM) in Osaka, Japan. Long-term prognosis and causes of death. Diabetes research and clinical practice, 1996, 34(1):47–55. 19. Morgan CL, Currie CJ, Peters JR. Relationship between dia- betes and mortality: a population study using record linkage. Diabetes care, 2000, 23:1103–7. 20. Thomason MJ et al. Reporting of diabetes on death certificates using data from the UK Prospective Diabetes Study. Diabetes medicine, 2005, 22(8):1031–6. 21. Goldacre MJ et al. Trends in mortality rates for death-certifi- cate-coded diabetes mellitus in an English population 1979– 99. Diabetes medicine, 2004, 21:936–9. 22. Lee ET et al. A follow-up study of diabetic Oklahoma Indians. Mortality and causes of death. Diabetes care, 1993, 16:300–5. 23. Roaeid RB. Hospital admissions of diabetic patients in Beng- hazi. Diabetes international, 2002, 12:24–5 24. McEwen LN et al. Diabetes reporting as a cause of death: results from the Translating Research Into Action for Diabetes (TRIAD) study. Diabetes care, 2006, 29:247–53. 25. Phillips CB, Patel MS, Weeramathri TS. High mortality from renal diseases and infections in Aboriginal Australians with diabetes. Australian journal of public health, 1995, 19:282–6. 26. Smith CA, Barnett E. Diabetes-related mortality among Mexi- can Americans, Puerto Ricans, and Cuban Americans in the United States. Revista panamericana de salud pública, 2005, 18(6):381–7. 27. Tseng CH. Mortality and causes of death in a national sample of diabetic patients in Taiwan. Diabetes care, 2004, 27(7):1605–9. 28. Waernbaum I et al. Excess mortality in incident cases of diabe- tes mellitus aged 15 to 34 years at diagnosis: a population-based study (DISS) in Sweden. Diabetologia, 2006, 49(4):653–9. 29. Skrivarhaug T et al. Long-term mortality in a nationwide cohort of childhood onset type 1 diabetic patients in Norway. Diabe- tologia, 2006, 49(2):298–305. 30. Telishevka M, Chenett L, McKee M. Towards an understanding of the high death rate among young people with diabetes in Ukraine. Diabetes medicine, 2001, 18:3–9. 31. Kadiki OA, Roaed RB. Epidemiological and clinical patterns of diabetes mellitus in Benghazi, Libyan Arab Jamahiriya. Eastern Mediterranean health journal, 1999, 5:6–13. Note from the Editor We wish to draw the kind attention of our potential authors to the importance of applying the editorial requirements of  EMHJ when preparing their manuscripts for submission for publication. These provisions can be seen in the Guidelines  for Authors, which are available online at http://www.emro.who.int/emhj.htm, and are published at the end of the first  issue of each volume. We regret that we are unable to consider papers that do not conform to the Guidelines. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 70 ABSTRACT The aim of this study in Tunisia was to classify ketosis-onset diabetes in adult patients. All patients aged ≥ 30 years without known diabetes, presenting with ketosis and admitted to our department were studied. Patients with secondary or gestational diabetes and those on corticoid therapy or with coinciding infection were excluded. The data included clinical characteristics, immunological markers and β-cell function. Of the 63 patients, islet-cell antibodies were present in 27.0%, glutamic acid decarboxylase antibodies in 25.4% and thyrosin phosphatase antibodies in 19.0%. β-cell functional reserve was preserved in 54.0%. Our results confirm that patients with ketosis-onset diabetes mellitus in adulthood are a heterogeneous group. 1Department of Endocrinology and Diabetology; 2 Immunology Laboratory; 3Biochemistry Laboratory, La Rabta Hospital, Tunis, Tunisia (Correspondence to F. Harzallah: fatma.harzallah@rns.tn). Received: 18/05/07; accepted: 27/09/07 β ايلالخا ةفيظوو ةيعانلما تماساولا :سنوت في ينغلابلا يركسلا ضىرم ىدل مسلجا نوتيك طرف ءدب نمايلس ةيداه ،شيابعك ةيهزن ،ينقم سدنس ،نيوتيز رذنم ،يقف فصنم ،راذعلا ايليل ،ميهارب نب ءماسأ ،للها زرح ةمطاف مهرماعأ تناك ضىرلما عيجمو .ينغلابلا يركسلا ضىرم ىدل مسلجا نوتيك طرف ءدب فينصت لىإ سنوت في تيرجأ يتلا ةساردلا هذه فدته :ةصلالخا يوناثلا يركسلاب نوباصلما ضىرلما دعبتساو .ةساردلل نوثحابلا هيف لمعي يذلا مسقلا لىإ اولخدأو ،مسلجا نوتيك طرف نم نوناعيو ،رثكأ وأ ةنس 30 تماساولاو ،ةيكينيلكلإا تماسلا تانايبلا تنمضتو .ةقفاترم ىودعب نوباصلما وأ ،تاديويرتسوكيتروكلاب نولجاعي نيذلا كلذكو ،لملحا يركس وأ دادضأ تدجوو ،ضىرلما نم %27 ىدل ةدوجوم islet-cell ةيسايركنبلا رزلجا ايلاخ دادضأ تناك ،ًاضيرم 63 ينب نمو .β ايلالخا ةفيظوو ،ةيعانلما اهيلع ًاظفامح β ايلالخا ةفيظو تناكو .%19 في )ميزنإ( نيزويرثلا زاتافسف دادضأو ،ضىرلما نم %25.4 في )ميزنإ( كيماتولغلا ضحم ليسكوبرك ةعزان .أشنلما ةيرغتم ةعوممج نوتيكلا طرف ثودح ءدب ميهدل نيذلا ينغلابلا يركسلا ضىرم نأ ةساردلا جئاتن دكؤتو .ضىرلما نم %54 في Ketosis-onset diabetes in Tunisian adults: immunological markers and β-cell function F. Harzallah,1 A. Ben Brahim,1 L. Laadhar,2 M.Feki,3 M. Zitouni,2 S. Makni,2 N. Kaabachi3 and H. Slimane1 Diabète débutant par une cétose chez des adultes tunisiens : marqueurs immunologiques et fonction de la cellule β RÉSUMÉ L’objectif de cette étude menée en Tunisie était de classifier le diabète débutant par une cétose chez des patients adultes. Tous les patients âgés de 30 ans ou plus sans diabète connu, présentant une cétose et admis dans notre service ont été étudiés. Nous avons exclu ceux atteints d’un diabète secondaire ou gestationnel et ceux sous corticothérapie ou présentant une co-infection. Les données comprenaient les caractéristiques cliniques, les marqueurs immunologiques et la fonction de la cellule β. Des anticorps anti-îlots de Langerhans étaient présents chez 27,0 % des 63 patients, des anticorps anti-acide glutamique décarboxylase chez 25,4 % d’entre eux et des anticorps anti-thyrosine phosphatase chez 19,0 % d’entre eux. La masse fonctionnelle des cellules β était préservée chez 54,0 % des patients. Nos résultats confirment que les patients atteints d’un diabète sucré débutant par une cétose à l’âge adulte constituent un groupe hétérogène. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 71 Introduction Despite  the difference  in physiopatho- logical mechanisms of type 1 and type 2  diabetes,  the distinction between the 2  types can be notoriously difficult at the  time of diagnosis, particularly in atypical  presentations [1].  Ketosis-onset diabetes  is  the most  common presentation of adult patients  in our department [2] and it can lead to  a problem of classification. Acute onset,  particularly with ketosis, was previously  considered  to be  a  characteristic  fea- ture of  type 1 diabetes  [3]. However,  descriptions of  atypical presentations,  characterized by a prolonged remission  after acute need for insulin, demonstrate  that  type 2 diabetes may start with ke- tosis without any known precipitating  factor  [4]. Ethnic differences  in  initial  presentation of type 2 diabetes are well  documented and seem to be a conse- quence of a predominant insulin secre- tory defect in people of African ancestry  and a potential difference in ketogenesis  among ethnic groups [5,6].  The  Tunisian  population  has  a  growing epidemic of diabetes [7]. The  aim of  this  study  in Tunis,  the capital  city of Tunisia, was  to  classify newly  diagnosed  diabetes  in  adult  patients  who presented initially with ketosis.  Methods We  included  in  this  case  series  study  all  adult patients aged ≥ 30 years with  newly  diagnosed  diabetes  who  pre- sented with  an acute-onset ketosis  to  the  emergency department  and were  admitted  to our department between  July 2003 and July 2005. Ketosis onset  was defined as  the presence of hyper- glycaemia  (>  2  g/L),  ketonuria  and  immediate need for insulin without pre- viously known diabetes. Patients with  secondary or gestational diabetes and  those on corticoid  therapy or with an  infectious disease were excluded. A total  of 63 consecutive, unrelated Tunisian  patients were investigated. Data were collected on clinical char- acteristics  (family history of diabetes,  associated diseases, age, symptoms and  anthropometric  features),  biological  parameters [glycaemia,  total and high- density  lipoprotein (HDL)-cholesterol  and  triglycerides  performed  once  at  the time of the study in a fasting state],  immunological markers and β-cell func- tion.  Islet-cell  antibodies  (ICA)  were  detected by  indirect  immunofluores- cence using monkey pancreas sections  (The Binding Site, UK). Glutamic acid  decarboxylase  (GADA) and  thyrosin  phosphatase antibodies (IA-2A) were  detected  by  radio-immunoprecipita- tion  (Euroimmun, Germany).  β-cell  function was  assessed at  least 1 week  after  the acute episode, when patients  were in a nearly normoglycaemic state.  C-peptide levels were assessed at fasting  state  and 6 minutes  after  intravenous  administration of 1 mg glucagons by the  radio-immunological method using a  commercial kit (Immunotech, France).  β-cell functional reserve was considered  preserved  if  the  fasting C-peptide  level  was > 1 ng/dL or glucagon-stimulated  C-peptide > 1.5 ng/dL. Data were analysed using Epi-Info, version 6. Results are expressed as mean  and standard deviation (SD). Analysis  of variance or the Kruskall–Wallis tests  were used  to compare means and  the  chi-squared  test  to  compare propor- tions. Pair-wise comparisons were made  when there were significant differences  between groups. Results A total of 63 patients (23 women) aged  ≥ 30 years presenting with ketosis were  investigated. Among them, 36 (57.1%)  reported  a  family history of diabetes.  All patients complained of polyuria and  polydipsia, with a median duration of 30  days (range: 2 days to 1 year), and 80%  reported weight loss. Four patients had  associated  autoimmune disease. The  mean age of our patients was 46.0 (SD  11.6)  years  and  the mean body mass  index (BMI) was 26.0 (SD 5.4) kg/m2.  BMI was ≥ 25 kg/m2 in 52.4% of cases.  ICA were present  in  17  (27.0%),  GADA were detected  in 16  (25.4%)  and IA-2A were positive in 12 (19.0%)  of  patients.  At  least  1  immunologi- cal marker was  detected  in  23  cases  (36.5%). The mean C-peptide level was  1.07 (SD 0.80) ng/mL at  fasting and  1.42 (SD 1.07) ng/mL after glucagon.  β-cell  functional  reserve was preserved  in 54.0% of patients. According to immunological mark- ers (present A+ or absent A–) and β-cell  functional reserve (present β+ or absent  β–), our patients were divided  into 4  groups: 14 patients  (22.2%) were A+  β–; 15 (23.8%) were A– β–, 9 (14.3%)  were A+ β+; and 25 (39.7%) were A–  β+.  Among  the 14 patients who were  A+  β–,  12  (86%)  were  positive  for  GADA, 9 (64%) for IA-2A and 6 (43%)  for both antibodies.  In  the group who  were A+ β+, positive  antibodies were  mainly ICA, detected in 7 (78%) of the  9 patients.  There  were  no  significant  group  differences  in  the  sex  ratio  and  in  the  proportions of patients with a family his- tory of diabetes. Mean BMI and waist  circumference  increased  significantly  from group A+ β– to A– β+ (P < 0.01)  (Table 1). The A+ β– group,  i.e. patients with  immunological markers and β-cell defi- ciency, was the youngest group, with the  lowest means of BMI, waist circumfer- ence, total cholesterol and triglycerides.  The HDL level was the highest in the A+  β– group (Tables 1 and 2). The 2 groups with preserved β-cell  function (A+ β+ and A– β+) were simi- lar in most clinical features and biologi- cal parameters.  EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 72 Discussion These results demonstrate that patients  with ketosis-onset diabetes in adulthood  are a heterogeneous group in which type  2 diabetes is the most frequent cause. Despite  the  fact  that we  included  all  patients  presenting with  an  acute  onset  ketonuria  and  not  exclusively  patients with acidosis,  the proportion  of  typical  type  1  diabetes  with  im- munological markers  and  low  β-cell  functional  reserve was  relatively high  (22.2%),  slightly more  than  reported  by Maldonado (17%) in a multi-ethnic  study  with  younger  patients  [8].  It  may  suggest  that  autoimmune  type 1  diabetes contributes  to  the  increasing  incidence of diabetes  in  the Tunisian  adult population. Ketosis-prone diabetes with  remis- sion is a well-known sub-type of type 2  diabetes  rather  than  type 1. The acute  presentation at diagnosis or sometimes  later  is  explained by  a  functional  and  partially  reversible  β-cell  deficiency  [8,9]. This  subtype was  the most  fre- quent  in our study (39.7%) and to our  knowledge this is the first time that such  presentation has been documented  in  a North African population. Ketosis- prone  type  2  diabetes,  first  reported  in black populations  [10,11], is distin- guishable from other subtypes by clinical  and biological features of the metabolic  syndrome  [12].  Indeed, mean  BMI,  waist  circumference  and  triglycerides  were  the highest  in  this  group  in our  study. However, the mean BMI as well  as  the  triglycerides were  lower  in our  patients  than  levels  reported  in other  studies  [13,14], probably because of a  lower  rate of  insulin  resistance  in our  population. Moreover,  the presence of  the metabolic  syndrome  is more  fre- quently associated with preserved β-cell  function, and consequently a better gly- caemic control after  the acute episode  and long-term remission [14,15]. In this  kind of type 2 diabetes, the acute β-cell  failure inducing ketosis [15] seems to be  linked to a genetic propensity to gluco- toxicity and lipotoxicity [16–18]. Diabetes  in patients with β-cell de- ficiency  and without  immunological  markers may belong  to  type 1A,  since  it  is well demonstrated  that auto-anti- bodies may be  absent  even when  the  initial process of diabetes is an autoim- mune  reaction  [19]. Our  patients  in  this  group were  the  oldest  and  lean- est  and 2  scenarios may be possible:  the  disappearance  of  autoantibodies  with evolution of  type 1 diabetes or a  decline  in β-cell  function  some years  after the hyperglycaemic state that initi- ated authentic type 2 diabetes [20]. The  presence of diabetes-associated autoan- tibodies confirm the process leading to  β-cell  alteration and, as expected,  they  were detected  in our 4 patients with  associated autoimmune disease. In type  1A diabetes, the frequencies of ICA and  IA2 positivity decreased with increasing  age, whereas  the  frequency of GADA  positivity  increased [21]. The absence  of all 3  tested  immunological markers  and the clinical features, mainly age and  BMI, in our A– β–group argue in favour  of  the  latter hypothesis. However,  the  possibility of idiopathic type 1 diabetes  cannot be excluded. This type, classified  as 1B, is frequent in Japanese adults [22] and reported to be around 12% among  young  typical  type  1  Italian  patients  [21]. The  relationship between β-cell  function  and  autoantibodies  varies  between  studies,  but  the presence of  immunological markers  is mostly  as- sociated with greater decline  in  insulin  secretion  [21,23]. The  patients with  ketosis-prone  type 2 diabetes and per- manent insulin dependence represented  about 25% in a cohort of patients of sub- Saharan African origin [16]. They were  different  from type 1 diabetic patients  Table 1 Clinical characteristics of the 4 groups, classified according to immunological markers (present A+ or absent A–) and β-cell functional reserve (present β+ or absent β–) Characteristic Group 1 A+ β– Group 2 A– β– Group 3 A+ β+ Group 4 A– β+ P-value (n = 14) (n = 15) (n = 9) (n = 25) Mean (SD) age (years) 39 (7) 50 (13) 47 (10) 47 (12) < 0.07a Sex (no. of male:female) 10:4 10:5 6:3 14:11 NS Family history of diabetes (%) 64 60 67 48 NS Associated autoimmune disease (no.) 3 0 1 0 NS Mean (SD) waist circumference (cm) 80 (10) 90 (12) 93 (12) 100 (12) < 0.001c Mean (SD) BMI (kg/m2) 22.6 (3.7) 24.8 (3.7) 26.6 (6.4) 28.3 (6.4) < 0.01b Weight group (no.) NS Lean (< 25 kg/m2) 10 9 4 7 Overweight (< 30 kg/m2) 4 4 4 12 Obese (≥ 30 kg/m2) 0 2 1 6 Pair-wise significant differences between: agroups 1 & 2, groups 1 & 3, groups 1 & 4; bgroups 1 & 3, groups 1 & 4; cgroups 1 & 2, groups 1 & 3, groups 1 & 4, groups 2 & 4. SD = standard deviation; BMI = body mass index; NS = not significant. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 73 mainly because of maintenance of  re- sidual β-cell  function some years after  the diagnosis.  In our  study, C-peptide  levels in this group (A– β– group) were  similar  to autoimmune type 1 diabetic  patients (A+ β– group).  The most difficult patients  to clas- sify  are  those  represented by  the A+  β+ group with immunological markers  and preserved β-cell  function. These  features may  lead  to  the diagnosis of  latent autoimmune diabetes  in adults  (LADA), which  is  defined  as  adult- onset  diabetes with  circulating  islet  antibodies  but not  requiring  insulin  therapy initially [24]. It may not seem  appropriate  to  consider  this  condi- tion—revealed by an acute onset and  temporary need  for  insulin—as  latent  diabetes. However,  this kind of diabe- tes is characterized by features of type 2  diabetes and the autoimmune markers  and so transient insulinopenia may oc- cur as in ketosis-prone type 2 diabetes,  leading to an acute onset and then fol- lowed by  remission until progression  to insulin dependence. The acute β-cell  dysfunction  is probably  linked  to  an  autoimmune process, which  induces  initially only functional alteration, with- out massive destruction of islet cells, as  observed  in  type 1 diabetes  [25]. Ke- tonuria was present at  the moment of  the diagnosis in about 30% of patients  with slow type 1 diabetes  in a French  study [26].  Table 2 Biochemical parameters in the 4 groups, classified according to immunological markers (present A+ or absent A–) and β-cell functional reserve (present β+ or absent β–) Parameter Group 1 A+ β– Group 2 A– β– Group 3 A+ β+ Group 4 A– β+ P-value (n = 14) (n = 15) (n = 9) (n = 25) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Glycaemia (g/L) 2.95 (0.72) 3.16 (0.68) 3.10 (0.89) 3.39 (0.98) NS Total cholesterol (g/L) 1.45 (0.33) 1.79 (0.35) 2.06 (0.40) 1.90 (0.28) < 0.001a Triglycerides (g/L) 1.02 (0.30) 1.35 (0.43) 1.72 (0.79) 1.84 (0.79) < 0.005b HDL cholesterol (g/L) 0.45 (0.09) 0.41 (0.11) 0.37 (0.06) 0.37 (0.10) < 0.07c Fasting C-peptide (ng/dL) 0.39 (0.29) 0.48 (0.27) 1.42 (0.45) 1.68 (0.76) < 0.001 d Stimulated C-peptide (ng/dL) 0.55 (0.31) 0.71 (0.35) 2.07 (1.03) 2.10 (1.04) < 0.001e Pair-wise significant differences between: agroups 1 & 2, groups 1 & 3, groups 1 & 4; bgroups 1 & 2, groups 1 & 3, groups 1 & 4; cgroups 1 & 3, groups 1 & 4; dgroups 1 & 3, groups 1 & 4, groups 2 & 3, groups 2 & 4; egroups 1 & 3, groups 1 & 4, groups 2 & 3, groups 2 & 4. SD = standard deviation; NS = not significant; HDL = high-density lipoprotein. In  summary,  the  classification  of  diabetes using  insulin secretion evalua- tion and immunological markers, which  seems to be  the most effective scheme  [27],  allowed us  to distinguish 4  sub- groups of patients.  In more  than half  of  the cases (autoimmune  type 1 and  ketosis-prone type 2 diabetes), patients  may be diagnosed by classical character- istics. However,  the 2 other subgroups  may require further investigations, such  as repeat testing of β-cell cell function or  genetic studies.  In conclusion, ketosis-onset diabe- tes is in the majority of Tunisian adults  a presentation of type 2 diabetes. How- ever, autoimmune type 1 was more fre- quent than expected in this population. 1. Sobngwi E, Gautier JF. Adult-onset type I or ketosis-prone type II diabetes: evidence to revisit diabetes classification. Diabeto- logia, 2002, 45:283–5. 2. Harzallah F et al. Clinical and metabolic characteristics of newly diagnosed diabetes patients: experience of a university hospi- tal in Tunis. Diabetes & metabolism, 2006, 32:632–5. 3. Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabetic medicine, 1998, 15:539–53. 4. Aizawa T et al. Ketosis-onset diabetes in young adults with sub- sequent non-insulin-dependency, a link between IDDM and NIDDM. Diabetic medicine, 1997, 14:989–91. 5. UK Prospective Diabetes Study. XII: Differences between Asian, Afro-Caribbean and white Caucasian type 2 diabetic References patients at diagnosis of diabetes. Diabetic medicine, 1994, 11:670–7. 6. Kazlauskaite R et al. Ethnic differences predicting ketonuria in patients with type 2 diabetes. Journal of diabetes and its complications, 2005, 19:284–90. 7. Bouguerra R et al. The global diabetes pandemic: the Tunisian experience. European journal of clinical nutrition, 2007, 61:160–5. 8. Maldonado M et al. Ketosis-prone diabetes: dissection of a heterogeneous syndrome using an immunogenetic and beta- cell functional classification, prospective analysis, and clinical outcomes. Journal of clinical endocrinology and metabolism, 2003, 88:5090–8. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 74 9. Sobngwi E et al. Diabetes in Africans. Part 2: Ketosis-prone atypical diabetes mellitus. Diabetes & metabolism, 2002, 28:5–12. 10. Winter WE et al. Maturity-onset diabetes of youth in black Americans. New England journal of medicine, 1987, 316:285–91. 11. Umpierrez GE et al. Diabetic ketoacidosis in obese African– Americans Diabetes, 1995, 44:790–5. 12. Otiniano ME, Balasubramanyam A, Maldonado M. Presence of the metabolic syndrome distinguishes patients with ketosis- prone diabetes who have a type 2 diabetic phenotype. Journal of diabetes and its complications, 2005, 19:313–8. 13. Umpierrez GE et al. Immunogenetic analysis suggests differ- ent pathogenesis for obese and lean African–Americans with diabetic ketoacidosis. Diabetes care, 1999, 22:1517–23. 14. Sobngwi E et al. Metabolic and immunogenetic prediction of long-term insulin remission in African patients with atypical diabetes. Diabetic medicine, 2002, 19:832–5. 15. Linfoot P, Bergstrom C, Ipp E. Pathophysiology of ketoacidosis in type 2 diabetes mellitus. Diabetic medicine, 2005, 22:1414–9. 16. Mauvais-Jarvis F et al. Ketosis-prone type 2 diabetes in patients of sub-Saharan African origin: clinical pathophysiology and natural history of β-cell dysfunction and insulin resistance. Diabetes, 2004, 53:645–53. 17. Mauvais-Jarvis F et al. PAX4 gene variations predispose to ketosis-prone diabetes. Human molecular genetics, 2004, 13:3151–9. 18. Sobngwi E et al. High prevalence of glucose-6-phosphate dehydrogenase deficiency without gene mutation suggests a novel genetic mechanism predisposing to ketosis-prone diabetes. Journal of clinical endocrinology and metabolism, 2005, 90:4446–51. 19. Borg H et al. A 12-year prospective study of the relationship between islet antibodies and beta-cell function at and after the diagnosis in patients with adult-onset diabetes. Diabetes, 2002, 51:1754–62. 20. Goetz FC et al. Declining beta-cell function in type 2 diabetes: 5-year follow-up and immunologic studies of the population of Wadena, MN. Metabolism, 2002, 51:144–8. 21. Bruno G et al. Residual beta-cell function and male/female ratio are higher in incident young adults than in children: the registry of type 1 diabetes of the province of Turin, Italy, 1984–2000. Diabetes care, 2005, 28:312–7. 22. Imagawa A et al. A novel subtype of type 1 diabetes mellitus characterized by a rapid onset and an absence of diabetes- related antibodies. Osaka IDDM Study Group. New England journal of medicine, 2000, 342:301–7. 23. Bakhtadze E et al. HLA-DQB1 genotypes, islet antibodies and beta cell function in the classification of recent-onset diabetes among young adults in the nationwide Diabetes Incidence Study in Sweden. Diabetologia, 2006, 49:1785–94. 24. Tuomi T et al. Clinical and genetic characteristics of type 2 diabetes with and without GAD antibodies. Diabetes, 1999, 48:150–7. 25. Shimada A et al. T-cell insulitis found in anti-GAD65+ diabetes with residual beta-cell function. A case report. Diabetes care, 1999, 22:615–7. 26. Dessalloud R et al. Autoimmune markers in slow type 1 diabe- tes: confrontation to type 1 diabetes. Diabetes and metabolism, 2000, 26:353–60. 27. Balasubramanyam A et al. Accuracy and predictive value of classification schemes for ketosis-prone diabetes. Diabetes care, 2006, 29:2575–9. Note from the Editor We wish to draw the kind attention of our potential authors to the importance of applying the editorial requirements of  EMHJ when preparing their manuscripts for submission for publication. These provisions can be seen in the Guidelines  for Authors, which are available online at http://www.emro.who.int/emhj.htm, and are published at the end of the first  issue of each volume. We regret that we are unable to consider papers that do not conform to the Guidelines. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 75 Corrected QT dispersion improves diagnostic performance of exercise testing in diagnosing coronary artery disease H. Hasan-Alia,1 M.H. Maghraby,2 D.A. Fouad 1 and A.A. Abd-Elsayed 3 ABSTRACT To determine the best combination of parameters that would improve the diagnostic performance of exercise testing, coronary angiography plus exercise testing were done on 112 patients with angina pectoris and normal electrocardiogram. The univariate predictors of coronary artery disease included: age ≥ 40 years, male sex, hypertension, smoking, development of exertional chest pain, decrease in systolic blood pressure (BP) ≥ 10 mmHg or systolic BP 3 min post-exercise > 90% of peak, heart rate drop < 12 beats/min 1 min post- exercise, exercise-induced ST-segment depression ≥ 1 mm. Multivariate logistic regression analysis showed that using either ST depression ≥ 1 mm or peak exercise QTDc > 70 ms significantly improved sensitivity and negative predictive value of the test without a significant decrease in specificity. 1Department of Cardiovascular Medicine; 2Department of Internal Medicine, Assiut University Hospital; 3Department of Public Health and Community Medicine, Assiut University, Assiut, Egypt (Correspondence to A.A. Abd-Elsayed: alaaawny@hotmail.com). Received: 01/04/07; accepted: 02/09/07 يجاتلا نايشرلا ضرم صيخشت في نيرمتلا رابتخلا صييخشتلا ءادلأا نسيح QT تتشت حيحصت ديسلا دبع ءلاع ،داؤف ءاعد ،بيرغم دممح ،ليع نسح ماسح ـل نيرمتلا رابتخاو ةيجاتلا ةيعولأا ريوصت يرجُأ ،نيرمتلا رابتخلا صييخشتلا ءادلأا نّستح يتلا ةتباثلا لماوعلا نم جيزم لضفأ ديدحتل :ةصلالخا بركأ رمعلا :يجاتلا نايشرلا ضرلم يرغتلما ةيداحلأا تائبنلما تن َّمضتو .ًمايلس ميهدل بلقلا ةيبرهك ططمخ ناكو ةيردصلا ةحبذلاب ينباصم ًاضيرم 112 وأ نم بركأ ضيابقنلاا مدلا طغض ضافخنا ،دوهجلما لذبل ةجيتن يردص لمأ ةأشن ،ينخدتلا ،مدلا طغض طرف ،يركذلا سنلجا ،ًاماع 40 يواسي نم لقلأ بلقلا ضبن لدعم ضافخناو ،ةورذلا نم %90 نم لىعأ نيرمتلا ءادأ نم قئاقد 3 دعب ضيابقنلاا مدلا طغض نوكي وأ ،يقبئز ترميلم 10 يواسي يتسجوللا فوحتلا ليلتح رهظأو .رثكأ وأ ةقيقد دعب نيرمتلا ببسب ST في ضافخنا روهظ وأ ،نيرمتلا ءادأ نم ةقيقد دعب ةقيقدلا في ةضبن 120 نم نسحيس ةيناث ليم 70 نم رثكأ نيرمتلا ةورذ في QTDc ةدايز وأ دحاو ترميلم يواسي وأ نم رثكأ ST ضافخنا نم يأ مادختسا نأ تايرغتلما ديدعلا .ةيعونلا في ةسوملم ةدايز نودب رابتخلال يبلسلا ءوبنتلاو ةيساسلحا ةميق ةسوملم ةجردب Amélioration de la performance diagnostique de l’épreuve d’effort aux fins du diagnostic de coronaropathie grâce à la dispersion du QT corrigée RÉSUMÉ Afin de déterminer la meilleure combinaison de paramètres permettant d’améliorer la performance diagnostique de l’épreuve d’effort, une angiographie coronarienne et une épreuve d’effort ont été pratiquées sur 112 patients présentant un angor et un électrocardiogramme normal. Les facteurs prédictifs univariés de la coronaropathie étaient les suivants : âge supérieur à 40 ans, sexe masculin, hypertension, tabagisme, apparition de douleurs thoraciques à l’effort, baisse de la tension artérielle (TA) systolique supérieure à 10 mmHg ou de la TA systolique trois minutes après l’effort de plus de 90 % de la valeur maximale, chute de la fréquence cardiaque à moins de 12 pulsations/min une minute après l’effort, et dépression du segment ST induite par l’effort de plus de 1 mm. L’analyse de régression logistique multivariée a montré que l’utilisation de la dépression du ST de plus de 1 mm ou de la dispersion du QT corrigée à l’acmé de l’effort de plus de 70 ms améliorait significativement la sensibilité et la valeur prédictive négative de l’épreuve d’effort, sans baisse sensible de la spécificité. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 76 Introduction The exercise electrocardiogram (ECG)  is  used  in  the  evaluation  of  sympto- matic patients  to predict  the presence  and extent of  coronary  artery disease  (CAD) [1,2]. Although a large number  of non-invasive stress testing modalities  are currently available,  the ECG is  still  used as  standard because  it  is  the  least  costly of  all  provocative non-invasive  tests [3]. The conventional criterion for  designating  an exercise  test  abnormal  is  demonstration  of  > 1 mm of  slow  upsloping or horizontal or downsloping  ST-segment. However, when exercise- induced  ST-segment  change  is  used  as  a  single  criterion  for  ischaemia,  its  value  is  limited by  low sensitivity  and  specificity [1–4]. An alternative to using  more expensive tests would be the more  efficient use of available  low cost data.  Several parameters have been studied in  a number of reports to improve the sen- sitivity,  specificity and predictive value  of the exercise stress test [4–18]. This  study  was  designed  to  de- termine  the best  combination of  pa- rameters, clinical and exercise-induced  haemodynamic  and  electrocardio- graphic, that would improve the capac- ity of exercise testing in diagnosing CAD  with best sensitivity and specificity. Methods The study group comprised all 112 pa- tients presenting to our hospital during  the  period  February  2006–October  2006 with typical (definitive) or atypical  (probable) angina associated with nor- mal or non-conclusive  electrocardio- graphic  changes  for  the  diagnosis  of  CAD and who gave  informed consent  to participate in the study. The protocol  of  the  study was  fully  explained  to  all  participants. Chest discomfort was classified as  follows:  typical  angina  (definitive)  which • meets all the 3 of the following crite- ria:  substernal chest discomfort with  characteristic quality  and duration;  provoked by exertion or  emotional  stress;  and  relieved by  rest or nitro- glycerine;  atypical  angina  (probable),  which • meets 2 of  the above 3 criteria; non- cardiac chest discomfort which meets  ≤ 1 of the above criteria [19].  Patients were excluded  if  they had  current unstable  angina, documented  previous myocardial  infarction, a prior  revascularization procedure,  ejection  fraction < 50%,  valvular or  congenital  heart disease or haemoglobin  level < 8  mg/dL. Patients were also excluded  if  they were unable  to exercise due  to a  non-cardiac  illness,  they had an unin- terpretable electrocardiogram (ECG)  (such  as  in Wolf–Parkinson–White  syndrome or bundle branch block) and  they  could not  achieve > 85% of  age- predicted heart  rate  (HR) during  the  test without  evidence of  positivity  in  their exercise ECG (inadequate test).  Exercise stress test Before  the  test  the patients had  to be  free of  chest discomfort  for  at  least 1  week, stop anti-anginal, anti-arrhythmic  and antipsychotic drugs (each drug ac- cording to its half-life), and fasting (with  no cigarette  smoking)  in  the previous  3 hours. Standard Bruce protocol was  used  for all patients  [20]. The test was  stopped if the target heart rate (HR) was  achieved or on the occurrence of any of  the  following: exertional hypotension,  limiting symptoms (chest pain, evidence  of poor peripheral perfusion, dyspnoea,  fatigue or  leg cramps); ST-depression  > 3 mm; bundle branch block; or  seri- ous arrhythmias (multiform complexes,  couplets,  triplets,  salvos or ventricular  tachycardia). The following variables were meas- ured during the stress test: Basic data: resting HR, resting systolic • blood pressure (BP), maximum HR  achieved, duration of  exercise, peak  systolic  blood  pressure,  and  chest  pain with exertion.  Abnormal BP response (either systo-• lic BP  fails  to  increase > 130 mmHg  or decreases by > 10 mmHg  in  re- sponse  to exercise)  [5];  systolic BP  at 3 minutes post exercise; > 90% of  peak exercise systolic BP [6]. Abnormal HR response (either HR • at peak exercise < 100 beats/min [3] or  failure of HR  to drop > 12 beats  at 1 minute post exercise  from peak  exercise value [7]). ST  segment  changes  (measured  in • ≥ 6  beats)  occurring  peak  exercise  and/or during recovery; > 1 mm hor- izontal  or downsloping depression  measured  80 ms  from  the  J-point,  > 1.5  mm  upsloping  depression  measured 80 ms from the J-point, or  > 1 mm elevation  in > 2 contiguous  leads except aVR [3]. ST/HR  index > 1.6 µV/beats/min • (measured in the lead with the maxi- mum ST depression, in ≥ 6 beats) as  ST depression at peak stress divided  by  the difference between  the peak  exercise HR and resting HR [8–10]. ST/HR  slope:  a  linear  regression-• based computed measurement  [ST  depression  = dependent  variable;  HR = independent variable. Both are  measured  in  each  lead  (excluding  aVR, aVL and V 1 ) at the end of each  stage and at peak exercise]. A  linear  regression analysis  is made  for each  lead: the maximal ST/HR slope is re- corded and the highest ST/HR slope  with  a  statistically  significant  corre- lation coefficient  among all  leads  is  taken as the final result. ST/HR slope  ≥ 2.4  µV/beats/min  is  considered  an indicator of the presence of CAD  [9,10]. Abnormal T-wave  response (meas-• ured in ≥ 6 beats);  increased T-wave  amplitude  in V 2   > 2.5 mm  [11]  or  T-wave  inversion with exercise  in V 5 (< 5 mm or ≥ 5 mm) [12]. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 77 Lengthening or no change in P-wave • duration in V 2  at peak exercise (meas- ured in ≥ 6 beats) is considered posi- tive, while  shortening  is  considered  negative [13]. Q-wave depth  in  lead V• 5  (measured  in > 6 beats). This is considered posi- tive if absent both at rest and at peak  exercise, present at  rest but with no  change with  exercise,  or present  at  rest but decreases or disappears with  exercise.  It  is  considered negative  if  absent at  rest but appears with exer- cise, or present at  rest and  increased  by exercise [14]. Decreased R-wave amplitude > 1 mm • [4] or increased ≥ 2 mm [15] at V 5 at peak  exercise  compared  to  resting  value (measured in ≥ 6 beats) is con- sidered positive.  QT dispersion (QTD): QT interval • was measured manually  in as many  pericardial and limb leads as possible  (≥ 8  leads) after being magnified on  a Cannon  photocopier  (× 3).  It  is  measured  from the onset of Q-wave  to  the  end of T-wave.  If  the  end of  T-wave is not seen, for example when  it is fused with the U-wave or P-wave  as in the setting of rapid HR, a straight  line  is drown tangential  to  the down  stroke of  the T-wave  till  it meets  the  base line (identified from level of PR  segment) and this is taken as the end  of the T-wave. QTD is the difference  between  the highest  and  the  lowest  QT. The  test  is  considered positive  if QTD at peak exercise  is > 60 ms  [16].  Delta QTD (from rest  to peak exer-• cise) > 16 ms. [17]. Corrected QT dispersion (QTDc) • at peak exercise: QT interval (QT) is  measured in as many pericardial and  limb  leads as possible (≥ 8  leads) as  mentioned. Corrected QT (QTc)  is calculated  from Bazett’s equation:  QTc  = QT/(√RR  interval). QTDc  is  the difference between  the high- est  and  the  lowest QTc. The  test  is  considered  positive  if QTDc  > 70  ms [16]. Q-X/QT ratio > 0.5 measured  in V• 5 in  ≥ 6  beats  (Q-X measured  from  the beginning of QRS to crossing of  ST) [18]. Coronary angiography Coronary angiography was carried out  within a maximum of 90 days from the  exercise test. Multiple views were taken  for both  the  left and right coronary ar- teries  to  achieve  complete  visualiza- tion of all coronary segments  from ≥ 2  orthogonal planes. The coronary artery  was considered diseased if stenosis was  ≥ 50% diameter. Statistical analysis All  data  were  analysed  using  SPSS,  version  11.  Continuous  variables  were expressed as mean and standard  deviation (SD) and discrete variables  were presented as frequencies and per- centages. Continuous  variables were  compared between the 2 groups (with  and without CAD) using the unpaired  Student  t-test  for normally distributed  data  and  the Mann–Whitney U-test  for non-normally distributed data. Dis- crete  variables were  compared using  the chi-squared  test with Fisher  exact  correction. Statistical  significance was  set at P < 0.05.  Variables  with  a  significant  dif- ference  between  the  ischaemic  and  non-ischaemic groups were considered  univariate predictors of  the presence  of CAD. Validation of  these variables  was  tested by computing  the  sensitiv- ity, specificity and positive and negative  predictive values. The categorical univariate predictors  of CAD were entered into multivariate,  stepwise,  logistic  regression analysis  to  identify  independent predictors. Only  variables with P  < 0.05 were  eligible  to  enter  the  stepwise  analysis  and be  retained  in  the final model. Validation  of  the model was also  tested using  the  Holmer–Lemeshow  goodness-of-fit  statistics across groups of risk. To deter- mine the cut-off point for a positive test  according to the above model, a receiver- operating-characteristic (ROC) curve  was plotted for the predicted probability  of each case in the study group. Sensitiv- ity, specificity and positive and negative  predictive values were compared using  the McNemar test. Results The mean age of  the patients was 46  (SD  9)  years. There were  81  (72%)  males,  47  (42%)  participants  with  hypertension,  26  (23%) with  diabe- tes, 60 (54%)  smokers  and 85 (76%)  who had had  typical chest pain. Based  on  coronary  angiography,  significant  CAD (> 50% stenosis) was present  in  57 (51%) participants: 21 (19%) had  single  vessel,  8  (7%) had 2-vessel,  28  (25%) had 3-vessel disease. The remain- ing 55 participants (49%) did not have  significant CAD.  All  those  with  a  negative  test  achieved ≥ 85% of the age-predicted HR  with exercise. We were able to measure  V 5  variables in 110 (98%) participants;  peak exercise QT, QTD, QTc, QTDc  was measured  in 109 (97%) patients.  All missing values were  from  those  in  the non-CAD group. Predictors of CAD Compared  to  those  without  CAD,  patients with CAD had higher mean  peak  exercise QT  interval  [327  (SD  40) versus 272 (SD 28)] (P < 0.001),  QTD [61 (SD 21 versus 38 (SD 10)]  (P  < 0.001), QTc  interval  [485  (SD  36 versus 435 (SD 29)]  (P  < 0.001),  QTDc [52 (SD 47) versus 33 (SD 30)]  (P < 0.001). The univariate predictors of  CAD are shown in Table 1.  The statistically  significant univari- ate  predictors  of CAD were  entered  into  a multivariate,  stepwise,  logistic  regression  analysis  to  determine  the  best diagnostic model. The  independ- ent predictors of CAD were horizontal  or  downsloping  ST  depression  ≥ 1  EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 78 mm and peak exercise QTDc > 70 ms  (Table 2). The Holmer–Lemeshow goodness- of-fit  statistic across groups of  risk was  not  statistically  significant  (P  = 0.89)  indicating little departure from a perfect  fit. The area under  the ROC curve  for  the predicted probability of each case in  the study group  from this multivariate  model was 0.94. The cut-off point of the  predicted probability  for a positive  test  according  to  the above model was ob- tained from the ROC curve. The cut-off  point of the predicted probability of the  model was 0.39 with  the best  sensitiv- ity (93%) and specificity (85%) (Table  3). The predicted probability  from the  above model was computed  from  the  following equation: where, α is the constant (intercept) of  the regression model, B is the B coef- ficient of the variables, X is the value  of the variable (0 when absent, 1 when  present). This  predicted  probability  ≥ 0.39  can be achieved when ≥ 1 variables  in  Table 1 Univariate predictors of coronary artery disease (CAD) Predictor With CAD (n = 57)a No CAD (n = 55)a PPV NPV No. % No. % % % Age ≥ 40 years 57 100 24 44 100 75 Male sex 53 93 28*** 51 65 87 Hypertension 33 58 14*** 25 70 63 Diabetes 18 32 8* 15 67 52 Smoking 40 70 20*** 36 67 67 Typical ischaemic chest pain 53 93 32*** 58 62 58 Chest pain with exertion 56 98 24*** 44 70 94 Abnormal BP response with exercise: 20 35 4*** 7 83 53 Peak systolic BP < 130 mmHg 4 7 0 0 Decrease systolic BP ≥ 10 mmHg 8 14 1* 2 89 52 Systolic BP 3 min post-exercise > 90% peak 16 28 1*** 2 94 57 HR at peak exercise < 100 b/m 0 0 0 0 HR failed to drop ≥ 12 b/m at 1 min post-exercise 16 28 6* 11 73 54 ST-segment shift with exercise: 49 86 24*** 44 86 80 ≥ 1 mm horizontal or downsloping depression 40 70 5*** 9 89 75 ≥ 1.5 mm upsloping depression 9 16 15 27 ≥ 1 mm elevation 0 0 Peak exercise ST/HR index ≥ 1.6 µV/b/m 25 44 16 29 Peak exercise ST/HR slope ≥ 2.4 µV/b/m 30 53 15** 27 67 59 Increased T amplitude ≥ 2.5 mm in V2 33 58 8 15 81 66 T-wave inversion with exercise 1 2 0 Lengthened or no change in P-wave duration in V2 49 86 35*** 64 58 71 Decrease or no change in Q-wave depth in V5 50 88 39* 71 56 70 R amplitude in V5 increase ≥ 2 mm or decrease ≥ 1 mm 45 79 20*** 36 69 73 Peak exercise QTD > 60 ms 37 65 4*** 7 90 71 Delta QTD rest to peak exercise ≥ 16 mm 26 46 10** 18 72 58 Peak exercise QTDc > 70 ms 45 80 4*** 7 92 80 Peak exercise Q-X/QT ratio in V5 > 0.5 28 49 16* 29 64 56 Axis shift with exercise 2 4 1 2 Transient bundle branch block with exercise 0 0 1 2 Exercise-induced ventricular ectopics 12 21 4 7 *P < 0.05; **P < 0.01; ***P < 0.001. a% within the group with CAD is equivalent to sensitivity while % within the group with no CAD is equivalent to 1 – specificity. HR = heart rate; b/m, beats per minute; BP = blood pressure; QT = QT interval; QTD = QT dispersion; QTDc = corrected QT dispersion; PPV, positive predictive value; NPV = negative predictive value. 2211 2211 1 XBXB XBXB e eyProbabilit ++ ++ + = α α Prob lity طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 79 the equation are positive. So,  accord- ing  to  the  above model,  the presence  of horizontal  or downsloping ST de- pression ≥ 1 mm and/or peak exercise  QTDc > 70 ms  is  an  indication  of  a  positive test. To study the additive effect of both  independent variables  in  the model, 3  logistic regression models were created,  1  for each  independent variable alone  and 1 using either or both variables as  an indication of a positive test. The dis- criminative ability of  the 3 models was  compared by computing the area under  the ROC curve  for  each.  Sensitivity,  specificity, positive and negative predic- tive values were computed for each and  compared to those of ST depression to  make a  simple numerical  comparison  (Table 4). Adding peak exercise QTDc  > 70 ms  to horizontal or downsloping  ST depression ≥ 1 mm in the diagnosis  of CAD during the interpretation of the  exercise  test  significantly  improved the  sensitivity (70% to 93%; P < 0.001) and  the negative predictive value of the test  (75% to 92%; P < 0.01) with no signifi- cant decrease in the specificity.  The validity  indices were higher  for  the peak exercise QTDc compared  to  ST depression but the differences were  not statistically significant. The additive effect of the independ- ent variables in the model was re-tested  in the detection of single vessel disease  as well as multi-vessel disease (Table 4).  ST depression had a lower sensitivity in  single vessel (57%) than in multi-vessel  disease (78%; P < 0.01), with specificity  91%  for both. Similarly, peak exercise  QTDc had  sensitivity 81%  for  single  and 78% for multi-vessel, with specificity  92%  for both. The diagnostic accuracy  was even better  than ST depression  in  single vessel disease, as  indicated  from  the greater area under  the ROC curve  (0.87 versus 0.74) and higher sensitivity  (81% versus 57%; P < 0.001). Although  the  specificity  and  predictive  values  were higher,  the differences were not  statistically  significant.  In  single vessel  disease, adding peak exercise QTDc to  ST depression offered advantages over  QTDc alone. In multi-vessel disease the  diagnostic accuracy of the test improved  (area under ROC curve 0.97, which  is  higher than either alone). The sensitivity  and negative predictive value  in multi- vessel disease  increased significantly  to  100% with no  significant decrease  in  specificity. Discussion The exercise  test  has  a  reported  sen- sitivity of 50%–70% and  specificity of  70%–90% using conventional ST de- pression criteria with exercise [3].  In a  meta-analysis, mean sensitivity was 68%  (range 23%–100%) and mean specifi- city 77% (range 17%–100%) [1]. In our  study, sensitivity was 86% and specificity  Table 2 Multivariate stepwise logistic regression analysis for prediction of coronary artery disease (CAD) Variable β coefficient (SE) OR (95% CI) P-value ST depression ≥ 1 mma 3.3 (0.8) 27.3 (6.2–60.2) < 0.001 Peak exercise QTDc > 70 ms 3.8 (0.7) 43.6 (10.3–84.9) < 0.001 Constant –9.6 (1.7) – < 0.001 aHorizontal or downsloping. QTDc = corrected QT dispersion; SE = standard error; OR = odds ratio; CI = confidence interval. 44%. This relatively high sensitivity is at- tributed to the use of 50% angiographic  stenosis as a  reference standard  for  the  presence of CAD and measurement of  ST depression at peak exercise and/or  during  recovery, which  improves  test  sensitivity. Recovery-onset ST depres- sion  has  been  reported  to  represent  about 30% of ischaemic ECG response  with exercise [21].  Another  explanation could be  re- ferral bias as  the participants  included  patients with  typical  and probable  is- chaemic  chest pain. Referral bias was  reported to be the most important fac- tor increasing sensitivity and decreasing  specificity [2]. This referral bias  is ethi- cally unavoidable as coronary angiogra- phy could not be done for patients with  atypical, likely non-ischaemic, chest pain  and negative exercise test. Horizontal or  downsloping ST depression > 1 mm had  a  significantly  lower  sensitivity  (70%)  and a higher  specificity (91%). Sansoy  Watson and Beller  similarly  reported  that  adding  upsloping  ST-segment  depression  increased  sensitivity at  the  expense of  specificity and a  significant  decrease in the positive predictive value  of  the  test  [22]. Also,  in a more  recent  report, both  rapid and slow upsloping  ST depression were found to be associ- ated with very  low  likelihood of CAD  compared to horizontal or downsloping  ST depression [23]. Similar to previous  reports  [1,2], we  found  that  in  single  vessel  disease,  ST  depression  had  a  lower  sensitivity  than  in multi-vessel  disease, with a similar specificity. Normally, the QT interval (correct- ed for HR) shortens with exercise [24].  Table 3 Sensitivity and specificity of the predicted model at different predicted probabilities Positive if predicted probability ≥: Sensitivity Specificity 0.00 1.00 0.00 0.39 0.93 0.85 0.74 0.79 0.92 0.89 0.57 1.00 1.00 0.00 1.00 EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 80 Some investigators have found that this  interval  fails  to  shorten, or  lengthens,  when ischaemia is present [18,25]. They  have also  reported a higher Q-X/QT  ratio  in CAD patients with no additive  value  to ST segment criteria  in  terms  of  sensitivity  and  specificity  [18,25].  QT  interval  difference with  age  and  sex  is not  thought  to  affect  its useful- ness  in exercise ECG. This  is based on  previous findings that sex differences in  QT disappear at HR ≥ 110 beats/min,  whereas age differences are smaller but  are present  throughout  exercise, with  no significant age–sex interaction [26].  Moreover, QTD, QTDc and/or  their  differences between rest and peak exer- cise have emerged as useful additional  diagnostic criteria  in  the  interpretation  of  the exercise  test,  irrespective of  sex  [16,17,26,27]. Exercise QTD > 60 ms  has  been  found  to be  a  clinically useful  indica- tor  of  significant  coronary  stenosis  independent of  sex or  the presence or  absence of  significant exercise-induced  ST-segment  depression  [26] and in patients  who  do  not  have  exercise- induced chest pain or  significant ST- segment depression  [27].  It has been  reported  in a  study on  female patients  to have a significantly higher sensitivity  and specificity for the diagnosis of CAD  compared with 1-mm ST-segment de- pression. When a QTD > 60 ms was  added  to ST-segment depression as a  condition for a positive test, the specifi- city increased to 100% [16]. Also, it has  been  reported  to have a greater  sensi- tivity  and  specificity  than ST depres- sion in the detection of restenosis after  percutaneous coronary angioplasty  at  ≥ 50 ms [28]. Adding QTD ≥ 60 ms to  ST depression improved the diagnostic  value of  the exercise  test  in diagnosing  restenosis after percutaneous coronary  angioplasty  [29]. A  rise of QTD with  exercise ≥ 16 mm was another predictor  of CAD [17]. Exercise QTDc of > 70  ms significantly increased the sensitivity  of exercise testing for CAD; in addition,  combining with ST-segment depres- sion gave  a  specificity of  100%. Both  QTD  and  QTDc  were  measurable  with an acceptable reproducibility [16].  Similarly Ozdemir et al.,  in a study of a  series of  female patients, have reported  that  QTDc  with  a  different  cut-off  point of  a positive  test  (> 60 ms) had  a greater sensitivity and specificity than  ST-depression [30]. In our  study,  peak  exercise QTD  > 60 ms, delta QTD rest to peak exercise  ≥ 16 mm, QTDc > 70 ms  and Q-X/ QT ratio  in V 5  > 0.5 were significantly  higher in CAD patients. Q-X/QT ratio  in V 5  > 0.5 had the lowest sensitivity and  specificity. The other 3 parameters had  high specificity but differed  in sensitiv- ity, high for QTDc > 70 ms and low for  QTD > 60 ms and delta QTD.  Peak exercise QTDc and horizontal  or downsloping ST depression were the  Table 4 Validity of the additive effect of the 2 variables in the logistic regression model for the detection of coronary artery disease (CAD), single vessel disease (SVD) and multi-vessel disease(MVD) Measure Horizontal or downsloping ST depression ≥ 1 mm Peak exercise QTDc > 70 ms Either or both positive Detection of CAD Area under ROC curve (SE) 0.80 (0.04) 0.86 (0.04) 0.94 (0.02) Sensitivity (%) 70 80 93*** Specificity (%) 91 92 85 PPV (%) 89 92 87 NPV (%) 75 80 92*** Detection of SVD Area under ROC curve (SE) 0.74 (0.07) 0.87 (0.06) 0.88 (0.06) Sensitivity (%) 57 81*** 81*** Specificity (%) 91 92 85 PPV (%) 71 81 68 NPV (%) 85 92 92 Detection of MVD Area under ROC curve (SE) 0.84 (0.05) 0.85 (0.05) 0.97 (0.02) Sensitivity (%) 78 78 100*** Specificity (%) 91 92 85 PPV (%) 85 86 82 NPV (%) 86 86 100*** ***P < 0.001 (compared with ST depression). 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American journal of cardiology, 1997, 79:709–12 Desai MY et al. Slow upsloping ST-segment depression during 23. exercise: does it really signify a positive stress test? American heart journal, 2002, 143:482–7. Mayuga KA et al. Effects of age and gender on the QT response 24. to exercise. American journal of cardiology, 2001, 87:163–7. Egloff C et al. Sensitivity, specificity and predictive accuracy of 25. Q wave, QX/QT ratio, QTc interval and ST depression during exercise testing in men with coronary artery disease. American journal of cardiology, 1987, 60:1006–8. Ulgen MS et al. Contribution of the peak exercise QT disper-26. sion to the accuracy of an exercise test during the evaluation of coronary artery disease. Acta cardiologica, 2000, 55:335–9. Koide Y et al. Usefulness of QT dispersion immediately after 27. exercise as an indicator of coronary stenosis independent of gender or exercise-induced ST-segment depression. American journal of cardiology, 2000, 86:1312–7. 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Clinical cardiology, 2002, 25:187–92. only  variables  found  to be  independ- ent predictors of CAD  in multivariate  analysis. The  validity  indices,  despite  being higher  for peak  exercise QTDc  compared  to ST depression, were not  statistically  significant. The diagnostic  accuracy of QTDc was even better than  ST depression  in  single vessel disease,  as  indicated by  the greater  area under  the ROC curve  and better  sensitivity.  We  showed  that using  either  variable  as  a marker of  a positive  exercise  test  significantly  improved  the  sensitivity  and negative predictive value of the test  without  a  significant  decrease  in  the  specificity. In conclusion, clinical and exercise- induced  haemodynamic  and  ECG  changes  could  provide  additional  information  that  could  increase  the  ability  of  the  exercise  test  to  diag- nose CAD. Using  either  horizontal  or  downsloping  ST  depression  ≥ 1  mm or QTDc peak exercise > 70 ms  as a marker of a positive exercise  test  significantly  improves  the diagnostic  value of the test. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلمالولأا ددعلا 82 Biological activity resulting from exposure to aquatic environmental genotoxic pollutants in northern Egypt A.A. Saad,1 A.M. El-Sikaily,2 S.F. Kholeif,3 E.S. Khalil,4 H.S. Mahrous,3 E.M.S. Al-Zabedi5 and H.A. Kassem1 ABSTRACT We estimated pollution in Lake Edku and the Mediterranean Sea, El-Maadiya Region, with 3 aromatic amines (1-naphthylamine, 2-naphthylamine and benzidine) in the muscle tissue of fish. There were marked seasonal variations in the aromatic amine levels. We also determined oxidative stress (blood glutathione, and catalase activity) and genotoxic effects (chromosomal aberrations and urinary metabolites) in fishermen from each area. The fishermen suffered from oxidative stress and had high levels of the urinary metabolite sulfanilamide [mean (μg/mg creatinine): Lake Edku 20.7, Mediterranean 14.5, controls 5.3]. Frequencies for total chromosomal aberrations were significantly raised in the peripheral blood lymphocytes of fishermen in both areas [frequency (per 100 metaphases ): Mediterranean 67, Lake Edku 45, controls 14]. 1Department of Applied Medical Chemistry; 3Department of Human Genetics; 4Department of Internal Medicine, Medical Research Institute, Alexandria University, Alexandria, Egypt. 2Marine Pollution Laboratory, Environmental Division, National Institute of Oceanography and Fisheries, Alexandria, Egypt (Correspondence to A.M. El-Sikaily: dramany_mas@yahoo.com). 5Department of Applied Medical Chemistry. University of Sana’a, Sana’a, Yemen. Received: 12/04/07; accepted: 02/09/07 صرم لماش في تانيجلل ةماسلا ةيئيبلا ةيرحبلا تاثولملل ضُّرعتلا نع مجانلا يجولويبلا طاشنلا مساق نياه ،يديبزلا يدهم ماستبا ،سورمح نانح ،ليلخ نمايإ ،فيلوخ ىهس ،لياقيسلا نيامأ ،دعس ةزيزع 1-naphthylamine) يه ةيتامورأ ةينيمأ تابكرم ةثلاث ،ةيدعلما ةقطنم في ،طسوتلما رحبلاو وكدإ ةيرحب في نوثحابلا ساق :ةصلالخا ماك .ةيتامورلأا ةينيملأا تابكرلما تايوتسم في حضاو يمسوم نيابت كانه ناكو .كمسلا تلاضع ةجسنأ في (2-naphthylamine, benzidine (ةيلوبلا تابلقتسلماو ،تاردقتلما يرغت) تانيلجا لىع ةماسلا تايرثأتلاو (زلاتاكلا ميزنإ طاشنو ،مدلا نويثاتولغ) يدسكأتلا داهجلإا نوثحابلا ددح 14.5 طسوتلما) ديملاينافلسلل ةيلوبلا تابلقتسلما نم ةعفترم تايوتسمو يدسكأت داهجإ نم اوناع نيدايصلا نأ ينبتو .ينتقطنلما لاك في نيدايصلا ￯دل هب ُّد َت ْع ُي وحن لىع تاردقتلما تايرغت لياجمإ راركت عفتراو .(دهاوشلا ￯دل مارغ ليم لكل مارغوركيم 5.3 ـب ةنراقم مارغ ليم لكل مارغوركيم 20.7و .(دهاوشلا ￯دل لاتروط 100 لكل 14 ـب ةنراقم ٍلات ٍروط 100 لكل 45و 67) ينتقطنلما اتلك في نيدايصلا ينب ةيفرطلا مدلا تايوافلم ايلاخ في ًايئاصحإ Activité biologique résultant de l’exposition à des polluants génotoxiques en milieu aquatique dans le nord de l’Égypte RÉSUMÉ Nous avons réalisé une estimation de la pollution dans le lac Edkou et en Méditerranée (région d’El- Maadiya), sur la base de trois amines aromatiques (1-naphthylamine, 2-naphthylamine et benzidine) dans les tissus musculaires de poissons. Nous avons constaté de fortes variations saisonnières des niveaux d’amines aromatiques. Nous avons également déterminé le stress oxydatif (glutathion sanguin et activité de la catalase) et les effets génotoxiques (aberrations chromosomiques et métabolites urinaires) chez les pêcheurs de chaque région. Ces pêcheurs souffraient de stress oxydatif et présentaient des niveaux élevés de sulfanilamide, un métabolite urinaire [moyenne (μg/mg de créatinine) : lac Edkou 20,7, Méditerranée 14,5, témoins 5,3]. La fréquence des aberrations chromosomiques totales était significativement plus élevée dans les lymphocytes circulants des pêcheurs des deux régions [fréquence (pour 100 métaphases) : Méditerranée 67, lac Edkou 45, témoins 14]. 14 H Biological activity resulting from exposureindd fc 11-12.indd 82 2/28/2013 8:42:04 AM EMHJ • Vol. 16 No. 1 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 83 Introduction The development of modern industry causes increasingly serious pollution in the environment where we live, constituting a catastrophic health risk, including for cancer [1]. Pollution of the aquatic environment is one of the worst legacies of development of the 20th century [1] and marine coastal ar- eas are particularly impacted by human activities [2]. Aquatic ecosystems serve as a sink for pollutants, which bind to sediment and tend to accumulate in the tissues of aquatic organisms [3]. The concentrations of these compounds in the fresh tissues of aquatic organisms are several orders of magnitude higher than those found in the environment. Moreover, due to their lipophilic na- ture, organic compounds tend to bio- accumulate in fatty tissues [2]. Aromatic amines are environmen- tal pollutants found in lakes, rivers and soil; they represent one of the most important classes of industrial and envi- ronmental chemicals. Many have been reported to be powerful carcinogens and/or haemotoxicants [4]. Their me- tabolites, N-hydroxy arylamines and nitro soarenes, react with DNA, proteins and glutathione; the resulting damage to biomolecules is often responsible for the toxic or genotoxic effects [5]. In Egypt the coastal areas around El-Maadiya and Lake Edku are the main recipients for a number of pollutants from agriculture as well as industrial drainage. The biomarker of exposure to these pollutants is the measurement of urinary metabolites. This enables the determination of the internal dose of pollutants and provides important information for biomonitoring of oc- cupational and environmental human exposure [6]. Living beings are protected from reactive oxygen species (ROS) by sev- eral defence mechanisms, including glu- tathione, which has many antioxidant functions, such as control of the protein redox status and defence against free radicals and oxygen toxicity [7]. Most of these functions oxidize reduced glu- tathione (GSH) to the disulfide form (GSSG), the concentration of which is an index of oxidative stress [8]. Catalase is a haeme-containing enzyme which is localized in most mammalian cells exclusively in peroxisomes [9]. Human erythrocytes with a high catalase content provide a general defence against toxic concentrations of hydrogen peroxide, while the lower the catalase activity in red cells, the more effective the action of the oxidizing agents [10]. Oxidative stress may result in damage to criti- cal cellular macromolecules, including DNA, lipids, and proteins [11]. Oxida- tive DNA damage may participate in ROS-induced carcinogenesis [12]. A common form of damage is the forma- tion of hydroxylated bases of DNA, which is considered an important event in chemical carcinogenesis [12]; this adduct formation interferes with normal cell growth by causing genetic mutations and altering normal gene transcription [12]. According to INCHEM guidelines, “Somatic mutations, either genetic or chromosomal, are not transmitted to the offspring of an exposed individual. However, increases in the frequency of these mutations may contribute to an increase in the frequency of acquired disorders, for example, cancer. There is, therefore, a clear need to develop and apply methods to study exposed populations at risk of increased levels of somatic or germinal mutations” [13]. Thus, the aim of this study was to estimate some aromatic amines in the flesh of fish taken from Lake Edku and the Mediterranean Sea at El-Maadiya and to investigate oxidative stress and chromosomal aberrations as biological markers reflecting the genotoxic effects of aquatic environmental pollutants in local fishermen. The Mediterranean costal area of the north-eastern Egypt was selected for this study because it is the recipient of extensive agricultural and industrial wastes. The fresh water lake, Lake Edku, lies in the north of the Nile Delta, west of the Rosetta branch of the Nile between long 30° 8' 30" N and 30° 23' 100" E and is connected to the Mediterranean Sea through Boughaz El-Maadiya, a narrow, shallow channel. The hydro- graphic and biological characteristics of the water in El-Maadiya connec- tion depend on the water exchange between Abu-Qir Bay and Lake Edku. Great amounts of industrial wastes are discharged into the bay through Tabia pumping station. These wastes come from about 36 factories in a cultivated area extending from Kafr El-Dawar to Alexandria. Tabia pumping station pumps the highly polluted water of El- Amia Drain, which receives the drain- age from El-Behira district as well as the industrial wastes of the factories. These waste discharges originate from 5 main activities: the fertilizer industry, the pes- ticides industry, textile manufacturing, the paper industry and food processing and canning. Methods This study was carried out over the period 2002–2004. Males living in El Maadiya region were invited to take part in the study and about 60% of those we contacted agreed to participate. The study group comprised 102 male sub- jects with an average age of 38 (standard deviation 13) years; they were classified into 2 groups: non-fishermen, (n = 20) with low fish eating habits (healthy con- trol group) and fishermen (n = 82). The fishermen were divided into 2 groups: Mediterranean Sea fishermen (n = 55) and Lake Edku fishermen (n = 27). 14 H Biological activity resulting from exposureindd fc 11-12.indd 83 2/28/2013 8:42:44 AM طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلمالولأا ددعلا 84 Determination of aromatic amines in fish flesh We followed the method of Diachenko [14] for the determination of selected industrial aromatic amines in fish. Sam- ples of Tilapia sp. and Claris sp. were collected from Lake Edku, and samples of Mugil sp. and Siganus rivulatus from the Mediterranean Sea in El-Maadiya region during the 4 seasons (winter, spring, summer and autumn). The flesh of the fish was separated and the skin removed. The fish flesh was dried in an incubator at 37–40 °C for 2–7 days depending on the size of the fish. After drying, a mechanical grinder was used to grind the fish to powder form. The fish powder was digested with aqueous NaOH and extracted with benzene. The extract was washed with diluted acid and cleaned up using silica gel column chromatography. The amines were separated, and quantita- tively determined by gas chromatog- raphy–mass spectrometry using a fully automated mass spectrometer (Agilent model HP6890) equipped with HP- data system to acquire and process all GC-MS data. A gas chromatograph (Agilent) was interfaced to the mass spectrometer and fitted with a capillary column (model HP19091S-433) with HP-5 on 5% phenyl methyl siloxane, with nominal length 30 m, nominal diameter 250 μm and nominal film thickness 0.25 μm. Blood analyses The participants were requested to fast for 6 hours. Samples of peripheral blood (10 mL) were collected by a physician by venepuncture in heparinized tubes at the Medical Research Institute in Alexandria. The blood samples were processed immediately. Blood glutathione content was de- termined using 0.2 mL of whole blood according to the method of Beutler E, Duron O, Kelly BM [15]. DTNB rea- gent was obtained from Sigma Chemi- cal Company and optical density was measured at 412 nm using a PRIME automatic photometer (BPC BioSED srl, Italy). Erythrocyte catalase activity was determined according to the method of Donald and Hugo [16]. The con- centrated haemolysate was diluted 500 times (v/v) with phosphate buffer immediately before carrying out the assay (in duplicate) to determine hae- moglobin content using the method of Drabkin [17]. The enzyme activity level was measured at 412 nm. Determination of urinary sulfanilamide Early morning urine samples were col- lected from those participants who had abnormal levels of blood glutathione (< 35 mg/dL) and/or erythrocyte catalase activity (< 805 U/g Hb) to detect urinary metabolites of aromatic amines (sulfanilamides) according to the method of Hayashi M, Amino G, Uchida MS [18]. Cytogenetic analysis Blood culture for chromosome aberra- tions was carried out according to the methods described by Smerhovsky Z et al. [19]. One hundred metaphases were counted and scored for structural chromosomal aberrations according to the International System for Human Cytogenetic Nomenclature (ISCN). Statistical analysis The data obtained were statistically analysed using SPSS, version 10. One way analysis of variance was used to compare between the levels of the dif- ferent parameters in the study groups. A difference was considered significant at P < 0.05. Results Oceanographic data The pollution status of Lake Edku and the Mediterranean Sea (El-Maadiya region) was studied by estimating the levels of 1-naphthylamine, 2-naphthyl- amine and benzidine in the muscle tissue of 4 types of fish: Tilapia sp. and Claris sp. from Lake Edku and Mugil sp. and Siganus rivulatus from the Mediter- ranean Sea. High concentration of 1-naphthyl- amine and benzidine were found in Tilapia sp. in summer (Table 1) while high concentrations of 2-naphthyl- amine were found in spring. In Claris sp. the concentration of 1-naphthylamine was high in all seasons except spring, and high concentrations of 2-naph- thylamine and benzidine were found in spring and summer (Lake Edku). Elevated levels of all 3 aromatic amines were found in autumn in Mugil sp., the 3 aromatic amines were found in elevated levels in Siganus revulatus in all 4 seasons (Mediterranean Sea). Biochemical data Statistical analysis between groups (1-way ANOVA) showed a signifi- cantly lower blood glutathione level in both groups of fishermen compared with the control group (P < 0.001) (Table 2). Erythrocyte catalase activ- ity was significantly lower in both the fishermen groups compared with the control group (P < 0.001) (Table 2). Significantly higher urinary sulfanila- mide levels were seen in both fishermen groups compared with the control group (P < 0.001) (Table 2). There was a significant negative cor- relation between urinary sulfanilamide (μg/mg creatinine) and blood glutath- ione (mg/dL) content in the studied groups (r = –0.549, P = 0.004) (Figure 1, available in online version). There was also a significant negative corre- lation between urinary sulfanilamide (μg/mg creatinine) and erythrocyte catalase enzymatic activity (U/g Hb) (r = –0.523, P = 0.006) (Figure2, available in online version). 14 H Biological activity resulting from exposureindd fc 11-12.indd 84 2/28/2013 8:42:44 AM EMHJ • Vol. 16 No. 1 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 85 Cytogenetic results Table 3 compares the frequencies of different types of chromosomal aberra- tions in each group. Chromosome-type exchanges, chromosome-type breaks plus exchanges, chromosome-type aberrations, total breaks plus exchanges as well as total chromosomal aberra- tions were significantly increased in both fishermen’s groups compared with the control group (P = 0.003, P = 0.001, P < 0.001, P = 0.001, P = 0.001 respectively). There was a highly signifi- cant negative correlation between total chromosomal aberrations “excluding gaps” (/100 metaphases) and blood glutathione content in the studied groups (r = –0.648, P < 0.001) (Figure 3, available in online version). There was also a significant negative correla- tion between total chromosomal aber- rations excluding gaps and erythrocyte catalase enzymatic activity (r = –0.672, P < 0.001) (Figure 4, available in online version). Finally, there was a signifi- cant positive correlation between total chromosomal aberrations excluding gaps and urinary sulfanilamide in the 3 groups (r = 0.488, P = 0.011) (Figure 5, available in online version). Discussion Concentrations of the 3 studied aro- matic amines were highly elevated in Claris sp. compared with Tilapia sp. Additionally, Tilapia sp. was free from all 3 aromatic amines in winter and autumn, while Claris sp. was free from 2-naphthylamine and benzidine in winter and autumn. The variation may be related to the feeding habits or the greater body size and body fat content of Claris sp. [20]. In addition, a marked elevation in concentrations of the 3 studied aro- matic amines was detected in Siganus revulatus, while in Mugil sp., the pollu- tion occurred only in autumn. This may be due to the feeding habits and species Table 1 Concentration of aromatic amines in flesh of 4 fish species from Lake Edku and the Mediterranean Sea according to season Species & season 1-Naphthylamine (µg/kg dry weight) 2-Naphthylamine (µg/kg dry weight) Benzidine (µg/kg dry weight) Tilapia sp.a Winter – – – Spring – 932 – Summer 2801 – 934 Autumn – – – Claris sp.a Winter 1060 – – Spring – 3476 2812 Summer 4019 3221 952 Autumn 3480 – – Mugil sp.b Winter – – – Spring – – – Summer – – – Autumn 1713 1286 650 Siganus revulatusb Winter 3213 2048 1347 Spring 3765 953 618 Summer 2742 2989 1185 Autumn 5541 2148 975 aFrom Lake Edku. bFrom the Mediterranean Sea, El-Maadiya region. Table 2 Oxidative stress markers in the blood of a healthy control group and 2 groups of fishermen from El-Maadiya region Oxidative stress marker Controls (n = 20) Mediterranean Sea fishermen (n = 55) Lake Edku fishermen (n = 27) Glutathione (mg/dL whole blood) Mean 39.95 34.36 34.41 SD 2.96 5.63 6.16 SE 0.66 0.76 1.19 Rangea 35–44 25–46 19–45 Erythrocyte catalase activity (U/g Hb) Mean 974.00 661.00 589.30 SD 92.20 146.90 117.12 SE 20.62 19.81 22.54 Rangeb 1163–805 933–352 858–329 Urinary sulfanilamide (µg/mg creatinine) (n = 9) (n = 13) (n = 6) Mean 5.3 14.5 20.7 SD 3.1 9.4 9.65 SE 1.0 2.5 3.9 Rangec 0.5–9.9 4.1–35.1 6.1–33.1 aF = 8.634, P < 0.001; bF = 56.294, P < 0.001; cF = 4.278, P = 0.024 (1-way analysis of variance). SD = standard deviation; SE = standard error; Hb = haemoglobin. 14 H Biological activity resulting from exposureindd fc 11-12.indd 85 2/28/2013 8:42:44 AM طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلمالولأا ددعلا 86 differences. These finding are in agree- ment with the results of other studies which found that the mean concentra- tion of pollutants in the sea animals varied according to species, season and area [21,22]. High levels of genotoxic el- ements in fish can confirm the pollution of sea water and the possibility of the presence of genotoxic elements [23]. The biochemical results of this study shows that the fishermen groups of Lake Edku and El-Maadiya region of the Mediterranean Sea were suffering from oxidative stress, which manifested in a significant decrease in the levels of both whole blood glutathione and erythrocyte catalase enzymatic activity compared with the control group. A significantly high level of the urinary metabolite sulfanilamide was found in both fishermen groups in comparison with the control group. Sulfanilamide stimulates the formation of methaemo- globin in red blood cells; this may be a result of exposure to pollutants such as aromatic amines and pesticides during recreational activities as well as high consumption of polluted fish [24]. Oxidative stress may result in dam- age to critical cellular macromolecules, including DNA, lipids, and proteins [11]. Oxidative DNA damage may participate in ROS-induced carcino- genesis [12]. A common form of dam- age is the formation of hydroxylated DNA bases, which are considered an important event in chemical carcino- genesis [12,25]. This adduct formation interferes with normal cell growth by causing genetic mutations and altering normal gene transcription. To counteract oxidative stress, the human body has evolved various defence mechanisms [26]. Antioxidants, which scavenge the reactive oxygen species prior to their interaction with cellular compo- nents are the first line of defence against exogenous oxidative stress [26]. If a large amount of the toxic substance is present then the detoxication mechanisms are overwhelmed. Excess superoxide is pro- duced, reduced glutathione and NADPH are depleted and hydroxyl radicals and singlet oxygen are formed [27]. Chromosomal analysis of periph- eral human lymphocytes is the most widely used method for biomonitoring human exposure to genotoxic chemi- cals. In our study, the frequency of chromosomal aberrations in fishermen exposed to benzidine was significantly higher than in the control group. Data on the chromosomal effect of human exposure to benzidine is, however, scarce. Mirkova and Lalchev observed a statistically significant increase in frequency of chromosome aberrations in lymphocytes of workers exposed to benzidine compared to a control group [28], an observation in accord- ance with our own findings. In con- trast to our study, the main type of aberration observed in the Mirkova and Lalchev study [28] was chromatid breaks, whereas the main type of aber- rations we observed was chromosome exchanges. The presence of dicentric, rings and chromatid exchanges in our study confirms the very high dose of benzidine to which these fishermen have been exposed, and demonstrates the mutagenic effect of benzidine on the lymphocytes. The chromosomal aberration assay has also been shown to be a convenient test for somatic risk assessment. Clear evidence has been presented that an enhanced frequency of chromosomal aberrations correlates with an increased incidence of cancer in epidemiological Table 3 Chromosomal aberrations in a healthy control group and 2 groups of fishermen from El-Maadiya region Chromosomal aberration Controls (n = 6) Mediterranean Sea fishermen (n = 13) Lake Edku fishermen (n = 7) ANOVA Freqa Mean (SD) Freqa Mean (SD) Freqa Mean (SD) F P Chromosome-type gap 0 0 2 0.002 (0.004) 3 0.004 (0.005) 2.13 0.141 Chromosome-type break 0 0 6 0.005 (0.008) 6 0.010 (0.011) 1.94 0.167 Chromosome-type exchange 4 0.007 (0.008) 39 0.030 (0.014) 27 0.040 (0.020) 7.79 0.003 Chromosome-type break + exchange 4 0.007 (0.008) 45 0.035 (0.016) 33 0.047 (0.023) 9.95 0.001 Chromosome-type aberration 4 0.007 (0.008) 47 0.036 (0.016) 38 0.051 (0.022) 12.11 < 0.001 Chromatid-type gap 10 0.017 (0.010) 19 0.015 (0.011) 7 0.010 (0.010) 0.69 0.512 Chromatid-type break 0 0 0 0 0 0 – – Chromatid-type exchange 0 0 1 0.001 (0.003) 0 0 0.48 0.625 Chromatid-type break + exchange 0 0 1 0.001 (0.003) 0 0 0.48 0.625 Chromatid-type aberration 10 0.020 (0.010) 20 0.015 (0.012) 7 0.010 (0.010) 0.72 0.499 Total breaks + exchanges 4 0.007 (0.008) 46 0.035 (0.015) 33 0.047 (0.023) 10.74 0.001 Total aberrations 14 0.023 (0.005) 67 0.052 (0.020) 45 0.061 (0.002) 8.86 0.001 a Freq = frequency of chromosomal aberrations/100 metaphases. ANOVA = analysis of variance; SD = standard deviation. 14 H Biological activity resulting from exposureindd fc 11-12.indd 86 2/28/2013 8:42:44 AM EMHJ • Vol. 16 No. 1 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 87 surveys and is of predictive value for subsequent cancer risk [29–32]. We found an elevated level of the herbicide metabolite sulfanilamide in the urine of both groups of fishermen. There was a negative correlation between sulfanila- mide and both glutathione and catalase activity. Our study also demonstrated a high frequency of chromosomal aberrations in the peripheral blood lymphocytes of both fishermen groups. There was a positive correlation between sulfani- lamide and chromosomal aberrations, and a negative correlation between chromosomal aberrations and both glutathione and catalase activity were found. Therefore, it may be considered that oxidative stress and sulfanilamide contribute to the induction of chromo- somal aberrations, and a consequential serious effect on human health. Conclusion Our findings emphasize that the pol- lution of El-Maadiya region induces a panic oxidative stress in fishermen in the vicinity of this area. The risk will persist because of the decrease in the levels of antioxidant glutathione and catalase enzyme activity in the blood of fishermen. These f indings indicate that oxidative biomarkers in combination with other types of biomarkers (chro- mosomal aberrations) can be useful in the large scale for environmental monitoring. 1. Hiramoto K, Ohkawa T, Kikugawa K. Release of nitric oxide together with carbon-centered radicals from N-nitrosamines by ultraviolet light irradiation. Free radical research, 2001, 35:803–13. 2. Varanasi U. Metabolism of polycyclic aromatic hydrocarbons in the aquatic environment. Boca Raton, Florida, CRC Press, 1989:341. 3. Corsi I et al. Monitoring a marine coastal area: use of Mytilus galloprovincialis and Mullus barbatus as bioindicators. Marine ecology, 2002, 23(1):138–53. 4. Benigni R, Passerini L. Carcinogenicity of the aromatic amines: From structure- activity relationships to mechanisms of action and risk assessment. Mutation research, 2002, 511:191–206. 5. Zwirner-Baier I, Neumann HG. Biomonitoring of aromatic amines V: acetylation and deacetylation in the metabolic activation of aromatic amines as determined by haemoglobin binding. Archives of toxicology, 1998, 72(8):499–504. 6. Falck K. Biological monitoring of occupational exposure to mutagenic chemicals in the rubber industry. Use of the bacte- rial urinary mutagenicity assay. Scandinavian journal of work, environment & health, 1983, 9(Suppl. 2):39–42. 7. Kosower NS, Kosower EM. The glutathione status of cells. Inter- national review of cytology, 1978, 54:109–60. 8. Alonso-Moraga A et al. 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Guide- lines for the study of genetic effects in human populations. Gene- va, World Health Organization, United Nations Environment References Programme, International Labour Organisation, 1985 (Envi- ronmental Health Criteria 46) (http://www.inchem.org/docu- ments/ehc/ehc/ehc46.htm, accessed 10 November 2009). 14. Diachenko GW. Determination of several industrial aromatic amines in fish. Environmental science and technology, 1979, 13:329–33. 15. Beutler E, Duron O, Kelly BM. Improved method for the deter- mination of blood glutathione. Journal of laboratory & clinical medicine, 1963, 61:882–8. 16. Donald W, Hugo E. Enzymes I: Oxidoreductases, transferases. In: Bergmeyer HU, Bergmeyer J, Grassi M, eds. Methods of enzymatic analysis, 3rd ed. Weinheim/Basel, Verlag Chemie, 1987:273–86. 17. Drabkin DL. Crystallographic and optical properties of the hemoglobin of man in comparison with those of other species. Journal of biological chemistry, 1946; 164:703–23. 18. Hayashi M, Amino G, Uchida MS. High performance liquid chromatographic determination of primary aromatic amines in urine after derivatization to an azo dye with 2-aminoanthra- cine. Journal of chromatography, 1995, 665:209–12. 19. Smerhovsky Z et al. Risk of cancer in an occupationally ex- posed cohort with increased level of chromosomal aberra- tions. Environmental health perspectives, 2001, 109:41–5. 20. Neely WB. Chemicals in the environment. New York, Marcel Dekker, 1980:15–7. 21. Saad AA et al. Effect of polluted fish intake on Interleukin 1, 2 production, phagocytic function of mononuclear phagocytes and liver β-glucuronidase in rats. Journal of the Medical Research Institute, 1998, 19:126–41. 22. Papadopoulou C, Kanias GD. Trace element distribution in seven mollusc species from Saronikos Gulf. Acta adriatica, 1976, 18:367–78. 23. Uysal H. Accumulation and distribution of heavy metals in some marine organisms in the bay of Izmir and in Aegean coasts (Turkey). IV. Journées études pollutions, Antalya, CIESM, 1978, 4:213–7. 24. Zenser TV et al. Methemoglobin oxidation of N-acetylbenzi- dine to form a sulfinamide. Drug metabolism and disposition, 2001, 29:401–6. 25. Chaudhary AK et al. Analysis of the malondialdehyde-2’-de- oxyguanosine adduct in rat liver DNA by gas chromatograph/ electron capture negative chemical ionization mass spectrom- etry. Biological mass spectrometry, 1994, 23:457–64. 14 H Biological activity resulting from exposureindd fc 11-12.indd 87 2/28/2013 8:42:44 AM طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلمالولأا ددعلا 88 26. Besaratinia A et al. A multi-biomarker approach to study the effects of smoking on oxidative DNA damage and repair and antioxidative defense mechanisms. Carcinogenesis, 2001, 21:395–401. 27. Timbrell J, ed. Principles of biochemical toxicology. London, Taylor & Francis, 2000:199–200. 28. Mirkova ET, Lalchev SG. The genetic toxicity of the human car- cinogens benzidine and benzidine-based dyes: chromosomal analysis in exposed workers. Mutation and the environment, 1990, 3:397–405. 29. Hagmar L et al. Cancer risk in human predicted by increased levels of chromosomal aberrations in lymphocytes: Nordic study group on the health risk of chromosome damage. Cancer research, 1994, 54:2919–22. 30. Toyokumi S. Reactive oxygen species-induced molecular dam- age and its application in pathgology. Pathology international, 1999, 49:91–102. 31. Amici M et al. Peroxynitrite-induced oxidation and its effects on isolated proteasomal systems. Free radical biology & medi- cine, 2003, 34:987–96. 32. Huttner E, Gotze A, Ni Kolova T. Chromosomal aberration in humans as genetic endpoints to assess the impact of pollution. Mutation research, 1999, 445:251–7. Principles for modelling dose-response for the risk assessment of chemicals This volume, Principles for modelling dose-response for the risk assessment of chemicals, is part of the ongoing review of the underlying scientific bases for decision-making in chemical risk assessment by International Programme on Chemical Safety. It involves specific consideration of the area of dose–response assessment in the evaluation of information from toxicological studies in animals and from human clinical and epidemiological studies. It covers toxicants with threshold effects and those for which there may be no practical threshold, such as substances that are genotoxic and carcinogenic. The discussions are concerned with that subset of cause–effect relationships commonly referred to as dose–response models, which are typically used to characterize the biological effects of intentional (e.g. drugs and nutrients) and unintentional (e.g. contaminants) exposure to chemicals. This report is intended primarily to provide descriptive guidance for risk assessors in using dose-response modelling in hazard characterization. It will also provide mathematical modellers with an appreciation of issues to be considered when modelling in the context of the risk assessment process. Risk managers will be able to obtain a general understanding of the applications and limitations of dose-response modelling. For both risk assessors and risk managers, some considerations for communicating the results of risk assessments that use dose-response modelling are presented Further information about this and other WHO publications can be found at: http://www.who.int/bookorders/ anglais/home1.jsp?sesslan=1 14 H Biological activity resulting from exposureindd fc 11-12.indd 88 2/28/2013 8:42:44 AM طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 89 ABSTRACT Although cutaneous leishmaniasis lesions usually heal spontaneously they cause unsightly scarring. This study evaluated a possible new therapy in 38 patients, with 70 lesions, randomly assigned to intralesional injection of ciprofloxacin (0.2%) or intralesional sodium chloride hypertonic solution (7%). After excluding patients who defaulted on treatment, lesions assigned to sodium chloride treatment (n = 21) were completely healed (with or without scarring) in 76.2% of cases, and, when a scar remained, the scar size was reduced 66.0% compared with the original lesion. Lesions assigned to ciprofloxacin (n = 27) showed an 81.5% healing rate with an average scar size reduction of 68.6%. Intralesional 0.2% ciprofloxacin was as effective as hypertonic saline in the treatment of cutaneous leishmaniasis infection. 1Department of Dermatology, College of Medicine; 2Department of Biology, College of Education; 3Department of Pharmacology, College of Pharmacy, University of Basra, Basra, Iraq (Correspondence to K.I. Al Hamdi: Khalil_hamdi2003@yahoo.com). Received: 18/02/07; accepted: 31/07/07 %0.2 ينساسكولفوبريسلاب ةيدللجا اينماشيللا تافلآ ةيلخادلا ةلجاعلما مييقت ركوم يدهم يدانه ،داوع شبح ينسلحا دبع ،يدملحا ليعماسا ليلخ ـل ًلامتمح ًاديدج ًاجلاع ةساردلا هذه مّيقتو .رظنلما ةئيس ةبدن ببست انهأ لاإ ًايئاقلت ةداعلا في ىفشت ةيدللجا اينماشيللا تافآ نأ نم مغرلاب :ةصلالخا مويدوصلا ديرولك لولحمب ايلخاد تافلآا ةلجاعم وأ ، %0.2 ينساسكولفوبريسلاب ليخادلا نقلحا ةبرجتل ًايئاوشع اويرتخا ،ةفآ 70 ميهدل ًاضيرم 38 مويدوصلا ديرولك لولحمب جلاعلا تقلت يتلا تافلآا ًاماتم تيفش ،جلاعلا لىع اوبظاوي لم نيذلا ضىرلما داعبتسا دعبو .)%7( رتوتلا طرفلما تافلآا امأ .ليصلأا ةفلآا مجحب ةنراقم %66 ةبسنب ضفخنا دق اهمجح نإف ةبدنلا دوجو رمتسا امدنعو ،تلاالحا نم %76.2 في )21=اهددعو( ليخادلا جلاعلا نإ .%68.6 ةبدنلا مجح ضافخنا طسوتم ناكو ،%81.5 اهيف ءافشلا لدعم ناكف )27=اهددعو( ينساسكولفوبرسلاب تلجوع يتلا .ةيدللجا اينماشيللا تافلآ ةبسنلاب رتوتلا طرفلما يحللما لولحلماب جلاعلا لثم ًلااعف ناك %0.2 ينساسكولفوبريسلاب Evaluation of intralesional 0.2% ciprofloxacin as a treatment for cutaneous leishmaniasis K.I. Al Hamdi,1 A.H. Awad 2 and H.M. Moker3 Évaluation de la ciprofloxacine en injection intralésionnelle à 0,2 % comme traitement de la leishmaniose cutanée RÉSUMÉ Bien que les lésions causées par la leishmaniose cutanée guérissent en général spontanément, elles laissent une cicatrice disgracieuse. Cette étude a évalué une possible nouvelle thérapie chez 38 patients présentant 70 lésions, soumis de façon aléatoire à une injection intralésionnelle de ciprofloxacine (0,2 %) ou à l’administration intralésionnelle d’une solution de chlorure de sodium hypertonique (7 %). Après exclusion des patients qui n’avaient pas suivi le traitement, les lésions soumises au traitement par le chlorure de sodium (n = 21) avaient complètement guéri (avec ou sans cicatrice) dans 76,2 % des cas et lorsqu’il restait une cicatrice, sa taille avait diminué de 66,0 % par rapport à la lésion d’origine. Les lésions soumises à la ciprofloxacine (n = 27) montraient un taux de guérison de 81,5 % avec une réduction moyenne de la taille de la cicatrice de 68,6 %. L’administration intralésionnelle de ciprofloxacine à 0,2 % était aussi efficace que le soluté salin hypertonique dans le traitement de la leishmaniose cutanée. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 90 Introduction Cutaneous  leishmaniasis  is  a parasitic  disease  transmitted  by  biting  insects  (sandflies) [1,2]. The disease is endemic  in Iraq [3] and  in other neighbouring  countries such as Kuwait, Saudi Arabia  and  the  Islamic Republic of  Iran  [4]. In  Iraq  there are 2 main species of  the  genus Leishmania causing the infection:  L. tropica and L. major [5]. Lesions usually heal  spontaneously  within  several weeks  or months  [6], but  it  is  reasonable  to  treat  the  lesions  since  they may persist  for  a  long  time  leaving unsightly scars on healing [7,8].  Although antimony  is  the first  choice  of treatment,  it  is an unstable and toxic  drug [9]. This has led many workers to  try other drugs, such as sodium chloride  hypertonic  solution,  zinc  sulfate  and  metronidazole in local studies [5,10,11].  Good  results were also obtained with  ciprofloxacin,  a wide-spectrum antibi- otic, used  topically  in an experimental  study on BALB/c mice infected with L. major [12].  The aim of this study was to evaluate  intralesional  ciprofloxacin (0.2%) as a  new therapy  for cutaneous  leishmania- sis  in humans and compare  its efficacy  with sodium chloride hypertonic solu- tion (7%).  Methods The study sample was all patients with  cutaneous  leishmaniasis  who  were  diagnosed clinically by the same derma- tologist in the outpatient clinic of Basra  teaching hospital, south Iraq, from April  2004 to March 2005. Information was  taken  from each  patient, including the number of lesions,  sites, history of  infections and whether  lesions had been  treated previously or  not. Thin blood films were made  from  the edge of  the  lesion and  stained by  Giemsa stain [13] and  then examined  microscopically. Exudates  from  lesions  were  also  sampled  and  injected  into  semi-solid culture medium which was  incubated at 26 ºC and examined after  5–6 days to detect parasites. The 38 patients  had  a  total  of  70  cutaneous  leishmaniasis  lesions. The  patients were  randomly divided  into 2  groups with equal numbers of  lesions  in each: group 1  lesions (n = 35) were  treated with hypertonic  sodium chlo- ride solution (7%) (7 g dissolved in 100  mL distilled water and autoclaved) and  group 2  lesions (n = 35) were  treated  with ciprofloxacin solution (2 mg/mL).  Both drugs were injected into the lesions  in amounts of 0.1–0.5 mL according to  the size of the lesion. In  order  to measure  the  effect  of  each treatment, the diameter, erythema  and  induration of  the  lesions were as- sessed at  the start and again at 2-week  intervals after  treatment  for 8 weeks. A  scoring system was specially designed as  follows. The diameter of lesions was re- corded in millimetres using a ruler and  scored as: 0 (total healing); 1 (0–< 0.5  cm); 2 (0.5–< 1 cm); 3 (1–< 1.5 cm);  4 (1.5–< 2 cm); 5 (2–< 2.5 cm); or 6 (≥  2.5 cm). The degree of  induration was  assessed by palpation  in  comparison  with the patient’s normal skin and given  the  following scores: 0, 0.5, 1, 1.5, 2 or  3. The degree of erythema was assessed  by naked eye  and  scored as: 0, 0.5, 1,  1.5, 2 or 3. Ulceration was scored as: 1  (present) or 0 (absent). All parameters  scores were converted  to percentages,  and then the mean and standard devia- tion (SD) % score were calculated. The  scores of these 4 parameters were added  to give a total score for each lesion. The changes in total score between  weeks 0–2, weeks 2–4, weeks 4–6 and  weeks 6–8 were compared. Follow-up  continued  for 8 weeks until  complete  healing  took place  (i.e.  resolution of  active  lesion with or without scarring).  After  healing,  the  scar  size  for  each  group was recorded and compared with  the original  lesion  size  to evaluate  the  efficacy of drugs in reducing scar size.  Statistical analysis was done by anal- ysis of variance (ANOVA) and Student  t-test test with significance at P < 0.05.  Results A total of 38 patients with 70 cutaneous  leishmaniasis  lesions were  treated and  followed up during  this  study. The  le- sions were on different parts of the body  but predominantly on  the upper  and  lower extremities. The age of patients  ranged  from 1.5  to 64  years  (1.5–45  years in group 1 and 3–64 years in group  2) with a mean of 21.1 years. There was  no significant difference in the sex of the  patients (52.5% males, 47.5% females).  The duration of lesions before the study  started ranged from 1 month to 5 years  (Table 1).  Group 1  lesions were  treated with  hypertonic  sodium  chloride  solution  while group 2  lesions were  treated with  ciprofloxacin. After  excluding  patients  who defaulted on treatment, a total of 21  lesions were analysed in group 1 and 27 in  group 2. In both groups 1 and 2 marked  reductions were seen in the total % scores  of lesions after 2, 4, 6 and 8 weeks of treat- ment,  with  significant  improvements  within each group in the % scores between  weeks 0–2 and weeks 2–4 (ANOVA test,  P < 0.05) but not between weeks 4–6 and  6–8 (Table 2). After 8 weeks  there was  no significant difference in the mean total  % scores between groups 1 and 2 (1.8%  versus 5.4%). At the end of the 8 weeks follow-up  the mean % scores for diameter, indura- tion and erythema  separately  showed  some differences between the 2 groups  but none were significant (Table 3). After 8 weeks,  16/21  (76.2%)  le- sions were completely healed (with or  without scarring) in group 1 and 22/27  (81.5%)  in  group 2  (Table 4). Heal- ing was mostly  achieved by 6 weeks.  There were 5 lesions in both groups that  showed no  response. One  lesion had  been treated previously with pentostam  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 91 Table 2 Total lesion scores during the 8 weeks of treatment Time (weeks) Group 1 Sodium chloride ( 21 lesions) Group 2 Ciprofloxacin (27 lesions) Mean (SD) % score Mean (SD) % score 0 100.0 100.0 2 70.2 (17.3) 62.1 (20.4) 4 33.3 (25.3) 39.3 (29.2) 6 9.5 (15.6) 9.3 (19.0) 8 1.8 (4.9) 5.4 (12.9) SD = standard deviation. Table 3 Mean percentage reduction in parameter scores after 8 weeks of treatment Parameter Group 1 Sodium chloride (n = 21 lesions) Group 2 Ciprofloxacin (n = 27 lesions) Mean (SD) % score Mean (SD) % score Diameter 31.1 (35.9) 37.1 (36.4) Induration 30.3 (29.7) 30.8 (30.1) Erythema 44.9 (38.0) 32.7 (34.2) SD = standard deviation. Table 1 Characteristics of cutaneous leishmaniasis lesions in each treatment group before the start of the study Variable Group 1 Sodium chloride Group 2 Ciprofloxacin No. of lesions treated at start of study 35 35 No. of lesions/patient 1 7 7 2 5 8 3 1 2 > 3 7 5 No. of lesions by site Face and neck 8 3 Upper limbs 19 10 Lower limbs 7 18 Trunk 1 4 Mean lesion size before study (cm) 1.74 1.70 Range of lesion duration before study 1 month–1 year 1 month–5 years with no healing but, when treated with  the hypertonic  solution, healed within  4 weeks.  In  group 1,  4/21  (19.0%)  lesions  healed  without  scarring  and  7/21  (33.3%) left a scar of < 40% of the origi- nal lesion size. In group 2, 5/27 (18.5%)  of  the  lesions  left no  scar  on healing  while  13/27  (48.2%)  lesions were  <  40% of  the original. No significant dif- ferences  in scar size were  recorded be- tween the groups.  Table 4  summarizes  the outcome  of treatment. Scar size at the end of the  study  for  lesions which healed with a  scar was greatly reduced in comparison  with  the original  size of  the  lesion:  in  group 1 the mean reduction in scar size  was 66.0%, while  in group 2  the mean  reduction was 68.6%.  Discussion Treatment of cutaneous  leishmaniasis  lesions  is  recommended  since  their  duration  cannot  be  predicted  in  an  individual  case  [14]  and  in  order  to  ameliorate ugly  scars  left after healing.  Many drugs have been tried for treating  the infection, but most are not available  in our country, in addition to their high  cost  and  side-effects  that may  result  when they are used systemically [8].  Intralesional  injection of  leishma- niasis  sores  is  a  traditional method of  treatment recommended by the World  Health Organization  in endemic areas,  where many drugs have been  tried by  this method [5,10,15–17].  It  is reason- able to treat these infections individually  since  the  lesions persist  locally and the  parasite does not migrate  [15]. Only  a small amount of  the drug  is used but  the effect  is  local  and direct with  slow  absorption [15].  To evaluate the efficacy of the drugs  in this study, 2 weeks were left between  each visit,  as was done  in other  stud- ies with  local  therapy  [5,18,19]. The  follow-up  scoring  system  depended  on 4 parameters (diameter,  erythema,  induration and ulceration) and a final  total  score was devised  and used  for  the first time in this study. Using multi- ple parameters  is a good feature  in any  study, where  it minimizes mistakes  in  measurement and gives a more precise  assessment of  the  lesion. Other  stud- ies estimated only  lesion diameter and  erythema,  depending mainly  on  the  reduction in size as a sign for healing [5] or depended on  the area of ulceration  multiplied by the area of induration for  evaluation during  the  treatment  and  followed cases until  re-epitheliazation  EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 92 occurred [20]. The cases were followed  up mostly for 8 weeks. Al-Shaikhly  and Sayidmarie  used  hyperthermia  for  treating  cutaneous  leishmaniasis [18] and, as in the present  study, most  lesions were healed by 6  weeks. Najim recorded cure in 6 weeks  also with  local  application of  zinc  sul- fate and hypertonic saline solution [5].  Hypertonic  sodium chloride  solution  has not been previously  evaluated  in  south Iraq. In the present study, hyper- tonic  saline  showed  a  76.2% healing  rate  after 8 weeks, mostly by 6 weeks  after 2–3 injections, while Najim in Iraq  recorded 85% cure (mean time 4 weeks)  with  zinc  sulfate  [5].  Ciprofloxacin  showed a cure rate of 81.5%. The results  are  difficult  to  compare,  however,  as  there are different  species or  strains of  the parasite present in south Iraq as well  as differences in host reaction, immune  status of patients and age of lesions that  may affect treatment.  Both  the antibiotic and hypertonic  solution were effective in reducing scar  size  after  healing. Hypertonic  saline  gave an average 66.0% reduction, while  the ciprofloxacin gave an average 68.6%  reduction compared with  the original  size of  the  lesions.  If  lesions are  left  to  heal spontaneously, we would expect a  scar that is similar in size to the original  lesion [14]. Ciprofloxacin  is  effective  against  intracellular  pathogens  such  as Bru- cella and Legionella spp., where  it  inhib- its  the  enzyme DNA gyrase which  is  responsible  for DNA replication [21].  Ciprofloxacin was also  found to be ac- tive  against  some protozoa  including  L. donovani. Others  have  recorded  a  reduction  in  lesion size and  induration  of L. major  lesions after  treatment with  ciprofloxacin  as  a  topical  paste  (250  mg)  [12,22]. The mode  of  action  of  ciprofloxacin  in  the  treatment of Leish- mania  infection  is not well established,  but  it may exert  its  effect by  the  same  mechanism mentioned above, and local  injection leaves the drug in contact with  the  pathogen  for  as  long  as  possible  where it may act directly.  In  conclusion,  intralesional  0.2%  ciprofloxacin was as least as effective as  hypertonic  sodium chloride  solution  in the treatment of cutaneous  leishma- niasis  infection. Further  studies using  this drug on a large sample and for other  clinical forms of infection are suggested. Table 4 Summary of outcome of treatment after 8 weeks of treatment Variable Group 1 Sodium chloride (n = 21 lesions) Group 2 Ciprofloxacin (n = 27 lesions) Lesions unhealed [No. (%)] 5 (23.8) 5 (18.5) Lesions healed, with or without scarring [No. (%)] 16 (76.2) 22 (81.5) Lesions healed, without scarring [No. (%)] 4 (19.1) 5 (18.5) Healing time (weeks) (No.) 2 1 2 4 5 8 6 7 9 8 3 3 Mean reduction in lesion size (%) 66.0 68.6 Definition of Leishmania infection1. . MedicineNet.com [web- si te] (http://www.medterms.com/script/main/art . asp?articlekey=15243, accessed 21 April 2009). Mandell GL, Douglas RG, Bennett JE. 2. Principles and practice of infectious disease, 3rd ed. New York, Churchill Livingstone, 1990:975. Al-Mahdawi SK. Rapid survey of an outbreak of cutaneous 3. leishmaniasis. Bulletin of endemic diseases, 1988, 29:23–6. Kadir MA. A study on cutaneous leishmaniasis in Arbil. 4. Bulletin of endemic diseases, 1988, 29:51–6. Najim RA. 5. Treatment of cutaneous leishmaniasis by zinc sulphate [PhD thesis]. College of Mediicne, University of Baghdad, Baghdad, Iraq, 1996. Lachmann PJ et al. 6. Clinical aspects of immunology. Volume 3. Hong Kong, Maple-Vial Book, 1993:1575–97. Markle WH, Makhoul K. Cutaneous leishmaniasis: recognition 7. and treatment. American family physician, 2004, 69:1455–60. Burns T et al. 8. Rook’s textbook of dermatology, 7th ed. Volume 2. Oxford, Blackwell Scientific, 2004. References Beck JW, Davies JE. 9. Medical parasitology. St Louis, Mosby, 1981 (Translated into Arabic by the University of Mosul, Iraq, 1985). Sharquie KE. 10. A new intralesional therapy of cutaneous leishma- niasis with hypertonic sodium chloride solution. Baghdad, Iraq, Iraqi Central Organization for Specification and Quality Con- trol/Patent Section, 1993 (Patent No. 2459). Sharquie KE, Waiz MM, Assir MA. 11. Intralesional metronidazole: a new treatment of cutaneous leishmaniasis [diploma disserta- tion]. College of Mediicne, University of Baghdad, Baghdad, Iraq, 1996. Jarallah HM. 12. Effect of some plant extracts and antibiotics with histopathological study on Leishmania major strain [MSc thesis]. College of Education, University of Basra, Basra, Iraq, 2003. Colle J et al. 13. Mackie and Macartney practical medical microbiol- ogy, 14th ed. New York, Churchill Livingstone, 1996:978. Bryceson ADM, Hay RJ. Parasitic worms and protozoa, In: 14. Champion RH et al., eds. Textbook of dermatology, 6th ed. Vol- ume 2. Oxford, Blackwell Scientific, 1998. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 93 Waller GD, Renwick AG, Hillier K. 15. Medical pharmacology and therapeutics. Philadelphia, WB Saunders, 2001:653. Ahmed AM. Case report: chronic cutaneous leishmaniasis suc-16. cessfully treated with pentostam. Iraqi medical journal, 1982, 29:99–101. Dowlati Y. Treatment of cutaneous leishmaniasis (old world). 17. Clinics in dermatology, 1996, 14:513–7. Al-Shaikhly IAS, Sayidmarie KH. Treatment of cutaneous leish-18. maniasis by local hyperthermia. Bulletin of endemic diseases, 1985, 26:93–8. Sharquie KE, Al-Talib K, Chu AC. Intralesional therapy of cu-19. taneous leishmaniasis with sodium stibogluconate antimony. British journal of dematology, 1988, 119:53–7. Velez I et al. Inefficacy of allopurinol as monotherapy for Co-20. lombian cutaneous leishmaniasis: a randomized, controlled trial. Annals of internal medicine, 1997, 126:232–6. Gorbach SL, Bartlett JB, Blacklow NR. 21. Infectious disease, 1st ed. Philadelphia, WB Saunders, 1992:2115. Furet YX, Pechère JC. Newly documented antimicrobial activ-22. ity of quinolones. European journal of clinical microbiology and infectious diseases, 1991, 10:249–54. Innovative and Intensified Disease Management (IDM) Innovative and Intensified Disease Management (IDM) focuses on diseases for which cost-effective control tools do not exist and where large-scale use of existing tools is limited. The diseases include Buruli ulcer, Chagas disease, human African trypanosomiasis and leishmaniasis and they share the following characteristics: they are difficult and costly to manage – diagnosis, treatment and follow up; • the burden is poorly understood; • there is a lack of appropriate control tools; • there has been relatively lower investment in research and development; • people affected often live in remote rural areas with limited access to diagnosis and treatment. • The goal of IDM is to allow these diseases to be easily managed within the primary health-care system and ultimately eliminated as a public health problem. The objectives are to: intensify disease management using existing tools; encourage the rapid development and implementation of better control tools and to ensure the full involvement of national control programmes; and advocate for health service development in affected areas. Further information about IDM can be found at: http://www.who.int/neglected_diseases/disease_ management/en/index.html EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 94 ABSTRACT This cross-sectional observational study assessed the pattern of musculoskeletal disorders (MSDs) suffered by bank office workers in Kuwait. A self-administered validated questionnaire was used that included the Nordic musculoskeletal questionnaire and 12-item general health questionnaire (GHQ12). Of 750 employees, 80% suffered at least 1 episode of MSD during the previous year and 42% suffered at least 1 disabling episode. The most affected body parts were the neck (53.5%), lower back (51.1%), shoulders (49.2%) and upper back (38.4%). Nationality, GHQ12 score, smoking and sex were significant predictors of MSDs during the previous year, while alcohol drinking, marital status, GHQ12 score, years in Kuwait and sex were significant predictors of disabling MSDs during the previous year. 1Department of Occupational Health, Ministry of Health, Kuwait. 2Department of Occupational Health, University of Birmingham, Birmingham, United Kingdom. 3Department of Occupational Health, University of Alexandria, Alexandria, Egypt (Correspondence to M.I. Kamel: kamelafm@yahoo.com). Received: 20/06/07; accepted: 13/09/07 تيوكلا في كونبلا ليماع ينب ةيلكيلها ةيلضعلا تابارطضلاا لماك ميهاربإ دممح ،يطشلا ضرخ دحمأ ،دروفوارك ناوج ،فوركأ مساق مِدختسا دقو .تيوكلا في كونبلا في نولماعلا اهنم نياعي يتلا ةيلضعلا ةيلكيلها تابارطضلاا طمن ةيضرعلا ةيعطقلما ةساردلا اذه مّيقت :ةصلالخا ىناع ،ًافظوم 750 ينب نمو . ًادنب 12 نم نوكم ماع يحص نايبتساو ،ابوروأ لماشل ليضعلا ليكيلها نايبتسلاا لىع يوتيح ًايتاذ أبعي قوثوم نايبتسا نكامأ رثكأ تناكو .زجعلا نم لقلأا لىع ةبون نم %42 ىناعو ،ةقباسلا ةنسلا للاخ ةيلكيلها ةيلضعلا تابارطضلاا نم لقلأا لىع ةبون نم مهنم %80 تاجرد تناك ،ينطولا ديعصلا لىعو .)%38.4( رهظلا لىعأو ،)%49.2( ينفتكلاو ،)%51.1( رهظلا لفسأو ،)%53.3( قنعلا يه ةرضرتلما مسلجا ،قباسلا ماعلا للاخ ةيلكيلها ةيلضعلا تابارطضلال اهيلع لوعي تائبنم سنلجاو ،ينخدتلاو ،ًادنب 12 نم نوكلما ماعلا يحصلا نايبتسلاا )زارحأ( لوعي تائبنم تيوكلا في تاونسلاو ،سنلجاو ،ًادنب 12 نم نوكلما ماعلا يحصلا نايبتسلاا )زارحأ( تاجردو ،ةيجوزلا ةلالحاو ،رملخا بشر ناكو .ةقباسلا ةنسلا للاخ زجعلل ةببسلما ةيلكيلها ةيلضعلا تابارطضلال اهيلع Musculoskeletal disorders among bank office workers in Kuwait Q.A.S. Akrouf,1 J.O. Crawford,2 A.S. Al-Shatti1 and M.I. Kamel3 Troubles musculosquelettiques chez des employés de banque au Koweït RÉSUMÉ Cette étude transversale d’observation a évalué les caractéristiques des troubles musculosquelettiques (TMS) chez des employés de banque au Koweït. Nous avons utilisé un autoquestionnaire validé comprenant le questionnaire « nordique » sur les TMS et le questionnaire GHQ12 (questionnaire général de santé en 12 questions). Sur 750 employés, 80 % d'entre eux avaient connu au moins un épisode de TMS au cours de l’année précédente et 42 %, au moins un épisode invalidant. Les parties du corps les plus touchées étaient le cou (53,5 %), le bas du dos (51,1 %), les épaules (49,2 %) et le haut du dos (38,4 %). La nationalité, le score au GHQ12, le tabagisme et le sexe étaient des facteurs prédictifs significatifs de TMS au cours de l’année précédente, alors que la consommation d’alcool, l’état matrimonial, le score au GHQ12, les années passées au Koweït et le sexe étaient des facteurs prédictifs significatifs de TMS invalidants au cours de l’année précédente. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 95 Introduction Rapid  technological  developments,  especially  in  the use of electronic data,  have  affected  both  workers  and  the  workplace. Electronic data are mainly  displayed on visual display  terminals.  Improper body posture and long hours  in  front of  these  terminals  can  result  in many health hazards,  including eye  strain  and  fatigue  and musculoskel- etal disorders (MSDs) [1].  It has been  stated  that MSDs are  the most  com- mon occupational health problem [2].  Around 1.1 million people in the United  Kingdom suffered  from MSDs caused  by or made worse by work in 2001–02  [2] and MSDs accounted for 11.6 mil- lion working days lost during 2006 [3].  In the United States, MSDs constituted  41.4% of all adult disabilities (41.2 mil- lion) during 1990 [4]. Work-related  MSDs  can  affect  shoulders, arms, elbows, wrists, hands,  back, legs and feet. They are caused by  forceful  or  repetitive movements  or  a  poor working  posture.  Symptoms  include  tenderness,  aches  and pains,  tingling,  stiffness and swelling. Lower  and upper back pain and muscle spasm  could be due to incorrect seating, which  also affects the cervical spine and neck  muscles  leading  to pain  [5,6]. Craw- ford et al. concluded that physical and  psychosocial risk factors are implicated  in  the  etiology  of MSDs  especially  those affecting  the neck and shoulder  regions  [7].  Jensen et al.  showed  that  neck  symptoms were  the most  com- mon (53%) among  female call-centre  workers,  followed by  shoulder (42%)  and hand/wrist (30%) symptoms [1]. Although many studies have dealt  with MSDs among office workers  in  other countries,  the exact nature and  prevalence of  this  important health  problem has not been studied before  in Kuwait. This study was  formulated  to  fill  the  gap  of  knowledge  in  this  area. The aims of  the  study were  to  assess  the  pattern of MSDs  among  bank office workers and to identify the  impact of demographic, occupational,  psychological  and  social  factors on  MSDs. Methods This study was carried out during 2006  in the 36 branches of one banking com- pany in Kuwait, randomly selected from  among the major banks in the country.  An observational cross-sectional  study  design was adopted. All bank workers  (n = 800) using visual display units were  recruited  for  the  study. A  self-admin- istered questionnaire was distributed  personally to each employee. Tools A specially designed self-administered  questionnaire  included  the  following:  sociodemographic characteristics (age,  sex, nationality, marital  status,  level of  education, years  in Kuwait and smok- ing history) and occupational history  (type of  job and duration in that  job).  The modified 12-item Goldberg gen- eral health questionnaire  (GHQ12)  was used  [8]. This questionnaire  as- sesses  psychiatric morbidity  or  the  “inability  to  carry  out  one’s  normal  ‘healthy’ functions and the appearance  of  new  phenomena  of  a  distressing  nature”. Each question  is  scored  from  0  (better  than  normal)  to  3  (much  less than normal). The short version of  the standardized Nordic musculoskel- etal questionnaire was used to evaluate  MSDs  [6]. This questionnaire deals  with  the occurrence of MSDs during  the previous 7 days and 12 months as  well as  their severity.  It also deals with  the distribution of  these disorders by  body organ. An Arabic  translation of  the questionnaire was prepared. Back  translation was used to ensure correct  translation. The questionnaire was as- sessed by a jury of 6 occupational and  psychiatrist  consultants  to  ensure  its  validity. A pilot study was carried out on 15  workers  to assess  the suitability of  the  questions  in Kuwaiti  culture  and  to  reveal any defects in the administrative  plan  for data  collection. Reliability of  the questionnaire was studied through  repeating  the  same questionnaire on  the 15 workers  included  in  the pilot  study. The Cronbach  reliability  coef- ficient  was  more  than  0.87  for  the  questionnaire. Approval to carry out the study was  obtained  from the headquarters of  the  bank. Oral  consent was also obtained  from workers before filling the question- naire. All  collected data were handled  confidentially. Data analysis The pre-coded questionnaire facilitated  data entry. The Microsoft Excel program  was  used  for  data  entry  and Epi-Info for  statistical  analysis of  the data. The  quality of data was assured by meeting  with  the workers and  their  supervisors  to explain the purpose of  the studyand  the nature of the questionnaire, and by  checking  the  completeness of data  in  the field. After data entry, both manual  and electronic (frequency analysis and  cross-tabulation)  revisions were per- formed to verify data entry. The prevalence of MSDs during the  previous 12 months or  attacks occur- ring during 7 days were calculated if any  part of  the body was affected. Also  the  mean GHQ12 score and  the number  of body parts  affected by MSDs were  calculated. Statistical  analysis  of  the  results  included  both  descriptive  and  ana- lytic  techniques.  Statistical  tests used  for analysis of  the  results  included  the  chi-squared  and Fisher  exact  test  for  qualitative data  and Mann–Whitney  and  Spearman  coefficients  for  non- parametric data. Odds ratio (OR) and  multiple  logistic  techniques were used  to determine  risk  factors. The  level of  significance adopted  for  this  study was  P ≤ 0.05. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 96 Results The questionnaire was completed and  returned by 750 of the 800 bank workers,  giving  a  response  rate of 93.8%. Their  mean age was 33.2 (SD 9.1) years (Ta- ble  1)  and  over  half  the  respondents  were females (52.5%). The predominant  nationality was Kuwaiti (53.9%). Almost  all  the respondents (90.2%) had higher  than  secondary education. A majority  were married (62.9%). Only one-quar- ter were smokers (25.7%), while alcohol  drinkers  were  only  9.7%. The mean  duration  in  their  job was 7.6 (SD 7.5)  years. The mean score on the GHQ12  was  “upper normal”  [11.5  (SD 5.4)]  and only a minority (2.0%) were  rated  as having moderate  to  severe psycho- logical distress (score 25–36). Of all bank workers, 57%  reported  suffering from MSDs during the previous  week, while 80% suffered such disorders  during the previous year. A total of 42% of  the bank workers had suffered disabling  attacks of MSDs  in  the previous  year.  Table 2 shows that lower back (30.3%),  shoulders  (29.5%)  and neck  (28.0%)  were the most affected body parts during  the previous week. Elbow (5.1%), hips  (7.5%) and ankles/feet (9.5%) were the  least affected. For MSDs occurring dur- ing  the previous year,  the affected body  parts showed a slightly different priority,  as  neck  (53.5%),  lower back  (51.1%)  and shoulders (49.2%)  topped  the  list,  and elbows (11.5%), hips (13.3%) and  ankles/feet (16.8%) respectively had the  lowest prevalence. The most disabling  MSDs affecting bank workers were  in  the  wrists/hands  (28.3%)  and  lower  back (24.5%). Table 3 portrays the univariate anal- ysis of  factors  associated with MSDs  among  bank  workers.  Factors  posi- tively associated with the occurrence of  MSDs during  the previous week were:  being female, having Kuwaiti nationality  and scoring high on the GHQ12; while  factors positively associated with the oc- currence of MSDs during the previous  year were: being female, having Kuwaiti  nationality,  being  younger,  holding  more than a secondary education certif- icate and having a high GHQ12 score.  Factors associated with disabling MSDs  were: being  female,  drinking  alcohol,  being married,  longer job duration and  a higher GHQ12. Table 4  shows  the  significant pre- dictors of MSDs using multiple logistic  regression models. Female sex and high  GHQ12  score were  significantly  as- sociated with all  forms of MSDs, while  Kuwaiti  nationality was  significantly  associated with attacks, whether occur- ring during  the previous week or year.  Older age,  longer  job duration, drink- ing  alcohol  and  being married were  Table 1 Characteristics of the sample of bank workers in Kuwait (n = 750) Characteristic No. % Sex Male 356 47.5 Female 394 52.5 Mean (SD) age (years) 33.2 (9.1) Nationality Kuwaiti 404 53.9 Non-Kuwaiti 346 46.1 Marital status Married 472 62.9 Single 278 37.1 Education level Secondary or less 67 8.9 Post-secondary institute 256 34.2 University 387 51.6 Higher university 40 5.3 Mean (SD) time in Kuwait (years) 19.1 (11.8) Smoker Yes 193 25.7 No 557 74.3 Alcohol drinker Yes 73 9.7 No 677 90.3 Job Clerical 43 5.7 Public relations 69 9.2 Customer services 377 50.3 Supervisor 18 2.4 Assistant manager 46 6.1 Manager 95 12.7 Other 102 13.6 Mean (SD) job duration (years) 7.6 (7.5) GHQ12 score Normal (0–12) 472 62.9 Mild distress (13–24) 263 35.1 Moderate to severe distress (25–36) 15 2.0 Mean (SD) score 11.5 (5.4) SD = standard deviation; GHQ12 = 12-item general health questionnaire. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 97 additional  risk predictors  for disabling  MSDs among these bank workers. Discussion The increased use of computer screens,  keyboards and mouses in recent years  has been associated with an increased  prevalence of disorders in the neck and  upper extremities  [9]. Poor worksta- tion design, continuous computer use  for  the entire workday and  repetitive  computer work,  such  as  data  entry,  have been associated with an increased  risk of developing symptoms related to  musculoskeletal disorders [10,11]. Musculoskeletal disorders are high- ly prevalent  and potentially disabling  conditions  that undermine  the  avail- able health  resources  [4]  and  impose  heavy costs on employers  and  society  [2,3,12,13].  In  industrialized  societies,  Table 2 Prevalence of musculoskeletal disorders (MSDs) by affected body part among bank workers in Kuwait during the previous week or year and prevalence of disabling disorders (n = 750) Body part affected by MSD Previous 7 days Previous 12 months Disabling attack No. % No. % No. % Neck No 540 72.0 349 46.5 642 85.6 Yes 210 28.0 401 53.5 108 14.4 Shoulder No 529 70.5 381 50.8 622 82.9 Yes 221 29.5 369 49.2 128 17.1 Right 82 10.9 139 18.5 – – Left 34 4.5 57 7.6 – – Both 105 14.0 173 23.1 – – Elbow No 712 94.9 664 88.5 727 96.9 Yes 38 5.1 86 11.5 23 3.1 Right 14 1.9 33 4.4 – – Left 11 1.5 18 2.4 – – Both 13 1.7 35 4.7 – – Hand/wrist No 641 85.5 538 71.7 538 71.7 Yes 109 14.5 212 28.3 212 28.3 Right 69 9.2 140 18.7 – – Left 16 2.1 30 4.0 – – Both 24 3.2 42 5.6 – – Upper back No 580 77.3 462 61.6 640 85.3 Yes 170 22.7 288 38.4 110 14.7 Lower back No 523 69.7 367 48.9 566 75.5 Yes 227 30.3 383 51.1 184 24.5 Hips No 694 92.5 650 86.7 716 95.5 Yes 56 7.5 100 13.3 34 4.5 Knees No 649 86.5 578 77.1 674 89.9 Yes 101 13.5 172 22.9 76 10.1 Foot/ankle No 680 90.7 624 83.2 700 93.3 Yes 70 9.3 126 16.8 50 6.7 EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 98 MSDs  are  one  of  the  most  common  causes of  temporary work disability and  the main cause of permanent work dis- ability,  accounting  for high productivity  losses [14,15]. The current study was  formulated to  assess  the prevalence of MSDs among  bank workers  and  reveal  the  impact of  personal  and psychological  factors  on  such  disorders.  To  achieve  such  aims  an observational  cross-sectional  study  was  carried  out  in  branches  of  one  of  the major  banks  in Kuwait. The  study  comprised 800 bank workers with a  re- sponse  rate of 93.5%. The short version  of  the Nordic questionnaire was used to  analyse MSDs and a modified GHQ12  self-administered questionnaire was used  for  assessment of psychiatric disorders.  The large number of studied workers and  high response  rate can be considered as  a good  representation of bank workers.  However, the differences in the design of  workstations  in  the  studied branches of  the bank could  form one source of bias.  Although  in cross-sectional design only  survivors are  studied,  the mild nature of  MSDs rarely leads to high rates of turno- ver among bank workers. Our study showed that 80% of workers  suffered from at least 1 attack of a MSD in  the previous year, while 57% suffered from  attacks during  the previous week. Disa- bling MSDs were suffered by 42%. Using  the same questionnaire Woods reported  the following corresponding proportions:  86%, 56% and 30% respectively [16]. The  2 studies agree with regard to ranking of  commonly  affected organs. Our  study  revealed  that neck (53.5%),  lower back  (51.1%) and shoulders (41.6%) were the  most commonly affected body parts dur- ing the previous year. Similar results were  also found for MSDs occurring in the pre- vious week. Several studies have shown an  increased  risk of neck disorders  among  office workers  [17–19]. There  is  strong  evidence supporting static or maintained  postures as a risk factor for MSDs of the  neck and  shoulders  [20] and a positive  relationship has been  identified with  the Ta bl e 3 Re la ti on sh ip b et w ee n ch ar ac te ri st ic s of b an k w or ke rs a nd p re va le nc e of m us cu lo sk el et al d is or de rs (M SD s) d ur in g th e pr ev io us w ee k or y ea r a nd p re va le nc e of d is ab lin g di so rd er s C ha ra ct er is ti c M SD in p re vi ou s 7 da ys Pr ev io us 1 2 m on th s D is ab lin g at ta ck N o M SD (n = 3 22 ) M SD (n = 4 28 ) St at is ti cs N o M SD (n = 1 52 ) M SD (n = 5 98 ) St at is ti cs N o M SD (n = 4 36 ) M SD (n = 3 24 ) St at is ti cs % % O R (9 5% C I) % % O R (9 5% C I) % % O R (9 5% C I) Fe m al e 44 .7 58 .4 1.7 4* (1 .2 9– 2. 32 ) 39 .5 55 .9 1.9 4* (1 .3 5– 2. 79 ) 47 .2 59 .9 1.6 7* (1 .2 4– 2. 23 ) N on -K uw ai ti 56 .2 38 .6 0 .4 9* (0 .3 6– 0 .6 6) 65 .8 41 .1 0 .3 6* (0 .2 5– 0 .5 3) 48 .9 42 .4 0 .7 7 (0 .5 7– 1.0 3) A bo ve se co nd ar y ed uc at io n 90 .6 91 .4 1.0 6 (0 .7 6– 1.4 9) 87 .5 92 .1 1.7 2* (1 .16 –2 .5 4) 90 .8 91 .4 1.0 7 (0 .7 6– 1.5 1) Si ng le 34 .8 38 .8 1.1 9 (0 .8 8– 1.6 0 ) 36 .8 37 .1 1.0 1 ( 0 .7 0 –1 .4 6) 40 .8 31 .8 0 .6 8* (0 .5 0 –0 .9 2) Sm ok er 26 .4 25 .2 0 .9 4 (0 .6 8– 1.3 1) 20 .4 27 .1 1.4 5 (0 .9 4– 2. 24 ) 23 .2 29 .3 1.3 8 (0 .9 9– 1.9 1) A lc oh ol d rin ke r 10 .6 9. 1 0 .8 5 (0 .5 2– 1.3 8) 7.2 10 .4 1.4 8 (0 .7 6– 2. 89 ) 6. 9 13 .7 2. 15 * (1. 31 –3 .5 1) M ea n (S D ) M ea n (S D ) Te st (P -v al ue ) M ea n (S D ) M ea n (S D ) Te st (P -v al ue ) M ea n (S D ) M ea n (S D ) Te st (P -v al ue ) A ge (y ea rs ) 33 .8 (9 .5 ) 32 .8 (8 .7 ) t = 0 .7 3 (0 .4 68 ) 34 .7 (1 0 .4 ) 32 .8 (8 .7 ) t = 2 .0 6* (0 .0 41 ) 33 .4 (9 .4 ) 33 .0 (8 .5 ) t = 0 .6 0 (0 .5 46 ) Jo b du ra tio n (y ea rs ) 7.9 (7 .8 ) 7.5 (7 .2 ) Z = 0 .19 (0 .8 48 ) 7.6 (8 .1) 7.7 (7 .3 ) Z = 0 .6 8 (0 .4 95 ) 6. 9 (7 .5 ) 8. 7 (7 .3 ) Z = 4. 64 * (< 0 .0 0 1) G H Q 12 (s co re ) 10 .0 (5 .0 ) 12 .6 (5 .4 ) Z = 6. 73 * (< 0 .0 0 1) 8. 5 (4 .8 ) 12 .2 (5 .3 ) Z = 8. 25 * (< 0 .0 0 1) 10 .2 (4 .9 ) 13 .2 (5 .6 ) Z = 7.8 8* (< 0 .0 0 1) *P < 0 .0 5. O R = od ds ra tio ; C I = co nfi de nc e lim its o f o dd s r at io ; S D = st an da rd d ev ia tio n. G H Q 12 = 12 -it em g en er al h ea lth q ue st io nn ai re . طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 99 Table 4 Significant risk predictors of musculoskeletal disorders (MSDs) among bank workers using multiple logistic regression Factor Previous 7 days Previous 12 months Disabling attack β OR (95% CI) β OR (95% CI) β OR (95% CI) Age – – – – –0.062 0.94 (0.91–0.97) Sex 0.335 1.40 (1.03–1.90) 0.477 1.63 (1.09–2.45) 0.409 1.51 (1.09–2.09) Nationality –0.593 0.55 (0.41–0.75) –0.919 0.40 (0.27–0.59) – – Marital status – – – – –0.523 0.59 (0.41–0.85) Job duration – – – – 0.079 1.08 (1.05–1.21) Smoker – – 0.639 1.90 (1.18–3.06) – – 2.40 (1.42–4.06)Alcohol drinker – – – – 0.877 GHQ12 score 0.09 1.09 (1.06–1.13) 0.153 1.16 (1.11–1.22) 0.101 1.11 (1.07–1.14) Constant –0.359 – 0.377 – –0.617 – Age, job duration and GHQ12 scales were quantitative variables; sex was coded: male = 1, female = 2; nationality: Kuwaiti = 1, Non-Kuwaiti = 2; marital status: married = 0, currently single = 1; smoker and alcohol drinker: yes = 1, no = 0. 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International journal of industrial ergonom- ics, 2000, 26(3):347–56. duration of fixed  sedentary posture at  work  [21]. Also  limited  breaks  are  a  significant risk factor for neck disorders  [22,23]. The  current  study  showed  that  women were more likely to suffer from  MSDs than men, either during the previ- ous year (84.8% compared with 74.2%)  or the previous week (63.5% compared  with  50%).  Furthermore  they  also  tended to suffer more disabling attacks  (47.7% compared with 35.4%). Many  studies revealed a gender difference with  more women being affected [7,24,25].  These gender differences could be at- tributed  to differences  in workloads or  biological  and anthropometric meas- urements [25].  Gender  differences  in  addition  to psychological  status proved  to be  significant predictors of  all  forms of  MSDs detected by this study. Psycho- social  status was  found  to be consist- ently related to MSDs by other workers  [3,7,26]. Smoking was  also  shown  to  be  a  significant predictor  for MSDs occur- ring during  the  previous  12 months,  while drinking alcohol, duration at work  and age could predict disabling attacks  of MSDs.  The high prevalence of MSDs may  be a  symptom of  “system  failure”  that  should be addressed  to  improve both  quality and productivity. Programmes  for  prevention  of  MSDs  should  be  incorporated within  a widener  ergo- nomic approach to promote the health  of  workers.  Also,  a  comprehensive  approach  including  system goals,  task  allocation, work organization and  job  design is needed. Further studies are re- quired to elaborate the relation between  job demands and loads as well as other  organizational and social factors on oc- currence of MSDs EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 100 Sillanpaa J 10. et al. 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Epidemiological study to investigate potential interaction between physical and psychosocial factors at work that may increase the risk of symp- toms of musculoskeletal disorder of the neck and upper limb. Occupational and environmental medicine, 2002, 59(4):269–77. Bergqvist U 23. et al. The influence of VDU work on musculoskel- etal disorders. Ergonomics, 1995, 38(4):754–62. Korhonen T 24. et al. Work related and individual predictors for incident neck pain among office employees working with video display units. Occupational and environmental medicine, 2003, 60(7):475–82. Jensen C 25. et al. Work-related psychosocial, physical and indi- vidual factors associated with musculoskeletal symptoms in computer users. Work and stress, 2002, 16(2):107–20. Baker 26. NA, Jacobs K, Carifio J. The ability of background factors, work practices, and psychosocial variables to predict the se- verity of musculoskeletal discomfort. Occupational ergonomics, 2000, 2(1):27–41. Note from the Editor We wish to draw the kind attention of our potential authors to the importance of applying the editorial requirements of  EMHJ when preparing their manuscripts for submission for publication. These provisions can be seen in the Guidelines  for Authors, which are available online at http://www.emro.who.int/emhj.htm, and are published at the end of the first  issue of each volume. We regret that we are unable to consider papers that do not conform to the Guidelines. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 101 ABSTRACT Carbon monoxide (CO) poisoning from coal and gas heaters is a public health concern in Turkey. This study estimated the prevalence, mortality rate and clinical predictors of severity of CO poisoning cases treated at the emergency unit of the Uludağ University Medical School, Bursa from 1996 to 2006. Of 305 patients treated over a 10-year period, only 1 case was recorded as suicide. The CO source was a coal heater in 85.9% of cases. Mean Glasgow coma score (GCS) on admission was 12.8 (SD 0.2) and mean carboxyhaemoglobin level was 21.6% (SD 0.92%). There were statistically significant associations between higher GCS score, older age and higher HbCO level. Better education of the public is vital for the prevention of these injuries. 1Department of Emergency Medicine; 2Department of Forensic Medicine; 3Department of Biostatistics; 4Department of Anaesthesiology, Uludağ University Medical School, Bursa, Turkey (Correspondence to B. Eren: bulenteren2000@yahoo.com). Received: 30/05/07; accepted: 27/09/07 ايكترب اسروب في نوبركلا ديسكأ لوأب ممستلا تلااح ليلتح نارآ تنلوب ،نماجشا يزمر ،زوكأ ارمس ،تولوب باتهم ،نماكروت لاسرون ،اسوككأ لاوش لدعم ريدقت لىإ ةساردلا هذه ىعستو .ايكرت في ًاقلق زاغلاو محفلاب لمعت يتلا ةئفدتلا ةزهجأ نع مجانلا نوبركلا ديسكأ لوأب ممستلا يرثي :ةصلالخا ،غادلوأ ةعماجب بطلا ةيلك في ئراوطلا ةدحو في تلجوع يتلا نوبركلا ديسكأ لوأب ممستلا تلااح ةدش لىع ةلادلا تاشرؤلماو تايفولا راشتنا .راحتنا ةلاح انهأ لىع ةدحاو ةلاح تَلِجُس ،تاونس شرع نع ديزت ةترف للاخ اولجوع ضىرم 305 ينب نمو .2005 ىتح 1996 ماع نم اسروب ةنيدمب ضىرملل ةيوبيغلل وغسلاغ زارحأ طسوتم غلبو .محفلاب لمعت يتلا ةئفدتلا ةزهجأ وه تلاالحا نم %85.9 في نوبركلا ديسكأ لوأ زاغ ردصم ناكو َفِشُتكاو .)%0.92 يرايعلما فارحنلااو( %21.6 ينبولغوميه سيكوبرك ىوتسم طسوتمو ،)0.2 يرايعلما فارحنلااو( 12.8 ىفشتسلما ملهاخدإ دنع سانلا ةماع ةيعوت برتعتو .ينبولغوميه سيكوبرك نم لىعلأا تايوتسلماو ،نسلا بركو ،ةبوبيغلل وغسلاغ زارحأ ةدايز ينب ًايئاصحإ هب ُّدَتْعُي ًاطبارت .تاباصلإا هذه ءاقتلا ةيروضر An analysis of carbon monoxide poisoning cases in Bursa, Turkey Ş. Akköse,1 N. Türkmen,2 M. Bulut,1 S. Akgöz,3 R. İşcimen4 and B. Eren2 Analyse des cas d’intoxication au monoxyde de carbone à Bursa (Turquie) RÉSUMÉ L’intoxication au monoxyde de carbone (CO) due à des appareils de chauffage au charbon et au gaz est un problème de santé publique en Turquie. Cette étude a estimé la prévalence, le taux de mortalité et les facteurs cliniques prédictifs de la gravité des cas d’intoxication au CO traités au service des urgences de l’hôpital de la faculté de médecine de l’université Uludağ de Bursa entre 1996 et 2005. Sur 305 patients traités au cours des dix années, un seul cas a été enregistré comme étant un suicide. Le CO était émis par un appareil de chauffage au charbon dans 85,9 % des cas. Le score de Glasgow moyen au moment de l’admission était de 12,8 (E.T. 0,2) et le niveau moyen de carboxyhémoglobine (HbCO), de 21,6 % (E.T. 0,92 %). Il existait des associations statistiquement significatives entre un score de Glasgow élevé, l’âge et un niveau de carboxyhémoglobine élevé. Il est indispensable de mieux informer le public si l’on veut éviter ce type de traumatisme. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 102 Introduction Carbon monoxide  (CO)  is  a  colour- less, odourless, tasteless and nonirritant  gas. The major  source  of CO  in  the  environment  is  incompletely burned  organic material. Common exposures  include smoke from fires and barbecues,  wood or  coal  heaters  that  burn with  inadequate oxygen, incomplete burning  of butane or methane used  in  lighting  and heaters, exhaust gases  from motor  vehicles and cigarette smoke [1,2].  While CO inhalation is a common  method of suicide in some countries, in  Turkey most deaths caused by CO poi- soning result from accidents. Especially  in  the winter months,  leaks  from coal  heaters  are  the major  culprits  [3–6].  Although these deaths can be prevented  with simple measures, they still persist. CO poisoning  is a  serious concern  in Bursa, which is  located in the north- west  part  of Turkey  in  the  southern  Marmara  region where approximately  4 million people reside [7]. Bursa, with  a population of 2.2 million, is the largest  city in the region [7]. Especially during  periods of south-east wind in the winter  months,  coal  heaters  become  instru- ments  of  death.  Every  year,  approxi- mately 900 people suffer CO poisoning.  Approximately 80% of  these patients  are treated at outpatient clinics, the rest  are hospitalized [8]. According  to  the  records of the Bursa Forensic Institute,  in the last 10 years, 211 patients died of  CO poisoning due  to accidents  in  the  home or workplace. This  study was  carried  out  to  re- veal  the prevalence, mortality  rate and  clinical  predictors  of  the  severity  of  CO poisoning in patients treated at the  emergency unit of  the Uludağ Univer- sity Medical School. Methods This  study was  a  retrospective  review  of  records of  cases of CO poisoning  treated between 1  January 1996 and 1  January 2006 at  the emergency unit of  the Uludağ University Medical School  in Bursa, Turkey. Not all poisonings oc- curring in Bursa are referred to Uludağ  Medical School Hospital for treatment;  the  intensive  care  unit  (ICU) of  the  Uludağ Medical School Hospital has  a  limited number of beds and 3 public  hospitals in Bursa also receive poisoning  cases. The study was originally planned  as a collaborative project, but the records  of the public hospitals were incomplete  and they were not included.  A data collection form was designed  and data were compiled retrospectively.  The admission records of the emergency  unit, the ICU files and the patient charts  were  examined. There  are 2  separate  emergency units in our hospital: paedi- atric and adult. During the period of the  study patients aged 14 years and over  were treated in the adult emergency unit  and  it was decided to exclude younger  patients. The  following data were col- lected  for patients:  age;  sex;  source of  CO; Glasgow  coma  score  (GCS)  at  admission  [9];  symptoms  at  admis- sion;  and blood carboxyhaemoglobin  (HbCO)  level at admission measured  using  a  blood gas  analyser  (Omni S,  Roche Diagnostics, Indianapolis, USA).  The  severity  of  CO  poisoning  was  graded with respect to the GCS as: mild  (GCS 15), moderate  (GCS 13–14)  and severe (GCS ≤ 12). Outcome vari- ables  collected were: whether  treated  in emergency unit or admitted to ICU;  duration of stay in the ICU (days); need  for and duration of mechanical ventila- tion (days); and death. It  should be noted  that  the HbCO  levels were not  evaluated properly  in  the  initial  years of  the  study and  thus  records for this period were incomplete.  Also the central record office in the hos- pital was not established until 2006. Statistical analysis Statistical  analysis was performed us- ing SPSS,  version 11.0  for Windows.  The  results  were  expressed  as mean  and standard deviation (SD), median  (interquartile  range;  25th–75th  per- centiles) and frequency, as appropriate.  One-sample chi-squared test and Pear- son chi-squared  test were used  in  the  comparison of categorical variables. The  Kruskall–Wallis  test  and  the Mann– Whitney U-test were used for compari- son of  the distributions of continuous  variables. Correlations were determined  by Spearman rank correlation analysis.  The  clinical  predictors  of  the  sever- ity of CO poisoning were identified by  multivariate logistic regression analysis.  All  statistical analyses were performed  according  to 2-sided hypothesis  tests  and a P-value < 0.05 was  considered  statistically significant.  Results Characteristics of patients and poisonings The total number of patients in the 10- year period was 305. Their mean age  was 36.8 (SD 16.2) years (range 14–79  years)  and  approximately  half  of  the  patients (152, 49.8%) were between 20  and 40 years old; 174 patients (57.0%)  were women  and  131  (43.0%) were  men (P = 0.014) (Table 1).  Except  for  1  suicide  attempt,  all  poisonings (304 patients, 99.7%) were  reported as being due to accidents. The  source of CO was a coal heater  in 262  patients (85.9%), a  liquefied gas heater  in 41  (13.4%)  and motor  vehicle  ex- haust in 2 (0.7%) (Table 1).  The main symptoms at admission in  the mild poisoning cases (n = 180) were  headache  (32.9%),  fatigue  (30.6%),  nausea (19.1%) and dizziness (13.3%)  (Table 1).  The mean GCS at  admission was  12.8 (SD 0.2) (range 3–15). Accord- ing  to  our  GCS  classification,  180  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 103 patients (59.0%) had mild CO poisoning (GCS 15),  42 (13.8%) had moderate poi- soning (GCS 13–14) and 83 (27.2%) had severe poisoning (GCS ≤ 12) (Table 1). Records of HbCO level were avail- able for 188 of the 305 patients (61.6%).  The  mean  HbCO  level  among  was  21.6% (SD 0.92%) (range 1%–63%). As  to  seasonal  distribution,  197  (64.6%)  poisonings  occurred  in  the  winter, 75 (24.6%) in spring, 29 (9.5%)  in  autumn and 4  (1.3%)  in  the  sum- mer. The number  of  cases  increased  significantly after 2001 (P < 0.001) with  the majority occurring in the winter (P <  0.001) (Figure 1).  Outcome One-quarter of the patients (74, 24.3%)  were  admitted  to  the  ICU and 46 of  them (62.2%) required mechanical ven- tilation. The mean duration of ICU stay  was 11.2 (SD 15.8) days (range 1–79  days). The mean duration of mechani- cal ventilation was 8.5 (SD 10.5) days  (range 1–57 days). Of the 231 patients  not admitted to the ICU, 180 (77.9%)  were  treated  at  the  emergency  unit  and discharged and 44 (19.0%) were  referred  to another hospital. Poisoning  was graded severe in 41 (89.1%) of the  46 patients who  required mechanical  ventilation and 57 (77.0%) of  the 74  patients admitted to the ICU. A total of  10 patients died (3.3%), all were cases  of  severe poisoning: 7  in  the  ICU and  3 patients after  treatment  in  the emer- gency unit. Risk factors When the association of the GCS with  the duration of mechanical ventilation,  ICU stay and HbCO levels were inves- tigated highly significant but weak nega- tive correlations were  found. As GCS  decreased, there was longer duration of  mechanical ventilation, longer ICU stay  and higher HbCO levels (r = –0.499, r = –0.452 and r = –0.260 respectively, P < 0.001) (Table 2). There was a statisti- cally  significant but weak negative  as- sociation between age and HbCO level  (r = –0.147, P < 0.045) (Table 2). Of patients aged ≥ 60 years, 54.1%  (20/37) had severe CO poisoning;  in  the other age groups,  the  frequency of  mild poisoning varied between 54.1%  and 69.6% (P < 0.001). The source of  mild CO poisoning was a coal heater in  Table 1 Demographic and clinical characteristics of patients with carbon monoxide (CO) poisoning (n = 305) Characteristic No. % Sex Male 131 43.0 Female 174 57.0 Age group (years) 14–19 37 12.1 20–29 88 28.9 30–39 64 21.0 40–49 46 15.1 50–59 33 10.8 ≥ 60 37 12.1 Cause Accident 304 99.7 Suicide 1 0.3 Source of CO Coal heater 262 85.9 Liquefied gas heater 41 13.4 Motor vehicle exhaust 2 0.7 Glasgow coma score Severe (≤ 12) 83 27.2 Moderate (13–14) 42 13.8 Mild (15) 180 59.0 Blood HbCO level (%) (n = 188) 0–9 33 17.6 10–19 62 33.0 20–29 54 28.7 30–39 21 11.1 40–49 11 5.9 50–59 5 2.7 ≥ 60 2 1.0 Symptoms at admission (n = 173)a Headache 57 32.9 Fatigue 53 30.6 Nausea 33 19.1 Dizziness 23 13.3 Syncope 15 8.7 Blurred vision 6 3.5 Urinary incontinence 1 0.6 aOnly for patients with mild symptoms (Glasgow coma score 15); there was more than 1 symptom for some patients. HbCO = carboxyhaemoglobin. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 104 62.2% of patients (P < 0.05). The HbCO  level was significantly higher (P < 0.01)  and  the duration of  ICU stay  signifi- cantly  longer (P < 0.01)  in severe poi- soning cases compared with mild and  moderate poisoning cases (Table 3). Although more cases were due  to  coal-fired heaters,  the poisoning was  more severe in terms of GCS in patients  poisoned by  liquefied gas sources  than  by coal heaters (Table 3). Regression analysis In univariate logistic regression analysis  where CO poisoning  (severe  versus  moderate/mild) was  the  dependent  variable, age ≥ 60 years old significantly  increased the likelihood of having severe  CO poisoning compared with age ≤ 19  years (OR = 4.3; 95% CI: 1.5–11.8).  In multivariate  logistic  regression  analysis, where CO poisoning (severe  versus moderate/mild) was the depend- ent  variable  and  age  group,  HbCO  level and  interaction  term (age groups  × HbCO level) were  independent vari- ables, a 1% increase in HbCO slightly in- creased  the odds of having severe CO  poisoning (adjusted OR = 1.05; 95% CI:  1.02–1.08).  Discussion CO poisoning from heaters is a serious  risk of death  and disability  in Turkey  Table 2 Spearman correlations (r) of age, Glasgow coma score, duration of mechanical ventilation, duration of stay in intensive care unit (ICU) and blood carboxyhaemoglobin (HbCO) level Variable Glasgow coma score Duration of mechanical ventilation Duration of stay in ICU Blood HbCO level r r r r Age NS NS NS –0.147* Glasgow coma score – –0.499** –0.452** –0.260** Duration of mechanical ventilation – – 0.795** NS Duration of ICU stay – – – NS *P < 0.05; **P < 0.001. NS = not significant. Table 3 Evaluation of patients according to the severity of carbon monoxide (CO) poisoning using Glasgow coma scores (GCS) Variable Severe Moderate Mild P-value (GCS ≤ 12) (GCS 13–14) (GCS ≥ 15) No. % No. % No. % Source of CO Coal heater 66 25.2 33 12.6 163 62.2 0.042a Liquefied gas heater 16 39.0 8 19.5 17 41.5 Age group(years) 14–19 8 21.6 9 24.3 20 54.1 0.001a 20–29 19 21.6 16 18.2 53 60.2 30–39 18 28.1 4 6.3 42 65.6 40–49 12 26.1 2 4.3 32 69.6 50–59 6 18.2 7 21.2 20 60.6 ≥ 60 20 54.1 4 10.8 13 35.1 No. Median (i/q range) No. Median (i/q range) No. Median (i/q range) Blood HbCO level (%) 42 27.5 (16.5–39.0) 24 23.0 (14.3–28.8) 122 18.0 (12.8–26.0) 0.002 b Duration of ICU stay (days) 57 7.0 (2.5–16.0) 10 2.5 (2.0–4.3) 7 3.0 (2.0–6.0) 0.004 b aPearson chi-squared test. bKruskal–Wallis test. HbCO = carboxyhaemoglobin; i/q = interquartile; ICU = intensive care unit. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 105 especially  in  the  winter months.  In- complete burning of coal,  for example  in  small  heaters  with  an  inadequate  chimney  system,  results  in  the  forma- tion of CO which can cause poisoning.  Lack of public  safety  information and  inadequate  regulations are  responsible  for CO poisoning  from heaters  [3–6].  In our country, CO poisoning occurs  in particular cities including Bursa [8,9].  In Bursa,  south-east winds, which are  particularly  strong  in  late December,  January and February, blow through the  chimneys and cause regurgitation of the  exhaust gases into the houses.  The majority of  the CO poisoning  cases in our study occurred in the win- ter (64.6%). This  is  in accordance with  the  literature [10–12]. The use of coal  heaters  in  the winter months and  the  strong  south-east winds contribute  to  the increased number of cases. Our study covered a 10-year period.  The number of  recorded  admissions  increased every year, despite the serious  efforts  in public education, particularly  in  the  last 5 years. The Department of  Health,  Uludağ  University Medical  School and various nongovernmental  organizations  issue  warnings,  in  the  form of public meetings,  reports  in  the  written and visual media and websites,  especially  in  the winter months  and  days  of  the  strong  south-east  wind.  However, the apparent increase in cases  in recent years may be an artefact due to  the inadequacy of the older records, the  development of  intensive care  facilities  in our institutions and increased referral  of the poisoning cases to the university  hospital.  The  present  study  included  305  patients. The  proportion  of  women  (57.0%) was  significantly higher  than  men (43.0%). Other published studies  reported  equal  frequencies  or  a  pre- dominance  of men  [10–16].  A  pre- dominance of men may be due  to  the  workplace fires  and  suicide  attempts.  In our  study,  the majority of  the CO  poisonings (99.3%) occurred at home. CO poisoning is ubiquitous world- wide.  It  is  a  commonly  encountered  poison in accidents, such a smoke from  fires,  vehicle  exhaust  fumes  in  closed  garages and generators used  in poorly  ventilated areas, and in suicide attempts  [11,12,14,16,17]. Operation  of  vehi- cles  in  closed garages  is  a method of  suicide  in  some countries  [16,18].  In  the present study, almost all the patients  were  accident  victims  and  there was  only 1 known case of suicide.  It  is pos- sible that other methods are used more  frequently  in  suicide  attempts  in  this  region (e.g. ingestion of poison) [7]. According to the GCS at admission,  59.0% had mild CO poisoning, 13.4%  had moderate  and 27.2% had  severe  poisoning.  In a 5-year  study  in France,  80.9% of patients had mild poisoning,  14.4% moderate poisoning and 34.7%  had severe poisoning [11]. Of our 305  patients with CO poisoning, 10 (3.3%)  died. The mortality  reported  in other  studies varied between 2.6% and 9.8%  [1–3,9], so our rate is in the same range. The affinity of CO to haemoglobin is  approximately 240 times that of oxygen.  Consequently, CO blocks  transport of  oxygen by haemoglobin to the tissues by  inducing a state of asphyxia. Symptoms  such as  fatigue and headache  typically  occur when  the HbCO  level  exceeds  20%;  levels  above  40%  cause  loss  of  consciousness  and convulsions, while  levels above 60% may be lethal [19,20].  Nevertheless,  the  effects of particular  levels are subject to variation due to per- sonal and environmental factors such as  haemoglobin level, age, physical activity,  metabolic rate, history of cardiovascular  and/or systemic disease, and degree and  duration of exposure to CO [13,19,20].  The HbCO level was measured in 61.6%  of our CO poisoning cases (n = 188).  Figure 1 Annual and seasonal distribution of cases of carbon monoxide (CO) poisoning (n = 305) N o. 50 45 40 35 30 25 20 15 10 5 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 106 Cobb N, Etzel RA. Unintentional carbon monoxide-related 1. deaths in the United States, 1979 through 1988. Journal of the American Medical Association, 1991, 266:659–63. Weaver LK. Carbon monoxide poisoning. 2. Critical care clinics, 1999, 15:297–317. Aksoy E, Polat O, İnanıcı MA. [Retrospective analysis of 293 3. carbon monoxide poisoning cases.] Clinical development, 1995, 8:3545–9 [in Turkish]. Türkmen N, Akgöz S. [Carbon monoxide intoxication related 4. deaths autopsies in Bursa.] Journal of forensic medicine, 2005, 19:20–5 [in Turkish]. Salaçin S. Acute carbon monoxide intoxications due to simple 5. and preventable fatal accidents. American journal of forensic medicine and pathology, 1991, 12:191–3. Azmak D et al. [Carbon monoxide-related deaths.] 6. Journal of forensic medicine, 1994, 10:73–81 [in Turkish]. Akköse Ş et al. Acute poisoning in adults in the years 1996–2001 7. treated in the Uludağ University Hospital, Marmara region. Turkey. Clinical toxicology, 2005, 43:105–9. 2000 census of population: social and economic characteristics of 8. population of Bursa province. Ankara, Turkey, State Institute of Statistics Printing Division, 2002. Genel istatistikler9. . Bursa Sağlık Müdürlüğü [General statistics. Bursa Health Department] [website] (http://www.bsm.gov.tr/ istatistik, accessed 26 May 2009). Ministry of Health, Turkey10. [website] (http://www.saglik.gov.tr, accessed 26 May 2009). Lıu K et al. Unintentional carbon monoxide deaths in California 11. from residential and other nonvehicular sources. Archives of environmental health, 2000, 55:375–81. References Sam-Laï NF, Saviuc P, Danel V. Carbon monoxide poisoning 12. monitoring network: a five-year experience of household poisonings in two French regions. Journal of toxicology, Clinical toxicology, 2003, 41(4):349–53. Bowen D et al. Carbon monoxide poisoning. 13. Forensic science international, 1989, 41:163–8. Satran D et al. Cardiovascular manifestations of moderate to 14. severe carbon monoxide poisoning. Journal of the American College of Cardiologists, 2005, 45(9):1513–6. Homer CD et al. Carbon monoxide-related deaths in a met-15. ropolitan county in the USA: an 11-year study. Forensic science international, 2005, 149:159–65. Handa PK, Tai DYH. Carbon monoxide poisoning: a five-year 16. review at Tan Tock Seng Hospital, Singapore. Annals of the Academy of Medicine of Singapore, 2005, 34:611–4. McDowell R, Fowles J, Phillips D. Deaths from poisoning in 17. New Zealand: 2001–2002. New Zealand medical journal, 2005, 11: 118:U1725. Unintentional non-fire-related carbon monoxide exposures—18. United States, 2001–2003. Morbidity and mortality weekly report, 2005, 54(2):36–9. Dolan MC. Carbon monoxide poisoning. 19. Canadian Medical Association journal, 1985, 133:392–9. Olson KR. Carbon monoxide poisoning mechanisms presenta-20. tions and controversies in management. Journal of emergency medicine, 1984, 1:233–43. Intermittent  equipment  failure  is  the  reason  for  the missing measurements.  There was a  statistically  significant but  weak negative relationship between the  HbCO level and age.  The GCS showed statistically highly  significant but weak negative  relation- ships with duration of mechanical ven- tilation,  ICU  stay  and HbCO  levels.  Patients with  lower GCS had  longer  periods of mechanical ventilation, ICU  stay and higher HbCO levels. Among  patients  aged  60+  years,  54.1%  suf- fered  severe CO poisoning, whereas  in other  age groups  this  ranged  from  18.2%  to 28.1%. The determinants of  severity, morbidity and mortality in CO  poisoning in other studies were patient’s  age,  cardiovascular  co-morbidity  and  duration of  exposure  [13,19,20]. Our  study confirmed a statistically significant  association between age and severity of  CO poisoning. After the effect of age was  controlled for in multivariable analysis, a  higher HbCO level was associated with  more severe CO poisoning.  Liquefied  gas  sources  were more  dangerous  than coal heaters  in  relation  to the severity of the CO poisoning. This  may be explained by the fact that in those  instances, victims are exposed to higher  concentrations of CO  in a  shorter pe- riod. Because the half-life of carboxyhae- moglobin is approximately 250 minutes,  breathing  for  a  few minutes  in  an  at- mosphere containing 0.1% CO, will lead  to  the  formation of 50% HbCO in  the  blood [13,19]. In coal heater poisonings,  victims are exposed to lower concentra- tions of CO for longer periods.  Poisoning due to CO leaks from coal  heaters  is  a  common problem  in  our  country  and  surrounding  regions. The  elderly population is at a higher risk. Vari- ous institutions are expending efforts to  educate the public and prevent CO poi- soning. However,  these are  inadequate.  Extensive use of CO detectors, wide- spread intensive education and monitor- ing of equipment that may emit CO will  prevent most of these poisonings. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 107 New criteria and quality of health care services in the governorate of Monastir, Tunisia ABSTRACT In 2005 new quality criteria (7 items) were introduced for services provided to mother and child under the national perinatality programme. We evaluated this new version in a descriptive study conducted among a random sample of 400 parturient women from Monastir governorate. Mean age was 29.3 (SD 5) years and 42% were primipara. Although prenatal care was adequate in terms of number of antenatal visits for 82.5% of women, for only 21% were all 7 quality criteria fulfilled. The rates of caesarean section and premature birth were significantly higher in women who received quality care (P < 0.05). In logistic regression analysis, age and parity were the only factors independently associated with the quality of care. Additional efforts are needed to ensure good maternal and infant quality of care. RÉSUMÉ En 2005, de nouveaux critères (7) portant sur la qualité des prestations offertes au couple mère- enfant ont été introduits dans le programme national de périnatalité. Dans le cadre d’une évaluation de cette nouvelle version, nous avons réalisé une étude descriptive auprès d’un échantillon aléatoire de 400 parturientes originaires du gouvernorat de Monastir. L’âge moyen des parturientes était de 29,3 ans (ET 5) et 42 % étaient des primipares. Bien que le suivi prénatal ait été adéquat en termes de nombre de consultations pour 82,5 % des femmes, l’ensemble des sept critères de qualité ont été satisfaits pour 21 % d’entre elles seulement. Le taux de césariennes et d’accouchements prématurés était significativement plus élevé chez les femmes ayant eu un suivi prénatal de qualité (p < 0,05). Dans l’analyse de régression logistique, l’âge et la parité étaient les seuls facteurs indépendamment associés à la qualité du suivi prénatal. Des efforts supplémentaires sont nécessaires pour assurer des soins maternels et infantiles de qualité. 1Service de Médecine préventive et d’Epidémiologie ; 2Service de Gynécologie obstétricale, CHU Fattouma Bourguiba, Monastir (Tunisie) (Correspondance à adresser à S. El Mhamdi : sanaelmhamdi@yahoo.fr). Reçu : 21/01/09 ; accepté : 09/04/09 سنوت في ةيروصنلما ةظفامح في ةيحصلا ةياعرلا تامدخ ةدولج ةديدج يرـياعم لماس نب لماك ،فيطللا رذنم ،دادح سينأ ،نياطلس سيوس دممح ،يدمحلما ءانس ةترفلل ينطولا ةيحصلا ةياعرلا جمانرب نمض لافطلأاو تاهملأل ةمدقلما تامدخلل )دونب 7 نم ةنوكم( ةديدج يرياعم تلخدأ ،2005 ماع في :ةصلالخا .ةيروصنلما ةظفامح نم لماح ةأرما 400 تمض ةيئاوشع ةنيع لىع تيرجأ ةيفصو ةسارد في ةديدلجا ةخسنلا هذه نوثحابلا مَّيقو .ةدلاولاب ةطيحلما ةترفلا في ةياعرلا ةمئلام نم مغرلاب .)ةَّيرْكب( ةرم لولأ لمتح نهنم %42 تناكو ،)تاونس 5 يرايعلما فارحنلااو( ةنس 29.3 نهرمع طسوتم ناك تناكو .ةدولجا يرياعلم ةعبسلا دونبلا عيجم ينفوتسا نهنم طقف %21 نأ لاإ ،ءاسنلا نم %82.5 تطغ يتلا لملحا تارايز ددع ثيح نم ةدلاولاب ةطيحلما ليلتح فيو .)0.05 نم لقأ p( ةدولجا ةيلاع ةياعر ين َّقلت تيلالا ءاسنلا ينب ًايئاصحإ هب ُّدَتْعُي وحن لىع لىعأ جدلخا ةدلاوو ةيصريقلا ةحارلجا تلادعم نماضل دهلجا نم ديزلما لذبل ةجاح كانه .ةياعرلا ةدوجب ناقلعتلما نلاقتسلما ناديحولا نلاماعلا اهم ةدلاولا تارم ددعو رمعلا ناك ،يتسجول فوتح .لافطلأاو تاهملأا ةياعرل ةيلاع ةدوج Les nouveaux critères et la qualité des services de soins de santé dans le gouvernorat de Monastir (Tunisie) S. El Mhamdi,1 M.S. Soltani,1 A. Haddad,2 M. Letaief 1 et K. Ben Salem1 EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 108 Introduction Le  suivi  prénatal  est  une  activité  de  dépistage des complications maternelles  et  fœtales.  En Tunisie,  cette  activité  a  débuté  dans  les  années  1960.  Elle  a  connu plusieurs  améliorations  et  a  été  érigée  en programme national de  périnatalité (PN-PRN) depuis 1990,  fondé sur la conformité du nombre des  visites prénatales aux recommandations :  un minimum  de  quatre  visites  avec  un contenu spécifique était préconisé.  Actuellement,  et depuis  l’année 2005,  les taux de conformité de ces visites ont  dépassé  les 90 % à  l’échelle nationale  [1].   Cette  performance  a  amené  les  responsables  du  programme  à  se  focaliser  sur  la qualité de  ce  suivi par  l’introduction  de  nouveaux  critères  visant la santé du couple mère-enfant.  Notre  travail vise  l’évaluation de ce  programme dans  sa nouvelle  version  au  niveau  de  la  région  sanitaire  de  Monastir.  Méthodes Il   s ’agit   d’une  étude  descriptive  rétrospective  réalisée  au  niveau  de  la  région  sanitaire  de Monastir  qui  compte,  selon  le dernier  recensement  de 2004, 127 162  femmes  en  âge de  procréer (15-50 ans),  soit 27,8 % des  habitants de cette région [2].  Notre   populat ion  d’étude  était  composée de  l’ensemble des  femmes  ayant accouché au niveau des structures  sanitaires  publiques  de  la  région  de Monastir  du  1er  janvier  2006  au  31 mars 2006 (n = 400). Le  suivi  prénatal,  assuré  par  le  médecin et la sage-femme, est réalisé au  niveau des centres de santé de base de la  région d’étude.  Les informations ont été obtenues à  partir d’un entretien avec la parturiente,  après  son  consentement  verbal  lors  de  la  présentation de  l’étude,  couplé  à  une  revue  de  son  dossier  de  suivi  prénatal.  L’entretien était  fondé  sur  un questionnaire préalablement  testé  explorant les dimensions suivantes : identification  de  la  parturiente  et • caractéristiques socio-économiques ; antécédents  personnels  et  profil • obstétrical ; caractéristiques  de  la  grossesse • actuelle ; c on t enu   d e s   c on su l t a t i on s • prénatales ; caractéristiques de l’accouchement et • du nouveau-né ; critères de qualité :  examen médical • systématique, dépistage des grossesses  à haut risque, etc. (Tableau 1). Les  données  recueil l ies   sont  légalement  couvertes  par  le  secret  professionnel dans notre pays,  ce qui  leur  assure  la  confidentialité  requise  pour ce genre de travaux [3]. Analyse statistique Cette  analyse  s’est  intéressée  à  la  recherche  des  facteurs  associés  à  un  suivi de qualité en se basant sur les tests  statistiques appropriés (test t de Student  pour  la  comparaison  des moyennes  et test de χ2 pour  la  comparaison des  effectifs).   Nous  avons  également  procédé à une étude multivariée pour  identifier les facteurs indépendamment  associés à un suivi prénatal de qualité.  Cette étude était fondée sur un modèle  de  régression  logistique  incluant  les  variables significatives au seuil de 20 %  dans  l’étude  univariée.  Les  variables  retenues  dans  le  modèle  final  sont  celles significatives au seuil de 5 %. Les  intervalles  de  confiance  au  seuil  de  5 % ont  été utilisés pour  l’estimation  et  la  généralisation  des  différentes  fréquences.  Résultats Profil des parturientes L’âge moyen de nos parturientes est de  29,3 ans (ET 5) avec des extrêmes allant  de 19 à 42 ans. Leur niveau scolaire et  socio-économique  est moyen :  ainsi  51 % (n = 204) d’entre elles n’ont pas  dépassé  l’enseignement  secondaire  et  50 % étaient des femmes au foyer. Le  passé  obstétrical  de  ces  femmes  a  montré  que  42 %  d’entre  elles  étaient  des  primipares  et  10 %  des  multipares (parité ≥ 4). Dix-sept pour  cent de l’ensemble des femmes et 31 %  des primipares étaient âgées de 35 ans  et plus.  Étude de la qualité du suivi prénatal Le  suivi  prénatal  était  jugé  adéquat  dans  82,5 %  des  cas (n = 330),  et  la  première  visite  était  réalisée  au  cours  du  premier  trimestre  pour  90 %  des  parturientes. Cependant  et  selon  les  nouvelles  recommandations, pour être  considéré de qualité,  le  suivi prénatal  doit satisfaire en plus à un ensemble de  sept  critères (voir  annexe)  ajoutés  au  PN-PRN.  L’étude  de  la  réalisation  de  ces  différents critères a montré que sur  les  sept  critères  de  qualité,  trois  étaient  inférieurs  à  26 % (Tableau 2).  La  notification de  l’âge, de  la  taille  et du  groupe sanguin (critère 1) était satisfaite  dans 98 % des cas. L’examen médical avec  auscultation cardio-pulmonaire (critère  3)  et  la  conclusion  générale  de  l’état  de  chaque  parturiente (critère  4)  étaient notifiés dans 70 % et 65 % des  cas  respectivement.  Cependant,  la  détermination du poids, de  la  tension  artérielle,  de  la  protéinurie  et  de  la  glycosurie (critère 2)  lors des quatre  consultations n’était  réalisée que dans  26 % des cas.  La notification du niveau de risque  de  la grossesse (critère 5) n’a été  faite  que  pour  84  parturientes (21 %) ;  34 d’entre elles étaient classées comme  étant à haut risque.  Ainsi   seulement  21 % (IC 95  % [18,97-23,03])  des  femmes  peuvent  être  considérées  comme ayant  eu un  suivi prénatal de qualité conforme aux  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 109 nouvelles  recommandations  du PN- PRN (Tableau 2). Suivi prénatal de qualité et profil des parturientes Une étude de la qualité du suivi prénatal  selon le profil des parturientes a montré  qu’il  était  significativement  associé  à  l’âge : plus  la  femme est  jeune, plus  le  suivi est de qualité (p = 0,03). Au niveau  scolaire,  le  taux est passé de 50 % chez  les  femmes  scolarisées  à  91 %  pour  celles  ayant  un niveau universitaire  ;  par contre,  les multipares ont un suivi  de qualité  significativement plus  faible  (p = 0,04) (Tableau 3).  Suivi prénatal de qualité et issue de la grossesse L’étude  de  l’issue  de  la  grossesse  en  fonction de  la qualité du suivi prénatal  a  montré  que  les  césariennes  et  les  accouchements  prématurés  étaient  significativement plus  fréquents  chez  les parturientes ayant un suivi prénatal  de  qualité (p  = 0,002  et  p  = 0,005,  respect ivement) ,   a lors   que   les  complications (rupture prématurée des  membranes, hémorragie, pré-éclampsie,  etc.)  étaient  significativement  plus  fréquentes dans le groupe du suivi non- qualité. Ce  taux  a diminué de 23,6 %  dans  le  groupe du  suivi non-qualité  à  18 % dans le groupe du suivi de qualité  (p = 0,03) (Tableau 4).  Concernant  le nouveau-né, aucune  relation  statistiquement  significative  n’a été observée entre  le  suivi prénatal  de  qualité  d’une  part,  et  le  poids  de  naissance et le transfert en néonatologie  d’autre part (Tableau 4).  Étude multivariée Les variables qui étaient incluses dans  le modèle  étaient  l’âge,  la  parité,  la  profession et le niveau scolaire ; seuls  l’âge  et  la  parité  ont  été  identifiés  comme  facteurs  indépendamment  associés   au  suivi   prénatal   de  qualité (Tableau 5). Discussion En Tunisie, les activités du programme  national de santé maternelle et infantile  ont  débuté  en  1966,  puis  ont  été  spécifiées  en PN-PRN en 1992. Ces  activités  ont  abouti  à  des  résultats  appréciables en matière de diminution  de  la  morbi-mortalité  maternelle  et  fœtale [4]. Actuellement, depuis l’année  2005,  le  PN-PRN  a  été  enrichi  par  l’introduction de sept nouveaux critères  visant  l’amélioration de  la  qualité du  suivi prénatal en couplant le nombre de  Tableau 1 Définitions opérationnelles Suivi prénatal adéquat : grossesse ayant bénéficié de quatre visites prénatales et plus, conformément au PN-PRN. Suivi prénatal inadéquat : grossesse ayant bénéficié de moins de quatre visites prénatales. Suivi prénatal de qualité : un suivi est considéré de qualité lorsque, d’une part, les quatre consultations prénatales sont réalisées au cours du 1er trimestre, 6e, 8e et 9e mois et d’autre part, le suivi répond aux sept critères cliniques et paracliniques suivants. Critère 1 : le groupe sanguin, l’âge et la taille de la femme ont été enregistrés dans le dossier. Critère 2 : à chacune des quatre consultations prénatales, le poids, la tension artérielle, la glycosurie et l’albuminurie ont été enregistrés sur la fiche de consultations prénatales. Critère 3 : la femme a bénéficié d’au moins un examen médical avec une auscultation cardio-pulmonaire durant sa grossesse. Critère 4 : une conclusion générale sur la grossesse figure sur la fiche prénatale. Critère 5 : en cas de présence d’un facteur de risque, la femme est répertoriée dans le « cahier des grossesses à risque ». Critère 6 : en cas de facteur de risque dépisté, la conduite à tenir qui lui a été appliquée est conforme aux recommandations du programme national de périnatalité. Critère 7 : l’enfant à naître a été notifié EP (enfant protégé contre le tétanos néonatal) sur le registre. Prématurité : naissance d’un enfant avant le terme de 37 semaines d’aménorrhée (SA), calculé à partir du premier jour des dernières règles. Post-maturité : naissance survenue après la 41e SA, calculée à partir du premier jour des dernières règles. Faible poids de naissance : poids du nouveau né < 2500 g. Anémie : taux d’hémoglobine inférieur à 8 g/dl. Tableau 2 Les différents critères d’un suivi prénatal de qualité Critère de qualité Nbre % Critère 1 392 98 Critère 2 104 26 Critère 3 280 70 Critère 4 260 65 Critère 5 84 21 Critère 6 15 44 Critère 7 96 24 Suivi de qualité 84 21 EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 110 visites à leur contenu. Tous ces critères  doivent être  satisfaits pour parler d’un  suivi prénatal de qualité. Cette nouvelle  démarche  est  devenue  impérative  au  vu de  l’actuel  profil  épidémiologique  des  femmes  qui  se  présentent  pour  accouchement dans nos  structures de  soins  [5]. En  effet,  notre  échantillon,  qui était composé de 42 % de  femmes  primipares dont 31 %  avaient un  âge  supérieur ou égal à 35 ans confirme ce  profil épidémiologique.  Profil des parturientes Actuellement, partout dans  le monde,  les grossesses à un âge avancé sont de  plus  en  plus  fréquentes,  exposant  à  plusieurs complications [6]. En Tunisie,  ce nouveau profil des parturientes est lié  à la transition sociale que vit notre pays,  marqué par  le  travail des  femmes et  le  retard de l’âge au mariage. L’orientation  vers une prise en charge de qualité est  donc devenue une nécessité.  Concernant  la  parité,  42 %  des  femmes  de  notre  série  étaient  des  primipares  et  10  %  des  multipares.  D’autres  études ont montré des  taux  plus  importants  de  multiparité  [7].  Cette parité relativement faible de notre  série est en partie le reflet de l’adoption  par  notre  pays  d’une  politique  de  contrôle  des  naissances  depuis  les  années soixante.  Qualité du suivi prénatal Dans  notre  contexte  tunisien,  le  suivi prénatal  est  assuré par  le  couple  médecin - sage-femme.  Le  rôle  de  cette dernière, surtout dans  le suivi des  grossesses à faible risque, est bien établi  par la littérature [8].  Le  nombre  de  consultat ions  prénatales  constitue  un  dilemme  à  travers  le monde. En Tunisie,  quatre  consultations étaient préconisées. Dans  notre étude,  le  taux de couverture est  de  82,5 %.  Il  est  supérieur au  chiffre  national  (54,8 %)  et  à d’autres  séries  régionales [9,10]. Cependant, le nombre  de consultations à  lui seul ne suffit pas.  Tableau 3 Suivi prénatal et profil des parturientes Variable Suivi prénatal de qualité p Nbre % Âge (ans) < 35 71 21,3 0,006 ≥ 35 13 18,9 Parité Primipares et paucipares 79 22,3 0,001 Multipares 5 11,4 Niveau scolaire Non scolarisées et niveau primaire 17 13,5 0,005 Secondaire 48 25,0 Universitaire 19 46,4 Profession Oui 57 28,9 0,035 Femmes au foyer 27 13,5 En effet,  la  répartition  temporelle de  ces consultations constitue un critère  de  qualité  du  suivi  prénatal,  surtout  la première  consultation  qui  doit  être  faite  le  plus  tôt  possible  lors  du  premier trimestre. Cette première visite  est  l’occasion  de  juger  l’aptitude  de  la mère à bien mener  sa grossesse en  recherchant par un examen physique  et  des  examens  complémentaires  appropriés d’éventuelles  tares pouvant  nuire au déroulement normal de cette  grossesse.  Depuis 2005,  afin de promouvoir  la  qualité  de  ce  suivi,   un  certain  nombre  de  critères  supplémentaires  tels  qu’énumérés  par  le  PN-PRN  doivent  être  réalisés. Parmi  ces  examens, la prise de la tension artérielle  est  indiquée  au  cours  des  quatre  consultations,  afin  de  dépister  une  hypertension artérielle préexistante ou  une toxémie gravidique  [11], de même  que  la  recherche  d’une  protéinurie  dont  le  rôle  dans  le  dépistage  de  l’hypertension  gravidique  demeure  controversé [12,13]. La pratique de ces  deux examens (critère 2) s’élève à 26 %  dans notre étude. Ce faible taux pourrait  s’expliquer soit par la non-réalisation de  ces examens, soit par la non-notification  sur  le  dossier médical  de  la  femme,  reflétant l’absence d’une culture écrite.  L’auscultation cardio-pulmonaire,  au même titre que le reste de l’examen  clinique,  était  réalisée dans 70 % des  cas.  Tableau 4 Suivi prénatal de qualité et issue de la grossesse Issue de la grossesse Suivi prénatal de non-qualité Suivi prénatal de qualité p Nbre % Nbre % Accouchement par césarienne 24 7,7 11 13,5 0,002 Complications 20 6,3 3 4,0 0,005 Prématurité 25 8,0 10 11,5 0,03 Transfert en néonatologie 25 8,2 5 5,8 NS Faible poids naissance 35 11,2 6 6,1 NS NS : non significatif. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 111 Parmi  les autres critères de qualité  figure  la  vaccination  antitétanique  au  cours de  la  grossesse, dont  l’efficacité  en  termes de réduction de  la  survenue  du  tétanos néonatal  [14] n’est plus  à  démontrer. Cet acte n’a été notifié que  chez 30 % des  femmes. Ce chiffre  est  inférieur  à  la  réalité  de  la  protection  contre cette affection dans notre pays,  protection  qui  dépasse  les  90 % [9].  L’absence  d’intégration  entre  le  programme national de vaccination et  le PN-PRN pourrait expliquer  le  faible  de  taux  de  couverture  par  le  vaccin  antitétanique rapporté dans notre travail.  Ces résultats confirment la nécessité de  l’intégration  et  de  l’horizontalisation  des  soins,  et d’éviter  les programmes  verticaux  ne  tenant  pas  compte  des  autres actions réalisées.  Selon plusieurs études,  le profil des  parturientes est un facteur déterminant  de  la qualité du suivi prénatal  [15]. En  effet, une  revue de  la  littérature  [16] a montré que  le  statut des  femmes (âge,  parité, origine géographique, éducation,  etc.)  devrait  être  considéré  dans  la  qualité du  suivi prénatal dans  les pays  en développement. Ces  résultats ont  été  confirmés  dans  notre  travail,  et  un  modèle  de  régression  logistique  a permis d’identifier  l’âge  et  la  parité  comme  facteurs  indépendamment  associés au suivi prénatal de qualité. Ces  facteurs  peuvent  s’expliquer  par  une  sorte de fausse sécurité liée aux grossesses  antérieures chez  les parturientes âgées  et multipares.  Concernant  l’issue de  la grossesse,  les résultats de la littérature ont montré  qu’un suivi prénatal de qualité permet  d’identifier  les  facteurs  de  risque  et  de prévoir  l’issue de  la grossesse  [17], de  même  qu’il  permet  d’éviter  les  issues  défavorables  et  les  différentes  complications  [18]. Ces  résultats ont  été retrouvés dans notre étude. Ainsi, un  suivi de qualité a permis d’identifier des  Tableau 5 Étude multivariée des facteurs associés à un suivi prénatal de qualité Variable Odds ratio (exp β) IC95 % p Âge 2,1 1,03-3,02 0,03 Parité 3,2 2,02-5,27 0,04 Niveau scolaire 1,16 0,3-1,59 0,08 Profession 1,2 0,87-1,98 0,1 IC : intervalles de confiance. 1. Tunisie. Surveillance prénatale. Tunis, Programme National de Périnatalité, Ministère de la Santé publique, 2005. 2. Enquête démographique de santé en Tunisie 2004. Tunis, Office national de la Famille et de la Population, 2004. 3. Code de déontologie médicale tunisien. Décret n° 93-1155 du 17 mai 1993, Article 8. Journal officiel de la République tunisienne, 1993, 40:764. 4. Hansen JP. Older maternal age and pregnancy outcome: A review of the literature. Obstetrical and gynecological survey, 2002, 41:726–42. 5. Antenatal care in developing countries: promises, achievements and missed opportunities: an analysis of trends, levels and differentials, 1990–2001. Geneva, World Health Organization, 2003. 6. Delpisheh A et al. Pregnancy late in life: a hospital-based study of birth outcomes. Journal of women’s health (Larchmt), 2008, 17(6):965–70. 7. Le Coutour X, Papin F. Mortalité périnatale : épidémiologie. La Revue du Praticien, 2001, 51(13):1484–7. 8. Khan-Neelofur D, Gülmezoglu M, Villar J. Who should provide routine antenatal care for low-risk women, and how often? A systematic review of randomized controlled trials. WHO Antenatal Care Trial Research Group. Paediatric and perinatal epidemiology, 1998, 12(Suppl. 2):7–26. 9. Rapport annuel 2006. Tunis, Ministère de la Santé publique/ Direction des Soins de santé de base, 200. 10. Bchir A et al. Le registre des naissances : outil d’évaluation des activités de santé maternelle et infantile à l’échelle du district. La Revue de Santé de la Méditerranée orientale, 1996, 2(3):418–24. 11. Chandiramani M, Shennan A. Hypertensive disorders of pregnancy: a UK-based perspective. Current opinion in obstetrics and gynecology, 2008, 20(2):96–101. taux  significativement plus  importants  d’accouchements  prématurés  et  par  césarienne. Ces constatations peuvent  être en  rapport avec  la qualité du suivi  qui  a permis d’identifier précocement  les  complications nécessitant un arrêt  prématuré de la grossesse ou d’indiquer  un  accouchement  par  césarienne.  Hormis  la  prématurité,  les  autres  complications étaient significativement  influencées par la qualité du suivi prénatal  dans  plusieurs  études  [19,20]. Dans  notre cas, ces complications étaient plus  fréquentes dans  le groupe non-qualité,  ce qui prouve  l’intérêt d’une prise  en  charge de qualité des femmes enceintes  et d’un dépistage précoce des  facteurs  de risque.  Conclusion L’introduction dans le PN-PRN, depuis  2005, de nouveaux critères portant sur  l’amélioration  de  la  qualité  du  suivi  prénatal  dans  notre  pays  a  montré  des niveaux élevés de couverture pour  certains d’entre eux, alors que d’autres  restent en deçà des attentes. Un effort  de sensibilisation et de formation nous  paraît nécessaire dans notre région afin  de réaliser les attentes d’un programme  de PN-PRN de qualité. Références EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 112 12. Waugh JJ et al. Accuracy of urinalysis dipstick techniques in predicting significant proteinuria in pregnancy. Obstetrics and gynecology, 2004, 103(4):769–77. 13. Alto WA. No need for glycosuria/proteinuria screen in pregnant women. Journal of family practice, 2005, 54(11):978–83. 14. Dikici B et al. Neonatal tetanus in Turkey; what has changed in the last decade? BMC infectious diseases, 2008, 8:112. 15. Bashour H et al. Patterns and determinants of maternity care in Damascus. Eastern Mediterranean health journal, 2008, 14(3):595–604. 16. Simkhada B et al. Factors affecting the utilization of antenatal care in developing countries: systematic review of the literature. Journal of advanced nursing, 2008, 61(3):244–60. 17. Viller J et al. WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. Lancet, 2001, 357(9268):1551–64. 18. Ickovics JR et al. Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstetrics and gynecology, 2007, 110(2 Pt 1):330–9. 19. Ebeigbe PN, Enabudose E, Ande AB. Ruptured uterus in a Nigerian community: a study of sociodemographic and obstetric risk factors. Acta obstetricia et gynecologica Scandinavica, 2005, 84(12):1172–4. 20. Klerman LV et al. A randomized trial of augmented prenatal care for multiple-risk, Medicaid-eligible African American women. American journal of public health, 2001, 91(1):105–11. Manuel de suivi et d’évaluation des ressources humaines pour la santé Dans bon nombre de pays, le manque de personnel est l’un des obstacles majeurs au renforcement de la prestation des  services de santé primaires et des autres services de santé, qu’il s’agisse des services curatifs, des services de promotion  de la santé, de prévention ou de réadaptation. Nombreux sont les pays qui ne disposent pas des capacités techniques  nécessaires pour assurer un suivi précis de leur propre personnel de santé : les données sont souvent peu fiables et  obsolètes ; il n’y a pas de définitions communes ni d’outils d’analyse reconnus, et les compétences et l’expérience  permettant d’évaluer des questions politiques cruciales font défaut. Le présent guide vise à renforcer ces capacités techniques. Il offre aux gestionnaires de la santé, aux chercheurs et aux  responsables politiques un outil de référence global, normalisé et convivial leur permettant de suivre et d’évaluer les  ressources humaines pour la santé. Il comporte un cadre analytique proposant différentes options stratégiques pour  améliorer l’information et la base de connaissances relatives au personnel de santé, et présente en outre les expériences  des pays pour mettre en lumière les approches qui ont été fructueuses. Il convient de considérer la présente publication comme un travail appelé à évoluer qui aboutira à une meilleure  compréhension des ressources humaines pour la santé et représentera une contribution notable à l’ensemble des outils  et travaux de recherche appliquée conçus pour relever le défi qui consiste à mesurer et à améliorer les résultats du  personnel de santé, à renforcer les systèmes de santé et, finalement, à améliorer la santé de la population. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 113 ABSTRACT In Saudi Arabia, local interpretations of Islamic laws and social norms have a negative impact on the health and well-being of women. The objective of this literature review was to discuss gender inequity in Saudi Arabia and its relation to public health. Despite the scarcity of recent statistics and information regarding gender inequity in Saudi Arabia, this review is an attempt to explore this sensitive issue in this country. Women’s roles and rights in Saudi society were examined, including education, marriage, polygamy, fertility, job opportunities, car driving and identification cards. Further research to assess knowledge, attitudes and practices towards health care of Saudi men and women is recommended. 1Department of Radiation Oncology, Graduate School of Medicine, University of Gunma, Maebashi City, Gunma, Japan (Correspondence to A.E.H. Mobaraki: mazkor@hotmail.com). 2Department of Oral Public Health, Faculty of Odontology, University of Malmö, Malmö, Sweden. Received: 28/05/07; accepted: 26/09/07 ةيمومعلا ةحصلا لىع هيرثأتو ةيدوعسلا في ينسنلجا ينب ةلادعلا مدع تلفريدوس نرويب ،يكرابُم ينسح للها دبع ةلاقلما هذه نم فدلهاو .ءاسنلا ةيفاعو ةحص لىع يبلس يرثأت ةيعمتجلما تاداعلاو ةيملاسلإا ةعيشرلل ةيلحلما تايرسفتلل نوكي ،ةيدوعسلا في :ةصلالخا ةصالخا تامولعلماو تايئاصحلإا ةردن نم مغرلابو .ةيمومعلا ةحصلاب كلذ ةقلاعو ةيدوعسلا في ينسنلجا ينب ةلادعلا مدع ةشقانمو ةعجارم وه في ةأرلما قوقحو رود دقفت ىرجو .ديرفلا دلبلا اذه في ةيضقلا ةيساسح نع فشكلا لواتح ةلاقلما هذه نأ لاإ ،ةيدوعسلا في ينسنلجا ينب ةلادعلا مدعب ديزلماب صىويو .ةيولها تاقاطبو ،تارايسلا ةدايقو ،لمعلا صرفو ،باجنلإاو ،تاجوزلا ددعتو ،جاوزلاو ،ميلعتلا كلذ في ماب ،يدوعسلا عمتجلما .تايدوعسلاو ينيدوعسلل ةيحصلا ةياعرلا لوح تاسرمالماو تاهجوتلاو ةفرعلما مييقتل ثحبلا نم Review Gender inequity in Saudi Arabia and its role in public health A.E.H. Mobaraki1 and B. Söderfeldt 2 L’inégalité entre hommes et femmes en Arabie saoudite et ses conséquences sur la santé publique RÉSUMÉ En Arabie saoudite, les interprétations locales des lois islamiques et des normes sociales ont des effets négatifs sur la santé et le bien-être des femmes. L’objectif de cette revue de la littérature était d’étudier l’inégalité entre hommes et femmes en Arabie saoudite et le rapport de cette dernière avec la santé publique. Malgré la rareté des statistiques et des informations récentes sur ce sujet dans le pays, notre revue tente d’explorer cette question sensible. Nous avons examiné le rôle et les droits de la femme dans la société saoudienne, notamment sous l’angle de l’éducation, du mariage, de la polygamie, de la fertilité, des possibilités d’emploi, de la conduite automobile et des documents d’identité. Nous recommandons de poursuivre le travail de recherche afin d’évaluer les connaissances, les attitudes et les pratiques en matière de soins de santé des hommes et des femmes saoudiens. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 114 Introduction Inequity based on  gender  exists  to  a  varying extent in all societies and varies  over  time and across  social and ethnic  groups  [1].  Within  every  commu- nity, nationality  and class,  the burden  of hardship often  falls disproportion- ately on women [2–4]. “Inequality” and  “inequity”  are different  concepts;  the  former  applies  to  any variation, while  the latter applies to both avoidable and  unjust causes [5]. There are many dif- ferent kinds of  gender  inequity  in,  for  example, mortality  rates, natality  rates,  basic facilities such as schooling, special  opportunities  for  training, professional  aspects such as employment, ownership  of property  and  land,  and household  duties  [6]. Gender  inequity  is usually  translated into a power imbalance with  women  being more  vulnerable. This  vulnerability is more precarious in tradi- tional patriarchal societies.  Saudi Arabia has a population esti- mated  to be about 23 million  in 2006  including 27.1%  foreigners  [7]. Of  the  Saudi  citizens,  90% are Arabs  and  all  are Muslims. Annual per capita  income  is about US$ 13 600 [8]. The system of  government  in Saudi Arabia  is a mon- archy, with  the constitution governed  by a strict  interpretation of  Islamic  law  [9]. The Council of Ministers  is nomi- nated by the King. The media (print and  visual) are government owned. Policies  are  formulated  and  implemented  by  the government. There are no people’s  representatives or independent interest  groups to represent health concerns to  the government. The government  ran  municipal  elections  for  the first  time  in 2005, although women were not al- lowed to vote [8]. In this unique country, local interpre- tations of Islamic laws and social norms  can have a negative impact on the health  and well-being of women. The objective  of  this  literature  review was  to discuss  gender  inequity  in  Saudi Arabia  and  its  relation  to public health. Women’s  roles and rights in Saudi society were ex- amined,  including education, marriage,  polygamy,  fertility,  job opportunities,  car driving and identification cards. Methods The PubMed  online database  and  the  Google  search engine were used for  the  literature  review. The  inclusion criteria  were based on scope, content, accuracy,  authority, currency, purpose, workabil- ity,  searching,  connectivity  and  cost  of  the chosen  journals and web-based  information [10]. Most of  the sources  were articles  in peer-reviewed  journals,  websites of reputable organizations and  national official websites. The WHOIS tool was used to check the ownership of  the domain names.  A PubMed  database  search  were  made using the phrases “gender inequi- ty”, “Saudi women” and “Muslim wom- en”. The search was  limited  to English  language articles  and  the period  from  1985 to the present. A Google search was  made for “Saudi women health” and out  of 16 000 hits,  the  top 50  items were  scanned. Related books were accessed  through the general  library at  the Uni- versity of Lund, Sweden. The  Islamic  holy book, the Quran, was an important  source  for  this  review. To draw  some  comparisons with a European country,  a Google  search  for  “Swedish  health”  found 99 900 hits and the top 150 items  were  scanned. Unpublished data, pre- dominantly  theses, were  searched  at  the University  of Lund,  Sweden,  the  University of Leeds, United Kingdom,  and the University of Gunma, Japan, but  no relevant information was found.  Health care in Saudi Arabia The health  care  system  in Saudi Ara- bia  is mostly  owned  and handled by  the Ministry of Health  (MOH),  and  health care expenditure accounted  for  5.9% of  the 2006 government budget.  The MOH goal  is  to provide universal  free medical care for Saudi citizens and  also  for  the millions  of  international  pilgrims undertaking the hajj to the holy  city of Mecca. The MOH is supported  directly  by  the  government  and  has  good  infrastructures  and  administra- tive  structures.  About  60% of  health  services are provided by the MOH and  18%  by  other  government  hospitals  such  as universities  and military hos- pitals which are open  to  the public.  In  the  last decade more private hospitals  have  been  established,  financed  by  some medical  companies and by  self- payment. These private hospitals cover  the  remaining 22% of health  services  which are monitored by the MOH [7].  Due to the rapid increase in the popula- tion,  the  government has planned  to  adopt  a health  insurance policy  [11] to  reduce  its  financial  burden  and  to  improve health standards [12].  In 2006, the ratio of doctors in Saudi  Arabia was 20 and of dentists was 2.14  per 10 000 inhabitants [7]. In compari- son, the ratios of doctors and dentists in  Sweden  in 2003 were about 44.4 and  15.6 per 10 000 inhabitants respectively  [13]. The infant mortality rate in Saudi  Arabia was high in the early 1980s, with  an estimated 118 deaths per 1000  live  births [14]. By contrast, based only on  deliveries of  infants  in hospitals of  the  MOH,  the  infant mortality  rate was  18.6 per 1000 in 2006 [15]. Despite the  dramatic progress  in health care  in  the  last 3 decades,  the high birth  rate  [7] and other factors have left Saudi Arabia  a  country where only 70% of  females  are  literate  [8] and  the child mortality  rate was 20 per 1000 children  in 2006  [7]. In comparison, Sweden had an esti- mated child mortality rate of 4 per 1000  children in 2005 [16].  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 115 Women’s education Although  at  present  there  are more  female graduates  than males  in Saudi  Arabia  [9],  statistics  reveal  that  about  30% of Saudi women are  still  illiterate  [8]. This might  be  because  opening  schools for girls initially met with strong  opposition in some parts of Saudi Ara- bia, where nonreligious education was  regarded  as  unsuitable  for  girls  [17].  Moreover,  coeducation  is not allowed  and the curriculum in girls’ schools has  long been a less comprehensive version  of that taught in boy’s school [9]. There is no sports education in girls’  school  and  it  is  prohibited  by  social  norms  for  females  to  practise  physi- cal activities  in public. Lack of exercise  is  a  known cause of obesity.  It  is  not  surprising  therefore  that  the  preva- lence of obesity (body mass index > 30 kg/m2)  for  30–70-year-old Saudi  fe- males was 44.0% compared with only  26.4% in males [18]. In comparison the  prevalence of obesity  for 25–64-year- old Swedes was 11.0% for  females and  14.8% for males [19].  Saudi  women  cannot  study  engi- neering,  law or  journalism. According  to the latest official figures, 49.9% of the  Saudi  population  are  female  [7] and barely  21% of  them contribute  to  the  social development, because it is socially  unacceptable for women to work in fields  other than teaching and medicine [9].  Even though Saudi Arabian women  work  in  the  medical  field  and  have  achieved  good  success  at  junior  lev- els,  they  are  exposed  to  some degree  of discrimination at higher  levels [20].  Furthermore, due to contact with male  medical  staff  and  patients  and  night  shift-work, medical  employment  for  women  is  not  always  welcomed  by  Saudi  society and may be an obstacle  to  future marriage  for  a woman. This  could explain  the  low  level of  satisfac- tion among Saudi female nurses [21].  Marriage In Saudi Arabian personal  status  law  an unmarried adult woman is the ward  of her  father,  a married woman  is  the  ward of her husband and  a widowed  woman is the ward of her sons. In a male- dominated and  tribal community with  a high  social  coherence,  it  is not unu- sual for a woman to be forced to marry  a relative. More than 50% of marriages  in  Saudi  Arabia  are  consanguineous  [22]. The  infant mortality  rate  is high  (18.5 per 1000  in 2006) despite good  health  care  facilities  and  an  effective  vaccination programme,  and  genetic  diseases  are  probably  a  contributory  factor [17]. Roughly 1.5 million Saudi  Arabians  suffer  from or are carriers of  inherited blood diseases and this consti- tutes a heavy burden to families and the  nation. For  instance,  in a  single  region  the prevalence of beta-thalassaemia trait  alone was found to be 3.4% [23]. The  law affects women’s health care  at  many  levels. There  is  a MOH  law  preventing a woman being admitted  to  a government hospital unless  she  is  ac- companied by her male guardian [24].  Furthermore, especially  in  rural areas,  a  male relative may prevent a woman being  treated by a male gynaecologist or obste- trician even  in an emergency. An adult  woman cannot herself  sign  the consent  for an invasive medical procedure which  might be urgently required [25].  Due to the fact that there is no legal  minimum  age  for marriage  in  Saudi  Arabian society,  females can be  forced  by  tradition  to marry under  the age of  16 years  [26]. Early  teenage marriage  was  found  in 27.2% of Saudi Arabian  women. Most of  these were  illiterate  (57.1%),  housewives  (92.4%)  and  grand multiparae (66.7%)  [27]. Thus  teenage pregnancy may be a  factor be- hind the high maternity mortality rate of  12 per 100 000 live births in 2006 [7]. In  contrast, Sweden had a maternal death  rate of 2.4 per 100 000 live births during  1991–93 [28]. Abortion  is  forbidden  according  to  the Saudi Arabian  interpretation of  Islamic law and is only allowed when a  medical  committee decides  there  is  a  risk  to  the mother  if  she continues her  pregnancy [22]. Therefore, although ge- netic haematological disease is common  due to consanguineous marriages, ante- natal  screening programmes  for  incur- able genetic diseases have no practical  use. Consequently primary prevention  programmes such as premarital genetic  screening tests are the only option [23].  A  study has  shown  that  a majority of  Saudi Arabian mothers were unaware  of  the  increased risks of haemoglobin- opathies from consanguinity. However,  the women accepted  the general  idea  of prenatal screening with the option of  abortion, presumably because most of  the burden and stress of taking care of a  child with a genetic disease falls on the  woman [29]. An additional burden on Saudi Ara- bian women  is  the high  fertility  rate.  It has  led  to  a high prevalence of  low  bone density and osteoporosis among  postmenopausal Saudi Arabian women  and  its  complications,  such  as  bone  fractures  [30].  In  fact,  high  fertility  is  encouraged by society and government  health policy. Like abortion, female per- manent sterilization is permitted under  only very  restricted circumstances and  both potential parents must agree [31].  Contraceptives can have an  impact on  better spacing between children, better  child  care,  improvement of  children’s  health and preservation of the mother’s  health  [32].  Yet,  while most  Islamic  scholars do not expressly forbid contra- ception, there is no effective family plan- ning programme supported directly by  the Saudi Arabian government.  Because  of  high  fertility  and  the  inaccessibility  of  contraception,  it  is  the norm  in Saudi Arabian  society  that women continue giving birth  late  into  their  reproductive  life, which  in- creases the risk of having children with  congenital  and genetic  abnormalities  EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 116 such  as Down  syndrome. There  is  a  relation between Down syndrome and  advanced maternal  age  or  increased  maternal parity. Thus,  the  incidence of  the Down syndrome in a 9-year period  study  in Riyadh was 1.8 per 1000  live  births  [33].  In comparison,  the actual  live birth prevalence of Down syndrome  during the same period in Sweden was  1.3 per 1000 [34,35]. Male polygamy  is another  issue  for  women  in  Saudi  Arabian  culture.  In  Islam polygamy  is neither mandatory,  nor encouraged, but  is permitted [36].  It  is obligatory, however,  to  treat one’s  wives  justly;  this  applies  to  housing,  food, clothing, kind  treatment, etc.,  for  which  the husband  is  fully  responsible.  All wives have  the same status and are  entitled  to  identical  rights  and claims  over  their  husband  [37].  However,  poly gamy can have negative impacts on  the family’s physical and mental health.  Wives  in polygamous marriages expe- rience  higher  levels  of  psychological  distress  and more problems  in  family  functioning, marital relationship and life  satisfaction  than monogamous mar- riages, while  children  in polygamous  families  have  a  higher  rate  of  school  conflicts and lower school achievement  compared with children from monoga- mous families [38–40]. Other social issues Local  interpretations of  Islamic  law af- fect  women’s  legal  and  social  status  in Saudi Arabia. For example, women  in Saudi Arabia are  forbidden  to drive.  Local custom is that male relatives drive  females  to  their  segregated schools or  hospitals and collect them later on. This  makes it hard for women to accept job  opportunities in locations far from their  families  and  homes.  Consequently,  non-Saudi Arabian female health work- ers cannot easily be replaced with Saudi  Arabian women [14].  In  the past,  Saudi Arabian women  were only named, and not pictured, on  family identity (ID) cards which identify  them as dependants of their husbands or  fathers. This means that women’s rights  can be abused by  their male guardians.  For instance, in banks, courts and hospi- tals, with her face covered and without a  photo-ID, the woman’s  identity cannot  be confirmed. If a wife delivers, the new- born could be registered under another  female’s  name  especially  if  the  Saudi  Arabian  father has more  than one wife.  Thus birth, marriage and death records  are not reliable [9]. Recently, after a long  debate with religious scholars about the  permissibility of photographs of  the  fe- male  face,  the government has allowed  photo-ID cards to be issued to women.  Nevertheless,  as  the male  guardian’s  consent  is obligatory, many Saudi Ara- bian females are still unable to obtain an  individual ID [9]. Discussion The distribution of power and resources  in society is a key issue for public health  policy  and practice  [41]. The World  Health Organization  has  stated  that  gender  inequity  is not only a  threat  to  economic  development  but  also  to  population health,  including  that of  fu- ture generations [42]. Gender inequity  in health  still  exists even  in developed  countries  of  the world.  For  example,  women in the United Kingdom report  more problems with access to diabetes  care  than men [43]. Canadian women  experience higher levels of distress (de- pression,  anxiety, poor quality of  life)  than men after myocardial  infarction  [44]. Swedish women earn 10%–20%  less than men at the same occupational  level  and with  the  same  level of  edu- cational  achievement;  this has public  health  implications, as 90% of Swedish  single parents of children below school  aged 1–6 years are women [45]. In the  United States of America female gender  is associated with lower annual incomes  among general practitioners [46], anaes- thetists [47] and psychiatrists [48].  The  traditional Arab  family  affects  women’s health  in multiple ways. Fi- nances are strictly the man’s obligation.  Young women are assigned the toughest  household tasks. Marriage and mother- hood are highly valued, but the pressure  to produce sons is strong [49]. Women  can be victims of “honour crimes” [50].  Poor  relationships  with  fathers  and  history  of  abuse  during  adolescence  can  lead  to  depressive  symptoms  in  girls  [51]. There  is an  inverse  relation- ship between the number of children a  woman has and her education, income  and age at marriage [52]. Education and  employment  status  are  good predic- tors of birth spacing preference and the  health  of mothers  and  children. The  highest proportion of women with birth  intervals < 3  years  are  reported  from  the Middle East (in Jordan, Yemen and  Saudi Arabia)  [53,54]. Consanguin- ity—which is associated with women’s  lower education,  lower socioeconomic  status,  younger  age  at marriage  and  higher  fertility  rate—remains high  in  many Middle Eastern  countries. The  prevalence of consanguinity varies from  68.0%  in  rural areas of Egypt  to 57.7%  in Saudi Arabia, 58.1% in southern Jor- dan,  50.5%  in United Arab Emirates,  40%–47%  in Yemen, 54.4%  in Kuwait  and 35.9%  in Oman [55–63]. Literacy  levels are low: for example, 68% of Yem- eni  females are  illiterate  [64]. For half  of Qatari women, the husband decides  whether  contraception  is used or not  [55] and half of Saudi Arabian women  have a  short birth  interval  (< 2 years)  because of the husband’s wish [53].  Only  the  Islamic Republic of  Iran,  Saudi Arabia and Sudan apply  Islamic  law  to  all  matters  of  jurisprudence.  However, different  religious  leaders  in- terpret Islamic religious texts differently,  particularly  regarding women’s  issues  such as wife abuse  [65] and abortion.  Hessini believes  that  the arguments of  some conservative religious leaders, who  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 117 are all men, are still being used to  legiti- mize patriarchal practices  [22]. Hassan  argues  that  “The Qur’anic description  of marriage suggests closeness, mutual- ity,  and equality, but  tradition defines a  husband as his wife’s god in earthly form  (despite  the Qur’an prohibition against  human deification as the one unpardon- able  sin),  her  gateway  to heaven,  and  the arbiter of her final destiny”  [66].  In  other  verses,  the Quran  has  indicated  indirectly the optimum birth interval by  specifying a suggested time of 24 months  for breastfeeding (Quran 2:233; 31:14;  46:15)  but  there  is  a mistaken  belief  that  family planning  is  anti-Islam [53].  Customs  that were originally  intended  to protect women and even guarantee  women’s autonomy (polygamy, inherit- ance rights, purdah and veiling) have, ac- cording to Hassan [66], become instead  instruments of oppression.  Social norms and conservative  re- ligious  beliefs  have  a  powerful  effect  on women’s  lives  and health  in Saudi  Arabian society. The Saudi Arabian gov- ernment  issues  ID  cards  to  women  but  only  if  her male  guardian  allows  it  [9]. The government does not  for- bid  females  to practice  sport  in pub- lic or  in  segregated private places but  societal norms  limit  females’ outdoor  exercise  [18]. The  government  has  implemented  a  compulsory  national  premarital  screening  programme  for  common  inherited  haematological  diseases. However,  the purpose of  the  health programme  is abused since  the  final  result does not affect  the validity  of  the marriage [23]. The same applies  to  female medical education, which  is  encouraged  by  the  government,  but  can be  socially unacceptable  and can  be  an  obstacle  to women’s marriage  [19]. There is a MOH law that permits  adult woman to sign consent  for some  invasive  radiological procedures but  it  is not  always  applied by medical  em- ployees [25]. A Saudi Arabian woman  cannot be admitted to hospital without  her male guardian and  is not  allowed  to give her own consent for an invasive  medical procedure [25]. Saudi Arabian  law requires a male relative’s agreement  before  seeking work,  education,  travel  or  issuing an  identity card or passport  [9]. The  high  prevalence  of  obesity  among Saudi Arabian  females  can be  attributed to social restrictions that pre- vent women participating in exercise in  schools or in public [18].  The major  limitation of  this  review  was  the scarcity of  recent data and  infor- mation about gender inequity, particularly  about health care  in Saudi Arabia. Nev- ertheless, to our knowledge this review is  the first attempt  to explore  this  sensitive  issue  in  this unique country.  In general,  there  is  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The effect of consanguineous marriages on reproductive wastage. Clinical genetics, 1986, 29:384–8. Rajab A, Patton 63. MA. A study of consanguinity in the Sultanate of Oman. Annals of human biology, 2000, 27:321–6. Date J, Okita 64. K. Gender and literacy: factors related to diag- nostic delay and unsuccessful treatment of tuberculosis in the mountainous area of Yemen. International journal of tuberculo- sis and lung disease, 2005, 9(6):680–5. Ammar NH. Wife battery in Islam: a comprehensive understand-65. ing of interpretations. Violence against women, 2007, 13(5):516–26. Hassan 66. R. Women in Islam: Qur’anic ideals versus Muslim re- alities. Planned parenthood challenges, 1995, (2):5–9. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 119 Report Supporting the Saudi e-health initiative: the Master of Health Informatics programme at KSAU-HS M.M. Altuwaijri1 ABSTRACT The health sector in Saudi Arabia has made significant progress in recent decades with some hospitals receiving international recognition. However, this has not been accompanied by advancements in the field of health informatics, which are necessary for hospitals to achieve certain objectives such as enhancing the quality of health care and reducing the time and cost of health care delivery. In this paper we describe the status of e-health in Saudi Arabia, along with some of the national e-health initiatives such the establishment of a new Master of Health Informatics degree programme and the Saudi Association for Health Informatics. A proposal for an e-health plan in Saudi Arabia is also discussed. 1College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia (Correspondence to M.M. Altuwaijri: majid_tuwaijri@yahoo.com). Received: 09/06/07; accepted: 26/09/07 مولعلل دوعس كللما ةعماج في ةيحصلا تايمولعلما في يرتسجالما ةجرد جمانرب :ةينوتركللإا ةحصلل ةيدوعسلا ةردابلما معد ةيحصلا يريجوتلا دممح نب دجام لم مدقتلا اذه نأ لاإ .ًايلود ًافاترعا تايفشتسلما ضعب تّقلت ثيح ةيرخلأا دوقعلا في ًاظوحلم ًامدقت ةيدوعسلا في يحصلا عاطقلا زرحأ :ةصلالخا تقو نم دلحاو ،ةيحصلا ةياعرلا ةدوجب ءاقترلاا لثم ةددحلما اهفادهأ ققتح يك تايفشتسملل ةيروضرلا ،ةيحصلا تايمولعلما لامج في مدقت هبحاصي ةينطولا تاردابلما ضعب ضرعتسيو ،ةيدوعسلا في ةينوتركللإا ةحصلا ةلاح ثحابلا فصي ةيملعلا ةقرولا اذه فيو .ةيحصلا ةياعرلا ءاتيإ فيلاكتو ًاحترقم شقان ماك .ةيحصلا تايمولعملل ةيدوعسلا ةيعملجاو ةيحصلا تايمولعلما في يرتسجالما ةجردل ديدلجا جمانبرلا ءاشنإ لثم ةينوتركللإا ةحصلل .ةيدوعسلا في ةينوتركللإا ةحصلا ةطلخ Promotion de l’initiative saoudienne en matière de cybersanté : le programme de master en informatique médicale de la Faculté de médecine de l’université des sciences de la santé Roi Saoud ben Abdelaziz RÉSUMÉ Le secteur de la santé en Arabie saoudite a fait d’importants progrès au cours des dernières décennies et plusieurs hôpitaux ont acquis une reconnaissance internationale. Pour autant, ces progrès ne se sont pas accompagnés d’avancées dans le domaine de l’informatique médicale, sans lesquelles les hôpitaux ne sauraient atteindre des objectifs tels que l’amélioration de la qualité des soins et la diminution des délais et des coûts de la prestation de soins de santé. Dans cet article, nous décrivons la situation de la cybersanté en Arabie saoudite, ainsi que certaines des initiatives nationales menées dans ce domaine, par exemple la création d’un programme de master en informatique médicale et de la Saudi Association for Health Informatics [Association saoudienne d’informatique médicale]. Une proposition de plan pour la cybersanté en Arabie saoudite est également examinée. EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 120 Introduction The health  care  industry has become  increasingly  reliant upon  information  and communication technology (ICT).  This has  resulted  in a  significant  tech- nology gap between those professionals  entrusted  to provide clinical  care  and  those who are in charge of managing the  complex  information systems required  to operate modern health care systems.  Such a gap  threatens  the effective and  efficient management  of  health  care  information. The need  to use  ICT  in  health care has resulted in a new science  called health  informatics which  is a so- cio-technical discipline concerned with  the use of  ICT to support  the delivery  of health care [1]. Health informatics is  a broad discipline which includes many  subjects  such as bio-informatics,  elec- tronic patient records, telemedicine and  clinical decision-making support [2].  The  International Medical  Infor- matics Association (IMIA) has made  significant  efforts  to  promote  and  enhance health  informatics education  worldwide. IMIA suggested that proper  education  is  essential  for health  care  professionals  to meet  the  increasing  demand  for  health  informatics  or  e- health  [3]. Such education would en- able  health  professionals  to  take  full  advantage of ICT. A special issue of the  International journal of medical informat- ics  (volume 73,  2004) was dedicated  to  health  informatics  education  and  comprised papers presented at the 2003  meeting of the IMIA working group on  education which was  attended by 80  educators from all over the world.  The aim of  the current paper  is  to  introduce  the  status of  e-health  initia- tives in Saudi Arabia, including the new  Master of Health  Informatics degree  programme at King Saud bin Abdulaziz  University for Health Sciences (KSAU- HS). The  programme  was  designed  following  the  recommendations pre- sented by IMIA [3].  It was established  in 2005 as the first programme in health  informatics in Saudi Arabia. No known  programme  in  health  informatics  is  available in neighbouring countries. This  paper  also  introduces  other  e-health  initiatives in Saudi Arabia, including the  establishment of  the Saudi Association  for Health  Informatics (SAHI) which  organized  the first e-health conference  in Riyadh 2006. A proposal for a master  e-health  plan  in  Saudi Arabia  is  pre- sented. Why e-health? Over  the past 4 decades, Saudi Arabia  has spent billions of dollars  in  improv- ing  the quality of  its health care and  in  expanding its scope and coverage in the  country. Due to this rapid expansion, the  range of health care providers  in Saudi  Arabia  is diverse. While  the Ministry  of Health provides around 60% of  the  health care services, the remaining por- tion  is provided by other government  bodies such as the National Guard, the  Ministry of Defence and Aviation,  the  Ministry of Interior and university hos- pitals plus  the  rapidly growing private  sector. This variation  in health  service  providers has led to variations in the way  health  care  facilities  are  administered  and managed, with significant variation  in the information systems used.  As  a  result,  patient  information  records have become scattered  in dif- ferent health care  facilities with no one  provider having  the complete patient  record, except  in very  rare cases where  the patient  chooses  to  receive health  care from one provider at all times. One  additional  negative  impact  of  varied  health care systems is the great waste of  effort and money resulting from treating  patients repeatedly  for  the same health  problems  in  several medical  centres.  Patients may at  times be  asked  to  re- peat X-rays and other  laboratory  tests  and may be given different medications  which may compromise patient safety.  In  the year 2000,  the government  of Saudi Arabia formed a health reform  committee  to  conduct  a  comprehen- sive  review of  the health care  services  provided to its citizens. The committee  highlighted that a lack of proper health  informatics applications was one of the  top challenges  facing  the Saudi health  sector,  in  addition  to  health  services  financing, health services management  and  health  service  distribution.  As  a  result of the health reform committee’s  recommendations,  a  special  taskforce  was  formed  in 2002  to develop an  in- formation  technology  (IT)  strategic  plan  for  health  care  in  Saudi Arabia.  The main objective of the strategic plan  was to build a national electronic health  record. The highest priority recommen- dations made by  the  taskforce were as  follows (Figure 1): To  build  cadres  specialized  in  the • field of health informatics. To establish an association or  soci-• ety  for  health  informatics  in  Saudi  Arabia. To establish centres of excellence  in • health informatics in Saudi Arabia.  To design  the  specifications of  the • electronic health records. To expand the telemedicine network • in the country. Health  informatics  is of particular  importance  in Saudi Arabia  for the fol- lowing reasons: Most hospitals  and medical  centres • in  Saudi  Arabia  still  rely  on  paper  records. The amount of health  information is • increasing. However, different health  sectors  use  disparate  systems with  little  interoperability between  these  systems,  thus creating unconnected  islands of information. Most  of  the  existing  information • systems are administrative  in nature  rather than patient-care focused. There is a serious lack of people quali-• fied  in  health  informatics  in  Saudi  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 121 Arabia  and neighbouring  countries  which means  that many health or- ganizations find it difficult to identify  and  recruit  health  informatics  pro- fessionals. As  a  consequence, many  organizations  invest unproductively  in ICT. Some literature has shown that taking • advantage of  ICT  in health care will  have  significant  economic benefits  and will enhance quality and patient  safety [4]. The growth rate of the Saudi popula-• tion is one of the highest in the world,  which dictates  the need  for proper  utilizations of  resources. The use of  ICT is essential to achieve that objec- tive.  Master of Health Informatics at KSAU-HS As a result of the e-health needs assess- ment, KSAU-HS developed a Master  of Health  Informatics degree  in order  to provide advanced health  informat- ics  education  and  to  prepare  health  informatics  specialists who would be  able  to participate  in  research  and  in  the  advancement of  the health  infor- matics field. The programme provides  graduates with  the  technical,  human  and practical skills in health informatics  to meet the increasing demand on ICT  use in health care.  The  2-year  programme  was  de- signed following the recommendations  of the IMIA on education in health and  medical  informatics  [3]. However,  the  emphasis is on applied health informat- ics which highlights the need for health  informatics specialists to deploy ICT to  support health systems.  The programme started in Septem- ber 2005 with a group of 25  students  (16  female and 9 male  students). The  students  came  from different  educa- tion backgrounds,  including medicine,  health,  IT and biomedical engineering,  and from different health organizations  such as the National Guard, the Ministry  of Defence and Aviation, the Ministry of  Interior, university hospitals and private  hospitals. Twenty more students were  accepted the following year. About KSAU-HS KSAU-HS is a newly founded university,  established in early 2004, specializing in  health sciences. It is housed within King  Abdulaziz Medical City of the National  Guard Health  Affairs,  a  large  health  organization which provides modern  medical  care  to National Guard  em- ployees and  their dependents,  as well  as  to Saudi Arabian nationals. Under  the  umbrella  of  the National Guard  Health Affairs, there are 4 hospitals and  60 primary and secondary health cen- tres around Saudi Arabia having 2000  inpatient beds  in  total. The University  comprises  the Colleges of Medicine,  Nursing, Allied Medical Sciences and  Public Health and Health Informatics.  IMIA recommendations for health and medical informatics education The IMIA has made significant efforts  to promote and enhance health  infor- matics education worldwide. IMIA has  proposed a set of recommendations on  education [3], which provide an excel- lent  foundation  for health  informatics  education. They have  evolved  from 7  conferences organized by  the working  group for health and medical informatics  education. Such recommendations are  not only important in providing an edu- cation framework but also as a basis for  establishing international collaboration  which enables international exchange of  standards and teachers.  The IMIA recommendations identi- fied 2 learning objectives: Enabling health care professionals to • become good IT users. Preparing graduates to become health • and medical informatics specialists.  The  recommendations  identified  the  level  of  knowledge  and  skills  re- quired  for each  learning outcome. The  knowledge and skills are classified  into  3 domains: Health informatics.• Medicine, health, and health services • management. Informatics, mathematics and biom-• etry.  As per the IMIA recommendations,  the Master of Health  Informatics de- gree should be at  least 1 year  full-time  corresponding  to at  least 60 credits as  defined by the European credit transfer  system (ECTS [5]) (Table 1).  Programme mission The mission  of  the  programme  is  to  advance  the quality  and  efficiency of  the Saudi health care  system  through  improved information management.  Programme objectives and target students The programme aims  to provide a  sci- entific education  that  includes  theory,  specialized  knowledge,  and practical  skills. Graduates should be able  to: ap- ply practice-oriented methods and tools  Table 1 Recommended student workload in European credit transfer system (ECTS) for the Master of Health Informatics degree at King Saud bin Abdulaziz University for Health Sciences Knowledge and skills area ECTS workload (credit hours) Health and medical informatics 40 Medicine, health and health systems organization 10 Informatics, computer science, mathematics, and biometry 10 Total ECTS workload 60 EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 122 from health  and medical  informatics;  and participate in research and in meth- odological advancement within the field  of health and medical informatics. As  per  the  IMIA  recommenda- tions,  the master  degree  programme  accepts students with a bachelor degree  in health  information management,  in  medicine or health sciences or in com- puter science. Programme infrastructure The programme depends on  the  fol- lowing  infrastructure:  a  Centre  for  Health  Informatics  and director with  strong  academic  credibility  in health  informatics;  faculty members with  a  clear vision and philosophy; and effec- tive  collaborations with  internal  and  external academic institutions. Some of  these will be able  to provide part-time  teaching,  research and project mentor- ing opportunities. Programme structure The Master of Health  Informatics  is  a  dedicated  full-time 2-year programme.  It  is  organized  in modules  (courses)  consisting  of  3  hours  of  lectures  per  week,  excluding  the  time  spent  for  exercises,  seminars  and  practicums.  It  requires  a minimum of 14  courses  totalling 42  semester  credit  hours  (a  credit  hour  is  equivalent  to  1-hour  lecture per week  for  a  semester of 16  weeks,  i.e. 3 semester credit hours may  be equivalent to 6 ECTS of course work  [5]). The programme of study includes  a  variety of  graduate  level  foundation  and required health informatics courses  as well  as elective health management  courses. The master degree is conferred  upon the successful completion of 42- semester  credits  towards  the degree.  Students must complete 2  foundation  courses  (which  depend  on  the  stu- dent’s  background);  7  courses  from  the health  informatics knowledge area;  2 courses  from the knowledge area of  medical, health sciences, and health sys- tem organization; and 3 courses  from  informatics knowledge (Table 2). Students’ evaluation of theprogramme In order  to  verify whether KASU-HS  succeeded  in  fulfilling  the aims we set  in developing  the master degree pro- gramme, an evaluation was conducted  in  using  a  questionnaire  survey  sent  to  the first  group of  graduates of  the  programme. The  23  graduates  who  graduated in May 2007 were 15 female  students and 8 male students. The ques- tionnaire was returned by 22 students, a  response rate of 96%.  The evaluation was concerned with  student’s personal opinions of the Mas- ter programme. Students were  asked  about  their opinion about  the overall  programme, faculty and staff, topics and  knowledge,  teaching  environment,  li- brary, student group coherence, educa- tional tools, interrelation of subjects and  the  significance of  the programme  to  government and private health sectors.  A  rating  scale of 1–5 was used  from:  (1) totally disagree to (5) totally agree.  Table  3  shows  the  students’  mean  scores. The students were satisfied with  the outcomes of the programme in gen- eral,  and believed  that  the programme  was  important  for  both  government  and private health sectors. The students  Table 2 Master of Health Informatics degree at King Saud bin Abdulaziz University for Health Sciences: structure of courses (each course is 3 semester credit hours) Study core areas and course titles Required foundation courses (6 credit hours) Students are required to complete 2 courses from the following: Foundation of medicine & medical terminologya Introduction to information technologyb Statistical analysis Health informatics courses (21 credit hours) Students are required to complete the following 6 courses: Introduction to health informatics Health information systems Electronic health records & standards Legal, ethical, and social aspects of health informatics Decision support in health care & knowledge management Health informatics project Students are required to select 1 course from the following: Topics in health informatics Directed study in health informatics Health sciences courses (6 credit hours) Students are required to take research methodologies and select 1 course from the other courses: Research methodologies in health care Health services administration International health systems Financial management of health organization Organizational behaviour in health care Informatics courses (9 credit hours) Students are required to complete the following 3 courses: Web technology Database design & management Information technology project management in health care aRequired course for students from non-health sciences background. bRequired course for students from non-information technology background. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما لولأا ددعلا 123 had some concerns regarding the qual- ity of reading materials in the library. We recommend an evaluation of the  future performance of  these graduates  based on the set of skills and knowledge  as suggested by IMIA. We suggest con- ducting a formal interview with the em- ployers of  these graduates  to ask  them  about the changes that have taken place  in  the  skills,  knowledge  and  attitudes  of  these  graduates  as  a  result of  their  2-year study programme.  If employers,  paymasters and possibly peers and col- leagues can identify areas of change and  improvement in the course, it would be  a  successful exercise. Another  sugges- tion  is  to plan a  follow-up  study with  these graduates about career develop- ment  and change,  continuous  educa- tion, regular meetings and formation of  a community of practice and  research  on their performance. Saudi Association for Health Informatics As  per  the  recommendation  of  the  taskforce  formed  in 2002 (Figure 1),  SAHI was established in 2005 under the  direct  supervision of KSAU-HS. SAHI  aims  to develop  and promote health  informatics  knowledge by organizing  scientific and professional conferences,  seminars, workshops  and exhibitions.  SAHI also aims to provide a  forum for  the exchange of ideas and experience in  health informatics among its members. One of the most important activities  of SAHI  is  the Saudi  e-health confer- ence which was held over 2 days in 2006  in Riyadh, Saudi Arabia. The main top- ics  addressed  in  the conference were:  hospital  information  systems; picture  archiving and communications systems;  enterprise resource planning  for health  care;  emerging  technologies  in health  care; and  telemedicine and medical e- learning. The main  recommendation  of  the conference emphasized  the  im- portance of building a national e-health  strategy for the country. Table 3 Students’ opinions of the first Master of Health Informatics degree programme at King Saud bin Abdulaziz University for Health Sciences (n = 22) Question Mean score SD Programme met student’s expectation 3.73 0.85 I would recommend the programme to others 4.32 0.64 My colleagues from other fields appreciated health informatics 4.09 0.75 My employer appreciated health informatics 3.95 1.00 Satisfied with the programme staff and faculty 4.04 0.65 Satisfied with topics and knowledge covered in the programme 4.23 0.67 Satisfied with library 3.09 1.11 Satisfied with the group (students coherence) 4.59 0.50 Found the educational tools useful 4.27 0.80 Satisfied with interrelations between subjects 4.18 0.59 I think the programme is significant to the public health sector 4.64 0.65 I think the programme is significant to the private health sector 4.45 0.86 Attained more insight about health informatics 4.90 0.29 SD= standard deviation. Figure 1 e-health initiatives in Saudi Arabia Challenges facing the Saudi Health Sectors Fina1. ncing the health services Managing the health 2. services Availability of health 3. information systems Distribution of 4. health services Recommendations Build health infor-1. matics cadres Establish HI Society2. Establish centers of 3. excellence for HI Design e-Health 4. records Expand telemedicine5. Set up of MS programme in Health Informatics at KSAU-HS Establishment of the Saudi Association for Health Informatics (SAHI) Set up of the National e-Health Programme First Group of HI grad- uates (23 Students) Saudi e-Health Conference 2006 Saudi e-Health Conference 2008 Health Reform Commitee 2000 Health IT strategic planning 2002 2005 2008 2008–2013 2006 2005 2007 EMHJ  •  Vol. 16  No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 124 Proposed project for e-health in Saudi Arabia In order  to  achieve  the main  recom- mendation of  the Saudi e-health con- ference  in 2006,  a new proposal  for  a  master plan for e-health in Saudi Arabia  is proposed. Problem statement Most  health  systems  are  still  paper- based, and those that are electronic have  poor  capability  to  share  information.  Hence, communication with the wider  health  information environment  is  se- verely  limited, which  fragments patient  information and results  in duplication  of procedures and data entry. The  lack  of integration also has a negative impact  on health service planning. The e-health programme objectives The main  goal  of  the  e-health  pro- gramme is to develop an e-health strat- egy  for  Saudi Arabia which,  through  better use of ICT, aims to:  Increase  the efficiency and effective-• ness of health organizations. Help provide better patient care that • is  continuous,  integrated,  closer  to  patient homes and well coordinated. Increase the return on investment of • health assets and resources. Reduce duplicate records.• Project stakeholders The Health  Services  Council:  the • project  sponsor, who will  authorize  the  setting up of  the project,  secure  the  necessary  funds  required  and  manage the progress of the project. Citizens:  the main  beneficiaries  of • implementing e-health initiatives. The Ministry of Finance: to fund the • project. The  e-government  programme:  to • support  the  e-health  initiatives  and  recognize this project as an important  initiative in e-services.  Telecommunication companies:  to • provide  the major networking  infra- structure  that  can only be done by  major  telecommunication  compa- nies. Major  IT companies:  to provide  the • IT infrastructure. IT departments in hospitals.• The SAHI• . Scope of work The  proposed  project  has  2  main  phases: Phase I:  Development  of  the  re- quired  strategy, plans, policies, proce- dures,  standards,  design  and  training  materials. This  phase  has  a  number  of  sub-phases  and  sub-tracks  as well.  The detailed action plan spans 5 years  (2008–13) and  includes,  at  least,  the  following components: The Saudi e-health vision. • The specific goals  and priorities  for • the coming 5 years. The e-health projects  that must be • implemented within  the  coming 5  years. Estimation of the budget required for • implementing  the proposed detailed  action plan.  Phase II: Provide project manage- ment services. The services of this phase  will start after completion of phase I. Health organizations need  to  sug- gest the team structure, team members  and expertise  required  for  these activi- ties. This team must work on a full-time  basis.  Conclusion There are already some  initiatives with  regard to e-health in Saudi Arabia, such  as the establishment of a new Master of  Health  Informatics degree programme  and of the SAHI. Moreover, an e-health  conference was organized  in 2006  to  address e-health topics. The conference  presented  some  recommendations  to promote  e-health  in Saudi Arabia.  However the e-health movement is still  very slow.  The proposal definition for e-health  in Saudi Arabia starts with strategic plan- ning which should  tie  the projects and  programmes resulting from the plan to  the national strategies of the country.  Hovenga EJ. Globalisation of health and medical informatics 1. education—what are the issues? International journal of medical informatics, 2004, 73:101–9. The IMIA vision2. . International Medical Informatics Association [website] (http://www.imia.org, accessed 14 May 2009). International Medical Informatics Association, Working Group 3. 1: Health and Medical Informatics Education. Recommenda- tions of the International Medical Informatics Association (IMIA) on Education in Health and Medical Informatics. Meth- ods of information in medicine, 2000, 39:267–77. References Rigby M. Protecting the patient by promoting end-user compe-4. tence in health informatics systems—moves towards a generic health computer user “driving license”. International journal of medical informatics, 2004, 73:151–6. European Credit Transfer and Accumulation System (ECTS).5. Euro- pean Commission [website] (http://ec.europa.eu/education/ programmes/socrates/ects/index_en.html, accessed 14 May 2009). طسوتلما قشرل ةيحصلا ةلجلما شرع سداسلا دلجلما لولأا ددعلا 125 Professor Hilmy Abaza Professor Ahmed Amr Abbassy Dr Ahmed Abdel Monem Abdalla Dr Fardous Hanem Abdel Aal Abdel Hafez Professor Sonia Abdelhak Professor Laila A. Abdel Megid Professor Nagwa Abdel-Meguid Professor M. Yosri Abdel-Mohsen Professor Mohamed Abdel Sabour Professor Ekram Abdel-Salam Dr Alaa Awny Ramzy Abd-Elsayed Professor Ahmed Ezzat Abdou Professor Yousef Abdulrazzaq Professor Abdellatif Abid Professor Mostafa Abdelfattah Abolfotouh Professor Samir F. Aboul Azm Professor Kamilia Ragab Abou Shabana Dr Hala Abou-Taleb Dr Niveen Abu-Rmeileh Professor Ahmed Awad Abdel-Hameed Adeel Professor Salim Adib Professor Suhail Ahmad Dr Awad Mohamed Ahmed Dr Kamel Ajlouni Dr Tasleem Akhtar Ms Deena Alasfoor Dr Sadika A. Al-Awadi Dr Nabil Al-Beiruti Professor Zohair A. Al Sebai Dr Moazzam Ali Professor Ahmed M. B. Alkafajei Dr Ali Hassan Mohammad Allan Mrs Batool Ali Al-Muhandis Professor Widad Al-Nakib Dr Mansour M. Al-Nozha Professor Faizeh Al-Quobaili Dr Asya Ali Al-Riyami Dr Najeeb Al-Shorbaji Dr Nabil Al-Tawil Professor Nada Abdul Sahib Alwan Professor Ezzat Khamis Amine Dr Yaser Aly Ammar Professor George F. Araj Professor Mohamed Ardekani Dr Fazal Ather Professor Sherif Sabri Ayad Dr Abla Ibrahim Ayoub Professor Fereidoun Azizi Mr Bachar Azmeh Dr Rafic Baddoura Dr Hanan Al-Sayed Badr Dr Kunal Bagchi Dr Jennifer Wendi Bailey Professor Mohamed Adel Bakr Dr Faris Bakri Dr Mohamed Hassan Baldo Dr Faraj Barah Dr Rashida Barakat Dr Hyam Bashour Dr Heli Bathija Dr Anwar Batieha Dr Faten Ben Abdelaziz Professor Abdulbari Bener Dr Silvia Bertagnolio Dr Mohamed Bin Shahna Professor Laila Maurice Boulos Dr Irtaza Chaudhri Dr Carlo Chizzolini Dr Abdul Hannan Choudhury Dr Antoinette M. Cilliers Dr Filippo Curtale Professor Fazal Karim Dar Professor Khaldoun Darwich Professor Adekunle H. Dawodou Dr Jocelyn DeJong Dr Samiha Samuel Wissa Doss Dr Bassel H. Doughan Professor Nabil Dowidar Professor Soad Abdel Hameed Draag Dr Abdi Hassan Dualeh Professor Mohamed Farid El-Asmer Professor Tarek Hussein El-Badawy Professor Mohamed Hassan El Banoudy Professor Hussein El Charkawi Professor Ezzeldin Saeed M. El-Denshary Professor Ibrahim Sadek El-Gendy Professor Abdul Salam El Gatit Professor Zenab El-Gothamy Dr Magdy El Guinaidy Dr Ahmed-Refat A.G. El Kashmery Dr Mohammed El-Khateeb Professor Abdel Rahman M. El-Naggar Professor Farouk Mohamed F. El-Sabban Professor Fikrat Ahmed El-Sahn Professor Ihab Hafez El-Sawy Professor Hamdy Mahmoud El-Sayed Professor Fawzi Amin El-Shobaki Professor Mahmoud Mohammad El-Sibaei Professor Salah Naguib El-Tallawy Dr Abdalla Ismail ElGzoli Dr Eman Ellabany Dr Mohamed Elmi Professor Ahmad A. R Elsadr Dr Sarah Beatrice England Professor Alaa Mohamd Fadel Dr Ibtihal Fadel Professor Hoda Famhy Farag Dr Mounir Farag Professor Mahmoud Fahmy Fathalla Dr Heba Fouad Dr Bryony Dean Franklin Dr Ahmed Heshmat Gado Professor Salma Badr El-Din Galal Dr Gihan Ismail Gewaifel Professor Rita Giacaman Professor Bulent Gorenek Dr Allan Gottschalk Mr Peter Graaff Dr Margaret Grigg Dr Motasim Habiballah Dr Rana A Hajjeh Dr Zouhair Hallaj Professor Randah R. Hamadeh Professor Hossam Hamdy Dr Jalil Hariri Professor Effat Abdel Ghani Haroon Professor Abd El-Gawad Mohamed Hashem Dr Javid Azim Hashmi Professor Ezzeldin Osman Hassan Dr Nasser Boukly Hassan Eastern Mediterranean Health Journal reviewers’ panel, 20091 The Eastern Mediterranean Health Journal extends sincere thanks the following experts for their generous and invaluable assistance in the review of papers considered for publication during the year 2009. Professor Ali Sadeghi Hassanabadi Professor Marianne Hattar-Pollara Dr Mohamed Kamal Helmi Dr Joumana Hermez Professor Claus Christian Heuck Dr Kathleen A. Holloway Dr Qudsia Huda Dr Pierre Huguet Dr Syed Jaffar Hussain Dr Mohamed Sayed Hussein Dr Seif Eddin Saleh Hussein Dr Abdullatif Husseini Dr Afaf Gaber Ibrahim Dr Mohammed Fakhry Ibrahim Dr Nahla Khamis Ragab Ibrahim Professor Salah Eldin Ibrahim Professor Carel IJsselmuiden Dr Jamshaid Iqbal Professor Khaili Ismail Professor Mostafa Kamel Ismail Dr Mohamad Itani Dr Ivan Dimov Ivanov Dr Abdo Romanos Jurjus Dr Ibrahim Ali Kabbash Professor Samir Mohamed Kabil Professor Mohamed Kamar Dr Kassem M. Kassak Dr Andrew Kennedy Professor Nawal Mohamed Khalafallah Professor Fawzy Megahed Khalil Dr Hussein Assai Khalil Dr Wasiq Mehmood Khan Dr Ibrahim Fahmy Kharboush Dr Zahra Khatami Dr Hamida Khattabi Dr Ali Khogali Dr Tawfik A.M. Khoja Professor Samia Morsi Kotb Professor Nabil Kronfol Dr Hans Oluf Lyon Dr Haifa Madi Dr Emad A. Magdy Dr Ramez Mahaini Dr Sawsan Majali Mahasneh Dr Dermot Maher Professor Ahmed Abdel Rahman Mahfouz Professor El-Sheikh Mahgoub Professor Moghazy Ali Mahgoub Dr Jaouad Mahjour Professor M. Khairy Makled Professor Ahmed M. A Mandil Dr Adel Mahmoud Mohamed Mansour Professor Mona Kamal Marei Dr Silvio Paolo Mariotti Professor Mohamed Naguib Massoud Professor Ghassan Matar Dr Jacqueline Wilson Matta Dr Salimah Meghani Professor Afaf I. Meleis Dr Mohammed Osama Mere Professor Mohamed Mokhtar Messahel Dr Nabila E. Metwalli Professor Anthony B. Miller Dr Zafar Mirza Dr Abraham Mnzava EMHJ  •  Vol 16     No. 1  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Médiderranée orientale 126 Dr Hosam Hassan Ali Mohamed Professor Soltani Mohamed Dr Ezzeddine Mohsni Professor Kamel Monastiri Professor Ali Monis Dr Robert Emmet Morris Professor Tosson Aly Morsy Dr A. Taher Moustafa Professor Salman Mroueh Professor Abu Salim Mustafa Dr Samar Muwakkit Professor Amr Nadim Professor Kamal K. Naguib Professor Samir Najjar Dr Boubker Naouri Professor Fouad Wadie Nasr Professor Nabil Taha Nasr Mr Sidrah Nausheen Professor Samia Ahmed Nossier Professor Nuha Nuwayri-Salti Professor U. Nydegger Dr Omar Obeid Professor Stephen Abimbola Odusanya Professor Ahmed Mahmoud Fahmy Okasha Professor Tarek Ahmed Okasha Dr Ikushi Onozaki Dr Adelheid Onyango Dr Abdalla Sid Ahmed Osman Dr Salah-Eddine Ottmani Dr Giorgi Pkhakadze Dr Maqbool Qadir Dr Naseem Akhtar Qureshi Professor Azza Saleh Radwan Professor Ahmed Ragaa Ragab 1Arranged in alphabetical order according to the family name. Professor Mohamed Mansour Ragheb Professor Wafaa Mohammad Ramadan Professor Ahmad Rashed Mohamad Rashed Professor Hashem Mohamed Rashwan Professor William A. Reinke Dr Habib Rejeb Dr Camillo Ribi Dr Gabriele Riedner Professor Walter Riesen Dr Tonia Rifaey Dr Gojka Roglic Dr M.B. Rokni Dr Belgacem Sabri Professor Ali Ahmed Ali Sadek Dr Bijan Sadrizadeh Dr Khalid Saeed Professor Tarek Salah Eldine Professor Hosny Mohamed Salama Dr Abdel Aziz Saleh Dr Hossein Salehi Dr Haytham Ibrahim Salti Professor Ibrahim Salti Dr Ashoor R. Sarhat Dr Raja Sawaya Dr Aristarhos Seimenis Dr Salaam Semaan Professor Gamal I. Serour Professor Mohamed Shaarawy Dr Abdel Aziz Mohamed Shaheen Dr Irshad Shaikh Professor Samia Abdel Fattah Sharaf Professor Rabah Mohamed Shawky Dr Sherine Shawky Dr Fatma Mohamed Shebl Dr Dina Ibrahim Hassan Shehab Professor Asem A. Shehabi Dr Masood Ali Sheikh Professor Cees Th. Smit Sibinga Dr Sameen Siddiqi Dr Amany Abdel Fattah Siyam Dr Felicity Smith Dr Arif Hussain Syed Dr Sabira Tahseen Professor Wagdy Talaat Dr Salwa Tayel Dr Mohammed Adnane Tazi Dr Nadia Teleb Dr Jean-Francois Tessier Dr Maria Regina Torloni Dr Salah Tumsah Professor Sayenna Abdulkareem Uduman Dr Mojtaba Vaismoradi Dr Hassan Vatandoost Ms Joana Vogel Dr Fritz Wagner Mr Wick Warren Dr Momtaz Omar Wasfy Dr Robin Weingarten Professor Walther Helmut Wernsdorfer Professor Keith Whaley Professor Polrat Wilairatana Professor William Graham Wood Professor Mohamed A.H. Yehia Professor Mustafa Z. Younis Professor Salwa Mohamed Yousef Professor Randa M. Youssef Dr Ghazi Zaatari Dr Xiaorui Zhang Dr Hany Ziady Note of appreciation The scientific integrity and standard of the information disseminated through EMHJ depends greatly on the critical judgement of our reviewers listed above. We would like to extend our sincere thanks and gratitude to them all for giving voluntarily of their time so willingly. طسوتلما قشرل ةيحصلا ةلجلما شرع سداسلا دلجلما لولأا ددعلا 127 1.   Papers submitted for publication to the Eastern Mediterranean Health Journal  (EMHJ) must not have been published, accepted for publication or currently be under consideration for publication elsewhere. The World Health Organization (WHO) Regional Office for the Eastern Mediterranean reserves all rights of reproduction and republication of material that appears in the EMHJ. 2.   Papers submitted for publication to the EMHJ should conform with the Uniform Requirements for Manuscripts Submitted to Biomedical Journals (URM) of the International Committee of Medical Journal Editors (ICMJE) 3. Submission: Original papers written in Arabic, English or French may be submitted for consideration by e-mail to EMHJ@emro.who.int. Papers can also be sent to the Editor-in-chief, Eastern Mediterranean Health Journal, WHO Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City (11371), Cairo, Egypt.  Abstracts of papers accepted for publication will be translated into all three languages. To ensure the correct spelling of authors’ names to accompany the Arabic abstract, authors writing in English or French but whose mother tongue is written using Arabic characters should provide their full names in Arabic script along with transliterations in English or French 4. All papers considered for publication will be peer reviewed. The Editorial Board reserves the right to accept or reject any paper based on the reviewers’ comments, scientific rigor and suitability for the journal. Papers are accepted on the understanding that they are subject to statistical and editorial revision as deemed necessary, including abridgement of the text and omission of tabular or graphic material. 5. Topics: The subject of the paper should pertain to public health or a related biomedical or technical subject within the field of interest of the WHO, and should have particular relevance to the Eastern Mediterranean Region. 6.   The title of the paper should be as concise as possible, preferably not more than  15 words. The full name(s) of the author(s), institutional affiliations(s) and highest  scientific degrees obtained should be provided. Please include the e-mail address and any other contact information (mailing address, fax, telephone) of the corresponding author. The number of authors should not exceed seven. All authors should have made material contribution to the design, analysis or writing of the study and have approved the final version submitted. No change in authorship will be permitted after the paper has been accepted for publication and any change before this must be agreed by all authors listed. Authors may be asked to verify their contribution. Names of other contributors may be included in the acknowledgements. Please see the ICMJE guidelines for authorship and contributorship. 7. Research articles and Reports: Papers reporting original research findingsshould follow the IMRAD format: Introduction; Methods; Results; Analysis; and Discussion. The text of Research articles and Reports should not exceed 3000  words (excluding the accompanying abstract, references, tables and figures). An abstract of not more than 150 words should be supplied, clearly and briefly stating the objectives,  context, results and conclusions. The maximum number of references permitted is 25.  The number of tables and figures should not exceed one per 1000 words. 8.   Review articles, i.e. critical assessments of research on topics of relevance to public health in the Region. These should contain sections dealing with objectives, sources, methods of selection, compilation and interpretation of data and conclusions. The text should not exceed 3000 words (excluding the accompanying abstract,  references, tables and figures), and should be accompanied by an abstract of not more than 150 words. The number of tables and figures should not exceed one per 1000  words. 9. Case reports: Only reports of cases of an unusual nature are considered for publication. Text should include an Introduction, the Report of the case(s) and a Discussion. The text should not exceed 1500 words and the number of references kept  to a minimum. No abstract is required. 10.   Letters to the Editor: Letters commenting on published articles are welcome. Letters will be sent to the authors of the original article for their comments, and these will be published along with the letter. The text of letters should be kept as short as possible. 11.   Short communications: Articles which do not constitute a complete research study but are of particular relevance or importance to public health issues in the Region are occasionally considered for publication. The text should not exceed 1500 words  (excluding the accompanying abstract, references, tables and figures), and should be accompanied by an abstract of not more than 150 words. The number of tables and  figures should not exceed one per 1000 words. 12.   Ethical considerations: Where applicable, a statement must be included indicating approval for the study was granted by the ethics committee/institutional review board of the relevant institution. Authors should verify where appropriate that all persons on whom research has been carried out have given their voluntary, informed, written consent, and where participants (living or dead) were unable to give such consent, that surrogate consent was obtained. Authors may be asked to supply such consent forms. In cases where participants cannot read and write, oral consent is acceptable. 13.   Conflicts of interest: Authors must provide a statement detailing any competing interests. Please see the ICMJE guidelines. 14.   Manuscripts should be provided in word processed format (preferably Microsoft  Word) double-spaced, A4-size. Manuscripts submitted as hard copy should be double- spaced, A4 pages typewritten or printed on one side only. 15.   References: In-text citations of published works should be limited to essential up-to-date references. These should be numbered separately as they occur in the text with sequential Arabic numerals in parentheses, e.g. [1,5-8]. These references should  appear in a numbered list on a separate page after the Discussion. They should contain the following elements as appropriate: name(s) and initial(s) of author(s); title of paper or book in its original language plus translation; for research articles, complete name of journal plus volume number and page range; for books and other texts, place of publication (city and country) and name of publisher (commercial or institutional); and date of publication; for texts published exclusively on the Internet, exact URL of the page cited and date when last accessed. For texts with up to 3 authors, all authors must be named. For texts with more than 3 authors, only the first author is named followed by “et al”. The following are examples of the Journal’s preferred style: Book: Al Hamza B, Smith A. The fifth sign of identity. Cairo, American University Press, 1990. Journal article: Jones A et al. One day in Tibet. Journal of tautology, 1993, 13(5):23–7. Document: Al-Itneen M, ed. The principles of uncertainty. Geneva, World Health Organization, 1985  (WHO/DOC/537). Web text: Child growth standards. Geneva, World Health Organization, 2006 (http://www.who. int/childgrowth/en/, accessed 8 October 2008). 16.   Figures and tables with appropriate captions should each be on a separate page, numbered sequentially with Arabic numerals and attached at the end of the paper. Each figure and table must be referred to in the text. Where appropriate, sources should be given. If any figures, tables or other materials have been copied from other sources, authors have the sole responsibility for securing the necessary permission. In order to avoid layout problems in final production, tables and figures should be limited as far as possible. Figures must be supplied in a format which can be edited, preferably Microsoft Excel format, and figures derived from data must be accompanied by those data, e.g. Excel data sheet, to enable redrawing if necessary. Photographs and illustrations should also be sent as separate files. The preferred format is JPG or TIFF; resolution should be minimum 300 dpi. For manuscripts submitted as hard copy, it is necessary to provide  two sets of original photographs and figures along with the background data. 17.   Submissions that do not comply with these Guidelines will be returned to the  author for correction before being considered for publication. 18.   On publication, the authors will receive one copy each of the issue in which the  article appears and the principal author will receive 50 reprints. Requests for further  reprints and pricing information may be obtained from the Editor-in-Chief. Guidelines for authors lanruoJ htlaeH naenarretideM nretsaE 0102  •  1 .oN     61 loV  •  JHME elatneiro eénarredidéM al ed étnaS ed euveR aL 821 دلائل إرشادية للمؤلفين 1. إن الأوراق البحثية المقدَّ مة للمجلة الصحية لشرق المتوسط للنشر يجب ألا يكون قد تم نشرها من قبل، أو تم قبول نشرها، أو أنها قيد الدراسة بغرض النشر في أي مكان آخر (نرجو الرجوع إلى السياسة الخاصة بأخلاقيات النشر الخاصة بنا).ويحتفظ المكتب الإقليمي لمنظمة الصحة العالمية لشرق المتوسط بالحق في إعادة نشر وطباعة أي مادة علمية تظهر في المجلة الصحية لشرق المتوسط. 2. إن الأوراق البحثية المقدَّ مة للنشر في المجلة الصحية لشرق المتوسط يجب أن تـتوافق مع المتطلَّ بات الموحدة للمخطوطات المقدَّ مة للمجلات الطبية البيولوجية التابعة للجنة الدولية لمحرري المجلات الطبية. 3. التقديم: تقدَّ م الأوراق البحثية الأصلية المكتوبة باللغة العربية أو الإنكليزية أو الفرنسية للدراسة عن طريق البريد الإلكتروني tni.ohw.orme@JHME كما يمكن إرسال الأوراق البحثية لرئيس تحرير المجلة الصحية لإقليم شرق المتوسط، بالمكتب الإقليمي لشرق المتوسط، صندوق بريد 8067، مدينة نصر: (17311)، القاهرة، مصر. ويتم ترجمة ملخصات الأوراق البحثية التي يتم قبول نشرها إلى اللغات الثلاث. ولضمان كتابة أسماء المؤلفي المرفق أسمائهم بالملخصات العربية كتابة صحيحة، فإنه يتعيَّ على المؤلفي الذين تكون العربية هي لغتهم الأم، ويكتبون بالإنكليزية أو الفرنسية، أن يرفقوا أسماءهم بالكامل بالعربية، بالإضافة إلى كتابة الحروف العربية باللغة الإنكليزية أو الفرنسية. 4. تخضع كل الأوراق البحثية المقترح نشرها لمراجعة الزملاء. ويحتفظ مجلس التحرير بالحق في قبول أو رفض أي ورقة بحثية استنادًا إلى تعليمات المراجعي، والدقة العلمية ومدى الملاءمة للمجلة. ويتم قبول الورقة البحثية على أساس أنها تخضع للمراجعة الإحصائية والتحريرية إذا لزم الأمر، بما في ذلك تلخيص النص وحذف الجداول أو مادة الرسم البياني. 5. الموضوعات: يتعيَّ أن يرتبط موضوع الورقة البحثية بالصحة العمومية، أو موضوع طبي بيولوجي متعلق بها، أو موضوع تقني يرتبط بمجالات المنظمة، وذي أهمية خاصة لإقليم شرق المتوسط. 6. يتعيَّ أن يكون عنوان الورقة مختصرًا قدر الإمكان، ويحّبذ ألا يزيد على 51 كلمة، على أن يرسل الاسم الكامل للمؤلف، والمؤسسات التي يكون عضوًا فيها، وأعلى درجة علمية حصل عليها. لذا نرجو إرسال عنوان البريد الإلكتروني، والمعلومات الأخرى اللازمة للاتصال بالكاتب (العنوان البريدي، الفاكس، الهاتف). ويتعيَّ ألا يزيد عدد المؤلفي على سبعة، على أن يسهم جميع المؤلفي بشكل مادي في تصميم أو تحليل أو كتابة الدراسة، والموافقة على النسخة الأخيرة. ولن يسمح بإجراء أي تغيـير يتعلَّ ق بالتأليف بعد قبول الورقة للنشر، وأي تغيـير قبل ذلك يجب أن يقّره جميع المؤلفي المدرجي. وقد يطلب من المؤلفي تأكيد مساهمتهم. كما يمكن تضمي أسماء أي مساهمي آخرين في الشكر والتقدير. نرجو الرجوع إلى الدلائل الإرشادية للجنة الدولية لمحرري المجلات الطبية فيما يتعلق بالتأليف والمساهمة. 7. التقارير والمقالات البحثية: وينبغي في الأوراق التي تدون النتائج البحثية الأصلية اتباع الشكل الخاص: المقدمة والطرق والنتائج والمناقشة، على ألا يزيد نص التقارير والمقالات البحثية عن 0003 كلمة (ولا يتضمن ذلك الملخص المرفق، والمراجع، والجداول، والأشكال). ويتعيَّ تقديم ملخص لا يتعدى 051 كلمة ليوضح الأغراض والسياق والنتائج والخلاصة بشكل مختصر وواضح، بالإضافة إلى أن أقصى عدد للمراجع يجب ألا يتجاوز 52 مرجعًا، وكذلك عدد الجداول والأشكال يجب ألا يتجاوز واحدًا لكل 0001 كلمة. 8. مقالات حول المراجعات بمعنى التقيـيم النقدي للبحوث حول الموضوعات ذات الصلة بالصحة العمومية في الإقليم. ويتعيَّ أن تـتضمَّ ن قسًما يتناول الأغراض، والمصادر، وطرق الاختيار، والتجميع وتفسير المعطيات والاستنتاجات. ويتعيَّ ألا يتعدَّ ى النص 0003 كلمة (ولا يتضمن ذلك الملخص المرفق، والمراجع، والجداول، والأشكال). وعلى أن يصحبها ملخص لا يزيد عن 051 كلمة؛ وألا يتجاوز عدد الجداول والأشكال واحدًا لكل 0001 كلمة. 9. تقارير الحالات: يتم دراسة نشر التقارير الخاصة بالحالات ذات الطبيعة غير المعتادة فقط. ويتعيَّ أن يشمل النص مقدمة، وتقرير الحالة، والمناقشة، وألا يتجاوز النص 0053 كلمة مع إيراد أقل عدد من المراجع. ولا يلزم في هذه الحالة تقديم ملخص. 01. رسالة إلى المحرر: ُيَرحَّ ب بتلقي الرسائل والملاحظات حول المقالات المنشورة في المجلة، وسترسل هذه الرسائل إلى مؤلفي المقالات الأصلية، للتعليق عليها. وينشر التعليق مصاحبًا للرسالة، على أن يكون نص الرسائل موجزًا قدر الإمكان. 11. الاتصالات الموجزة: إن المقالات التي لا تشكل دراسة بحثية مكتملة، ولكنها ذات أهمية خاصة لموضوعات الصحة العمومية في الإقليم يتم من حي لآخر دراسة إمكانية نشرها. ويتعيَّ ألا يزيد النص عن 0051 كلمة (ولا يتضمن ذلك الملخص المرفق، والمراجع، والجداول، والأشكال) وأن يصحبها ملخص لا يزيد عن 051 كلمة. ويجب ألا يزيد عدد الجداول والأشكال عن واحد لكل 0001 كلمة. 21. الاعتبارات الأخلاقية: متى وجب ذلك، يرفق بيان بموافقة لجنة الأخلاقيات ومجلس المراجعة في المؤسسة المعنّية. ويتعّي على المؤلفي إثبات أن جميع الأشخاص الذين شملهم البحث، قد وافقوا موافقة واعية كتابية وطوعية، وإذا لم يتمكن المشاركون (أحياءًا كانوا أم أمواتًا) من إعطاء هذه الموافقة، يتم الحصول على موافقة أوليائهم. وقد يطلب من المؤلفي تقديم نماذج الموافقة هذه، وحتى في حالة عدم إلمام المشاركي بالقراءة والكتابة، فقد تقبل الموافقة الشفهية. 31. تضارب المصالح: ينبغي أن يقّدم المؤلفون بيانًا يوضح أي تضارب في المصالح بالتفصيل. يرجى الرجوع إلى الدلائل الإرشادية للجنة الدولية لمحرري المجلات الطبية. 41. تقديم المخطوطات في شكل إلكتروني (يحّبذ استخدام برنامج مايكروسوفت وورد) مع ترك مسافتي بي السطور. وأن يكون مقاس الورقة 4A. أما بالنسبة للمخطوطات التي تقدَّ م في شكل ورقي فيجب أيضًا ترك مسافتي بي السطور، وأن يكون حجم الورقة 4A على أن تـتم الطباعة على وجه واحد من الصفحات. 51. المراجع: ينبغي أن يقتصر الاستشهاد من نصوص أي أعمال منشورة على المراجع الحديثة الأساسية. ويلزم ترقيم المراجع، كلما ظهرت في النص، وأن يليها إعداد عربية بي أقواس مربعة مثل: [1، 8-5]. كما ينبغي تدوين هذه المراجع في قائمة مرقمة، في صفحة منفصلة، في نهاية الورقة، وأن تـتضّمن المعلومات التالية إن أمكن: اسم المؤلف، أو أسماء المؤلفي، والأحرف الأولى من أسمائهم، وعنوان الورقة البحثية أو الكتاب في اللغة الأصلية، إضافة إلى ترجمتها؛ وبالنسبة للمقالات البحثية، يتم ذكر الاسم الكامل للمجلة بالإضافة إلى رقم المجلد، وعدد الصفحات؛ وبالنسبة للكتب وسائر النصوص، يتم ذكر مكان النشر (البلد والمدينة) واسم الناشر (التجاري أو المؤسسة) وتاريخ النشر؛ وبالنسبة للنصوص التي تنشر حصرًا على الإنترنت، يتم ذكر العنوان الإلكتروني للرابط (LRU) الخاص بالصفحة المستشهد بها وتاريخ آخر وصول لها. بالنسبة للنصوص التي يشترك فيها أكثر من ثلاثة مؤلفي، يذكر اسم المؤلف الأول فقط يتبعه كلمة "وزملائه". وفي ما يلي أمثلة للأسلوب الذي تفضل المجلة الصحية لشرق المتوسط أن يتبع: .ytitnedi fo ngis htffi ehT .A htimS ,B azmaH lA :kooB .la te A senoJ :elcitra lanruoJ .0991 ,sserP ytisrevinU naciremA ,oriaC 7-32 :(5)31 ,3991 ,ygolotuat fo lanruoJ .tebiT ni yad enO ,aveneG .ytniatrecnu fo selpicnirp ehT .de ,M neentI-lA :tnemucoD (735/COD/OHW) 5891 ,noitazinagrO htlaeH dlroW htlaeH dlroW ,aveneG .sdradnats htworg dlihC :txet beW ,/ne/htworgdlihc/tni.ohw.www//:ptth) 6002 ,noitazinagrO (8002 rebotcO 8 dessecca 61. وفي ما يتعّلق بالرسومات والجداول، المشفوعة بالشروح الملائمة، فإنه ينبغي أن ترد كل منها في صفحة منفصلة، ومرقمة على التوالي بالأعداد العربية، وملحقة في نهاية الورقة. كما ينبغي الإشارة إلى كل رسم وكل جدول يشار إليه في النص، وحّبذا لو أمكن تحديد مصدر كل رسم وكل جدول. وفي حالة نقل أي رسومات أو جداول من مواد أخرى، فإنه تقع على عاتق المؤلف أو المؤلفي المسؤولية الكاملة عن الحصول على الأذون اللازمة. وُبْغَية تجنب أي مشكلات في طريقة تنسيق المنتج النهائي، فإنه يتعيَّ الاقتصار قدر الإمكان في إدراج الجداول والرسومات. وينبغي تقديم الأشكال بالشكل الذي يسمح بتنقيحها، ويحّبذ برنامج ميكروسوفت إكسيل. وبالنسبة للأشكال المستندة إلى بيانات، فيجب أن ترفق بها هذه البيانات، مثل قوائم بيانات إكسيل على سبيل المثال لتيسير عملية إعادة الرسم إذا لزم الأمر. أما بالنسبة للصور والإيضاحات فينبغي إرسالها كملفات منفصلة، ويحّبذ في صورة GPJ أو FFIT وألا يقل وضوح الصورة عن003 ipd. بالنسبة للمخطوطات المقدَّ مة بشكل ورقي، فينبغي إرفاق مجموعتي من الصور والأشكال الأصلية مع المعطيات الأساسية. 71. سيتم إعادة الأوراق المقّدمة والتي لا تلتزم بهذه الدلائل الإرشادية إلى المؤلف للتصويب قبل دراسة نشرها. 81. عند النشر، يحصل المؤلفون على نسخة من العدد الذي ترد فيه المقالة، بينما يحصل المؤلف الرئيسي على 05 نسخة من البحث المنشور. وتقدَّ م الطلبات للحصول على المزيد من النسخ، أو على معلومات حول الأسعار إلى رئيس التحرير. طسوتلما قشرل ةيحصلا ةلجلما شرع سداسلا دلجلما لولأا ددعلا 129 Directives à l’intention des auteurs 1.    Les articles soumis pour publication à La Revue de Santé de la Méditerranée  orientale ne doivent pas avoir été publiés, être en cours d’examen par d’autres revues, ou avoir été acceptés pour publication dans d’autres revues (veuillez vous reporter à notre  Politique en matière d’éthique). Le Bureau régional de l’Organisation mondiale de la Santé (OMS) pour la Méditerranée orientale se réserve tous les droits de reproduction et de republication des matériels qui paraissent dans La Revue de Santé de la Méditerranée orientale. 2.    Les articles soumis pour publication à La Revue de Santé de la Méditerranée  orientale doivent être conformes aux Uniform Requirements for Manuscripts Submitted to Biomedical Journals [Exigences uniformes appliquées aux manuscrits soumis aux revues médicales, URM] de l’International Committee of Medical Journal Editors  (Comité international des éditeurs de revues médicales, ICMJE). 3. Soumission : Les articles originaux rédigés en anglais, arabe ou en français peuvent être soumis pour examen par courrier électronique à l’adresse suivante :  EMHJ@emro.who.int. Les articles peuvent aussi être envoyés au Rédacteur en chef, La Revue de Santé de la Méditerranée orientale, Bureau régional de l’OMS pour la Méditerranée orientale, BP 7608, Cité Nasr (11371), Le Caire (Égypte).  Les résumés des articles acceptés pour publication seront traduits dans les trois langues. Pour assurer que les noms des auteurs soient correctement écrits dans les résumés en arabe, les auteurs rédigeant en anglais ou en français mais dont la langue maternelle s'écrit en caractères arabes doivent fournir leur nom complet en écriture arabe et une translittération de leur nom en anglais ou en français. 4. Tous les articles dont la publication est envisagée seront revus par des pairs. Le Comité de rédaction se réserve le droit d’accepter ou de refuser tout article, sur la base des commentaires des réviseurs, de la rigueur scientifique et de la pertinence de l’article pour la Revue. Les articles sont acceptés sous réserve de la révision statistique et rédactionnelle dont ils feront l’objet, comme jugé nécessaire, ce qui peut amener à abréger le texte et à  supprimer certaines données présentées sous forme de tableaux ou de graphiques. 5. Sujets : Le sujet de l’article doit concerner la santé publique ou un autre sujet biomédical ou technique connexe faisant partie du champ d’intérêt de l’OMS, et se rapporter plus particulièrement à la Région de la Méditerranée orientale. 6.    Le titre de l’article doit être aussi concis que possible, et de préférence ne pas  dépasser 15 mots. Le(s) nom(s) complet(s) du ou des auteur(s), leur(s) affiliation(s)  institutionnelle(s) et l’intitulé de leur plus haut diplôme scientifique doivent être indiqués. Une adresse électronique et toute autre information permettant de contacter le ou les auteurs(s) (adresse postale, numéro de télécopie, numéro de téléphone) devront aussi être mentionnées. Le nombre des auteurs ne devrait pas être supérieur à sept.  Tous les auteurs devraient avoir apporté une contribution importante à la conception, à  l'analyse ou à la rédaction de l'étude et avoir approuvé la version finale soumise. Aucun  changement dans les noms des auteurs ne sera autorisé après l’acceptation de l’article pour publication ; avant cette acceptation, tout changement doit être accepté par l’ensemble des auteurs figurant dans la liste. Une vérification de leur contribution peut être demandée aux auteurs. Les noms d’autres contributeurs peuvent être inclus dans les remerciements. À ce sujet, veuillez vous reporter aux ICMJE guidelines for authorship and contributorship [Directives de l’ICMJE relatives à la qualité d’auteur et de contributeur]. 7. Articles et rapports de recherche : Les articles présentant des résultats de recherche originale devront suivre le format IMRAD : introduction, méthodes, résultats, analyse et discussion. Le texte des articles et des rapports de recherche ne doit pas excéder 3000 mots (résumé, références, tableaux et figures exclus) Un résumé de  150 mots maximum sera fourni et mentionnera clairement et brièvement les objectifs, le  contexte, les résultats et les conclusions. Le nombre maximal de références autorisées est de 25. Il ne faut pas inclure plus d’un tableau ou d’une figure tous les 1000 mots. 8.    Articles d’analyse (évaluations critiques d'études de recherche sur des sujets pertinents concernant la santé publique dans la Région). Ils doivent être composés de paragraphes traitant des objectifs, des sources, des méthodes de sélection, de la compilation et de l’interprétation des données et des conclusions. Le texte ne doit pas excéder 3000 mots (résumé, références, tableaux et figures exclus) et doit être  accompagné d’un résumé de 150 mots au maximum. Il ne faut pas inclure plus d’un  tableau ou figure tous les 1000 mots. 9. Études de cas : Seules les études de cas inhabituels seront examinées pour publication. Le texte doit comprendre une introduction, un exposé du/des cas et une discussion. Il ne doit pas excéder 3500 mots et le nombre de références doit être minimal.  Il n’est pas nécessaire de fournir un résumé. 10.   Lettres à la rédaction : Les lettres commentant des articles publiés sont les bienvenues. Elles seront envoyées aux auteurs de l’article afin qu'ils fournissent leurs commentaires, qui seront publiés aux côtés de la lettre. Le texte des lettres doit être aussi court que possible. 11.    Communications brèves : Les articles ne constituant pas une étude de recherche  complète, mais présentant un intérêt ou revêtant une importance particulière pour les questions de santé publique dans la Région sont occasionnellement examinés pour publication. Le texte ne doit pas excéder 1500 mots (résumé, références, tableaux et  figures exclus) et doit être accompagné d’un résumé de 150 mots au maximum. Il ne faut  pas inclure plus d’un tableau ou d’une figure tous les 1000 mots. 12.    Considérations éthiques : Le cas échéant, une déclaration devra être incluse,  indiquant que le Comité d’éthique ou le Comité d’examen institutionnel de l’organisme concerné a donné son accord à l’étude.  Les auteurs doivent vérifier, le cas échéant, que toutes les personnes sur lesquelles la recherche porte ont donné leur consentement volontaire et informé par écrit et que si certains participants (en vie ou décédés) n’ont pas pu le donner, un consentement de substitution a été obtenu. Il peut être demandé aux auteurs de fournir ce type de formulaire de consentement. Lorsque les participants ne savent ni lire ni écrire, un consentement oral est acceptable. 13.    Conflits d’intérêts : Les auteurs doivent fournir une déclaration détaillant tout conflit d'intérêts. Veuillez vous reporter aux directives de l'ICMJE (ICMJE guidelines).  14.   Les manuscrits doivent être fournis en format traitement de texte (Microsoft Word, de préférence), A4 avec double interlignage. Les manuscrits soumis en version papier doivent être dactylographiés ou imprimés sur le recto seulement, sur des feuilles A4 avec double interlignage. 15.   Références : Les citations dans le texte de travaux publiés doivent être limitées aux références essentielles récentes. Elles doivent être numérotées séparément à l’aide de  chiffres arabes indiqués entre crochets, par exemple [1,5-8], selon l’ordre dans lequel elles  apparaissent dans le texte. Les références doivent figurer sous forme de liste numérotée sur une page séparée après la partie « Discussion ». Elles doivent contenir les éléments suivants, selon le cas : nom(s) et initiales du ou des auteurs ; titre de l’article ou de l’ouvrage dans sa langue originale ainsi que sa traduction ; pour les articles de recherche, le nom complet de la revue ainsi que le numéro du volume et les pages concernées ; pour les ouvrages et autres textes, le lieu de publication (ville et pays) et le nom de la maison d’édition (commerciale ou institutionnelle) ; la date de publication ; pour les textes publiées exclusivement sur Internet, l'URL exact de la page citée et la date du dernier accès. Lorsque les textes comptent moins de trois auteurs, tous les auteurs doivent être nommés. Lorsque les textes comptent plus de trois auteurs, seul le nom du premier auteur est mentionné, suivi de « et al. ». Exemples du style préféré de La Revue : Livre : Al Hamza B, Smith A. The fifth sign of identity. Cairo, American University Press, 1990. Article de Revue : Jones A et al. One day in Tibet. Journal of tautology, 1993, 13(5): 23–7. Document : Al-Itneen M, ed. The principles of uncertainty. Geneva, World Health Organization, 1985  (WHO/DOC/537). Texte Web : Child growth standards. Geneva, World Health Organization, 2006 (http: //www. who.  int/childgrowth/en/, accessed 8 October 2008). 16.   Les figures et les tableaux accompagnés des légendes appropriées doivent être placés chacun sur une feuille séparée, numérotés en chiffres arabes selon leur ordre et joints à la fin de l’article. Chaque figure et chaque tableau doit être référencé(e) s dans  le texte, et le cas échéant, les sources doivent être indiquées. Si des figures, tableaux ou d’autres matériels ont été copiés d’autres sources, les auteurs portent l’entière responsabilité d’obtenir les autorisations nécessaires. Afin d’éviter les problèmes de mise en page lors de la production finale, le nombre de tableaux et de figures doit être aussi limité que possible. Les figures doivent être fournies dans un format permettant les modifications, de préférence Microsoft Excel, et celles qui sont établies à partir de données doivent  être accompagnées de ces données, sur une fiche technique Excel par exemple, pour permettre une recomposition, le cas échéant. Les photographies et illustrations doivent être envoyées dans des fichiers séparés. Les formats préférés sont JPG et TIFF, et la résolution des images doit être de 300 dpi au minimum. Si les manuscrits sont soumis en version papier, deux jeux de photographies et de figures originales accompagnées des données de base doivent être fournis. 17.    Les manuscrits ne respectant pas ces directives seront renvoyés à leur auteur pour  correction avant d’être examinés en vue de la publication. 18.    Lors de la publication, les auteurs recevront chacun un exemplaire du numéro dans  lequel l’article paraît et l’auteur principal recevra 50 tirés à part. Les demandes de tirés  à part supplémentaires et les informations sur le prix peuvent être obtenues auprès du  Rédacteur en chef. طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ةيبيللا ةيبرعلا ةييرهمالجا . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . ةينميلا ةيروهملجا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما Subscriptions and Distribution Enquiries regarding subscriptions and distribution of the print edition of EMHJ should be addressed to: Printing and Marketing of Publications at: email: pam@emro.who.int; tel: (+202) 2276 5000; fax: (+202) 2670 2492 or 2670 2494 Permissions Requests for permission to reproduce or translate articles, whether for sale or non-commercial distribution should be addressed to EMHJ at: emhj@emro.who.int Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libyan Arab Jamahiriya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Republic of Yemen Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Jamahiriya arabe libyenne . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar République arabe syrienne . Somalie . Soudan . Tunisie . République du Yémen Correspondence Editor-in-chief EMHJ WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: sabrib@emro.who.int/emhj@emro.who.int EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con- cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col- laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser-vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collabora- teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line) and the ExtraMed-Full text on CD-ROM, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), CAB International, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). ©World Health Organization 2010 All rights reserved Disclaimer The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. ISSN 1020-3397 Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تاسايسلا لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما طسوتلما قشرل ةيحصلا ةلجلما Cover 6.indd 2 5/24/2010 11:46:47 AM Contents Healthy newborn baby, Syrian Arab Republic: global progress in achieving Millenium Development Goal 4 (two-thirds reduction by 2015 of the 1990 mortality rates among children under 5 years) is contingent upon improvements in neonatal health. Eastern Mediterranean Health Journal La Revue de Santé de le Méditerranée orientale Letter from the Editor ...............................................................................................................................................................................................................................................3 Research articles Case–control study to evaluate risk factors for acute hepatitis B virus infection in Egypt ................................................................................4 Hepatitis B and C viral infection: prevalence, knowledge, attitude and practice among barbers and clients in Gharbia governorate, Egypt .............................................................................................................................................................................................................................................10 HIV/AIDS knowledge, attitudes and beliefs among a group of Iraqis ........................................................................................................................18 Seroprevalence of Toxoplasma gondii in unmarried women in Qazvin, Islamic Republic of Iran .............................................................24 Comparison of pregnancy and implantation rates in zygote intrafallopian transfer and uterine embryo transfer for nontubal infertility .....................................................................................................................................................................................................................................29 Perinatal outcomes of singleton term breech deliveries in Basra ......................................................................................................................................34 Nosocomial infections in a neonatal intensive care unit in south-western Saudi Arabia ................................................................................40 Antibiotic resistance trends in paediatric community-acquired first urinary tract infections in the United Arab Emirates ...45 National survey of the oral health of 5-year-old children in the United Arab Emirates ....................................................................................51 Pattern and prevalence of smoking among students at King Faisal University, Al Hassa, Saudi Arabia ...............................................56 Diabetes mortality and causes of death in Benghazi: a 5-year retrospective analysis of death certificates ..........................................65 Ketosis-onset diabetes in Tunisian adults: immunological markers and β-cell function ................................................................................70 Corrected QT dispersion improves diagnostic performance of exercise testing in diagnosing coronary artery disease .........75 Biological activity resulting from exposure to aquatic environmental genotoxic pollutants in northern Egypt.............................82 Evaluation of intralesional 0.2% ciprofloxacin as a treatment for cutaneous leishmaniasis ...........................................................................89 Musculoskeletal disorders among bank office workers in Kuwait ..................................................................................................................................94 An analysis of carbon monoxide poisoning cases in Bursa, Turkey ............................................................................................................................101 Les nouveaux critères et la qualité des services de soins de santé dans le gouvernorat de Monastir (Tunisie) ............................107 Review Gender inequity in Saudi Arabia and its role in public health .........................................................................................................................................113 Report Supporting the Saudi e-health initiative: the Master of Health Informatics programme at KSAU-HS .............................................119 Eastern Mediterranean Health Journal reviewers’ panel, 2009 .................................................................................................................................125 Guidelines for authors .......................................................................................................................................................................................................................................127 Volume 16 / Number 1 January / Janvier 2010 1 ددع / شرع سداسلا دلجلما رياني / لولأا نوناك Volum e 16 N um ber 1 January / Janvier 2010