Eastern Mediterranean Health Journal [2006; Vol.12, Issue 3-4]

264 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Prevalence of HCV/HIV co-infection among haemophilia patients in Baghdad W.A. Al-Kubaisy,1 K.T. Al-Naib2 and M.A. Habib2 1Department of Community Medicine; 2Department of Microbiology, College of Medicine, Al-Nahrain University, Baghdad, Iraq (Correspondence to W.A. Al-Kubaisy: waqar_abd@yahoo.co.uk). Received: 03/03/03, accepted: 02/12/04 ABSTRACT To estimate the seroprevalence of HCV infection among HIV-infected haemophiliacs and to demonstrate the most prevalent HCV genotype, 47 HIV-infected haemophilia patients were screened for anti-HCV antibodies. By performing polymerase chain reaction and DNA enzyme immunoassay, HCV-RNA was detected with subsequent genotyping. Seroprevalence of anti-HCV antibodies was 66.0%. Of 31 HCV/HIV co-infected patients, 21 (67.7%) had no history of blood transfusion. We de- tected 4 HCV genotypes: 1a, 1b, 4 and 4 mixed with 3a, HCV-1b being the most frequent. Contaminated factor VIII (clotting factor) could be responsible for disease acquisition. Prévalence de la co-infection VHC-VIH chez des patients hémophiles à Bagdad RÉSUMÉ Afin d’estimer la séroprévalence de l’infection par le VHC chez des hémophiles infectés par le VIH et de connaître le génotype du VHC le plus répandu, on a procédé à une recherche d’anticorps anti-VHC chez 47 patients hémophiles infectés par le VIH. La polymerase chain reaction (PCR) et une méthode de révélation immunoenzymatique d'ADN ont été utilisées pour détecter l’ARN du VHC et un génotypage a été ensuite effectué. La séroprévalence des anticorps anti-VHC était de 66,0 %. Sur les 31 patients co-infectés VHC-VIH, 21 (67,7 %) n’avaient pas d’antécédents de transfusion sanguine. On a détecté 4 génotypes du VHC : 1a, 1b, 4 et 4 mixte avec 3a, le VHC-1b étant le plus fréquent. Le facteur VIII contaminé (facteur de coagulation) pourrait être responsable de l’acquisition de la maladie. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 265 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction The introduction of factor VIII concentrates in 1970 has improved the treatment of pa- tients with coagulopathy. Early administra- tion of these concentrates has resulted in a longer life span and a better quality of life. However, a rise in cases of acute viral hepa- titis was observed following the use of these factor VIII concentrates [1,2]. The high in- cidence of hepatitis after such treatment was first identified by Kasper and Kipnis in 1972 [2]. Since the 1980s, the rate of transmis- sion of hepatitis C virus (HCV) to patients with haemophilia was reported to be 100% until effective procedures to inactivate the virus were introduced [3–5]. Studies on HCV genotypes in people with haemophilia have identified types 1, 2, 3 and 4, in addition to genotype 5, which is found in only a few people. Such studies have lead to speculation about the source of some commercial factor VIII concentrates [5]. Hepatitis C virus and human immuno- deficiency virus (HIV) co-infection in hae- mophilia patients is common and causes a complex interaction. Replication of HCV is accelerated in the presence of HIV (prob- ably as a result of immunodeficiency): the level of HCV-RNA in co-infected haemo- philia patients has been found to be 58 times greater than in those infected with HCV alone [6]. Telfer et al. found the relative risk of developing liver failure in HCV infection increased 21-fold after HIV infection [7]. Interferon alpha remains the most prom- ising treatment for hepatitis C. For patients who do not have haemophilia, a liver biopsy is essential in deciding who will benefit from treatment, but this is a hazardous proce- dure for a patient with haemophilia. Hence, knowledge of other variables, such as HCV genotype and viral load, may be helpful as patients with type 2 and 3 and those with lower viral loads have the greatest chance of responding [8]. Therefore, we conducted this study in order to identify the prevalence of HCV among HIV patients in Baghdad and to determine the most prevalent geno- types among this group. Methods All 47 HIV-infected haemophilia patients attending Ibn Al-Khatib hospital in Bagh- dad From January 1998 to June 1998 were selected for this study. The age range was 12–46 years. Serum samples from each par- ticipant were dispensed into 2 screw-capped vials; 1 was stored at –20 °C and the other at –70 °C. The former was used for detection of HCV-specific antibodies and the latter was used for molecular analysis. Informed consent was obtained from all participants, or from the mother for those under 18 years. There were no refusals to participate. For determination of anti-HCV anti- bodies we used a third generation enzyme immunoassay (HCV EIA, United Biomedi- cal Inc., Hauppauge, New York). Positive results were confirmed by third generation immunoblot assay (Lia-Tek-III kit, Or- ganon, Amsterdam). All assays were car- ried out at the Central Health Laboratory, Baghdad. Twenty anti-HCV positive sera (stored at –70 °C) were transferred in dry ice to the laboratories of Sorin Biomedica, Saluggia, Italy. There, they were tested for HCV-RNA positivity and subsequent HCV genotyping using an advanced molecular method based on a combination of 2 well-established techniques, the polymerase chain reaction and DNA enzyme immunoassay. First, RNA was extracted from 140 μL of the serum sample according to the method used by Garson et al. [9] and was subjected to reverse transcriptase. The cDNA devel- oped was amplified at the 5'UTR region 266 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم by single step polymerase chain reaction according to the manufacturer’s method. The amplified cDNA was then hybridized to specific oligonucleotide probes fixed to a solid phase through an avidin–biotin bridge, using an avidin-coated plate from Genetik (Sorin Biomedica, Saluggia, Italy). The hybrids were then detected by a standard enzyme linked immunosorbent assay (Sorin Biomedica) using monoclonal antibody specific for double stranded DNA. All steps were carried out according to the manufac- turer’s instructions. Positive and negative control samples were included throughout the assay. The absorbance of the coloured reaction was read at 450 nm and 630 nm. Using the same DNA enzyme immu- noassay method but 6 different oligonu- cleotide probes, HCV genotypes as well as their different subtypes were detected (Sorin Biomedica). The test was then car- ried out as described above. The HCV genotypes/subtypes were clas- sified according to Simmond’s nomencla- ture [10]. Statistical analysis was performed by using chi squared and t-test with P < 0.05 significant. Results Overall seroprevalence of anti-HCV anti- bodies among Iraqi haemophilia patients infected with HIV was 66.0% (31/47). A history of blood transfusion was reported among 21 (44.6%) haemophilia patients infected with HIV; only 10 of these (32.3%) were co-infected with HCV (Table 1). Of the 26 patients who had no history of blood transfusion, 21 (67.7%) were HIV/ HCV co-infected. Co-infection was sig- nificantly higher among these patients (χ2 = 4.3, P < 0.005) (Table 1). Of the 31 sera confirmed positive for anti-HCV antibodies, 20 were randomly selected for molecular analysis. Only 14 of these (70.0%) demonstrated HCV-RNA positivity. In 13 HIV/HCV co-infected pa- tients with positive results for HCV-RNA, we detected 4 different genotypes/subtypes: single (1a, 1b and 4) and mixed (3a plus 4) (Table 2). The highest proportion of patients (61.5%) was infected with HCV genotype 1b. Genotype 3a was detected in the mixed pattern of HCV infection only. A single RNA sample failed to reveal a positive signal based on DNA enzyme immunoassay analysis with any of the investigated prim- ers for HCV specific genotypes. Discussion The haemophilia community, already hit by HIV infection, is now facing the prob- lem of HCV infection [11]. Extensive se- roepidemiological studies have shown that 60%–91% of patients with haemophilia Table 1 Association of history of blood transfusion with HCV infection in haemophilia patients infected with HIV Anti-HCV History of blood transfusion Total status Yes No No. % No. % No. % Positive 10 32.3 21 67.7 31 66.0 Negative 11 68.8 5 31.3 16 34.0 Total 21 44.7 26 55.3 47 100.0 χ2 = 4.3 (with Yates correction); P < 0.005. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 267 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم have antibodies to HCV [12–14]. Other studies have recorded a rate of 85%–98% [15,16]. However, the prevalence of HCV infection in HIV-infected patients varies widely in different studies and depends, above all, on the distribution of the vari- ous risk factors for acquiring HIV in each population. In our study, the overall preva- lence of anti-HCV antibodies among HIV infected patients was 66.0% a finding that is in agreement with results recorded by others [12–14] but much higher than the 3.21% de- tected among pregnant Iraqi women by Al- Kubaisy [17]. The high prevalence of HIV/ HCV co-infection may be related to the fact that both viruses share the parenteral route as the main portal of entry [18]. Although, the risk of acquiring HCV and HIV infection by blood transfusion is great- ly reduced in the developed countries [19], it is still considered a major risk factor for acquiring such infections in the developing countries [20] owing to a lack of new detec- tion techniques based on determination of viral genetic material before the appearance of antibodies (window period). In addition to blood transfusion, un- screened factor VIII is considered a ma- jor source of HCV transmission. Overall, 55.3% of haemophilia patients infected with HIV and 67.6% of those co-infected with HIV/HCV had no history of blood transfusion. This finding supports the theory that factor VIII could be the source of infec- tion of both HIV and HCV in our country. There has been speculation that the route of HCV transmission could be one of the determinants of outcome, as patients who receive a greater viral inoculum are those infected by transfusion of blood and blood products [21,22]. Also, 70% of 20 haemophilia patients who were co-infected displayed HCV-RNA positivity. The fluctuating pattern of HCV viraemia is one explanation; cure from HCV infection cannot, however, be exclud- ed. There is conflicting opinion about the outcome of HIV/HCV co-infection. Some studies have, however, indicated that there is a greater progression of HIV in the pres- ence of HCV infection [23,24] and that for every 10-fold increase in HCV-RNA level there was a 1.6-fold increase in the risk of progression to acquired immune deficiency syndrome (AIDS) [25]. There are few data available at the mo- ment on HCV genotypes which predomi- nate in HIV/HCV co-infected patients. We detected 4 different genotypes. Patients treated with multiple batches of clotting factor concentrate will have been exposed to a large amount of virus as well as to many viral genotypes [26], which may explain why we found mixed HCV genotypes in 1 of our patients. However, the presence of an untypeable HCV genotype was probably a result of the limited availability of HCV- specific primers for genotype analysis [27]. In recent years several studies have analysed the distribution of HCV genotypes in different populations and have found a clear predominance of genotype 1, espe- cially 1a and 1b [28,29], which is compat- ible with the finding in this study. A global genotype 1 prevalence of 83.3% was found in HIV patients in a recent American study; Table 2 HCV genotype distribution among HCV-RNA positive sera of haemophilia patients infected with HIV HCV genotype HCV-RNA positive sera No. % 1a 2 15.4 1b 8 61.5 4 2 15.4 3a & 4 1 7.7 Total 13a 100.0 aOne HCV-RNA positive sample was untypeable. 268 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم type 3 was found in 9% [30,31]. Studies on co-infected patients in Europe had, how- ever, reported a higher probability of find- ing genotype 3. It was suggested that this was related to the low rate of intravenous drug users in the United States of America compared to Europe. There has been much speculation about whether some HCV genotypes can them- selves be a factor in poor prognosis. In most cases, genotype 1b (the most prevalent in our study) has been identified as being associated with a worse outcome and with greater prevalence of cirrhosis. It has been speculated that genotype 1 might be an inducer of T-cell helper type 2 immunologic response instead of type 1, which is the most effective for correct control of the disease [25]. On the other hand, the association has not been found in all studies [26]. We suggest that contaminated factor VIII may be the source of transmission of HCV to haemophilia patients infected with HIV, and further studies should be carried out to investigate this. Further studies are also necessary to evaluate the impact of HCV infection on HIV survival rates and, if possible, to evaluate the benefits of treat- ing HCV infection in HIV seropositive patients. References 1. Dragoni F et al. Rapid liver failure related to chronic C hepatitis in an HIV seroposi- tive haemophilic patient with severe im- munodepression. Haematologica, 1996, 81(4):335–8. 2. Kasper CK, Kipnis SA. Hepatitis and clotting factor concentrates. Journal of the American Medical Association, 1972, 221(5):510. 3. Fletcher ML et al. Non A non B hepatitis after transfusion of factor VIII in infre- quently treated patients. British medical journal, 1983, 287(6407):1754–7. 4. Kernaff PA et al. High risk of non-A non-B hepatitis after first exposure to volunteer or commercial clotting factor concen- trates: effect of prophylactic immune serum globulin. British journal of haema- tology, 1985, 60(3):469–79. 5. Preston FE et al. Heterogeneity of HCV genotypes in haemophilia: relationship with chronic liver disease. Blood, 1995, 85(5):1259–62. 6. Eyster ME et al. Increasing C virus RNA levels in hemophiliacs: relationship in hu- man immunodeficiency virus infection and liver disease. Multicenter Hemophilia Co- hort Study. Blood, 1994, 84(4):1020–3. 7. Telfer P et al. The progression of HCV- associated liver disease in a cohort of haemophilic patients. British journal of haematology, 1994, 87(3):555–61. 8. Telfer P et al. Alpha interferon for C virus infection in haemophilic patients. Haemo- philia, 1995, 1:54–8. 9. Garson JA et al. Demonstration of vi- raemia patterns in haemophiliacs treat- ed with hepatitis-C-virus-contaminated factor VIII concentrates. Lancet, 1990, 336(8722):1022–5. 10. Simmonds P et al. A proposed system for the nomenclature of hepatitis C viral geno- type. Hepatology, 1994, 19(5):1321–4. 11. Ockenga J et al. Hepatitis B and C in HIV-infected patients. Prevalence and prognostic value. Journal of hepatology, 1997, 27(1):18–24. 12. Makris M et al. Hepatitis C antibody and chronic liver disease in haemophilia. Lan- cet, 1990, 335(8698):1117–9. 13. Brettler DB et al. Prevalence of hepatitis C virus antibody in a cohort of haemophilia patients. Blood, 1990, 76(1):254–6. 14. Pistello M et al. Hepatitis C virus sero- prevalence in Italian haemophiliacs in- Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 269 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم jected with virus inactivated concentrates: five year follow-up and correlation with antibodies to other viruses. Journal of medical virology, 1991, 33(1):43–6. 15. Yee TT et al. The natural history of HCV in a cohort of haemophilic patients infect- ed between 1961 and 1985. Gut, 2000, 47:845–51. 16. Hanley JP et al. Patterns of hepatitis G viraemia and liver disease in haemophili- acs previously exposed to non-virus inac- tivated coagulation factor concentrates. Thrombosis and haemostasis, 1998, 79(2):291–5. 17. Al-Kubaisy WA. Epidemiologic and geno- typic distribution of hepatitis C in Ira- qi pregnant women [thesis]. Baghdad, Saddam University (Al Nahrain Univer- sity), 1998. 18. Saillour F et al. Prevalence and deter- minants of antibodies to hepatitis C vi- rus and markers for hepatitis B virus infection in patients with HIV infection in Aquitaine. British medical journal, 1996, 313(7055):461–4. 19. Schreiber GB et al. The risk of transfusion- transmitted viral infections. New England journal of medicine, 1996, 334(26):1685– 90. 20. Hepatitis C. Geneva, World Health Or- ganization, 2000 (Fact sheet No. 164). 21. Tremolada F et al. Antibody to hepatitis C virus in post-transfusion hepatitis. Annals of internal medicine, 1991, 114(4):277– 81. 22. Alter HJ et al. Detection of antibody to hepatitis C virus in prospectively fol- lowed transfusion recipients with acute and chronic non-A, non-B hepatitis. New England journal of medicine, 1989, 321(22):1494–500. 23. Sabin CA et al. The association between hepatitis C virus and human immuno- deficiency virus disease progression in a cohort of haemophilic men. Journal of infectious diseases, 1997, 175(1):164–8. 24. Haydon GH et al. The impact of hepati- tis C virus infection on HIV disease and progression in intravenous drug users. European journal of gastroenterology and hepatology, 1998, 10(6):485–9. 25. Daar ES et al. Hepatitis C virus is associ- ated with human immunodeficiency virus type 1 disease progression in hemophili- acs. Journal of infectious diseases, 2001, 183(4):589–95. 26. Fretz C et al. HCV infection in a rural population of the Central Africa Republic (CAR): evidence of three additional sub- types of genotype 4. Journal of medical virology, 1995, 47(4):435–7. 27. Devereux H et al. Hepatitis C genotypes in haemophilic patients treated with alpha-interferon. Journal of medical virol- ogy, 1995, 45(3):284–7. 28. Rapicetta M et al. Molecular heterogenic- ity and new subtypes of HCV genotype 4. Research in virology, 1998, 149(5):293– 7. 29. Sherman K et al. HCV prevalence among patients infected with Human Immuno- deficiency Virus: a cross sectional analy- sis of the US adults AIDS Clinical Trial Group. Clinical infectious diseases, 2002, 34(6):831–7. 30. Carten M et al. Comparative sensitivity of HCV antibody vs qualitative RNA in screening for HCV in HIV infected pa- tients. Paper presented at the 9th confer- ence on retroviruses and opportunistic infection, Seattle, 28 February 2002. 31. Dieterich DT, Purow JM, Rajapaksa R. Activity of combination therapy with in- terferon alfa-2b plus ribavirin in chronic hepatitis C patients co-infected with HIV. Seminars in liver disease, 1999, 19(suppl. 1):87–94. 270 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Epidemiology of malaria and predictions of retransmission in Babylon governorate, Iraq A.A. Al-Ghoury,1 W.K. El-Hashimi2 and J. Abul-Hab3 1Department of Parasitology, College of Medicine, University of Sana’a, Sana’a, Yemen (Correspondence to A.A. Al-Ghoury: basit_alghoury@yahoo.com). 2Department of Microbiology; 3Department of Public Health, College of Medicine, Al-Mustansiriya University, Yarmouk, Baghdad, Iraq. Received: 28/03/04; accepted: 06/07/04 ABSTRACT After the 1997–98 malaria epidemic in Babylon governorate, Iraq, malaria transmission in this area was successfully interrupted. A parasitological survey in 2002 identified no malaria cases but an entomological survey found both Anopheles stephensi and A. pulcherrimus in high densities. The highest density was recorded in September and the lowest in December and January. Despite the high density of Anopheles, no parasite sporozoites or oocysts were found in dissected mosquitoes. Nev- ertheless, malaria transmission could recur if A. stephensi indoor resting density exceeds the critical threshold and imported malaria cases are not monitored. Épidémiologie du paludisme et prévisions concernant la reprise de la transmission dans le gouvernorat de Babylone (Iraq) RÉSUMÉ Après l’épidémie de paludisme de 1997-1998 dans le gouvernorat de Babylone (Iraq), la transmission du paludisme dans cette région a pu être interrompue. Lors d’une enquête parasitologique en 2002, aucun cas de paludisme n’a été identifié mais une enquête entomologique a trouvé de fortes densités d’Anopheles stephensi et d’A. pulcherrimus. La densité la plus forte a été enregistrée en sep- tembre et la plus faible en décembre et janvier. Malgré la forte densité d’anophèles, aucun sporozoïte ou oocyste n’a été trouvé dans les moustiques disséqués. Néanmoins, la transmission du paludisme pourrait reprendre si la densité de A. stephensi au repos à l’intérieur des habitations dépassait le seuil critique et si les cas de paludisme importés n’étaient pas suivis. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 271 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction Malaria is considered one of the greatest challenges of all the health problems in tropical countries. The Plasmodium parasite undergoes a complete cycle of sporogony leading to the formation of the infective stages that propagate the infection during the feeding process of the mosquito. The efficiency of transmission of the disease depends mainly on the presence of fa- vourable environmental conditions for the anopheline vectors [1]. Iraq has achieved a dramatic reduction in the number of malaria cases from an estimated 1 million per year in the early 1950s to less than 4000 cases per year by the 1990s. Recently, the situation has been deterio- rating in the 3 north-eastern governorates and malaria has spread outside this area [2]. Babylon governorate has been free of indigenous malaria cases since 1977, but a sudden epidemic occurred during the period 1997–98 in Hilla city, the capital of Babylon governorate [3]. The epidemiological fea- tures contributing to the epidemic included: increased rainfall and temperature in Baby- lon province after 1995 that favoured malaria transmission during that period; agricultural development projects around the city of Hilla that created new mosquito breeding habitats; and population movements when migrant workers returned from endemic ar- eas in the north of Iraq. Control measures at the time included anti-plasmodial measures (treatment of cases, chemoprophylaxis and anti-relapse treatment, i.e. mass treatment); vector control (chemical and biological larvicides/insecticides and spraying with residual insecticides); individual protection aimed at reduction of man–vector contact; establishment of a malaria surveillance programme; and public health education. The present study in 2002 aimed to evaluate the success of the interruption of malaria transmission after control measures at the focus of the 1997–98 epidemic. Para- sitological and entomological criteria were used to predict the possible recurrence of transmission. Methods The study period was 1 year from 1 January to 31 December 2002. A longitudinal parasitological and en- tomological survey was carried out in 2 districts: Centre district, which covers Hilla city, the capital of Babylon province and the focus of the 1997–98 epidemic, and the villages of Al-Hashimiyah district. Centre district includes 3 fixed stations, Al-Askery, Al-Zuweer and Offee, whereas Al- Hash- imiyah district includes 3 fixed stations, Al-Owidine, Kisher and Al-Jebssah. Parasitological survey According to the World Health Organi- zation there are 2 parasitological criteria indicating that transmission has been inter- rupted at a certain date. First, no resident child born after that date should ever be found positive. Second, careful surveillance with adequate coverage should detect no new cases after that date. The sample was selected by multi-stage methods and the population of the study was then stratified into 5 groups as fol- lows: malaria cases reported to the Primary Health Care Directorate during 1997–98 (n = 455), contacts of malaria cases (n = 795), children below 5 years of age from the same area (n = 314), foreigners arriving in the province (n = 24) and subjects from sur- rounding areas which had a high mosquito density (n = 97). The total for all groups was 1685 individuals. Table 1 indicates the age groups included. As both sexes are usually equally infected, sex was not included as a category. 272 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Blood samples were collected from study subjects and all 1685 individuals were tested by ordinary thick and thin blood smears as this is regarded as the gold standard in malaria diagnosis. Thee other diagnostic methods were included to corroborate the smear method: haematocrit concentration (n = 352 individuals) [4]; improved thick blood films (n = 111) [5]; and rapid diag- nostic (dipstick) test (n = 102) [6]. Financial constraints did not allow the same tests to be used on all samples. All thick and thin blood films were double checked by the general health laboratory of Primary Health Care Directorate in Babylon governorate. Entomological survey For the entomological survey, 6 fixed sta- tions in the study areas were visited every month to carry out malaria vector surveil- lance in these areas. The vectors were monitored at both larval and adult stages from various habitats. The sucking tube collection method was used for outdoor and semi-indoor resting mosquitoes, but pyrethrum space spray was used for indoor resting mosquitoes. In each station, 5 rooms were searched by 1 person who spent half an hour using an aspirator and a torch light. Also 5 rooms were searched by the pyrethrum space spray method in the morning [7]. In each station 10 suspected breeding places were searched and 10 dips were made in each place. The samples of adult mosquitoes and larvae were examined and identified ac- cording to the keys described by Abul-Hab [8]. In addition, the salivary glands and stomach of the captured female mosquitoes were dissected for the detection of malaria sporozoites and oocysts [7]. Prediction of malaria epidemics Entomological survey and indoor resting density were used for this purpose as well as entomological records before, during and after the 1997–98 epidemic. A. stephensi is the major malaria vector in central and southern Iraq [18], so that the indoor rest- ing density of this species was used in a theoretical trial for predicting a malaria epidemic. Two methods were used to deter- mine whether the household indoor resting density of A. stephensi has exceeded critical levels associated with epidemic transmis- sion: the direct approach and the minimum sample size approach [9]. Statistical analysis The results were presented in simple tables and graphs, using simple statistical meas- ures as mean and variance as well as regres- Table 1 Methods of diagnosis and number of tests used in the malaria parasitological survey in Babylon governorate according to patient age group Diagnostic method Age (years) 0–5 6–10 11–15 16–20 > 20 Total Thick & thin blood films 314 246 238 220 667 1685 Haematocrit concentration method 82 57 55 59 99 352 Improved thick blood films 45 26 14 2 24 111 Rapid diagnostic tests 12 16 19 16 39 102 Total 453 345 326 297 829 2250 Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 273 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم sion. P < 0.05 was considered statistically significant. The following measures were calculated for the purpose of prediction of malaria epidemics: 1. Taylor’s power law, to measure the rela- tionship between variance (s) and mean (x) as a power function [10]. parameters a and b are Taylor’s power law coefficients and provide information on insect aggregation. 2. An equation for calculating the number of houses required to estimate the mean Anopheles density for selected allowable errors using the direct approach [11]. where Z a/2 = 1.96 at P = 0.05 n = number of houses required to calcu- late mean Anopheles density. AE = allowable error, typically set be- tween 10% and 50% of the mean. 3. An equation for calculating the number of houses required to estimate the mean Anopheles density using the minimum sample size approach [9]. where 0.05 = error rate Results Parasitological survey A total of 2250 samples were tested from the 1685 individuals (Table 1). Although more than 1 diagnostic method was used in this study, no malaria cases were found using any of the 4 diagnostic tests. It is important to note that no cases were found among children below 5 years of age who were born after the epidemic of 1997–98. Entomological survey The entomological survey found that the 2 main malaria vectors in central and south- ern Iraq (A. stephensi and A. pulcherrimus) were present at the adult and larval stages. The findings from all 6 fixed stations were grouped together according to the method of collection of the adults and larvae by month of collection (Figure 1). A. stephensi adults were present during all months of the year except January, whereas A. pulcherrimus adults were present only during May to November. The highest number of both A. stephensi and A. pulcherrimus adults were found in June and September/October respectively. The larval stages of A. stephensi disappeared in December and January when the mean tem- perature was below 14 ºC. A. pulcherrimus larvae appeared in May and continued to be present until November. Two peaks of the Anopheles larvae were seen: the first in June and the second in October. A small number (n = 85) of captured Anopheles adults were dissected for malaria oocysts and sporozoites. Neither oocysts nor sporozoites were found in either A. stephensi or A. pulcherrimus. 274 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Figure 1 Annual numbers of Anopheles stephensi and Anopheles pulcherrimus species in Babylon governorate (Al-Hashimiyah and centre districts) according to collection method and month a) Total adults found by sucking tube method b) Total adults found by pyrethrum spray method c) Total larvae found Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 275 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Prediction of malaria epidemics The total number of A. stephensi caught in 6 stations from January to December 2002 was 1731 mosquitoes by pyrethrum spray collection method. This number was pooled into 1 sample, giving a mean 9.2 of mosqui- toes per room (Table 2). The malaria annual reports in 1997–98 indicated that the epi- demic began in October 1997 and peaked in January 1998 [3]. During the pre-epidemic months of August and September, the mean Anopheles density ranged from 0 to 11.2 mosquitoes per room. After the incidence of malaria began to decline in February, the mean Anopheles density ranged from 0 to 1.6 mosquitoes per room. An indoor resting density of 6 mosquitoes per room was chosen as the critical density indicating epidemic risk, because this value appeared to provide good separation between pre- and post-epidemic periods. Conversely, 1 mosquito per room was chosen as a normal density expected during non-epidemic peri- ods. Because we were interested in periods of elevated Anopheles density, only those sampling periods with a mean Anopheles density > 1 mosquito per room were used to determine Taylor’s power law coefficients. The number of A. stephensi caught in 6 sta- tions over 7 sampling periods (April to Oc- tober 2002) were pooled into 1 sample with mean of 16.5 mosquitoes per room (95% confidence interval, 14.4–18.6). This was significantly greater than the mean Anoph- eles density in 1997–98, 8.1 mosquitoes per room. Using the 7 sampling periods in which the mean A. stephensi density was > 1 mosquito per room, regression of [log (sam- pling period variance)] on [log (sampling period mean)] indicated a strong positive correlation (r = 0.98, P = 0.05). Estimates for the parameters a and b were 0.16 and 2.36 respectively, indicating aggregation in the data. Direct approach The number of houses required to calculate mean Anopheles density with allowable er- rors ranging from 10% to 50% of the mean was calculated using equation 2 with esti- mates of a and b as determined above. Sam- ples of 115, 29, 13, 7 and 5 houses would be needed to calculate mean mosquito densities with allowable errors of 10%, 20%, 30%, 40%, and 50% respectively (Figure 2). Minimum sample size approach The number of houses required to find at least 1 A. stephensi according to the mean Anopheles density was calculated using equation 3 and the parameters a and b as determined above. Samples of only 1 house would be needed to calculate mean mos- quito density with an error rate of 0.05%. Table 2 Indoor resting density of Anopheles stephensi during the study period in Babylon governorate (Al-Hashimiyah and centre district) Month A. steph. Sampled Indoor resting (No.) rooms density (No.) (No./room) Jan 0 15 0 Feb 1 15 0.1 Mar 2 10 0.2 Apr 14 10 1.4 May 30 12 2.5 Jun 260 15 17.3 Jul 164 13 12.6 Aug 397 18 22.1 Sept 625 18 34.7 Oct 230 18 12.8 Nov 8 21 0.4 Dec 0 24 0 Total 1731 189 9.2 r = 0.98. 276 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Failure to find any mosquitoes in a sample of 1 house would indicate that Anopheles spp. density was not yet above the critical threshold. Using the above 2 methods revealed that A. stephensi density had exceeded the criti- cal threshold and indicated there was a risk of an epidemic (Figure 2). Discussion In the parasitological survey the total number of blood films examined was higher than other diagnostic methods, because this method is considered the gold standard in malaria diagnosis in Iraq and other countries [12,13]. Blood smears were collected from all age groups, but were carefully focused on children below 5 years of age who were born after the epidemic of 1997–98. All of their results were negative. The World Health Organization has 2 parasitological criteria indicating that transmission has been interrupted at a certain date. First, no resident child born after that date should ever be found positive. Second, careful surveillance with adequate coverage should detect no new cases after that date [14,15]. Similar studies in central and southern areas of Iraq [16] and in Nineveh governorate in 1998–2000 (G. Al-Mukhtar, in press) found that malaria transmission had been inter- rupted and was under control. Northern Iraq belongs to the palaearctic region of the zoogeographical zones while its central and southern regions belong to the oriental zone and the annual occurrence of mosquito fauna differs accordingly between these regions. The annual occur- rence of A. stephensi and A. pulcherrimus recorded by the entomological survey in the present study agree closely with the find- Figure 2 Direct approach operating curve (AE = allowable error) Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 277 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم ings of Abul-Hab and Kassal [17] as well as Macan [18]. Our survey was extended to neighbouring districts from the original epidemic to check for the presence of the vectors. This is necessary now because Iraq is experiencing a re-emergence of the A. stephensi population after it had been well controlled since the 1960s [19]. It was found that the A. stephensi popu- lation was more abundant than A. pulcher- rimus. A. stephensi is regarded as the only important vector of malaria in the central and southern regions [18]. There were 2 peaks of Anopheles species, larvae and adults, the first in June and the second in October. These findings agreed with the findings of Macan [18] and Abul-Hab and Kassal [17]. It is important to note that while both malaria oocysts and sporozoites were detected in these other studies, no such stages were found in the dissected speci- mens of either A. stephensi or A. pulcher- rimus in this study. Malaria transmission in Iraq is regarded as unstable in the whole country [20]. Therefore, it is vital to develop the tools to predict epidemics. In Iraq, increased Anopheles densities are not always associ- ated with an epidemic but could be used as an indicator of epidemic risk. A. stephensi is the major malaria vector in the central and southern regions of Iraq. Indoor rest- ing A. stephensi density was used as an indicator of epidemic risk when its density exceeded the critical level. Both the critical and normal thresholds were determined from the entomological data before, during and after the epidemic of 1997–98 [3]. We chose 6 mosquitoes per room as the critical threshold indicating the risk of an epidemic because it appeared to adequately separate mean A. stephensi density associ- ated with epidemic transmission from the normal threshold during the post-epidemic period of 1997–98. Similarly, 1 mosquito per room was chosen as a normal threshold of A. stephensi density that was not associ- ated with the risk of an epidemic. It was observed that closely similar thresholds of A. stephensi densities were found and re- corded by the Communicable Disease Cen- tre Baghdad, i.e. 5 mosquitoes per room was regarded as a critical level and below this value was regarded as a normal level [3]. In our study, both the direct approach and the minimum sample size approach were used for determining whether A. stephensi density had exceeded a critical level [9]. In the direct approach, it was demonstrated that calculation of mean Anopheles density with a high degree of precision requires a large number of houses, because of the vari- ance in Anopheles density among houses. The number of houses required to sample would range from 5 to 115 houses for al- lowable errors of 50%–10% of the mean respectively. The mean A. stephensi density of 16.5 mosquitoes per room exceeded the critical level and indicated epidemic risk. In the minimum sample size approach, a mean density of 1 mosquito/house was required to determine whether A. stephensi density had exceeded the critical level. Less than this would indicate that the critical level had not been reached. However, it could be used as an initial screening tool during periods when Anopheles density was expected to be increasing. If a mean Anopheles density of 1 mosquito/house was found, monitoring could continue using the direct approach. A similar study in the African Highlands [9] found that it is feasible and probably appro- priate to include monitoring of Anopheles spp. density in the prediction of malaria epidemics. 278 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم This study concludes that malaria trans- mission in the Babylon governorate was successfully interrupted after the recent epidemic of 1997–98. However, malaria transmission could recur if A. stephensi indoor resting density exceeds the critical threshold and imported malaria cases are not monitored. We propose that malaria epidemics should be predicted by measur- ing the indoor resting mosquito density. Acknowledgements We thank Dr Jalil Al-Zudaidi, Director of Endemic Diseases Institute, Baghdad, for his assistance and all the staff of the ma- laria unit Primary Health Care Directorate, Babylon Governorate for their continuous help during most stages of the fieldwork of this study. References 1. Radford A J, Van Leeuwen H, Christian SH. Social aspects in the changing epi- demiology of malaria in the highlands of New Guinea. Annals of tropical medicine and parasitology, 1976, 70:11–23. 2. Roll back malaria. Epidemiological situa- tion. Iraq. Online fact sheet. Cairo, World Health Organization Eastern Mediterra- nean Regional Office (http://www.emro. who.int/rbm/EpidemiologicalSituation- CountryProfiles.htm, accessed 30 Octo- ber 2005). 3. Annual reports of malaria in Iraq. Bagh- dad, Iraq, Communicable Disease Cen- tre, Ministry of Health, 1997–98. 4. Worth MR. The heparinized capillary tube as an epidemiologic tool. II. concentra- tion of blood parasites by centrifugation. American journal of hygiene, 1964, 80:70–4. 5. Al-Khairy KS. An improved method of preparing thick blood films for the exami- nation of malaria parasites. Saudi medical journal, 1992, 13:542–5. 6. Malaria diagnosis—new perspectives. Report of a joint WHO/USAID informal consultation, 25–27 October 1999. Ge- neva, World Health Organization, 2000 (WHO/CDS/RBM/2000). 7. Manual on practical entomology in malaria prepared by the WHO division of malaria and other parasitic diseases. Geneva, World Health Organization, 1975. 8. Abul-Hab J. Medical and veterinary ento- mology in Iraq. Baghdad, Iraq, Baghdad University, 1979. 9. Lindblade KA, Walker ED, Wilson ML. Early warning of malaria epidemics in African highlands using Anopheles (Dip- tera: Culicidae) indoor resting density. Journal of medical entomology, 2000, 37: 664–74. 10. Taylor LR. Aggregation, variance and the mean. Nature, 1961, 189:732–5. 11. Wilson LT, Room PM. Clumping patterns of fruit and arthropods in cotton, with im- plications for binomial sampling. Environ- mental entomology, 1983, 12:50–4. 12. Ossi GT. Malaria in Iraq from 1980 to 1983. Bulletin of endemic diseases, 1984, 24:5–23. 13. Gilles HM, Warrell DA, eds. Bruce-Ch- watt’s essential malariology, 3rd ed. Lon- don, Edward Arnold, 1993. 14. WHO Expert Committee on Malaria [meet- ing held in Geneva from 21 to 27 Septem- ber 1965]: twelfth report. World Health Organization, Geneva, 1966 (Technical Report Series, No. 324). 15. WHO Expert Committee on Malaria [meet- ing held in Geneva from 19 to 30 October Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 279 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 1970]: fifteenth report. Geneva World Health Organization, 1971 (Technical Report Series, No. 467). 16. Shihab KI et al. Immunological and para- sitological survey in areas of Iraq where malaria transmission has been interrupted since several years. Bulletin of endemic diseases, 1987, 28:17–28. 17. Abul-Hab J, Kassal, S. Impact of anti-ma- laria spraying on the occurrence of Anoph- eles (Diptera: Culicidae) in Iraq. Bulletin of endemic diseases, 1986, 27:37–51. 18. Macan TT. The anopheline mosquitoes of Iraq and North Persia. In: Leeson HS et al., eds. Anopheles and malaria in the Near East (Memoirs of the London School of Hygiene and Tropical Medicine, No. 7). London, HK Lewis, 1950. 19. Annual reports of malaria in Iraq. Bagh- dad, Iraq, Communicable Disease Cen- tre, Ministry of Health, 1960–2001. 20. Al-Kafajei A, Ahmed KJ. Effectiveness of malaria control programs in Nineveh 1992. Journal of community medicine, Baghdad, 1993, 6:135–42. Malaria control in complex emergencies The areas of the world whose populations are most affected by com- plex emergencies are often those with the greatest malaria burden. Consequently, malaria is a significant cause of death and illness in complex emergency situations. This inter-agency handbook focuses on effective malaria control responses to complex emergencies, particularly during the acute phase when reliance on international hu- manitarian assistance is greatest. It provides policy-makers, planners, field programme managers and medical coordinators with practical guidance on designing and implementing measures to reduce malaria morbidity and mortality. Such measures must address the needs of both the displaced and the host populations and must accommodate the changes in those needs as an acute emergency evolves into a more stable situation. A glossary is provided at the beginning of the handbook and suggestions for further reading are included at the end of several chapters. Malaria control in complex emergencies. An inter-agency field hand- book (ISBN 92 4 159389) is available at the WHO bookshop at (http:// www.who.int/publications/en/) 280 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Environmental mycobacteria in areas of high and low tuberculosis prevalence in the Islamic Republic of Iran E. Ghaemi,1 K. Ghazisaidi,2 H. Koohsari,3 B. Khodabakhshi4 and A. Mansoorian4 1Department of Microbiology, Faculty of Medicine, Golestan University of Medical Sciences, Gorgan, Islamic Republic of Iran (Correspondence to E. Ghaemi: eghaemi@yahoo.com). 2Department of Pathobiology, Health Faculty, University of Tehran, Tehran, Islamic Republic of Iran. 3Department of Microbiology, Lahijan Free University, Islamic Republic of Iran. 4Faculty of Medicine, Golestan University of Medical Sciences, Gorgan, Islamic Republic of Iran. Received: 24/03/04; accepted: 05/10/04 ABSTRACT This research compared the numbers and types of different Mycobacterium species in soil samples taken from 2 areas of Golestan province, Islamic Republic of Iran, 1 with a high prevalence of tuberculosis and 1 with a low prevalence. From 220 samples, 91 grew positive cultures (41.4%) and 161 different strains were diagnosed. The most common species isolated were Mycobacterium fortuitum, M. flavescens and M. chelonae. The frequencies of environmental Mycobacterium in the low-prevalence area were much higher than in the high-prevalence area, perhaps due to different environmental fac- tors. Mycobactéries environnementales dans des zones à forte et faible prévalence tuberculeuse en République islamique d’Iran RÉSUMÉ La présente recherche a comparé le nombre et les types des différentes espèces de Myco- bacterium dans des échantillons de sol prélevés dans deux zones de la province de Golestan (Répu- blique islamique d’Iran), l’une ayant une forte prévalence tuberculeuse et l’autre une faible prévalence. Sur les 220 échantillons, 91 ont produit des cultures positives (41,4 %) et 161 souches différentes ont été diagnostiquées. Les espèces les plus couramment isolées étaient Mycobacterium fortuitum, M. flavescens et M. chelonae. La fréquence des mycobactéries environnementales dans la zone à fai- ble prévalence était beaucoup plus élevée que dans la zone à forte prévalence, ce qui tient sans doute à différents facteurs environnementaux. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 281 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction There are currently 71 recognized or pro- posed species of Mycobacterium [1], all of which, except M. tuberculosis complex and M. leprae, are considered as environmental mycobacteria and can usually be isolated from environmental samples including wa- ter, soil and dust [2]. The different environ- mental mycobacteria are very similar and for many years were mistakenly assumed to be M. tuberculosis in patients [1,2]. Nowa- days these bacteria are believed to have an important role in infections, allergies, immunity to other pulmonary infections and the efficacy of bacille Calmette-Guerin (BCG) vaccination [3]. These facultative pathogens can cause infection, especially among immunosup- pressed or immunodeficient patients [4]. Four types of opportunistic mycobacterial disease of humans have been described: skin lesions (following traumatic inocula- tion of bacteria), localized lymphadenitis, tuberculosis (TB)-like pulmonary lesions and disseminated disease [5]. However, the relative incidence of the environmental Mycobacterium spp. involved in human disease varies from region to region and is related to the occurrence of the species in the environment [6,7]. These bacteria are ubiquitous, so the nature, route and dose of exposure to environmental saprophytes are variables that depend on where and how an individual lives. Another reason for the medical impor- tance of environmental Mycobacterium is the potential impact on the immune re- sponse. Exposure to environmental myco- bacteria has been suggested to influence immune responsiveness to the pathogenic mycobacteria and to sensitize individuals to skin test reagents; it can also affect the ef- ficacy of BCG vaccination [3,7–9]. Contact with different species of environmental My- cobacterium can cause acquired immunity to M. tuberculosis or increase the efficacy of BCG vaccine protection (M. vaccae, M. microti), although some species of these bacteria reduce the efficacy of BCG vaccine (M. scrofulaceum) [8,10–13]. Golestan province, which is located in north of the Islamic Republic of Iran, near the Caspian Sea, has one of the highest rates of incidence of TB in the country (45.5 per 100 000). However, the distribution of TB is not homogenous and the incidence is higher in the western than the eastern part of the province: mean incidences are 54.6 to 28.1 per 100 000 respectively (provincial health centre, personal communication). Our objective in this research was to compare the number and types of different species of Mycobacterium in the soil from these 2 areas of the province. Methods The study took place in 2001–02. During the summer of 2001, a total of 220 soil samples were taken from humid and wet mud from a depth of 3–5 cm; 120 samples from 20 loca- tions in an area of high TB prevalence in the western part of Golestan province and the remainder from 24 locations in an area of low TB prevalence in the eastern part of the province. The locations, mostly agricultural areas, were chosen randomly and 5 samples were taken from each. Samples were taken from upper layers of soil, at a depth of 5 cm, and placed in separate sterile glass tubes. Samples were transferred directly to the Microbiology Laboratory of Golestan University of Medi- cal Sciences. A suspension was made using 1 g of soil in 10 mL of sterile distilled water containing 2–3 drops of Tween 80 [14]. The prepared suspensions were shaken for 30 min, left for undisturbed for 30 min, 282 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم then 3 mL of supernatant was transferred to another test tube and 3 mL of solution (11.7 g/L NaOH and 5% NaHCl, ratio 6:1) added to decontaminate the samples. The test tubes were centrifuged for 20 min at 2000 rpm, then the supernatant was decanted and a few drops of sterile distilled water were added to the sediment to neutralize the sam- ple, 200 μL of sample were inoculated in Lowenstein–Jensen media and growths were assessed every 2–3 days for a period of 1 month. The isolated colonies were as- sessed by growth rate, morphology of colo- ny, pigmentation in dark and light, and the results of a battery of standard biochemical tests: catalase production test at 25 ºC and 68 ºC, growth on MacConkey agar plate, NaCL tolerance, niacin production test, tel- lurite and nitrate reduction test, urease test and Tween 80 hydrolysis [6,15]. Results From 220 soil samples, environmental my- cobacteria were isolated from 91 samples (41.4%). Overall 161 strains of Mycobac- terium belonging to 12 species were iso- lated. The isolation rate of environmental mycobacteria in the high-prevalence area was 20.8% (25 samples) but in the low- prevalence area was 66.0% (66 samples). This difference was statistically significant (P < 0.05) (Table 1). In the high-prevalence area, 47 strains of environmental mycobacteria were isolated from 25 positive samples and M. fortuitum, M. flavescens and M. chelonae were the most common species. In 9 samples 2–5 strains were isolated. All the isolated Mycobacterium from this area belonged to 8 species (Table 2). In the low-prevalence area, 114 strains belonging to 11 species were isolated from 66 positive soil cultures, and M. flavescens, M. chelonae and M. fortuitum were more prevalent than other strains (23, 21 and 19 cases, respectively). M. phlei were isolated from 14 soil samples in the low-prevalence area but were not isolated from the high-prevalence area. M. terrae, M. gordonae, M. kansasii were also isolated in limited numbers from the low-prevalence but not from the high- prevalence area. M. gastri was only isolated from the high-prevalence area (Table 2). In 35 samples 2–6 strains were isolated. Discussion In this study in Golestan province 41.4% of soil samples contained environmental mycobacteria. This figure is similar to the results from other provinces in the north of the Islamic Republic of Iran bordering the Caspian Sea [16–18], presumably due to the Table 1 Partial distribution of positive soil culture of environmental Mycobacterium spp. in a Caspian Sea province in areas of high and low tuberculosis prevalence Variable High- Low- Total prevalence area prevalence area No. % No. % No. % Samples taken 120 100 220 Positive cultures 25 20.8 66 66.0 91 41.4 Isolated species 8 11 12 Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 283 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم similarity in climate (Mediterranean-type), humidity and plant flora in these areas. In the present study, the isolation rate of Mycobacterium spp. in the area of high TB prevalence (20.8%) was significantly lower than in the area of low TB prevalence (66.0%). Environmental factors are the most likely explanation for this differ- ence (high-prevalence areas are warmer, dryer, further from the sea with less herbal coverage than low-prevalence areas). It suggests, however, that people living in low-prevalence areas have more contact with environmental Mycobacterium strains than residents of high-prevalence areas. The most prevalent species isolated from the soil in this study was M. fortuitum complex. This is similar to Kampala’s study from south India [19]. Some of the isolated environmental Mycobacterium, such as M. marinum, M. kansasii and some rapid- growing species such as M. chelonae and M. fortuitum, can be pathogenic for humans [1,6]. They are almost always acquired directly from the environment. A major factor determining the occurrence of infec- tions caused by the various species is their distribution in the environment, especially in water pipes [6]. As for the high preva- lence of 2 species of M. fortuitum and M. chelonae in this region, physicians should be aware of opportunistic Mycobacterium when encountering patients with pulmonary and soft tissue diseases [5,6]. Geographical variation in the efficacy of Mycobacterium bovis BCG vaccination against TB is well recognized [12]. Dif- ferent studies in human populations and experimental studies with animals show that infection with some environmental mycobacteria can offer a level of protection against TB similar to that offered by BCG and that, depending on the nature of the environmental mycobacteria and the tim- Table 2 Partial distribution of different environmental Mycobacterium spp. isolated from soil in a Caspian Sea province in areas of high and low tuberculosis prevalence Species High- Low- Total prevalence area prevalence area No. % No. % No. % M. fortuitum 16 34.0 19 16.6 35 21.8 M. flavescens 10 21.2 23 20.1 33 20.5 M. chelonae 6 12.8 21 18.4 27 16.8 M. thermoresistibile 5 10.6 15 13.1 20 12.4 M. phlei – – 14 12.3 14 8.7 M. triviale 4 8.5 6 5.3 10 6.2 M. terrae – – 8 7.1 8 4.9 M. gordonae – – 4 3.5 4 2.5 M. fallax 2 4.3 2 1.8 4 2.8 M. gastri 3 6.4 – – 2 1.9 M. marinum 1 2.1 1 0.9 2 1.2 M. kansasii – – 1 0.9 1 0.6 Total 47 100.0 114 100.0 161 100.0 284 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم ing, this exposure can also enhance, mask or interfere with the effect of subsequent BCG vaccination. Thus, regional differ- ences in environmental mycobacteria flora along with several other mechanisms could be responsible for the widely varying results of BCG trials or could influence the course of subsequent infection with virulent TB bacilli [6,11,13,19]. A study in Karonga dis- trict in Northern Malawi (a region in which BCG vaccination has no effect against pulmonary TB but provides over 50% protection against leprosy) demonstrated that prior sensitization with environmental mycobacteria can inhibit BCG multiplica- tion and thereby prevent the induction of an efficient BCG-mediated immune response and protection against TB challenge [8]. Geographic gradients of leprosy prevalence are reported in Karonga District, with the disease more common in the north than in the south, a pattern that may be related to protective mycobacterial exposure in the low-incidence area [9]. The data presented in the above studies provide strong evidences that exposure to various environmental mycobacteria can influence the immune response to BCG vaccination and subsequent prevalence of TB [9]. However, there have been few stud- ies on the effect of repeated environmental mycobacteria contact on those individuals whom received earlier BCG vaccine (in infancy) and in its efficacy on inhibition of TB. BCG vaccination is given to all infants at the time of birth in Golestan province, and the prevalence of environmental my- cobacteria is higher in locations of high TB incidence than locations of low TB incidence. This raises the question whether these mycobacteria can act as booster dose of BCG vaccine to continually stimulate the immune system and keep it as active form in case of contact with M. tuberculosis. Further studies are required to answer this question. References 1. Collier L, Balows A, Sussman M, eds. Topley and Wilson’s microbiology and mi- crobial infections, 9th ed. London, Edward Arnold, 1998. 2. Zyazarifi A. Biology and bacteriology of mycobacteria. Tehran, Aboryhan Press, 1987:10–5 [in Farsi]. 3. Primm TP, Lucero CA, Falkinham JO. Health impacts of environmental myco- bacteria. Clinical microbiology reviews, 2004, 17(1):98–106. 4. Covert TC et al. Occurrence of nontu- berculous mycobacteria in environmen- tal sample. Applied and environmental microbiology, 1999, 65:2492–6. 5. Wallace RJ et al. Spectrum of disease due to rapidly growing mycobacteria. Reviews of infectious diseases, 1983, 5: 657–79. 6. Murray PR et al. Manual of clinical microbi- ology, 7th ed. Washington DC, American Society for Microbiology Press, 1999. 7. Howard CJ. Exposure to Mycobacteri- um avium primes the immune system of calves for vaccination with Mycobacteri- um bovis BCG. Clinical and experimental immunology, 2002, 130:190–5. 8. Brandt L et al. Failure of the Mycobacte- rium bovis BCG vaccine: some species of environmental mycobacteria block multi- plication of BCG and induction of protec- tive immunity to tuberculosis. Infection and immunity, 2002, 70(2):672–8. 9. Black GF et al. Patterns and implications of naturally acquired immune responses to environmental and tuberculous mycobac- terial antigens in northern Malawi. Journal of infectious diseases, 2001, 184:322–9. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 285 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 10. Stanford JL, Shield MJ, Rook GA. How environmental mycobacteria may prede- termine the protective efficacy of BCG. Tubercle, 1981, 62:55–62. 11. Palmer CE, Long MW. Effects of infection with atypical mycobacteria on BCG vacci- nation and tuberculosis. American review of respiratory disease, 1966, 94:553–68. 12. Fine PE. Variation in protection by BCG: implications of and for heterologous im- munity. Lancet, 1995, 346:1339–45. 13. Lozes E et al. Cross-reactive immune responses against Mycobacterium bovis BCG in mice infected with non- tuberculous mycobacteria belonging to the MAIS-group. Scandinavian journal of immunology, 1997, 46(1):16–26. 14. Donoghue HD, Overend E, Stanford JL. A longitudinal study of environmental mycobacteria on a farm in South-West England. Journal of applied microbiology, 1997, 82:57–67. 15. Isenberg HD. Essential procedures for clinical microbiology, 1st ed. Washington DC, American Society for Microbiology Press, 1998:187–97. 16. Bashiri AR. Environmental mycobacte- ria isolation from soil in Gilan Province [thesis]. Tehran, Islamic Republic of Iran, Tehran University, 1998:69–75 [in Farsi]. 17. Rastegar M. Environmental mycobacteria of soil in Mazenderan Province [thesis]. Tehran, Islamic Republic of Iran, Tehran University, 1992:85–91 [in Farsi]. 18. Mohammadi M. Environmental mycobac- teria in fish pools in Gilan and Mazendran Provinces of Iran [thesis]. Tehran, Is- lamic Republic of Iran, Tehran University, 1994:78–89 [in Farsi]. 19. Kamala T et al. Isolation and identifica- tion of environmental mycobacteria in the Mycobacterium bovis BCG trial area of South India. Applied and environmental microbiology, 1994, 60(6):2180–3. 280 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Environmental mycobacteria in areas of high and low tuberculosis prevalence in the Islamic Republic of Iran E. Ghaemi,1 K. Ghazisaidi,2 H. Koohsari,3 B. Khodabakhshi4 and A. Mansoorian4 1Department of Microbiology, Faculty of Medicine, Golestan University of Medical Sciences, Gorgan, Islamic Republic of Iran (Correspondence to E. Ghaemi: eghaemi@yahoo.com). 2Department of Pathobiology, Health Faculty, University of Tehran, Tehran, Islamic Republic of Iran. 3Department of Microbiology, Lahijan Free University, Islamic Republic of Iran. 4Faculty of Medicine, Golestan University of Medical Sciences, Gorgan, Islamic Republic of Iran. Received: 24/03/04; accepted: 05/10/04 ABSTRACT This research compared the numbers and types of different Mycobacterium species in soil samples taken from 2 areas of Golestan province, Islamic Republic of Iran, 1 with a high prevalence of tuberculosis and 1 with a low prevalence. From 220 samples, 91 grew positive cultures (41.4%) and 161 different strains were diagnosed. The most common species isolated were Mycobacterium fortuitum, M. flavescens and M. chelonae. The frequencies of environmental Mycobacterium in the low-prevalence area were much higher than in the high-prevalence area, perhaps due to different environmental fac- tors. Mycobactéries environnementales dans des zones à forte et faible prévalence tuberculeuse en République islamique d’Iran RÉSUMÉ La présente recherche a comparé le nombre et les types des différentes espèces de Myco- bacterium dans des échantillons de sol prélevés dans deux zones de la province de Golestan (Répu- blique islamique d’Iran), l’une ayant une forte prévalence tuberculeuse et l’autre une faible prévalence. Sur les 220 échantillons, 91 ont produit des cultures positives (41,4 %) et 161 souches différentes ont été diagnostiquées. Les espèces les plus couramment isolées étaient Mycobacterium fortuitum, M. flavescens et M. chelonae. La fréquence des mycobactéries environnementales dans la zone à fai- ble prévalence était beaucoup plus élevée que dans la zone à forte prévalence, ce qui tient sans doute à différents facteurs environnementaux. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 281 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction There are currently 71 recognized or pro- posed species of Mycobacterium [1], all of which, except M. tuberculosis complex and M. leprae, are considered as environmental mycobacteria and can usually be isolated from environmental samples including wa- ter, soil and dust [2]. The different environ- mental mycobacteria are very similar and for many years were mistakenly assumed to be M. tuberculosis in patients [1,2]. Nowa- days these bacteria are believed to have an important role in infections, allergies, immunity to other pulmonary infections and the efficacy of bacille Calmette-Guerin (BCG) vaccination [3]. These facultative pathogens can cause infection, especially among immunosup- pressed or immunodeficient patients [4]. Four types of opportunistic mycobacterial disease of humans have been described: skin lesions (following traumatic inocula- tion of bacteria), localized lymphadenitis, tuberculosis (TB)-like pulmonary lesions and disseminated disease [5]. However, the relative incidence of the environmental Mycobacterium spp. involved in human disease varies from region to region and is related to the occurrence of the species in the environment [6,7]. These bacteria are ubiquitous, so the nature, route and dose of exposure to environmental saprophytes are variables that depend on where and how an individual lives. Another reason for the medical impor- tance of environmental Mycobacterium is the potential impact on the immune re- sponse. Exposure to environmental myco- bacteria has been suggested to influence immune responsiveness to the pathogenic mycobacteria and to sensitize individuals to skin test reagents; it can also affect the ef- ficacy of BCG vaccination [3,7–9]. Contact with different species of environmental My- cobacterium can cause acquired immunity to M. tuberculosis or increase the efficacy of BCG vaccine protection (M. vaccae, M. microti), although some species of these bacteria reduce the efficacy of BCG vaccine (M. scrofulaceum) [8,10–13]. Golestan province, which is located in north of the Islamic Republic of Iran, near the Caspian Sea, has one of the highest rates of incidence of TB in the country (45.5 per 100 000). However, the distribution of TB is not homogenous and the incidence is higher in the western than the eastern part of the province: mean incidences are 54.6 to 28.1 per 100 000 respectively (provincial health centre, personal communication). Our objective in this research was to compare the number and types of different species of Mycobacterium in the soil from these 2 areas of the province. Methods The study took place in 2001–02. During the summer of 2001, a total of 220 soil samples were taken from humid and wet mud from a depth of 3–5 cm; 120 samples from 20 loca- tions in an area of high TB prevalence in the western part of Golestan province and the remainder from 24 locations in an area of low TB prevalence in the eastern part of the province. The locations, mostly agricultural areas, were chosen randomly and 5 samples were taken from each. Samples were taken from upper layers of soil, at a depth of 5 cm, and placed in separate sterile glass tubes. Samples were transferred directly to the Microbiology Laboratory of Golestan University of Medi- cal Sciences. A suspension was made using 1 g of soil in 10 mL of sterile distilled water containing 2–3 drops of Tween 80 [14]. The prepared suspensions were shaken for 30 min, left for undisturbed for 30 min, 282 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم then 3 mL of supernatant was transferred to another test tube and 3 mL of solution (11.7 g/L NaOH and 5% NaHCl, ratio 6:1) added to decontaminate the samples. The test tubes were centrifuged for 20 min at 2000 rpm, then the supernatant was decanted and a few drops of sterile distilled water were added to the sediment to neutralize the sam- ple, 200 μL of sample were inoculated in Lowenstein–Jensen media and growths were assessed every 2–3 days for a period of 1 month. The isolated colonies were as- sessed by growth rate, morphology of colo- ny, pigmentation in dark and light, and the results of a battery of standard biochemical tests: catalase production test at 25 ºC and 68 ºC, growth on MacConkey agar plate, NaCL tolerance, niacin production test, tel- lurite and nitrate reduction test, urease test and Tween 80 hydrolysis [6,15]. Results From 220 soil samples, environmental my- cobacteria were isolated from 91 samples (41.4%). Overall 161 strains of Mycobac- terium belonging to 12 species were iso- lated. The isolation rate of environmental mycobacteria in the high-prevalence area was 20.8% (25 samples) but in the low- prevalence area was 66.0% (66 samples). This difference was statistically significant (P < 0.05) (Table 1). In the high-prevalence area, 47 strains of environmental mycobacteria were isolated from 25 positive samples and M. fortuitum, M. flavescens and M. chelonae were the most common species. In 9 samples 2–5 strains were isolated. All the isolated Mycobacterium from this area belonged to 8 species (Table 2). In the low-prevalence area, 114 strains belonging to 11 species were isolated from 66 positive soil cultures, and M. flavescens, M. chelonae and M. fortuitum were more prevalent than other strains (23, 21 and 19 cases, respectively). M. phlei were isolated from 14 soil samples in the low-prevalence area but were not isolated from the high-prevalence area. M. terrae, M. gordonae, M. kansasii were also isolated in limited numbers from the low-prevalence but not from the high- prevalence area. M. gastri was only isolated from the high-prevalence area (Table 2). In 35 samples 2–6 strains were isolated. Discussion In this study in Golestan province 41.4% of soil samples contained environmental mycobacteria. This figure is similar to the results from other provinces in the north of the Islamic Republic of Iran bordering the Caspian Sea [16–18], presumably due to the Table 1 Partial distribution of positive soil culture of environmental Mycobacterium spp. in a Caspian Sea province in areas of high and low tuberculosis prevalence Variable High- Low- Total prevalence area prevalence area No. % No. % No. % Samples taken 120 100 220 Positive cultures 25 20.8 66 66.0 91 41.4 Isolated species 8 11 12 Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 283 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم similarity in climate (Mediterranean-type), humidity and plant flora in these areas. In the present study, the isolation rate of Mycobacterium spp. in the area of high TB prevalence (20.8%) was significantly lower than in the area of low TB prevalence (66.0%). Environmental factors are the most likely explanation for this differ- ence (high-prevalence areas are warmer, dryer, further from the sea with less herbal coverage than low-prevalence areas). It suggests, however, that people living in low-prevalence areas have more contact with environmental Mycobacterium strains than residents of high-prevalence areas. The most prevalent species isolated from the soil in this study was M. fortuitum complex. This is similar to Kampala’s study from south India [19]. Some of the isolated environmental Mycobacterium, such as M. marinum, M. kansasii and some rapid- growing species such as M. chelonae and M. fortuitum, can be pathogenic for humans [1,6]. They are almost always acquired directly from the environment. A major factor determining the occurrence of infec- tions caused by the various species is their distribution in the environment, especially in water pipes [6]. As for the high preva- lence of 2 species of M. fortuitum and M. chelonae in this region, physicians should be aware of opportunistic Mycobacterium when encountering patients with pulmonary and soft tissue diseases [5,6]. Geographical variation in the efficacy of Mycobacterium bovis BCG vaccination against TB is well recognized [12]. Dif- ferent studies in human populations and experimental studies with animals show that infection with some environmental mycobacteria can offer a level of protection against TB similar to that offered by BCG and that, depending on the nature of the environmental mycobacteria and the tim- Table 2 Partial distribution of different environmental Mycobacterium spp. isolated from soil in a Caspian Sea province in areas of high and low tuberculosis prevalence Species High- Low- Total prevalence area prevalence area No. % No. % No. % M. fortuitum 16 34.0 19 16.6 35 21.8 M. flavescens 10 21.2 23 20.1 33 20.5 M. chelonae 6 12.8 21 18.4 27 16.8 M. thermoresistibile 5 10.6 15 13.1 20 12.4 M. phlei – – 14 12.3 14 8.7 M. triviale 4 8.5 6 5.3 10 6.2 M. terrae – – 8 7.1 8 4.9 M. gordonae – – 4 3.5 4 2.5 M. fallax 2 4.3 2 1.8 4 2.8 M. gastri 3 6.4 – – 2 1.9 M. marinum 1 2.1 1 0.9 2 1.2 M. kansasii – – 1 0.9 1 0.6 Total 47 100.0 114 100.0 161 100.0 284 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم ing, this exposure can also enhance, mask or interfere with the effect of subsequent BCG vaccination. Thus, regional differ- ences in environmental mycobacteria flora along with several other mechanisms could be responsible for the widely varying results of BCG trials or could influence the course of subsequent infection with virulent TB bacilli [6,11,13,19]. A study in Karonga dis- trict in Northern Malawi (a region in which BCG vaccination has no effect against pulmonary TB but provides over 50% protection against leprosy) demonstrated that prior sensitization with environmental mycobacteria can inhibit BCG multiplica- tion and thereby prevent the induction of an efficient BCG-mediated immune response and protection against TB challenge [8]. Geographic gradients of leprosy prevalence are reported in Karonga District, with the disease more common in the north than in the south, a pattern that may be related to protective mycobacterial exposure in the low-incidence area [9]. The data presented in the above studies provide strong evidences that exposure to various environmental mycobacteria can influence the immune response to BCG vaccination and subsequent prevalence of TB [9]. However, there have been few stud- ies on the effect of repeated environmental mycobacteria contact on those individuals whom received earlier BCG vaccine (in infancy) and in its efficacy on inhibition of TB. BCG vaccination is given to all infants at the time of birth in Golestan province, and the prevalence of environmental my- cobacteria is higher in locations of high TB incidence than locations of low TB incidence. This raises the question whether these mycobacteria can act as booster dose of BCG vaccine to continually stimulate the immune system and keep it as active form in case of contact with M. tuberculosis. Further studies are required to answer this question. References 1. Collier L, Balows A, Sussman M, eds. Topley and Wilson’s microbiology and mi- crobial infections, 9th ed. London, Edward Arnold, 1998. 2. Zyazarifi A. Biology and bacteriology of mycobacteria. Tehran, Aboryhan Press, 1987:10–5 [in Farsi]. 3. Primm TP, Lucero CA, Falkinham JO. Health impacts of environmental myco- bacteria. Clinical microbiology reviews, 2004, 17(1):98–106. 4. Covert TC et al. Occurrence of nontu- berculous mycobacteria in environmen- tal sample. Applied and environmental microbiology, 1999, 65:2492–6. 5. Wallace RJ et al. Spectrum of disease due to rapidly growing mycobacteria. Reviews of infectious diseases, 1983, 5: 657–79. 6. Murray PR et al. Manual of clinical microbi- ology, 7th ed. Washington DC, American Society for Microbiology Press, 1999. 7. Howard CJ. Exposure to Mycobacteri- um avium primes the immune system of calves for vaccination with Mycobacteri- um bovis BCG. Clinical and experimental immunology, 2002, 130:190–5. 8. Brandt L et al. Failure of the Mycobacte- rium bovis BCG vaccine: some species of environmental mycobacteria block multi- plication of BCG and induction of protec- tive immunity to tuberculosis. Infection and immunity, 2002, 70(2):672–8. 9. Black GF et al. Patterns and implications of naturally acquired immune responses to environmental and tuberculous mycobac- terial antigens in northern Malawi. Journal of infectious diseases, 2001, 184:322–9. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 285 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 10. Stanford JL, Shield MJ, Rook GA. How environmental mycobacteria may prede- termine the protective efficacy of BCG. Tubercle, 1981, 62:55–62. 11. Palmer CE, Long MW. Effects of infection with atypical mycobacteria on BCG vacci- nation and tuberculosis. American review of respiratory disease, 1966, 94:553–68. 12. Fine PE. Variation in protection by BCG: implications of and for heterologous im- munity. Lancet, 1995, 346:1339–45. 13. Lozes E et al. Cross-reactive immune responses against Mycobacterium bovis BCG in mice infected with non- tuberculous mycobacteria belonging to the MAIS-group. Scandinavian journal of immunology, 1997, 46(1):16–26. 14. Donoghue HD, Overend E, Stanford JL. A longitudinal study of environmental mycobacteria on a farm in South-West England. Journal of applied microbiology, 1997, 82:57–67. 15. Isenberg HD. Essential procedures for clinical microbiology, 1st ed. Washington DC, American Society for Microbiology Press, 1998:187–97. 16. Bashiri AR. Environmental mycobacte- ria isolation from soil in Gilan Province [thesis]. Tehran, Islamic Republic of Iran, Tehran University, 1998:69–75 [in Farsi]. 17. Rastegar M. Environmental mycobacteria of soil in Mazenderan Province [thesis]. Tehran, Islamic Republic of Iran, Tehran University, 1992:85–91 [in Farsi]. 18. Mohammadi M. Environmental mycobac- teria in fish pools in Gilan and Mazendran Provinces of Iran [thesis]. Tehran, Is- lamic Republic of Iran, Tehran University, 1994:78–89 [in Farsi]. 19. Kamala T et al. Isolation and identifica- tion of environmental mycobacteria in the Mycobacterium bovis BCG trial area of South India. Applied and environmental microbiology, 1994, 60(6):2180–3. 286 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Antimicrobial effectiveness of furazolidone against metronidazole- resistant strains of Helicobacter pylori R. Safaralizadeh,1 F. Siavoshi,2 R. Malekzadeh,3 M.R. Akbari,3 M.H. Derakhshan,3 M.R. Sohrabi3 and S. Massarrat3 1Immunology, Asthma and Allergy Research Institute; 3Digestive Disease Research Centre, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 2Faculty of Sciences, University of Tehran, Tehran, Islamic Republic of Iran (Correspondence to F. Siavoshi: Siavoshi@Khayam.ut.ac.ir). Received: 25/12/03; accepted: 11/11/04 ABSTRACT The occurrence of strains resistant to metronidazole is causing failure of the 4-drug regi- men for eradication of Helicobacter pylori in the Islamic Republic of Iran. This study compared the in vitro efficacy of furazolidone with metronidazole, clarithromycin, amoxicillin and tetracycline in 70 H. pylori isolates from dyspeptic patients. Of the isolates, 33% were resistant to metronidazole but all were susceptible to furazolidone. Furazolidone could be considered as an appropriate substitute for metronidazole for H. pylori infections. Efficacité antimicrobienne de la furazolidone contre les souches d’Helicobacter pylori résistantes au métronidazole RÉSUMÉ L’apparition de souches résistantes au métronidazole cause l’échec du schéma associant quatre médicaments pour un traitement d’éradication d’Helicobacter pylori en République islamique d’Iran. La présente étude a comparé l’efficacité in vitro de la furazolidine avec le métronidazole, la clarithromycine, l’amoxicilline et la tétracycline pour 70 isolats de H. pylori provenant de patients dys- peptiques. Parmi ces isolats, 33 % présentaient une résistance au métronizadole, mais tous ont montré une sensibilité à la furazolidone. La furazolidone pourrait être considérée comme substitut approprié du métronidazole pour les infections à H. pylori. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 287 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction Many studies on the chemotherapy of Helicobacter pylori infections have indi- cated that eradication of H. pylori from the human stomach is hard to achieve and recrudescence occurs as a result of a per- sistent residual population that survived the therapy or re-infection with new strains. The low efficacy of currently used antimi- crobials, even as quadruple regimens, urges researchers to look for novel antimicrobials with higher efficacy. Metronidazole has been included in quadruple therapies in the Islamic Republic of Iran, but due to suboptimal eradication rates, investigators have attempted to replace it with other antimicrobials such as furazolidone [1]. However, resistance to metronidazole has been reported with varying degrees (20%–30%), reaching up to 70% in some European countries [2]. There is evidence that most metronidazole-resist- ant strains have a mutation in the RDXA gene, which leads to an inability to reduce the active nitro- group in metronidazole [3]. Although clarithromycin is effective when used in combination with a bismuth salt, a proton pump inhibitor (PPI), and amoxicillin or metronidazole [4,5], world- wide reports also describe an increasing emergence of resistant strains [6,7], reach- ing up to 14% in France [8]. Clarithromycin resistance is believed to result from clonal selection of resistant variants rather than from reinfection with exogenous clari- thromycin-resistant strains [9]. Resistance appears to be due to a single nucleotide mu- tation [10] or post-transcriptional methyla- tion of the 23S rRNA [11]. Amoxicillin and tetracycline are the 2 most highly effective antimicrobials against H. pylori in vitro and there are very few reports of resistant strains emerging [12–14]. Furazolidone appears to be an effective antimicrobial agent against H. pylori, particularly in combination with other antimicrobials such as clarithromycin [15,16] or tetracycline [17]. Furthermore, there are few reports of H. pylori resistance to furazolidone [18,19]. H. pylori infection is highly prevalent in the population of the Islamic Republic of Iran (> 80% in one study [20]) and a consid- erable proportion of individuals suffer from dyspeptic diseases such as gastric ulcer [20] or cancer [21]. Furthermore, a high frequency (37%) of metronidazole-resistant strains in the country increases the risk of persistence of H. pylori infection [22]. Ac- cordingly, this might be a plausible reason for incorporating furazolidone in quadruple regimens for the eradication of metronida- zole-resistant strains of H. pylori. In this study, epsilometer (E-test) and disk diffusion methods were used to compare the susceptibility of H. pylori isolates from Iranian patients to a range of antimicrobials including furazolidone. The minimum inhibitory concentration (MIC) of the antimicrobials was also determined. Methods The study group was 70 dyspeptic patients referred to the endoscopy unit at Shariaty Hospital in Tehran, Islamic Republic of Iran between 2001–03. The patients were diag- nosed with ulcer (9), oesophagitis (18), Bar- rett’s oesophagus (15) and gastritis (28). Antral biopsies were cultured on se- lective Brucella blood agar (Merck), and plates were incubated under microaerobic conditions (5% CO2) at 37 °C. The iden- tity of bacterial isolates was confirmed by microscopy and positive catalase, oxidase and urease reactions. Three-day cultures were used to prepare bacterial suspensions in normal saline, with the turbidity equiva- 288 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم lent to McFarland standard no. 1. Volumes of 100 μL of bacterial suspensions were spread evenly over the Mueller–Hinton agar containing 7% defibrinated blood. E-test strips (AB Biodisk, Solna, Sweden) or blank paper disks were then deposited on the surface of the inoculated plates. Plates were incubated as mentioned earlier and examined after 2–5 days. The E-test was used to assess the sus- ceptibility of H. pylori isolates to met- ronidazole, clarithromycin, amoxicillin and tetracycline. The MIC obtained for amoxicillin, tetracycline and clarithromycin were within the same range of 0.016–0.25 μg/mL. Highly susceptible strains produced inhibition zones at MIC ≤ 0.016 mμg/mL. Susceptible isolates had MIC ranging from 0.016–0.25 μg/mL. Those H. pylori strains which were not inhibited by antimicro- bial concentrations of ≥ 0.25 μg/mL were considered as resistant or highly resistant. For metronidazole, however, the MIC was different, ranging from 8–32 μg/mL. Highly resistant strains were not inhibited by con- centrations of ≥ 32 μg/mL and resistant strains grew at metronidazole concentra- tions between 8–32 μg/mL. Susceptible strains produced inhibition zones at metro- nidazole concentrations of < 8 μg/mL. The antimicrobial efficacy of furazo- lidone against H. pylori was assessed by the disk diffusion method. Serial dilutions of furazolidone (Sigma): 1, 0.75, 0.5, 0.25, 0.12 and 0.06 μg/mL were prepared in dimethylformamide. Then 10 μL volumes of furazolidone dilutions were introduced into paper disks on the surface-inoculated blood agar. The plates were examined after 2–5 days of microaerobic incubation. The MIC for furazolidone was determined as 0.12 μg/mL and susceptibility of H. pylori isolates was determined on the basis of the diameter of inhibition zones. Strains of H. pylori exhibiting the inhibition zones of 13–16 mm were considered as susceptible, and those producing inhibition zones of > 16 mm were considered as highly suscepti- ble. Growth inhibition was not observed on plates deposited with blank discs containing dimethylformamide only. Results From 70 H. pylori isolates tested for suscep- tibility to amoxicillin, 61.4% were highly susceptible, 37.1% susceptible, and only 1 strain (1.4%) exhibited resistance (Table 1). The latter was highly susceptible to other antimicrobials. The majority of H. pylori isolates (72.8%) were highly susceptible to low concentrations of tetracycline, but 27.1% were inhibited by higher concentra- tions (0.016–0.25 mμg/mL), and are thus considered as susceptible. Resistance to tet- Table 1 Susceptibility of 70 isolates of H. pylori to amoxicillin, tetracycline and clarithromycin by epsilometer (E-test) Antimicrobial Highly susceptible Susceptible Resistant agent MIC ≤ 0.01 0.016 < MIC < 0.25 MIC ≥ 0.2 No. % 95% CI No. % 95% CI No. % 95% CI Amoxicillin 43 61.4 49.0–72.8 26 37.1 25.9–49.5 1 1.4 0.0–7.7 Tetracycline 51 72.9 60.9–82.8 19 27.1 17.2–39.1 0 0.0 Clarithromycin 65 92.9 84.1–97.6 4 5.7 1.5–13.9 1 1.4 0.0–7.7 MIC = minimum inhibitory concentration (μg/mL). CI = confidence interval. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 289 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم racycline was not observed among H. pylori isolates (Table 1). Clarithromycin showed a considerable efficacy in inhibiting H. pylori. Sixty-five out of 70 (92.9%) strains were highly sus- ceptible, 5.7% susceptible, and only 1 strain (1.4%) showed resistance to clarithromycin (Table 1). H. pylori isolates were also resistant to metronidazole: 21.4% were highly resistant, 11.4% resistant and 67.1% susceptible to metronidazole (Table 2). The frequency of metronidazole resistance in isolates from patients with Barrett’s oesophagus (20.0%), ulcer (22.2%), and oesophagitis (27.8%) was higher than those from gastritis patients (17.9%), but t-test analysis showed it was not significant (P = 0.56) (Table 3). Among 70 H. pylori isolates, 7 (10.0%; 95% CI: 4.1–19.5%) were susceptible and 63 (90.0%; 95% CI: 80.5–95.9%) were highly susceptible to furazolidone. None of the isolates exhibited resistance to furazo- lidone (Table 4). The number of highly sus- ceptible H. pylori isolates to furazolidone was significantly more than to amoxicillin (P < 0.001; t-test), tetracycline (P < 0.01; t- test), and metronidazole (P < 0.001; t-test). Discussion Quadruple therapies have been proved to be the most effective antimicrobial regimens against H. pylori in the Islamic Republic of Iran [1,4,23], and recrudescence of infec- tion occurs mainly due to the occurrence of strains resistant to metronidazole [1]. Metronidazole, although considered as one of the most suitable antimicrobials, induces the highest rate of resistance (15%–90%) in H. pylori populations [24]. In this study, resistance to metronidazole was 33%. It appeared that patients with ulcer, Barrett’s oesophagus and oesophagitis were more often infected with resistant strains com- pared with gastritis patients. Previous study in the Islamic Republic of Iran showed that 37% of isolates were resistant to metroni- dazole [22]. Resistance to metronidazole is also prevalent in Japan with frequencies of 54.5% [25] and 26.5% [26], and in Nether- lands with a rate of 24% [27]. Resistance as high as 61% is reported from Peru [28]. Clarithromycin efficacy, when used in combination therapies, has been reported [4,5], but the emergence of resistant strains plus its high cost, make its application limited. The frequency of resistance to clarithromycin in this study was 1.4%. This was close to the lower range of resistance (1%–13%) reported from different regions of the world, including Sweden, Poland and Spain [2]. Amoxicillin and tetracycline have ap- plications against a wide range of patho- genic microorganisms and there are very few reports on the emergence of resistant strains. These 2 antimicrobials thus con- tinue to be successfully used in combination therapies against H. pylori [29,30]. In this study, resistance to tetracycline was not ob- served, indicating its high efficacy against Table 2 Susceptibility of 70 isolates of H. pylori to metronidazole by epsilometer (E-test) Antimicrobial Susceptible Resistant Highly resistant agent MIC > 8 8 ≤ MIC ≤ 32 MIC > 32 No. % 95% CI No. % 95% CI No. % 95% CI Metronidazole 47 67.1 54.9–77.9 8 11.4 5.6–21.3 15 21.4 12.5–32.8 MIC = minimum inhibitory concentration (μg/mL). CI = confidence interval. 290 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم H. pylori. Bacterial isolates from Peruvian patients did not show resistance to tetracy- cline [28], although 4.9% resistant strains occurred in Korea and 6.7% in Japan [31], and 58% in China [32]. Among 70 H. pylori isolates, 1 (1.43%) exhibited resistance to amoxicillin. The majority of studies re- ported no resistance to amoxicillin [13,14]; however, resistance as high as 71.9% was found in China [32]. Furazolidone with MIC of 0.12 μg/mL was comparable to amoxicillin, tetracycline and clarithromycin and showed a remark- able efficacy against H. pylori. None of the isolates exhibited resistance to this antimi- crobial. Reports from different regions of the world also describe the high efficacy of furazolidone in eradication of H. pylori [33]. Furazolidone was effective in eradica- tion of H. pylori when used in triple [15,34] or quadruple therapies [35]. Different MIC have been obtained in various laboratories, e.g. from < 0.006–0.2 μg/mL in China [36,37]. However, 4% furazolidone resist- ance and 42% metronidazole resistance were reported for H. pylori in Brazil [19]. A similar report from South Korea described 2% furazolidone and 52% metronidazole- resistant strains of H. pylori [18]. It was also found that metronidazole-resistant and -susceptible strains were both similarly inhibited by furazolidone [33,38]. These data are confirmed by other reports, indicat- ing that there is no cross-resistance between metronidazole and furazolidone among H. pylori strains [33]. Furazolidone is an antimicrobial from the nitrofuran group. Like that of metro- nidazole, the bactericidal mechanism of ac- tion of this group of antimicrobials involves enzymatic reduction of the parent com- pound to electrophilic radicals [39,40]. In spite of the similarity in the mechanisms of action, it appears that development of bac- terial resistance to metronidazole [41,42] is different from that of nitrofurans [43]. Furthermore, H. pylori does not appear to readily acquire resistance to nitrofurans [44]. Prescription of furazolidone in com- bination with amoxicillin or tetracycline, plus ranitidine and a bismuth salt has led to a higher eradication rate of H. pylori (82%) compared with metronidazole (56%) [1]. Furazolidone has been also effective in the clearance of H. pylori and resolution of acute gastric inflammation [3,37] and duodenal ulcer healing [15]. The results of this study suggest the recruitment of fura- zolidone as an effective, cheap and readily available antimicrobial [33] in quadruple therapy regimens especially in areas with high prevalence of metronidazole-resistant strains of H. pylori. Table 3 Susceptibility of 70 isolates of H. pylori to metronidazole according to patient diagnosis Patient No. Resistant diagnosis tested No. % 95% CI Barrett’s oesophagus 15 3 20.0 4.3–48.1 Ulcer 9 2 22.2 2.8–60.0 Oesophagitis 18 5 27.8 9.7–53.5 Gastritis 28 5 17.9 6.1–36.9 CI = confidence interval. Table 4 Susceptibility of 70 H. pylori strains to furazolidone with the minimum inhibitory concentration of 0.12 μg/mL Bacterial Diameter of % response inhibition resistant zone (mm) Susceptible 13–16 10 Highly susceptible > 16 90 Resistant < 13 0 Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 291 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Acknowledgements The authors wish to thank Mrs Janeshin for her assistance in the endoscopy room and Miss Alamshahi for helping to organize the manuscript. References 1. Malekzadeh R et al. Furazolidone versus metronidazole in quadruple therapy for eradication of Helicobacter pylori in duo- denal ulcer disease. Alimentary and phar- macology therapy, 2000, 14:299–303. 2. O’Morain C, Montague S. Challenges to therapy in the future. Helicobacter, 2000, 5(suppl. 1):S23–6. 3. Jenks PJ, Ferrero RL, Labigne A. The role of the RDXA gene in the evolution of metronidazole resistance in Helicobacter pylori. Journal of antimicrobial chemo- therapy, 1999, 43:753–8. 4. Fakheri H et al. Clarithromycin vs. fura- zolidone in quadruple therapy regimens for the treatment of Helicobacter pylori in a population with a high metronidazole resistance rate. Alimentary and pharma- cology therapy, 2001, 15:411–6. 5. Gisbert JP et al. High efficacy of ranitidine bismuth citrate, amoxicillin, clarithromycin and metronidazole twice daily for only five days in Helicobacter pylori eradication. Helicobacter, 2001, 2(6):157–62. 6. Megraud F. Strategies to treat patients with antibiotic resistant Helicobacter pylori. International journal of antimicrobial agents, 2000, 16:507–9. 7. Weissfeld A et al. Geographical distribu- tion in the United States of primary resist- ance to clarithromycin and metronidazole in patients infected with Helicobacter py- lori. Gastroenterology, 1997, 112:A328. 8. Broutet N et al. Survey of the in vitro sus- ceptibility of Helicobacter pylori to antibi- otics in France: preliminary results. Gut, 1998, 43(suppl. 2):A11. 9. Debets-Ossenkopp YJ et al. Mechanism of clarithromycin resistance in clinical isolates of Helicobacter pylori. FEMS microbiology letters, 1996, 142:37–42. 10. Vester B, Garrett RA. A plasmid-coded and site-directed mutation in Escherichia coli 23S rRNA that confers resistance to erythromycin: implications for the mecha- nism of action of erythromycin. Biochem- istry, 1987, 69:891–900. 11. Arthur M, Brisson-Noël A, Courvalin P. Origin and evolution of genes specify- ing resistance to macrolide, lincosamide and streptogramin antibiotics: data and hypotheses. Journal of antimicrobial chemotherapy, 1987, 20:783–802. 12. Boyanova L et al. Primary and combined resistance to four antimicrobial agents in Helicobacter pylori in Sofia, Bulgaria. Journal of medical microbiology, 2000, 49:415–8. 13. Cabrita J et al. Features and trends in Helicobacter pylori antibiotic resistance in Lisbon area, Portugal (1990–1999). Jour- nal of antimicrobial chemotherapy, 2000, 46:1029–31. 14. Wolle K et al. Prevalence of Helicobacter pylori resistance to several antimicrobial agents in a region of Germany. European journal of clinical microbiology and infec- tious disease, 1998, 17:519–21. 15. Dani R et al. Omeprazole, clarithromycin and furazolidone for the eradication of Helicobacter pylori in patients with duode- nal ulcer. Alimentary and pharmacology therapy, 1999, 13(12):1647–52. 16. Liu WZ et al. Furazolidone-containing short-term triple therapies are effective in the treatment of Helicobacter pylori infection. Alimentary and pharmacology therapy, 1999, 13:317–22. 292 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 17. Graham DY et al. Furazolidone combi- nation therapies for Helicobacter pylori infection in the United States. Alimen- tary and pharmacology therapy, 2000, 14(2):211–5. 18. Kwon DH et al. Furazolidone- and nitro- furantoin-resistant Helicobacter pylori: prevalence and role of genes involved in metronidazole resistance. Antimicro- bial agents and chemotherapy, 2001, 45: 306–8. 19. Mendonca S et al. Prevalence of Helico- bacter pylori resistance to metronidazole, clarithromycin, amoxicillin, tetracycline, and furazolidone in Brazil. Helicobacter, 2000, 5:79–83. 20. Massarrat S et al. Peptic ulcer disease, irritable bowel syndrome and constipation in two populations in Iran. European jour- nal of gastroenterology and hepatology, 1995, 7:427–33. 21. Mikaeli J et al. Prevalence of Helicobacter pylori in two Iranian provinces with high and low incidence of gastric carcinoma. Archives of Iranian medicine, 2000, 3: 6–9. 22. Siavoshi F et al. Susceptibility of various strains of H. pylori to selected agents. Ar- chives of Iranian medicine, 2000, 3:60–3. 23. Sotudehmanesh R et al. A randomized controlled comparison of three quadruple therapy regimens in a population with low Helicobacter pylori eradication rates. Journal of gastroenterology and hepatol- ogy, 2001, 16:264–8. 24. Torres J et al. A comprehensive review of the natural history of Helicobacter pylori infection in children. Archives of medical research, 2000, 31:431–69. 25. Sakurai K et al. Importance of drug selec- tion and the use of sensitivity tests for the eradication therapy for Helicobacter pylori. Nippon rinsho, 1999, 57:72–5. 26. Murakami K et al. Selection of antibi- otics and planning of eradication for H. pylori infection. Nippon rinsho, 2001, 59:308–13. 27. Weel JFL et al. Heterogeneity in suscep- tibility to metronidazole among Helico- bacter pylori isolates from patients with gastritis or peptic ulcer disease. Journal of clinical microbiology, 1996, 34:2158–62. 28. Vasquez A et al. Metronidazole and clarithromycin resistance in Helicobacter pylori determined by measuring MICs of antimicrobial agents in color indicator egg yolk agar in a miniwell format. Journal of clinical microbiology, 1996, 34:1232–4. 29. Huang J Q, Hunt RH. Treatment after fail- ure: the problem of ‘non-responders’. Gut, 1999, 45:40–4. 30. Mégraud F, Doermann HP. Clinical rele- vance of resistant strains of Helicobacter pylori: a review of current data. Gut, 1998, 43:S61–5. 31. Kwon DH et al. Isolation and charac- terization of tetracycline-resistant clinical isolates of Helicobacter pylori. Antimicro- bial agents in chemotherapy, 2000, 44:3, 203–3, 205. 32. Wu H et al. Resistance of Helicobacter pylori to metronidazole, tetracycline and amoxicillin. Journal of antimicrobial chemotherapy, 2000, 46:121–3. 33. Segura AM et al. Furazolidone, amoxicil- lin, bismuth triple therapy for Helicobacter pylori infection. Alimentary and pharma- cology therapy, 1997, 11(3):529–32. 34. Xiao SD et al. High cure rate of Helico- bacter pylori infection using tripotassium dicitrato bismuthate, furazolidone and clarithromycin triple therapy for 1 week. Alimentary and pharmacology therapy, 1999, 13:311–5. 35. Liu WZ et al. A new quadruple therapy for Helicobacter pylori using tripotas- sium dicitrato bismuthate, furazolidone, josamycin and famotidine. Alimentary and pharmacology therapy, 2000, 14(11): 1519–22. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 293 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 36. Van Zwet AA et al. Low cure rate of Heli- cobacter pylori infection with omeprazole and furazolidone dual therapy for one week. Alimentary and pharmacology therapy, 1997, 11:533–5. 37. Xiao SD et al. The efficacy of furazolidone and metronidazole in the treatment of chronic gastritis associated with Helico- bacter (Campylobacter) pylori—a rand- omized double-blind placebo-controlled clinical trial. Hepatogastroenterology, 1990, 37:503–6. 38. Coudron PE, Stratton CW. In vitro evalu- ation of nitrofurantoin as an alternative agent for metronidazole in combination antimicrobial therapy against Helico- bacter pylori. Journal of antimicrobial chemotherapy, 1998, 42:657–60. 39. McOsker CC, Fitzpatrick PM. Nitrofuran- toin: mechanisms of action and impli- cations for resistance development in common uropathogens. Journal of antimi- crobial chemotherapy, 1994, 33:23–30. 40. Asnis RE. The reduction of furacin by cell-free extracts of furacin-resistant and parent-susceptible strains of Escherichia coli. Archives of biochemistry and bio- physics, 1957, 66:208–16. 41. Kwon DH et al. Analysis of a rdxA gene and involvement of additional genes encoding NADPH flavin oxidoreductase (FrxA) and ferredoxin-like protein (FdxB) in metronidazole resistance of Helico- bacter pylori. Antimicrobial agents in chemotherapy, 2000, 44:2133–42. 42. Goodwin A et al. Metronidazole resist- ance in Helicobacter pylori is due to null mutations in a gene (rdxA) that encodes an oxygen-insensitive NAD(P)H nitrore- ductase. Molecular microbiology, 1998, 28:383–93. 43. Whiteway J et al. Oxygen-insensitive nitroreductases: analysis of the roles of nfsA and nfsB in development of re- sistance to 5-nitrofuran derivatives in Escherichia coli. Journal of bacteriology, 1998, 180:5529–39. 44. Hass CE, Nix DE, Schentag JJ. In vitro selection of resistant Helicobacter pylori. Antimicrobial agents in chemotherapy, 1990, 34:1637–41. 294 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Evaluation of rK39 strip test for the diagnosis of visceral leishmaniasis in infants A. Alborzi,1 M. Rasouli, 1 Z. Nademi, 1 M.R. Kadivar1 and B. Pourabbas1 1Clinical Microbiology Research Centre, Nemazee Hospital, Shiraz, Islamic Republic of Iran (Correspondence to A. Alborazi: cmrc@sums.ac.ir). Received: 01/03/04; accepted: 06/07/04 ABSTRACT This study estimated the sensitivity and specificity of the rK39 strip test compared with the immunofluorescent antibody test and microscopy of bone marrow aspirate smears (the gold standard) in 47 children with suspected visceral leishmaniasis. A control group of children with other diagnoses (tuberculosis, toxoplasmosis, systemic lupus erythematosus, malaria or cutaneous leishmaniasis) were also tested to check false positive results. The sensitivity and specificity of the strip test were 82.4% and 100% and that of immunofluorescent antibody were 100% and 92.7%. The rK39 strip test is reliable where there is no access to laboratory facilities. Évaluation du test sur bandelette réactive au rK39 pour le diagnostic de la leishmaniose viscérale chez le jeune enfant RÉSUMÉ Cette étude a estimé la sensibilité et la spécificité du test sur bandelette au rK39 par rapport à la recherche des anticorps par immunofluorescence et à l’examen microscopique de frottis médullai- res (la méthode de référence) chez 47 enfants suspects de leishmaniose viscérale. Un groupe témoin d’enfants ayant d’autres diagnostics (tuberculose, toxoplasmose, lupus érythémateux systémique, paludisme ou leishmaniose cutanée) a également été soumis à un test pour vérifier les résultats faux positifs. La sensibilité et la spécificité des bandelettes réactives étaient de 82,4 % et de 100 % et celles de la recherche des anticorps par immunofluorescence étaient de 100 % et de 92,7 %. Le test sur bandelette au rK39 est fiable en l'absence de moyens de laboratoire. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 295 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction Visceral leishmaniasis is caused by various strains of Leishmania spp. [1]. While a mi- nority of infected individuals develops full- blown visceral leishmanaisis, characterized by fever, hepatosplenomegaly, anaemia, neutropaenia and hypergammaglobulinae- mia, most of them remain asymptomatic with the disease self-limiting [2,3]. Visceral leishmaniasis is endemic in the south of the Islamic Republic of Iran, especially in Fars province where it involves mostly infants [4]. The disease is observed mainly among nomads and in rural areas that are far from equipped medical centres. Therefore, there is a need for a non-invasive, cost-effective, reliable, easily available and fast method of diagnosis of visceral leishmaniasis in these regions. For decades, definite diagnosis of visceral leishmaniasis has required in- vasive procedures to find the parasite in the organs, such as spleen, bone marrow, lymph nodes and liver [5]. Non-invasive serological methods such as immunofluo- rescent antibody (IFA) and enzyme-linked immunosorbent assay (ELISA) are sensitive methods of diagnosing visceral leishmaniasis [6–8], but they require fluo- rescent microscopy and ELISA equipment. Samples for direct agglutination test (DAT) can be easily obtained, but must be sent to distant medical centres [9]. Polymerase chain reaction (PCR) amplification testing for leishmania DNA is also not practical in the field [10,11]. It has been shown that detection of circulating antibody to Leishmania antigen rK39 had both high sensitivity and specifi- city for active Indian visceral leishmaniasis, which mostly affects adults [12,13]. The rK39 strip-test is a simple and cost-effec- tive test that uses chromatographic strips impregnated with rK39 antigen and can be easily used in the field. While previous stud- ies have shown the efficacy of this test, their study groups were mainly adults [14]. The present study was made on infants, who are more commonly affected by visceral leish- maniasis in the Islamic Republic of Iran due to infection with L. infantum. The aim was to compare the sensitivity and specificity of the rK39 strip test with that of the IFA test (the usual laboratory method at this centre) in the detection of visceral leishmaniasis. Methods The study group consisted of 47 children, age range 3 month to 5 years old, who were admitted to 2 teaching hospitals at Shiraz University of Medical Sciences over a 1- year period (2003). The inclusion criteria were patients with hepatosplenomegaly, fever, anaemia (with or without neutropae- nia) or hypergammaglubolinaemia who had been referred from endemic regions. The following data were recorded: age, sex, place of residence, history of visceral leish- maniasis in the area, adjacent health centre and grandfather’s name. Informed consent was obtained from the parents of all patients before the study started. The study group was tested for visceral leishmaniasis by 3 different methods: light microscopy of bone marrow aspirate smears, and IFA and rK39 strip tests on serum samples. Bone marrow aspiration was taken as the gold standard. We followed all 47 patients monthly to find out the time of the disappearance of the anti-rK39 antibody after treatment, but only 13 of them finished the 6-month follow-up. We repeated the test for those who were positive with the rK39 strip test in order to identify the time of the disappearance of anti-rK39 antibody. 296 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم A control group of 161 children with other diagnoses were selected: tuberculosis (positive sputum test for mycobacterium tuberculosis); toxoplasmosis (clinically and serologically positive); systemic lupus ery- thematosus (clinical evaluation and labora- tory findings from antinuclear antibody and LE cell test); malaria (positive peripheral blood smear); or cutaneous leishmaniasis (smear-positive for leishman bodies). The control group were patients with a positive record of those diseases who did not have visceral leishmaniasis and did not live in an endemic area of leishmaniasis. The IFA test was used on serum samples of all 161 control children: 40 with toxoplasmosis, 56 with systemic lupus erythematosus, 25 with malaria and 40 with tuberculosis. Due to supply difficulties, the rK39 strip test was used on samples from only 137 of the children: 32 with tuberculosis, 40 with toxoplasmosis, 20 with systemic lupus erythematosus, 5 with malaria and 20 with cutaneous leishmaniasis. Laboratory methods For the confirmatory tests, bone marrow aspirated smears were stained with Giemsa and examined using light microscopy. For IFA, the promastigotes of Leishma- nia infantum were coated onto slides and after drying at room temperature, preserved at –70 ºC. Serum at various dilutions was added and the slides were incubated at room temperature. After washing with phosphate- buffered saline, conjugated anti-human globulin was added and after further incuba- tion and washing, the slides were studied under fluorescent microscope. A titre ≥ 1:128 was considered as positive. For the rK39 strip test, nitrocellulose strips impregnated with recombinant rK39 antigen (InBios International, Seattle, Wash- ington, USA). One drop of peripheral blood (or finger-stick blood), serum or plasma was applied at the base of nitrocellulose strips. After being air-dried, 3 drops of the test buffer (phosphate-buffered saline, plus bovine serum albumin) were added and the strip was placed upright for 60 seconds. The appearance of a lower red band (control) indicated the proper functioning of the test, while the appearance of an upper red band indicated the presence of anti-rK39 IgG signifying a positive test. Analysis The data were analysed using SPSS software and compared using Fisher’s exact test. The sensitivity of the tests was calculated as 100 × [TP/(TP +FN)] and specificity as 100 × [TN/(FP +TN)], where TP = true positives, TN = true negatives, FP = false positives and FN = false negatives. Results Visceral leishmaniasis was confirmed in 17 out of 47 study patients who were posi- tive using bone marrow aspiration. All 17 patients were also positive by the IFA test, giving a sensitivity of 100% for IFA (Table 1). Of the 17 patients, 14 (82.4%) were posi- tive for rK39 strip test and 3 were negative, Table 1 Comparison of the immunofluorescent antibody test and the rK39 strip test for visceral leishmaniasis in 17 patients with confirmed visceral leishmaniasis and 161 control patients with other diseases Group rK39 rK39 positive negative VL confirmed cases IFA positive 14 3 IFA negative 0 0 Controls IFA positive 0 10 IFA negative 0 127 Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 297 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم giving a sensitivity for the rK39 strip test of 82.4%. The control group was used to test for false positives. Ten out of the 137 control group patients were positive for IFA test (9 of them had tuberculosis involvement and 1 had systemic lupus erythematosus). No positives cases were detected with the rK39 test. Thus, the specificities of the rK39 strip test and IFA were 100% and 92.7% respectively. Statistical analysis did not show any sig- nificant differences between the sensitivity of rK39 and IFA test (Fisher’s exact test, P = 0.227) while there was a significant dif- ference between the specificity of rK39 and IFA test (Fisher’s exact test, P = 0.002). All positive patients were treated with meglumine antimoniate, as amphoteracin B is not routinely used in our centre except for special cases such as jaundice, ascitis and patients in a poor condition. We performed follow-up rK39 strip tests for several months on 13 patients who completed the treatment and showed signs of being cured (i.e. were afebrile after 6 months). Out of them, 8 pa- tients had a negative rK39 strip test before 3 months, 3 cases had a positive rK39 test after 3 but before 6 months and in only 2 patients (15.3%) the test remained positive for more than 6 months. Discussion The present study shows that the rK39 strip test is a reliable test for the diagnosis of visceral leishmaniasis. Our data showed no false positives by the rK39 strip test that would not also have been false positive by IFA, which is the currently used test in our centre. Thus the specificity for the diagnosis of visceral leishmaniasis using rK39 was 100%. This specificity figure is the same as figures reported by Bern et al. [15] (100%), Iqbal et al. [16] (100%) and Sunder et al. [14] (98%) who were working in Nepal, Kuwait and India, respectively. However, Sundar et al. [17] reported 99% specificity of rK39 in 100 cases in Indian patients. The specificity of IFA in our study was 92.7%, which is similar to the results of a study conducted in Kuwait (93%) [16]. The estimated sensitivity of the rK39 strip test was 82.4%, which is in agreement with Iqbal et al. [16] (80%) from Kuwait but not with Bern et al. [15] (100%), and Sundar et al. [14] (100%). The striking similarities between our results and those of Iqbal et al. [16] may be explained by the causative agent of visceral leishmaniasis. L. infantum is responsible in most of the cases of visceral leishmaniasis seen in the Middle East, while L. donovani is the major cause of visceral leishmaniasis in India. The sensitivity of IFA in our study (100%) was higher than that of Iqbal [16] (86.6%). We tested the 13 apparently cured vis- ceral leishmaniasis patients with strip test during their monthly follow-up. A positive strip test after 6 months was only seen in 2 patients while the rest of them showed a negative strip test before 6 months. Our study group showed a negative strip test after successful treatment earlier than Zijlstras et al. [18], suggesting that anti- rK39 antibodies persist for several months. Hence, the rK39 strip test is not suggested for following up the disease. In many developing countries, visceral leishmaniasis occurs in distant urban and tribal regions, where there are no proper laboratory facilities. 298 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Conclusion This study shows that the rK39 strip test is a sensitive and specific indicator of visceral leishmaniasis in children. About 18% of infected patients showed false negative results of rK39 and for those suspected pa- tients with negative results other sensitive diagnostic methods should be performed in a well-equipped medical centre. However, the specificity of the rK39 strip test was 100%, which means that all positive results can be considered as visceral leishmaniasis. The rK39 strip test can be readily used under field conditions and needs only one drop of peripheral blood. Clinicians can perform it independently without labora- tory facilities and treat patients without any requirement to refer them to equipped hospitals or clinics. Our results confirm that the rK39 strip test is suitable for use in this region and other developing countries for the diagnosis of visceral leishmaniasis in infants. References 1. Control of the leishmaniases. Report of a WHO Expert Committee. Geneva, World Health Organization, 1990 (WHO Techni- cal Report Series, No. 793). 2. Badaro R et al. New perspectives on a subclinical form of visceral leishmaniasis. Journal of infectious disease, 1986, 154: 1003–11. 3. Evans T et al. American visceral leish- maniasis (kala-azar). Western journal of medicine, 1985, 142:777–81. 4. Alborzi A, Torab Jahromi F. Autoantibod- ies and complement levels of kala-azar patients in the south of Iran. Iranian jour- nal of medical sciences, 1993, 18 (3&4): 94–8. 5. Pearson RD, Sousa AQ. Clinical spec- trum of Leishmaniasis. Clinical infectious disease, 1991, 22:1–13. 6. Choudhry AP et al. Enzyme linked im- munosorbent assay in the diagnosis of kala-azar in Bhadoni (Varanasi), India. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1994, 84: 363–6. 7. Gupta S et al. Evaluation of enzyme linked immunosorbent assay in the dignosis of kala-azar in Malda district (West Bengal). Indian journal of medical research, 1993, 97:242–6. 8. Choudhary A et al. An indirect fluorescent antibody (IFA) test for the serodiagnosis of kala-azar. Journal of communicable disease, 1992, 24:32–6. 9. El-Harith A et al. Improvement of a di- rect agglutination test for field studies of visceral leishmaniasis. Journal of clinical microbiology, 1988, 26:1321–5. 10. Piarroux R et al. Comparison of PCR with direct examination of bone marrow aspiration, myeloculture and serology for diagnosis of visceral Leishmaniasis in immunocompromised patients. Journal of clinical microbiology, 1994, 32:746–9. 11. Nuzum E et al. Diagnosis of symptomatic visceral leishmaniasis by the use of the polymerase chain reaction on patient blood. Journal of infectious diseases, 1995, 171:751–4. 12. Singh S et al. Diagnostic and prognostic value of K39 recombinant antigen in In- dian Leishmaniasis. Journal of parasitol- ogy, 1995, 81:1000–3. 13. Badaro R et al. rK39: a cloned antigen of Leishmania chagasi that predicts active visceral leishmaniasis. Journal of infec- tious disease, 1996, 173:758–61. 14. Sundar S et al. Rapid accurate field di- agnosis of Indian visceral leishmaniasis. Lancet, 1998, 351:363–5. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 299 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 15. Bern C et al. Use of recombinant K39 dipstick test and the direct agglutination test in a setting endemic for visceral leish- maniasis in Nepal. American journal of tropical and medical hygiene, 2000, 63: 153–7. 16. Iqbal J et al. Imported visceral leishmania- sis: diagnostic dilemmas and comparative analysis of three assays. Journal of clini- cal microbiology, 2002, 40:475–9. 17. Sundar S et al. Immunochromatographic strip-test detection of anti-K39 antibody in Indian visceral leishmaniasis. Annals of tropical medicine and parasitology, 2002, 96:19–23. 18. Zijlstra EE, El-Hassan AM. Leishmaniasis in Sudan. Visceral leishmaniasis. Trans- actions of the Royal Society of Tropical Medicine and Hygiene, 2001, 95 (suppl. 1):S27–58. Leishmania/HIV co-infection Leishmania/HIV co-infection is emerging as an extremely serious, new disease and it is increasingly frequent. There are important clinical, diagnostic, chemotherapeutic, epidemiological and economic implica- tions of this trend. Although most people bitten by sandflies infected with Leishmania pro- tozoa do not develop the disease, those who are immunosuppressed quickly evolve to a full clinical presentation of severe leishmaniasis. Furthermore, AIDS and VL are locked in a vicious circle of mutual reinforcement. This duo of diseases produces cumulative deficiency of the immune response since Leishmania parasites and HIV destroy the same cells, exponentially increasing disease severity and conse- quences. Visceral leishmaniasis is considered a major contributor to a fatal outcome in co-infected patients. Use of tri-therapy, where it is available, has improved the prognosis for Leishmania/HIV cases. Source: WHO. Fact sheet No.116. Revised May 2000 (http://www.who. int/mediacentre/factsheets/fs116/en/) 300 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Hajj-associated acute respiratory infection among hajjis from Riyadh A.J. Choudhry,1 K.S. Al-Mudaimegh,2 A.M. Turkistani1 and N.A. Al-Hamdan1,3 1Field Epidemiology Training Programme, Riyadh, Saudi Arabia (Correspondence to A.J. Choudhry: abduljamilch@hotmail.com). 2Infection Control and Environmental Health Department, Children’s Hospital, King Fahd Medical City, Riyadh, Saudi Arabia. 3Department of Community and Family Medicine, Riyadh, Saudi Arabia. Received: 28/08/04; accepted: 29/12/04 ABSTRACT A prospective cohort study was conducted to estimate the incidence of acute respiratory infections (ARI) among hajjis registered at primary health care centres of Riyadh. Out of 1027 hajjis, 39.8% developed symptoms of ARI. The incidence of ARI was not statistically significantly associated with age, sex, educational status or smoking. The risk of illness was significantly higher among diabet- ics, hajjis who stayed longer in the hajj area and who prayed at Namera mosque. Use of a facemask by men, but not use of a facecover by women, was a significant protective factor against ARI. Infection respiratoire aiguë associée au Hadj chez des pèlerins de Riyad RÉSUMÉ Une étude de cohorte prospective a été réalisée pour estimer l’incidence des infections respiratoires aiguës (IRA) chez des pèlerins enregistrés dans des centres de soins de santé primaires de Riyad. Sur les 1027 pèlerins, 39,8 % ont développé des symptômes d’IRA. Il n’y avait pas d’asso- ciation statistiquement significative entre l’incidence des IRA et l’âge, le sexe, le niveau d’instruction ou le tabagisme. Le risque de maladie était significativement plus élevé chez les diabétiques, chez les pèlerins qui étaient restés plus longtemps dans la zone du Hadj et ceux qui avaient prié à la mosquée de Namera. L’utilisation d’un masque facial chez les hommes était un facteur de protection important contre les IRA, mais pas l’utilisation d’un voile facial par les femmes. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 301 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction Acute respiratory infections (ARIs) are the most common infections among humans, accounting for 35% of communicable dis- ease consultations in primary care [1,2]. Yet even with such a high prevalence, res- piratory infections receive only 0.15% of the research and development budget for health [3]. The hajj represents a major challenge to the Saudi Ministry of Health in addressing infection control at this gathering of over 2 million people. Infection hazards at the hajj include meningococcal meningitis, respira- tory tract infections, blood-borne diseases and zoonotic diseases, all of which have domestic and international ramifications as Muslim pilgrims return home [4]. However, leaving aside the threat of meningococcal meningitis, the importance of other infec- tious diseases is generally not appreciated. ARIs are considered a low priority health problem due to the low risk of mortality and complications, except in physically de- bilitated and immunocompromised people [3]. However this attitude undermines their importance due to high infectiousness, ca- pacity to lower the general immunity and high short-term disability. In an attempt to identify the etiology of ARI in hajj, a study during the 1991 –92 CE pilgrimage season found bacterial patho- gens in 29.9% of sputum specimens and throat swabs and viruses in 19.5% [5]. Another study conducted in hajj 2001 CE of selected clinical influenza cases among pilgrims visiting outpatient clinics in Mecca and Medina hospitals found 14.8% were seropositive. Among seropositive cases, 60% were influenza type B, 27% were type A, and the rest were positive for both types A and B [6]. A large number of domestic hajjis com- plain of ARI immediately after returning from hajj. Except for a few cross-sectional studies giving some idea of the causative or- ganisms, no systematically collected infor- mation is available about the magnitude and distribution of the problem. In the absence of such information, it is not possible to as- sess the burden of illness on the health care system or the need for preventive measures. This study in Riyadh was conducted to assess the incidence of hajj-related ARIs among domestic hajjis in the hajj of 1423 AH (2002 CE), and to identify the risk fac- tors associated with these illnesses. Methods The study was designed as a prospective cohort study to estimate the incidence of hajj-related ARIs among hajjis travelling from the capital of Saudi Arabia, Riyadh city (population approximately 4 million). It is mandatory for all hajjis to have a valid certificate of vaccination against meningo- coccal meningitis, which is available free of charge in Saudi primary health care (PHC) centres for both Saudi Arabian nationals and non-Saudis prior to the hajj season. This provided a good opportunity to recruit the study cohort. Sample After developing the study protocol, per- mission was obtained from the Saudi Min- istry of Health to conduct the study. In the absence of any previous study estimating the incidence of post-hajj ARI, incidence was assumed at 50% (to obtain the maxi- mum sample size for a given level of preci- sion). With a precision of 3% around the assumed incidence at a confidence level of 95%, a sample size of 1066 was calculated. To recruit the cohort, a single-stage strati- fied random cluster sampling technique was used. A list of all the 72 PHC centres was 302 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم obtained from the Directorate of Health in Riyadh and was stratified into 5 administra- tive sub-regions. Two PHC centres were selected from each of these areas using a random number table. All people visiting the centres for vaccination against menin- gococcal meningitis were considered as the potential cohort. Data collection A data collection instrument was designed with several parts. Part 1 collected basic demographic information about the study subjects before the hajj: any current illness, smoking habit, history of chronic illness and vaccination against influenza. Part 2 included information about the events in hajj and later, including history of symp- toms of ARI, health care sought and ARI- related practices during and after the hajj. It was filled by the investigator during the first week after the hajj through telephone contact. Part 3 included the same informa- tion but was filled 2 weeks after the hajj by telephone contacts with the hajjis who did not report any history of ARI in the first post-hajj contact. All the directors of the selected PHC centres were visited to obtain their consent for participation in the study and informa- tion about the number of hajjis vaccinated. All the personnel responsible for vaccinat- ing the potential hajjis were trained in filling the questionnaire. All the potential hajjis visiting the par- ticipating primary health care centres were asked to participate in the study and those who agreed to participate were given part 1 of the data collection instrument by the nurse in the vaccination room. In the proc- ess, all people who had any ARI-like symp- toms at the time of the visit were excluded from the cohort. Patients were told that they would be contacted by telephone after the hajj regarding their illness history. The re- cruitment continued from 10 Dhu al-Qi’da to 1 Dhu al-Hijja 1423 AH, with a total recruitment of 1560 potential hajjis. During the first week after the hajj, the whole of the cohort was contacted by tel- ephone by the investigating team to respond to questions in part 2 of the data collection instrument. Female doctors interviewed the female hajjis. The hajjis who did not have any ARI symptoms by the time of the first post-hajj contact were contacted again in the 3rd week after hajj, and part 3 of the questionnaire was filled. For the purpose of this study, ARI was defined as one of the constitutional symp- toms (fever, headache, myalgia) along with one of the local symptoms (running nose, sneezing, throat pain, cough with/without sputum, difficulty breathing) that developed after reaching Mecca for the hajj. The study asked about use of a facemask among male hajjis and a facemask or a face- cover (hijab/niqab) by female hajjis. At the time of this study, facemasks were not of- ficially recommended by the Saudi Ministry of Health but they are becoming used more frequently during the hajj, especially among domestic hajjis and those from south-east Asia. Although the wearing of niqab by women is not customary for the ritual cloth- ing (ihram) of the hajj, Saudi women prefer to cover their face even in ihram. Data analysis The data were entered, cleaned and ana- lysed using Epi-Info, version 6.04. After describing the characteristics of the study cohort and ARI patients, the risk ratios with their 95% confidence interval (CI) were calculated to estimate the effect of different exposure factors on the outcome. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 303 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Results Background characteristics Out of 1439 persons recruited to the study, 1130 were traceable after the hajj. Among these, only 1027 actually performed the hajj for the year 1423 AH. Of these, 73.0% of hajjis were male and 79.1% were Saudi nationals. The mean age of hajjis was 33.5 years [standard deviation (SD) 11.7 years]. Regarding level of education, 114 (11.1%) hajjis were illiterate, 52 (5.1%) had received only primary school education, 114 (11.1%) intermediate school education, 336 (32.7%) high school education, and 411 (40.0%) university education. The mode of travel showed 513 (50.0%) hajjis travelled by air, 468 (45.6%) by bus and 46 (4.5%) by car. The total duration of travel was 4 days for 46 hajjis (4.5%), 5 days for 437 (42.6%), 6 days for 411 (40.0%), 7 days for 115 (11.2%) and 8+ days for 18 (1.8%). The mean travel dura- tion was 5.6 days (SD 0.8 days). Among the total, 139 (13.5%) hajjis were current smokers. Eighty-three (8.1%) hajjis suffered from one or more chronic diseases: 47 (4.6%) diabetes, 19 (1.9%) a history of chronic sinusitis, 16 (1.6%) chronic tonsillitis and 16 (1.6%) bronchial asthma. During their stay in the hajj area 281 hajjis (27.4%) visited health care centres for some medical problem. During the hajj, 477 hajjis (46.4%) never used a facemask while 550 (53.6%) used a facemask, i.e. 340 (33.1%) used it most of time and 210 (20.4%) used it some of the time. Among the males, 478 (63.7%) used a facemask at least sometimes, while among females this figure was 72 (26.0%). Among the females, 197 (71.1%) used a facecover most of time during hajj, 37 (13.4%) used it sometimes and 43 (15.5%) never used it. When com- bined with the facemask used by females it turned out that 248 (89.5%) women used either a facemask or a facecover for at least some of the time during the hajj. Only 31 hajjis (3.0%) prayed in Namera mosque during the hajj. Incidence of ARI Out of the 1027 hajjis, 409 suffered from an ARI, in accordance with the case definition given earlier, during the hajj and within 2 weeks of the end of the hajj. So the cumula- tive incidence of ARI among the hajjis was 39.8% (95% CI: 36.8%–42.9%). The date of onset of illness ranged from 8 Dhu al-Hi- jja to 27 Dhu al-Hijja, while by 12 Dhu al- Hijja (the last day of hajj) 169 (41.3%) had developed symptoms of ARI (Figure 1). Among the cases, 219 (53.5%) had a positive history of contact with ill patients. During the hajj, 281 cases (68.7%) had vis- ited PHC centres and 298 cases (72.9%) had used an antibiotic. Only 15 cases (3.6%) were admitted to hospital due to ARI. The small group of hajjis aged 70+ years had an ARI incidence of 83.3% compared with 37.7% among the hajjis aged < 25 years [risk ratio (RR) = 2.2; 95% CI: 1.47– 3.21]. However, compared with hajjis < 25 years, the increase in other age groups was not statistically significant. Males showed a slightly higher incidence of ARI (40.4%) than females (38.3%) (RR = 1.06; 95% CI: 0.89–1.26). Non-Saudi hajjis had a cumula- tive incidence of ARI of 46.9%, which was 1.25 times higher than Saudi hajjis (95% CI: 1.06–1.48). There was some variation of risk of ARI among hajjis with different educational status, with the lowest risk for high-school graduates (34.8%) and highest for primary education (50.0%), but the difference was not statistically significant (Table 1). The risk of ARI was higher for hajjis who travelled by bus (44.0%) or car (47.8%) compared with hajjis who used the aero- 304 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم plane (35.3%). But the increased risk was statistically significant for travel by bus, while it was not significant for those who travelled by car compared with travel by air (Table 2). The duration spent in the hajj area showed a positive linear association with the incidence of ARI (Table 2). Among the hajjis who used a facemask most of time during the hajj, fewer (15.0%) had ARI compared with hajjis who used it sometimes (31.4%) or never (61.2%). The risk was 2-fold among sometime users and 4-fold among never users compared with hajjis who used a facemask most of time. When the data was stratified by sex, the pro- tective effect of a facemask was found only in men, in whom the strength of association increased on stratification, whereas using a facemask had no association with ARI among women (Table 3). For women who only used a facecover (hijjab/niqqab) there was a higher risk of ARI for occasional (43.2%) or never use (44.2%) compared with use most of time (36.0%) during the hajj, but the difference was not statistically significant. The pattern remained the same when the effect for the effect of using either a facemask or facecover (Table 3). When the relationship of certain lifestyle factors on the incidence of ARI was studied, it was found that hajjis who opted to pray in Namera mosque in Arafat had 3.17 times higher risk of ARI compared with hajjis who did not pray in Namera mosque. Smok- ing, however, did not show an increase in the risk of ARI (Table 4). Suffering from a chronic disease gave a 1.46 increased risk of ARI and the difference was statistically significant (95% CI: 1.13–1.89). Among the individual diseases studied, only diabetes mellitus showed a statistically significant increased risk of ARI, while chronic sinusi- tis, chronic tonsillitis and bronchial asthma Figure 1 Date of onset of symptoms of acute respiratory tract infection among hajjis from Riyadh AH Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 305 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Table 1 Effect of demographic characteristics on the incidence of acute respiratory tract infection among hajjis from Riyadh Demographic No. of hajjis No. of cases Cumulative Risk ratio 95% CI characteristics (n = 1027) (n = 409) incidence % Age (years) 10–24 257 97 37.8 1 – 25–39 470 181 38.5 1.02 0.81–1.20 40–54 242 102 42.1 1.11 0.89–1.36 55–69 52 24 46.2 1.20 0.86–1.68 70+ 6 5 83.3 2.20 1.47–3.21 Sex Female 277 106 38.3 1 – Male 750 303 40.4 1.06 0.89–1.26 Nationality Saudi Arabian 812 308 37.9 1 – Non-Saudi Arabian 215 101 47.0 1.25 1.06–1.48 Education status Illiterate 114 50 43.9 1.07 0.84–1.35 Primary school 52 26 50.0 1.21 0.90–1.63 Intermediate school 114 46 40.3 0.97 0.76–1.26 High school 336 117 34.8 0.85 0.70–1.02 University 411 170 41.4 1 – n = total number of cases. CI = confidence interval. Table 2 Effect of travel on risk of acute respiratory tract infection among hajjis from Riyadh No. of hajjis No. of cases Cumulative Risk ratio 95% CI (n = 1027) (n = 409) incidence % Mode of travel Airplane 513 181 35.3 1 – Bus 468 206 44.0 1.25 1.07–1.46 Car 46 22 47.8 1.36 0.98–1.87 Duration of stay in hajj area (days)a 4–5 483 169 35.0 1 6 411 168 40.9 1.17 0.99–1.38 7 115 61 53.0 1.52 1.23–1.87 8+ 18 11 61.1 1.75 1.18–2.57 aChi-squared test for linear trend = 15.078, P < 0.001. n = total number of cases. 306 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Table 3 Effect of use of facemask for men and use of facemask or facecover for women on incidence of acute respiratory tract infection among hajjis from Riyadh Used face mask No. of hajjis No. of cases Cumulative Risk ratio 95% CI (n = 1027) (n = 409) incidence % All hajjis Used facemask Most of the time 340 51 15.0 1 – Sometimes 210 66 31.4 2.10 1.52–2.89 Never 477 292 61.2 4.00 3.14–5.31 Total 1027 409 39.8 Male hajjis Used facemask Most of the time 319 43 13.5 1 Sometimes 159 52 32.7 2.43 1.70–3.47 Never 272 208 76.5 5.67 4.26–7.55 Total 750 303 40.4 Female hajjis Used facemask Most of the time 21 8 38.1 1 Sometimes 51 14 27.5 0.72 0.36–1.46 Never 205 84 41.0 1.08 0.61–1.90 Used facecover (hijab/niqab) Most of the time 197 71 36.0 1 Sometimes 37 16 43.2 1.20 0.79–1.81 Never 43 19 44.2 1.23 0.84–1.80 Used facecover or facemask Ever 248 93 37.5 1 Never 29 13 44.8 1.20 0.77–1.85 Total 277 106 38.3 n = total number of cases. CI = confidence interval. Table 4 Effect of some potential risk factors on incidence of acute respiratory tract infection among hajjis from Riyadh Variable No. of hajjis No. of cases Cumulative Risk ratio 95% CI (n = 1027) (n = 409) incidence% Prayed in Namera mosque 31 25 80.6 3.17 1.54–6.52 Smoker 139 60 43.2 1.07 0.92–1.25 Any known chronic disease 83 48 57.8 1.46 1.13–1.89 Diabetes mellitus 47 29 61.7 2.54 1.34–4.93 Chronic sinusitis 19 11 57.9 2.11 0.76–6.09 Chronic tonsillitis 16 9 56.3 1.96 0.64–6.25 Bronchial asthma 16 8 50.0 1.21 0.74–1.97 n = total number of cases. CI = confidence interval. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 307 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم showed an increase in risk that was not statistically significant (Table 4). Discussion ARIs are a group of diseases occurring worldwide throughout the year and are not limited to any specific age, sex or national- ity. Several factors contribute to the wide spread of ARIs, including direct contact with affected people, change in climate and crowded places [3]; all of these contribut- ing factors are present in the hajj environ- ment. As observed in other studies, the risk of viral origin ARI, especially respiratory syncitial and influenza viruses, increases during the colder months, with a peak in January and February [7]. The winter sea- son coincides with the current dates of the hajj, so a high ARI incidence was expected. Under the circumstances, it was not surpris- ing to find that almost 40% of the hajjis from Riyadh had an attack of ARI during and immediately after the hajj. But this high incidence of illness, even with low severity, as indicated by the low hospital admission rate, reveals a high burden of disease. As presented earlier, a large proportion of the cases developed the sickness even before they left Mecca for their homes, highlight- ing the inconvenience hajjis might have had in completing the rituals of the hajj and the heavy workload in the health care system in the hajj area. The problem has another dimension; ARIs are a communicable dis- ease with high secondary attack rates [8] and thus there is great potential for ARIs to spread among the susceptible home popula- tion when the hajjis return, a problem which is further compounded by large family sizes in Saudi Arabia. However, specific post-hajj data is not available to establish the increase in the ARI cases presented in Riyadh or the rest of the country, indicating the need to study the issue of burden on the community due to a secondary wave of ARI among the non-hajjis exposed to infected hajjis. The disease was uniformly distributed among both sexes and different nationali- ties, with a higher risk for older hajjis or dia- betics. Both old age and diabetes mellitus are known to reduce immunity and increase the risk for ARIs and other viral infections, indicating the importance of special atten- tion to these high-risk groups [3]. Crowdedness is also a known major risk factor for transmission of respiratory illnesses, but due to the universal exposure to crowdedness in the hajj environment, it is difficult to quantify this exposure. Visit- ing very crowded places such as during tawaaf (circumambulating the Ka’ba) and sa’ee (walking between Safaa and Marwa mountains) were not studied as indicators of crowdedness as they are compulsory rituals of the hajj. However, the higher risk of ARI for those praying at Namera mosque in Arafat (an optional activity) indicated that crowdedness is playing its role in the spread of ARI in the hajj environment. Further evidence of a causal relationship between the hajj and the occurrence of ARI is the positive dose–response relationship between the number of days stayed in the hajj area and the risk of ARI among hajjis. The main question is how to reduce this heavy burden of ARI. Given the circum- stances of the hajj it is almost impossible, under the current circumstances, to control the issue of crowding and exposure to con- tacts during tawaaf and sa’ee; and even in residential areas in Mina. The remaining alternatives to explore are personal protec- tive measures such as vaccination, chemo- prophylaxis and use of a facemask. Keeping in view the diverse etiology of ARI, including both viruses and bacteria, the use of vaccines against one or multiple 308 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم organisms does not appear to be rational [5]. However, use of influenza vaccine can be advocated for older hajjis, who were found to be at higher risk of ARI in this study and are known to have severe illness if infected by the influenza virus [3]. Similarly, chemo- prophylactic use of antibiotics is not a sen- sible option [5]. Use of antibiotics for ARIs that are not confirmed as bacterial infections can increase the risk of developing drug resistance, with the dubious advantage of preventing a mild illness [9]. Nevertheless this study found that 63% of ARI cases had already been prescribed antibiotics to treat the symptoms of upper respiratory tract infections (URTIs). The rationale, however, for using antibiotics was not justified since according the current Centers for Disease Control (CDC) recommendations for treat- ing ARIs, antibiotics should not be used to treat URTIs unless there is a documented bacterial infection [10]. In our study, regular use of a facemask was the most important practical protective factor, leading to a substantial decrease in the incidence of ARI. Although there is no clear research-based evidence on the effectiveness of facemasks in preventing transmission of ARIs, surgical facemasks are an established part of clinical practice. The use of facemasks has been advocated to protect people from inhalation of aerosols containing organic and inorganic particles [11]. Therefore, the CDC recommenda- tions for the prevention of influenza include wearing a facemask [12]. Although wearing a mask may not provide complete protection from infection, it will reduce the incidence of infection by preventing droplet inhala- tion, which is considered one of the main modes of transmission of most URTIs. Use of a facecover (hijab/niqab) by the women can also be considered as similar to use of a facemask. Most of the female hajjis were Saudis, who are more likely than other nationalities to cover their face during the hajj, and therefore the use of a facecover was quite frequent. But there was no evidence of a significant decrease in the incidence of ARI among women related to using a facemask or facecover. This differ- ence from males can be explained by other customs, for example, women do not cover their face when alone in their tents with other females, and therefore have the same high risk of disease transmission in a closed environment with exposure to droplet infec- tion. So using the facecover as a proxy for a facemask in women may be leading to misclassification of exposure status. Men, however, were using the facemask as a personal hygiene measure, independent of the place where they were. This high proportion of ARI, along with the secondary wave of ARI in the city from which hajjis originated, is a heavy burden on the health care system. One objective of the investigation—to quantify this burden—has been achieved, but the other objective—to identify the cause—was not. In the ab- sence of any laboratory-based evidence, it is difficult to comment about the etiology of ARI, especially when almost two-thirds of patients suffering ARIs had taken antibiot- ics before being contacted in the post-hajj period. Discouraging antibiotic use may be a difficult task, but more public information about the viral etiology of ARIs may be necessary. So it is concluded that almost 40% of hajjis developed ARI during and immedi- ately after the hajj, with a higher duration of stay in the hajj area, praying at Namera mosque and suffering from diabetes melli- tus identified as the main risk factors. Using a facemask during hajj was found to be a major protective measure to decrease the risk of ARI among male hajjis. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 309 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم On the basis of this study the investiga- tors recommend that use of a facemask should be encouraged during the hajj to reduce the incidence of ARI; hajjis and health care providers should be advised not to use antibiotics for management of ARI without evidence of bacterial causation; and older people and diabetic patients should be informed about their high risk of ARI in order to adopt protective measures. Further studies should be conducted to establish the etiology of ARI among hajjis during the hajj winter season and to study the efficacy and effectiveness of the facemask in preventing ARI in the hajj as a health education based intervention trial. Acknowledgements We would like to acknowledge here the support of Dr Sahar Makki, Riyadh health directorate, and all the doctors and para- medical staff in the participating health care centres for their cooperation in recruiting the patients and their follow-up. We would also like to thank Dr Mona Bassurah, Dr Mona Anezi, Dr Aliya Al-Naji for their help in interviewing female hajjis. Last but not least, we would like to thank all the hajjis who participated in the study, without whose cooperation this study could not have been completed. References 1. Khoja TA, Al-Mohammad KK, Aziz KMS. Setting the scene for an ARI control pro- gramme: is it worthwhile in Saudi Arabia? Bulletin of the World Health Organization, 1999, 5(1):111–7. 2. Povey G, Mercer MA. East Timor in tran- sition: health and health care. Interna- tional journal of health services, 2002, 32(3):607–23. 3. Chin J, ed. Control of communicable diseases manual, 17th ed. Washington DC, American Public Health Association, 2000:425. 4. Memish ZA. Infection control in Saudi Arabia: meeting the challenge. Ameri- can journal of infection control, 2002, 30(1):57–65. 5. El-Sheikh SM et al. Bacteria and viruses that cause respiratory tract infections during the pilgrimage (Haj) season in Makkah, Saudi Arabia. Tropical medicine and international health, 1998, 3(3):205– 9. 6. Kholedi AN et al. Seropositivity in clinical influenza cases among pilgrims during Hajj 1421 H. Saudi epidemiology bulletin, 2001, 8(4):27–8. 7. Al-Hajjar S et al. Respiratory viruses in children attending a major referral centre in Saudi Arabia. Annals of tropical paedi- atrics, 1998, 18 (2):87–92. 8. Graham NMH. The epidemiology of acute respiratory infection. In: Nelson KE, Willimas CM, Graham NMH, eds. Infec- tious disease epidemiology: theory and practice. Maryland, Aspen Publishers, 2001:439–76. 9. Baron S, ed. Infections of the respira- tory system. In: Medical microbiology, 4th ed. Texas, University of Texas Medical Branch of Galveston, 1996:211–6. 10. Gonzales R et al. Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infections in adults: background. Annals of internal medicine, 2001, 134:490–4. 11. Pippin DJ, Verderame RA, Weber KK. Efficacy of face masks in preventing inha- lation of airborne contaminants. Journal of oral and maxillofacial surgery, 1987, 45(4):319–23. 12. Recommendations for the prevention of influenza. Morbidity and mortality weekly report, 2000, 49(RR03):1–38. 310 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Evaluation of the 10th External Quality Assessment Scheme results in clinical microbiology laboratories in Tehran and districts M. Abbassi,1 M. Rahbar,1 S. Hekmat Yazdi,1 F. Rashed Marandi,1 R. Sabourian1 and M. Saremi1 1Bo-Ali Hospital, Reference Laboratory of Iran, Tehran, Islamic Republic of Iran (Correspondence to M. Rahbar: reflabs@hbi.ir). Received: 09/02/04; accepted: 25/07/04 ABSTRACT We evaluated the performance of microbiology laboratories in the 10th run of the external quality assessment scheme (EQAS) in Tehran and districts. Each laboratory was sent 2 species of bac- teria for identification. Of the 487 laboratories that participated, 437 returned their findings. While 77.0% and 69.9% correctly identified Staphylococcus saprophyticus and Citrobacter freundii respectively, only 29.8% correctly identified Acinetobacter baumanii, 25.3% identified Enterococcus faecalis and 35.6% identified Enterobacter agglomerans. However 78.7% and 79.5% of the laboratories reported correct results for susceptibility testing for S. saprophyticus and C. freundii respectively. Évaluation des résultats du 10e programme d’évaluation externe de la qualité dans les laboratoires de microbiologie clinique à Téhéran et dans les districts RÉSUMÉ Nous avons évalué la performance des laboratoires de microbiologie lors du 10e cycle du programme d’évaluation externe de la qualité (EQAS) à Téhéran et dans les districts. Chaque labora- toire a reçu deux espèces de bactéries pour identification. Sur les 487 laboratoires participants, 437 ont envoyé leurs résultats. Alors que 77,0 % et 69,9 % des laboratoires ont identifié correctement Staphy- lococcus saprophyticus et Citrobacter freundii respectivement, seuls 29,8 % ont identifié correctement Acinetobacter baumanii, 25,3 % ont identifié Enterococcus faecalis et 35,6 % ont identifié Enterobacter agglomerans. Toutefois, 78,7 % et 79,5 % des laboratoires ont fourni des résultats corrects pour les tests de sensibilité sur S. saprophyticus et C. freundii respectivement.      
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( )*+, --  ./$01/ A@8JC3™JT“@3hiJ;86dªC3N>‘83hf:©jªWª@3:•P83™JT;W¤3hfp™J;3´Rq73x>“e3hWªd©rª83:RÃ3hAeJdH3:RÃ3 3 ! 2343A—8J^P3IJST5P3vP89p3<@3‡W•J?5P3‡89:5P3M3N>—656>\9WqOP3vPŽZOP3zPps3}>>YZ\3i6¥7Jd5P3IJ‘ 3‚‹JTOP93iPW“‹3M3‡p6P3}>>YZ53m3J“¤PW?Zec3ŽZÄ3Kq53}>¬PWP3<@3<©>ªH6j3aJe8l3Å3:‘93m<©>ªH6T5P38J>ZyP3Å9 3N>‰P6wH3‡86Q\3m3€\3<@948735P3N>GRH3M3´L8J•3oPŽZÄ33IJ‘3h}>>YZ4373·‰JZT5P3<H3W;8JYX3aJe8²\3oPŽZÄ33m:‘9 3³Æ3€73M34js3 l3·‰JZT5P3¸gr3v8J•s773Ç3³Æ93hNª@J=@W5P3N;p6YT?5P3FGH3½žW?Z5P3M3vPŽZOP3<@69.93ÇM 3is3cl3hN;:T;9Wb5P3N>j6R>G5P3FGH3½žW?Z5P29.83Ç35P3‡:LPW5P3FGH3½žW?Z5P3M3´BÆ3vPŽZOP3<@3†Y¤hN>jJ@9Jd 925.33Ç393hN;™PŽ5P3N;6?OP3‡86qOP3FGH3½žW?Z5P3M3´BÆ35.63Ç3NGŒZqOP3N>‰J?@…P3FGH3½žW?Z5P3M3´BÆ3m_@9 3Ar3N>eJ`­P38JdZyc3NB>BC3·‰JZj3´ºG\s3¿5P3vPŽZOP3Nd`j3´jJL3h±5n78.73Ç393hNª@J=@W5P3N;p6YT?G579.5Ç 3N;:T;9Wb5P3N>j6R>ÈG53m36¥7Jd5P3IUZ?;9·@PW\93N;pJ•8l3K‰cp3pP:Hl93hˆ•P6q5P3_>TQZ53vJeJ>e3_E93FGH3KR?5P3i vPŽZOP3zPps3€`’3Nª>©º\3hJ>G?5P3vJeP8:5P3Éx‹3¡;8:Z5m3 3 Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 311 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction An external quality assessment scheme (EQAS) is a component of quality assur- ance in which laboratories participating in the programme receive EQAS specimens at regular intervals, evaluate them by rou- tine methods and report the results to the organizing centres. In addition, EQAS is an educational tool that improves national and regional standards [1–5]. The reference laboratory of the Islamic Republic of Iran is part of the government sector. Since 1994 they have introduced EQAS in many public and private medical laboratories. In microbiology laboratories various steps have been taken to upgrade the EQAS programme. These steps have included running national training courses for trainers, sending unknown specimens at regular intervals to the laboratories of the national network and sending standardized methods to control and check the culture media and antibiotic discs. At present, 2000 microbiology labora- tories throughout the country participate in EQAS organized by the reference laborato- ry’s microbiology laboratory. In each trial, 2 different bacterial species are sent to the laboratories for identification (genus, spe- cies and subtype); sensitivity testing is also required for 1 of the species. The bacteria are in a pure form taken from samples sent by the World Health Organization (WHO) as part of the WHO external quality as- sessment scheme or bought from Difco, an American Type Culture Collection (ATCC) (part of BD Diagnostics, New Jersy, USA). Our goal is to use EQAS as an accreditation system for laboratories in the near future. In the present study we evaluated the 10th run of EQAS performance of the microbiology laboratories in Tehran and districts. Methods The 10th run of EQAS was carried out in July 2002 among 487 intermediate and peripheral laboratories (public and private) located in Tehran and surrounding districts. For this purpose, 5 different bacterial spe- cies (ATCC) or strains confirmed by WHO were selected and each laboratory randomly received 2 unknown samples for identifica- tion. The species were: • Staphylococcus saprophyticus (ATCC: 15305) • Citrobacter freundii (confirmed by WHO) • Acinetobacter baumanii (ATCC: 19606) • Enterococcus faecalis (ATCC: 29212) • Enterobacter agglomerans (confirmed by WHO) Second confirmation and other neces- sary biochemical tests were performed in the reference laboratory before distributing the species [2]. In addition, susceptibility testing was performed for S. saprophyticus and C. freundii using standard methods sug- gested by the National Committee for Clini- cal Laboratories Standards (NCCLS) [6]. The species then were cultured on trypticase soy agar (TSA) in screw-capped tubes. They were incubated at 35 ± 2 °C for 24 hours and then sealed. The TSA tubes, together with guidelines and necessary forms, were sent to each participating laboratory. The laboratories were asked to test one species (the S. saprophyticus) against ampicillin, tetracycline, nalidixic acid, ciprofloxacine and co-trimoxazole and the C. freundii against ampicillin, gentamicin, cephalexin, chloramphenicol and cefotaxime. They were also asked to measure the zone of 312 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم inhibition using standard methods and to categorize them as susceptible (S), interme- diate susceptibility (I) and resistant (R). After identifying the species, the labora- tories returned the completed forms within 1 month. The results were scored according to WHO criteria. The maximum points for complete identification of each unknown species was 3 and 5 for susceptibility test- ing. Each incorrect answer scored zero and a partially correct answer (doing some tests and identifying the genus) scored 0.5–2.5. If susceptibility for each antibiotic differed from the true result by one degree, 0.5 score was given [7]. Results A total of 487 laboratories participated in the 10th EQAS in Tehran and districts and were sent the species for identification. Of these, 437 laboratories returned their results (89.7%). Of the 291 laboratories that were sent S. saprophyticus, 224 (77.0%) identi- fied the organism correctly, and 102 of 146 (69.9%) laboratories correctly identified C. freundii. Of the other species, 34 of 114 (29.8%) laboratories correctly identified A. baumanii, 37 of 146 (25.3%) correctly iden- tified Enterococcus faecalis, and 63 of 177 (35.6%) laboratories correctly identified Enterobacter agglomerans. The incorrect identification of these bacteria were 7.9%, 27.3%, 43.8%, 26.0% and 52.5% respec- tively (Figure 1). The mean scores and standard deviations (SD) for each bacteria were as follows: • S. saprophyticus 2.5 (SD 0.96) • Enterococcus faecalis 1.8 (SD 1.21) • Enterobacter agglomerans 1.2 (SD 1.32) • C. freundii 2.1 (SD 1.33) • A. baumanii 1.4 (SD 1.21) Most of the laboratories were able to perform the susceptibility testing correctly. Figure 1 Identification scores for the 5 bacterial species Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 313 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم The results were as follows: 78.7% of labo- ratories reported correct susceptibility test- ing for S. saprophyticus and 79.5% for C. freundii (Tables 1 and 2). The mean scores for susceptibility testing were 3.64 (SD 0.65) for S. saprophyticus and 4.35 (SD 1.32) for C. freundii. Ampicillin resistance of S. sapropyticus was not reported correctly in 70% of the cases. Because of this observation, the amp- icillin disks, which are produced locally, were checked and we found that the failure in identification was related to a problem with the disks themselves. Therefore, this score was omitted from the total scoring. At the end of the evaluation process, expected correct answers were sent to each labora- tory. Correct identification guidelines and necessary references accompanied all the results as well. Discussion The main goal of EQAS is to improve the quality and strengthen the capabilities of laboratories. In evaluating the microbiol- ogy laboratories in Tehran and surrounding districts, it was presumed beforehand that the laboratories were functioning within an acceptable range. Unfortunately, our results did not confirm this assumption, and there was a wide range of capabilities of the laboratories to identify different spe- cies. This failure could have been a result of defective reagents and differential culture media, inappropriate internal quality con- trol programmes and inadequate numbers of qualified technicians. The first external quality assessment of clinical microbiology laboratories in Norway in 1982 included 15 country and regional laboratories [8]. The mean number of incorrect identifica- tions was 2.7 (11.3%). Eleven (11) strains were correctly identified by all laboratories, whereas 4 strains were misidentified by 4 to 7 laboratories, accounting for approximately 50% of all misidentifications [8]. According to Richardson and his associates in Canada, the number of participating microbiology laboratories in EQAS declined from 335 laboratories in 1974 to 190 laboratories in 1994 [9]. In the initial evaluation, 21% of laboratories did not have the expected capabilities. In 1989, 50% of laboratories achieved high points (above 80%) for iso- lating and identifying the microorganisms. However, 25% of laboratories scored less than 50% for bacterial sensitivity testing and only 10% of them had high scores (above 80%). This lack of effectiveness was related to inappropriate selection of chemicals [9]. Table 1 Accuracy of the results of susceptibility testing of 291 laboratories sent Staphylococcus saprophyticus Antibiotic Expected Correct Incorrect No answer No. of labs No. of labs No. of labs Ampicillin S 70 172 4 Tetracycline S 254 27 10 Nalidixic acid R 273 13 5 Ciprofloxacine S 273 12 6 Co-trimoxazole S 239 43 9 Total 1109 (89.3%) 267 (8.2%) 34 (2.6%) R = resistant, S = susceptible, I = intermediate. 314 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم In another study to evaluate bacterial resistance, the Centers for Disease Control and Prevention (CDC) and WHO distrib- uted 6 different strains of bacteria among 130 laboratories in the United States and other countries. Most of the laboratories were able to identify S. aureus, Entero- bacter faecalis and Klebsiella pneumoniae against methicillin, vancomycin and cepha- losporin respectively [10]. However, the rest, especially those that used the disk dif- fusion method for evaluating the sensitivity of S. pneumoniae against penicillin, had problems. In addition, the majority of labo- ratories had problems evaluating reduced sensitivity of S. epidermidis to vancomycin [10]. Another study showed only 3 of 23 reference laboratories were able to identify correctly 6 lyophilized Corynebacterium diphtheriae strains and to detect the C. diphtheriae toxigenicity [11]. A study by Kumasaka in Tokyo revealed that poor per- formance in the EQAS survey was closely related to poor laboratory management, the type of training, experience of the medical technicians, and the supervisory ability of the consultant physicians in independent laboratories [12]. In a study in the United Kingdom, Pitt and Sands concluded that the physiological concepts of job satisfaction and climate are factors that might affect external and internal quality control [13]. We are planning to establish a proper policy for manufacturers (or importers) to produce the necessary and important media and reagents. In addition, adding special postgraduate training courses and distribu- tion of scientific guidelines will be helpful. With these new policies, we hope in future to upgrade the capabilities of the microbio- logy laboratories in Tehran and districts. References 1. Isenberg HDE, ed. Essential procedures for clinical microbiology, 1st ed. Washing- ton DC, American Society for Microbiol- ogy, 1998:734–5. 2. Mahon C, Manuselis G. Textbook of diag- nostic microbiology, 2nd ed. Philadelphia, WB Saunders, 2000:106–28. 3. Koneman WEW et al. Color atlas and text- book of diagnostic microbiology, 5th ed. Philadelphia, Lippincott, 1977:113–20. 4. Schal KP. The German external qual- ity assessment scheme for bacteriolo- gy. Medical microbiology letters, 1994, 3:247–58. Table 2 Accuracy of the results of susceptibility testing of 146 laboratories sent Citrobacter freundi Antibiotic Expected Correct Incorrect No answer No. of labs No. of labs No. of labs Ampicillin R/I 141 4 1 Cephalexin R 113 26 7 Cefotaxime S 95 20 31 Chloramphenicol S 108 27 11 Gentamicin S 123 13 10 Total 580 (79.5%) 90 (12.3%) 60 (8.2%) R = resistant, S = susceptible, I = intermediate. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 315 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 5. Vandepitte J et al. Basic laboratory pro- cedures in clinical bacteriology. Geneva, World Health Organization, 1991. 6. Performance standards for antimicrobial susceptibility testing. Twelfth information supplement. Wayne, Pennsylvania, NC- CLS, 2002 (NCCLS document M100– 12). 7. Vandepotte J. External quality control in microbiology. Leven, Belgium, WHO col- laborating center for external quality as- sessment in clinical microbiology, 1998. 8. Lassen J, Sandven P. External quality assessment for clinical microbiological laboratories in Norway 1982. Evaluation of the identification of 24 bacterial strains. NIPH annals, 1983, 6:23–35. 9. Richardson H et al. Quality improve- ment of diagnostic microbiology through a peer-group proficiency assessment pro- gram. A 20-year experience in Ontario. The Microbiology Committee. Archives of pathology & laboratory medicine, 1996, 120(5):445–55. 10. Tenover FC et al. Ability of laboratories to detect emerging resistance: Proficiency testing and quality control results from the World Health Organization external assurance system for antimicrobial sus- ceptibility testing. Journal of clinical micro- biology, 2001, 39:241–50. 11. Engler KH, Kozlov RS, Copping SJ. In- ternational external quality assessment schemes for the laboratory diagnosis of diphteria. Journal of medical microbiol- ogy, 2000, 50:1006–12. 12. Kumasaka K. External quality assess- ment for clinical microbiology and good laboratory management. Rinsho byori, 1998, 46:124–31 [In Japanese]. 13. Pitt SJ, Sands RL. Effect of staff attitudes on quality in clinical microbiology ser- vices. British journal of biomedical sci- ence, 2002, 59:69–75. 316 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Differential aspects of consultation– liaison psychiatry in a Saudi hospital. I: referral pattern and clinical indices A.M. Alhamad,1 M.H. Al-Sawaf,2 A.A. Osman3 and I.S. Ibrahim4 1Department of Psychiatry, College of Medicine, King Saud University, Riyadh, Saudi Arabia (Correspondence to A.M. Alhamad: alhamad@ksu.edu.sa). 2Department of Psychiatry; 4 Department of Biostatistics, King Fahad Hospital, Jeddah, Saudi Arabia. 3Division of Psychiatry, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia. Received 29/07/03; accepted: 03/03/04 ABSTRACT Consultation–liaison psychiatry has emerged as an important sub-specialty in the general hospital setting during recent years as a result of psychiatric acute wards moving into these hospitals. This has inspired the need for better structured research to establish its relevance and effectiveness. We, therefore, carried out a prospective cohort study at King Fahad General Hospital. We report the interaction of sociodemographic, clinical and diagnostic factors, time lag of referral and diagnostic ability of referring physicians. A total of 206 patients were referred over a period of 6 months. Sensitivity and specificity of the diagnostic skills of the referring doctors were found to be generally poor, particularly for anxiety. Aspects différentiels de la psychiatrie de liaison dans un hôpital saoudien : I. Orientation et indices cliniques RÉSUMÉ La psychiatrie de liaison est devenue une importante sous-spécialité dans les hôpitaux gé- néraux ces dernières années du fait que ces hôpitaux se sont dotés de moyens d’accueil et de prise en charge psychiatrique en urgence. Ceci a soulevé la nécessité de mieux structurer la recherche afin d’établir sa pertinence et son efficacité. Nous avons donc réalisé une étude de cohorte prospective à l’Hôpital général Roi Fahd. Nous rapportons l’interaction de facteurs sociodémographiques, cliniques, diagnostiques, ainsi que du délai de transfert du patient et de la capacité diagnostique des médecins référents. Au total, 206 patients ont été adressés à une structure spécialisée sur une période de six mois. On a trouvé que la sensibilité et la spécificité des compétences des médecins référents en ma- tière de diagnostic étaient généralement faibles, notamment pour l’anxiété. .1 Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 317 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction A fundamental aim of consultation–liaison psychiatry is the integration of psychia- try into the medical mainstream [1,2]: in essence, to revive the orthodox, holistic medical approach that has prevailed since the time of Hippocrates, who asserted that “in order to cure the human body, it is necessary to have knowledge of the whole” [3]. To effectively achieve this, consulta- tion–liaison psychiatry must first establish its pertinence to other branches of medicine in the general hospital setting, and second, display adequately and reliably the magni- tude and the impact of psychiatric morbid- ity and mortality in physically ill inpatients [1,3]. Both objectives are only achievable through reliable and adequate research in the field, which should not only investigate the pattern of referral and the compliance with psychiatrists’ recommendations, but also assess the knowledge and attitude of both the hospital doctors and the patients, which are crucial determinants in referrals for psychiatric consultation [4]. To the best of our knowledge, however, none of the literature has addressed these issues simul- taneously in the same setting. Moreover, the many difficulties inherent in research into consultation–liaison psychiatry [5], com- bined with a lack of standard research measures [6,7], has rendered results from different studies widely variable and incon- sistent. Three closely related but distinct reasons might be responsible for this wide vari- ability in results, the nature of the patient population under investigation, the knowl- edge of hospital doctors and their attitude towards psychiatry, and the attitude of the patients themselves towards psychiatric consultation in the context of their current physical illness [3,4,8,9]. We carried out this study to demon- strate the corresponding influence of each of these 3 dimensions on the pattern of referral for psychiatric consultation in a general hospital. In this paper we report the sociodemographic data, the referral indices, the clinical characteristics, the diagnostic categories and concordance, and the con- sent of patients. Knowledge and attitude of referring doctors and patients are reported in part II of the study. Methods We carried out a prospective cohort study of all patients referred consecutively for psychiatric consultation at King Fahad Hos- pital in Jeddah, Saudi Arabia, over a period of 6 months between July and December 1994. These patients were referred either from inpatient departments or the extended emergency room, where patients stay up to 48 hours only. King Fahad Hospital in Jeddah is a large, 930-bed general hospital which serves mainly as a secondary care centre, but having 3 units which function basi- cally as tertiary care units, the open-heart surgery unit, the organ transplant unit and the haemodialysis unit. The psychiatric consultation service is provided by an outpatient unit with 2 full-time consultants, 2 residents, 2 psychologists, 2 social work- ers and 1 nurse. We designed 2 forms to collect the data needed for our study. Form A was to be filled in personally by the referring consult- ant or specialist (consultee). The questions covered basic demographic data, the rea- son for referral, the degree of urgency, the medical diagnosis, active psychiatric symp- toms he was able to elicit, and provisional psychiatric diagnosis. Form B was to be filled in personally by the responding psychiatrist (consultant). This covered clinical assessment, degree of urgency and final psychiatric diagnosis 318 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم according to the World Health Organization ICD-10 classification system [10]. The de- gree of urgency of the referral was divided in both forms into 4 categories to determine referral time lag. These were immediate (within 48 hours of admission), early (3–7 days after admission), delayed (8–15 days after admission) and late referral (> 15 days after admission). Results A total of 206 patients were referred over the period of the study, of which 188 came from inpatient departments and 18 from the extended emergency room. This repre- sented an overall referral rate of 3.9% of the total admissions to the hospital over the study period (5263 patients), 3.8% for inpa- tient departments and 6.3% for the extended emergency room. There were 120 referrals of male patients (58.5%), giving a male to female ratio of 1.4:1; this compares to a ratio of 1.8:1 in the general hospital population. Mean age was 37.14 years (standard deviation 15.2), range 11–80 years. There were only 10 patients (4.9%) older than 60 years. The highest rate of referral was from the nephrology and haemodialysis unit, 8.1%; the others are summarized in Table 1. The medical department tended to refer patients earlier than other departments (Ta- ble 2). Analysis of the time lag in relation to diagnosis, reason for referral, age and consent of the patient is shown in Table 3. There was a statistically significant differ- ence between time lag for patients under 40 years of age (shorter time lag) and those over 40 years of age (χ2 = 5.88; P < 0.05). Substance abuse patients diagnosed by the consultee were referred earlier (χ2 = 7.52; P < 0.01), while organic brain syndrome patients diagnosed by the consultant were significantly delayed in referral (χ2 = 7.52; P < 0.01). An interesting finding was that the earlier the patient was referred, the greater the likelihood he had consented to referral and this was statistically significant also (χ2 = 9.92; P < 0.02). Only 7 patients (3.7%) were referred for evaluation of competence for surgical treat- ment and the diagnoses were 3 with organic brain syndrome, 2 phobic states of surgery and 2 personality disorders. Table 4 shows the concordance of diagnoses made by the consultees and the consultants. Table 5 shows sensitivity and specificity for each diagnosis. Only 190 patients out of the total 206 referred were given diagnoses by the consultees, hence the difference be- tween total numbers of patients for consult- ees and consultants. Depression and drug abuse were rated relatively better in both specificity and sensitivity, while anxiety disorders showed the lowest sensitivity and specificity rates. Specificity for personality disorder was zero. Table 1 Psychiatric consultations and admissions for each department, King Fahad General Hospital, July–December 1994 Department Admissions Referrals Referral ratea No. No. % % Extended emergency 285 18 8.7 6.3 Medicine 1731 93 45.1 5.4 Nephrology 236 19 9.2 8.1 Orthopaedics 875 27 13.1 3.1 Surgery 2136 49 23.8 2.3 Total 5236 206 100.0 3.9 aReferral rate = no. of referrals from a department/no. of admissions to that department. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 319 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Discussion In view of the large array of variables which may prove difficult to control, and the limi- tations in generalizability of the results ob- tained from any one study, besides the small size and the short duration of the study, we must initially acknowledge the limitations of our findings. However, we believe that our findings may highlight a few, but never- theless significant, issues in this field, being probably the first study of its kind. Demographic characteristics In contrast to the majority of previous re- ports [4,8–13], in this study males exceeded females in both the hospital population and referral rates. This reversed sex ratio is in accord with the general trend in the Saudi hospital population [14]. Some research- ers consider this reversal of ratio may be because females tend to seek help from traditional local support systems for longer periods before they seek help from medi- cal centres or because females have higher acceptability and tolerance of psychiatric symptoms and the tendency to conceal them in view of their local, more stigmatizing, ef- fects on females, which may be true even among hospital populations [8,14]. The age range and mean age did not differ significantly from other reports in the literature, though patients older than 60 years were relatively under-represented, a finding which invites some investigation as psychiatric disorders tend to be more common among this group. The rate, 4.9%, was significantly lower than that reported among inpatients (13.3%) and also much lower than the usually reported ranges of 16%–23% in the literature [3,4,8]. Referral indices The mean referral rate of 3.8% for the inpatients is consistent with the usually reported rates of 3%–4% [3,4,8]. An im- portant, though not surprising, finding was the high referral rate (8.1%) from the neph- rology and haemodialysis unit. There is an acknowledged high psychiatric morbidity among patients on regular haemodialysis [15,16]. The finding that a good number of patients (18.4%) were referred for the mere presence of past history of psychiatric disorder or for taking some kind of a psy- chotropic drug, even though they were free of symptoms at the time, may reflect the poverty of psychiatric knowledge among Table 2 Time lag for psychiatric referral of patients for each department, King Fahad General Hospital, July–December 1994 Department Within 48 hours 3–7 days 8–15 days > 15 days Total No. % No. % No. % No. % No. % Extended emergencya 18 8.7 – – – – – – 18 8.7 Medicine 22 10.7 41 19.9 15 7.3 15 7.3 93 45.1 Nephrology 0 – 11 5.3 4 1.9 4 1.9 19 9.2 Orthopaedics 1 0.5 6 2.9 7 3.4 13 6.3 27 13.1 Surgery 6 2.9 14 6.8 21 10.2 8 3.9 49 23.8 Total 47 22.8 72 35.0 47 22.8 40 19.4 206 100 aPatients are only kept a maximum of 48 hours. 320 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم hospital doctors. Medico-legal factors can also influence psychiatric referral as it has been shown that 25% of referrals are for evaluation of competence in the absence of gross evidence of mental illness and 75% of such referrals were found to be mentally competent. This was explained by the medico-legal consequences, physicians’ anxiety and lack of appropriate understand- ing of patients’ rights during treatment [9]. The timing of consultation is influenced by many factors [17,18], and younger pa- tients were more likely to be referred early (3–7 days), which is closely related to the previously mentioned finding of under- representation of the elderly, and could be attributed to similar reasons. Intrapersonal factors, i.e. the individual characteristics of the patient and his/her response to the referral, and the stigmatiz- Table 3 Time lag in relation to diagnosis, reason for referral, age and consent of the patient Category No. of patients referred for each time period Within 48 3–7 8–15 > 15 Total hours days days days Diagnosis of psychiatrist Depression 16 22 17 15 70 Anxiety 6 12 5 3 26 Psychosis 4 4 3 4 15 Organic brain syndrome 1 11 10 10 32 Substance abuse 8 8 5 1 22 Personality disorder 5 6 1 3 15 Other 7 9 6 4 26 Diagnosis of consultee Depression 14 21 17 11 63 Anxiety 8 11 7 8 34 Psychosis 6 11 3 6 26 Organic brain syndrome 1 7 6 2 16 Substance abuse 12 8 4 2 26 Personality disorder 0 2 0 0 2 Other 3 7 7 6 23 Reason for referral To help in management 10 20 14 14 58 To help in diagnosis 29 33 24 18 104 Positive past history 8 16 8 6 38 Other 0 2 0 4 6 Age group (years) ≤ 40 35 50 29 18 132 41–60 8 16 14 19 57 > 60 4 6 4 3 17 Patient consent Yes 28 21 16 15 80 No 19 51 31 25 126 Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 321 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم ing effect of the consultation in the young patients compared to the elderly may explain the time-lag difference. It is also possible that the consultees were less con- cerned about the psychiatric symptoms in older patients, perhaps owing to their wrong assumptions that such symptoms are nor- mally expected in this age group, and do not warrant psychiatric consultation, or perhaps they found it more difficult to identify such symptoms in the elderly [19]. The shorter time lag in referrals from the medical units in comparison to the surgical ones may reflect a better knowledge of psy- chiatry in the internists, or that symptoms appear later in surgical patients, possibly related to the stress of surgery. Substance abuse was the only diagnosis which precipitated immediate referral by many of the consultees, most likely in anticipation of difficulties once the with- drawal symptoms appeared. However, or- ganic brain syndrome, which was expected to be referred early, showed a statistically significant delay [20]. This could be a re- flection of the hospital doctors’ reluctance to refer such cases because of their wrong assumption that organic brain syndrome belongs solely to their own domain, or because of their negative expectation of the Table 4 Concordance of diagnoses by consultant (psychiatrist) and consultee (non- psychiatrist physician) Diagnosis Consultant Consultee No. % No. % Depression 70 36.6 63 33.2 Anxiety 26 13.6 34 17.9 Psychosis 15 7.9 26 13.7 Organic brain syndrome 32 16.8 16 8.4 Substance abuse 22 11.5 26 13.7 Personality disorder 15 7.9 2 1.1 Other 26 13.6 23 12.1 Total 206 107.9a 190 100 aSome patients were given > 1 diagnosis. Table 5 Sensitivity and specificity of diagnosis made by consultees in relation to those made by consultants Diagnosis made by No. of diagnoses Total Sensitivitya psychiatrist Diagnosis made by consultee (%) A B C D E F G Depression (A) 33 16 6 1 3 1 5 65 50.8 Anxiety (B) 10 8 1 0 2 1 2 24 33.3 Psychosis (C) 3 0 7 0 0 0 4 14 50.0 Organic brain syndrome (D) 2 2 5 13 0 0 9 31 41.9 Substance abuse (E) 4 3 1 1 13 0 0 22 59.1 Personality disorder (F) 2 1 5 0 6 0 0 14 0.0 Other (G) 9 4 1 1 2 0 3 20 15.0 Total 63 34 26 16 26 2 23 190 bSpecificity (%) 52.4 23.5 26.9 81.3 50.0 0.0 13.0 aSensitivity = number correctly diagnosed by consultee in a certain diagnosis category/total number diagnosed by the psychiatrist in the same diagnosis category. bSpecificity = number correctly diagnosed by consultee in a certain diagnosis category/total number diagnosed by the consultees in the same diagnosis category. 322 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم help a psychiatrist might contribute in the management of such cases [20]. Consent of patients There are 3 possible explanations for the interesting finding of the strong association between consent of the patient and im- mediate referral. First, it might reflect the severity of symptoms, which may dissipate the ambivalence and fear of the consultee of informing the patient about the possibility of his symptoms being psychological. Sec- ond, earlier referral might reflect the better knowledge, and hence more positive at- titude towards psychiatry, on the part of the consultee, who therefore feels comfortable in informing his patient. Third, the longer the patient stays in the hospital under the care of the same doctor, the stronger the dominance of the doctor over the patient, and the more likely he or she will be to take decisions on the patient’s behalf without consent [21]. Diagnostic ability of consultees Deficiencies in the diagnostic abilities of hospital doctors may affect their ability to correctly recognize psychiatric symptoms. This could seriously distort the pattern of referrals and obscure the prevalence rates of these symptoms among their patients [22]. Our findings generally indicated that such abilities among our hospital doc- tors were disappointingly poor. Even in a disorder such as organic brain syndrome, which is strongly perceived by the major- ity of doctors to be solely within their own domain, the sensitivity of diagnosis was second poorest. The difficulty in correctly diagnosing these cases was also manifested in the unduly prolonged time lag in refer- ral. Diagnosis of depression and anxiety disorders, which are by far the commonest disorders among hospital patients [2,3,8], also showed inadequate sensitivity and spe- cificity. The poor specificity in diagnosing psychosis may be due to the consultees’ dif- ficulty in differentiating it from other con- ditions [22]. Sixteen out of the 26 patients who were diagnosed as having psychosis by the consultees were found to be suffer- ing from either personality disorder, severe depression, or organic brain syndrome (5, 6, and 5 patients respectively). Conclusion Our findings, for referral rates, diagnostic abilities of consultees or the relationship of time lag to other significant variables, reflect results which are generally compa- rable to reports in the literature. The poor knowledge of psychiatry of our hospital doctors necessitates the simultaneous inves- tigation of the correlation of these factors to the knowledge and attitude of the consultees and the referred patients. This will be re- ported in the second part of our study. This supports the liaison model [11,13] which gives priority to the teaching and education of hospital staff rather than to the provision of clinical services. References 1. Lipowski ZJ. Introduction to consulta- tion–liaison psychiatry. Psychiatry up- date, 1983, 3(3):177–87. 2. Gomez J. Liaison psychiatry–mental health problems in the general hospital. Beckenham, Kent, Croom-Helm Ltd, 1987:103–28. 3. Lipowski ZJ. Consultation–liaison psy- chiatry: an overview. American journal of psychiatry, 1974, 131(6):623–30. 4. Lipowski ZJ, Wolston EJ. Liaison psy- chiatry-referral patterns and their stability over time. American journal of psychiatry, 1981, 138(12):1608–11. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 323 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 5. Lipowski ZJ. Physical illness and psychi- atric disorder—a neglected relationship. Psychiatria fennica, 1979, 10:32–57. 6. Goldberg D, Huxley P. Mental illness in the community: the pathway to psychiat- ric care. London, Tavistock Publications, 1980:37–9. 7. Williams P, Tarnopolsky A, Hand D. Case definition and case identification in psychiatric epidemiology: review and as- sessment. Psychological medicine, 1980, 10(1):101–14. 8. Abu-Hijleh NS. Psychiatric consultation in Jordan University Hospital. Jordan medi- cal journal, 1987, 21(2):149–57. 9. Craig TJ. An epidemiologic study of a psy- chiatric liaison service. General hospital psychiatry, 1992, 4:131–7. 10. ICD-10. International classification of diseases: classification of mental and behavioural disorders. Geneva, World Health Organization, 1993. 11. Huyse FJ et al. European consultation– liaison psychiatric services: the ECLW collaborative study. Acta psychiatrica scandinavica, 2000, 101(5):360–6. 12. Mayou R, Hawton K. Psychiatric disorder in the general hospital. British journal of psychiatry, 1986, 149:172–90. 13. Smith GC, Clarke DM, Herrman HE. Con- sultation liaison psychiatry in Australia. General hospital psychiatry, 1993, 15(2): 121–4. 14. Osman AA, Al-Khateeb SO, Ali AS. The pattern of admission to Jeddah psychiat- ric hospital. Saudi medical journal, 1993, 14(4):334–9. 15. Sensky T. Psychiatric morbidity in renal transplantation. Psychotherapy and psy- chosomatics, 1989, 52(1–3):41–6. 16. Barrett BJ et al. Clinical and psychologi- cal correlates of somatic symptoms in pa- tients on dialysis. Nephron, 1990, 55(1): 10–5. 17. De-Jonge P et al. Timing of psychiatric consultations: the impact of social vulner- ability and level of psychiatric dysfunction. Psychosomatics, 2000, 41(6):505–11. 18. Handrinos D, McKenzie D, Smith GC. Timing of referral to consultation–liaison psychiatry unit. Psychosomatics, 1998, 39(4):311–7. 19. Wilkinson P, Bolton J, Bass C. Older patients referred to a consultation–liaison psychiatry clinic. International journal of geriatric psychiatry, 2001, 16(1):100–5. 20. Stevens LE, de-Moore GM, Simpson JM. Delirium in hospital: does it increase length of stay? Australian and New Zealand jour- nal of psychiatry, 1998, 32(6):805–8. 21. Schnyder U et al. Reference to psychiat- ric consultation in the discharge letter of general hospital inpatients. International journal of psychiatry in medicine, 1997, 27(4):391–402. 22. McGorry P, Copolov DL, Singh BS. The validity of the assessment of psychopa- thology in psychosis. Australian and New Zealand journal of psychiatry, 1989, 23: 469–82. 324 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Differential aspects of consultation– liaison psychiatry in a Saudi hospital. II: knowledge and attitudes of physicians and patients A.M. Alhamad,1 M.H. Al-Sawaf,2 A.A. Osman3 and I.S. Ibrahim4 1Department of Psychiatry, College of Medicine, King Saud University, Riyadh, Saudi Arabia (Correspondence to A.M. Alhamad: alhamad@ksu.edu.sa). 2Department of Psychiatry; 4Department of Biostatistics, King Fahad Hospital, Jeddah, Saudi Arabia. 3Division of Psychiatry, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia. Received: 29/07/03; accepted: 03/03/04 ABSTRACT To assess the attitude and knowledge of physicians and patients towards psychiatry, we asked 115 referring doctors and 188 referred patients to complete questionnaires. We examined the results along with the referral rates to try to identify factors that may affect a consultation–liaison psychiatry service. Generally, knowledge was poor and attitudes towards psychiatry negative in both groups. This negatively influenced the referral rates and reflected the lack of integration of psychiatry and medicine at the training level. This is an indication that psychiatrists need to work in collaboration with hospital doctors to integrate psychiatry into medicine at all levels and emphasizes the priority of education of hospital staff, patients and the community in consultation–liaison psychiatry. Aspects différentiels de la psychiatrie de liaison dans un hôpital saoudien : II. Connaissances et attitudes des médecins et des patients RÉSUMÉ Afin d’évaluer les attitudes et les connaissances de médecins et des patients concernant la psychiatrie, nous avons demandé à 115 médecins référents et 188 patients référés de remplir des questionnaires. Nous avons examiné les résultats et les taux d’orientation pour essayer d’identifier les facteurs qui peuvent affecter un service de psychiatrie de liaison. De manière générale, les connaissan- ces étaient faibles et les attitudes vis-à-vis de la psychiatrie étaient négatives dans les deux groupes. Ceci a eu une influence négative sur les taux d’orientation et a reflété le manque d’intégration de la psychiatrie et de la médecine au niveau de la formation. C’est une indication de la nécessité d’une collaboration entre les psychiatres et les médecins hospitaliers pour l’intégration de la psychiatrie dans la médecine à tous les niveaux et de la priorité à accorder à l'éducation du personnel hospitalier, des patients et de la communauté dans le domaine de la psychiatrie de liaison. .2 Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 325 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction Evaluative research in consultation–liaison psychiatry has gone through several phases of development. It has been clearly shown that factors contributing to a cost-effective service such as consultation setting; liaison activity; and physicians’ psychosocial at- titudes towards psychiatry, education and learning needs, vary widely and are dif- ficult to control [1]. This has prompted consultation–liaison committees and ac- ademics to set guidelines for seminars, training, education programmes and ethical aspects of consultation–liaison psychiatry [2]. Another important methodological con- tribution to enabling generalization from research findings in consultation–liaison psychiatry is to evaluate the interaction of the aforementioned factors simultaneously in the same setting [3]. Previously, we evaluated the interac- tion of sociodemographic factors of patients, time lag of referral, reason for referral, and clinical diagnoses and the concordance between consultants (psy- chiatrists) and consultees (non-psychiatric physicians) with the pattern of referral in consultation–liaison psychiatry [4]. In this paper we present the differential aspects of consultation–liaison psychiatry in the same setting, namely the attitude and knowledge of referring doctors (consultees) towards psychiatry and the consultation needs in this area, along with the attitude and knowledge of patients towards psychia- try and the consultation. Methods During the period July–October 1994, we assessed the knowledge and attitude of re- ferring physicians (consultees) and referred patients towards psychiatry and consulta- tion at King Fahad Hospital, a large 930-bed general hospital in Jeddah, Saudi Arabia. We produced a questionnaire which was sent to all consultees in the hospital. It com- prised 10 questions designed to measure knowledge and attitude towards psychiatry, including the need for psychiatric consul- tation; the reasons for urgent psychiatric consultation and situations they considered important; the need for informed consent of patients to the consultation; their experience of the usefulness of psychiatric consultation in the management of patients; the need for discussing the case with the psychiatrist; the concordance with the psychiatrists’ recom- mendations; and attitude to psychotropic medication side-effects and prescribing. Another specially designed question- naire comprising 9 yes/no questions was given to all patients referred during the study period. The questions covered knowl- edge and attitude towards the psychiatric consultation, stigma about psychiatry and psychotropic medication. Results Attitude and knowledge of doctors Only 88 (76.5%) of the 115 physicians at the hospital responded to the questionnaire, 58 surgeons (66.0%) and 30 internists (34.1%). Of the respondents, 50.8% had PhD equiva- lent, 41.3% had MSc and 7.9% had diploma only. The mean period of postgraduate experience for consultants was 9 years and for specialists 5 years (consultees). Fifty consultees (56.8%) needed psychiatric con- sultations occasionally (only once or twice) during their experience while 16 (18.2%) never needed such consultations. Only 21 doctors (23.9%) (10 internists out of 30 and 11 surgeons out of 58) needed psychiatric consultation more than 3 times during their 326 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم postgraduate experience, and this was sta- tistically significant (P < 0.01). Urgent consultation was requested by 40.0% of consultees when the patient had past psychiatric history, 42.4% when the patient refused to communicate, 67.4% when the patient threatened violence, 55.4% when the patient was delusional and 63.1% when the patient was hallucinating. In addition, 61.9% of consultees thought that psychiatric consultation was important for patients with behavioural problems. Seeking the help of a psychiatrist to reach a final diagnosis was thought important by only 38.1% of consultees. The responses regarding whether to ask for consent and inform the patient about the psychiatric consultation showed that 34.1% of consultees would always do it, 37.5% would do it sometimes and 28.4% would never do it. Psychiatric consultation was found to be almost always helpful in man- agement of patients by 55.7% of consultees, while 44.3% found it only sometimes or not at all helpful. After written consultations, 60.2% of consultees either never or only occasionally discussed the case with the psychiatrist; 75.0% said they would always take the psychiatrist’s recommendations seriously in the management of patients. In the event of adverse effects of psychotropic medications prescribed by a psychiatrist, 88.6% of consultees said they would inform the psychiatrist and 8.0% said they would discontinue them. Asked about prescribing psychotropic drugs to their pa- tients, 50.0% of consultees said they would never contemplate it while only 6.8% said they would most likely prescribe a psycho- tropic drug and 43.2% said they would pos- sibly prescribe one. Benzodiazepines were considered the safest psychotropic drugs by 64.9% of consultees, antipsychotics by 13.5% and the tricyclic antidepressants by only 5.4%. Unexpectedly, the number of years of postgraduate experience did not have any influence on the attitude of consultees or their knowledge about psychiatry, though internists responded more correctly for many items than surgeons. Nephrologists usually responded much more positively than other internists, while orthopaedic surgeons’ responses were much worse than other surgeons. For example, 62.5% of ne- phrologists said they would seek a psychia- trist’s help when a patient was delusional, compared to 55.0% of other internists. Only 28.6% of orthopaedic surgeons would ask for a psychiatric consultation for a delusional patient in contrast to 58.3% of other surgeons. Inconsistency in regard to psychiatric knowledge was even notice- able within the same specialty: while only 28.6% of orthopaedic surgeons thought a delusional patient needed a psychiatric consultation, 85.7% thought a hallucinating patient needed one. Attitude and knowledge of patients Only 4 (2.1%) of 188 patients, refused to fill in the questionnaire (18 extended emergency room patients were not included because of time constraints). Of the 184 who respond- ed, 34.0% considered there was a need for a psychiatric service in hospital, 42.0% said they would seek help from a psychiatrist if needed and only 37.8% thought that their complaint might be psychological. In response to questions about psycho- tropic medications, 31.9% thought that psychotropic drugs were treatments rather than sedatives, 58.5% thought they could cause addiction and 67.6% thought they had serious side-effects. In answering questions about stigma, only 26.1% admitted they needed to see a psychiatrist, 79.3% thought it was a social stigma to attend a psychiatric clinic and 98.4% emphasized they had to be informed about referral to psychiatry. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 327 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Discussion Attitude and knowledge of doctors Even though measuring attitude and knowl- edge is a complicated process that includes knowledge, attitude and perception, we used a simple questionnaire with simple yes or no answers that served the purpose of this study [5,6]. The response rate of doctors was much lower than that of patients. This may have been because of the doctors’ busy schedule, because patients were keener to please doc- tors or both. The number of doctors having over 5 years of experience who said there was a need for psychiatric consultation was very low. This may reflect poor psychiatric education in undergraduate medicine for this group and/or a negative attitude towards psychiatry [7]. Seeking urgent psychiatric consultation shows how non-psychiatrist doctors see the role of psychiatrists in the management of their patients and the great- est requirement was for patients displaying disturbed, abnormal behaviour such as violence, hallucinations, delusions and refusal to communicate. This may suggest a notion of calling in a psychiatrist to control a difficult patient rather than to collaborate in establishing clinical diagnosis and manage- ment [6,8]. These inferences were clearly confirmed by the fact that only 38.1% of doctors thought that a psychiatrist could help in establishing a final diagnosis, which may also reflect their view of the role of psychiatry in medicine [5]. Gaining the consent of a patient for a consultation, despite being basically an ethical dimension of the doctor–patient relationship [9], may be affected by the perception of the patient to the specialty. For example, referring a patient to oncol- ogy may have its own repercussions on the patient, inducing fear and distress [10], but referring a patient for psychiatric assess- ment may result in social stigmatization [5]. This may explain why 28.4% of doctors would never inform patients or ask their consent for psychiatric referral and 37.5% would only do it sometimes. On the other hand 34.1% of doctors would always obtain consent, perhaps as an expression of their own ethical approach rather than a positive attitude to psychiatry [9]. The finding that the majority of doctors found psychiatric consultation to be helpful in the management of patients may reflect both a positive attitude towards psychiatry on the part of consultees and an efficient liaison service. However, 44.3% found it only sometimes or not at all helpful, which may be a consequence of poor communi- cation with the psychiatrist, the difficult nature of referred patients, the negative attitude of consultees towards psychiatry and the poor service offered [11]. This is analogous to the finding that 60.2% of doctors never discussed their cases with the psychiatrist, emphasizing the importance of the liaison aspect of the service. It may also reflect a poorly written consultation and un- helpful recommendations. But considering that 75.0% of the consultees would always take the psychiatrist’s recommendations seriously, not discussing the cases with the psychiatrist may merely be due to lack of time or overwork. Informing the psychiatrist about adverse effects of psychotropic medication may be due to lack of knowledge about the medications and an inability to manage the side-effects. This is definitely more appropriate than the attitude of the 8.0% who would discontinue the medication and interrupt the plan of management [12]. Half the consultees said they would never take the initiative to prescribe psychotropic medication. This reflects the necessity of integrating psychiatry into the curriculum at both undergraduate and postgraduate 328 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم levels. Analysis of the safest psychotropic drugs confirms that knowledge and clinical experience of psychiatry of the consultees are poor [4,12]. It is expected that the more years of postgraduate experience a doctor has, the more positive the attitude towards psychia- try will be and the better their knowledge of psychiatry. On the other hand, recently graduated doctors are more likely to have been taught psychiatry and to have been exposed to clinical psychiatry teachings [7]. It is, therefore, difficult to infer or generalize from any result associating years of experience and attitude and knowledge about psychiatry. Differences in response between internists, surgeons and sub- specialties may merely reflect individual preferences and experience in dealing with psychiatric illnesses. This is emphasized by the inconsistency in responses between doctors in the same specialty. Attitude and knowledge of patients The response of our patients was similar to reported views of psychiatry overall [13]. Only 34.0% thought that a general hospital needed a psychiatric service, which may indicate that psychiatry is not viewed as a specialty of medicine. On the other hand, a similar proportion said they would seek psychiatric help if they needed to. This can be explained by the general view of the pub- lic, but also, by the attitude that psychiatry is a last resort [14]. This may be associated with the finding that only 37.8% of patients believed their complaints were psychologi- cal. This lack of insight may be due to the notion of many people of the dichotomy of mind and body, leading to an inability to accept psychological explanation for their bodily symptoms [5,14]. The view of pa- tients about psychotropic medication is no more positive than their view on psychiatric consultation: the majority view these drugs as sedative, addictive, and having serious side-effects. The need for long-term use of the drugs, the non-cure treatment re- sponse of many psychiatric disorders and the frightening extrapyramidal side-effects may explain this view [15,16]. The issue of social stigma of psychiatric disorders and treatments is more compli- cated and there may be a number of reasons for this. First, the patients in our study group were all referred for psychiatry and thus, may have a more negative attitude than the general population [17]. Second, if there is a poor doctor–patient relation- ship, where no explanation or education of patients takes place, patients will have little knowledge of psychiatry [6]. Third, the psychiatric services may be poorly de- veloped and a comprehensive approach to treatment rarely practised [18,19]. Finally, patients may have had a negative past ex- perience with psychiatry, either personally or through relatives or being influenced by public views [5]. Conclusions This study confirms the conclusions of our first paper [4], that knowledge of our hos- pital doctors about psychiatry is poor and negative. It also shows that knowledge and attitude towards psychiatry of referred pa- tients is also poor and negative. This empha- sizes that, if psychiatry is an integral branch of medicine and consultation–liaison psy- chiatry is a necessary service in the general hospital, liaison should be standard practice rather than merely to offer consultation. Joint collaboration of the psychiatrist and physicians in establishing clinical diagnosis and implementing the patient management plan will provide an atmosphere conducive Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 329 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم to discussion and exchange of knowledge and experience [20,21]. It is anticipated that this will have a positive effect on the attitude and knowledge of both consultees and patients about psychiatry [22]. References Finally, it is apparent that psychiatrists have a responsibility in this area to improve the status of psychiatry in general hospitals and in the community. 1. McKegney FP, Beckhardt RM. Evaluative research in consultation–liaison psy- chiatry. Review of literature: 1970–1981. General hospital psychiatry, 1982, 4(3): 197–218. 2. Gitlin DF et al. Recommended guidelines for consultation–liaison psychiatric train- ing in psychiatry residency programmes. A report from the Academy of Psychoso- matic Medicine task force on psychiatric resident training in consultation–liaison psychiatry. Psychosomatics, 1996, 37(1): 3–11. 3. Levenson JL. Consultation–liaison psy- chiatry research more like a ground cover than a hedgerow [editorial]. Psychoso- matic medicine, 1997, 59(6):563–4. 4. Alhamad AM et al. Differential aspects of consultation–liaison psychiatry. I: referral pattern and clinical indices. Eastern Medi- terranean health journal, 2006, 12(3–4): 316–23. 5. Guze SB. Why psychiatry is a branch of medicine. New York, Oxford University Press, 1992:18–9. 6. Goldberg DP, Benjamin S, Creed F. Psychiatry in medical practice, 2nd ed. London, Routledge, 1994:112–4. 7. Alhamad AM. Psychiatric education in King Saud University. Arab journal of psychiatry, 1998, 9(suppl.):26–36. 8. Chaleby K, Al-Qaragholi S. An overview of psychiatric consultations at King Faisal Specialist Hospital. King Faisal Special- ist Hospital medical journal, 1984, 4(3): 229–33. 9. Dyer AR. Ethics and psychiatry: toward professional definition. Washington DC, American Psychiatric Press Inc., 1988:97– 101. 10. Kissane DW, Smith GC. Consultation– liaison psychiatry in an Australian oncolo- gy unit. Australian & New Zealand journal of psychiatry, 1996, 30(3):397–404. 11. Popkin MK, Mackenzie TB, Callies AL. Consultation–liaison outcome evaluation system. I. Consultant–consultee interac- tion. Archives of general psychiatry, 1983, 40:215–20. 12. Zitman FG et al. Neuroleptic drug use in non-psychiatric departments of a Dutch university hospital. General psychiatry, 1994, 16(1):32–7. 13. Goldberg D, Huxley P. Mental illness in the community. The pathway to psychiat- ric care. London, Tavistock Publications, 1980:74–6. 14. Al-Fares EA, Alhamad AM, Al-Shammari S. Hidden and conspicuous psychiatric morbidity in Saudi primary health care (a pilot study). Arab journal of psychiatry, 1995, 6(2):162–75. 15. Qureshi NA et al. An analysis of psychiat- ric referrals, Saudi Arabia. Arab journal of psychiatry, 2001, 12(2):53–65. 16. Mahgoub OM. Psychiatric consultations in a university teaching hospital. Saudi medical journal, 1998, 19(5):599–603. 17. Alhamad AM. Spectrum of psychiatric morbidity in neurobiological inpatients. Saudi medical journal, 1998, 19(6):683– 7. 18. Wise TN, Schmidt CW Jr, Hayes JR. Reengineering consultation–liaison psy- 330 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم chiatry. Psychosomatics, 1996, 37(2):91– 2. 19. Gribble R. Shared care but not consul- tation–liaison psychiatry. Australian & New Zealand journal of psychiatry, 1998, 32(2):311–3. 20. Rigatelli M et al. Teaching and train- ing in the psychiatric–psychomatic consultation–liaison setting. Psychothera- py & psychosomatics, 2000, 69(4):221–8. 21. Smith GC. From consultation–liaison psy- chiatry to psychosocial advocacy: main- taining psychiatry’s scope. Australian & New Zealand journal of psychiatry, 1998, 32(6):753–66. 22. Ozbayrak KR, Coskun A. Attitudes of pediatricians towards psychiatric con- sultations. General hospital psychiatry, 1993, 15(5):334–8. Atlas of psychiatric education and training Do countries train adequate numbers of psychiatrists for their mental health needs? How satisfactory is the training? Does the training take into account enormously different environments? The Atlas: psychiatric education and training across the world 2005 provides an overview of the current situation on psychiatric education and training both globally and at country level and aims to stimulate health and medical education departments of countries to the enor- mous need for developing plans to establish or reform psychiatric training in their countries. Listed are key contacts and training insti- tutes/bodies in 74 countries. The Atlas is the result of a collaboration between the World Health Organization and the World Psychiatric As- sociation. The Atlas (ISBN 92 4 156307 9) is available at the WHO bookshop at http://www.who.int/publications/en/ Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 331 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Health Workers for Change: a tool for promoting behaviour change among health providers B.T. Shaikh,1 F. Rabbani1 and M. Rahim1 1Health Systems Division, Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan (Correspondence to B.T. Shaikh: babar.shaikh@aku.edu). Received: 03/05/04; accepted: 20/12/04 ABSTRACT Sensitizing health providers to customers’ needs and women’s health remains a challenge to the Pakistani health system. The Health Workers for Change methodology has been demonstrated to improve provider–client relationships in certain African and Latin American countries. This paper describes the experience of using Health Workers for Change participatory workshops in Pakistan to sensitize male and female health providers to gender issues. Health care providers identified the unmet needs of women clients as a function of individual, household and societal factors, and, unlike the Afri- can experience with this tool, not predominantly confined to factors associated with the health facility. Les agents de santé vecteurs du changement : un instrument pour promouvoir un changement de comportement chez les prestataires de santé RÉSUMÉ Sensibiliser les prestataires de santé aux besoins des clients et à la santé des femmes demeure un défi pour le système de santé pakistanais. Il a été démontré que la méthodologie des Agents de santé vecteurs du changement améliorait la relation entre le prestataire et le client dans cer- tains pays d’Afrique et d’Amérique latine. Le présent article décrit l’expérience pakistanaise qui consiste à sensibiliser les prestataires de santé, hommes et femmes, aux questions de sexospécificité à travers des séminaires-ateliers participatifs « Agents de santé vecteurs du changement ». Les prestataires de soins de santé ont identifié les besoins non satisfaits des clientes comme dépendant de facteurs indi- viduels, domestiques et sociaux, et contrairement à l’expérience africaine réalisée avec cet instrument, ne tenant pas essentiellement à des facteurs associés à l’établissement de santé. 332 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction Despite major technological advances in health, many poor people express feelings of powerlessness and dependence concern- ing their experience with the health serv- ices, especially in the public sector [1]. As in many other developing countries, the government health care system of Pakistan faces the problem of a poor relationship between health providers and clients, espe- cially women. Improving the provider–consumer re- lationship and the quality of services are among the most daunting challenges faced by the health system in Pakistan. In the total annual budget of Pakistan, 3.1% is earmarked for social sector development and just 0.8% of the gross domestic product (GDP) is spent on health care, which is even lower than in Bangladesh and Sri Lanka [2–4]. Poor quality of services and absence of appropriate sociocultural orientation in a health facility contribute to its under- utilization. It is, therefore, not surprising that almost 80% of the health expenditure goes in accessing private health care [5,6]. Pakistan is one of the few countries in the world where men outnumber women [7]. This unfavourable ratio could mainly be attributed to a high mortality of young girls and women of child-bearing age (340/ 100 000 live births) [8]. Added to this is the poor social status of women in Pakistan, ranking 135th out of 174 countries in the United Nations Development Programme (UNDP) gender-related development index (GDI), and 100th out of the 102 countries on the gender empowerment measurement (GEM) [9]. Poverty and negative cultural practices are among other factors that have an impact on the health of women in Pakistan, mak- ing them the most vulnerable members of society. Coupled with a shortage of human resources to cater for women clients, this has led to poor client–provider communica- tion and a deterioration in the quality of care provided [10]. Another important reason for the poor health of women in Pakistan are the inadequate services that fail to fulfil wom- en’s health care needs. The primary health care services largely consist of a network of over 5000 basic health units and rural health centres. However only 25% of them are manned by trained female staff and have the logistics to provide appropriate care [11,12]. The questions are: How much do the service providers, especially the frontline health workers, know about the real needs of their women clients? How do they interact with their clients? Are they sensitive to the health care needs of women? Do they “listen” to women? Do health managers know how to change the attitude and behaviour of health workers toward women? Health Workers for Change is a World Health Organization/World Bank/UNDP training tool that uses a series of participa- tory workshops with health care provid- ers to sensitize them towards issues such as gender [13]. Originally an initiative in Africa, the impact of its use has been dem- onstrated in various studies [14–17]. This paper presents the experience of using this tool in Pakistan. This study by the Depart- ment of Community Health Sciences of the Aga Khan University aimed to initi- ate a process of reflection and analysis of women’s needs among health providers, helping them to explore the reasons for the poor quality of care and identify solutions towards improving the quality of health service delivery. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 333 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Methods Study sites The study was carried out between June 2001 and July 2003 in 7 field sites, both urban and rural, in all the 4 provinces and the Federally Administered Northern Areas (FANA) of Pakistan. This included Ma- lir and Metroville (Sindh), Turbat (Balo- chistan), Uch Sharif and Lahore (Punjab), Peshawar (North-West Frontier Province) and Gilgit (FANA). In most of the sites, either a government or partner nongovern- mental organization (NGO) health facility was used as a venue for the workshop. Study team The research team included public health re- searchers, social scientists, anthropologists, community development specialists and health systems specialists. Besides these, there were research teams composed of staff and volunteers of the partner organizations: the Health and Nutrition Development So- ciety, the Marie Stopes Society and the Aga Khan Health Services Pakistan. An orientation workshop and training of the study team on participatory approaches, facilitation of activities, data gathering and documentation was conducted. The sessions were documented on activity forms as both process and analysis. This format required the involvement of 2 note-takers, mean- ing that the workshops were conducted and documented by 3 people including the facilitator. Participants Health care providers from both the public and private sectors were invited to par- ticipate. A total of 45 female and 36 male health workers participated in the work- shops: 19 doctors, 16 lady health visitors, 13 community health nurses, 18 field work- ers and 15 health managers of junior and senior levels (Table 1). The tool The Health Workers for Change tool was adapted and modified on the basis of the analysis of data gathered from health pro- viders in the field. Some modifications were made to the manual to make it more relevant to the Pakistani culture and system. To meet each objective of the workshops more than one methodology was used. The most im- portant criterion was that the method chosen from the African context should be appro- priate to the subject matter, easily applied and capable of yielding results that could be discussed and analysed. A participa- tory approach during interactive workshops enabled a wide range of underprivileged people from diverse cultures and conditions to share their views and contribute to the concepts and content of the tool. Workshops Various themes blending into 6 workshops were introduced to the health care provid- ers. The same themes were used in all the study sites without any change in the proc- ess. A social scientist conducted the work- shops, assisted by the research assistants for note-taking. The workshops required differ- ent amounts of time ranging from approxi- mately 2.5 to 4 hours. The objective of each workshop was to help health workers to: • categorize the factors that inspired in- dividual health workers to choose their occupation; Table 1 Distribution of participants who attended the workshops Sites Government Non- Total health government personnel health personnel Urban 17 28 45 Rural 7 29 36 Total 24 57 81 334 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم • express their perceptions of how their clients see them; • describe and explain their perceptions about women clients, their status in so- ciety and their problems; • explain the unmet needs and the prob- lems of the women and how to over- come them; • identify the factors and obstacles that affect their work; and • suggest solutions to these problems to ameliorate their working conditions. For the 1st workshop, the “river of life” exercise was used to create a representation of an individual’s life events in the form of a river. In the 2nd workshop, role plays and a questionnaire were used to ascertain the clients’ opinions about the health providers and the quality of services rendered. Story and role play in the local language and in a Pakistani context were used for the 3rd workshop to explore perceptions about women and women’s health. For the 4th workshop, again story-telling was used as a method. In the 5th and 6th workshops, brainstorming and group work were carried out, writing the main ideas on wall charts. “Ice breakers” and team-building exercises were used throughout the workshops. Synthesis During the workshops, following the note- taking, the main points were entered into log frames. A log frame comprised 5 columns detailing the problems or issue identified, a possible solution(s), person/authority to solve it, method to solve it and time needed to solve it. On return from the field sites, a synthesis workshop was held with partner NGOs to highlight the common trends and issues emerging from the workshops. Based on key findings, the specific site reports were then compiled and merged into the final study report. Ethical approval Besides institutional ethical approval for the whole study, free and informed consent of the participating health providers was also obtained. Results The participants participated actively in the workshops and provided their reflections on each theme as summarized below and in Table 2. Why am I a health worker? The workshop participants narrated multi- ple reasons for becoming a health worker, which included poor socioeconomic condi- tions, inspiration from others and a desire to serve humanity in general and the com- munity in particular. These are very similar to those cited in Africa [15,16]. The most common reason cited for becoming a health worker, however, was the desire to be as- sociated with a well-respected profession in society and to fulfil financial needs. The desire to serve their communities and the quest for spiritual peace also motivated some to become health workers. Some got inspired by other health workers, or took the profession as a family tradition or in response to family pressure. In some areas, the lack of availability of health care pro- viders (especially females) also motivated women to become a health worker to fill the gap. Self-development, gaining social status and desire for research had also prompted some providers to opt for this profession. How do our clients see us? The participants of the workshop were aware of their client’s perceptions of health care providers. A mixed impression, having both positive and negative aspects, emerged from the discussion regarding the client’s Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 335 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم perception of health care providers. Health care providers mentioned that clients ex- pect a proper understanding of their needs, satisfactory services and appropriate guid- ance. They also pointed out that clients had a considerable respect and trust for them. They said that the clients consider them as a Messiah (healer), a friend, someone who listens to their problems and solves them, a role model. Health workers reported that some of their clients carry negative feelings too and said, “Our clients think that we discriminate between the rich and the poor in health care provision, lack an empathetic attitude and competence to provide appro- priate information and quality services.” Such perceptions may well be just the tip of the iceberg, and require greater probing for a deeper understanding of client–provider relationships. Women’s status in society The participants admitted that despite being called the “honour of the family”, “symbol of love, faithfulness and fragrance” and “one who sacrifices for others”, women have a very subordinate status in Pakistani society and are expected to be submissive. Providers repeatedly mentioned, “Women do not enjoy any decision-making rights, even in matters pertaining to their own health”. During the workshop discussions, the position of the Pakistani woman in society was explored. Participants acknowl- edged the pivotal role of the woman within the family and the society. Lack of access to health care, education and information and a great deal of social restrictions were cited as factors hindering improvement of wom- en’s status. “Women are an untapped po- Table 2 Problems and potential solutions identified during the workshops with health workers Problems identified Solutions suggested Workload and staff shortage Planning and time management Create more posts Fill the existing vacancies Lack of support from management Encouragement for taking initiative Clear concept of essential and non-essential medicines System should have flexibility to look for alternatives if existing system is not working properly Personal problems of the staff Encourage sharing of problems Accept and provide support for genuine problems Counselling and alternate ways Building a relationship with community On-the-job training on: to know more about them and address Counselling skills difficult issues, e.g. infertility, teenage Participatory research methods sexuality, violence against women Incorporate research as part of making action plans 336 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم tential in a society”, quoted the participants. Additionally participants listed household skills, education, physical looks and good character as desirable attributes in women. “A good woman is one who always sacrific- es and doesn’t voice her problems,” health providers maintained. It also emerged that a woman’s status in society is a product of her family background, socioeconomic status, and father or husband holding high status jobs. Unmet needs of women There was a consensus among men and women health care workers at 7 sites about the unmet needs of women clients. Illiteracy, lack of proper nutrition and domestic work- load, compounded by the practice of early marriages, jeopardizes their health status. According to them, women generally have inadequate access to education and infor- mation about health care. No specific health education programmes cater for women on health-related matters especially reproduc- tive health. Participants mentioned that women’s needs were largely unmet because of their minimal “participation” and “power of decision” in any household matter. A participant quoted, “A woman will never be allowed by the husband to go and consult a male provider especially for reproductive health matters such as infertility, reproduc- tive tract infections, family planning etc.” Thus, in this sample of health providers it was felt that unmet needs of women are a function of individual, household and soci- etal factors, and, unlike the African context [15,16], not predominantly confined to fac- tors associated with the health facility. Overcoming obstacles at work Certain obstacles were identified that affect the performance of health workers. The impediments were categorized as logistical, managerial, social and behavioural. Quite similar to the African context [15,16], poor logistic arrangements, inadequate training and skills, lack of appreciation and mis- match between workload and salaries of the health care providers emerged as the common constraints affecting their per- formance. “At times senior colleagues and administration are very rude to us,” nar- rated the participants, highlighting the com- munication gap between the managers and the frontline workers, and lack of amicable working environment. One participant said, “If we don’t provide the medicines to the clients, a message will be passed on in the village that the health provider is not car- ing. We are answerable to the community. Mismanagement in drugs provision brings a lot of problems. Trust between clients and providers is lost. Those higher up have to understand it.” Solutions For initiating the process of women’s em- powerment, participants argued that equal opportunities for women in health, educa- tion and income are essential. “A change in the attitude of men would be a requisite to bring about any improvement in women’s health status.” They suggested that there is an immense need to involve men in all mat- ters pertaining to women’s health. The workshop participants strongly re- flected that the identified problems could be resolved through a process of consultations with each other and information sharing. “Health worker’s ongoing training is es- sential. If she/he has new information, only then could patients be helped properly, otherwise our relationship with our clients will not be worth it”, quoted the providers. One of them said, “Steps should be taken to address our problems at the workplace, to improve our fate and to alleviate our plight.” Better logistic arrangements at the work place, minimizing the communication Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 337 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم gap between the supervisors and workers, timely appreciation of good work, keeping aside the personal problems from the profes- sional work, and rationalizing the workload of the heath workers are the proposed solu- tions. They emphasized, “A participatory approach and consultative processes to find solutions of the problems at work cre- ates a friendly environment.” Dignity and recognition of work was more important for providers than a raise in salary or income. They also mentioned that the existing sys- tem needs to be changed; however, a care- ful determination of the inefficiencies and strengths in the exiting system is required before initiating any change. “We collabo- rate with government but we don’t get the equal welcoming support from their side,” quoted one participant. Discussion The objective of the study was to judge the effectiveness of the Health Workers for Change tool in sensitizing health care providers to women’s health issues and enabling them to reflect in a participatory way to identify solutions towards improv- ing quality of health service delivery. The role-plays and story telling techniques of the tool worked well and were found to be useful. Participants enjoyed the process and got deeply involved, sometimes leading to prolonged sessions. The process seemed to be flexible enough to be implemented in different cultures and the majority of the methodologies used in the African context worked well in the Paksitani setting. The workshops enabled a reflective thinking process among the health care providers, allowing a frank discussion, ir- respective of the type of health worker, without victimizing anyone. The workshops allowed difficult issues such as prejudice, bribery and negligence on the part of pro- viders to be discussed openly, fostering an open attitude. The result was a renewed commitment to work, with health providers expressing better motivation and willing- ness to examine their own practices criti- cally in an effort to improve the quality of care. The participatory process of Health Workers for Change also enabled the pro- viders to identify many constraints in the provision of adequate health services and how these affected their work in general and their relationship with women clients in particular, and to develop practical plans. Effective use of Health Workers for Change requires training in participatory methods, familiarity with the social model of health and good communication skills. This endeavour in Pakistan reconfirms that methodology and techniques such as role- plays and story-telling can be used in differ- ent settings and cultures. It also showed that the Health Workers for Change tool is likely to contribute towards reorientation and strengthening of the health system, particu- larly in the areas of provider–client relation- ships and problem-solving abilities of health workers. This will initiate a thought process in heath workers to become more conscious and empathetic while dealing with women clients. In other words, this could be a step towards initiating a behaviour change proc- ess. With the involvement of health provid- ers, an “enabling environment” to access health care particularly for women must be created. Such initiatives also tend to gener- ate information for health policymakers about what health care providers’ problems and issues are and how to devise policies to re-orient the health care system and service delivery. Moreover, besides designing the interventions, integrating knowledge on social determinants of health within public health policy and practice is essential. 338 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Investing in improving women’s health has become an international concern and is seen as a way not only to reduce pov- erty but also to improve the welfare of the entire family, especially the children [18]. It demands a focus on the determinants of health and health-seeking behaviour, particularly of women, by comprehending their position and status in society [19,20]. Effective change will thus require a shift from a physician-dominated system to a client-centred model. Similar strategies have been proposed by the World Bank a decade ago and are still very much achievable [21]. Continuing education and capacity-building initiatives for health providers are impera- tive for improving health care delivery in a highly pluralistic health care system and gender-sensitive culture. However, to see the real impact of such endeavours, more in-depth qualitative research would be re- quired to gauge any improved trends in health services utilization. Acknowledgements We would like to thank the team involved in design, fieldwork, compiling the final reports and in contributing to the draft man- ual. Notable among these are Dr Anwar Islam, Ms Fauzia Aman, Ms Kausar S. Khan, Ms Habiba Rehbar, Ms Gul Shamim, Dr Shazia Basaria, Dr Azra Mubarak, Ms Shama Dossa, Dr Syed Muhammad Israr, Dr Nabeel Akram, Mr Mohammad Afzal and Mr Arif Kamil. We are also grateful to our partner or- ganizations Health and Nutrition Develop- ment Society, Marie Stopes Society, Aga Khan Health Services Pakistan, Ministries of Health and all other co-coordinating organizations for their full involvement and support during the project activities. We would also like to acknowledge the Aga Khan Foundation, Pakistan for the financial support of the project. References 1. Narayan D et al. Voices of the poor: crying out for change. Oxford, Oxford University Press, 2000. 2. Budget 2001–2002. Islamabad, Finance Division, Government of Pakistan. Minis- try of Finance, 2000. 3. 1998–99 World Development Report: knowledge for development. Washington DC, World Bank, 1998/99. 4. Human Development Report. New York, United Nations Development Programme, 2001. 5. Health sector reform in Asia and the pacific: options for developing countries. Manila, Asian Development Bank, 1999. 6. The World Health Report 2002. Reduc- ing risks, promoting healthy life. Geneva, World Health Organization, 2002. 7. 1998 Census Report of Pakistan. Islama- bad, Government of Pakistan, Population Census Organization Statistics Division, 2000. 8. Islam A, Malik FA. Role of traditional birth attendants in improving reproduc- tive health: lessons from the family health project, Sindh. Journal of Pakistan Medi- cal Association, 2001, 51(6):218–22. 9. Women’s health project, 1999. Investing in women’s health: delivering better health care to all. Manila, Philippines, Asian De- velopment Bank, 1999. (http://www.adb. org/gender/practices/health/pakistan001. asp, accessed 25 July 2003). 10. Ghaffar A, Kazi BM, Salman M. Health care systems in transition III. Pakistan, Part I. An overview of the health care sys- Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 339 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم tem of Pakistan. Journal of public health medicine, 2000, 22(1):38–42. 11. Health workers for change: a manual to improve quality of care. Geneva, United Nations Development Programme/World Bank/World Health Organization, 1995. 12. Family Health project assessment re- port. Karachi, Department of Community Health Sciences, Aga Khan University, 2000. 13. Islam A, Tahir MZ. Health sector reform in South Asia: new challenges and con- straints. Health policy, 2002, 60:151–69. 14. Fonn S, Xaba M. Health Workers for Change: developing the initiative. Health policy and planning, 2001, 16(suppl. 1): 13–8. 15. Onyango-Ouma W et al. An evaluation of Health Workers for Change in seven set- tings: a useful management and health system development tool. Health policy and planning, 2001, 16 (suppl. 1):24–32. 16. Onyango-Ouma W et al. The Health Workers for Change impact study in Ken- ya. Health policy and planning, 2001, 16 (suppl. 1):33–9. 17. Vlassoff C, Fonn S. Health Workers for Change as a systems management and development tool. Health policy and plan- ning, 2001, 16 (suppl. 1):47–52. 18. Standing H. Gender and equity in health sector reform programs: a review. Health policy and planning, 1997, 12(1):1–18. 19. Navaneetham K, Dharmalingam A. Utili- zation of maternal health care services in Southern India. Social science and medi- cine, 2002, 55 (10):1849–69. 20. Fatimi Z, Avan I. Demographic, socio- economic and environmental determi- nants of utilization of antenatal care in rural setting of Sindh, Pakistan. Journal of Pakistan Medical Association, 2002, 52:138–42. 21. 1993 World Development Report: in- vesting in health. Washington DC, World Bank, 1993. 340 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Problems related to shiftwork for health care workers at Shiraz University of Medical Sciences A. Choobineh,1 A. Rajaeefard2 and M. Neghab1 1Department of Occupational Health; 2Department of Epidemiology and Biostatistics, School of Health, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran (Correspondence to A. Choobineh: alrchoobin@sums.ac.ir). Received: 03/11/04; accepted: 15/02/05 ABSTRACT A cross-sectional study of shiftwork-related problems was carried out among health care workers at hospitals of Shiraz University of Medical Sciences, Islamic Republic of Iran. Data on personal details, shift schedule and adverse effects of shiftwork were collected from 432 randomly selected sub- jects by questionnaire. Sleep, social and subjective problems were more prevalent in shiftworkers than day workers. Irregular shiftwork schedules caused more social and subjective problems, as well as work dissatisfaction. Voluntary selection of shiftworking produced fewer health problems. Problèmes liés au travail posté pour les agents de soins de santé à l’Université des Sciences médicales de Chiraz RÉSUMÉ Une étude transversale des problèmes liés au travail posté a été réalisée auprès des agents de soins de santé des hôpitaux de l’Université des Sciences médicales de Chiraz (République isla- mique d’Iran). Des données personnelles ainsi que des informations sur les horaires de postes et les effets néfastes du travail posté ont été recueillies par questionnaire chez 432 sujets choisis au hasard. Les problèmes de sommeil, les problèmes personnels et sociaux étaient plus courants chez les tra- vailleurs postés que chez les personnes travaillant le jour. L’irrégularité des horaires de travail causait davantage de problèmes personnels et sociaux, ainsi qu’une insatisfaction vis-à-vis du travail. Le choix volontaire du travail posté posait moins de problèmes de santé. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 341 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction Shiftwork is now a major feature of work- ing life across a broad range of industries. There are a number of reasons to expect that workers on a shift system may experience adverse consequences as a result of their work schedule [1,2]. It is well documented that certain physiologic functions, e.g. body temperature and hormonal release, vary systematically over the course of the day [3]. These circadian rhythms play an impor- tant role in regulating sleep, alertness and physiologic processes. When workers are forced to alter their sleep/activity schedule abruptly to correspond to a new work shift, there is usually a mismatch between the body’s resources and the demands placed upon it until the circadian phase can adjust. Also, working in a shift system disrupts so- cial activities. It is well established that the degree and quality of social interaction are related to physical and mental health [1]. Based on studies conducted in industri- alized countries the prevalence of shiftwork is approximately 20% to 30% of the work- force [1,3,4]. There is good evidence that shiftwork has a negative effects on workers’ health, safety and performance [2,3,5–8]. It is quite appropriate that attention is paid to this very important feature of socio- technical systems, which may adversely affect mental and physical health, social life and safety of shiftworkers. In the medical domain, physicians, nurses and other ancillary staff are expected to be performing their jobs or to be on-call around-the-clock. Studies have shown that a greater percentage of health service work- ers work in a shift system than in any other employment sector. Hospitals, the biggest employer in the health care field, employ more night shiftworkers than any other industry [9]. It can therefore be inferred that in the medical domain, a high percentage of the workforce may be affected by problems related to shiftwork. There has been little research in the Islamic Republic of Iran on the extent to which shift schedules are related to health, individual and social problems among health care workers and it has been a ne- glected area in occupational health and safety issues at hospitals. The present study at Shiraz University of Medical Sciences (SUMS) hospitals was carried out with the following objectives: to characterize the shift schedules of health care staff; to study shiftwork-related problems among health care workers; and to investigate the association between the shift schedule and the problems reported. It is believed that the results of this study can be used to establish preventive strategies to decrease the prob- lems of working in a shift system. Methods The cross-sectional study was conducted during June 2000 to August 2001. The participants were health care staff working in 38 different departments of 12 hospitals of SUMS, located in Shiraz city. In each department, 20% of the health care work- ers were randomly selected from the cor- responding list of personnel (systematic method of sampling). A total of 432 health care workers participated in this study. For each selected participant at each department, the person in charge of the study explained the purpose of the research and requested cooperation. An anonymous self-administrated questionnaire was used to collect the required data from each par- ticipant. The distribution and collection of questionnaires was performed through the person in charge of the study at each hospital. Identical questionnaires were used at all 12 hospitals. 342 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم The items included in the questionnaire were based on the related literature [3]. The questions were mostly Yes/No in type with some multiple choice questions. In addition to questions on insomnia, hypnotic drug use, effects of shiftwork on health (gas- trointestinal, heart and mental problems), consequences of shiftwork on individual life (e.g. not enough time for attending to personal affairs and hobbies), family life (e.g. not enough time for parenting roles, care-giving roles and social companions) and social life (e.g. not enough time for participation in social gatherings and cul- tural events), there were questions on sub- ject characteristics (e.g. age, sex, etc.), the shiftwork system that they worked under, whether they had voluntarily selected shift work and whether they intended to continue working in this system. For gastrointestinal problems, several questions were combined to produce the result (e.g. “Which one of the following problems have you experienced continuously: increased appetite, decreased appetite, constipation, diarrhoea, peptic ulcers, indigestion?”). For subjective prob- lems also, several questions were combined to produce the result (e.g. “Which one of the following problems have you had continu- ously: dizziness, nervousness, carelessness, repetitive errors, irritation, depression, fa- tigue, and poor sleep quality?”). Data regarding the shift schedule adopt- ed were gathered from interviews with su- pervisors of the departments. In this study, shiftwork was defined as any regularly taken employment outside the usual working day, defined arbitrarily as between 07.00 hours and 18.00 hours [3]. Based on this defini- tion of shiftwork, the study population was divided into day workers (those working in morning shift from 07.30 to 15.30 hours permanently) as a control group (17.6%), and shiftworkers (those working in a shift system including regular rotation, irregular rotation, permanent evening shift and per- manent night shift) as a case group (82.4%). The effects of working conditions on the participants were compared between the case and the control groups. No significant differences existed between the 2 groups regarding age and job experience. In order to estimate the reliability of the responses to items in the questionnaire, a test–retest method was applied [10] on 10% of the study population. The results of reliability testing revealed that for almost all subjective variables the Spearman cor- relation coefficients were greater than 0.71, which could be considered acceptable for these variables. McNemar and Wilcoxon tests also showed no significant difference between responses for the 2 occasions. The Pearson correlation coefficients for quantitative variables were greater than 0.9, indicating acceptable reliability of the questionnaire. After data collection, the data were coded and transferred to the computer for further analysis. Statistical analyses were performed using SPSS, version 9. The chi- squared test was used to assess univariate associations between shift variables and reported problems. The level of statistical significance was set at 5%. Results Table 1 summarizes the personal details of the participants, their job titles and some characteristics of the shift system adopted in different departments of the hospitals stud- ied. Most of the participants were female (71.5%). The majority of the study popula- tion were nurses and nurse’s aids (65.5%). Since only 10% of the participants were below diploma level, the study population Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 343 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Table 1 Participants’ personal details, job title and work pattern in the studied hospitals (n = 432 participants) Variable Value Mean (SD) Min.–max. Age (years) 34.78 (7.84) 19–59 Job experience (years) 13.74 (8.37) 1–40 Shiftwork experience (years) 13.27 (7.88) 1–32 No. % Sex Female 309 71.5 Male 123 28.5 Marital status Single 130 30.0 Married 302 70.0 No. of children ≤ 3 355 82.1 > 3 77 17.9 Education Below diploma 43 10.0 Diploma 127 29.3 Higher diploma 97 22.5 Degree or higher 165 38.2 Job title Nurse 147 34.0 Nurse’s aid 99 22.9 Co-nurse’s aid 37 8.6 Lab/radiology technician 67 15.5 Midwife 12 2.8 Other 70 16.2 Second job Yes 74 17.1 No 358 82.9 Work system Shiftworker 356 82.4 Day worker 76 17.6 Shift schedule Regular rotation 187 43.3 Irregular rotation 158 36.5 Evening (permanent) 6 1.4 Night (permanent) 5 1.2 Shift rotation Clockwise 122 35.5 Counterclockwise 223 64.5 SD = standard deviation. Min.–max. = range of minimum and maximum values. could be regarded as highly educated. Ap- proximately 80% of the participants were engaged in a rotating shift schedule with the following pattern: day work, 07:30–15:30 hours; evening work, 15:00–22:00; night work, 21:30–08:00. Only 2.6% of them were involved in fixed evening and fixed night shift schedules. In a majority of cases (64.5%), shift rotation followed a counter- clockwise pattern. Table 2 presents the prevalence of shift- work-related problems reported by the study population. The prevalence of insomnia was higher among shiftworkers than day work- ers, although the difference did not reach statistical significance (P < 0.1). Irregular shift rotation was significantly associated with insomnia (P < 0.05). However, there were no significant differences between the 2 groups in the prevalence of hypnotic drug use, individual and family life problems or gastrointestinal and heart problems (Table 2). Overall, 84.3% of shiftworkers believed that shiftwork adversely affected their so- cial lives, while this rate was 70.3% among day workers (P < 0.05). The prevalence of subjective problems (dizziness, nervousness, fatigue, depres- sion, carelessness and errors) among shift- workers was significantly higher (88.0%) than among day workers (73.6%) (P < 0.002). There were also significant asso- ciations between the shift schedule and the prevalence of subjective problems, with fixed shift schedules causing fewer subjec- tive problems than a rotating shift sched- ule. Significantly more shiftworkers were dissatisfied with their work schedule than were day workers (62.4% versus 37.0%) (P < 0.001) (Table 2). Homogeneity testing demonstrated that from the viewpoint of shiftwork, based on participants’ reports, regular rotation caused the least negative effects on social life (79.0%) and irregular 344 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم rotation caused the most negative effects on social life (89.0%) (P < 0.02). Only 24.5% of shiftworkers said that they had selected shiftwork voluntarily. The reasons for doing this were: interest, variation, having a second job and having more days off. The remaining 75.5% of shiftworkers reported that they were re- quired to work in a shift system. There was a significant relationship between voluntary selection of shiftwork and an intention to continue shiftworking (P < 0.001). This indicated that those who had voluntarily se- lected shiftworking were willing to continue working in the shift system. “Involuntary” shiftworkers experienced a higher rate of negative effects of shiftwork on individual, family and social life and gastrointestinal problems than those who selected shift- working voluntarily (P < 0.05). Study of daily sleep duration in the fixed schedule workers demonstrated that the mean daily hours of sleep among day work- ers, fixed evening workers and fixed night workers were 7.2 hours, 7.14 hours and 4.6 hours, respectively. One-way analysis of variance showed a significant difference among the means (P < 0.001). Discussion This study showed that shiftwork might adversely affect shiftworkers in a number of ways. The results confirmed that the prevalence rates of insomnia and social and subjective problems among shiftworkers were high compared with day workers. This can be attributed to a work schedule that is unadjusted to workers’ circadian patterns. Table 2 Prevalence of shiftwork-related problems reported among the study population Problems reported Shiftworkers Day workers P-valuea (n = 356) (n = 76) % % Insomnia 47.7 34.0 < 0.1 Hypnotic drug use 10.3 13.8 > 0.05 Adverse effects on own life 70.6 71.8 > 0.05 Adverse effects on family life 75.6 74.0 > 0.05 Adverse effects on social life 84.3 70.3 < 0.05 Gastrointestinal problemsb 34.6 30.0 > 0.05 Heart problems 16.4 14.3 > 0.05 Subjective problemsc 88.0 73.6 < 0.002 Work schedule dissatisfaction 62.4 37.0 < 0.001 aChi-squared analysis of the prevalence of the problems between shift and day workers. bIncluding increased appetite, decreased appetite, constipation, diarrhoea, peptic ulcers and indigestion. cIncluding dizziness, nervousness, carelessness, repetitive errors, irritation, depression, fatigue, and poor sleep quality. n = total number of participants. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 345 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم This is in agreement with the results of other studies in industrialized countries [11–15]. Our study of the shift schedule in SUMS hospitals indicated that shift rotation was usually irregular and was based on depart- mental needs. Indefinite and irregular work schedules caused more social and subjec- tive problems, as well as shiftwork dissat- isfaction, than regular schedules. Regular rotation caused fewer negative effects on social life than irregular rotation. Further- more, counterclockwise rotation, which was observed in the majority of cases, could be regarded as a contributing factor for shiftwork-related problems among hospital staff [3,16]. Shiftworkers were not generally satis- fied with their work schedule as compared with day workers. Meanwhile, among the shiftworkers, working in a fixed schedule was related to more satisfaction with the work schedule than working in a rotating system. Furthermore, a regular rotating schedule produced more satisfaction than an irregular rotation. These findings imply that devising a regular rotating shift system can contribute to improved shiftworking conditions and, to some extent, increase workers’ satisfaction. As the results of this study revealed, choosing to work in a shift system led to fewer health problems. People who vol- unteered to be engaged in shiftwork had a greater tendency to continue working in the shift system and reported fewer individual, family and social problems or gastrointes- tinal disorders. It follows that selection of personnel who wish to work in the shift system may be important for reducing prob- lems associated with shiftwork. The average daily duration of sleep for fixed night workers was less than the other groups. This finding agrees with Ohayon et al. [17]. Sleep deprivation in night workers is a likely reason for fatigue, irritability, dizziness, depression and other subjective problems. As Ohayon et al. affirmed, work- ers in this situation are more likely to feel sleepy at work and more likely to have work-related problems and sick leave [17]. Conclusion In SUMS hospitals, shiftwork schedules are devised based on needs and workload. As this study showed, fixed and regular rota- tion schedules caused fewer problems for shiftworkers. It is therefore recommended that in each hospital a fixed regular shift schedule is devised. Alward and Monk stat- ed that hospital administrators need to be sophisticated in their approach to the shift systems and should choose shift systems that are appropriate and beneficial to their personnel [18]. Hospital administrators should realize that enhancing the personal and professional well-being of shiftworkers is a cost-effective contribution to the quality of patient care. The findings highlight the need to es- tablish strategies for preventing negative consequences of shiftwork and improv- ing occupational health among the health care workers of SUMS. Regarding this, appropriate personnel selection, improving shift schedules and devising regular shift systems based on chronobiology principles can be considered as effective measures. References 1. Gordon NP et al. The prevalence and health impact of shift work. American jour- nal of public health, 1986, 76(10):1225– 8. 346 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 2. Horwitz IB, McCall BP. The impact of shift work on the risk and severity of injuries for hospital employees: an analysis using Oregon workers’ compensation data. Oc- cupational medicine, 2004, 54:556–63. 3. Monk TH, Folkard S, eds. Making shift work tolerable. London, Taylor & Francis, 1992. 4. Helander MG, ed. A guide to the ergo- nomics of manufacturing. London, Taylor & Francis, 1995. 5. Colligan MJ, Tepas DL. The stress of hours of work. American Industrial Hygiene As- sociation journal, 1992, 47(11):686–95. 6. Folkard S. Is there a ‘best compro- mise’ shift system? Ergonomics, 1992, 35(12):1453–63. 7. Gold DR et al. Rotating shift work, sleep, and accidents related to sleepiness in hospital nurses. American journal of pub- lic health, 1992, 82(7):1011–4. 8. Smith L et al. Work shift duration: a review comparing eight hour and 12 hour shift systems. Occupational and environmen- tal medicine, 1998, 55:217–29. 9. Schirmer J. Health and safety hazards of shiftwork: implications for health care workers and strategies for prevention. In: Charney W, ed. Handbook of mod- ern hospital safety. New York, Lewis, 1999:799–817. 10. Colin D. Beginning research in psycholo- gy: a practical guide to research methods and statistics. Oxford, Blackwell, 1995. 11. Colligan MJ et al. Frequency of sickness absence and worksite clinic visits among nurses as a function of shift. Applied ergo- nomics, 1979, 10:79–85. 12. Smith MJ et al. Health and safety con- sequences of shift work in the food processing industry. Ergonomics, 1982, 25:133–44. 13. Kurumatani N et al. The effects of fre- quently rotating shift work on sleep and the family life of hospital nurses. Ergo- nomics, 1994, 37(6):995–1007. 14. Munakata M et al. Influence of night shift work on psychologic state and cardiovas- cular and neuroendocrine responses in healthy nurses. Hypertension research, 2001, 24(1):25–31. 15. Suzuki K et al. Mental health status, shift work, and occupational accidents among hospital nurses in Japan. Journal of oc- cupational health, 2004, 46:448–54. 16. Czeisler CA, Moore-Ede MC, Coleman RH. Rotating shift work schedules that disrupt sleep are improved by apply- ing circadian principles. Science, 1982, 217:460–3. 17. Ohayon MM et al. Prevalence and con- sequences of sleep disorders in a shift worker population. Journal of psychoso- matic research, 2002, 53(1):577–83. 18. Alward RR, Monk TH. Supporting shift workers. Journal of nursing administra- tion, 1994, 24(5):53–9. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 347 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Situation actuelle des services de santé dans les districts du nord de la Cisjordanie (Palestine) RÉSUMÉ Nous avons évalué la situation actuelle dans les services de santé des districts du nord de la Cisjordanie (Palestine) pour ce qui concerne les prestataires des services, les services fournis, les ressources humaines travaillant dans les services et la suffisance de ces services par rapport à la taille de la population. Nous avons constaté que 21 % de la population totale dans les districts du nord n’avait pas de consultations médicales privées et que 13 % n’avait même pas de centres de soins de santé primaires au sein de la communauté. Il y a eu une augmentation du nombre de centres de soins de santé primaires publics et une diminution du nombre de centres caritatifs et non gouvernementaux depuis que l'Autorité nationale palestinienne a pris la responsabilité des services de santé publics par le biais du ministère de la Santé. Current situation of health services in northern districts of the West Bank, Palestine ABSTRACT We assessed the current situation of health services in the northern districts of the West Bank of Palestine as regards the providers of the services, the services provided, the human resources working in the services and the sufficiency of the services with respect to the size of the populations. We found that 21% of the total population in the northern districts did not have private medical clinics and 13% did not even have primary health care centres. There has been an increase in the number of governmental primary health care centers and a decrease in the number of nongovernmental and charitable centres since the Palestinian National Authority took over responsibility for public health services through the Ministry of Health. ينطسلف ،ةيبرغل ةفضل ،تيÑب ةعماج ،ةيعمتجلم ةماعل ةحصل دهعم (1) ينطسلف ،الله  ،ةينيطسلفل ةحصل Õ ،ةيبطل ×اع$وتسلم Õرئ$ (2) Received: 03/11/04; accepted: 15/06/05  5  67 89#:; <= (!>? @A %: ¡>¢^P3:Ùs3IJQH13hiJR¥H3Fe6@3¨™82 B%43N>BQ5P3vJ@:^P3_‘P93N¤W?@3 l3NeP8:5P3¸gr3½:“XN>\Wº5P3Nbƒ5P3aJÚ3vJS¤JÃ3M3h€¢`G¤3<@3<@ ÛGe93hvJ@:^P3¸gÜ3N@:YOP3vJ“P3Ý>7YX3¿5P3N>BQ5P3vJ@:^P3NhvJ@:^P3¸gr3M3NG@J?5P3N;Wwd5P3œ6Y5P93hJ“@: 3c34js3¸WLn3W;:P3<@93ÞiJq`5P3p:?53Nd`T5J\3vJ@:^P3¸gr3N;JbL3œ:@9XN>G>QbX3vJeP8p3:—63_‘P93<H3N¥;:7 N>\Wº5P3Nbƒ5P3aJÚ3vJS¤JÃ3M3N>BQ5P3vJ@:^P.33:‘9:—9iJ¥7Jd5P3ßis3213ÇaJÚ3vJS¤JÃ3iJqe3D6R”3<@ >\Wº5P3Nbƒ5P3c3NX3:—6}“;:5w\3¡‹3vPpJ>H3CJy3fW93hN133Ç3cXN>59s3N>BC3N;JH83ULPW@3}“XJ?R¹3M3:—6m N¢G`5P3´RGZeP3gT@3N>@6q­P3N>59…P3N>BQ5P3N;JHW5P3ULPW@3p:H3M3NŠ6BG@3‡pJ;™3p6—93NeP8:5P3·‰JZj3<@3€dX9 H3 M3 _—PWX93 hNBQ5P3 ‡8P™93 N>T>¢`Gb5P3 N>T‹65P;JHW5P3 ULPW@3 p:5P3 N>BQ>59…P3 N>Gr…P3 N;t^P93 NCJ^P93 NN “T@bGqZ5P3¡d`\3ÞJ?bXWOP3N@™x5P3NULPWOP3¸gr3K>ºwZ53N. 348 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
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$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم References 1. Barghouthi M, Daibes I. Infrastructure and health services in the West Bank. Guide- lines for health care planning. Ramallah, Health Development Information and Pol- icy Institute, 1993. 2. Barghouthi M, Giacaman R. The emer- gence of an infrastructure of resistance. In: Nassar J, Heacock R, eds. Intifada, Pales- tine at the crossroads. New York, Praguer Press, 1990:73–87. 3. ï ةيحصل ×امدلخ عض (1977) . ةبتاك Ñö ÷دقل ،($لأ úطل سلجلم ،ةيبرغل ةفضل 4. Aruri N, ed. Occupation: Israel over Pales- tine. London, Zed Press, 1984. 5. Benvenisti M. The West Bank and Gaza Data Base Project. Pilot study. Washing- عجرلم ton DC, American Enterprise Institute for Public Policy Research, 1982. 6. Abu Libdeh H. The human resources sur- vey in health: Interim Report No. 2 – a, summary of the main findings. Jerusalem, Planning and Research Center, 1993. 7. Health status in Palestine: Annual Report 2001. Gaza, Ministry of Health, Health Management Information System, 2002. 8. اهلج ،1997-2010 ةينيطسلفل ×اعمجتل
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$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Évaluation de la gestion des déchets médicaux dans un hôpital palestinien RÉSUMÉ Nous avons examiné la gestion des déchets médicaux dans un hôpital palestinien de Cisjordanie et le rôle de la municipalité dans cette gestion. De manière générale, les « bonnes pratiques de gestion » étaient inadéquates ; les déchets dangereux n’étaient pas suffisamment séparés des déchets non dangereux. Il manquait les règlements nécessaires pour la collecte des déchets des services hospitaliers et le transport in situ vers un lieu de stockage temporaire à l’intérieur ou à l’extérieur de l’hôpital ; les procédés utilisés pour le traitement des déchets et l’élimination des déchets hospitaliers avec les ordures municipales étaient inadéquats. De plus, la formation du personnel faisait défaut et les équipements et mesures de protection pour le personnel n'étaient pas disponibles. Il n’y avait pas de décharges spéciales pour les déchets dangereux dans la municipalité. I.A. Al-Khatib and R.A. Khatib. Institute of Community and Public Health, Birzeit University, Palestine (Correspondence to I.A.Al-Khatib: ikhatib@birzeit.edu). Received: 17/03/05; accepted: 17/05/05 Assessment of medical waste management in a Palestinian hospital ABSTRACT We studied medical waste management in a Palestinian hospital in the West Bank and the role of municipality in this management. In general, “good management practices” were inadequate; there was insufficient separation between hazardous and non-hazardous wastes, an absence of necessary rules and regulations for the collection of wastes from the hospital wards and the on-site transport to a temporary storage location inside and outside the hospital and inadequate waste treatment and disposal of hospital wastes along with municipal garbage. Moreover, training of personnel was lacking and protective equipment and measures for staff were not available. No special landfills for hazardous wastes were found within the municipality. GA %:H6I  JA -6$ 
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$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم عجرلمReferences 1. Cole EC, Medical waste management, a basic guide for Central and Eastern Eu- rope. Durham, North Carolina, DynCorp, Biotechnology and Health Division, 1995. 2. Managing and tracking medical waste, a guide to the federal program for genera- tors. Washington DC, United States Envi- ronmental Protection Agency, 1989. 3. Collins CH, Kennedy DA. Microbiological hazards of occupational needle stick and ‘sharps’ injuries. Journal of applied bacte- riology, 1987, 62:385–402. 4. Model guidelines for state medical waste management. Lexington, Kentucky, Coun- cil of State Governments, 1992. 5. Guidelines for segregation, handling and transport of clinical waste. London, Lon- don Waste Regulation Authority, 1989. 6. Clinical waste: an appraisal. London, Lon- don Waste Regulation Authority, 1989. 7. Monreal J. Considerations on the manage- ment of hospital wastes in Latin America. Washington, Pan American Health Or- gainzation, 1991. 8. Medical Waste Management in the United States, First Interim Report to Congress. Washington DC, Environmental Protec- tion Agency, Office of Solid Waste, 1990 (EPA/530-SW-90-051a). 9. Guides to pollution prevention—selected hospital waste streams. Cincinnati, Ohio, Center for Environmental Research Infor- mation, Environmental Protection Agency, 1990. 10. Al-Khatib IA, Alshanableh TA. Medical waste management in the Turkish Re- public of Northern Cyprus, a case study: Dr. Burhan Nalbantoglu Governmental Hospital. Paper presented at the Third In- ternational Congress for Cyprus Studies, Eastern Mediterranean University, Fama- gosta, 13–17 November, 2000. 11. Managing medical waste in developing countries. Geneva, World Health Organi- zation, 1994. 12. Draft Guideline for Environmental Infec- tion Control in Healthcare Facilities. Rec- ommendations of CDC and the Health- care Infection Control Practices Advisory Committee (HICPAC). Atlanta, Georgia, Centers for Disease Control and Preven- tion, 2001:96–101. 13. Guidance for regulated medical waste treatment, storage, containment, trans- port and disposal. New York, Department of Environmental Conservation, Division of Solid & Hazardous Materials, 1996. 14. Anderson GK. Clinical waste disposal. Amman, WHO Regional Centre for Envi- ronmental Health Activities, 1992. 15. Anderson GK. Incineration as a waste disposal option in EMRO. Amman, WHO Regional Centre for Environmental Health Activities, 1995. 16. Anderson GK. Management of health care wastes. Amman, WHO Regional Centre for Environmental Health Activities, 1995. 17. Compendium of technologies used in the treatment of hazardous waste. Cincinnati, Ohio, Center for Environmental Research Information, Environmental Protection Agency, 1990:55 (Report No. EPA/625/8- 87/014). 18. Continuous Feed Auger. Clinical Waste Sterilization Technology. Aberdeen, Scot- Safe Ltd, 1993. )5(3 N>H6X3 <@3 }“>Y¤PW@93 €Y‰J`5Pd;8:X93 aJR?5P}“GR?\3 IJ>Y5P3 FGH3 }“N>d¢5P3 vJ;JbT5P3 ‡8Ppl3 M3¡ßT¹93 }Ü3N>Qw5P3N;J‘65P3vP:?@3t¤6X3N>Rrs3_@3hJrW‹JÄm3 3 Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 371 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 19. Hall T. Health care waste management handbook. Gateshead, Environmental Technology Consultants Limited, 1994. 20. Safe management of wastes from health- care activities. Geneva, World Health Or- ganization, 1999. 21. Mato RRAM, Kaseva ME. Critical review of industrial and medical waste practices in Dar es Salaam city. Journal of resourc- es conservation and recycling, 1999, 25:271–87. 22. Mato RRAM, Kassenga GK. A study on problems of management of medical solid waste in Dar es Salaam and their reme- dial measures. Journal of resources con- servation and recycling, 1997, 21:1–16. 23. NHS Estates. Safe disposal of clinical waste. Health Guidance Note. Whole Hospital Policy Guidance. London, Her Majesty’s Stationery Office, 1995. 24. Health-care waste management. Rapid assessment tool for country level. Gene- va, World Health Organization, 2001. 25. Al-Hmaidi MS. Solid waste management and disposal system in the Ramallah dis- trict. Palestine, Report to the Solid Waste Management Steering Committee, Ram- allah District, on behalf of GTZ, 1995. 26. Al-Khudari N. Minimizing the risk of solid medical waste. Palestine, Environmental Planning Directorate, Ministry of Planning and International Cooperation, 1996. 27. Atyani TH. Clinical waste management in the West Bank, Palestine [MSc disserta- tion]. Newcastle-upon-Tyne, University of Newcastle-upon-Tyne, 1996. 28. Zoarob ZK. Hazardous waste manage- ment in the Gaza Strip [MSc thesis]. Delft, The Netherlands, International Institute for Infrastructure, Hydraulics, and Envi- ronmental Engineering, 1997. 29. Healthcare waste management in Pal- estine. Report and Plan of Action, and Report of Joint Healthcare Waste Work- shops 4 and 5 January 1997, Gaza and Nablus, Palestine. Palestine, Ministry of Health, 1997. 30. Al-Khatib IA, Darwish R. Assessment of amalgam waste management in den- tal clinics in Ramallah and Al-Bireh cit- ies in Palestine. International journal for environmental health research, 2004, 14(3):179–83. 31. Hasan SE, ed. Geology and hazardous waste management. Upper Saddle River, New Jersey, Prentice Hall, 1998. 32. Jackman AP, Powell RL. Hazardous waste treatment technologies. Park Ridge, New Jersey, Noyes Publications, 1991. 33. National Association of Waste Disposal Officers. Clinical waste: a guidance to lo- cal authority client officers on the disposal of clinical waste. Northampton, Institute of Waste Management, 1995. 372 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Children’s indoor and outdoor play patterns in Ahwaz city: implications for injury prevention H. Soori1 1Department of Epidemiology and Biostatistics, Faculty of Public Health, Shaheed Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to H. Soon: hsoori@yahoo.com). Received: 23/06/03; accepted: 25/10/04 ABSTRACT A cross-sectional study in Ahwaz city, Islamic Republic of Iran, described children’s indoor and outdoor play patterns. A total of 952 pupils aged 7 and 9 years and 942 parents completed ques- tionnaires. Children’s favourite activities were: playing football (22.3%), cycling (13.2%) and watching television (12.3%). This differed from those perceived by the parents who reported watching television (20.3%), playing football (13.3%) and playing in street (11.4%). Children reported their favourite places to play were: street (27.4%), park/playground (18.3%) and home (17.8%). There were significant differ- ences in play patterns by age and sex. The play patterns of older children and boys exposed them to more hazardous situations than younger children and girls. Loisirs des enfants à l’intérieur et à l’extérieur du foyer dans la ville d’Ahwaz : implications pour la prévention des traumatismes RÉSUMÉ Une étude transversale réalisée dans la ville d'Ahwaz (République islamique d'Iran) a décrit les types de loisirs des enfants à l'intérieur et à l'extérieur du foyer. Au total, 952 enfants âgés de 7 et 9 ans et 942 parents ont rempli des questionnaires. Les activités préférées des enfants étaient les suivantes : jouer au football (22,3 %), faire de la bicyclette (13,2 %) et regarder la télévision (12,3 %). Ceci différait de celles perçues par les parents qui mentionnaient regarder la télévision (20,3 %), jouer au football (13,3 %) et jouer dans la rue (11,4 %). Les enfants ont déclaré que leurs lieux préférés pour jouer étaient la rue (27,4 %), le parc/terrain de jeu (18,3 %) et la maison (17,8 %). Il y avait des différences significatives dans les types de loisirs en fonction de l’âge et du sexe. Les types de loisirs des enfants plus âgés et des garçons les exposaient à plus de risques que les enfants plus jeunes et les filles. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 373 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction Many children’s unintentional injuries, particularly after the age of 5 years, occur while playing outdoors [1,2]. Play-related injury is common among children, and in some cases causes severe injury and death. In the United Kingdom, around 1.2 mil- lion children are injured outside the home every year and children aged 5–14 years old have 85% of non-home injuries [2]. In many inner city areas there is nowhere safe for children to play, and these are the areas where the casualty rate for children is high [3]. Children who spend most of their free time outdoor participating in games or other activities are more likely to be exposed to hazards than children who spend their time indoors. Higher rates of outdoor injuries are found in older children, and boys compared with younger children and girls [4]. This variation might be due to the mechanism of injury, behavioural differences or en- vironmental factors [1,5]. Fabes et al. [6] showed that with increasing age, children increased the time they spent outside, and that boys play more physically energetic games than girls. The types of injury also differed between boys and girls. Towner et al. [7] showed that exposure to injury risk in schoolchildren aged 11–14 years varied with sex and age. They showed that boys, and older children were more likely to be exposed to greater risk than girls and younger children. Some studies have shown that the high injury rates among different groups of children resulted from greater numbers of roads crossed [8,9]. Other stud- ies have examined the contribution of the traffic environment [10,11], the role of educational programmes, [12,13] and the role of the physical environment [14,15]. Nevertheless, the role of children’s play patterns on risk of after-school accidental injuries among primary school age groups is not clear and no survey evidence exists about the amount of time children in the Islamic Republic of Iran spend playing in the streets. The aim of this study is to deter- mine children’s play patterns in Ahwaz city, Islamic Republic of Iran, in order to gain an understanding of the proportion exposed to risk through outdoor play. Methods The target groups were children in primary school classes 1 and 3 (children aged ap- proximately 7 and 9 years old) living in the city of Ahwaz, Islamic Republic of Iran, and their parents. These age groups were chosen because the children are physically and behaviourally vulnerable in risky situa- tions [16], and are learning to adapt to adult society. The methods and rationale behind this method have been published before [17]. The target sample size, calculated from a pilot study, was 952 pupils from 61 700 pupils in class 1 and class 3 of 400 pri- mary schools. A total of 76 schools from 5 educational authority wards of the city were randomly selected according to the frequency of pupils in each ward and all the selected schools agreed to cooperate. The socioeconomic status of the subjects was assessed based on the ward level of census data on the proportion of the economically active population either employed, living in private households, living in a household with a car, or living in a home with not more than 1 person per room. The selected children and their parents completed questionnaires. The children completed a simple questionnaire during a school lesson with adult supervision (teacher and research assistant). They were asked to paste different response stickers 374 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم onto pictures about play situations (e.g. yes/no, safe/dangerous). To make it appeal- ing and easy to answer, the questionnaire included some cartoons and drawings. (The questionnaire is available on request from the author). The parents’ questionnaire was taken home to parents by the children and delivered back by the pupils after comple- tion. Parents’ questionnaires that were not returned within 15 days were excluded. To maximize the response rate, a letter from the headteachers was enclosed to encourage parents’ cooperation. The questionnaire had been tested before in the UK [17] and trans- lated into Farsi for this study. The data from the schools were collected during October 2000. Parents reported the time, on average, that their children spent paying outside the home after every school day when the weather was dry and wet. The data were analysed with the statisti- cal package SPSS for Windows, version 10.0. The chi-squared test was used to calculate the associations between categori- cal data, Mann–Whitney test for calculating the significant differences of non-normal distribution and numeric data, and 95% confidence interval for differences. McNe- mar test was done to test paired proportions (based on the frequencies of pairs with dif- ferent outcomes) between the parents’ and children’s responses. Results Out of 952, a total of 942 pupil question- naires (98.9%) and 832 parent question- naires (88.3%) were completed. Children’s favourite activities Table 1 shows children’s favourite activi- ties with respect to age and sex, based on parents’ and children’s responses. Playing football was their favourite activity according to 23.3% of children. Seven-year-olds were more likely to say they prefer to play with toys than 9-year- olds (P = 0.005). Nine-year-olds were more likely to prefer to play football than 7-year- olds (P = 0.006). Girls were more likely to prefer to watch television (P = 0.013), read or draw (P < 0.001) and play with toys (P = 0.009) than boys. However, boys were more likely to prefer to play with a computer (P < 0.001) and play football (P < 0.001) than girls. There was no significant differ- ence between other activities by age and sex. Many parents reported that the favourite activity for both age groups of children was watching television (23.4% and 20.6%). They said that older children were more likely to prefer to play football (P = 0.041) than younger children. According to parents, boys were more likely to prefer to play football (P < 0.001) and play with a computer (P = 0.013) than girls. Girls were more likely to prefer to play with friends (P = 0.002) and to draw or read (P = 0.002) than boys. Table 2 shows the proportion of occa- sions when parents agreed with children about their favourite activities. Overall, there was poor agreement between parents’ and children’s responses for all individual activities (excluding “other sports”, the proportions agreeing ranged between 0% and 53.1%). There was poorer agreement between parents and children for outdoor play activities than indoor play activities, e.g. playing (14.8%) and cycling in the street (21.6%). About half the parents disagreed with their children’s responses on favourite activities in outdoor play. Children’s favourite places to play Table 3 shows children’s responses about their favourite place to play. This shows that the street was the favourite place to play for more than a quarter of children. Seven-year- Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 375 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم olds were significantly more likely to prefer to play in the home than 9-year-old children (P < 0.001). However, 9-year-olds were more likely to prefer to play in the field (P = Table 1 Children’s favourite activities as reported by parents and children by age and sex Activity Age 7 Age 9 Boys Girls Total years years % % % % % Watching TV Parents 23.4 20.6 25.3 18.6 22.0 Children 13.6 11.1 8.8 16.4 12.3 Football Parents 10.9 18.3 25.8 2.2 14.4 Children 17.4 27.9 34.9 8.2 22.3 Playing in street Parents 11.9 12.8 10.1 14.8 12.3 Children 6.6 6.6 3.2 10.5 6.6 Playing with friends Parents 12.4 8.9 6.1 15.8 10.8 Children 7.4 5.3 6.0 6.8 6.4 Drawing/reading Parents 10.0 7.8 4.5 13.7 8.9 Children 5.8 5.8 1.2 10.9 5.8 Cycling Parents 7.5 7.2 9.1 5.5 7.3 Children 14.5 11.9 15.1 10.9 13.2 Computer Parents 7.0 6.1 9.6 3.3 6.6 Children 9.5 8.4 13.5 3.6 8.9 Playing with toys Parents 5.0 4.4 3.0 6.6 4.7 Children 14.0 6.2 6.8 14.1 10.2 Other sports 5.0 Parents 4.0 6.1 4.0 6.0 2.8 Children 1.7 4.0 1.6 4.1 Other indoor play 3.4 Parents 3.0 3.9 0.5 6.6 1.7 Children 2.5 0.9 1.6 1.8 Other outdoor play 2.4 Parents 2.0 2.8 2.0 2.7 5.8 Children 4.5 7.1 4.4 7.3 Total number of parentsa 402 360 396 366 762 Total number of childrena 484 452 498 438 936 aTotals less than 942 are due to missing data on questionnaires. 376 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Ta bl e 2 Pr o po rti on o f o cc as io ns w he n pa re nt s ag re ed w ith c hi ld re n’ s as se ss m en t o f t he ir fa vo u rit e ac tiv iti es Pa re n ts ’ r es po ns es Ch ild re n’ s re sp on se s W at ch in g Pl ay in g D ra w in g C om pu te r Pl ay in g F oo tb al l Cy cl in g Pl ay in g O th er O th er O th er TV w ith to ys / re ad in g in s tre et w ith sp or ts in do or o u td oo r fri en ds pl ay pl ay % % % % % % % % % % % W a tc hi ng T V 53 .1 20 .9 13 .6 25 .7 11 .1 14 .9 17 .6 20 .0 22 .2 16 .7 9. 1 Pl ay in g w ith to ys 2. 0 14 .0 13 .6 0. 0 7. 4 0. 0 9. 8 4. 0 0. 0 0. 0 0. 0 D ra w in g/ re ad in g 2. 0 14 .0 40 .9 2. 9 0. 0 2. 7 5. 9 12 .0 0. 0 33 .3 18 .2 Co m pu te r 0. 0 4. 7 4. 5 22 .9 11 .1 8. 1 3. 9 4. 0 0. 0 0. 0 9. 1 Pl ay in g in th e st re et 10 .2 18 .6 0. 0 8. 6 14 .8 9. 5 17 .6 16 .0 0. 0 16 .7 9. 1 Fo o tb al l 2. 0 2. 3 0. 0 17 .1 11 .1 44 .6 9. 8 12 .0 0. 0 16 .7 4. 5 Cy cli ng 2. 0 2. 3 0. 0 2. 3 0. 0 6. 8 21 .6 4. 0 11 .1 0. 0 4. 5 Pl ay in g w ith fr ie nd s 12 .2 14 .0 4. 5 2. 9 40 .7 5. 4 5. 9 20 .0 11 .1 16 .7 4. 5 O th er s po rts 6. 1 4. 7 4. 5 0. 0 0. 0 4. 1 2. 0 8. 0 55 .6 0. 0 9. 1 O th er in do or p la y 6. 1 2. 3 9. 1 0. 0 3. 7 1. 4 2. 0 0. 0 0. 0 0. 0 13 .6 O th er o u td oo r p la y 2. 0 0. 0 4. 5 2. 9 0. 0 1. 4 2. 0 0. 0 0. 0 0. 0 18 .2 To ta l n u m be r o f re sp on de nt sa 98 86 44 70 54 14 4 10 2 50 18 12 44 a To ta ls le ss th an 9 42 a re d ue to m iss in g da ta o n qu es tio nn ai re s. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 377 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 0.006) and a friend’s house (P < 0.001) than 7-year-olds. Boys were more than 3 times more likely to prefer to play in the field than girls (P < 0.001). There was no significant difference between other responses for the sexes. Children’s usual activities after school hours Overall, 74.5% of children reported that they usually played in the street every day after school. Nine-year-olds were more likely to play in the street every day than 7- year-olds (79.5% versus 69.8%, P = 0.016). Boys also were more likely to play outside the home compared with girls (78.5% ver- sus 70.0%, P = 0.035). Table 4 shows how much time parents estimated that their children spent in play the day before by age and sex. On average, children spent 127 minutes indoor, 48 min- utes in the street, 12 minutes at a children’s club, 4 minutes in the park, 1 minute in the playground and 15 minutes on other places. There were no significant differences by age group and sex of children in the amount of time they spent in play the day before. Children of all groups spent a mean time of 107 min (standard deviation = 82) playing outside when the weather was dry and 12 min (SD = 33) when the weather was wet every day after school. Regarding the time spent playing outside when it was dry, there was no significant difference between 7- and 9-year-olds and boys and girls. There was no significant difference between other groups of children in the time spent playing outside when it was wet, and time spent playing in the home. Parents were asked whether their children usually play in the street, park or playground, sport/leisure centres and other places after school, every day. The responses was recorded as “sometimes” and “never”. According to parents’ responses, 7-year-old children were more likely to play in the playground than 9-year-old children (44.0% versus 33.5%, P = 0.028), while 9-year-olds were more likely to play in the street than 7-year-olds (84.0% Table 3 Children’s responses to their favourite places to play after school hours Place of play Age 7 Age 9 Boys Girls Total years years (n = 484) (n = 458) (n = 502) (n = 440) (n = 942) % % % % % Street 25.6 29.3 27.1 27.7 27.4 Park/playground 17.4 19.2 17.1 19.5 18.3 Home 24.0 11.4 15.9 20.0 17.8 Garden/hut 14.1 10.9 10.8 14.5 12.6 Field 6.6 14.4 15.1 5.0 10.4 Friend’s house 1.2 8.3 3.6 5.9 4.7 Back lane 5.4 2.6 4.8 3.2 4.0 Club 0.8 2.2 1.6 1.4 1.5 Building site 2.1 0.4 0.8 1.8 1.3 Others 2.8 1.2 3.2 1.0 2.1 378 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم versus 75.5%, P = 0.031). With respect to sex, there was no statistically significant difference between the 2 groups relating to different activities. Nearly two-thirds (64.7%) of parents thought that there was a dangerous place for their children near their home within 5 minutes walk. Nevertheless, 29.3% of their children played there. There was no statisti- cal significant difference between parents’ views on dangerous place/s near their home by age or sex of the children. Discussion This study showed that many children in Ahwaz city usually play outside their home and spend most of their after-school hours outdoor in the street. Streets were the fa- vourite place to play for more than a quarter of children. Older children and boys had different play patterns than other groups of children. This exposes them to hazards that increase the risk of injuries. Older children spent more time in play outdoors compared with younger ones, as did boys compared with girls, and they were more likely to play outdoors without an adult, exposing them to more hazardous situations. Parents of different groups of children had different views about their children’s activities after school. This could reduce their potential influence on preventing injuries. This study obtained a very good response rate (98.9% for children’s and 88.3% for parents’ questionnaires), higher than the response rate of studies that used a similar method for collecting parental information [17,18], or children’s data [7]. It is unlikely that parents could remember accurately how much time their children spent in various type of play, so the times should be consid- ered as estimates. Also, weather conditions varied between the days of data collection, which also could have affected the findings. The number of children in the family, and which guardian/parent is answering may also influence the subject’s responses. Little has been written about children’s play patterns and the need for children to play outdoors in safety alone or with their friends. According to one US survey by Thackray and Dueker [19], 90% of children of 6–7 years of age played in the streets without an adult, and Sadler [20] found that three-quarters of all the schoolchildren spent Table 4 Parents’ responses to how much time their children spend after school in play in different places the day before completing the questionnaire Place of play Age 7 years Age 9 years Boys Girls Total (n = 484) (n = 452) (n = 498) (n = 438) (n = 936) Mean % of Mean % of Mean % of Mean % of Mean % of time children time children time children time children time children (min) playing (min) playing (min) playing (min) playing (min) playing Indoors 131 89.3 123 87.1 124 86.4 131 90.1 127 88.2 In the street 45 45.1 52 50.0 55 49.3 41 45.5 48 47.5 At a club 12 13.7 13 13.0 12 13.2 13 13.6 12 13.4 In the park 4 4.9 5 5.5 6 6.6 3 3.5 4 5.1 In the playground 1 1.9 2 2.5 1 2.4 2 2.0 1 2.2 In other places 11 10.4 20 18.5 17 16.0 13 12.8 15 14.4 Totals less than 942 are due to missing data on questionnaires. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 379 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم some time after-school hours playing away from home. Chapman et al. [21] believed that many injuries occur when children use streets as play areas. Tight [22] examined the exposure of children (pre-school, pri- mary school and secondary school) to risk while using roads for reasons other than going to and from school, with particular emphasis on play. In terms of age alone, he found that 38.2% of children observed in the street were of primary school age, which was greater than pre-school (35.3%) or secondary schoolchildren (26.5%). Of all children, 66.6% were involved in some type of play activities in the street. Earlier studies on children’s play pat- terns give a general picture of the type of use that children make of the street for playing. This study found that about two-thirds of children play outside every day after school. Some of them played near dangerous places and did not like to use playgrounds or play areas in their neighbourhood. This result can be used to inform efforts to improve the safety of residential streets, and to make playgrounds more attractive for children. A previous study in Ahwaz showed that almost as many girls as boys were observed to visit dangerous places in their neighbour- hood [5]. There was, however, a tendency for a more boys to be found in traffic areas. Chapman et al. [21] showed that boys more than girls use streets for recreational pur- poses. The findings of the present study are similar for many outdoor activities not only by the child’s sex but also by age. Parents have to weigh up the risks of children’s outdoor activities. For child pe- destrian injuries, it has been shown that one possible cause is a relative mismatch between the children’s risk perception, chil- dren’s skills and the parents’ expectations [23]. Surveys suggest that parents have unrealistic expectations of their children’s pedestrian skills [18]. In this study, the street was the favourite place to play for more than a quarter of children. One explanation may lie in the benefit of playing outside perceived by both parents and children. An- other explanation may be that these groups of children live in houses without gardens where they can play or in areas without children’s preferred play facilities. Playgrounds and play areas can provide an alternative to playing in dangerous places such as roads [1,3,5,24]. The results of the present study showed that providing a play area close to home will not be enough be- cause although most children had access to a play area within less then 10 minutes walk, only half of them usually played there. The message is clear; children are not attracted to many play areas probably because avail- able playgrounds are not interesting enough for children and need to be modified [25]. Therefore it will be important to provide ad- equate safe play areas close to home, where children can enjoy the play equipment or play facilities (for instance, football play- grounds or appropriate places for cycling). Some after-school injuries may be avoidable by changing the nature of chil- dren’s play patterns (e.g. by emphasizing the avoidance of street play) or by incor- porating minimal safety precautions. Other means of reducing after-school injuries might be through modifying features of residential areas where children usually like to play, and through education. One of the greatest improvements in the safety of play outside the home may occur if children learn to transfer the principles and habits of safety they learn in their education pro- grammes to non-organized activities. The gains will come when children recognize the danger of unsafe activities and policy- makers establish organized after-school programmes [26]. In conclusion, even if built-up areas where children play outside are made safer, 380 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم their play patterns might expose them to other dangerous situations, such as falling from heights, from bicycles and so on. Many after-school injuries and mainly child pedestrian injuries in different geographic areas tend to be scattered diffusely rather than clustered [27]. Therefore, it seems that environmental improvements such as traffic engineering interventions at “black spot” locations will not cover all the children who usually play outside after school and are at risk. Therefore, changing children’s play patterns and putting emphasis on avoiding unsafe activities by providing organized after-school programmes, considering chil- dren’s favourite activities especially for vulnerable children is recommended. In ad- dition, parents should discourage children from playing in unsafe places or taking part in some risky activities without supervi- sion or adequate safety devices. Further studies are required to determine which of these strategies has the greatest potential to reduce after-school injuries in children. References 1. Posner JC et al. Exposure to traffic among urban children injured as pedestrians. Injury prevention, 2002, 8(3):231–5. 2. The 1994 Dettol report. Child accidents in the UK. London, Dettol Care Network in association with Child Accident Preven- tion Trust, 1994. 3. Preston B. Statistical analysis of child pedestrian accidents in Manchester and Salford. Accident analysis and preven- tion, 1972, 4:323–32. 4. Avery J, Jackson R, eds. Children and their accidents. London, Arnold Edward, 1993. 5. Soori H. Epidemiology of children’s cycling injuries in Ahwaz, Iran. Eastern Mediterranean health journal, 2002, 8(2/ 3):308–14. 6. Fabes RA, Hanish LD, Martin CL. Chil- dren at play: the role of peers in under- standing the effects of child care. Child development, 2003, 74(4):1039–43. 7. Towner E et al. Measuring exposure to in- jury risk in schoolchildren aged 11–4. Brit- ish medical journal, 1994, 302:449–52. 8. Hillman M, Whalley A. Fair play for all. A study of access to sport and informal rec- reation. London, Political and Economic Planning, 1977. 9. Roberts I, Norton R, Taua B. Child pedes- trian injury rates: the importance of “ex- posure to risk” relating to socioeconomic and ethnic differences, in Auckland, New Zealand. Journal of epidemiology and community health, 1995, 50:162–5. 10. Pless I, Peckham C, Power C. Predict- ing traffic injuries in childhood: a cohort analysis. Journal of pediatrics, 1989, 115: 932–8. 11. Mueller BA et al. Environmental factors and the risk for childhood pedestrian– motor vehicle collision occurrence. American journal of epidemiology, 1990, 132(3):550–60. 12. Preusser DF, Lund AK. And keep on look- ing: a film to reduce pedestrian crashes among 9 to 12 year olds. Journal of safety research, 1988, 19:177–85. 13. Tucker S. The operation of the Eastern Region Traffic Club. In: Working Paper WP/ RUS/ 116. Berkshire, Transport and Road Research Laboratory, 1992. 14. Westfelt JN. Environmental factors in childhood accidents. A prospective study in Guttenberg, Sweden. Acta paediatrica scandinavica, 1982, 291:1–75. 15. Roberts I, Marshall R, Lee-Joe T. The urban traffic environment and the risk of Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 381 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم child pedestrian injury: a case-crossover approach. Epidemiology, 1995, 6(2): 169–71. 16. Wilson M et al. Saving children. A guide to injury prevention. New York, Oxford University Press, 1991. 17. Soori H. Study of some factors influencing primary school children after school out- door accidents [PhD thesis]. Newcastle, UK, University of Newcastle upon Tyne, 1996. 18. Rivara FP, Bergman AB, Drake C. Paren- tal attitudes and practices toward children as pedestrians. Pediatrics, 1989, 84(6): 1017–21. 19. Thachray R, Dueker R. Child pedestrian supervision and guidance. Washington DC, National Highway Traffic Administra- tion, 1983 (DOT HS–501226). 20. Sadler J. Children and road safety: a survey amongst mothers. London, Her Majesty’s Stationery Office, 1972. 21. Chapman AJ, Foot HC, Wade FM. Chil- dren at play. In: Oborne DJ, Levis JA, eds. Human factors in transport research. Vol- ume 2. London, Academic Press, 1980: 380–7. 22. Tight MR. Accident involvement and ex- posure to risk for children as pedestrians on urban roads [PhD thesis]. London, University College London, 1987. 23. Soori H, Bhopal RS. Parental permission for children’s independent outdoor activi- ties: implications for injury prevention. Eu- ropean journal of public health, 2002, 12: 104–9. 24. Rivara FP, Mueller BA. The epidemiology and causes of childhood injuries. Journal of social issues, 1987, 43:13–31. 25. Mott A et al. Patterns of injuries to children on public playgrounds. Archives of dis- ease in childhood, 1994, 71(4):328–30. 26. Halpern R. The role of after-school pro- grams in the lives of inner-city children: a study of the Urban Youth Network. Child welfare, 1992, 71(3):215–30. 27. Moustaki M, Petridou E, Trichopoulos D. Person, time and place coordinates of pe- destrian injuries: a study in Athens. Acta paediatrica, 2001, 90(5):558–62. 382 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Epidemiology of deaths from injuries in the Islamic Republic of Iran M.E. Akbari,1 M. Naghavi2 and H. Soori1 1Shaheed Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to H. Soori: hsoori@yahoo.com). 2Ministry of Health and Medical Education, Tehran, Islamic Republic of Iran. Received: 11/01/04; accepted: 20/12/04 ABSTRACT A 1-year study of fatal injuries was carried out in 10 provinces of the Islamic Republic of Iran based on a population of 16 740 637 in 2000–01. All reported deaths were compared and validated with other sources of death registration. Out of 66 846 deaths, 9733 (58/100 000) resulted from injuries. Overall, 14.9% of all deaths with 26.9% of years of lost life were from injuries. Most fatal injuries were unintentional (48.0/100 000). Deaths from traffic injuries (30.0/100 000) are the highest in the world. Of 1693 intentional fatal injuries, 61% were due to suicide, at a mean age of 29 years. Épidémiologie des décès dus à des traumatismes en République islamique d’Iran RÉSUMÉ Une étude d’un an sur les traumatismes mortels a été réalisée en 2000-2001 dans 10 pro- vinces de la République islamique d’Iran à partir d’une population de 16 740 637 personnes. Tous les décès déclarés ont été comparés et validés au moyen d’autres sources d’enregistrement des décès. Sur les 66 846 décès, 9733 (58 pour 100 000) étaient dus à des traumatismes. Globalement, 14,9 % de tous les décès impliquant 26,9 % d’années de vie perdues étaient imputables à des traumatismes. La plupart des traumatismes mortels étaient non intentionnels (48,0 pour 100 000). La mortalité par accident de la circulation (30,0 pour 100 000) est la plus élevée au monde. Sur les 1693 traumatismes mortels intentionnels, 61 % étaient dus à des suicides, à un âge moyen de 29 ans. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 383 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction Injuries are a major cause of avoidable death in many countries of the world. It is estimated that in the year 2000 more than 6 million deaths resulted from accidental injuries worldwide, with 3.8 million unin- tentional and 2.2 million intentional injuries [1]. The spectrum of death and diseases has changed in recent decades in many coun- tries [2,3] and deaths from injury have become a serious concern. Most injuries are preventable and in many developed coun- tries injury prevention has been established as a national priority and deaths rates from injuries have been falling steadily for many years. The collection of more data on injury and ill-health caused by accidental injuries is a priority [4]. The usual data sources about deaths in the Islamic Republic of Iran are reports col- lected from the national registry for deaths, the hospital and cemetery data information systems, and medico-legal data. All these 4 sources of data are computerized and checked against each other. However, like many other developing countries, the Is- lamic Republic of Iran suffers from a lack of a complete data capture system for injuries; the epidemiological pattern of deaths from injuries is not available and the police and national death registration is inadequate. In rural areas, data on deaths are mainly col- lected in local community “health houses” whose main function is to offer primary health care services to rural areas of the country and their data exclude details about intentional and unintentional injuries. A population-based study on deaths from injuries in the Islamic Republic of Iran published in 1999 [5] only included the unintentional injury deaths and some rural areas of the country. Therefore, no previous study in the Islamic Republic of Iran has attempted to present a full epidemiological picture of intentional and unintentional fatal injuries. The goal of this study was primarily to assist health managers and relevant di- rectors in the Islamic Republic of Iran to develop strategies for reducing mortality in each key area. In this paper an epidemio- logical description of deaths from injuries from a sample of provinces is presented and some possible implications for control and prevention measures will be suggested. Methods A 1-year study was carried out in 10 out of 28 provinces of the Islamic Republic of Iran randomly selected from 21 March 2000 to 20 March 2001 (21 March is the first day of the year in the Iranian calendar) in the year 2000. The provinces, selected randomly ac- cording to their geographical distribution, were West Azerbaijan, Ilam, Kermanshah, Bushehr, Charmahal-Bakhtiari, Semnan, Fars, Kerman, Markazi and Yazd, with a total population of 16 740 637 inhabitants. The urban and rural areas were defined ac- cording to the criteria from the Ministry of Interior of the Islamic Republic of Iran. Trained staff (rural health workers in ru- ral areas and either urban health workers or health volunteers in urban areas) of the Na- tional Health Network followed all deaths that occurred in their area within the year of study and completed a checklist question- naire on the cause of death, epidemiological information about the injuries that resulted in death and other demographic information such as age, sex and place of residence. Cause of death was classified according to 3-digit coding system of the International classification of diseases (ICD-10) [6]. “Ex- ternal causes of morbidity and mortality” followed codes V01 to Y98 (for example, transport accidents were coded as V01 to V99, falls as W00 to W19, and exposure to 384 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم forces of nature coded from X30 to X39). To ensure the completeness and accuracy of the data, all data obtained from the above study were compared and validated with other sources of death registration, includ- ing: the national registry for deaths, the hospital and cemetery data information systems, and medico-legal data. The standard expected years of life lost (SEYLL) was calculated as: SEYLL = Σdx ex I-0 where I = limited age, X = age at death, dx = number of deaths from a particular type of injury, and ex= expected years of life at a particular age [1]. All confirmed data were referred to the Ministry of Health every month and entered into a computer for statistical analyses. All analyses were conducted using SPSS for Windows, version 10.0. Results During the year 2000–01, 9733 out of 66 846 deaths in the Islamic Republic of Iran resulted from all types of injuries. Overall, 14.6% of all deaths were from injuries, accounting for 261 848 (26.9%) of SEYLL. Based on the total population in these provinces of 16 740 637 (42.9% were females and 66.8% from urban areas), the death rate of injuries was estimated as 58.0 per 100 000. This figure was sig- nificantly higher for males than females (84.2 versus 31.0 per 100 000). The leading causes of deaths from injuries in descending order were: transport accidents (30.0 per 100 000), suicide (6.2 per 100 000) and vio- lence and homicide (3.9 per 100 000). Table 1 shows more details on distribution of fatal intentional and unintentional injuries occur- ring during the year of study by age group, sex and place of residence. Unintentional fatal injuries Overall, 8040 deaths (48.0 per 100 000 population) caused by unintentional injuries occurred during the study year, at a mean age of 35.3 years. These were 12.0% of all deaths in the year and 82.6% of deaths from injury. The rate of unintentional fatal injury was higher among males than females (71.3 versus 23.0 per 100 000). However, this figure was nearly equal among residents of urban and rural areas (47.9 versus 48.2 per 100 000). The total years of lost life from unintentional fatal injuries was 210 754 years (21.6% of SEYLL for all deaths). Table 2 shows some epidemiological measures of deaths from unintentional in- juries. The top 3 common injuries for all age groups were transport accidents (30.0 per 100 000), burns and scalds (4.0 per 100 000) and falls (2.1 per 100 000). Except for burns and scalds, deaths from other types of unintentional injuries were more common among males than females. The lowest and highest mean age at death were for suffocation after ingestion (mean age 18.1 years) and for complications of medical and surgical care (58.2 years). In urban areas the top 3 causes of un- intentional fatal injuries were transport accidents (30.3 per 100 000), burns from heat and hot substances and fire and flames (4.0 per 100 000) and poisoning (1.7 per 100 000). For rural areas the rates was similar as the top 2 causes were transport accidents (29.5 per 100 000), burns from heat and hot substances, and flame and fires (3.9 per 100 000); however falls were the 3rd ranked cause (3.0 per 100 000). Intentional injuries The death rate of intentional injuries was 10.1 per 100 000 (2.5% of all deaths in the year), with a mean age of 30.1 years at the time of death. Of 1693 intentional fatal injuries, 61.0% were from suicides (6.2 Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 385 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم per 100 000) and the rest from homicide, war, violence, assault, etc. (other types of intentional injuries) (3.9 per 100 000). In- tentional fatal injuries were more common among males than females (12.9 versus 8.0 per 100 000), and in rural versus urban ar- eas (11.8 versus 9.0 per 100 000). The years of lost life resulted from fatal intentional injuries was 51 093 years (5.3% of SEYLL for all deaths). Table 3 shows some of the epidemiologi- cal measures of intentional fatal injuries by type of injury. The top 3 types of intentional fatal injuries were intentional self-harm by smoke, fire and flames (2.3 per 100 000), homicide (2.0 per 100 000) and intention self-harm by hanging (1.5 per 100 000). Except for intentional self-harm by smoke, fire and flames, deaths were more common among males than females for all types of intentional injury. Deaths from homicides, injuries by explosion of mines and suicides by self-burnings, poisons, and gunshots were more common among those living in rural areas. The lowest and highest mean age of deaths were from suicides by fall from heights (23.0 years), and suicide by drowning and submersion (40.2 years). Table 1 Frequency of deaths resulting from injuries by age group, sex and place of residence in 2000 (total deaths = 66 846; total population = 16 740 637) Type of injury/ Urban areas Rural areas Total age group Male Female Male Female Unintentional fatal injuries < 1 year 38 27 54 57 176 1–4 years 68 42 94 51 255 5–14 years 299 150 269 134 852 15–49 years 2 421 561 1 438 315 4 735 > 50 years 830 352 584 256 2 022 Total 3 656 1 132 2 439 813 8 040 Intentional fatal injuries < 1 year 0 0 0 0 0 1–4 years 1 0 1 0 2 5–14 years 10 9 8 6 33 15–49 years 527 255 404 275 1 461 > 50 years 78 28 65 26 197 Total 616 292 478 307 1 693 Total deaths < 1 year 38 27 54 57 176 1–4 years 69 42 95 51 257 5–14 years 309 159 277 140 885 15–49 years 2 922 802 1 829 583 6 196 > 50 years 908 380 649 282 2 219 Total 4 246 1 410 2 904 1 113 9 733 386 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Ta bl e 2 Se le ct ed e pi de m io lo gi ca l m ea su re s of d ea th s fro m u n in te nt io na l i nju rie s b y ty pe o f i nju ry (t ot al de ath s = 66 8 46 ; t ot al p op ul at io n = 16 7 40 6 37 ) Ty pe o f i nju ry % o f a ll To ta l R at e pe r 1 00 0 00 M ea n ag e Y ea rs o f To ta l de at hs ra te p er M al e Fe m al e R ur al Ur ba n o f d ea th lo st li fe de at hs 10 0 00 0 ar ea s ar ea s (ye ar s) Tr a n sp or t a cc id en ts 7. 51 30 .0 47 .1 12 .0 29 .5 30 .3 35 .7 13 1 28 8 5 01 9 Bu rn s fro m h ea t a nd h ot su bs ta nc es , a n d fir e a n d fla m es 0. 99 4. 0 3. 1 5. 0 3. 9 4. 0 30 .5 19 1 73 66 2 Fa lls 0. 53 2. 1 3. 2 1. 0 3. 0 1. 5 40 .3 8 04 8 35 1 Ac ci de nt al d ro w n in g an d su bm er sio n 0. 43 1. 7 2. 8 1. 0 2. 3 1. 3 21 .4 9 32 6 28 6 Ac ci de nt al p oi so ni ng s 0. 38 1. 5 2. 1 1. 0 1. 2 1. 7 33 .1 6 71 9 25 1 St ru ck b y th ro w n , pr oje cte d o r fa llin g o bje ct 0. 29 1. 2 1. 9 0. 0 1. 0 1. 3 37 .1 4 95 3 19 4 Co m pl ica tio ns o f m ed ica l a n d su rg ica l c a re 0. 23 0. 9 1. 0 1. 0 0. 9 1. 0 58 .2 2 21 3 15 6 Ex po su re to e le ct ric c ur re nt s, e tc . 0. 20 0. 8 1. 3 0. 0 1. 0 0. 7 29 .4 3 89 6 13 3 O th er a cc id en ta l t hr ea ts to br ea th in g 0. 18 0. 7 1. 0 0. 0 0. 7 0. 7 35 .1 3 14 8 11 9 Ac ci de nt al s uf fo ca tio n an d st ra n gu la tio n 0. 15 0. 6 0. 8 0. 0 0. 8 0. 4 18 .1 2 92 2 97 Co nt ac t w ith ve n o m o u s a n im al s a n d pl an ts 0. 07 0. 3 0. 3 0. 0 0. 5 0. 1 24 .6 1 30 1 44 Ex po su re to fo rc e s o f n at ur es 0. 05 0. 2 0. 3 0. 0 0. 3 0. 1 31 .2 87 1 31 Ac ci de nt al e xp os e to o th er a n d u n sp ec ifie d fa ct or s 1. 02 4. 0 6. 5 2. 0 3. 2 4. 9 42 .1 16 8 96 69 7 To ta l 12 .0 3 48 .0 71 .3 23 .0 48 .2 47 .9 35 .3 21 0 75 4 8 04 0 Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 387 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Ta bl e 3 So m e ep id em io lo gi ca l m ea su re s of d ea th s fro m in te nt io na l i nju rie s b y ty pe o f i nju ry (t ot al de ath s = 66 84 6; to ta l p op ul at io n = 16 7 40 6 37 ) Ty pe o f i nju ry % o f a ll To ta l R at e pe r 1 00 0 00 M ea n ag e Y ea rs o f To ta l de at hs ra te p er M al e Fe m al e R ur al Ur ba n o f d ea th lo st li fe de at hs 10 0 00 0 ar ea s ar ea s (ye ar s) Vi ol en ce a nd h om ici de H om ic id e/ in jur ie s in flic te d by a n o th er p er so n 0. 51 2. 0 3. 4 1. 0 2. 6 1. 7 32 .0 9 71 4 33 8 In jur ie s by ex pl os io n of m in es 0. 26 1. 0 1. 9 0. 0 1. 3 0. 8 27 .7 5 33 0 17 1 Le ga l in te rv e n tio n (ex e cu tio n) 0. 11 0. 5 0. 9 0. 0 0. 3 0. 6 33 .1 2 17 1 76 O pe ra tio ns o f w a r 0. 03 0. 1 0. 2 0. 0 0. 1 0. 1 28 .6 59 0 19 As sa ul t b y o th er s pe cif ie d m e a n s (as sa ult s, fig ht s) 0. 08 0. 3 0. 5 0. 0 0. 3 0. 4 34 .8 1 52 9 56 Su ici de b y: Sm ok e, fir e an d fla m es 0. 58 2. 3 0. 8 4. 0 2. 8 2. 0 26 .9 12 4 98 39 1 H an gi ng 0. 37 1. 5 2. 4 1. 0 1. 4 1. 5 32 .3 7 04 1 24 5 Se lf- po iso ni ng 0. 30 1. 2 1. 2 1. 0 1. 7 0. 9 29 .1 6 18 7 20 2 D ru gs , m e di ca m en ts a n d bi ol og ica l s ub st an ce s 0. 07 0. 3 0. 4 0. 0 0. 2 0. 3 30 .8 1 34 8 45 R ifle a nd s ho tg un 0. 06 0. 2 0. 4 0. 0 0. 4 0. 1 27 .9 1 28 5 41 D ro w n in g an d su bm er sio n 0. 01 0. 0 0. 01 0. 0 0. 01 0. 0 40 .2 12 3 5 Ju m pi ng fr om a h ig h pl ac e 0. 00 0. 0 0. 01 0. 0 0. 01 0. 0 23 .0 35 1 O th er s el f-h ar m b y u n sp ec ifie d m e a n s 0. 15 0. 6 0. 7 1. 0 0. 8 0. 5 27 .8 3 24 3 10 3 To ta l 2. 53 10 .0 12 .8 8. 0 11 .9 8. 9 30 .3 51 0 94 16 93 388 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Discussion This study showed that the Islamic Republic of Iran has one of the highest death rates of unintentional injuries relative to other countries. This study was the first to be conducted on fatal injuries in the country and recorded both intentional and uninten- tional injuries in a large population for rural and urban areas. However, this study does not present complete data about the place and time of deaths from injury or more details about the victims. Furthermore, be- cause cases from remote populations of the country may be unreported, the data may be incomplete. With an incidence of 30.0 per 100 000, deaths from traffic accidents in the Islamic Republic of Iran are the highest in the world (compared with 22.6 per 100 000 worldwide and 13.9 per 100 000 in the Eastern Medi- terranean Region) [7,8]. This is probably due to the mass production of automobiles within the past 2 decades, which has not been accompanied by improvements in other components of injury prevention such as environmental and behavioral modifica- tions. For intentional injuries, however, the death rate at 10.1 per 100 000 is substan- tially lower than in many countries in the Eastern Mediterranean Region [7,8]. In industrialized countries, intentional and unintentional injuries have become the 3rd most important cause of overall mortal- ity among all age groups [7]. This figure is similar in the Islamic Republic of Iran and there is evidence, moreover, that the inci- dence of injuries, particularly unintentional injuries, is growing. Overall, injuries in the Islamic Republic of Iran represent about 15% of all deaths, which is greater than the global estimate of 12% [7,8]. Road traffic injuries are the leading cause of death by injury and the 3rd leading cause of all deaths nationally. They take the lives of 1.2 million individuals around the world each year [9]. They are the leading cause of years of lost life in the Islamic Republic of Iran, with 7.5% of all deaths nationally for all age groups. This is greater than the global estimate of 2.9% and the average figure in the Eastern Mediterranean Region of 1.9% [1]. Road traffic fatal injuries are largely preventable. Policies such as lower- ing average vehicle speeds, environmental modifications on roads, road safety educa- tion aimed at drivers and children, use of restraints for car occupants, and operational and interventional programmes have been shown to afford protection and prevention of motor vehicle traffic injuries [10,11]. Fatal burns and scalds in this study were the 2nd leading cause of unintentional fatal injuries with an incidence of 4.0 per 100 000. They also resulted in about 2% of all years of life lost in the Islamic Republic of Iran. This figure is greater than the mean incidence of fatal burns in other countries in the Eastern Mediterranean Region (2.7 per 100 000) [12]. Burns from heat and hot substances and fire and flames are one of the leading causes of death in many communities and over 90% of burns occur in low and middle-income countries. Safe homes and product designs, surveillance systems, installation of smoke detectors in high-risk places and educational campaigns to increase awareness of the risks have been suggested as important strategies to reduce the risk of burn and scald injuries [10]. Globally, an estimated 283 000 people die due to falls each year [7,8]. Falls are the leading cause of non-fatal injuries in some countries [13]. The incidence of fatal unintentional falls is estimated at 5.6 per 100 000 worldwide and 2.1 per 100 000 in the Eastern Mediterranean Region. This study showed that falls from heights are the 3rd leading cause of unintentional injuries (similar to the average incidence in the Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 389 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم region with 2.1 per 100 000), after deaths from traffic and burn injuries. Suicide has been recognized as the 11th leading cause of all deaths in developed coun- tries [14]. The death rate for suicide attempts in the Islamic Republic of Iran is lower than many other countries [3,15,16]. However, the low age of suicide attempters results in 3.3% of all years of lost life in this country. Younger adults may experience more life crises and there is a need for careful assess- ment and evaluation of attempted suicides among them. The broad context of social, behavioural, regulation and environmental research and land use policies is rarely addressed in rela- tion to intentional and unintentional injuries in this community. Many health workers in the Islamic Republic of Iran have posi- tive attitudes about participating in injury prevention programmes [17]. Therefore, their incorporation into these activities needs systematic support. It is essential to develop good quality measures of injuries. The potential for further research in this field appears to be high. In conclusion, the epidemiology of injuries the Islamic Republic of Iran, particularly for traffic accident deaths, has a completely different pattern of death compared to past decades [18] and these are lessons for developing countries. Injury-re- lated policies must therefore be considered as key elements of health promotion and as a priority for the health-related organizations in this country. Participating in local multi- agency schemes and international support as well as national efforts may enhance the chances of prevention and control of injuries in the Islamic Republic of Iran. Acknowledgements The authors wish to thank the Deputy for Health of all the provinces for supporting this study and also all the participants in this survey. 1. Murray CJL, Lopez AD, eds. The Global Burden of Disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge, Massachusetts, Harvard University Press on behalf of the World Bank and WHO, 1996. 2. Arias E et al. Deaths: final data for 2001. National vital statistics reports, 2003, 52(3):1–115. 3. Zhao Z, Svanstrom L. Injury status and perspectives on developing community safety promotion in China. Health promo- tion international, 2003, 18(3):247–53. 4. Kletz TA. Learning from accidents, 3rd ed. Oxford, Butterworth–Heinemann, 2001:1–12. References 5. Soori H, Naghavi M. Deaths from uninten- tional injuries in rural areas of the Islamic Republic of Iran. Eastern Mediterranean health journal, 1999, 5(1):55–60. 6. International statistical classification of diseases and related health problems, 10th ed. Geneva, World Health Organiza- tion, 1992. 7. Injury: a leading cause of the global bur- den of disease. Geneva, World Health Organization, 1999. 8. World Health Organization. Factsheet: Injur ies and violence prevention . Available on http://www.who.int/vio- lence_in jury_prevent ion/v io lence/ world_report/factsheets/en/index.html (accessed 8 February 2006). 390 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 9. Road safety is no accident. WHO news- letter on road safety. Newsletter 1: World Health Day 2004. Geneva, World Health Organization, 2003 (http://www.who.int/ world-health-day/2004/en/newsletter_ nov03_en.pdf, accessed 30 January 2006). 10. Towner E et al. Health promotion in child- hood and young adolescence for the pre- vention of unintentional injuries. London, Health Education Authority, 1996:5. 11. Jacobs GD. The potential for road ac- cident reduction in developing countries. Transport reviews, 1982, 2(2):213–24. 12. The world health report 2002. Reducing risks, promoting healthy life. Geneva, World Health Organization, 2002. 13. Meller JL, Shermeta DW. Falls in urban children: a problem revisited. American journal of diseases of children, 1997, 141:1271–5. 14. Minino AM et al. Deaths: final data for 2000. National vital statistics reports, 2002, 50(15):1–119. 15. Weissman MM et al. Prevalence of sui- cide ideation and suicide attempts in nine countries. Psychological medicine, 1999, 29(1):9–17. 16. Facts and figures about suicide. Geneva, World Health Organization, 1999. 17. Soori H, Motlagh E. Iranian rural health workers (behvarz) and risk factors of childhood injury. Eastern Mediterranean health journal, 1999, 5(4):684–9. 18. Mehryar H, Malekpour M. Changing pattern of mortality in Iran: a review of available evidence. Tehran, Institute for Research in Planning and Development, 1994. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 391 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Attitudes towards euthanasia among final-year Khartoum University medical students A.M. Ahmed1 and M.M. Kheir 2 1Department of Medicine, Faculty of Medicine, University of Bahr Elghazal, Khartoum, Sudan (Correspondence to A.M. Ahmed: awad_sd@hotmail.com). 2Department of Medicine, Faculty of Medicine, University of Khartoum, Khartoum, Sudan. Received: 28/03/04; accepted: 11/11/04 ABSTRACT To investigate the attitudes of final-year medical students at Khartoum University towards euthanasia an anonymous questionnaire was answered by 141 students. Most were familiar with the concept of euthanasia. The majority, 108 (76.6%) opposed euthanasia and their reasons included re- ligious beliefs, belief that euthanasia was unethical and fear of misuse. The supporters of euthanasia (23.4%) stated reasons such as preventing the suffering of patients and respecting their autonomy and dignity. More students who described themselves as strongly religious were opponents of euthanasia (83/87, 95.4%) than those who were moderately religious (25/54, 46.3%). Attitudes à l’égard de l’euthanasie chez des étudiants en dernière année de médecine à l’Université de Khartoum RÉSUMÉ Afin d’examiner les attitudes des étudiants en dernière année de médecine à l’Université de Khartoum à l’égard de l’euthanasie, un questionnaire anonyme a été soumis à 141 étudiants. La plupart étaient familiarisés avec le concept de l’euthanasie. La majorité d’entre eux, soit 108 étudiants (76,6 %), étaient opposés à l’euthanasie et les raisons mentionnées comprenaient les croyances religieuses, la conviction que l’euthanasie est contraire à l’éthique et la crainte d’abus. Les partisans de l’euthanasie (23,4 %) ont invoqué des raisons telles que la prévention des souffrances des patients et le respect de leur autonomie et de leur dignité. Les étudiants qui se décrivaient comme étant très religieux étaient plus nombreux à s’opposer à l’euthanasie (83/87, 95,4 %) que ceux qui étaient modérément religieux (25/54, 46,3 %). 392 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction Euthanasia is the deliberate ending of life of a patient suffering from an incurable and painful disease. Historically, scientific and legal debate about the ethics of euthanasia dates back to at least ancient Greece and Rome [1,2]. In 1870, Williams proposed that anaesthetics could be used to intention- ally end the lives of patients with painful and incurable disease [2]. Williams’ pro- posal initiated extensive debates about the ethics of euthanasia in America and Britain [2]. The debate about euthanasia continues, and in some areas in the world euthanasia is not a punishable act if performed accord- ing to the voluntary request of a suffering patient [3]. Although, worldwide, the popular media and medical literature have been actively debating the topic of euthanasia, this is not the case in Sudan. The only study on views about of euthanasia in Sudan was done by the authors among 248 doctors of different ages and specialties; 85% of respondents strongly opposed euthanasia, while the rest stated that euthanasia should be performed under strict safeguards [1]. Despite the increasing importance of ethical reasoning and decision-making in clinical practice [4–8], teaching about end-of-life decisions such as palliative care and euthanasia is almost absent in Sudanese medical schools. Therefore, a common reaction to an ethi- cally controversial issue is to immediately label it as “unethical”. Even internationally, teaching of ethics suffers some deficiencies. There is a focus on teaching bioethical theories and concepts rather than using this knowledge in case-based teaching and in reducing the uncertainties at the bedside [5,6]. Proper teaching of palliative care is received favourably by students and may positively influence the students’ attitudes toward care of and communication skills with terminally ill patients [8]. It is important to know the views of medical students as these may affect their future behaviour towards patients and peers. The aim of this study was to investigate the attitudes of the final year medical students of a Sudanese university toward euthanasia, and to determine factors that influence these attitudes in order to initiate a regional and national debate on this highly controversial issue. Methods The study was done among the final-year students of the Faculty of Medicine, Uni- versity of Khartoum, Khartoum, Sudan. The number of enrolled students was 270, of roughly equal sex distribution. Among 26 medical schools in Sudan, the Khartoum school is the largest and oldest (established in 1924) and has a standard 6-year curricu- lum. Situated in the northern part of Sudan, Khartoum is in an area where the religion of Islam plays a dominant role in people’s life. With the help of a research assistant, a questionnaire was distributed to all students available on a given day in January 2002. The questionnaire was based on one used by the authors in a study of Sudanese doctors [1], modified to be suitable for students. It was piloted on 30 students to ensure its validity. The questionnaires were completed and returned in a sealed envelope into a box in a special office. The students completed them anonymously and were given assurances about confidentiality. The following data were collected: student characteristics (age, sex, religion); degree of religiosity (students graded themselves on adherence to Islamic fundamental teachings as either strong or moderate religiosity); number of terminally ill patients seen in the last 6 months; famili- arity with the term and concept of euthana- Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 393 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم sia; whether there was formal teaching on euthanasia in the university; whether they personally would perform euthanasia if it were legalized. The questionnaire asked the students whether they thought that euthanasia is ethically justified and should be legalized (agree/disagree) and they were asked to give the reason for their opinion. We defined euthanasia as the deliber- ate administration of an overdose of a medication to a terminally ill patient with unbearable suffering at his/her request with a primary intention to end his/her life [1]. The data were analysed and presented as simple frequencies and percentages. Results Of the 182 students, 152 returned question- naires. They were aged between 23–27 years: 86 were males (58.6%) and 66 were females (43.5%). All the respondents were Muslim: 87 of them (57.2%) described themselves as strongly religious, and the rest (65, 42.8%) as moderately religious. Most students (131, 86.1%) were familiar with euthanasia as a term and concept, and reported that this was because they had read about it in professional journals or (non-Sudanese) magazines. All the students corrected reported that there was no formal teaching about euthanasia in their course. The question about experience of termi- nally ill patients revealed that 52 students (34.2%) had seen more than 3 cases in the last 6 months, while the rest had seen less than 3 cases. Of the 152 respondents, only 141 an- swered the questions about their attitudes toward euthanasia. Of them, 108 (76.6%) were against euthanasia and believed that it should not be legalized. The reasons stated for this view included the student’s religious background, belief that euthanasia was unethical, fear that euthanasia could be misused for incapable patients and fear of distorting future research away from better care of the dying. On the other hand, 33 respondents (23.4%) supported the idea of euthanasia, stating that in certain situations it can be performed and it should be legalized. Their reasons stated for this position included the need to relieve patients’ suffering, respect for the patients’ wishes and autonomy and helping patients to die in dignity. The sup- porters of euthanasia suggested safeguards or restrictions that should be observed if euthanasia were legalized; for example that it should only be used in the presence of se- vere and unrelieved pain, after a psychiatric consultation, after the second opinion of an official committee of doctors and lawyers and after consent of the family, and that the decision should be based on the current situation and not the presumed future conse- quences. Of the supporters, only 18 (54.5%) would personally perform euthanasia if it were legalized. Table 1 shows students’ attitudes towards euthanasia in relation to sex, religiosity, familiarity with the concept of euthanasia and the number of terminally ill patients they had seen in the last 6 months. More students who rated themselves as strongly religious were against euthanasia (83/87, 95.4%) compared with students who were moderately religious (25/54, 46.3%). More women (17/61, 27.9%) than men (16/80, 20.0%) supported euthanasia. Stu- dents who had seen more terminally ill pa- tients in the last 6 months were more likely to support euthanasia (15/47, 31.9%) than those who had seen fewer (18/94, 19.1%) but the difference was not significant. All the students (33/33, 100%) who reported being unfamiliar with the concept of eu- thanasia were opponents, compared with 95/128 (74.2%) of those who were familiar with the concept. 394 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Of the 11 (7.2%) students who did not answer the questions on attitudes toward euthanasia, 6 were males and 5 females, 3 (27.2%) were familiar with euthanasia, all of them (100%) were moderately religious and 5 of them (45.4%) saw more than 3 ter- minally ill patients in the last 6 months. The rest (6 students) saw less than 3 terminally ill patients in the same period. The only previous study on euthanasia in Sudan investigated the attitudes of 382 doctors of variable ages and experiences toward euthanasia [1]. The response rate was 64.9% (248/382 doctors). Those who supported euthanasia were 38 doctors (15.3%), 21 men and 17 women. Euthanasia was opposed by 210 doctors (84.7%), 109 men and 101 women. Discussion The response rate in this study (141/182, 77.5%) indicated the willingness of our students to participate and their interest in the international debate on euthanasia. The response rate is higher than that of the Sudanese doctors in a similar study by the authors [1] and is higher than other international studies, where is ranged from 34%–66% [9–11]. The overall opposition to euthana- sia among medical students in our study (76.6%) is not unexpected. Radulovic and Mojsilovic found that 71% of law and 62% of psychology students supported euthanasia in contrast to 36% of medical students [12]. Other international studies among students Table 1 Characteristics of supporters and opponents of euthanasia among 141 medical students in Khartoum University Variable Total Support Oppose euthanasia euthanasia No. % No. % Familiar with term and concept of euthanasia Yes 128 33 25.8 95 74.2 No 13 0 0.0 13 100.0 Sex Male 80 16 20.0 64 80.0 Female 61 17 27.9 44 72.1 Religiosity Strong 87 4 4.6 83 95.4 Moderate 54 29 53.7 25 46.3 No. of terminally ill patients in the last 6 months ≥ 3 47 15 31.9 32 68.1 < 3 94 18 19.1 76 80.9 Totala 141 33 23.4 108 76.6 aOf 152 respondents, 11 did not give their views about euthanasia. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 395 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم showed rates of opposition to euthanasia ranging from 40%–72% [10,12]. This de- gree of opposition among medical students, however, is less than our study of Sudanese doctors (84.7%) [1]. This is consistent with other studies, which confirmed that doctors are more conservative than students in their views of euthanasia [6–15]. The studies also showed that the doctors place a higher value on disease-based information as a strong determinant of their decision on euthanasia while the students prefer quality of life [15]. But it is difficult to take this finding as an indicator of a possible positive change toward euthanasia among future profession- als. Sudanese society in general is conserva- tive and such changes may need several generations. Doctors may also change their views over their years of practice. A distinction should be made between agreement to legalize, and willingness to personally carry out euthanasia. Our find- ings showed that only half of the students who supported euthanasia were personally prepared to perform euthanasia if it were legalized. This is consistent with studies indicating that the majority of proponents of euthanasia are unwilling to terminate the life of a patient by themselves [6]. Many factors might influence the atti- tudes of medical students toward euthanasia, including sex, religious and other personal beliefs and previous contact with terminally ill patients. In fact, religion was the most important factor in our students’ attitudes towards euthanasia: more students who rated themselves as strongly religious were against euthanasia compared with students who were moderately religious. Muslims strictly believe that only God should termi- nate their lives and Islam even encourages believers to view pain and suffering as a potential blessing or even as a cancelling of sins. However, there have been Islamic opinions (fatwa) that grant patients with an unbearable terminal disease the right to refuse medical treatment [16]. The Ro- man Catholic and Lutheran churches also uphold the principle of “sanctity of life” and do not allow interventions to end the life of terminally ill patients [17]. A study of Christian students showed similar results to our Muslim students: 75% of students with a Christian belief opposed euthanasia compared with 40% of students without a definable faith [10]. The personal philosophy of students largely shapes their attitudes toward eu- thanasia. Some of the students expressing opposition to euthanasia expressed feelings of responsibility towards the terminally ill and mentioned their belief that that eutha- nasia legalization could be dangerous for vulnerable patients (e.g. the fragile elderly, the mentally retarded, children). Debates about euthanasia highlight fears of threat- ening the moral integrity of the medical professional, subverting the social role of a doctor as a healer and leading to interfer- ence of lawyers, judges and police in daily medical practice [18–20]. Also some of the opponents in our study mentioned that euthanasia can divert attention away from attempts to improve terminal care. On the other hand, the students who supported euthanasia argued that euthanasia respects patients’ desires and hence their autonomy and that it relieves suffering. Supporters of euthanasia believe that the concept of autonomy can be extended to the timing and manner of death [21,22]. They argue that their aim is to avoid patient suffer- ing [22–24]. In addition, they approximate euthanasia to withholding life-sustaining treatments, as the result in both conditions is the same: the patient’s death [25]. Other factors thought to influence attitudes toward euthanasia are sex and clinical experience with terminally ill patients. The role of sex in determining the 396 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم attitude toward euthanasia has attracted the attention of some researchers. Some studies indicated that the female sex is significantly associated with a positive attitude toward euthanasia [26]. Some studies indicate the reverse [27]. However, the majority of the studies indicated no significant gender dif- ference [10,11]. The acceptance of euthanasia was found to be directly proportional to the clinical experience, especially with terminally ill patients [15]. Thus, medical students in Sudan are more willing than doctors to ac- cept euthanasia [1]. In a study in Hungary, social science students with no professional experience with terminally ill patients, had a more permissive attitude towards euthana- sia than medical students [27]. Oncologists in Mexico were also shown to be much less accepting of euthanasia than other special- ties [28]. Our study is not without limitations. About one-third of the final year students in this unversity are allocated to clinical activities at different areas in the city so only two-thirds of students were available at the faculty campus on the day of the questionnaire. Although the response rate is comparable to similar studies, it could have been higher. Junior medical students were not included. We suggest that future studies in Sudan involve not only junior medical students but also students from relevant fields such as psychology, nursing and law. Conclusions The students in this survey reported that they received no formal teaching about euthanasia. Profound changes are urgently needed in the curriculum of our medical schools to thoroughly cover the issues of end-of-life care. There is a need to establish teaching and training on medical ethics in Sudanese medical schools. We also suggest that a survey of the attitudes of the general Sudanese popula- tion towards euthanasia would be useful to generate a debate on euthanasia among the medical and lay community. 1. Ahmed AM et al. Attitudes toward eutha- nasia and assisted suicide among Su- danese doctors. Eastern Mediterranean health journal, 2001, 7:551–5. 2. Emanuel EJ. Euthanasia: historical, ethi- cal and empiric perspectives. Archives of internal medicine, 1994, 154:1890–901. 3. Oduncu FS. Euthanasia: killing as due care? Wiener medizinische Wochen- schrift, 2003, 153:387–91. 4. Stevens C, Firth ST. Response to moral dilemmas in medical students. Canadian Psychiatric Association journal, 1977, 22(8):441–5. 5. Myser C, Kerridge IH, Mitchell KR. Teach- ing clinical ethics as a professional skill: bridging the gap between knowledge References about ethics and its use in clinical prac- tice. Journal of medical ethics, 1995, 21(2):97–103. 6. Caralis PV, Hammond JS. Attitudes of medical students, housestaff, and faculty physicians toward euthanasia and termi- nation of life-sustaining treatment. Critical care medicine, 1992, 20(5):683–90. 7. Burge F et al. Family medicine residents’ knowledge and attitudes about end-of-life care. Journal of palliative care, 2000, 16(3):5–12. 8. Billings JA, Block S. Palliative care in undergraduate medical education. Status report and future directions. Journal of the American Medical Association, 1997, 278(9):733–8. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 397 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 9. Mangus R, Dipiero A, Hawkins CE. Medi- cal student’s attitudes toward physician- assisted suicide. Journal of the American Medical Association, 1999, 282:2080–1. 10. Schioldborg P. Studenters holdninger til aktiv dodshjelp, assistert suicid og fores- latt lovendring. [Students’ attitudes to- ward active euthanasia and proposed amendments to the penal code.] Tidsskrift for den Norske laegeforening, 2000, 120(19):2283–8. 11. Schioldborg P. Studenters holdninger til aktiv dodshjelp. [Student’s attitudes to ac- tive euthanasia.] Tidsskrift for den Norske laegeforening, 1999, 119(17):2515–9. 12. Radulovic S, Mojsilovic S. Attitudes of oncologists, family doctors, medical stu- dents and lawyers to euthanasia. Sup- portive care in cancer, 1998, 6(4):410–5. 13. Wanzer SH et al. The physician’s re- sponsibility toward hopelessly ill patients. A second look. New England journal of medicine, 1989, 320(13):844–9. 14. Howells K, Field D. Fear of death and dying among medical students. Social sci- ence and medicine, 1982, 16(15):1421– 4. 15. Ramirez RJ, Rodriguez R, Otero Y. Atti- tudes toward euthanasia, assisted suicide and termination of life-sustaining treat- ment of Puerto Rican medical students, medical residents, and faculty. Boletin de la Asociacion Medica de Puerto Rico, 2000, 92(1):18–21. 16. Albar MA. Rules of therapy and euthana- sia, 1st ed. Jeddah, Saudi Arabia, Elma- nar Publishing House, 1995:31–51. 17. Gula RM. Euthanasia: a Catholic perspec- tive. Health progress, 1987, 68:28–34. 18. Pohlmeier H. Suicide and euthanasia— special types of partner relationships. Suicide & life-threatening behavior, 1985, 15(2):117–23. 19. Oddie G. The moral case for legislation of voluntary euthanasia. Victoria Univer- sity of Wellington law review/Law Faculty, 1998, 28:207–24. 20. Singer PA, Siegler M. Euthanasia: a cri- tique. New England journal of medicine, 1990, 322(26):1881–3. 21. Shapiro RS et al. Willingness to perform euthanasia. A survey of physician at- titudes. Archives of internal medicine, 1994, 154:575–84. 22. Brock DW. Voluntary active euthanasia. The Hastings Center report, 1992 22: 10–22. 23. Angell M. Euthanasia. New England jour- nal of medicine, 1988, 319:1348–88. 24. Girsh FG. Physician aid in dying. What physicians say, what patients say. The Western journal of medicine, 1992, 157: 188–9. 25. The final anatomy. Lancet, 1992, 340: 757–8. 26. Muller MT et al. Voluntary active eutha- nasia and doctor assisted suicide: knowl- edge and attitudes of Dutch medical students. Medical education, 1996, 30(6): 428–33. 27. Fekete S, Osvath P, Jegesy A. Attitudes of Hungarian students and nurses to phy- sician assisted suicide. Journal of medical ethics, 2002, 28:126. 28. Hernandez-Arriaga JL, Morales-Estrada A, Cortes Gallo G. Encuesta de actitudes medicas ante el paciente terminal. [Sur- vey of physicians’ attitudes to terminal patients.] Revista de investigacion clinica, 1997, 49(6):497–500. 398 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Application d’un programme d’enseignement de la médecine en milieu communautaire RÉSUMÉ Un programme d’enseignement de la médecine en milieu communautaire à l’Université de Damas a été appliqué dans une collectivité du 2 au 12 juillet 2004 pour en évaluer les avantages et les inconvénients. Trois familles et 10 étudiants en médecine y ont participé. Le programme comprenait les objectifs d’enseignement, l’éducation sanitaire et des approches pour l’application et l’évaluation. Ce programme avait été adapté à l’environnement communautaire, mais il a nécessité une période plus longue pour sa mise en place et pour l’établissement de contacts entre les étudiants et la communauté. Les étudiants approuvaient la structure de ce programme ainsi que le rôle du tuteur et de la communauté, mais s’inquiétaient des difficultés concernant la mise en œuvre du programme. Les membres de la communauté ont accueilli le programme avec enthousiasme. Applying a teaching programme in community-based medical education ABSTRACT A community-based medical education programme at Damascus University was applied in a local setting from 2 to 12 July 2004 to assess the advantages and disadvantages. Three families and 10 medical students participated. The programme included teaching objectives, health education and approaches to application and evaluation. The design of the programme was appropriate for the community setting, but it needed a longer period to run and for contact between the students and the community. The students agreed with the structure of the programme and the role of the tutor and community, but were concerned about difficulties in implementation. Community members were enthusiastic about the programme. (1) W. Al-Faisal. Department of Family and Community Medicine, Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic. Received:02/02/05; accepted: 24/08/05 Ejk,lme  'kekfnA %'% )+.JA,  KQ>b5P3:>5913 3 B%4½W?ZG53h‚w@p3N?@J3¡¢5P3N>GL3M3UµqXWOP3ŒA?ªRªZ»P3¶¢5P3}>G?ZG53·@JjW\3‚>d¢X3 l3NeP8:5P3¸gr3©´ µ¤ª:ªr 4G>de3|á?X3:‘3¿5P3‚‰P6?5P3fŒW’934\6>H93¸J;PU@3FGH3mg>bTX93}>RQX3Å3:‘9UµqªX©WR5P3ŒA?ªRªZ»P3¶¢5P3}>G?ZG53·@JjW\3 3€\3N?‘P65P3‡áb5P3M29312™6ë3k36>56;2004‚G?Z;3œ6ZÃ93N>R>G?Z5P3½P:r…P3·@JjŽ5P3<RƒX93hW›­P34—93N;W‘3M3 };6YZ5P93‚>d¢Z5P3NY;W‹93ABQ5P3ˆ>Y¥Z5J\3m3Àx¬3‚>d¢Z5P3M3¦8J•93hŸÙ3NS¤JÃ3M3·@JjŽ5P3‚>d¢X3Å3:‘9<@3Wªe~s ¡¢5P3N>GL3M3N`@J^P3N>eP8:5P3}“ZTe3P6“js3Éx‹3‡WwH93_RZ»P3mA?RZ»P3_E6G53oJdeJT@3·@JjŽ5P3}>RQX3iJL9 _RZ»P93¡¢5P3€\3äJRZ5P93‚>d¢Z5P3<@3a6‹s3‡áb53éJZ°34Tq593mÉx¢5P3ìžR’3iJL93íJ›T\3·@JjŽ5P3‚>d¢X3Å3:‘9 3hoJBEP93·@PŽ5P3<@3D6T5P3Pgr3K¥OoJƒ;s3NBEP93Éx¢5P3p6—93M3_RZ»P3Ndu83v:\3JRL3m·@PW\3is3Ý7Jd5P3œW;9 3N=>?ªRªZ»P3¶¢5P3}>G?Z5PUµqªX©WR5PKdYZ`OP3M3NeP8:5P93W;6¢Z5P3<@3:;URG53éJZ’m 993 6002 ,4/3 soN ,21 .loV ,lanruoJ htlaeH naenarretideM nretsaE لمجلة لصحية لشر لمتوسط، منظمة لصحة لعالمية، لمجلد لثا( عشر، لعد$
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$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم عجرلمReferences 1. ينيحصل ينلماعل ميلعت ،ةيلماعل ةحصل ةمظنم ةيس$ ةعوم ريرقت ،عمتجلم ىلع زِكَتْرُمـل مق ةينقتل رياقتل ةلسلس ،ةيلماعل ةحصل ةمظنبم 1989 ،746. 2. University of Western Ontario, Undergrad- uate Medical Education, Curriculum Phi- losophy, Course Descriptions. Available at: http://www.schulich.uwo.ca/Schulich/ UME/General/overview.shtml#Course_ Descriptions (accessed 29 September 2005). 3. Chinese University of Hong King, Faculty of Medicine, Department of Community and Family Medicine, Undergraduate Stud- ies. Avaiable at: http://www.cuhk.edu.hk/ med/cmd/undergraduate.html (accessed 29 September 2005). 4. University of Manchester, Undergradu- ate Medicine, Course Materials, Lecture Notes & Resources, Handbooks & Guides, Student Learning Planner and Work- book Session 2005–2006. Available at: http://ug.medicine.man.ac.uk/ug_current/ doc/y5slpwbk0506.pdf (accessed 29 Sep- tember 2005). 5. University of North Dakota School of Med- icine & Health Sciences, Office of Medical Education. Avaliable at: http://ome.med. und.nodak.edu/Curric/ (accessed 29 Sep- tember 2005). 6. University of Kentucky, Community-based Faculty Program. Available at http://www. mc.uky.edu/cbfi/ (accessed 29 September 2005). 7. Flinders University, Faculty of Health Sci- ences, Flinders University Rural Clinical School. Available at: http://som.flinders. edu.au/FUSA/GP-Evidence/rural/educa- tion/med_stud/y3/med_stud_y3_PRCC. htm (accessed 29 September 2005). 8. فقوم ،وشب ايه .$ ،اش$ بي$ د .$ رفل ةفلتخلم ×اصاصتخلا $اتج بطل &لاط دلجلم ،قشم$ ةعماج ةل :ï ،ةيلبقتسلم ةينهلم 1997 ،(اثل $دعل ،رشع ثلاثل. 9. Henderson TM. State efforts to increase community-based medical education. Wa- shington DC, George Washington Univer- sity, 1994. 10. Lennox A, Petersen S. Development and evaluation of a community-based, mul- tiagency course for medical students: de- scriptive survey. British medical journal, 1998, 316(7131):596–9. 11. Worley P, Esterman A, Prideaux D. Cohort study of examination performance of un- dergraduate medical students learning in community settings. British medical jour- nal, 2004, 28(7433):207–9. 12. Boaden N, Bligh J. Community-based medical education, towards a shared agenda for learning. Oxford, Oxford Uni- versity Press, 1999. 13. Magzoub MEMA, Schmidt HG. A taxono- my of community-based medical educa- tion. Academic medicine, 2000, 75:699– 707. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 405 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Tabagisme chez les mères libanaises : connaissances, attitudes et pratiques B. Barbour1, P. Salameh1 et F. Ziadeh1 1Faculté de Santé publique, Faculté de Pharmacie, Université Libanaise, Beyrouth (Liban). (Correspondance à adresser à P. Salameh : pascalesalameh@yahoo.com). Reçu : 19/05/04 ; accepté : 05/04/05 Smoking among Lebanese mothers: knowledge, attitudes and practices ABSTRACT Smoking among women is increasing, especially in women of reproductive age. In a cross-sectional study of 1000 Lebanese mothers, we evaluated their knowledge, attitude and practice regarding cigarette smoking. We found that the amount of tobacco smoked by Lebanese mothers was related to age, educational level, profession and knowledge regarding smoking. A woman was more likely to stop or decrease smoking during pregnancy if she were more knowledgeable about the effects of smoking on the baby, if she smoked less, and if she had a higher degree of education. Knowledge about the effects of smoking on the smoker did not seem to affect this practice. RÉSUMÉ Le tabagisme progresse chez les femmes, surtout chez les femmes en âge de procréer. Dans une étude transversale de 1000 mères libanaises, nous avons évalué leurs connaissances, attitudes et pratiques concernant le tabagisme à la cigarette. Nous avons trouvé que la quantité de tabac fumée par les mères libanaises était liée à l’âge, au niveau d’instruction, à la profession et aux informations concernant le tabagisme. Une femme est plus susceptible d’arrêter ou de diminuer le tabagisme durant la grossesse si elle a plus de connaissances concernant les effets du tabagisme sur la grossesse et l’enfant, si elle fume moins et si elle est plus instruite. La connaissance des effets du tabagisme sur le fumeur lui-même n’influe pas ce type de pratique. 406 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction Quatre millions de décès par an dans le monde sont dus au tabac [1]. Actuellement, les preuves scientifiques des effets du tabac sont établies pour de nombreuses patholo- gies, que ce soit le tabagisme actif ou passif [2]. Il y a quelques décennies, les hommes fumaient plus que les femmes [3]. Actuel- lement, malgré une tendance globale à la baisse de la consommation de tabac dans les pays développés [4], il y a une féminisation de plus en plus nette de la population des fumeurs [5]. L’accroissement du tabagisme dans certaines catégories de la population, surtout les femmes et les jeunes, aura bien- tôt des conséquences dramatiques [6,7]. Nous sommes aussi témoins d’une sorte de transition du tabagisme des classes sociales les plus hautes aux plus basses [8,9], aux moins instruites [10] et aux sans travail [11]. Plusieurs facteurs jouent un rôle dans le déclenchement et l’entretien du tabagisme chez la jeune fille et la femme. Ce sont l’âge, le statut professionnel, l’environ- nement proche, l’image de soi, l’accepta- bilité sociale, le marketing du tabac et le cycle menstruel [8]. Les femmes de niveau socio-économique bas ont 4 fois plus de probabilité de fumer durant leur grossesse que les autres [12]. Une fumeuse enceinte court cependant plus de risques qu’une non-fumeuse, outre les risques encourus par le foetus [7]. On remarque d’ailleurs que les con- naissances concernant le tabagisme sont un facteur qui influe les pratiques du ta- bagisme dans plusieurs pays du monde [8]. Au Canada et aux États-Unis, les fu- meurs ont moins de connaissances que les non-fumeurs concernant les effets néfastes du tabagisme [10,3-5]. Dans les sociétés moins développées telles que l’Afrique du Sud et les régions rurales hispaniques de Californie, on retrouve la même tendance [8,16,17] ; les connaissances des jeunes filles concernant les effets du tabac sur la santé sont minimes, à cause du manque de programmes d’éducation systématique [8]. Effectivement, les femmes de niveau socio-économique bas fument plus et ont moins de connaissances concernant le ta- bagisme et sont incapables de se rappeler des avertissements inscrits sur le paquet de cigarettes [4,6,8]. En plus du tabagisme actif, les fumeurs ont tendance à considérer le tabagisme passif comme moins dangereux que les non-fumeurs, et le seul facteur qui puisse influencer l’arrêt du tabac est la croyance de nuire aux autres [19], et rarement la peur pour leur propre santé [4]. La ciga- rette constitue donc un problème sanitaire dont la gravité réside dans son potentiel de mortalité élevé et la non-appréciation de son danger dans quelques sociétés, surtout le tabagisme passif. Une étude menée aux États-Unis en 1990 montre que ce dernier y est peu considéré [20]. Dans la société libanaise, la cigarette est socialement très acceptée, procurant un intérêt à différents secteurs tels que l’État et les industries du tabac. Elle est de plus présentée au sein des foyers comme signe d’hospitalité et partagée entre amis comme support de convivialité. La société libanaise semble donc courir le même risque de non- prise en considération du tabagisme passif, y compris chez la femme enceinte. Au Liban, une étude a été menée dans le but de connaître le profil démographi- que et psychosocial des femmes enceintes qui fument ; il s’agit d’une étude transver- sale sur 576 femmes, qui a démontré une prévalence du tabagisme à la cigarette de 32 % avant et 20 % durant la grossesse [21]. De plus, d’autres études ont montré que le tabagisme à la cigarette a une prévalence de Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 407 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 18,9 % parmi les adolescents libanais [22], et un changement d’attitude est noté après éducation concernant les méfaits du tabac [23]. L’éducation pour la santé des femmes étant un moyen qui changerait éventuelle- ment les attitudes et pratiques, l’objectif de notre étude est d’évaluer les connaissances, attitudes et pratiques concernant le taba- gisme à la cigarette des mères fumeuses au Liban. Méthodes L’outil utilisé est un questionnaire standar- disé, comprenant 29 questions divisées en plusieurs rubriques : identification des mè- res tabagiques, tabac et santé, tabac et gros- sesse, tabac et nourrisson, tabac et sevrage. Le tabagisme actuel a été évalué par le nombre de paquets de cigarettes fumés par jour, alors que la dose cumulée de tabac a été évaluée par le nombre de paquets fumés par jour multiplié par le nombre d’années de tabagisme. Le tabagisme cu- mulé a ensuite été divisé en classes : le tabagisme léger (< 6 paquets-années), le tabagisme moyen (6-11 paquets-années), le tabagisme lourd (12-23 paquets-années) et le tabagisme très lourd (24 paquets-années et plus). L’âge a été défini en trois classes : 16-29 ans, 30-39 ans et 40-49 ans. La va- riable nombre d’enfants a aussi été divisée en trois groupes : 1-2, 3-4 et > 4 enfants. Les niveaux d’instruction ont été regroupés en 3 groupes : l’analphabétisme et niveau pri- maire en 1er niveau, études complémentaires et secondaires en 2e niveau, et universitaires et techniques en 3e niveau. Les connaissances concernant le taba- gisme ont été codées à 1 point pour chaque réponse correcte (maximum = 26). Les con- naissances concernant les effets du tabagis- me sur la santé ont été groupées : les effets sur le fumeur lui-même (maximum = 9), les effets durant la grossesse (maximum = 10) et ceux concernant le nourrisson (taba- gisme passif) (maximum = 5). Deux ques- tions séparées ont été posées concernant le passage des constituants du tabac dans le lait maternel durant l’allaitement (1 point) et la possibilité d’inhalation de la fumée de tabac par le nourrisson (1 point). La source des informations citées a aussi été évaluée. Un échantillon de 1000 mères fumeuses a été choisi sur tout le territoire libanais. La base d’échantillonnage est constituée de celle de l’Administration centrale de la Statistique établie en 1998 [24], dont nous avons tiré le nombre de femmes né- cessaires, proportionnellement au nombre d’habitants qu’héberge chacune des ré- gions libanaises. Ainsi, on avait besoin de 100 enquêtées à Beyrouth, 225 dans la banlieue de Beyrouth, 151 au Mont Liban, 201 au Liban-Nord, 136 à la Bekaa, 118 au Liban-Sud et 69 à Nabatieh. Dans chaque région, les femmes ont été incluses dans l’étude si elles étaient mariées, mères et fumeuses de cigarettes et si elles ne souffraient d’aucune maladie chronique connue. Toutes autres conditions, telles que le tabagisme au narguilé, les maladies chroniques et le célibat, sont des critères d’exclusion de l’étude. L’enquête a été exécutée en mars-juin 2002. Les femmes ont été abordées dans les cliniques privées de gynécologie et obstétrique : les femmes étaient enceintes ou consultaient pour frottis vaginal. Des enquêteurs formés ont soumis le ques- tionnaire aux femmes attendant leur tour dans les cliniques, en langue arabe locale. Après consentement éclairé des femmes, l’administration du questionnaire a duré 15 minutes, et les enquêteurs n’ont pas donné de renseignements complémentaires concernant les questions posées pour ne pas influencer les réponses des femmes. 408 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Analyse statistique La saisie et l’analyse statistique des résultats de l’enquête ont été faites sur SPSS, version 11.5. Un risque d’erreur de première espèce alpha = 5 % et de deuxième espèce beta = 20 % a été accepté. Les tests statistiques bilatéraux utilisés sont les suivants : test du khi2 pour les distributions des variables qua- litatives dichotomiques ou multinomiales, tests de Mann Whitney pour la comparaison des moyennes des variables quantitatives continues à variances non homogènes ou distribution non normale et l’ANOVA pour celles quantitatives à distribution normale. Concernant l’analyse multifactorielle, une régression multiple a été réalisée, le nombre de cigarettes fumées par jour étant pris comme variable dépendante. Les va- riables indépendantes sont : le total des connaissances et les informations concer- nant les effets sur le fumeur, les effets sur la grossesse, les effets sur le nourrisson, le passage dans le lait et l’inhalation du bébé. De plus, des régressions logistiques ont été réalisées, avec l’arrêt et la diminution du tabagisme durant la grossesse comme variables dépendantes. Les variables indé- pendantes sont : le nombre de cigarettes fumées par jour, le total des connaissances, les effets sur le fumeur, les effets sur la grossesse, les effets sur le nourrisson, le passage dans le lait et l’inhalation du bébé. Les variables d’ajustement pour les mo- dèles de régression multiple et de régression logistique sont : l’âge, le lieu de résidence, l’état civil, le nombre d’enfants, le niveau d’instuction, le travail, le revenu mensuel, la prise de la pilule et le tabagisme du mari. Résultats Description du tabagisme dans la population de l’étude Le tabagisme des femmes incluses dans la population est décrit au Tableau 1. Une moyenne d’un paquet par jour, pour une durée moyenne de 15 ans, donnant une ex- position cumulée moyenne de 15 paquets- années, est remarquée. Caractéristiques socio- démographiques Ces caractéristiques sont présentées pour la population de l’étude et par catégorie de tabagisme cumulé. De plus, la moyenne et l’écart type du tabagisme actuel en paquet/ jour sont présentés. Une différence signi- ficative du tabagisme variant avec l’âge, le niveau d’instruction et la profession est remarquée. Les femmes plus âgées, moins instruites, ouvrières ou de profession libé- rale fument plus que les autres (Tableau 2). Tableau 1 Description du tabagisme des mères libanaises Tabagisme Nbre % Moyenne (E.T.) Durée en années < 5 147 14,7 15,44 (8,56) 5-10 228 22,8 11-15 164 16,4 16-20 243 24,3 > 20 218 21,8 Nombre de paquets/jour < 0,5 336 33,6 1,00 (0,61) > 0,5-1,0 440 44,0 > 1,0-1,5 95 9,5 > 1,5-2,0 105 10,5 > 2,0 24 2,4 Nombre de paquets- années cumulés < 6 313 31, 3 15,65 (16,2) 6-11 205 20,5 12-23 265 26,5 24 et plus 217 21,7 Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 409 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Tableau 2 Caractéristiques socio-démographiques des mères libanaises et niveau de tabagisme Caractéristique Total Tabagisme Tabagisme Tabagisme Tabagisme pa Moyenne léger moyen lourd très lourd (E.T) (n = 313) (n = 205) (n = 265) (n = 217) tabagisme Nbre (%) Nbre (%) Nbre (%) Nbre (%) Nbre (%) actuel en paquet/jour Âge (ans) < 0,0001 16-29 178 (17,8) 111 (62,4) 31 (17,4) 25 (14,0) 11 (6,2) 0,87 (0,61) 30-39 455 (45,5) 144 (31,6) 118 (25,9) 127 (27,9) 66 (14,5) 0,94 (0,58) 40-49 367 (36,7) 58 (15,8) 56 (15,3) 113 (30,8) 140 (38,1) 1,05 (0,64) Résidence 0,24 Urbaine 596 (59,6) 183 (30,7) 123 (20,6) 147 (24,7) 143 (24,0) 1,00 (0,64) Rurale 404 (40,4) 130 (32,2) 82 (20,3) 118 (29,2) 74 (18,3) 0,92 (0,56) État civil 0,56 Mariée 902 (90,2) 291 (32,3) 196 (21,7) 229 (25,4) 186 (20,6) 0,95 (0,61) Divorcée 37 (3,7) 8 (21,6) 2 (5,4) 18 (48,6) 9 (24,3) 1,25 (0,59) Veuve 61 (6,1) 14 (23,0) 7 (11,5) 18 (29,5) 22 (36,0) 1,00 (0,53) Enfants 0,06 1-2 365 (36,5) 167 (45,8) 70 (19,2) 76 (20,8) 52 (14,2) 0,87 (0,54) 3-4 442 (44,2) 108 (24,4) 101 (22,9) 126 (28,5) 107 (24,2) 1,02 (0,64) > 4 193 (19,3) 38 (19,7) 34 (17,6) 63 (32,6) 58 (30,1) 1,04 (0,62) Instruction < 0,0001 Niveau 1 283 (28,3) 54 (19,1) 45 (15,9) 86 (30,4) 98 (34,6) 1,12 (0,65) Niveau 2 665 (66,5) 238 (35,8) 149 (22,4) 167 (25,1) 111 (16,7) 0,91 (0,59) Niveau 3 52 (5,2) 21 (40,4) 11 (21,2) 12 (23,1) 8 (15,4) 0,84 (0,48) Profession <0,0001 Foyer 641(64,1) 197 (30,7) 127 (19,8) 185 (28,9) 132 (20,6) 0,97 (0,61) Médicale 76 (7,6) 30 (39,5) 17 (22,4) 17 (22,4) 12 (15,8) 0,79 (0,56) Libérale 26 (2,6) 9 (34,6) 2 (7,7) 2 (7,7) 13 (50,0) 1,39 (0,70) Éducation 100 (10,0) 22 (22,0) 23 (23,0) 22 (22,0) 23 (23,0) 1,06 (0,62) Bureau 66 (6,6) 24 (36,4) 23 (34,8) 12 (18,2) 7 (10,6) 0,70 (0,64) Ouvrière 91 (9,1) 19 (20,9) 20 (22,0) 24 (26,4) 28 (30,8) 1,18 (0,65) Revenu 0,06 <500 MLb 264 (26,4) 70 (26,5) 51 (19,3) 83 (31,4) 60 (22,7) 1,01 (0,63) 500-1000 305 (30,5) 89 (29,2) 67 (22,0) 79 (25,9) 70 (23,0) 0,98 (0,62) > 1000 431 (43,1) 154 (35,7) 87 (20,2) 103 (23,9) 87 (20,2) 0,93 (0,59) Pilule 0,25 Oui 186 (18,6) 61 (32,8) 50 (26,9) 47 (25,3) 28 (15,1) 0,92 (0,56) Non 814 (81,4) 252 (31,0) 155 (19,0) 218 (26,8) 189 (23,2) 0,99 (0,63) Mari fumeur 0,69 Oui 640 (64,0) 200 (31,3) 135 (21,1) 170 (26,6) 135 (21,1) 0,98 (0,61) Non 360 (36,0) 113 (31,4) 70 (19,4) 95 (26,4) 82 (22,8) 0,94 (0,61) a Résultats de l’ANOVA. bML = mille livres libanaises. 410 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Tableau 3 Pratiques liées au tabac par les mères libanaises et niveau de tabagisme Variable Total Tabagisme Tabagisme Tabagisme Tabagisme pa Moyenne léger moyen lourd très lourd (E.T.) (n = 313) (n = 205) (n = 265) (n = 217) paquet/ Nbre (%) Nbre (%) Nbre (%) Nbre (%) Nbre (%) jour Causes du tabagisme Sentiment de maturité 45 (4,5) 10 (3,2) 12 (5,9) 12 (4,5) 11 (5,1) 0,34 1,04 (0,51) Influence de l’entourage 470 (47,0) 127 (40,6) 98 (47,8) 133 (50,2) 112 (51,6) 0,20 1,00 (0,63) Confort psychique 220 (22,0) 71 (22,7) 40 (2,0) 59 (22,3) 50 (23,0) 0,25 1,05 (0,60) Passe-temps 261 (26,1) 109 (34,8) 52 (25,4) 58 (21,9) 42 (19,4) 0,38 0,86 (0,54) Plaisir 242 (24,2) 81 (25,9) 51 (24,9) 64 (24,2) 46 (21,2) 0,66 0,94 (0,59) Arrête de fumer si grossesse < 0,0001 Oui 459 (45,9) 183 (58,5) 110 (53,7) 108 (40,8) 58 (26,7) 0,79 (0,52) Non 641 (64,1) 130 (41,5) 95 (46,3) 157 (59,2) 159 (73,3) 1,12 (0,64) Diminue le tabac si grossesse 0,45 Oui 250 (25,0) 75 (24,0) 51 (24,9) 75 (28,3) 49 (22,6) 0,99 (0,52) Non 750 (75,0) 238 (76,0) 154 (75,1) 190 (71,7) 168 (77,4) 0,96 (0,64) Arrête si coût du tabac augmente 0,001 Oui 333 (33,3) 123 (39,3) 77 (37,6) 77 (29,1) 56 (2,8) 0,87 (0,56) Non 632 (63,2) 181 (57,8) 122 (59,5) 178 (61,2) 151 (69,6) 1,02 (0,64) Ne sait pas 35 (3,5) 9 (2,9) 6 (2,9) 10 (3,8) 10 (4,6) 0,89 (0,46) a Résultats de l’ANOVA, sauf pour les causes du tabagisme (test du khi2). Pratiques du tabagisme Les pratiques concernant le tabagisme sont décrites au Tableau 3. Il n’y a pas de dif- férence de pratiques de tabagisme selon la cause de tabagisme : le fait que l’on fume pour se sentir plus mûr, à cause de l’entou- rage, comme passe-temps, par plaisir ou pour se relaxer psychiquement n’entraîne pas de différence de pratiques du tabagisme. Le coût qui augmente semble diminuer le tabagisme de celles qui fument moins seu- lement. De plus, les femmes qui n’arrêtent pas de fumer durant la grossesse sont celles qui fument le plus. Connaissances concernant les effets du tabagisme sur la santé Les scores des connaissances sont pré- sentés au Tableau 4. On remarque que les femmes qui fument plus ont le moins de connaissances concernant le tabagisme, alors que celles qui fument moins ont plus de connaissances concernant les effets du tabagisme. Il s’agit d’une relation dose- effets. Il n’y a pas de différence de source d’information dans les différentes catégo- ries de fumeuses (Tableau 5). Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 411 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Attitudes concernant le tabagisme Il y a des différences d’attitudes envers le tabac dans les différentes catégories de fumeuses. Celles qui fument plus n’écou- teraient pas les conseils qu’on leur donne- rait, ne respecteraient pas les interdictions, changeraient de chaîne de télévision si elles y rencontrent un programme d’information concernant le tabagisme, et auraient besoin de thérapie pour arrêter de fumer (Tableau 6). Analyse multivariée Dans les modèles retenus, aucune varia- ble indépendante n’a donné de corrélation significative avec le nombre de cigarettes Tableau 4 Connaissances concernant les effets du tabac sur la santé par les mères libanaises et niveau de tabagisme Connaissance Population Tabagisme Tabagisme Tabagisme Tabagisme p totale léger moyen lourd très lourd (n = 1000) (n = 313) (n = 205) (n = 265) (n = 217) Moyenne Moyenne Moyenne Moyenne Moyenne (E.T.) (E.T.) (E.T.) (E.T.) (E.T.) Effets sur le fumeur 5,07 (3,42) 5,11 (3,35) 5,08 (3,39) 5,05 (3,43) 5,04 (3,57) 0,20 Effets sur la grossesse et le foetus 2,4 (3,15) 2,77 (3,39) 2,48 (2,93) 2,47 (3,29) 1,70 (2,72) 0,004 Effets sur le nourrisson 1,89 (1,47) 2,08 (1,51) 1,91 (1,34) 1,76 (1,48) 1,74 (1,51) 0,003 Passage dans le lait [Nbre (%)] 698 (69,8) 235 (75,1) 157 (76,6) 185 (69,8) 121 (55,8) < 0,0001 Inhalation par le nourrisson [Nbre (%)] 879 (87,9) 282 (90,1) 189 (92,2) 228 (86,0) 180 (82,9) 0,01 Score totala 10,94 (6,39) 11,61 (6,65) 11,16 (6,14) 10,85 (6,37) 9,87 (6,14) 0,004 aLe score total des connaissances (maximum = 26) est la somme des effets sur le fumeur lui-même (maximum = 9), les effets durant la grossesse (maximum = 10) et ceux concernant le nourrisson (tabagisme passif) (maximum = 5), en plus des questions concernant le passage des constituants du tabac dans le lait maternel durant l’allaitement (1 point) et la possibilité d’inhalation de la fumée de tabac par le nourrisson (1 point). Tableau 5 Source des connaissances des mères libanaises concernant le tabac et niveau de tabagisme Source Total Tabagisme Tabagisme Tabagisme Tabagisme p d’information léger moyen lourd très lourd (n = 313) (n = 205) (n = 265) (n = 217) Nbre (%) Nbre (%) Nbre (%) Nbre (%) Nbre (%) Médias 219 (21,9) 75 (24,0) 54 (26,3) 55 (20,8) 35 (16,1) 0,06 Parents/amis 210 (21,0) 62 (19,8) 48 (23,4) 61 (23,0) 39 (18,0) 0,42 Médecin 304 (30,4) 99 (31,6) 70 (34,1) 86 (32,5) 49 (22,6) 0,05 Sage-femme 37 (3,7) 15 (4,8) 11 (5,4) 7 (2,6) 4 (1,8) 0,13 Personnelle 320 (32,0) 108 (34,5) 62 (30,2) 73 (27,5) 77 (35,5) 0,19 412 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Tableau 6 Attitudes des mères libanaises concernant le tabac et niveau de tabagisme Variable Total Tabagisme Tabagisme Tabagisme Tabagisme pa Moyenne léger moyen lourd très lourd (E.T.) (n = 313) (n = 205) (n = 265) (n = 217) (paquet/ Nbre (%) Nbre (%) Nbre (%) Nbre (%) Nbre (%) jour) Écoute les conseils < 0,0001 Oui 616 (61,6) 220 (70,3) 128 (62,4) 160 (60,4) 108 (49,8) 0,90 (0,58) Non 317 (31,7) 72 (23,0) 58 (28,3) 92 (34,7) 95 (43,8) 1,11 (0,63) Ne sait pas 67 (6,7) 21 (6,7) 19 (9,3) 13 (4,9) 14 (6,5) 0,91 (0,66) Respecte interdictions < 0,0001 Oui 856 (85,6) 283 (90,4) 178 (86,8) 223 (84,2) 172 (79,3) 0,93 (0,61) Non 144 (14,4) 30 (9,6) 27 (13,2) 42 (15,8) 45 (20,7) 1,17 (0,55) Arrêt du tabac < 0,0001 Besoin de volonté 509 (50,9) 161 (51,4) 98 (47,8) 143 (54,0) 107 (49,3) 0,96 (0,61) Besoin de thérapie 88 (8,8) 24 (7,7) 14 (6,8) 23 (8,7) 7 (12,4) 1,17 (0,27) Autre 403 (40,3) 128 (40,9) 93 (45,4) 99 (37,3) 83 (38,3) 1,21 (0,65) Orientation antitabac 0,82 Efficace 867 (86,7) 267 (85,3) 181 (88,3) 225 (84,9) 194 (89,4) 0,97 (0,62) Inefficace 133 (13,3) 46 (14,7) 24 (11,7) 40 (15,1) 23 (10,6) 0,96 (0,55) Programme antitabac < 0,0001 En profite 674 (67,4) 227 (72,5) 145 (70,7) 177 (66,8) 122 (56,2) 0,91 (0,59) N’écoute pas 163 (16,3) 45 (14,4) 28 (13,7) 47 (17,7) 46 (21,2) 1,07 (0,59) Change de canal 163 (16,3) 41 (13,1) 32 (15,6) 41 (15,5) 49 (22,6) 1,09 (0,66) aRésultats de l’ANOVA. fumées par jour ; seuls l’âge et le niveau d’instruction y étaient corrélés (p = 0,03 et p < 0,0001 respectivement). Plus la femme est âgée et moins elle est instruite, plus elle fume. De plus, il y a une association entre le fait d’arrêter de fumer durant la grossesse et les connaissances totales (p < 0,0001), les connaissances concernant la grossesse (p < 0,0001) et le nourrisson (p < 0,0001), en plus du niveau d’instruction (p < 0,0001) et du nombre de cigarettes fumées par jour (p < 0,0001). Les mêmes résultats ont été trouvés pour la diminution du tabagisme durant la grossesse (p < 0,01). Ainsi, une femme arrête ou diminue le tabagisme du- rant la grossesse si elle a plus de connais- sances concernant les effets du tabagisme sur la grossesse et le nourrisson, si elle fume moins, et si elle est plus instruite. La con- naissance des effets sur le fumeur lui-même n’influe pas ce type de pratique. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 413 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Discussion Dans cette étude, la quantité cumulée de tabac fumée par les mères libanaises s’est avérée liée à l’âge, au niveau d’instruction, au type de profession et aux informations concernant le tabagisme. Une femme arrête ou diminue le tabagisme durant la grossesse si elle a plus de connaissances concernant les effets du tabagisme sur la grossesse et le nourrisson, si elle fume moins et si elle est plus instruite. La connaissance des effets sur le fumeur lui-même n’influe pas ce type de pratique, sauf si le coût des cigarettes augmente. Des relations dose-effets ont été observées entre le nombre de paquets- années et les connaissances concernant le tabagisme, avec un score de connaissances qui diminue avec l’augmentation du taba- gisme cumulé ; ceci est en faveur d’une absence de biais de confusion. La mise en oeuvre d’analyses multivariées diminue de plus ce risque. La validité interne de cette étude a pour- tant ses limites : un biais de sélection est toujours possible, l’échantillon étant pris dans les cliniques privées de gynécologie. Ceci favorise la présence de femmes de niveau socio-économique plus élevé que la population générale, où des associations supérieures à celles obtenues seraient alors attendues. D’autre part, comme dans toute étude descriptive utilisant un questionnaire, il est possible qu’il y ait un biais d’informa- tion ; ceci concerne surtout les quantités fu- mées et les attitudes déclarées, le tabagisme des femmes n’étant pas toujours apprécié dans une société orientale. Les résultats que nous avons trouvés rejoignent partiellement ceux de Chaaya et coll., où le tabagisme durant la grossesse était associé à un niveau d’instruction bas ou moyen (OR = 3,77 [1,31-10,8]) et un tabagisme plus lourd avant la grossesse (OR = 13,9 [1,40-137,4]), excepté pour un âge plus jeune (OR = 1,11 [1,02-1,20]) [21]. Les données obtenues rejoignent aussi celles de l’Organisation mondiale de la Santé en ce qui concerne le profil socio-démographique des mères fumeuses et leur manque de connaissances concernant le tabac [8]. L’éducation des femmes semble être le premier moyen de prévention du taba- gisme. Les moyens d’information tels que la télévision, la radio et les journaux en sont des sources possibles [25] ; il est important aussi qu’on y bannisse la publicité pour les marques de tabac [16,26]. De plus, l’adap- tation de l’éducation aux femmes, jeunes surtout, est nécessaire ; bien que beaucoup d’entre elles sachent que le tabac cause des maladies, rares sont celles qui connaissent les effets spécifiques aux femmes, tels que l’ostéoporose, la stérilité, les grossesses extra-utérines et les fausses couches, etc. [27]. Les médecins peuvent jouer un rôle important en discutant du tabagisme avec leurs patientes et en leur conseillant d’arrê- ter de fumer [28]. La relation existant entre le tabagisme et le maintien du poids corpo- rel est aussi à prendre en considération. Les gens essayant de perdre ou de maintenir leur poids fument plus que les autres et n’essayent jamais d’arrêter de fumer. Une éducation concernant le contrôle du poids corporel par des moyens autres que le taba- gisme est nécessaire, surtout par rapport aux femmes [29,30]. Cependant, malgré les efforts d’infor- mation et les campagnes publicitaires faites dans certains pays, la demande de sevrage n’augmente pas, voire aurait tendance à diminuer légèrement [31]. La lutte contre le tabagisme semble peu efficace à cause des facteurs suivants : la mauvaise adaptation des programmes de sevrage à la grossesse, l’information insuffisante de la part des équipes soignantes, l’ignorance par les fem- mes des dangers qu’elles font courir à leurs 414 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم enfants en fumant, et le fait que la dépen- dance nicotinique n’est pas évaluée [31]. Contrairement à ce qui se passerait par rap- port à d’autres produits de consommation, la connaissance du risque ne suffisent pas à elle seule à modifier le comportement du tabagique, parce que l’usage de la cigarette est pour la plupart des fumeurs une dépen- dance [32]. Plus de 90 % des fumeurs con- naissent les associations entre le tabagisme et les maladies chroniques [33]. Indiquer le nombre de décès attribuables au tabac et décrire les risques pour la santé ne suffisent pas à convaincre des personnes d’arrêter de fumer. Néanmoins, il s’agit d’un élément d’information crucial et sur lequel nul ne peut faire impasse [7]. L’attitude semble être un élément pré- dictif des efforts de prévention beaucoup plus fort que la connaissance [34]. La pré- vention et l’arrêt du tabac chez les femmes requièrent une série de mesures, dont l’in- formation publique et l’éducation à l’école, mais aussi les restrictions sur la publicité et la disponibilité du tabac sur le marché [8]. Des restrictions sur le tabagisme doivent être appliquées dans les lieux publics ; ceci contribuera à changer les attitudes envers le tabagisme vers des opinions plus strictes [35]. Ainsi, en conclusion, il est important de développer la prévention auprès des plus jeunes, même si cet objectif se heurte à un système publicitaire et une image sociale valorisée du tabac qui restent très forts [7]. Les autorités concernées devraient mettre au point des stratégies plus efficaces que celles existantes pour entraîner le changement d’attitude attendu, surtout chez les femmes en âge de procréer. Références 1. Rapport sur la santé dans le monde, 2002. Réduire les risques et promouvoir une vie saine. Genève, Organisation mondiale de la Santé, 2002 2. Bates C et al. The future of tobacco prod- uct regulation and labeling in Europe: implications for the forthcoming European Union directives. Tobacco control, 1999, 8:225–35. 3. Rogers RG. Demographic characteristics of cigarette smokers in the United States. Social biology, 1991, 38(1–2):1–12. 4. Millar WJ. Reaching smokers with lower educational attainment [Article in English, French]. Health reports, 1996, 8(2):11– 9(Eng); 13–22(Fre). 5. Baldini EH, Strauss GM. Women and lung cancer: waiting to exhale. Chest, 1997, 112 (4 suppl.):229S–234S. 6. Arnold CL et al. Smoking status, reading level, and knowledge of tobacco effects among low-income pregnant women. Pre- ventive medecine, 2001, 32(4):313–20. 7. Sasco A. Lutte contre le tabagisme : le second souffle. Revue toxibase, 2002, 5:1–15. 8. Chollat-Traquet C. Les femmes et le tabac. Genève, Organisation mondiale de la Santé, 1992. 9. Curtin F, Morabia A, Bernstein M. Smok- ing behavior in a Swiss urban population: the role of gender and education. Preven- tive medecine, 1997, 26(5 Pt 1):658–63. 10. Ross N, Perez C. Attitudes toward smok- ing [Article in English, French]. Health reports, 1998, 10(3):23–33 (Eng); 23–34 (Fre). 11. Espinas JA et al. [The sociodemographic determinants of the tobacco habit and its cessation in the population of Cornella de Lobregat]. Gaceta sanitaria, 1999, 13(2):126–34. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 415 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 12. King G, Barry L, Carter DL. Smoking prevalence among perinatal women: the role of socioeconomic status, race, and ethnicity. Connecticut medicine, 1993, 57(11):721–8. 13. Brownson RC et al. Demographic and so- cioeconomic differences in beliefs about the health effects of smoking. American journal of public health, 1992, 82(1):99– 103. 14. Ashley MJ et al. Knowledge about tobacco and attitudes toward tobacco control: how different are smokers and nonsmokers? Canadian journal of public health, 2000, 91(5):376–80. 15. Pederson LL et al. A population survey in Ontario regarding restrictive measures on smoking: relationship of smoking status to knowledge, attitudes and predicted behaviour. International journal of epide- miology, 1987, 16(3):383–91. 16. Martin G, Steyn K, Yach D. Beliefs about smoking and health and attitudes toward tobacco control measures. South African medical journal, 1992, 82(4):241–5. 17. Butkovic T et al. How much do rural His- panics know about the adverse health risks of smoking? Journal of rural health, 2001, 17(3):151–5. 18. Nobile CG et al. Cigarette smoking: knowl- edge, attitudes and behaviour in an adult population in Italy. Public health, 2000, 114(5):348–52. 19. Glantz SA, Jamieson P. Attitudes toward secondhand smoke, smoking, and quit- ting among young people. Pediatrics, 2000, 106(6):E82. 20. Difranza JR, Lew RA. Effect of mater- nal cigarette smoking on pregnancy complications and sudden death syn- drome. Journal of family practice, 1995, 40(4):385–92. 21. Chaaya M et al. Demographic and psy- chosocial profile of smoking among preg- nant women in Lebanon: public health implications. Maternal and child health journal, 2003, 7(3):179–86. 22. Tamim H et al. Tobacco use by univer- sity students, Lebanon, 2001. Addiction, 2003, 98(7):933–9. 23. Afifi Soweid R et al.Changes in health-re- lated attitude and self-reported behaviour of undergraduate students at the Ameri- can university of Beirut following a health awareness course. Education for health. 2003, 16(3):265–78. 24. Administration Centrale des Statistiques. 1998. Conditions de Vie des ménages au Liban en 1997, numéro 9. 25. Sheridan DP et al. Demographic and educational differences in smoking in a to- bacco-growing state. American journal of preventive medecine, 1993, 9(3):155–9. 26. Reddy P, Meyer-Weitz A, Yach D. Smok- ing status, knowledge of health effects and attitudes towards tobacco control in South Africa. South African medical jour- nal, 1996, 86(11):1389–93. 27. Roth LK, Taylor HS. Risks of smoking to reproductive health: assessment of women’s knowledge. American jour- nal of obstetrics and gynecology, 2001, 184(5):934–9. 28. Ruchlin HS. An analysis of smoking pat- terns among older adults. Medical care, 1999, 37(6):615–9. 29. Klesges RC et al. Knowledge and beliefs regarding the consequences of cigarette smoking and their relationships to smok- ing status in a biracial sample. Health psychology, 1988, 7(5):387–401. 30. Wee CC et al. Relationship between smoking and weight control efforts among adults in the United States. Archives of internal medecine, 2001, 161(4):546–50. 31. Joussant S, Baudier F, Velter A. Les mé- decins et le tabac. La santé de l’Homme, 1999, 342(47):1. 416 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 32. Lagrue G. Tabac et Liberté : Réseau de médecins. Lettres Trimestrielles d’information, 2002, 32:1–14. 33. Kim KK et al. Smoking behavior, knowledge, and beliefs among Kore- an Americans. Cancer practice, 2000, 8(5):223–30. 34. Kurtz ME, Azikiwe U, Kurtz JC. Nigerian urban married women’s perceptions of exposure to secondary tobacco smoke. Health care women international, 1993, 14(3):239–48. 35. Pederson LL et al. Restrictions on smok- ing: changes in knowledge, attitudes and predicted behaviour in metropolitan To- ronto from 1983 to 1988. Canadian jour- nal of public health, 1992, 83(6):408–12. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 417 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Use of combined oral contraceptives: retrospective study in Isfahan, Islamic Republic of Iran M. Savabi-Esfahany,1 S. Fadaei1 and A. Yousefy2 1Faculty of Nursing and Midwifery; 2Department of Medical Education, Isfahan University of Medical Sciences, Isfahan, Islamic Republic of Iran (Correspondence to M. Savabi-Esfahany: Msavabi@yahoo.com). Received: 14/10/03; accepted: 12/10/04 ABSTRACT We carried out a retrospective cross-sectional study on 500 women in Isfahan who started taking combined oral contraceptives (COCs) during the period 21 March 1995–20 March 1997. The cu- mulative continuation rate fell from 77% to 12% over 60 months. The most common reason for discon- tinuation was side-effects. There was a significant correlation between side-effects and cumulative COC continuation rate (P < 0.05). The lowest rate was seen in women reporting nausea or vomiting. Women who are interested in COCs should receive extensive counselling about the possible side-effects and should be helped to find a method of birth control suited to their temperament and physiology. eq>$uJ]"( F^I -e6 W4 3c0-K -
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 Abe6;3JEtGH3hA;P:¤3€R>e3hAjJ“bCs3A\P6C3PWZ>@3 3 ! 23433´GÚ3hN;pJ?ZeP3NeP8p3zPW—²\3i6¥7Jd5P3IJ‘500<59JTX3<3hiJ“bCs3M3vJHJ¢Y5P3ˆGZÄ3<@3‡:>e3 3axy3 NLWZwOP3 N;6Rb5P3 KR­P3 _T@3É6d73<@3 ‡:OP218Pn«3k3ä8J@19953FZ73208Pn«3k3ä8J@19973 m:‘9 3<@3ARLPWZ5P3NdŠP6OP3a:?@3çb.P773Ç3 l123Ç3œ:@3FGH60oPW“•33mNdŠP6OP3I:H3M3A`>‰W5P3¡d`5P3iJL9 N>djJP38J¬P36r3mARLPWZ5P3NdŠP6OP3a:?@3€\93N>djJP38J¬P3€\3oJ>‰JQ7l34\3ž:ªZ©?;3†\PWX3±5JT“¤–30.053<Pm˜ iJ>¥u93zA‘3vcJ73<H3<ºG\s3AXx5P3vP:>`5P3€\3NdŠP6OP3vc:?@3Fjps3´jJL93ma6Q73<@3:\x¤3 =}ª¬3<@9 JRL3hNGRZP3‡W‰Jƒ5P38J¬P3a673Nb¥q@3vP8JwZeP3FGH3NLWZwOP3N;6Rb5P3KR­P3_T@3É6d73a9JTX3M3vJduPW5P ‡We…P3}>STZ53NG>e93pJ l3FGH3<“X:HJ`@3¡ N>—PUOP93N>—656;U>b5P3<“Z5J73_@3IzxZX3m3 3 Utilisation des contraceptifs oraux associés : étude rétrospective à Ispahan (République islamique d’Iran) RÉSUMÉ Une étude transversale rétrospective portant sur 500 femmes qui ont commencé à prendre des contraceptifs oraux associés durant la période du 21 mars 1995 au 20 mars 1997 a été réalisée à Ispahan. Le taux cumulatif de poursuite de la contraception est passé de 77 % à 12 % sur 60 mois. La raison la plus courante pour l’abandon de la contraception était les effets secondaires. Il y avait une corrélation significative entre les effets secondaires et le taux cumulatif de poursuite de l’utilisation des contraceptifs oraux associés (p < 0,05). Le taux le plus faible a été observé chez les femmes signalant des nausées ou des vomissements. Les femmes qui souhaitent prendre des contraceptifs oraux asso- ciés devraient être bien conseillées au sujet des effets secondaires possibles et devraient être aidées pour trouver une méthode de régulation des naissances correspondant à leur tempérament et à leur physiologie. 418 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction Despite advances in family planning, popu- lation growth remains a worldwide concern. In 1999, the world population reached 6 bil- lion (6 000 000 000), an increase of 4.4 bil- lion since 1900 [1]. Contraceptive technology has been a medical success. For the majority of us- ers, contraception enhances the quality of life, allowing couples to choose whether and when they have children [2]. Oral contraceptive pills have been studied since 1960; they are used every day by more than 50 million women around the world for prevention of unwanted pregnancy. The effects are reversible and there are many non-contraceptive health benefits, some of which last for years [3]. To ensure effective practice of family planning it is not necessary that the client makes the optimal choice of method but it is important that she continues to use the method properly [4]. Continuation rates are reliable indicators of the overall use of a contraceptive method. High rates of discontinuation are generally recognized as the major problem facing family planning programmes and there is a need to look for associated factors [5]. Women who discontinue oral con- traception often substitute a less reliable method or no method at all, often leading to unintended pregnancy. Side-effects of oral contraceptives were the most frequent rea- sons given by women for discontinuation of use [6]. Some studies indicate that 3%–25% of the women who use this method have reported at least 1 side-effect, and over half of those who discontinue the use report the occurrence of side-effects as the reason for discontinuation. Studies sponsored by the World Health Organization have shown substantial levels of discontinuation associ- ated with menstrual problems, gastrointes- tinal complaints and central nervous system disturbances. Less has been written about the occurrence of side-effects and their association with discontinuation in popula- tions from developing countries [7]. Although considerable work has been done on contraceptives in the Islamic Republic of Iran, little is known about the continuation rate of combined oral contra- ceptives (COCs) and problems concerning their use. The most commonly used COCs worldwide are monophasic formulations that contain a fixed amount of estrogen and progestogen throughout the cycle [8]. The purpose of this study was to investigate the occurrence of selected side-effects and the correlation between their occurrence and continuation rate of COCs among women in Isfahan using LD or HD contraceptives (containing 0.15 mg levonorgestrel plus 0.03 mg ethinyl estra- diol or 0.25 mg levonorgestrel plus 0.05 mg ethinyl estradiol). Methods A retrospective cross-sectional study was carried out on women in Isfahan who start- ed taking COCs (either LD or HD) during the period 21 March 1995–20 March 1997. This time period allowed us to select a large enough sample for the study. We obtained a list of all family planning service facilities, such as maternal and child health and family planning centres, and 16 centres were selected randomly by cluster sampling. Isfahan was divided geographi- cally into 5 regions and 20% of the medical centres in each region were randomly se- lected. In these centres, medical consultations or visits were set up on a confirmed appoint- ment basis and a schedule of regular medical Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 419 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم appointments made according to the chosen contraceptive method, e.g. monthly for the women using COCs. Data collection was carried out from 15 September 2001 to 15 December 2001. Each day interviewers approached the women who were attending clinics. They were asked if they had ever used COCs. If the answer was yes, the date of starting was determined and those who had started between 21 March 1995 and 20 March 1997 were asked to participate in the study. Sample size was determined based on probability calculations. A total of 500 women were enrolled and the data from their records over a 5-year period were analysed. There were no refusals to participate. We used a comprehensive questionnaire to collect data on characteristics such as age, level of education, employment status, number of living children and side-effects reported by the participants during the use of COCs. Collection of data was admin- istered by 4 trained interviewers, each of whom worked in 4 of the 16 centres Following the interviews, data were collected from medical staff and clinical records for the determination of continu- ation rates. We considered the duration of COC use to be from the beginning of the prescription until the date of stopping, as in O’Dell et al. [9]. Content validity was used in order to de- termine the validity of this questionnaire. Results were analysed using SPSS statis- tical software, version 5.5. Contraceptive continuation rates were also estimated using Kaplan–Meier analysis [5] and the association between reported side-effects and continuation rate was in- vestigated by χ2 test. P-value < 0.05 was considered statistically significant. Results Characteristics of users Table 1 shows basic information on the characteristics of COC users. The most nu- merous group (43.6%) was the 15–24 year age group; 9.0% were ≥ 35 years old. Mean age was 26.24 (standard deviation 6.22) years. More than half (62.6%) were edu- cated to secondary school level and 3.4% had a university education. Only 22.8% of the women in the study had ≥ 3 living children. The vast major- ity (92.4%) were not employed outside the home. Continuation rates The median duration of use was 21.38 (standard deviation 15.94) months. Table 1 Characteristics of combined oral contraceptive users in Isfahan (n = 500) Characteristic No. % Age (years) 15–24 218 43.6 25–29 164 32.8 30–34 73 14.6 ≥ 35 45 9.0 Education level None 20 4.0 Primary school 152 30.4 Secondary school 311 62.2 University 17 3.4 Employment status Employed 38 7.6 Not employed 462 92.4 No. of living children 0–2 386 77.2 ≥ 3 114 22.8 420 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم The cumulative proportion of continu- ation fell from 77% at 6 months to 12% at 60 months. The commonest reason for discontinuation was side-effects (37.0%). Other reasons included accidental pregnan- cy (2.8%), desire for pregnancy (16.8%), husband absent or divorce (1.2%), advice of the doctor or midwife (8.6%) and desire for a change of method (10.2%). Analysis of the results showed that there was a significant correlation between side- effects and cumulative proportion of COC continuation (P < 0.05). Kaplan–Meier analysis showed there was a significant difference in continuation rates between women reporting side-effects and those who had no side-effects. Cumula- tive proportion of continuation was 78% 12 months after starting COCs and 24% after 60 months for clients not reporting side- effects. These figures were 50% and 0% for the participants who had reported having side-effects. Table 2 shows the data on side-effects: 56.4% of the participants reported having ≥ 1 side-effect while using COCs. These included bleeding problems, nausea or vomiting, mood changes, facial complexion changes, weight gain, facial complexion with mood changes, heavy discharge and headaches. Using Kaplan–Meier analysis, we found that women who reported nausea or vomit- ing had the lowest cumulative proportion of continuation, 28% after 12 months; other causes included bleeding problems (50%), mood changes (52%), facial complexion changes (55%), weight gain (70%), facial complexion and mood changes (45%), heavy discharge (62%) and headaches (63%) after 12 months. Among women who discontinued, the next contraceptive methods recommended by the midwife or preferred by the women were condoms (20.0%) and the intrauterine device (13.6%). Combined oral contracep- tives were used by 5.8% of the women and withdrawal by 11.6%. Sterilization was preferred by 2.8% and 20.4% chose no contraceptive at all. Discussion After 18 months, the cumulative proportion of continuation of use of COCs was 52%. This is comparable to that found in the Phil- ippines (52.3%) [10]. The cumulative pro- portion of continuation in our study after 12 months (62%) was better than that observed by Alihonou in West Africa (40.8%) [11]. Some couples select a contraceptive method and continue using it throughout their reproductive lives. Others will dis- continue methods several times. There are many reasons why women stop using the COC method, for example, they may be dissatisfied with the side-effects, or have previously followed poor advice from clinic staff. Only 5.8% of the women in our study who discontinued using pills for contracep- Table 2 Side-effects reported by combined oral contraceptive users in Isfahan (n = 500) Side-effect No. % Bleeding problems 31 6.2 Nausea or vomiting 43 8.6 Mood changes 73 14.6 Facial complexion 16 3.2 Weight gain 28 5.6 Headaches 23 4.6 Facial complexion with mood changes 11 2.2 Heavy discharge 17 3.4 Other 40 8.0 Total 282 56.4 Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 421 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم tion used pills again and most of the re- mainder started some less efficient method, e.g. withdrawal was used by 11.6% and condoms by 20.0%. Therefore, it could be concluded that side-effects associated with some modern contraceptive methods may cause women to switch to other methods, some of which may be less reliable. On the other hand, 20.4% of the par- ticipants stopped using COCs and did not start using any other method. Clinic staff should, therefore, be prepared to facilitate switching methods so that each client can find a method of contraception suitable for her temperament and physiology [4]. In addition, if a client plans to discontinue a method and begin using another method, the provider should urge her to do so im- mediately. Otherwise she risks an unwanted pregnancy. In our study, side-effects were the most common reason cited for discontinuation of COCs and women who discontinued use for this reason had a lower cumulative propor- tion of continuation than those who had no complaints. In a similar study, Phillips also found side-effects were a major concern of pill acceptors and an important correlate of discontinuation [10]. Kaplan–Meier analy- sis of 9 specific types of side-effect showed that clients with nausea and vomiting had lower cumulative proportion of continua- tion than others. This finding was similar to that reported in Sri Lanka by Basnayake [7]. It is essential for women who are inter- ested in COCs to receive extensive counsel- ling about the possible side-effects before choosing this method of contraception. Women who are unable to tolerate side- effects such as nausea or vomiting may not be good candidates [12]. On the other hand, methods such as implants and the intrauterine device require the attention of a skilled practitioner for commencing and stopping, but users of COCs can easily discontinue the method. However, it has been shown that better edu- cation and support by health workers/family planning workers are needed for clients to improve the continuation rates and use- effectiveness of oral contraception [13]. Improving compliance and preventing early discontinuation is a shared responsi- bility of COC users, health care providers and COC manufacturers. Providers must assure adequate initial counselling for pa- tients about the correct use of COCs. To improve compliance, the prescriber should help women establish a regular routine for taking her COCs, ensure that she prop- erly understands use instructions and knows where to get information in future if prob- lems should arise. When COC use is initiated, providers should emphasize that side-effects may be expected, though most will be transient. The health worker must have the knowledge and ability to manage side-effects and to edu- cate women in the importance of scheduled COC use. It is also important that providers discuss with patients the immediate risk for pregnancy after discontinuation of this method. Our evaluation also had a number of limitations. First, the data on COC continu- ation and side-effects were based on subject recall (which may have led to underesti- mations) and chart review, similar to the O’Dell et al. study [9]. Second, it is possible that higher continuation rates were more a reflection on the training and attitudes of clinic staff (some were able to manage side- effects much better than others) [14]. 422 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم References 1. Achievements in public health, 1900– 1999: family planning. Journal of the American Medical Association, 2000, 283(3):326–31. 2. Trussell J et al. The economic value of contraception: a comparison of 15 meth- ods. American journal of public health, 1995, 85(4):494–503. 3. Ryan K et al., eds. Kistner’s gynecology and women’s health, 7th ed. St Louis, Missouri, Mosby Co., 1999:286 (chapter 13). 4. Huezo CM et al. Acceptability and con- tinuation of use of contraceptive methods: a multicentre study. In: Teoh ES, Ratnam SS. Fertility, sterility and contraception: proceedings of the XIIIth World Congress of Gynecology and Obstetrics, Singapore, 15–20 September 1991, vol. 1. New York, Parthenon Publishing, 1993:117–35. 5. Mahdy NH, el-Zeiny NA. Probability of contraceptive continuation and its deter- minants. Eastern Mediterranean health journal, 1999, 5(3):526–39. 6. Rosenberg MJ et al. Use and misuse of oral contraceptives: risk indicators for poor pill taking and discontinuation. Con- traception, 1995, 51(5):283–8. 7. Basnayake S et al. Early symptoms and discontinuation among users of oral con- traceptive in Sri Lanka. Studies in family planning, 1984, 15:285–90. 8. Huezo CM. Current reversible contra- ceptive methods: a global perspective. International journal of gynaecology and obstetrics, 1998, 62(suppl. 1):S3–15. 9. O’Dell CM et al. Depot medroxyproges- terone acetate or oral contraception in postpartum adolescents. Obstetrics and gynecology, 1998, 91(4):609–14. 10. Phillips JF. Continued use of contracep- tion among Philippine family planning ac- ceptors: a multivariate analysis. Studies in family planning, 1978, 9(7):182–92. 11. Alihonou E et al. Contraceptive continua- tion and its determinants in Benin. Contra- ception, 1997, 55(2):97–101. 12. Dinerman LM et al. Outcomes of adoles- cents using levonorgestrel implants vs oral contraceptives or other contraceptive methods. Archives of pediatrics & adoles- cent medicine, 1995, 149(9):967–72. 13. Bhatia S, Kim YJ. Oral contraception in Bangladesh. Studies in family planning, 1984, 15(5):233–41. 14. Measham AR, Villegas A. Comparison of continuation rates of intrauterine de- vices. Obstetrics and gynecology, 1976, 48(3):336–40. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 423 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Comparison of the effectiveness of fennel and mefenamic acid on pain intensity in dysmenorrhoea V. Modaress Nejad1 and M. Asadipour1 1Department of Obstetrics and Gynaecology, Kerman University of Medial Sciences and Health Services, Kerman, Islamic Republic of Iran (Correspondence to V. Modaress Nejad: vidamodaress@yahoo.com). Received: 27/07/04; accepted: 25/10/04 ABSTRACT A study in Kerman, Islamic Republic of Iran in 2002 compared the effectiveness of fen- nel and mefenamic acid on pain relief in primary dysmenorrhoea. Two groups of high-school girls (mean age 13 years) suffering dysmenorrhoea were randomized to receive fennel extract (n = 55) or mefenamic acid (n = 55) for 2 months. In the fennel group, 80% of girls and in the mefenamic acid group, 73% of girls showed complete pain relief or pain decrease, while 80% in the fennel group and 62% in the mefenamic acid group no longer needed to rest. There was no significant difference between the 2 groups in the level of pain relief. Comparaison de l’efficacité du fenouil et de l’acide méfénamique sur l’intensité de la douleur dans la dysménorrhée RÉSUMÉ Une étude réalisée à Kerman (République islamique d’Iran) en 2002 a comparé l’efficacité du fenouil et de l’acide méfénamique pour soulager la douleur dans la dysménorrhée primaire. Deux grou- pes d’élèves du secondaire (âge moyen 13 ans) souffrant de dysménorrhée ont été randomisés pour prendre un extrait de fenouil (n = 55) ou de l’acide méfénamique (n = 55) pendant 2 mois. Quatre-vingt pour cent (80 %) des filles du groupe ayant pris l’extrait de fenouil et 73 % des filles du groupe ayant pris l'acide méfénamique ont eu un soulagement total de la douleur ou une diminution de la douleur ; 80 % du groupe ayant pris l’extrait de fenouil et 62 % des filles du groupe ayant pris l’acide méfénami- que n’avaient plus besoin de repos. Il n’y avait aucune différence significative entre les deux groupes dans le niveau de soulagement de la douleur. 424 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction Dysmenorrhoea is pain with lower abdomi- nal cramps during menstruation [1,2]. It is a common gynaecologic disorder affect- ing up to 50% of menstruating women [1]. Primary dysmenorrhoea usually starts 1–2 years after menarche and is associated with normal ovulatory cycles without pelvic pa- thology, whereas secondary dysmenorrhoea is defined as painful menses associated with underlying pathology [1,2]. Primary dysmenorrhoea is more common in young women but may persist throughout the years of menstruation [1]. It is associated with ovulatory cycles and is due to myome- trial contractions induced by prostaglandins originating in the secretary endometrium that occurs mostly in the first 48 hours of menses [2]. Various treatments have been suggested for dysmenorrhoea, among them non- steroidal anti-inflammatory drugs (NSAIDs), which have been shown to be effective in 80% of cases [1–3]. Other treatments are oral contraceptives, transcutaneous electri- cal nerve stimulation, presacral neurotomy and even hysterectomy [1–3]. Some studies have shown the effectiveness of herbal drugs in the treatment of dysmenorrhoea [4–6]. One of the suggested herbal drugs is fennel extract, produced by distillation of fennel seeds with water vapour, which is be- lieved to have anti-spasmodic and analgesic properties. Studies on the isolated mouse uterus have demonstrated an antispasmodic effect of fennel on spasms induced by oxy- tocin and prostaglandin E2 [4]. NSAIDs such as mefenamic acid have a number of adverse effects (digestive dis- orders, diarrhoea, haemolytic anaemia and seizures) [7]. In view of the apparent safety of fennel in patients, with the exception of epileptic patients [6], the present study was designed to study the effectiveness of fennel for the treatment of dysmenorrhoea. This case–control semi-experimental study was carried out on 110 young women at a school in the Islamic Republic of Iran to compare the effects of fennel and mefenamic acid on pain intensity in primary dysmenorrhoea during 2 consecutive menstrual cycles. Methods The participants were selected randomly from 2 high schools in Kerman city. All were 13 or over years old and suffering from primary dysmenorrhoea. The inclusion cri- teria were: a history of 1 year regular men- ses, starting dysmenorrhoea 1–3 years after menarche, and no history of epilepsy, diges- tive disorders or other diseases. Informed consent for participation was obtained from the participants and their parents. After interviewing the students, 120 who consented to participate were randomly di- vided into 2 groups of 60 students. The case group received 30 drops of fennel extract (Barij Extract Co., Tehran, Islamic Republic of Iran) to be used at the onset of menses and then continuously every 6 hours for the first 3 days of menses. The effective dose of fennel extract was established from the manufacturer’s in- structions. The control group received 250 mg mefenamic acid (Alhavi Co., Tehran, Islamic Republic of Iran) to be used at the onset of menses and repeated every 6 hours during the first 3 days of menses. The fennel extract and mefenamic acid were distributed in similar packages and both the participants and the researcher distributing the treatments were blind to the type of treatment. Students were supplied with written instructions for treatment use and a questionnaire that included the scor- Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 425 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم ing sheet for pain symptoms. All students were also given face-to-face instructions for drug use and filling the questionnaire by a trainer not included in the research group. Participants were requested not to use any other drug during the study period and anyone who reported using other drugs was excluded from the study. Compliance with treatment use was checked regularly via phone calls and visits to subjects. One of the researchers was in direct contact with the trainer in order to control the project’s progress. The treatments were used in 2 consecu- tive menstrual cycles and subjects assessed the effectiveness of the treatments at the end of each menstrual cycle. Pain intensity was reported by subjects according to a verbal multidimensional scoring system taking ac- count of 3 dimensions (need for analgesics, limitation of activities and need for rest): • severe pain (need for analgesics, unable to carry out routine activities and com- plete need for rest); • moderate pain (need for analgesics, lim- itation in activities and limited need to rest); • mild pain (no need for analgesics, no limitation in routine activities or no need to rest). Data analysis was made using through Epi-Info, version 6 and by using descrip- tional statistics, distributional indexes and chi-squared tests. Results Of the 120 students, 10 did not complete the treatments and were excluded. There were no significant differences between the 2 groups of students in terms of mean age, age at menarche or age when dysmenorrhoea started (Table 1). Overall, there was no significant differ- ence in pain intensity between the 2 groups before treatment (Table 2). In the fennel group 65% had severe pain and 35% had moderate pain, and in the mefenamic acid group 62% had severe pain and 38% had moderate pain. The majority also suffered limitation of activities and a need to rest completely. After treatment, 80% in the fennel group and 73% in the mefenamic acid group had no pain. In regard to the limitation of ac- tivities, 80% in the fennel group and 62% in the mefenamic acid group were returned to the normal state and 83% in the fennel group and 71% in the mefenamic acid group needed no rest after treatment. There was no Table 1 Age of the 2 treatment groups Variable Fennel group Mefenamic P -value (n = 55) acid group (n = 55) Mean (SD) Mean (SD) Age (years) 15.5 (1.5) 15.5 (1.4) NS Age at menarche (years) 13.1 (0.9) 13.2 (0.9) NS Age at starting dysmenorrhoea (years) 13.7 (1.1) 13.7 (1.1) NS NS = not significant; SD = standard deviation. n = total number of participants. 426 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم significant difference between the 2 treat- ments in any of the dimensions of pain after treatment (Table 2). Discussion Dysmenorrhoea is the most common gy- naecological disorder among adolescent girls reducing their quality of life and caus- ing missed school or work [7]. NSAIDs, especially mefenamic acid, are the treat- ment of choice for dysmenorrhoea, show- ing 80% effectiveness. However, there is still a 20%–25% failure rate [1–3], and side-effects such as diarrhoea and rashes [8], immunohaemolytic anaemia [9] and nephrotoxicity; overdose is accompanied by central nervous system toxicity and con- vulsions [8]. Herbal remedies may be a safer way to treat many common ailments including dysmenorrhoea. Fennel has been shown to be effective in the treatment of dysmenorrhea [4]. Although one report has suggested that fennel extract can stimulate uterine contractions and lead to abortion [3], this claim has not been verified and is unlikely at treatment dose. In the present study, fennel extract and mefenamic acid (250 mg, 4 times a day) were equally effective in reducing pain intensity, limitations in activity and the need for rest among adolescent girls with primary dysmenorrhoea. The effectiveness of NSAIDs such as mefenamic acid in dys- menorrhoea has been reported to be about 75%–80% in previous studies [5,6,10–13]. In the present study 73% of participants taking fennel extract recorded a decrease or complete absence of pain. The failure Table 2 Comparison of the 2 treatment groups in regard to dysmenorrhoea symptoms before and after treatment Variable Before treatment After treatment Fennel Mefenamic Fennel Mefenamic group acid group group acid group (n = 55) (n = 55) (n = 55) (n = 55) No. % No. % No. % No. % Need to rest No need 0 0 0 0 46 83 39 71 Limited 37 67 33 60 8 15 13 24 Complete 8 33 22 40 1 2 3 5 χ2 = 0.63, df = 1, NS χ2 = 2.77, df = 2, NS Activity state Normal 0 0 0 0 44 80 34 62 Limited 15 27 20 36 9 16 18 33 No activity 40 73 35 64 2 4 3 5 χ2 = 1.5, df = 1, NS χ2 = 4.48, df = 2, NS Pain intensity No pain 0 0 0 0 44 80 40 73 Moderate 19 35 21 38 10 18 11 20 Severe 36 65 34 62 1 2 4 7 χ2 = 0.16, df = 1, NS χ2 = 2.04, df = 2, NS NS = not significant. n = total number of participants. df = degrees of freedom. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 427 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم rate of NSAIDs is still 20%–25% study [1–3]. In the present study about 20% of the mefenamic acid group reported moderate pain and 7% severe pain after treatment. In a study carried out in 1999 comparing the effectiveness of fennel with placebo, a significant decrease in pain symptoms was observed [4]. In the present study too, 80% of fennel-treated subjects had either pain decrease or pain relief after treatment and there was no significant difference in any of the dimensions of pain symptoms compared with the mefenamic acid-treated group. Half of the workforce in society is wom- en and the loss of well-being due to dys- menorrhoea diminishes the quality of life of women and the loss of several working days every month during the years of fertil- ity is a potential problem for the economy of any society. The effectiveness of herbal and dietary treatments in dysmenorrhoea are still under investigation and need more careful studies. However, any attempt to find treatments for dysmenorrhoea with less adverse effects is highly desired. References 1. Berek JS, Hillard PJA, Adashi EY, eds. Novak’s gynecology, 13th ed. Philadel- phia, Lippincott Williams and Wilkins, 2002:241–435. 2. Speroff L, Class RH, Kase NG. Clinical gynecology, endocrinology and infertility, 6th ed. Baltimore, Lippincott Williams and Willkins, 1999:557–75. 3. Scott JR, Danforth DN. Danforth’s ob- stetrics and gynecology, 8th ed. Phila- delphia, Lippincott Williams and Wilkins, 1999:613. 4. Khorshidi N et al. Clinical effects of fen- nel essential oil on primary dysmenor- rhea. Iranian journal of pharmaceutical research, 2003:89–93. 5. Shibata T et al. [The effect of Shakuyaku- kanzo-to on prostaglandin production in human uterine myometrium.] Nippon Sanka Fujinka Gakkai zasshi, 1996, 48(5):321–7 [in Japanese]. 6. Wu R, Han TY. Cold dysmenorrhea with blood stagnation treated with zhuyu wen- gong decoction. Zhong xi yi jie he za zhi, 1989, 9(8):455–7. 7. Zargari A. Medicinal plants, volume 2. Te- hran, Tehran University Press, 1996:553– 62. 8. Facchinetti F et al. A comparison of glyc- eryl trinitrate with diclofenac for the treat- ment of primary dysmenorrhea: an open, randomized, cross-over trial. Gynaecolog- ical endocrinology, 2002, 16(1):39–43. 9. Herfindahl ET, Gourley DR, eds. The text- book of therapeutics: drug and disease management, 7th ed. Philadelphia, Lip- pincott Williams and Wilkins, 2000. 10. Di Girolamo G et al. [Menstrual prostag- landin and dysmenorrhea: modulation by non-steroidal antiinflammatory drugs]. Medicina (B Aires), 1999, 59(3)259–64 [in Spanish]. 11. Harel Z. A contemporary approach to dysmenorrhea in adolescents. Paediatric drugs, 2002, 4(12):797–805. 12. Dawood MY. Nonsteroidal anti-inflamma- tory drugs and changing attitudes toward dysmenorrhea. American journal of medi- cine, 1988, 20, 84(5A):23–9. 13. Deligeoroglou E. Dysmenorrhea. Annals of the New York Academy of Sciences, 2000, 900:237–44. 428 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Knowledge, attitudes and beliefs about menarche of adolescent girls in Anand district, Gujarat H. Tiwari,1 U.N. Oza1 and R. Tiwari 2 1Department of Preventive and Social Medicine, Municipal Medical College, Ahmedabad, Gujarat, India (Correspondence to H. Tiwari: tiwarihemant1@rediffmail.com). 2International Institute for Population Sciences, Mumbai, Maharashtra, India. Received: 10/07/03; accepted: 25/04/04 ABSTRACT A questionnaire survey of knowledge, attitudes and beliefs towards menstruation was made in 22 schools in Anand district, Gujarat state. Of 900 schoolgirls aged 11–17 years, only 38.5% felt comfortable about menarche and only 31.0% believed that menstruation was a normal physiological process. Many (37.2%) had not been informed about menarche before its onset and 48.2% felt they were not mentally prepared. The major sources of information were the mother (60.7%) or an elder sister (15.8%); teachers and others relatives played a small role. In this area of India, many families continue the custom of celebrating the first menarche and observing social restrictions. Connaissances, attitudes et croyances concernant la menstruation chez des adolescentes dans le district d’Anand au Gujarat RÉSUMÉ Une enquête par questionnaire sur les connaissances, attitudes et croyances concernant la menstruation a été réalisée dans 22 écoles du district d’Anand, de l’État de Gujarat. Sur les 900 élèves âgées de 11 à 17 ans, 38,5 % seulement n’avaient pas d’appréhension vis-à-vis de la menstruation et 31,0 % seulement pensaient que la menstruation était un processus physiologique normal. Nombre d’entre elles (37,2 %) n’avaient pas été informées sur la menstruation avant son apparition et 48,2 % pensaient qu’elles n’y étaient pas préparées mentalement. La principale source d’information était la mère (60,7 %) ou une sœur plus âgée (15,8 %) ; les enseignants et les autres parents jouaient un rôle limité. Dans cette région de l’Inde, de nombreuses familles perpétuent la coutume de la célébration de la première menstruation et de l’observation de restrictions sociales. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 429 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction Of all the developmental milestones associ- ated with the adolescent years, menarche may be the most noteworthy. The onset of the first menstrual period is a qualitative event of major significance in a woman’s life, denoting the achievement of a major functional state. The bodily changes as- sociated with puberty affect a girl’s psy- chological and social development and the girl’s life experiences influence the physical changes that are occurring as well. In one study, researchers interviewed 35 white middle-class pre- and post-menarche girls at a summer camp [1]. The girls had learned about menstruation from friends, commercial booklets, school and their par- ents, especially their mothers. They per- ceived themselves as being knowledgeable about menstruation and used appropriate terms. However, their knowledge of female anatomy was poor. Therefore, despite their access to information about menstruation, the girls had not assimilated it well. They were most concerned about what to do when they got their periods, and many had mentally rehearsed what they would do in a variety of situations. Brooks-Gunn and Rubble found that girls in 7th and 8th school grades had most- ly negative beliefs about menstruation [2]. For example, most believed that physical discomfort, increased emotionality and a disruption of activities accompany menstru- ation. Williams, a nurse educator, found a more positive attitude towards menstruation in a group of 9- to 12-year-old girls, most of whom were pre-menarche [3]. These girls generally equated menstruation with growing up and being normal. However, about a third of them also believed men- struation to be embarrassing, 28% thought it a nuisance, 27% found it disgusting and 23% disliked the idea that it is not control- lable. The girls in the sample also believed some of the popular menstrual taboos about not participating in sports or discussing the subject with boys or their fathers. In other studies menarche has been found to be an anxiety-producing or negative event and mixed feelings, such as being “excited but scared” or “happy and embarrassed”, are common [4,5]. Several researchers have found that girls who report being adequately prepared have more positive initial experiences with men- struation [6,7]. Other studies indicate a need for more and better menstrual education. In a study of 95 women from 23 foreign coun- tries, Logan found that 28% complained of not having enough information [8]. Even girls who have had sufficient prior knowl- edge about menarche often feel unprepared for the event itself. In a study of 97 college womens’ recollections, Rierdan and Koff found that, as girls, they had wanted to know not only about menstrual physiol- ogy and menstrual hygiene—facts that are usually included in menstrual education materials—but also about menstruation as a personal event [7]. The feelings of fright and embarrassment that girls experience at menarche need to be acknowledged and the negative aspects of the menstrual experience need to be discussed in order to provide a balanced view of menstruation [6,7]. Cultural taboos about menstruation also need to be addressed. Until relatively re- cently, separation of menstruating women from the rest of the population was com- mon, and it is still practised in some areas of the world. “Beliefs or superstitions about dangers inherent in menstruation” and the rituals that accompany them, are extremely common and widespread [9]. It was in the context of these concerns that the present study was carried out to study the knowledge, attitudes and beliefs 430 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم of adolescent girls in Anand district of Gu- jerat province with respect to menarche. Methods The survey was conducted in Anand district of Gujarat state from July 1999 to August 1999. Anand and Kheda districts are 2 of the most prosperous areas, not only in Gujarat, but also the Indian subcontinent. A large inflow of earnings from migrant workers in industrialized countries means that the overall living standard of families and the status of women in these districts are very high. Anand and Kheda districts have been pioneers in the Milk Cooperative movement which has also contributed to improving the health status of the population, and particu- larly women, in the areas. Out of 49 schools in Anand, girls were interviewed from 22 schools: all the 4 girl’s schools run by the panchayat/municipality (434 respondents), all the 3 co-educational English medium convent schools run by trusts/missionaries (64 respondents) and 15 co-educational schools randomly selected from the remaining 37 schools (402 re- spondents). All the girls studying in grades 6 to 12 (in the age group 11–17 years) were included from the selected schools. A pretested structured questionnaire was administered to all the 900 girl students (763 had achieved menarche). The ques- tionnaires were distributed and collected by female medical interns who received a 1-day training. After obtaining permis- sion from the principals of the schools, girl students were assembled in a hall in the school and the printed questionnaire was distributed among them. During this proc- ess, the female class teachers of the school were also present. The students were asked to answer the questions and were helped by the interns if they faced and difficulties. The questionnaire was printed in both English and the local Gujarati language. The stu- dents were told not to write their names or class or section of the class in order to keep confidentiality. None of the girl students refused to participate in the study. The questionnaire was specially de- signed for the study and included general questions (age of first menarche, height, weight, type of diet); family information, (number of siblings, literacy and employ- ment status of father and mother, family income); experiences of menarche (sources of information about menarche, initial per- ceptions at the time of first menarche, feel- ings about the process of menstruation, who they first informed, how long it took to tell them, social reactions to menstruation in the community). All the questions were closed- ended, some with yes/no response and some with 4 or 5 possible responses. Results Around two-thirds of the 900 girls (62.7%) had been informed about menarche be- fore its onset. From Table 1 it can be seen that the major source of information was the mother (60.7%) followed by older sis- ters (15.8%). Teachers and others (which included near and distant relatives) played a small role. The mother was usually the first person informed about the start of me- narche (76.1%), followed by an older sister (13.4%). Two-thirds of the girls (37.2%) had no prior knowledge about the event, which accounts for the fact that 16.9% had the initial perception that it was a life- threatening disease or symptom of illness (Table 2). Asked if they felt they had been mentally prepared (yes/no), 48.2% of girls felt they were not mentally prepared for menarche (Table 2). Table 2 shows that at the time of first menstruation, 28.3% felt shame, 12.6% felt guilt and 20.6% had a sense of Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 431 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم fear. Asked how they felt about the process of menstruation, a majority of girls believed that menstruation is a purging of body im- purities (56.5%), 31.0% felt that it was a normal physiological event, whereas 10.0% felt it was something dirty. In this area of India, the custom of cel- ebrating the event of menarche continues; 43.7% of respondents reported that a social ceremony is held in their houses for the first menarche (Table 1). More than two- thirds of respondents (36.2%) reported that social restrictions are still observed in their family: the custom of not allowing them to hold prayers, go to the temple or enter the kitchen. A few girls reported that food restrictions are also imposed on them during menstruation, which do not allow them to consume spicy or non-vegetarian foods. Discussion When respondents were asked about their feelings regarding their first menstrual pe- riod it was found that, although they have completed 9 or more years of education, a majority of girls (61.5%) still have negative feelings about menarche. In a modern soci- Table 1 Knowledge about menarche and social conventions in their house among adolescent girls in Anand district, Gujarat Item % of respondents Had been informed about menarche before its onset (n = 763) Yes 62.7 No 37.2 Source of information about menarche (n = 486) Mother 60.7 Older sister 15.8 Teacher 6.0 Friend 13.6 Other 3.9 First person informed about menarche (n = 763) Mother 76.1 Older sister 13.4 Friend 6.9 Teacher 1.8 Other 1.5 Society reaction to menarche (n = 762) Social ceremony/ritual 43.7 Isolation from prayer/ household activities 36.2 Food restrictions 4.6 Other 15.5 n = number of respondents to each question. Table 2 Feelings about and mental preparedness for menarche among adolescent girls in Anand district, Gujarat Item % of respondents Felt mentally prepared for menarche (n = 763) Yes 51.9 No 48.2 Feelings at the time of first menstruation (n = 763) Normal 38.5 Shame 28.3 Fear 20.6 Guilt 12.6 Feelings about the process of menstruation (n = 763) Normal physiology 31.0 Dirty 10.0 Purging of body impurities 56.5 Other 2.5 Initial perceptions at the onset of menstruation (n = 478) Normal 83.1 Symptom of illness 14.3 Sign of life-threatening disease 2.6 n = number of respondents to each question. 432 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم ety where people have access to information through the television, radio, internet and print media, it is surprising that such a large proportion of girls (37.2%), all of whom are in school, do not have prior knowledge about such an important event. Overall, a girl’s psychological reactions to menarche are the result of a complex interplay of biological, psychological and social influences. Genes, hormones, en- vironmental factors and nutrition influ- ence the initiation process of menstruation. However, peer relationships, self-esteem and the way she feels about being a woman determine how the adolescent adapts to the changes menarche imposes. Several researchers have expressed concerns about the observation that post- menarche girls, even when they are intel- lectually well prepared for menstruation, report more feelings of shame, apprehen- sion and disgust and less pride than their pre-menarche peers [7]. If girls are mentally prepared for menarche, then the chances of depression or low self-esteem after ex- periencing menarche decrease; Ulman has reported such a finding [10]. Puberty initiation rites heralding me- narche are common in many cultures. Paige reflected that societies with the highest levels of social rigidity and male solidar- ity also have the strongest codification of menstrual taboos [11]. This may reflect a need to maintain clear sex roles, often by controlling women and their fertility. Social and cultural factors impact on adjustment to menses and have an effect on the early experiences of menarche. Certain common features were observed, however, in that most girls reported their mothers as a princi- pal source of information and received some limited education about menses in school with frequent emphasis on the hygienic aspects of menstruation. Since it is a very sensitive issue, girls prefer to report such things first to the woman they trust most. This highlights the need for health edu- cation and inclusion of such topics in their school and college curricula. Education about the menarche has come a long way in the last 50 years, although it is still given in very few schools and colleges in India. However, in trying to convey menstruation as normal and natural, and in directing girls to continue with their lives as usual, we have ignored some of the nuisance as- pects of menstruation. Girls are left to find these things out for themselves, perhaps contributing to post-menarche feelings of apprehension, shame and disgust. There is a need to acknowledge both positive and negative feelings about menstruation. In addition to the facts about physiology and hygiene, girls need an opportunity to talk about their reactions to body changes, looking older, growing up and parental and peer expectations. Because girls’ attitudes and ways of thinking change during early adolescence, menstrual education needs to be an ongoing process. References 1. Whisnant L, Zegans L. A study of attitude towards menarche in white middle class American girls. American journal of psy- chiatry, 1975, 132(8):809–14. 2. Brooks-Gunn J, Ruble D. Menarche. In: Dan AJ, Graham EA, Beecher CP, eds. The menstrual cycle, volume 1. New York, Springer, 1980:141–59. 3. Williams LR. Beliefs and attitude of young girls regarding menstruation. In: Golub S, ed. Menarche. Lexington, Massachusetts, Lexington Books, 1983:139–48. 4. Koff E, Rierdan J. Early adolescent girls’ understanding of menstruation. Women health, 1995, 22(4):1–21. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 433 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 5. Peterson AC. Menarche: meaning of measures and measuring meaning. In: Golub S, ed. Menarche. Lexington, Mas- sachusetts, Lexington Books, 1983:63– 76. 6. Rierdan J. Variations in the experience of menarche as a function of prepared- ness. In: Golub S, ed. Menarche. Lex- ington, Massachusetts, Lexington Books, 1983:119–26. 7. Rierdan J, Koff E. Timing of menarche and initial menstrual experience. Jour- nal of youth and adolescence, 1985, 14(3):237–43. 8. Logan DD. The menarche experience in twenty-three foreign countries. Adoles- cence, 1980, 15:247–56. 9. Swenson I, Havens B. Menarche and menstruation: a review of the literature. Journal of community health nursing, 1987, 4(4):199–210. 10. Ulman KH. Impact of menarche on self- image and mood in adolescent girls. Pa- per presented at the meeting of the Amer- ican Psychological Association, Toronto, August, 1984. 11. Paige KE. Virginity rituals and chastity control during puberty: cross cultural pat- terns. In: Golub S, ed. Menarche. Lex- ington, Massachusetts, Lexington Books, 1983:155–74. Adolescent sexual and reproductive health research The needs of adolescents remain poorly understood or served in much of the world. Neglect of this population has major implications for the future, since sexual and reproductive behaviours during ado- lescence have far-reaching consequences for people’s lives as they develop into adulthood. The work of the WHO Department of Reproductive Health and Re- search encompasses adolescent sexual and reproductive health and focuses on promoting research and filling gaps in the evidence base on the sexual health situation and needs of adolescents in developing countries; related to this are activities intended to strengthen research capacity and disseminate findings. Further information about adolescent reproductive health research can be found at the WHO Department of Reproductive Health and Research website at http://www.who.int/reproductive-health/adoles- cent/intro.en.html 434 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Prevalence and risk indicators of myopia among schoolchildren in Amman, Jordan Y.S. Khader,1 W.Q. Batayha,2 S.M.I. Abdul-Aziz3 and M.I. Al-Shiekh-Khalil 3 1Department of Community Medicine, Public Health and Family Medicine; 3Faculty of Medicine/Jordan University of Science & Technology, Irbid, Jordan (Correspondence to Y.S. Khader: yousef.k@excite.com). 2Ministry of Health/Princess Basma Teaching Hospital, Irbid, Jordan. Received: 12/10/04; accepted: 09/01/05 ABSTRACT We aimed to identify the prevalence and risk factors of myopia among secondary-school students in Amman. Thus 1777 (1081 males and 696 females) students aged 12–17 years old were recruited from 8 schools randomly selected from 8 different geographic locations in Amman. Data were collected by questionnaire, and self-reported myopia was checked against school medical records. The prevalence of myopia was 17.6%, with no significant difference between males and females after adjusting for other possible variables. Myopia was significantly associated with age, family history of myopia, computer use, and reading and writing outside school. Playing sports was inversely associated with myopia but there was no association with watching television. Prévalence et indicateurs de risque de la myopie chez des collégiens à Amman (Jordanie) RÉSUMÉ Notre objectif était d’identifier la prévalence de la myopie et les facteurs de risque chez des élèves du secondaire à Amman. Ainsi, 1777 élèves (1081 garçons et 696 filles) âgés de12 à 17 ans ont été recrutés dans 8 écoles choisies au hasard dans 8 lieux géographiques différents à Amman. Des données ont été recueillies par questionnaire et la myopie déclarée a été vérifiée par rapport aux dossiers médicaux scolaires. La prévalence de la myopie était de 17,6 %, sans différence significative entre les garçons et les filles après ajustement en fonction d'autres variables possibles. La myopie était significativement associée à l’âge, aux antécédents familiaux de myopie, à l'utilisation d'un ordinateur, et à la lecture et l’écriture en dehors du cadre scolaire. Pratiquer un sport était inversement associé avec la myopie mais regarder la télévision n’était pas un facteur associé. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 435 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction Myopia is the most common eye disorder in the world. High myopia (> –6 diopters) may be associated with glaucoma, cataract, retinal degeneration and myopic macular degeneration [1]. Several studies worldwide have shown that the prevalence of myopia varies consid- erably from one geographic area to another and that the prevalence has been increasing over that past few decades [2]. It is reported to be high (up to 80%) in the student popu- lation in Asia [2]. In a national survey of children in Taiwan, Lin et al. reported the prevalence of myopia to be over 70% [3]. Considerable research has been done to determine the risk factors of myopia [4–17]. The results of these investigations support both genetic and environmental compo- nents. Physiological myopia is thought to be a multifactorial condition with both genetic and environmental factors [4]. Twin stud- ies and segregation analysis studies have indicated that myopia is hereditary [5]. On the environmental front, near work is the most commonly implicated environmental factor, both by animal studies in monkeys [6–8] as well as by epidemiological studies [9]. Other possible risk factors include age, sex, education, occupation, intelligence, high socioeconomic status and decreased outdoor activities [10–16]. Studies on eye diseases in Jordanian schoolchildren are rare and there are few data on myopia [18]. Therefore, this study was conducted to identify the prevalence and risk factors of myopia among second- ary-school students in Amman in order to provide baseline information on this condi- tion for health care organizations. Methods This was a cross-sectional study of school- children aged 12–17 years attending sec- ondary schools in Amman city. There are a total of 770 schools in Amman with a total of 240 634 students. We divided Amman into 8 geographic locations of approximate- ly the same size of student population and 1 school from each location was selected by simple random sampling. Two of these schools were private and the other 6 were public schools. All children (1931) between 12 and 17 years of age in the 8 selected schools were asked for their and their par- ents’ permission to participate in this study. A total of 1777 (92%) of the children agreed to participate: 1081 males and 696 females. A questionnaire was constructed with the help of 2 ophthalmologists and was pilot tested with 75 children. The questionnaire was modified accordingly and given to all students by trained members of the research team who explained the purpose of this study and how to complete the questionnaire properly. The students were asked to fill the questionnaire at home in the presence and with the help of one of their parents. Partici- pants were followed up to ensure return of the questionnaire. The section of the ques- tionnaire concerning self-reported myopia and other eye problems was rechecked from the school medical records which contain a yearly updated eye test. Myopia was defined as spherical error of at least –0.50 diopters. Information on age, sex, socioeconomic status and family history of myopia was obtained. Near-work activity (visual task performed at a near distance) was measured by questions on the amount of time in hours per day spent on near-work 436 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم activity outside school on weekdays and weekends. Individual near-work activity tasks included reading and writing, watch- ing television and working on the computer. Information about physical exercises was also collected. Descriptive statistics, univariate analy- sis using the chi-squared test for categorical variables and independent t-test for continu- ous variables, and binary logistic regression were performed using SPSS, version 11.0. A P-value < 0.05 was considered statisti- cally significance. Results Table 1 shows the demographic characteris- tics and family history of myopia of the 1777 children (60.8% males and 39.2% females). About 8.6% of children were 12 years old, 19.2% were 13 years old, 21.9% were 14 years old, 18.6% were 15 years old, 23.4% were 16 years old, and 8.3% were 17 years old. A total of 54.6% of children had a family history of myopia. Overall, there were 313 (17.6%) children with myopia. The prevalence of myopia was significantly higher in females (20.3%) com- pared to males (15.9%) (P = 0.019). Myopia was also significantly related to age. The prevalence was lowest for the youngest age group (7.8%) and increased until it reached 20.6% for 14-year-old children. After this age, the prevalence decreased gradually. The prevalence among children varied according to the family history based on who was af- Table 1 Demographic characteristics, family history of myopia, and the prevalence of myopia among schoolchildren aged 12 to 17 years old in Amman, Jordan Variable No. Children with P-value examined myopia No. % Sex 0.019 Male 1081 172 15.9 Female 696 141 20.3 Age (years)a < 0.001 12 154 12 7.8 13 340 42 12.4 14 388 80 20.6 15 331 67 20.2 16 415 83 20.0 17 147 29 19.7 Family history of myopia < 0.001 No family history 807 70 8.7 1 myopic parent only 277 50 18.1 2 myopic parents only 66 16 24.2 1 myopic parent with at least 1 myopic sibling 516 129 25.0 2 myopic parents with at least 1 myopic sibling 111 48 43.2 aThe ages of 2 participants were missing. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 437 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم fected and the number of persons affected in the family. The prevalence was 8.7% for those who had no family history, and was highest for those with 2 myopic parents and with at least 1 myopic sibling (43.2%). With regard to the activities outside school, myopic and non-myopic children differed in the time they spent on these activities (Table 2). Myopic children spent significantly more time reading and writing outside school and in computer work compared with non- myopic children. Although myopic chil- dren spent less time watching television (1.7 hours per day) compared to non-myopic children (1.8 hours per day), this difference was not significant. On the other hand, myopic children spent significantly less time (1.87 hours per day) playing sports compared to non-myopic children (4.04 hours per day). In the binary logistic regression analysis, the variables that were significantly associ- ated with having myopia were age, family history, computer work, playing sports and reading/writing at home (Table 3). The odds of having myopia increased by 16% and 24% for each additional 1 hour spent on computer work and writing/reading outside of school respectively. While watching television was not significantly associated with myopia, playing sports was negatively associated with myopia. Discussion The occurrence of myopia varies in different countries as well as different localities [19,20]. The prevalence of myopia among school- Table 2 Difference between myopic and non-myopic children in the time they spend on activities outside school Activity No myopia Myopia t-test P-value (n = 1464) (n = 313) Mean SD Mean SD Watching television 1.80 0.79 1.71 0.48 1.94 0.0525 Playing sports 4.04 2.82 1.87 2.33 12.72 < 0.0001 Reading and writing 2.54 1.45 3.07 1.53 5.81 < 0.0001 Using the computer 0.69 0.64 0.95 0.46 6.82 < 0.0001 SD = standard deviation. Table 3 Factors associated with myopia in binary logistic regression analysis Variable Odds 95% ratio confidence interval Agea (years) 13 1.51 0.74–3.09 14 2.45 1.24–4.85 15 2.45 1.23–4.89 16 2.78 1.41–5.49 17 2.40 1.12–5.14 Family historyb 1 myopic parent 2.20 1.58–3.06 2 myopic parents 3.37 1.77–6.42 1 myopic parent with at least 1 myopic brother/sister 4.75 3.19–7.06 2 myopic parents with at least 1 myopic brother/sister 5.44 2.65–9.88 Activity Using a computer 1.16 1.06–1.26 Playing sports 0.89 0.86–0.93 Reading and writing at home 1.24 1.14–1.35 aReference group = age 12 years. bReference group = no family history of myopia. 438 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم children in Amman in our study was 17.6%. The prevalence was significantly higher in females than males but this difference was no longer significant after adjusting for other possible variables. The prevalence of myopia was significantly associated with age, being the lowest in the youngest age group. Chil- dren with a family history of myopia were more likely to have myopia. With regard to activities outside of school, myopic children spent significantly more time in computer work and reading and writing and less time in sports activities. These relationships remained significant even after controlling for possible confounders. On the other hand, hours spent watching television were not associated with myopia. The prevalence of myopia in the 12-year- olds in our study (7.8%) was slightly higher than that in Oman for the same age group (5.16%) [21]. Our results are consistent with previous epidemiological studies and sup- port the evidence of the near-work hypoth- esis [16,22]. The association between daily hours spent on reading and writing outside school and myopia was consistent with re- sults obtained from other cross-sectional and case–control studies [8,16,19–23]. The association we found between myopia and number of parents with myopia contra- dicts the results of a cross-sectional study of myopia in kindergarten children in Singapore [24], while it supports the results of another study that indicated that there is a familial component in myopia [5]. As our study was limited to data from 8 schools it may not be possible to generalize the results to the whole Jordanian population. Prospective longitudinal studies are needed to establish a causal relationship between near work and myopia in this age group. Similar measurements taken at birth to establish if such a state is congenital may provide further insight into the inheritance of myopia. Future studies should involve large sample sizes and long follow-up periods. References 1. Mavracanas TA et al. Prevalence of myo- pia in a sample of Greek students. Acta ophthalmologica Scandinavica, 2000, 78(6):656–9. 2. Lin LL et al. Epidemiologic study of the prevalence and severity of myopia among schoolchildren in Taiwan in 2000. Journal of the Formosan Medical Association, 2001, 100(10):684–91. 3. Lin LL et al. Nation-wide survey of myopia among schoolchildren in Taiwan, 1986. Acta ophthalmologica. Supplement, 1988, 185:29–33. 4. Grosvenor TP. Primary care optom- etry: anomalies of refraction and b i n o c u l a r v i s i o n , 3 r d e d . B o s t o n , B u t t e r w o r t h – Heinemann, 1996:76–9. 5. Sorsby A, Sheridan M, Leary GA. Refrac- tion and its components in twins. MRC Report No 303. London, HMSO, 1962. 6. Wiesel TN, Raviola E. Myopia and eye enlargement after neonatal lid fusion in monkeys. Nature, 1977, 266(5597):66–8. 7. Young FA. The effect of restricted visual space on the primate eye. American jour- nal of ophthalmology, 1961, 52:799–806. 8. Wallman J, Turkel J, Tracatman J. Ex- treme myopia produced by modest change in early visual experience. Science, 1978, 201(4362):1249–51. 9. Richler A, Bear JC. Refraction, near- work and education. A population study in Newfoundland. Acta ophthalmologica, 1980, 58(3):468–78. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 439 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 10. Sperduto RD. Prevalence of myopia in the United States. Archives of ophthalmology, 1983, 101:405–7. 11. Angle J, Wissmann DA. The epidemiol- ogy of myopia. American journal of epide- miology, 1980, 111(2):220–8. 12. Au Eong KG, Tay TH, Lim MK. Race, culture and myopia in 110,236 young Singaporean males. Singapore medical journal, 1993, 34(1):29–32. 13. Zhao J et al. Refractive error study in chil- dren: results from Shunyi District, China. American journal of ophthalmology, 2000, 129:427–35. 14. McBrien NA, Adams DW. A longitudinal investigation of adult-onset and adult- progression of myopia in an occupational group. Refractive and biometric findings Investigative ophthalmology & visual sci- ence, 1997, 38:321–33. 15. Teasdale TW, Fuchs J, Goldschmidt E. Degree of myopia in relation to intel- ligence and educational level. Lancet, 1988, 2:1351–4. 16. Wong L et al. Education, reading, and fa- milial tendency as risk factors for myopia in Hong Kong fishermen. Journal of epi- demiology and community health, 1993, 47(1):50–3. 17. Ito-Ohara M et al. Clinical course of newly developed or progressive patchy chorio- retinal atrophy in pathological myopia. Ophthalmologica, 1998, 212:23–9. 18. Mallen EA et al. Refractive error and ocular biometry in Jordanian adults. Ophthalmic & physiological optics, 2005, 25(4):302–9. 19. Lam CS, Goh WS. The incidence of re- fractive errors among schoolchildren in Hong Kong in relationship with the optical components. Clinical & experimental op- tometry, 1991, 74:97–103. 20. Saw SM et al. Epidemiology of myopia. Epidemiologic reviews, 1996, 18(2):175– 87. 21. Lithander J. Prevalence of myopia in school children in the Sultanate of Oman: a nation-wide study of 6292 randomly selected children. Acta ophthalmologica Scandinavica, 1999, 77(3):306–9. 22. Zylbermann R, Landau D, Berson D. The influence of study habits on myopia in Jewish teenagers. Journal of pediatric ophthalmology and strabismus, 1993, 30:319–22. 23. Ling SL et al. Myopia in ten year old chil- dren – a case control study. Singapore medical journal, 1987, 28(4):288–92. 24. Tan GJ et al. Cross-sectional study of near work and myopia in kindergarten children in Singapore. Annals of the Academy of Medicine, Singapore, 2000, 29(6):740–4. 440 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Influence of Surgicel gauze on the incidence of dry socket after wisdom tooth extraction A.M. Suleiman1 1Faculty of Dentistry, University of Khartoum, Khartoum, Sudan (Correspondence to A.M. Suleiman: drahmedsuliman@yahoo.com). Received: 28/09/03; accepted: 11/11/04 ABSTRACT At a hospital in Damman, Saudi Arabia, it was noticed that many patients had developed dry socket after surgical removal of wisdom teeth. To enhance haemostasis, Surgicel™ (oxidized cel- lulose) gauze was sometimes used in the tooth socket in patients who were operated under general anaesthesia. An analysis was made of the records of 104 lower wisdom teeth removed surgically from 86 patients. The incidence of dry socket in the 20 Surgicel-treated teeth was 25.0%, compared with 6.0% among the 84 non-Surgicel-treated teeth. The use of Surgicel in wisdom tooth extraction seems to be associated with an increased incidence of dry socket. Influence du pansement Surgicel® sur l’incidence de l’alvéolite après extraction d’une dent de sagesse RÉSUMÉ On a constaté dans un hôpital de Damman (Arabie saoudite) que de nombreux patients avaient développé une alvéolite après extraction chirurgicale d'une dent de sagesse. Pour améliorer l’hémostase, le pansement Surgicel® (cellulose oxydée) a parfois été utilisé dans l’alvéole dentaire chez des patients opérés sous anesthésie générale. Une analyse des dossiers de 104 extractions chirurgica- les de dents de sagesse inférieures réalisées chez 86 patients a été effectuée. L’incidence de l’alvéolite pour les 20 dents traitées avec des compresses Surgicel® s’élevait à 25,0 % contre 6,0 % pour les 84 dents n’ayant pas été traitées avec ces compresses. L’utilisation de Surgicel® dans l’extraction de dents de sagesse est associée à une augmentation de l'incidence de l’alvéolite. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 441 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction Dry socket or post-extraction alveolitis is a poorly understood form of inflammation occurring in a socket following removal of a tooth. The condition is more common in the mandible than in the maxilla and in the posterior teeth compared to the anterior [1–4]. There is no definitive cause for this condition but many precipitating factors have been implicated [5–8], including fre- quent changing of pressure-dressing gauze, frequent mouth rinsing [8], underlying infection [9–11], smoking [12], oral con- traceptive use [13], undue surgical trauma, [1–4,14] and excessive amounts of local anaesthesia [17]. In addition, the condition has been reported to occur more frequently in patients aged over 40 years [2,9]. Clinically the patient presents with pain often radiating to the ear on the same side as tooth extraction. Examination reveals an acutely painful tooth socket containing bare bone and some broken-down blood clots. Upon removal of the latter, the socket walls look white and clear of granulation tissue [3,4]. Several methods are reported to reduce the incidence of dry socket [16,19–22]. These include the use of chlorohexidine mouthwashes [20,22], the placement of medicated packing into the extraction sock- ets [22,23] and the prophylactic use of metronidazole and lenampicillin [24,25]. Oxidized regenerated cellulose gauze (Surgicel™, Johnson & Johnson, Piscata- way, New Jersey, USA) is a haemostatic packing agent that accelerates the clotting mechanism [25]. The material, when soaked with blood, swells to form a gelatinous mass that plugs the bleeding site and hence stops bleeding. Surgicel is one of the most commonly used bioabsorbable topical hae- mostatic agents used in general surgery. In periodontal surgery it was found to enhance healing [26], while in bone surgery it was reported to slightly retard healing [27,28]. Surgicel is not frequently used in oral surgery practice and the only indication of use is when there is bleeding that cannot be controlled by simple packing measures and suturing. In the Department of Oral and Maxil- lofacial Surgery of Al-Mouwasat Hospital, Dammam, Saudi Arabia, it was noticed that a number of patients developed dry socket after wisdom tooth removal under general anaesthesia. The records of these patients showed that in many cases Surgicel was placed in the tooth socket following tooth removal to enhance haemostasis. It was therefore decided to investigate the relation- ship between the occurrence of dry socket among these patients who had their wisdom teeth removed surgically and the use of the product Surgicel. Methods The records were studied for all patients who had their wisdom teeth removed surgi- cally during the period November 1996 to June 1998 at the Department of Oral and Maxillofacial Surgery, Al-Mouwasat Hos- pital. Patients operated outside this period as well as patients treated by general den- tists in the department were not included. Wisdom teeth with periapical pathosis or existing pericoronitis were excluded from this study. Carious wisdom teeth with no periapical pathology as well as wisdom teeth with treated pericoronitis were in- cluded in the study. One person (an oral and maxillofa- cial surgeon) performed all the surgical procedures. A class 1 envelope flap with a distal relieving incision was raised. The bone around the tooth was removed using an electrical drill. Of the lower wisdom 442 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم teeth removed under general anaesthesia, some sockets had Surgicel placed into them to achieve haemostasis. Black silk (3/0) suture was used to close the wound edges. All patients had an antibiotic cover of clindamycin 150 mg every 8 hours, for 6–7 days post-operatively, together with chorhexidine mouth rinse to be used every 8 hours, beginning the next day following the operation. Sutures were removed after 6 days. The results were analysed using the chi- squared test. Results The study included 86 patients (48 males, 38 females); 42 of these patients had their wisdom teeth (60 teeth) removed under general anaesthesia, while the remaining 44 patients had their wisdom teeth (44 teeth) removed under local anaesthesia. Mesio- angular impaction was the commonest type of impaction removed, followed by dis- toangular and horizontal impaction (56%, 37% and 8% of the patients respectively). The age of the patients ranged from 20 to 50 years. Of the 60 lower wisdom teeth removed under general anaesthesia, 20 sockets had Surgicel placed into them to achieve hae- mostasis. Overall 10 patients reported to the oral surgery clinic after 2–3 days complain- ing of severe pain at the site of surgery. Clinical examination revealed that all these patients had developed dry socket. Of the 10 patients, 7 were males and the remaining 3 were females. None of the females who developed this complication were taking oral contraceptives. The rest of the patients had an uneventful recovery. The overall incidence of dry socket was 9.6% (10/104 teeth removed) (Table 1). Of the teeth removed and treated with Surgicel, 25.0% (5/20 teeth) showed dry socket (Ta- ble 1). Two patients developed a short-lived numbness of the lower lip, probably due to surgical trauma. In patients who had both lower wisdom teeth removed, bilateral dry socket was not seen. In the teeth removed and treated without Surgicel, only 6.0% (5/84 teeth) developed dry socket, an inci- dence whish is significantly lower that the Surgicel-treated group (chi-squared test, P < 0.02). In the non-Surgicel group, 3/40 (7.5%) teeth were removed under general anaesthesia and 2/44 (4.5%) under local anaesthesia (P > 0.05, not significant) Discussion Dry socket results from a disruption of the normal healing mechanism. The incidence Table 1 Influence of Surgicel on the incidence of dry socket after wisdom tooth extraction Operation No. of teeth No. of dry Incidence extracted sockets % Without Surgicel 84 5 6.0 General anaesthesia 40 3 Local anaesthesia 44 2 With Surgicel 20 5 25.0 Total 104 10 9.6 P < 0.02, comparing groups treated with and without Surgicel. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 443 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم rate of this event is variable, ranging from 4.1% to 30%, and associated with a number of predisposing factors as well as the type of prophylaxis used [1,5,8]. In this study the overall incidence of dry socket after wisdom tooth removal was 9.6%, which is similar to other findings previously reported [1–4,7]. A higher rate of dry socket was found among patients having their wisdom teeth removed under general anaesthesia (7.5%) than under local anaesthesia (4.5%). This finding, although not significant, may be due to the severity of surgical trauma rendered, as many of these wisdom teeth were buried deep in the man- dible. The incidence of dry socket among the Surgicel-treated teeth was significantly higher (25.0%) than in the non-Surgicel- treated teeth (6.0%), under local and general anaesthesia. Surgicel is one of the most common biodegradable materials used to facilitate haemostasis and control bleeding. The ma- terial causes haemostasis by a physical mechanism rather than a chemical reaction, i.e. by compressing the bleeding vessels rather than influencing the clotting factors per se [25]. The phenomenon of dry sockets in patients in whom Surgicel was used is probably precipitated by the continued chemical effect of the material, which has been found to degrade and to resorb slowly at surgery sites [29,30]. According to the manufacturer’s instructions, users should be cautious when using Surgicel in solid bony cavities [25]. This may be the reason for our findings. However, this was a simple observational study and a properly designed experimental study is needed to take ac- count of the many confounding factors, such as the type of impaction of the tooth, the degree of impaction of the tooth, the amount of surgical trauma rendered, and the amount of debridement and socket washing performed. In summary, Surgicel is a potent hae- mostatic agent, the application of which in extraction sockets was associated with an increase in the incidence of dry socket after wisdom tooth extraction. If is to be applied it should be removed once haemostasis is achieved. References 1. Oginni FO, Fatusi OA, Alagbe AO. A clinical evaluation of dry socket in a Nige- rian teaching hospital. Journal of oral and maxillofacial surgery, 2003, 61(8):871–6. 2. Jaafar N, Nor GM. The prevalence of post-extraction complications in an out- patient dental clinic in Kuala Lumpur Ma- laysia—a retrospective survey. Singapore dental journal, 2000, 23(1):24–8. 3. Turner PS. A clinical study of “dry socket”. International journal of oral surgery, 1982, 11:226–31. 4. Sisk AL et al. Complications following re- moval of impacted third molars: the role of the experience of the surgeon. Journal of oral and maxillofacial surgery, 1986, 44:855–59. 5. Quinley JF et al. “Dry socket” after man- dibular odontectomy and use of soluble tetracycline hydrocholoride. Oral surgery, oral medicine, and oral pathology, 1960, 13:38–42. 6. Birn H. Aetiology and pathogenesis of fibrinolytic alveolitis (dry socket). Inter- national journal of oral surgery, 1973, 2:211–63. 7. Krekmanov L, Hallander HO. Relation- ship between bacterial contamination and alveolitis after third molar surgery. International journal of oral surgery, 1980, 9:274–80. 8. Sweet JB, Butler DP. Predisposing and operative factors: effect on the inci- dence of localized osteitis in mandibular 444 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم third-molar surgery. Oral surgery, oral medicine, and oral pathology, 1978, 46: 206–15. 9. Rud J. Removal of impacted lower third molars with acute pericoronitis and necro- tising gingivitis. British journal of oral sur- gery, 1970, 7:153–60. 10. Nitzan DW. On the genesis of “dry socket”. Journal of oral and maxillofacial surgery, 1983:41:706–10. 11. Sorensen DC, Preisch JW. The effect of tetracycline on the incidence of post- extraction alveolar osteitis. Journal of oral and maxillofacial surgery, 1987, 45:1029– 33. 12. Sweet JB, Butler DP. The relationship of smoking to localized osteitis. Journal of oral surgery, 1979, 37:732–5. 13. Garcia AG et al. Does oral contraceptive use affect the incidence of complications after extraction of a mandibular third mo- lar? British dental journal, 2003, 194(8): 453–5. 14. Hansen EH. Alveolitis sicca dolorosa (dry socket): frequency of occurrence and treatment with trypsin. Journal of oral surgery, anaesthesia and hospital dental service, 1960, 18:409–16. 15. Swanson AE. Reducing the incidence of dry socket: a clinical appraisal. Journal of the Canadian Dental Association, 1966, 32:25–33. 16. Sweet JB, Butler DP, Drager JI. Effect of lavage techniques with third molar sur- gery. Oral surgery, oral medicine, and oral pathology, 1976, 41:152–8. 17. Lehner T. Analysis of one hundred cas- es of dry socket. Dental practice, 1958, 8:75. 18. Meyer RA. Effect of anaesthesia on the incidence of alveolar osteitis. Journal of oral surgery, 1971, 29:724–6. 19. Sweet JB et al. Nitroblue tetrazolium and Limulus assays for bacteremia after den- tal extraction: effect of topical antiseptics. Journal of the American Dental Associa- tion, 1978, 96:276–82. 20. Hermesch CB et al. Perioperative use of 0.12% chlorhexidine gluconate for the prevention of alveolar osteitis: efficacy and risk factors analysis. Oral surgery, oral medicine, oral pathology, oral ra- diology, and endodontics, 1998, 85(4): 381–7. 21. Trieger N, Schlagel GD. Preventing dry socket. A simple procedure that works. Journal of the American Dental Associa- tion, 1991, 122:67–8. 22. Bloomer CR. Alveolar osteitis prevention by immediate placement of medicated packing. Oral surgery, oral medicine, oral pathology, oral radiology, and endodon- tics, 2000, 90(3):282–4. 23. Rood JP, Murgatroyd J. Metronidazole in the prevention of “dry socket”. British journal of oral surgery, 1979, 17:62–70. 24. Yoshii T et al. Differences in postoperative morbidity rates, including infection and dry socket, and differences in healing process after mandibular third molar sur- gery in patients receiving 1-day or 3-day prophylaxis with lenampicillin. Journal of infection and chemotherapy, 2002, 8(1): 87–93. 25. Essential product information: Surgicel, Surgicel Fibrillar and Surgicel Nu-Knit absorbable hemostats (oxidized regen- erated cellulose). Piscataway, New Jer- sey, Johnson & Johnson, (http://www. jnjgateway.com/public/USENG/SURGI- CEL_FIBRILLAR_Labeling_Information. pdf, accessed 8 January 2006). 26. Galgut PN. Oxidized cellulose mesh. I. Bi- ogradable membrane in periodontal sur- gery. Biomaterials, 1990, 11(8):561–4. 27. Mattsson T et al. ACP and Surgicel in bone hemostasis. A comparative ex- perimental and histologic study. Swedish dental journal, 1990, 14(2):57–62. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 445 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 28. Matthew IR et al. Subperiosteal behaviour of alginate and cellulose wound dressing materials. Biomaterials, 1995, 16(4):275–8. 29. Singh M et al. Potential biosoluble carri- ers: biocompatibility and biodegradability of oxidized cellulose. Biomaterials, medi- cal devices, and artificial organs, 1997, 7(4):495–512. 30. Voormolen JH et al. Hemostatic agents: brain tissue reaction and effectiveness. A comparative animal study using collagen fleece and oxidized cellulose. Neurosur- gery, 1987, 20(5):702–9. Communicable disease profile for Iraq The Communicable disease profile for Iraq aims to provide up-to-date information on the major communicable disease threats faced by the emergency-affected population. The list of endemic and epidemic diseases has been selected on the basis of the burden of morbidity and mortality and includes acute lower respiratory tract infections (ALRI), cholera, bacillary dysentery, measles, leishmaniasis, malaria, meningitis and tuberculosis. Diseases that have global eradication or elimination goals are also included. The document outlines the burden of communicable diseases in Iraq for which data are available, provides data on recent outbreaks in the country, and presents disease-specific guidelines on the prevention and control of these diseases. The Profile also includes an annex on the incidence of major communicable dis- eases and vaccination coverage rates in the 6 countries neighbouring Iraq. For more information contact the Communicable Diseases in Complex Emergencies Programme, Communicable Disease Cluster, HQ/Geneva http://www.who.int/infectious-disease-news/IDdocs/whocds200317/ index.htm Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 446 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Review Wastewater reuse for agriculture: regional health perspective S.S. Al Salem1 and H. Abouzaid1 1World Health Organization Regional Centre for Environmental Health Activities, Amman, Jordan (Correspondence to S.S. Al Salem: alsalems@ceha.emro.who.int). 2Supportive Environmental Health, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. Received: 18/11/01; accepted: 22/09/04 ABSTRACT The Eastern Mediterranean Region of the WHO is the poorest region in the world in water resources as a Region and per capita. This paper summarizes existing practices and constraints re- garding wastewater treatment and reuse in the Region and describes the health impact of inappropriate practices. Appropriate treatment for agricultural use from the health point of view, and the health regula- tions and guidelines for wastewater reuse in the Region are outlined. The work of the WHO Regional Office to assist countries face the challenges of water scarcity and wastewater reuse are described. Finally, key suggestions that could enhance the use of reclaimed wastewater while at the same time safeguarding human health are presented. D
E 376 {"(DK4%?c <= #$  1 :;™36\s3€`73h[J`5P3WYC3 3 ! 23433<@3†e6ZOP3¨Ww53N>OJ?5P3NBQ5P3NRST@3}>G‘l3ž:ª?;J@3M3zP6e3h¸J>OP38pJQ@3Ý>73<@3[J?5P3}>5J‘s3WY¤s 3pW¤3KL3¡>Qj3N>7Jj3<@39s3hKqL3}>G‘J\3‚ÛG?Z;3m‡pJHl3h8JRƒOP3Pgr3M3J“`bj3íW¢X3¿5P3a6G­P3:7s3K?59 WƒX3c3N>b>q\3J“b>Š6X3Å3J@3Pnl3h¸J>OP38pJQ@3FGH3ŠJb­P3M3}“`X3:‘3NY;W‹3Ar93hvxƒb5P3¸J>@3IP:ZeP 5J\3p8P6OP3/b°93iJ`jP3NBC3AR°3É6Ge§\93hNâ>d3mN>5J­P3vJe8JROP3N>¥Bd5P3N‘865P3¸gr3ŸßGX3=}ª¬3<@9 ¸gr3<H3}—JT5P3ABQ5P3W¬…P3ˆQX3JRL3h}>G‘P3M3J“@P:ZeP3‡pJHl93½WQ5P3¸J>@3NJ?@3FGH3p6>Y5P9 ¸J>O3NdeJTOP3NJ?OP3 l3¨=W¢ZX3}¬3hNR‰xOP3tu3vJe8JROPaJ”3M3J“@P:ZeP3}Z>53hABQ5P386STOP3<@3vxƒb5P3 3}>G‘P3M3½WQ5P3¸J>@3IP:ZeP3‡pJH²\3NYVG?ZOP3hN@J?5P3pJdOP93N>BQ5P3}~SžT5P3|PW?ZeP3<H3oxƒ¤3hNHP8U5Pm vJ;Œ:BZ5P3N“—P6@3FGH3iP:Gd5P3‡:HJ`@3M3hNRSTRG53AR>G‘P3¡ZqOP3p6“—3FGH3z6ƒ5P3NeP8:5P3¸gr3AYGX9 3vxƒb5P3¸J>@3IP:ZeP3‡pJHl93h¸J>OP3‡8:j3<H3N¯JT5P3m™ŒU?X3¿5P3N>eJe…P3vJ7PWZ‘cP3N‘865P3íW¢X3IJZ^P3M9 38PWL53NG\JY5P3vxƒb5P3¸J>@3IP:ZePrecyclingiJ`jP3NBC3FGH3ŠJb­P3_@3hm3 3 Réutilisation des eaux usées en agriculture : perspective sanitaire régionale RÉSUMÉ La Région OMS de la Méditerranée orientale est la région la plus pauvre du monde en ressources hydriques en tant que région et par habitant. Le présent article fait une synthèse des prati- ques et contraintes existantes en ce qui concerne le traitement et la réutilisation des eaux usées dans la Région et décrit l’impact sur la santé des pratiques inadéquates. Le traitement approprié des eaux usées pour utilisation dans l’agriculture d’un point de vue sanitaire, et les règlements et directives sani- taires pour la réutilisation des eaux usées dans la Région y sont exposés. L’action du Bureau régional de l’OMS pour aider les pays à faire face aux défis posés par la pénurie d’eau et la réutilisation des eaux usées y est décrite. En dernier, des suggestions clés qui permettraient de renforcer l’utilisation des eaux usées récupérées tout en préservant la santé humaine sont présentées. 447 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction The Eastern Mediterranean Region (EMR) of the World Health Organization is the dri- est region in the world. The region is poorly endowed for water; rainfall is low and poor- ly distributed. Drought and desert define the region. At the same time, water demand in the Region is growing fast and water avail- ability is falling to crisis levels [1]. As the population has grown against a background of finite freshwater resources, so the water available to individuals has fallen dramatically. In 1960, the average annual per-capita availability for the region was about 3300 m3 [2]. This has fallen by 60% to about 1250 m3 today. This is the lowest in the world and it is predicted to fall by another 50% to below 650 m3 by 2025. This figure covers all human activities, do- mestic, industrial and agricultural. In some countries, water availability is already well below the projected regional average 30 years from now. For example, in Yemen and Palestine, the per-capita availability today is less than 180 m3 [2]. Fortunately, solutions are available which reduce water consumption and de- mand in an environmentally acceptable manner. A number of technologies and devices can help water users to reduce their consumption and demand without any appreciable impact on lifestyles. These include minimizing unaccounted-for water (the difference between the quantity of water supplied to a city’s network and the metered quantity of water used by the customers), adopting a demand approach, wastewater reclamation and reuse and water conservation through low-flow toilets, low- flow shower heads and faucet flow restric- tors. Generally speaking, these technologies have been well received in the Region and have become steadily more popular as the cost of municipal water has risen. Adequate sanitation could be consider- ably expanded and pollution reduction achieved through on-site wastewater treat- ment and recycling systems that permit the reuse of greywater (all wastewater except toilet wastes and food wastes derived from garbage grinders) for landscape irrigation and toilet and urinal flushing. As an exam- ple, in the typical household, approximately 34% of water consumed is used in the flush- ing of toilets. The remaining 66% of the water for the most part is available for on- site recovery and reuse. On-site wastewater treatment and recycling systems can be used in all types of residential and commercial buildings and most types of institutional and industrial buildings. Further measures that could achieve significant water cutback in water con- sumption are the use of modern irrigation systems and the increase in plantation of high-value crops and decrease in plantation of crops that have high-water consumption but low economic value. Long-term plans in this context are likely to shift the economy from an agricultural-based to an industrial/ service-based economy. Other measures to overcome the water crisis could be achieved by using industrial water conservation and economic incentives, and maximising the recycling and reusing industrial waste- water. Wastewater reuse is an important ap- proach to help overcome the water scarcity problem of the Region. The objectives of this paper therefore are to summarize the existing practices of wastewater reuse and their environmental health effects and to suggest strategies to enhance the full use of reclaimed wastewater while at the same time safeguarding human health. A further objective is to list the constraints faced by the wastewater reuse sector, so that the countries of the Region can review the Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 448 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم problems and devise actions to overcome them. Wastewater reuse in the Region Wastewater reuse in the Region could con- tribute significantly to solving the problem of quality and quantity of water. However, this does depend on how it is used. In terms of costs, it is the most feasible option to augment the water resources in the Region for the coming years (Table 1). As a result, wastewater reuse will have a major impact on the agricultural economy, as well as on the well-being and the health of the soci- ety. Wastewater reuse is already practised in the Region [5]. The total quantity of reused treated wastewater in EMR is estimated at 1200 million cubic metres (MCM) per year. The Syrian Arab Republic, Saudi Arabia and Egypt are the largest users of treated wastewater in absolute terms, accounting for almost 66% of all the wastewater reused in the Region, with the Syrian Arab Repub- lic alone accounting for almost 31% [6]. However wastewater is not yet being used to its full potential. At present, the Gulf Cooperation Council (GCC) countries recycle no more than 43% of their total treated wastewater, which con- tributes to 1.8% of their total water supply, being used mainly in landscaping, irrigation of fodder crops and some industrial uses. It is estimated that if only 50% of domestic water supplies in the GCC countries is treated and recycled in agriculture, recycled water will have the potential to meet more than 11% of their countries’ total water demand, satisfy more than 14% of the agri- cultural sector’s demand, and reduce fossil groundwater withdrawal by more than 15% by the year 2020 [7]. Appropriate treatment for agricultural use from the health point of view Currently, wastewater reuse in the Region is mostly haphazard and presents significant health risks, especially where untreated wastewater is used to irrigate vegetables [5]. To avoid the spread of diseases, waste- Table 1 Cost and options for enhancing water resources Option for enhancing Estimated water resources costs (in US cents/m3) Reducing end-user demand (recirculation, low-water use technology and leakage repair) 5–50 Rain water harvesting and cloud harvesting Variable Secondary treatment of wastewater for irrigation 16–60 Tertiary treatment of wastewater for irrigation 32–100 Greywater reuse for toilet flushing and landscape irrigation 11a Desalination of brackish water 45–70 Desalination of sea water 50–100 Water conveyance by pipelines 10–1500b Transport of water by marine vessels 0.5–1500b Transport of giant floating bags by sea, not including the costs of terminals, inland transport or purification 15–35b aInitial cost for combined wastewater treatment and recycling systems in larger commercial and industrial facilities/gross m2 [3]. bThe price of the water itself is not included. The cost depends mainly on the distance [4]. 449 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم water should be suitably treated for the type of the irrigated crop and in accordance with the health protection measures. Most of the treatment plants in the EMR use an activated sludge process followed, in some cases, by rapid sand filtration [8]. These techniques were developed to reduce the suspended matter load and oxygen de- mand of the discharged reclaimed waters and to reduce water eutrophication of the water bodies. These technologies are not efficient in removing pathogenic micro- organisms and are not intended to achieve high removal of excreted pathogens, while at the same time they may reduce substan- tially the nutrients for the soil. Their use in EMR, where excreted infections are endemic and where wastewater is mostly used for agriculture irrigation, is justifiable only in specific circumstances. The above situation has the following environmental and health impacts to differ- ing extents. • Soil, surface water and groundwater pollution occurs as a result of the dis- charge of untreated or partially treated wastewater into the environment. This can raise the nitrate concentration in the water and subsequently affect children and pregnant women. • Farm workers are at risk of infection as a result of direct or indirect contact with reclaimed effluent and contaminated soil. • Direct and indirect risks to human health exist as a result of consumption of pol- luted crops and fish, with especial impact on vulnerable groups such as pregnant women and children. • Contamination of the coastal seawater occurs, threatening swimmers, the fish- eries, as well as the marine ecosystems. There are alternative treatment pro- cesses available that are superior and can reduce the survival of excreted pathogens and bring the load to an acceptable level so that such water will not pose an unac- ceptable risk [9]. There are 6 processes that can achieve complete removal of helminth eggs and pathogenic larvae and an overall excreted pathogen reduction suitable for unrestricted irrigation. These processes are: • Waste stabilization ponds with detention time of more than 14 days for removal of nematode eggs and 21 days for inactiva- tion of Strongyloides stercoralis larvae. • Combination of treatment and effluent storage to reduce the required detention time. • Conventional secondary sewage treat- ment with the effluent upgraded in pol- ishing ponds. • Conventional secondary treatment fol- lowed by slow sand filtration. • Enhanced primary treatment either chemically or by using an up-flow sludge blanket reactor (site-specific fur- ther studies are needed to confirm the performance). • Conventional secondary sewage treat- ment with effluent filtration using mem- branes. Health effects of inappropriate wastewater treatment and reuse in the Region The main constraint in wastewater reuse in the Region continues to be the control of the spread of diseases due to inappropri- ate treatment and uncontrolled reuse of the reclaimed water. The chemical composition of wastewater is not discussed in this paper because we have restricted our review to domestic wastewater, where the chemical concentration is usually approximate to Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 450 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم drinking water quality, not industrial waste- water. Nevertheless the chemical effects of wastewater reuse and guidance are covered by manuals and guides published by the Food and Agriculture Organization. Significant occurrence of diseases is associated with wastewater irrigation and caused by pathogens, particularly helminths, which are neither detected by the techniques used in conventional microbiological monitoring of effluent quality nor removed completely by conventional wastewater treatment processes. Thus, helminthic infections (intestinal nematodes) pose the greatest risk to farm workers as well as to consumers of farm produce. Prevalence and intensity of helminth infections in the Region Intestinal parasitic diseases are endemic and quite widespread in the most countries of the Region. In Faizabad City, Afghanistan, it was found that the prevalence of ascariasis for male schoolchildren (7–12 years) was 96.6%, whereas the prevalence for female schoolchildren of the same age group was 79.5%. The highest prevalence was in the 7-year-old girls (87.05%) and the lowest prevalence was in 12-year-old girls (55.5%) (S. Al Salem, unpublished report, 1996). In Morocco, a study showed that the prevalence of intestinal helminthic infec- tions caused by 5 parasites (Ascaris lum- bricoides, Trichuris trichiura, Enterobius vermicularis, Hymenolepis nana and Tae- nia saginata) in children in the areas of wastewater use was 30.8% compared to only 5.6% among children living in the con- trol areas [10]. Children in the study sample suffered low-intensity infection with A. lumbricoides and T. trichiura. The parasite load of Ascaris infection, as expressed by the number of eggs per gram of faeces (epg), was much higher among children liv- ing in wastewater-exposed areas (18.3 epg) than unexposed areas (2.3 epg). In Amman, Jordan, the enforcement of the laws on the reuse of reclaimed water and the use of appropriate technology have led to a reduction in the concentration of intestinal nematodes in stabilization ponds influent to undetectable levels (data from the Royal Scientific Society in Amman). The health records show that the average rate of intestinal nematode infections was 1.33% among schoolchildren during the period of 1995–1999 (Ministry of Health, unpublished reports, 1995–1999). A study in Nablus, West Bank, Palestine of 6 years of accumulated data on 22 970 faecal specimens showed that the preva- lence of Ascaris was 17.7% and Trichuris was 1.3% [11]. A study from Gaza Strip showed that more than 50% of the children under the age of 10 years were infected with Ascaris [12]. A study of parasitic infestation and the use of untreated sewage for irrigation of vegetables in the Syrian Arab Republic showed that the domestic sewage of Aleppo contained 3340 Ascaris eggs/L, which rep- resents an Ascaris infestation rate of 42% of the total Aleppo population excreting an average of 800 000 eggs daily per person [13]. The correlation between the number of parasites in Aleppo and the irrigation of vegetables with sewage is that irrigation completes the cycle by returning the para- sites to the community. On the other hand, a sample of untreated sewage from the Syrian coastal town of Lattakia contained 460 Ascaris eggs/L. Untreated sewage is not used for irrigation in Lattakia and this is reflected in the lower parasite count of Lattakia sewage. A study carried out in 1999 showed that in the Barada river basin, which contains treated wastewater, 11.4% of the people were infected with Ascaris worms [14]. 451 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم A survey of the prevalence of some diseases related to wastewater from records of the health offices in Helwan, Egypt dur- ing the years 1994–1995 showed that 0.55% of the population in the area were infected with Ascaris in 1994 and 3% in 1995; 0.7% of the people were infected with Taenia in 1994 and 0.3% in 1995. The concentration of viable Ascaris eggs at the inlet of raw wastewater at the Helwan wastewater treat- ment plant (activated sludge) was 70 eggs/L while at the outlet (secondary effluent fol- lowed by chlorination for Helwan waste- water treatment plants) the viable Ascaris eggs were 15 eggs/L and the concentration of Ascaris eggs in the River Nile water at Faroque corner was 60 eggs/L. The result of clinical examination for Helwan sewage plant workers and some of the sewage farm workers showed that 38.2% had parasitic infections (Ascaris, Entamoeba histolytica and Giardia) [15]. In South Batinah Region, Oman an epidemiological study of intestinal parasitic infestation among schoolchildren showed that 19% of the children examined were infected with H. nana. The frequency of A. lumbricoides infection was relatively low (0.1%) and the infestation of Strongyloides was 5 per 1000 of the examined school- children (S. Al Salem, unpublished report, 1998). Wastewater reuse constraints in the EMR The Region’s low coverage in adequate sanitation and high infestation in sanita- tion-based diseases can be attributed to the following factors. • Institutional inefficiency is one of the major constraints in managing the sec- tor. There is an insufficient number of national professionals in the field of wastewater treatment design, opera- tion, and reuse; a lack of bylaws or their enforcement; political domination of the decision-making; short-term rather than long-term planning; and seepage of brackish or saline groundwater into the sewer system, which limits the reuse of wastewater. • Donor agencies tend to impose unsus- tainable/unaffordable technologies and projects, which are not within the long- term integrated planning or within the affordability of the community. • Trustworthy, valid, and reliable data and information are lacking in most of the countries in the Region. Informa- tion is scarce regarding quality, cover- age, use and cost. The inadequacy and insufficiency of the information can lead to incorrect planning and decisions. This situation does not permit correct decision-making either for the politi- cians or for the professionals. • There is inadequate and/or insufficient research into the situation at the regional and local level. The Region is reliant on research generated from Europe and North America. There are few surveys or investigations carried out in the Re- gion addressing the Region’s problems. There are Region-specific problems that need to be thoroughly investigated by the resource institutions and universi- ties located in the Region. More funds need to be allocated for the research and development in the field of wastewater treatment and reuse. • Inadequate financing exists in most countries of the Region. There is a need to reform the wastewater reuse sector and its operations, striking a balance between the capability of the sector to sustain itself and the health and social benefits of the people. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 452 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم • There is a lack of participation of the beneficiaries themselves in decision- making and an absence of consideration of the ability of communities to contrib- ute to the sector’s planning and invest- ment. The cultural and spiritual beliefs in the Region do not oppose the use of reclaimed wastewater for agriculture use, but for direct or indirect human con- sumption or body contact activities there will be social resistance for such reuse. • The coverage of adequate sanitation is low in the Region and the technology used for wastewater treatment is inad- equate and is not usually designed to be compatible with the end use, or the end discharge point. • The laws and regulations governing wastewater reuse in the Region are gen- erally weakly enforced or inadequate. • The primary measure for protection of health in wastewater reuse is the treat- ment used. In the Region, this is usually an expensive method or an unreliable one and is associated with the wrongly selected technology • Reclaimed water and greywater are not used to their full potential in the Region and the resources are often reused to ir- rigate low-value agricultural crops. • The costs of serving one household with a conventional sewer system are high due to the unusual terrain and topo- graphy of the Region, and the construc- tion of sewers which predominantly takes place after urbanization. All of these factors contribute to limiting the expansion of wastewater collection systems which consequently limits the wastewater available for reuse Health regulations and guidelines for wastewater reuse in EMR Most of the standards and government regulations in the Region are set as country effluent standards to control the quality of discharge. However, the fact is that the ap- plication of uniform effluent standards may be uneconomical and inappropriate [5]. Moreover, the effluent standard is usually too stringent and environmentally unjusti- fied. This is due to the great variation in the end uses covered by one uniform standard. It is suggested that standard discharge to stream be imposed only in the case of indi- rect reuse and to be based on using the total assimilative capacity of the rivers or water- courses and on the water quality level for the predominant water reuse downstream. Ultimately, water reuse standards must protect public health and the environment and must match with end reuse objectives and the methods of application. Most of the EMR standards are based either on United States Environmental Protection Agency (USEPA) or WHO guidelines regardless of the end use or the country’s disease profile. But most of the time these standards are not reinforced. Some countries with a high prevalence of sanitation-based diseases lack the proper standards for reuse of waste- water. A consultation was convened in CEHA/WHO for professionals in the field of wastewater treatment and reuse in the Region in October 2003; guidance criteria were suggested at this meeting for health as- pects of wastewater reuse which reflect the health map of the Region (Table 2) [16]. 453 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Ta bl e 2 R ec om m en de d re v is ed m ic ro bi ol og ic al g ui de lin es fo r tr ea te d w as te w at er u se in a gr ic ul tu re [1 7]a Ca te go ry /re us e Ex po se d Irr ig at io n In te st in al Fa ec al c ol ifo rm s W as te w at er tr ea tm en t co n di tio ns gr o u p te ch ni qu e n em at od es b (g eo m et ric m ea n ex pe ct ed to a ch ie v e (ar ith me tic m ea n n o ./1 00 m Lc ) re qu ire d m ic ro bi ol og ic al n o . o f e gg s/ Lc ) qu al ity A. Un re st ric te d irr ig at io n W a st e st ab iliz at io n po nd s wi th a Fo r ve ge ta ble a nd W o rk e rs , co n su m e rs , An y < d et ec tio n ≤ 10 3 re te nt io n tim e of 2 1 da ys o r sa la d cr op s ea te n th e pu bl ic se co n da ry tr ea tm en t f o llo w e d u n co o ke d, s po rts by e qu iva le nt s to ra ge o r s lo w fie ld s, pu bl ic p ar ks d sa n d filt ra tio n or e qu iva le nt B. R es tri ct ed ir rig at io n Ce re al c ro ps , W o rk e rs , n e a rb y Sp ra y o r < d et ec tio n ≤ 10 5 As fo r ca te go ry A in du st ria l c ro ps , co m m u n iti es sp rin kl er fo dd er c ro ps , Fl oo d/ fu rro w < d et ec tio n ≤ 10 3f As fo r ca te go ry A pa st ur e an d tre es e C. Lo ca liz e d irr ig at io n N on e Tr ick le , dr ip o r N ot a pp lic ab le N ot a pp lic ab le Pr e- tre at m en t a s re qu ire d by o f c ro ps in c at eg or y bu bb le r th e irr ig at io n te ch no lo gy , B if e xp os ur e of bu t n ot le ss th an p rim ar y w o rk e rs a n d th e pu bl ic se di m en ta tio n do es n ot o cc ur a In s pe cif ic ca se s, lo ca l e pi de m io lo gi ca l, so cio cu ltu ra l a nd e nv iro nm en ta l f a ct or s sh ou ld b e ta ke n in to a cc ou nt a nd th e gu id el in e s m o di fie d ac co rd in gl y. b F o r As ca ris a n d Tr ic hu ris sp ec ie s an d ho ok wo rm s, th e gu id el in e lim it is al so in te nd ed to p ro te ct a ga in st ri sk s fro m p ar a si tic p ro to zo a . c G ui de lin e va lu es a re g ive n fo r de sig n pu rp o se s. Th ey sh ou ld b e ac hi ev e d du rin g th e pl an ni ng a nd d es ig n st ag es fo r e ffl ue nt re us e p ro jec ts, a n d no t u se d as a st an da rd s pe cif ica tio n fo r m o n ito rin g ef flu en t q ua lity a nd s am pl e co lle ct io n. d A m or e st rin ge nt g ui de lin e lim it (£ 20 0 fa e ca l c ol ifo rm s/ 10 0 m L) is ap pro pri a te fo r pu bl ic la w n s, su ch a s ho te l l aw n s, w ith w hi ch th e pu bl ic m ay c om e in to d ire ct co n ta ct . e In th e ca se o f f ru it tre es , irr ig at io n sh ou ld s to p 2 we e ks b ef o re th e fru it is p ick e d, a nd n o fru it sh ou ld b e pi ck e d of f t he g ro u n d. Sp ra y/ sp rin kl er ir rig at io n sh ou ld n ot be u se d. f In c as es w he re th e tre at m en t m et ho d fa ils to a ch ie ve th e gu id el in e lim it, u se fa e ca l c ol ifo rm s < 1 05 , pr ov id ed th at p re ca ut io ns a re ta ke n s u ch a s pr ot ec tiv e cl ot he s, cr o p re st ric tio n an d pr ov id in g a bu ffe r zo n e b et we e n th e irr ig at ed a re a an d ne ar by co m m u n iti es . Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 454 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Specific health issues In 1989, WHO published new guidelines for wastewater use in agriculture and aqua- culture [9]. The guidelines included a new dimension, which had not been considered in the previous WHO reports on reuse [17]. The new guidelines set microbiological quality criteria for wastewater use in the irrigation of: crops to be eaten cooked or eaten raw, sports fields, public parks, cereal crops, industrial crops, fodder crops and trees. The new dimension in the guidelines required that treated wastewater should contain less than 1 nematode egg/L. In ad- dition to nematode eggs, the faecal coliform criteria have been revised and state that treated wastewater should contain less than 1000 faecal coliforms per 100 mL for veg- etables eaten raw. The 1989 WHO health guidelines for the use of wastewater in agriculture and aquacul- ture state that: “The presence of free-living nematode larval stages, sometimes in large numbers, in stabilization pond effluents IS OF NO PUBLIC HEALTH SIGNIFI- CANCE because they are not pathogenic to human beings” (emphasis added) [9]. This statement is valid for all helminthic pathogens excreted in faeces except for Strongyloides stercoralis (threadworm) and Enterobius vermicularis (pinworm), since their eggs are NOT normally ex- creted in faeces. The pinworm is of minor public health importance because it is an infection that does not commonly cause serious illness. Strongyloides is potentially serious, particularly in malnourished or immune-suppressed individuals. When the body’s immune responses are deficient, dis- seminated strongyloidiasis may occur, with larvae attaching to most organs of the body; such cases are usually fatal [18]. The mode of transmission of Strongy- loides infective filariform larvae, which develop in most soils contaminated with faeces, is by penetrating the skin (usually through the foot), entering the venous circu- lation and being carried to the lungs. They hatch and liberate non-infective, rhabditi- form larvae, which migrate into the lumen of the intestine, leaving the host in the faeces and developing either into infective filariform larvae, which may infect the same or a new host, or into free-living adults after reaching the soil [19]. The eggs are ovoid and measure 50–60 by 30–35 μm but are seldom seen because larvae hatch out and are passed in the faeces. S. stercoralis exists in night soil and sludge as a delicate larva, not as a robust egg. A new infection can be initiated by the penetration of a single larva. Since Strongyloides represent a high actual risk, it is recommended to eliminate or remove 100% of its concentration. This would mean having zero S. stercoralis lar- vae/L, because infection can be initiated by skin penetration of a single S. stercoralis larva. The period of communicability is as long as there are living worms in the intes- tine, which may extend up to 35 years [19]. Concerning inactivation of Strongy- loides in sewage treatment processes, there are no studies reported [18]. However, it is suggested that sludge pasteurization, as currently applied in Switzerland and Germany at 70 °C for 30 minutes may offer considerable safety. Pathogens may be reduced in rapid sand filtration but not substantially and probably insufficiently to justify investment in this filtration method by the health benefits it yields, and most helminth eggs will be totally unharmed by effluent chlorination [18]. This was con- firmed by a study carried out in Jordan and by the performance of the Bahrain tertiary treatment plant operating on dual media filtration, chlorination and ozonation (S. Al Salem, unpublished report, 1992). 455 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم So far, there is no guaranteed feasible method of inactivation of S. stercoralis larvae either in sewage or sludge treatment processes. It is recommended to take protec- tion measures by a high dose of chlorination for the final effluent, wearing shoes and gloves, burying the sludge at least 0.5 m be- low ground surface, and stopping irrigation of crops at least 3 weeks before harvesting (S. Al Salem, unpublished report, 1992). It is worth mentioning here that WHO/ HQ is currently updating the 1989 health guidelines for the use of wastewater in agriculture and aquaculture. Work of the WHO/EMRO in facing the challenges WHO/EMRO through the Centre for En- vironmental Health Activities (CEHA) is working with Member States to address the challenges of water scarcity and waste- water reuse, to find solutions and to ensure sufficient and safe water for the people of the Region. The following activities and projects have been carried out by the Regional Office in relation to wastewater reuse. • Training is a vital activity and the fol- lowing courses have been organized by the Regional Office. • In order to disseminate the appropri- ate technology transfer in wastewa- ter treatment and reuse in EMR, 19 training courses in various aspects of wastewater reuse and treatment were carried out from September 1999 un- til April 2004 for professionals in several countries, namely Egypt, Iraq, Jordan, Kuwait, Oman, Saudi Arabia, Syrian Arab Republic, Tunisia and Yemen. • A regional training course was held in 1999 for 12 professionals from 10 countries, the main objectives of which were to: • disseminate knowledge on the re- gionally recommended procedure for the testing of nematodes eggs (Ascaris and Trichuris species and hookworms) in raw sludge and treated wastewater and to introduce periodic programmes regarding the frequency of sampling, times, days, and numbers of samples to ensure better safety and foster community health during wastewater reuse in agriculture; • disseminate knowledge on the monitoring and surveillance of re- claimed water and sludge for agri- culture. • A course on treatment of sewage and agriculture use of treated efflu- ent, sponsored and co-organized by WHO/CEHA, was held at Jordan Uni- versity, Amman, 2–20 April 2000. • Recognizing the importance of informa- tion, guides and manuals, the Regional Office has commissioned the preparation of several publications in Arabic and in English. • A manual in Arabic on the operation and maintenance of wastewater treat- ment plants written for wastewater superintendents. • Guidance for design, operation, and maintenance of wastewater treatment plants (in Arabic) written for a wider audience than the manual above. • Integrated guide to sanitary para- sitology. The guide is the first of its kind dealing with nematodes eggs screening and enumeration in the wastewater, final effluent, and sludge. It is available in Arabic and English. • A regional overview of wastewater management in the Eastern Mediter- Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 456 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم ranean Region. This publication is intended to delineate the status of wastewater management and reuse in the EMR. • Grey water reuse in the Eastern Med- iterranean Region (in Arabic). This pamphlet will be produced in English in the near future. It defines greywater and the health aspects of its reuse in the EMR. It summarizes the existing experiences in the Region. • Overview of health aspects of grey- water reuse (in Arabic and English). The purpose of this overview is to provide guidance for local govern- ment officers, homeowners, site and soil evaluators, designers, installers and service technicians on the impact of greywater reuse on human health, plants, animals and the environment. • Country profiles on wastewater man- agement and reuse for: Egypt, Jordan, Morocco, Oman, Saudi Arabia, Su- dan, Syrian Arab Republic, Tunisia, and Yemen. The following profiles are being prepared: Lebanon, Libyan Arab Jamahiriya, Kuwait, Palestine and United Arab Emirates. • The Regional Office has also commis- sioned the translation of useful docu- ments into Arabic. These include: • The first volume of the USEPA publi- cation Operation and maintenance of wastewater collection systems. • The World Bank/United Nations De- velopment Programme publication Reuse of wastewater in agriculture: a guide for planners • A series of research projects were car- ried out during 2002–2003 to assess the efficiency of wastewater treatment plants in the removal of helminth eggs and to find the most viable methods for removal or inactivation of helminth eggs from reclaimed wastewater. It was found that conventional wastewater treatment used in the Region is not effective in removing nematode eggs. The slow sand filtration and lagoon system could re- move eggs, and chemically enhanced treatment and the up-flow sludge blanket could partially remove eggs. • The following countries of the Region were provided in 2002–2004 with the laboratory equipment necessary to iden- tify and enumerate nematode eggs in wastewater and sludge: Egypt, Iraq, Kuwait, Morocco, Sudan, Syrian Arab Republic, Tunisia and Yemen. • The following conferences were con- vened: • Wastewater Management and its Ef- fect on the Environment on Hot and Arid Countries, Oman, 12–14 Octo- ber 2002 (unpublished report). • WHO/AFESD Regional Consultation to Review National Priorities and Ac- tion Plans for Wastewater Reuse and Management, Amman, Jordan, 20–22 October [16]. In this consultation, suggested guidance for health aspects of wastewater reuse and greywater reuse in the EMR were agreed upon. Key suggestions to achieve full use of reclaimed wastewater and safeguard human health • Policy-makers and high-ranking profes- sionals in each country need to review the current constraints on wastewater re- use related to their country and to decide how to overcome them. • It should be planned to treat all gener- ated wastewater and to use the whole amount in appropriate contexts. 457 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم • Only high-value agriculture products should be irrigated and water should be allocated to uses that have the highest- value and prevent pollution. • Incentives for conservation should be provided and sanctions/penalties for irrational use should be imposed. Con- sumers should meet the cost for the eco- nomic water value; this will help prevent uneconomical use/reuse of water. • Water use activities should be coordinat- ed and water plans, strategies and invest- ments for the long-term should be set according to the priorities to be decided with the participation of beneficiaries. • Reclaimed water should not be dis- charged into the sea as it is a waste of this valuable water resource. • Wastewater reuse guidelines should be updated to match newly gained knowl- edge and a comprehensive approach should be used for health protection measures not depending on the treat- ment measure as the sole method for health protection. • Wastewater reuse/greywater projects should be designed as an integral part of the wastewater network and water resources plans. References 1. Al Salem SS. Environmental consider- ation for wastewater reuse in agriculture. Water science and technology, 1996, 33(10–11):345–53. 2. Engelman R et al. People in the balance: Population and natural resources at the turn of the millennium. Washington DC, Population Action International, 2000:24– 6. 3. Assessment of on-site graywater and combined wastewater treatment and re- cycling systems. Falls Church, Virginia, National Association of Plumbing–Heat- ing–Cooling Contactors, 2001. 4. From scarcity to security: Averting a wa- ter crisis in the Middle East and North Africa. Washington DC, The World Bank 1997:11–12 (http://lnweb18.worldbank. org/mna/mena.nsf/0/F2953DF0DB1100F 685256AFE0072EEE5?OpenDocument, accessed: 27 November 2005). 5. Al-Salem S.S. Overview of the water and wastewater reuse crisis in the Eastern Mediterranean Region. Eastern Mediter- ranean health journal, 2001, 7(6):1056– 60. 6. AQUASTAT. General summary Near East. Rome, Food and Agriculture Orga- nization, 1999:1–10 (http://www.fao.org/ ag/agl/aglw/aquastat/regions/neast/in- dex.stm, accessed 28 November 2005). 7. Al-Zubari WK. Towards the establishment of total cycle management and re-use program in the GCC countries. Presented at the 7th Regional Meeting of the Arab International Hydrological Programme Committee, 8–12 September 1997, Ra- bat, Morocco. 8. Al Salem S. Potential and existing treated wastewater reuse in selected ESCWA countries. Beirut, United Nations Economic and Social Commission for Western Asia, 1993:9–23. 9. Health guidelines for the use of wastewater in agriculture and aquaculture: report of a WHO scientific group [meeting held in Geneva from 18 to 23 November 1987]. Geneva, World Health Organization, 1989 (WHO Technical Report Series, No. 778):39–48. 10. Habbari K et al. Heminthic infections as- sociated with the use of raw wastewater Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 458 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم for agriculture purposes in Bani Mellal, Morocco. Eastern Mediterranean health journal, 1999, 5(5):912–21. 11. Ali-Shtayeh MS et al. Prevalence and seasonal fluctuations of intestinal parasitic infections in the Nablus area, West Bank of Jordan. Annals of tropical medicine and parasitology, 1989, 83(1):67–72. 12. Smith C. Geohelminth infection in the Gaza Strip. Paper presented at the Water and Sanitation Study Day, March 1990, Birzeit University, Palestine. 13. Bradley RM, Hadidy S. Parasitic infesta- tion and the use of untreated sewage for irrigation of vegetables with particular reference to Aleppo, Syria. Public health engineer, 1981, 9:154–7. 14. Gatlan MMA. A study on epidemiology of gastrointestinal diseases related to microbiological pollution of Barada River [Master thesis]. Damascus, University of Damascus, 2000. 15. Progress Report Helwan Wastewater Re- use (phase 1). A situation analysis. Cairo, Academy of Science & Technology Co- operation & US Agency for International Development, 1995. 16. Report on the WHO/AFESD regional con- sultation to review national priorities and action plans for wastewater reuse and management, Amman, Jordan, 20–22 October 2003. Amman, World Health Organization Regional Centre for Envi- ronmental Health Activities, 2004 (WHO- EMRO/CEH/106/E). 17. Reuse of effluents: methods of wastewater treatment and health safeguards. Report of a WHO meeting of experts. Geneva, World Health Organization, 1973 (WHO Technical Report Series, No. 517). 18. Feachem R et al. Sanitation and disease: Health aspects of excreta and wastewater management. New York, John Wiley and Sons (for The World Bank), 1983. 19. Benenson AS, ed. Control of commu- nicable diseases in man. Washington DC, American Public Health Association, 1985. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 459 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Report Rebuilding of the Lebanese health care system: health sector reforms N.M. Kronfol1 1Lebanese Healthcare Management Association, Beirut, Lebanon (Correspondence to N.M. Kronfol: dino@cyberia.net.lb). Received: 09/01/03; accepted: 06/07/04 ABSTRACT The civil war in Lebanon from 1975 to 1992 had a significant negative impact on the public health care system. This paper describes the health care system in Lebanon and its financing as of 2001. The efforts that have been made and are being made to rehabilitate and reform this sector since the end of the war are outlined. Reconstruction du système libanais de soins de santé : réformes du secteur de la santé RÉSUMÉ La guerre civile au Liban de 1975 à 1992 a eu un impact négatif considérable sur le sys- tème public de soins de santé. Le présent article décrit le système de soins de santé au Liban et son financement en 2001. Les efforts qui ont été déployés depuis la fin de la guerre et qui se poursuivent aujourd’hui pour le redressement et la réforme de ce secteur y sont présentés. 0$J  <=  -D "#+O$DK4 <= dA |32K KbjW‘3K>dj3 3 ! 233æ3IJH3<@3v:Z@P3¿5P3N>Gr…P3ÉWBG53iJL19753IJH3 l31992N;JH83IJSj3FGH3:;:•3¶Ge3W¬s3iJTd53M3 N>@6R?5P3NBQ5P3m4G;6ë3IJSj93iJTd53M3N>BQ5P3N;JHW5P3IJSj3ˆC65J\3N‘865P3¸gr3a9JTZX93IJH3<@3oP8JdZHP32001m N>Gr…P3ÉW­P3N;J“j3gT@347xCl93DJ¢Y5P3Pgr3K>r§Z53agdX3aPUXc93´5g\3¿5P3p6“P3<=>dX3JRL3m3 3 460 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction Lebanon is a middle-income country with a population estimated at 4 million, over 80% of whom live in urban areas.The population consists of Lebanese citizens (93%) and foreign and migrant workers from neigh- bouring countries, as well as Palestinian refugees. Before the civil war, which began in 1975 and lasted until 1992, the Lebanese economy was robust, enterprise flourished, and Lebanon was considered the banking centre of the Middle East. The civil war led to the relocation of many service sectors out of the country. Much of the industrial and agricultural infrastructure was destroyed and the economy went into decline. In- creased spending on security forces and the reduction in government revenues from taxes and other duties led to a steep increase in public debt. The civil war had a major negative im- pact on the public health care system. The state facilities were in their majority de- stroyed, looted or deserted. The staff found difficulty in reaching work. To provide care to the traumatized population, the Govern- ment relied on the private sector. Whereas before the war, in 1970, only 10% of the Ministry budget was spent on the care of patients in private facilities, that proportion reached 80% in the late 1990s. Of all the sectors in the economy, none has flourished as much as the private health sector during the past 2 decades. This paper describes the health care system of Lebanon, and the efforts that have been made to rehabilitate the sector after the 17-year civil war. Health facilities and human resources Table 1 gives the health care resources for the year 1999 per 10 000 population. Hospitals Lebanon has 26 beds per 1000 population making this one of the highest ratios in the Middle East. Only 12% of the hospitals and 10% of the beds are in the public sec- tor. According to the Syndicate of Private Hospitals, there were 139 private hospitals in 1999 with 8297 medium-stay active beds. The growth of private hospitals was phe- nomenal during the war (a 60% growth). This expansion was fuelled mainly through the financing of medical care by the public funding agencies, principally the Ministry of Public Health (MOPH). The average number of beds per hospital is 59: only 3% have more than 200 beds and these are all in the private sector. The high percentage of hospitals with fewer than 70 beds and the fact that they tend to be multi- specialty facilities mean that it is difficult to achieve economies of scale. Added to this is a low occupancy rate: 59% in 1998, according to MOPH sources. More than 70% of the hospitals of the private sector are owned by private indi- viduals or groups of doctors. The rest are owned and operated by nongovernmental organizations (NGOs), usually religious, charitable or community groups. Table 1 Human and physical health resources, Lebanon, 1999 Resource No. per 10 000 population Physicians 22.4 Dentists 10.1 Pharmacists 7.8 Nursing & midwifery personnel 10 Hospital beds 26 Primary health care units & centres 2.3 Source: Ammar, Walid. Health system and reform in Lebanon, 2003. Ministry of Health. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 461 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم In addition to the above, there are some 19 private hospitals with 3478 long-stay beds catering to the old and disabled. These hospitals receive an annual contribution from the MOPH depending on the number of beds and the type of sickness of the patients. Health care services have become in- creasingly oriented towards curative care with a rapid growth in the number of hospi- tals and centres with high technology serv- ices. However, the utilization of this high technology equipment has remained much below the optimum. The fastest expansion has been in areas covered by the MOPH (e.g. open heart surgery, MRI) while there has been virtually no expansion in the areas not covered by the Ministry (e.g. radio- therapy). After the end of the civil war, the Gov- ernment began to rehabilitate the exist- ing public hospitals and build new ones. From 15 public hospitals with 810 beds, the number will increase to 28 hospitals with close to 2680 beds; another 1000 beds are currently being commissioned in the private sector. Health centres and ambulatory services While hospital services are growing, the primary health care system has remained weak. The private sector and NGOs domi- nate this sector with public involvement being minimal. NGOs own over 80% of the 110 primary health care centres and 734 dispensaries spread across the country. The MOPH and the Ministry of Social Affairs provide health services at health centres and dispensaries. These consist of curative and preventive health care services, vaccinations, primary health care, advice on reproductive health and services aimed at the disabled population. Both Ministries also support a number of centres belonging to not-for-profit organizations and NGOs that include health services among their activities. After the war the MOPH began to refur- bish its network of health centres and build additional ones. However, the use of public health centres has been low and private clin- ics are the main outlet for ambulatory care for 79% of patients. Only 20% of house- holds have a family physician to take care of their health concerns on a regular basis. The reimbursement of the cost of ambu- latory services is, in effect, with the various public agencies, except for the MOPH that offers care at no or minimal cost within its own network. However, since the patient has to pay first, to be reimbursed later, there is evidence that many prefer not to go through the process of reimbursement as it is considered tedious and time-consuming. Physicians There is a plethora of physicians in Leba- non which has been exacerbated in the past few years. In the last 3 decades, the yearly increase of physicians has been in the range of 500–700. Until the late 1970s, most of the physi- cians practising in Lebanon were graduates of the 2 medical schools that existed then in Lebanon, namely the American University of Beirut and the Saint Joseph University. In 1999, however, the graduates of Lebanese universities made up only 39% of the total pool and of the new yearly inflow; the re- maining graduated from universities outside of Lebanon. There are 2 orders of physicians in Leba- non: the Order of Lebanon based in Beirut for all the country except the Mohfazat in North Lebanon (8500 registered physi- cians), and the Order of Physicians of the North (1200 registered physicians). In addi- tion, there are those who are not registered with either order but are practising illegally. 462 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم At the same time, there are those who are registered but are not practising, mostly be- cause they have emigrated and are working outside the country. The estimated ratio of physician to population is therefore around 1 physician per 412 persons. Around 70% of physicians registered in the Beirut Order of Physicians are spe- cialists. Legislation enacted in the 1970s required medical graduates to opt for prac- tice for 2 years in the rural areas or opt for specialty training. Although the law intended to encourage practice outside the cities, the effect has been to encourage specialty training. Dentists Dentists face almost the same situation as the physicians in Lebanon. There are cur- rently 3471 dentists registered in the Order of Dentists of Lebanon and another 400 registered in the Order of Dentists of North Lebanon. Dental care does not have as ex- tensive a coverage by funding agencies as medical care. Dental graduates from univer- sities in Lebanon made up 41% of the pool of dentists in 1994 while “foreign” dental graduates made up the rest. Nurses and paramedical personnel In contrast to doctors and dentists, the ratio of nurses to population is very low (1 to 1150 population). This is one of the highest ratios in the world. In 1997, there was a total of 3453 nursing personnel. The ratio of hos- pital beds to nurses is a high of 4.5 beds per nurse. As a result of this shortage, the use of nursing aids and on-the-job trained nurses’ aids in place of nurses has become common in most hospitals. Schools of nursing have been in ex- istence in Lebanon since the turn of the 20th century at the American University of Beirut and the Saint Joseph University. Nursing institutes exist all over the country to prepare technical nurses. Other nursing programmes are hospital-based. Legislation in 2002 established the Order of Nurses. Pharmaceutical sector In 1998, pharmaceutical expenditure ac- counted for over 25% of the total health ex- penditure. Only 2% of the pharmaceuticals sold in Lebanon are generic products; 98% are proprietary products. Similarly, import- ed drugs account for 94% of consumption with locally manufactured drugs making up only 6%. Thus, the per capita expendi- ture on pharmaceuticals is high (US$ 120). Expenditure on pharmaceuticals has been increasing at 7% per annum, a figure that is higher than the rate of inflation. Household out-of-pocket expenditure accounts for 94% of the spending on pharmaceuticals. The increase in expenditure on phar- maceuticals has been accompanied by a rapid increase in the number of pharmacies in Lebanon. Between 1995 and 1998 the number rose by 59% and the number of registered pharmacists grew by 34%. Reforming the health care system When the civil war ended in 1992, the health sector in Lebanon faced several prob- lems: the weakened MOPH, rapid cost es- calation in health expenditure, particularly MOPH expenditures, unrestricted growth of the private sector and a weakened primary health care system. In response to these problems, the Gov- ernment adopted a health sector strategy in 1993. Important elements of this strategy in- cluded strengthening the role of the MOPH and containing the rapid growth in health expenditure. While the long-term objective of the health sector strategy is to improve the allocation and use of resources in the public Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 463 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم and private sectors, the short- to medium- term objectives have focused on improving the managerial and administrative functions of the MOPH, to include the introduction of a comprehensive package of curative and preventive services at all primary health care facilities, the strengthening of hospital management and service delivery capability and the implementation of alternative health financing options. The Government of Lebanon negotiated a loan with the World Bank to undertake the restructuring of the health system. In consultation with the World Health Or- ganization, a series of carefully designed surveys and studies was carried out, in collaboration with academic institutions and governmental agencies. The process of reforms involved most of the stakeholders in the public as well as the private sector. Health care utilization As part of the reforms, a National House- hold Health Expenditures and Utilization Survey (NHHEUS) was undertaken. Of- ficially released in December 2001, the sur- vey represents the first time a specific health survey has been conducted in Lebanon. A nationally representative sample of roughly 6500 households (and 33 000 individuals) was used. It showed that on average the Lebanese had 3.6 outpatient visits per year, with males having 3.1 visits per year and females 4.1 visits. While regional disparities exist in use rates, these do not appear to be significant. An interesting finding is that, unlike many other counties, lower income individuals have higher use rates than those in higher income groups. This indicates that there do not appear to be inequities in access to health services if these are measured by use rates. Those over 60 years and those under 5 years had the highest use rates. Those with insurance had higher use rates than the uninsured. The overall hospitalization rate was 12% per year (1.5% of the population had more than 1 hospitalization per year). The average length of stay was 4 days, and the overall occupancy rate of hospitals was 55%. For those over 60 years, the rate of hospitalization was 28%, with 4.5% having more than 1 episode per year. Hospitaliza- tion was more frequent amongst lower in- come groups. Hospitalization rates varied between the insured and the non-insured, 10% versus 8% for 1 admission per year. With regard to the use of day surgery, while the elderly had higher use rates than other age groups, there was no difference by insurance status as was seen in the case of outpatient care and hospitalization. Contrary to the trend with regard to other services, the elderly access far less dental care than those in the age group 15–59 years. Similarly, those in the lower income groups use less dental care than those in the higher income groups. This is likely because most insurance policies do not cover dental care. Financing health care: the National Health Accounts Study The compilation of National Health Ac- counts (NHA) estimates for Lebanon is comparable both conceptually and meth- odologically to the compilation of NHA in other advanced economies. A special effort was made to ensure maximum compat- ibility between the Lebanon NHA frame- work and the Organization for Economic Cooperation and Development proposals for standardization of health accounts. The NHA was undertaken by the World Health Organization in close collaboration with official representatives of all public and pri- vate funds under the overall supervision of 464 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم the MOPH. The health expenditure reported from this account is shown in Table 2 Expenditure on hospital care by public fi- nancing agents is very high. Overall, 66.4% of the recurrent public health expenditure is spent on hospital-based care, 14.0% on ambulatory care, 7.8% on pharmaceuticals, 5.0% on other goods accounts and 6.8% on administration. In the case of the MOPH, 71% of its budget is used to pay for hospital- based care. Expenditure on primary health care accounts for less than 5% of public expenditure. There are 3 governmental health insur- ance providers in Lebanon, in addition to the payments made by the MOPH to private hospitals for the hospitalization of the un- insured applicants. There are also various other sources of health care financing. National Social Security Fund (NSSF) The NSSF was established in 1964 and is similar to the French model of social security. As essentially a service for work- ers, the NSSF comes under the Ministry of Labour. The MOPH has little input into its operations or decisions. The NSSF is the most important source of public health insurance in Lebanon. It covers, in principle, Lebanese citizens who are: workers and employees in the private, non-agricultural sector; permanent employ- ees in agriculture, employees of public institutions and independent offices who are not subject to civil service; teachers in pub- lic schools; taxi drivers; newspaper sellers; and university students. Health coverage includes sickness and maternity allowances amounting to 90% of hospitalization costs and 80% of medical consultations and medication excluding dental care. Thus to a large extent, the Fund is financed from private sources yet it is a public institution. In April 2000, a project law was approved by the Cabinet instituting the provision of health care to the entire population above the age of 64 years, under the auspices of the NSSF. The law has not been imple- mented as yet and may be revised. In 2003, coverage was extended to physicians and their dependents. The household survey of 1997, under- taken by the Ministry of Social Affairs (MOSA), revealed that only 15.2% of the sample interviewed were covered by the NSSF. The NHHEUS reported a coverage of 26.1%, while the NSSF maintains that it provides coverage for 33% of the Lebanese population. Table 2 Health care expenditure, Lebanon, August 2001a Expenditure Value Total health care expenditure US$ 2 billion Per capita expenditure US$ 500 Total gross domestic product US$ 16.2 billion Health expenditure as % gross domestic product 12.3% % Government of Lebanon budget allocated to health 6.6% Sources of funds Public 18.0% Private 82.0% Households 69.7% Employers 10.3% Donors 2.0% Distribution of health care expenditure Public hospitals 1.7% Private hospitals 22.8% Private non-institutional providers 41.0% Pharmaceuticals 25.4% Others 9.1% aInformation compiled from the National Health Accounts Study, released in August 2001 and based on 1998 data. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 465 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Security forces coverage Insurance for the security forces is organ- ized through several funds. The Military are covered by the Ministry of Defence. The Internal Security Forces have their own plan, under the Ministry of Interior. The staff of Public Security, Customs employ- ees and those of State Security are covered through 2 different funds, under the Office of the Prime Minister. All uniformed staff members are covered with their dependents and their parents. Together, these funds constitute the second most important source of public health insurance. Coverage here is the most generous: 100% of hospitaliza- tion and medical expenses for the member, 75% for spouse and children and 50% for dependent parents. Cooperative of the Civil Servants The Cooperative of the Civil Servants (CCS) is the third most important source of public health insurance which was instituted in 1964. The CCS insures all employees of the public sector who are subject to the laws of the Civil Service. Health insurance covers 90% of hospitalization costs and 75% of consultations, medication and dental treat- ment for the employee (up to a ceiling, be- yond which the CCS covers all). The CCS is operated by the Office of the Prime Minister and is financed from a 1% deduction off the payroll of the individual; the balance is covered by the Government. Ministry of Public Health – insurer of last resort The MOPH funds the hospitalization costs for any citizen who is not covered under a public insurance plan. This coverage is independent of the income and assets of the individual. In addition, the MOPH cov- ers the cost of some interventions such as chemotherapy, open heart surgery, dialysis and renal transplant, and drugs for chronic diseases. This coverage engulfs some 40%– 45% of the Ministry’s budget for contracted services. As such, the Ministry has the larg- est share of the total cost of public expendi- ture, including insurance, on health services in the country. The MOPH covers 85% of hospital care: the incumbent is expected to pay 15% of the hospital bill. However, even this co-payment is frequently waived alto- gether, on account of need. Recently, the Ministry has taken steps to introduce “flat rate” payments in its contracts with private hospitals. Private insurance Private health insurance is well established in Lebanon. According to the Ministry of Economy, approximately 70 private insur- ance companies provide both complemen- tary and comprehensive health insurance policies. The former are to complement and fill gaps in the benefits provided by NSSF, CCS, and health insurance arrangements for the army and police. The latter refer to stand alone health insurance policies that can cover a range of benefits, including inpa- tient and outpatient care, and coverage for pharmaceutical expenses. Nearly 85% of the policies are purchased by employers as an employee benefit or to fill gaps in NSSF coverage. The private insurance market is not well regulated. Consequently, insurers indulge in “cream skimming”, selecting only good risks and either denying coverage or setting very high premiums for individu- als with pre-existing conditions. Mutual funds There is a growing number of mutual funds covering health expenses in the context of syndicates, associations and other groups. This sector comes under the Ministry of Housing and Cooperatives. The law gov- erning mutual funds allows any group of 50 persons (or above) to form a mutual fund. 466 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم The linkage could be professional, religious or community-based. Tax laws that provide tax breaks to not-for-profit groups have led to a proliferation of mutual funds that offer health insurance coverage to those enrolled in the fund. Mutual funds do not pay taxes on the premium, unlike the private insur- ance companies. Local and foreign not-for-profit organizations There is a relatively small proportion of the total health bill that is covered by local and foreign not-for-profit organizations and NGOs operating generally at the local level in poorer urban districts and underprivileged rural areas. Medical care offered through NGOs increased during the war but this has waned somewhat since 1990. However, the involvement of the community in the provi- sion of medical care did offer some innova- tive models for the financing, governance and management of health services. Donor assistance In 1998, donor assistance amounted to 1.96% of the total health care financing. The sharpest decline in donor assistance has been to immunization and control of diseases and there has been a significant increase in support for family planning ac- tivities. The MOPH and other government agencies are the primary beneficiaries of donor assistance. Large companies Major firms such as banks and large manufacturers often offer employees health insurance. The majority of this health ex- penditure represents reimbursements for services in private clinics. Survey results show that 78% of companies have private insurance for their employees, which is complementary to the NSSF in 75% of the cases: 20% of these companies provide ex- tra health services that may not be covered by NSSF or the private health insurance. Out-of-pocket payments Last, but certainly not least, the most im- portant item in the total health bill is the out-of-pocket payments, which is the health expenditure borne directly by individuals, covering supplementary payments by those who are covered by insurance or the MOPH as well as full payment by those who are not covered by any insurance or are not beneficiaries of MOPH assistance. House- hold expenditure accounts for 69.7% of total health expenditure. Of this, 97% is spent in the private sector, 2% in the NGO sector, and just 1% in the public sector. On average, households spend a little over 14% of their household expenditure on health services. However, the burden of out-of-pocket expenditure, measured as a proportion of household expenditure, is not equitably distributed. Nearly a fifth of expenditure in households in the lowest income category goes to health. The propor- tion spent on health decreases with income and households in the highest income group spend only 8% on health care. Extent of coverage and expenditure According to the NHHEUS, 46.8% of the population reported having some form of insurance (either social or private). If the non-Lebanese population is excluded (es- timated at 7.6%), the government is thus responsible for the remaining 45.6% of the population. Data show that 12.3% of the GDP of the country was spent on the health bill in 1998 (Table 2). It is noteworthy that the Treasury effectively spent only US$ 333 millions out of a total of close to US$ 2 billions (17%) in 1998. The lion’s share has been funneled through the MOPH (US$ 207 millions or 62%). Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 467 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Per capita expenditure amounted to 522 Lebanese pounds per year. Of these 15% was spent on insurance, 10% on hospitaliza- tion, 2% on one-day surgery, 22% for dental care, 36% for outpatient care (excluding drugs), and 15% on drugs. The health care system of Lebanon is experiencing a strong tilt towards curative care, fuelled by an oversupply of physi- cians, hospital beds, abundance of expen- sive high-tech equipment, poor regulation and third-party payment, as well as through the incentives inherent in third-party cover- age and provider payments. The rise in health expenditures can also be attributed to the high expectations of the population. These expectations are closer to those in developed economies. Therefore, unless the health care delivery system undergoes re-structuring, the overall cost of medical care cannot but go on rising. Actuarial studies of financing reforms Extensive analyses of reform options have been executed by the Inter-Ministerial Coun- cil for Health Reform. Prior to the initiation of this modelling activity, detailed outlines of 3 proposals were reviewed. As part of a contract with the World Health Organiza- tion, the Actuarial Research Corporation provided technical assistance in dynamic modelling of proposed health insurance programme options. The purpose of the as- signment was to gain a better understanding of the impact of the proposed health financ- ing options on the Lebanese economy, the health system in general and those parts of the health system to be included in the health insurance programme. Social Health Insurance Programme The most comprehensive reform approach is the Social Health Insurance Programme. In its basic form, it would represent manda- tory insurance for all citizens, with a mini- mum level of coverage specified, and with supplementation allowed for all enrolees except those relying on publicly financed coverage. The current funds would continue to provide services reflecting their mem- bers’ preferences, subject to the requirement that every enrollee must have coverage at least as rich as the minimum package. This minimum, referred to as SHIP0, would be a comprehensive set of services with lim- ited cost-sharing, but potentially restrictive provider networks. Costs associated with providing SHIP0 services would be pooled across all funds. For persons not covered by any other fund, MOPH would arrange for provision of SHIP0 services but such enrolees would be required to register with one primary care centre and to have all their services coordinated by that centre. Provid- er payment negotiations and other functions would be administered by an autonomous health care authority. The authority would be responsible for utilization review, audits, quality assurance, effectiveness studies and similar activities. Interface and Resource Body An incremental reform option intended to bring unified administrative processes and improved data for fund management (espe- cially with respect to provider negotiations) is the Interface and Resource Body option. Using a third-party administrator, the option would phase in contracts between all funds and the third-party administrator, to provide claims processing, enrolment, premium col- lection, and management information. The funds would continue to provide benefits ac- cording to their own preferences. Uninsured persons who currently rely on MOPH for hospital and clinic services (but who pay for other ambulatory care out-of-pocket) would receive improved outpatient care through upgrades to the nation’s public clinics. The 468 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم third-party administrator would provide for improved data collection, which would put the fund’s negotiating power with providers on a stronger basis than they have tradition- ally had. The ultimate responsibility for the negotiations, however, would remain with the funds. NSSF expansion The third option is also an incremental re- form, but represents minimal system change by using the original legislative expectation that the NSSF would expand through time to cover the entire population. The basic option would expand NSSF coverage to in- clude all persons not covered by a public or private insurance programme. Current pub- lic insurance programmes would remain, although any that wished to be absorbed by the NSSF would be permitted to do so. Current comprehensive private insurance (in place of direct NSSF coverage) would remain. The expanded coverage would have similar cost-sharing to current coverage, but premium collections from newly covered populations would be assumed to be set at modest levels. Findings Based on discussions with representatives of the MOPH, Ministry of Finance, NSSF, MOSA, Military Medical Services, other ministries, and a range of private and public providers and insurers, it became clear that there are 4 main findings based on the mod- elling work. • Any insurance reform is likely to lead to more health services utilization. • Comprehensive reform, with manda- tory insurance coverage (SHIP0), would likely add costs but provide substantial improvements in service and financial protection. • Incremental reform using NSSF expan- sion to new groups would likely increase costs somewhat less, while offering less in improved services and risk reduction. • Incremental reform using unified admin- istration would likely increase costs less, while offering still less improvement in services and risk reduction. Costing of various benefit packages The Inter-Ministerial Council for Health Reforms commissioned the preparation of studies to cost the various benefit pack- ages that could be included within any fi- nancing reform. The packages included the costing of inpatient and ambulatory care, dental provision, pharmaceuticals, medical diagnostics and therapeutic modalities. The costing included an assessment of the burn rate, the probability of occurrence and the overall cost of insurance, including admin- istration. Burden of disease study Despite extensive information available on specific clinical health conditions, knowl- edge about the health conditions of Leba- non has been fragmentary. Most of the surveillance systems have been incomplete, inaccurate and heavily biased towards mor- tality. The Burden of Disease and Injuries analysis provides a methodology for and assessment of aggregate disease burden that combines into the disability-adjusted life year or DALY measure combining burden from premature mortality with that from liv- ing with disability. Data were obtained from the major hospitals, insurance companies and research centres. Analysis of hospital expenditure For the first time, as part of the NHA ac- tivity, a sample of hospital bills paid by government agencies was analysed to bet- ter understand their breakdown. Table 4 shows that 73% of the amount MOPH’s reimbursements for hospital care was on Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 469 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم surgical care. The CCS spent 59% of its hospital reimbursements for surgical care, the Internal Security Forces 53%, the Army 51% and the NSSF 60%. The distribution of costs associated with hospitalization by category of service is shown. An interesting finding is that di- agnostic tests accounted for 19.4% of the costs and drugs and medical supplies for 25.1% of costs. Surgery costs were 15.0% of total costs, operating theatre accounted for 11.0% of costs, and room and board was 15.9% of costs. Doctor fees were only 8.0% of the costs. These findings would appear to support the perception that hospitals tend to perform a large number of investigations and prescribe a number of drugs for each episode of hospitalization as a means of optimizing their revenues. Accreditation of hospitals Within the reform process that started in 1995, a system for hospital accreditation has just been completed. It is expected that the accreditation system will promote and perhaps lead to the legislation of minimal criteria for hospitals and hospital services. This should assist the MOPH in differentiat- ing between hospitals and services, i.e. lead to the development of the hospital sector on more scientific and objective basis. Autonomy of public hospitals An attempt was made in 1978 to make pub- lic hospitals autonomous. The laws were revised in July 1996 and are currently being applied in some of the newly built public hospitals in Nabatieh, Dahr El Bachek and Tannourine. The driving force behind au- tonomy lies in promoting the efficiency of the public hospital. It is anticipated that the MOPH will contract with the public hos- pitals in much the same manner as it does with private hospitals. In this manner, pub- lic hospitals could retrieve their operating costs through contracts with the MOPH, the Table 4 Percentage distribution of hospital reimbursement by type of service Hospital service Ministry Internal Army National Cooperative Weighted of public Security Social of the average health Forces Security Civil Fund Servants Surgery 16.7 10.2 11.7 13.1 16.1 15.0 Doctors fees 8.6 14.4 9.4 11.1 11.4 8.0 Anaesthesia 4.8 2.5 3.1 4.8 4.9 4.2 Room and board 15.6 13.6 18.4 17 12.8 15.9 Operating room 12.6 9.6 8.4 18.2 10.3 11.0 Laboratory tests 12.2 12.3 13.2 10.5 9.2 11.0 Radiology exams 7.1 4.7 7.3 6.9 4.6 6.0 MRI 0.5 0.8 0.8 0.9 0.2 0.6 CT scan 2.4 1.8 1.9 0 1.0 1.8 Medicines 15.7 19.1 14.6 12 19.3 19.1 Miscellaneous 2.8 9.0 6.2 4.7 3.7 6.0 Others 1.1 2.1 5.1 0.7 6.4 2.1 Source: National Health Accounts Spreadsheets. 470 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم public agencies and private insurance com- panies, much as the private hospitals do at this time. It appears that public hospitals are also favouring inpatient care that is reim- bursed by the MOPH, thus acting much like the private hospital. Patients, physicians and hospitals seem to opt for hospitalization since it is covered by the MOPH. Human resources Policies controlling both the quantity and quality of physicians are needed. There have been calls, particularly from the Order of Physicians, to stop the licensing of new schools of medicine and impose quotas on entrants into the existing schools. But direct government intervention in determining the supply of doctors is said to conflict with the liberal state of the economy and the pre- rogatives of the private education sector. In May 2000, licences were granted to 2 addi- tional medical schools in the country. This brings the total number of medical schools licensed in the country to 6. It may be worthwhile to invite medi- cal schools in Lebanon to diversify into graduate medical education, or postdoctoral education. This may reduce the number of physicians seeking training abroad, par- ticularly if such programmes become joint programmes with academic medical centres in North America or Europe. Postgraduate education will also assist in the develop- ment of fellowship programmes, research and faculty members. Financial incentives may be introduced to encourage the devel- opment of postgraduate education in needed specialties for Lebanon and the region such as gerontology, emergency medicine, fo- rensic medicine, administration and quality care. The heterogeneity of nursing education and practice has undermined efforts to “pro- fessionalize” nursing. The reform activities at the MOPH include a major component for the development of the nursing profession, financed by Italian, Swedish and Spanish protocols of cooperation with Lebanon. Main policy issues for Lebanon’s health care system Sustainability Lebanon spends over 12% of its GDP on health care services. Unless there are sig- nificant gains in the country’s economic performance, the current pattern of health care expenditures (as a per cent of GDP) will put significant strain on scarce health resources. In the long-term, this will likely adversely affect the current level and qual- ity of services provided. Cost containment The Lebanese health care system is an ex- ample where the financing and provision functions are separated but without effective controls to contain costs. Provider payment reforms are key to cost containment. In this regard the MOPH started implementing a flat rate system for same-day surgical proce- dures in May 1998. An analysis conducted on the potential impact of extending this to other surgical procedures indicated that this might lead to lower costs. The principal financing intermediaries have a separate supervising Ministry. This makes inter-agency coordination difficult. At a minimum, consideration should be given to setting up an institution that can coordinate payments, monitor utilization, and oversee providers across the different public financing agencies. Centralized budgeting and managerial controls extend little authority and discre- tion to managers of public facilities. Hence, managers are provided with few incentives to engage in cost containment efforts. The MOPH has initiated efforts to make its Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 471 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم hospitals autonomous. This effort needs to be strengthened and expanded. Rationalizing capacity in the hospital sector The Lebanon NHA findings draw attention to the fact that 62% of public expenditures are spent on hospital care. Quality of care and financial viability of many of these fa- cilities remains a concern. Reallocating expenditure from curative to primary health care Less than 10% of resources are currently allocated to primary health care. There is a need to both strengthen the capacity of the system to deliver primary health care serv- ices as well as increase funding for these services. Controlling capital investment in medical technology The Lebanon NHA study reiterates previous findings that government reimbursements for high cost services have resulted in a rap- id growth of high technology centres. This in turn has contributed to cost escalation. For efforts at cost containment to be effec- tive, policies need to be developed that will control investments in medical technology. Draft legislation was introduced in 2004 to implement the “carte sanitaire” that would assist in health mapping and planning. Rationalizing expenditure on pharmaceuticals Lebanon has not only a high per capita expenditure on pharmaceuticals (US$ 120) but almost all of the drugs are imported proprietary products. To effectively contain overall health care expenditures, the Gov- ernment should initiate policies for improv- ing the efficiency by which pharmaceuticals are imported, distributed and sold in the country and improve its management and overseeing of this sector. Expanding health insurance coverage, limiting multiple coverage In Lebanon health insurance is tied with employment and those in low income households are less likely to be employed in the formal sector. Further, the presence of multiple insurance coverage also allows for inefficiencies and cost escalation. The Gov- ernment needs to improve its management of the private insurance market and reduce multiple insurance coverage. Equity Household out-of-pocket expenditure ac- counts for 69% of the health expenditure in Lebanon. The burden of out-of-pocket expenditure appears to be inequitably dis- tributed, with lower income households spending a much greater proportion of their income on health than higher income house- holds. Even though the MOPH as the insurer of last resort pays for hospitalization costs for all (including those with low incomes) there is no formal financing mechanism for primary and preventive health services. The government should consider designing a targeted programme to provide good qual- ity basic health services for those with low incomes. Health reforms Health sector reform has been described as a sustained purposeful attempt to improve the performance of the health sector. It is motivated by the need to address funda- mental deficiencies in health care systems. It is an inherently political process, and it is often implemented on a sector-wide level. Countries undertake health reforms when there is evidence of poor performance, when public expenditure neglects the poor, when resources are scarce and demands are increasing forcing governments to recon- sider the situation, when consumers are un- 472 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم happy about poor treatment and when there are concerns about sustainability. This has been the case in Lebanon. Health reform measures include: • new approaches to finance health care (charging fees, social and private insur- ance schemes, sectoral funding) • new payment mechanisms (perform- ance-based contracting, capitation) • a reorganization of functions (new roles for ministries, separation of finance and provision, enhanced stewardship) • decentralization and devolution (budg- ets, control shift from central to local government) • changes in legal and regulatory environ- ment. As regards the situation in Lebanon the following reforms have been addressed. • Organizational reforms such as decen- tralization and autonomy for provider institutions include the autonomy of the Lebanese public hospitals. • Reforms in the financing of health care include proposed universal health insur- ance and the establishment of a health- care financing authority. • Provider payment mechanisms include the introduction of flat fees for the pay- ment of private hospitals, the prepay- ment and capitation modalities. • Regulatory environment and legal framework include the accreditation of hospitals in Lebanon. Lebanon has initiated the reform process through a sizeable grant from the World Bank. There has been no lack of technical competence but perhaps the political will to change at this time needs strengthening. Any serious reforms would increase the contribution of the Treasury in the financ- ing of medical services. This may not be an attractive proposition at a time when the public finances of the State are precarious and when the servicing of the country’s debt is a very serious concern to all. Lessons learned The lessons learned from the Lebanese health sector are important for the Region where health sector reform efforts are in- creasingly focusing on public/private mix in the financing and provision of health services. The most important lessons are the need for the MOPH to be the central player in a pluralistic system, particularly in defin- ing the areas of public and private sector operation based on a needs assessment, and having the capacity to monitor and regulate the private sector. In the absence of a policy framework and of a regulation capacity, there is a danger that health systems based on public and private participation will not produce the desired health outcomes, nor provide health services that are equitable, efficient and of good quality. Sources 1. Awar M, Choujaa M, Papagallo R. Human resources for health. 1997 (unpublished report). 2. Central Administration of Statistics, 1997. 3. Household living conditions. Beirut, Cen- tral Administration of Statistics, 1996. 4. Central Bank of Lebanon (Periodic finan- cial data). 5. Chidiac P. Benefit packages for the pro- posed SHIP0 financing plan (unpublished report). Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 473 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 6. Council of Reconstruction and Develop- ment Lebanon, 2002. 7. Doughan B, Doumit M. Oral health in Lebanon: A situation analysis. 1994 (un- published report). 8. Economist Intelligence Unit country pro- file 1992–93. 9. Kronfol N. The Lebanese Health Care System, options for reform. May 2000 (unpublished report). 10. Kronfol N. Analysis of options for financing reforms. December 2000 (unpublished re- port). 11. Ministry of Social Affairs, Housing and Population database 1996. 12. Mroueh A. Physician manpower in Leba- non. 1999 (unpublished report). 13. National Health Accounts 1998. Beirut, Ministry of Health, 2000. 14. National Household Health Expenditure and Utilization Survey. Beirut, Ministry of Public Health, 2001. 15. Order of Physicians of Lebanon, data- base. 16. Principles of health accounting for in- ternational data collections. Paris, Or- ganisation for Economic Cooperation and Development, 1997. 17. Syndicate of Owners of Private Hospitals database 2001. 18. Tabbarah R. The health sector in Leba- non. Beirut, MADMA, March 2000. 474 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Short communication Meriones libycus is the main reservoir of zoonotic cutaneous leishmaniasis in south Islamic Republic of Iran Y. Rassi,1 E. Javadian,1 M. Amin,1 S. Rafizadeh,1 H.Vatandoost1 and H. Motazedian1 1School of Public Health and Institute of Health Research, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to Y. Rassi: y_rassi@yahoo.com). Received: 18/07/04; accepted: 25/10/04 ABSTRACT A study was made in rural regions around Neiriz city, Fars province in the south of the Islamic Republic of Iran during 2002–03 to further investigate a new focus of zoonotic cutaneous leishmaniasis. Meriones libycus was the dominant rodent (100% of 65 rodents collected) and 4.6% were naturally infected with the amastigote form of Leishmania spp. Promasigotes were identified as L. major. This confirms M. libycus as the main reservoir host of zoonotic cutaneous leishmaniasis in southern parts of the country. Meriones libycus, principal réservoir de leishmaniose cutanée zoonosique dans le sud de la République islamique d’Iran RÉSUMÉ Une étude a été réalisée dans une région rurale autour de la ville de Neiriz, province de Fars, dans le sud de la République islamique d’Iran durant les années 2002-2003 pour approfondir les recherches sur un nouveau foyer de leishmaniose cutanée zoonosique. Meriones libycus était le principal rongeur (100 % des 65 rongeurs capturés) et 4,6 % étaient naturellement infectés par la forme amastigote de Leishmania sp. Les promastigotes ont été identifiés comme L. major. Ceci confirme que M. libycus est le principal réservoir hôte de la leishmaniose cutanée zoonosique dans les parties méridionales du pays. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 475 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction Zoonotic cutaneous leishmaniasis (ZCL) is an important health problem in many coun- tries of the Mediterranean area as well as in the Islamic Republic of Iran. There are sev- eral foci of disease in the country [1–11]. In the last decade, the annual incidence of ZCL has been rising gradually; the total number of cases increased from 1560 to 3861 during 1991–2001 (unpublished data, Ministry of Health, Islamic Republic of Iran). In 1999 a new focus of ZCL, with a high incidence (850.9 per 100 000), was found in some villages of Arsanjan city, Fars province, in the southern part of the Islamic Republic of Iran. Increasing sandfly–human contact is believed to be occurring due to agricultural development in many parts of these areas and this leads to more exposure to infection. Detection of Leishmania spp. is not always easy in wild rodents, because the parasite may cause no or only minor skin lesions in these animals [12]. A previous study in Arsanjan showed that Meriones libycus was the principal res- ervoir of ZCL in the area [13]. The objective of the present study in Neiriz, an adjacent city to Arsanjan, was to collect further data from this new focus of ZCL. Methods The study was carried out in rural areas around Neiriz city, Fars province (28 42 N, 53 25 E, altitude 1620 m). The population was 96 929 in 1996 and their main activities are agriculture and animal farming. Rodents were captured monthly by Sherman live traps baited with roasted wal- nuts during October 2002 to March 2003 from the villages of Gassem-Abad, Gale- Bahman and Kooh-Sorkh. After identifying active colonies adjacent to selected villages, traps were set near the rodent’s burrows in the mornings and evenings twice a month. Rodents were identified according to the national systematic key [14]. Impression smears were taken from the rodents’ ears and investigated microscopi- cally for amastigotes. Smears from infected animals were injected into Balb/c mice. The parasites from infected mice were cultured and the isolated promastigotes were identi- fied from nested polymerase chain reaction (PCR) techniques, using standard methods [15], as described in our earlier paper [13]. Results In Neiriz city, 65 rodents were collected during the study period; all (100%) were identified as M. libycus. Three (4.6%) were infected with amastigotes. Isolated para- sites were injected into 10 mice; nodules and ulcers were recognized in 5 mice after 1 month. The promastigotes isolated were identified as L. major using PCR. Discussion This finding in Neiriz confirms our previ- ous study in Arsanjan [13] that M. libycus is the main reservoir host of ZCL in southern Islamic Republic of Iran. No other species (for example Rhombomys opimus or Tatera indica) were captured in the study areas. L. major has been isolated from M. libycus in central parts of the Islamic Republic of Iran [16], Uzbekistan [17], the Libyan Arab Jamahiriya [18] and Saudi Arabia [19]. There are currently 3 zones of ZCL in the Islamic Republic of Iran. The 1st zone is the centre and north-east, including Isfahan, Esfarayen, Lotf-Abad and Bekran- Shahrood. The great gerbil, R. opimus, is ac- tive in these areas and shows high infection rates (44%–100%) [1,5,7]. The 2nd zone is located in the west of the Islamic Republic 476 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم of Iran, where T. indica is the primary and main reservoir of disease with a 12.5% infection rate [7,9]. In both the above zones, M. libycus is a secondary reservoir host with a low infection rate and does not play a key role in maintaining the disease. The 3rd zone is in the south-east in Baluchistan [11]. Here M. hurrianeh is the main reservoir; we have not captured M. libycus from Baluchistan. In recent years, human cases of ZCL were observed to be endemic in Isfahan (central Islamic Republic of Iran), which borders Fars province. In this region, M. libycus is the main reservoir with a high infection rate (6.8%–25%) [13,16,20]. According to our findings, it seems that a 4th zone of ZCL has become established in the south of the Islamic Republic of Iran. In this area, M. libycus is the primary and main reservoir host of the disease, and R. opimus and T. indica were absent. We suggest that ZCL may be increasing in the southern region due to the proximity of rodent burrows to people’s houses (about 100 m) and increased agricultural activity and rural development in these areas. These factors facilitate more human contact with the rodent–sandfly–rodent cycle transmis- sion of leishmaniasis. Acknowledgements The authors are grateful to the Institute of Public Health Research, Tehran University of Medical Sciences for supporting of this investigation and the staff of the Training and Health Research of Kazerun Centre, for their assistance in the fieldwork. References 1. Javadian E et al. Epidemiology of cutane- ous leishmaniasis in Iran: B. Khorassan Part V: Report on a focus of zoonotic cu- taneous leishmaniasis in Esferayen. Bul- letin de la Societe de pathologie exotique et de ses filiales, 1976, 69:140–3. 2. Nadim A. Cutaneous leishmaniasis in southern Iran. In: Ecologies des leish- maniasis. (Colloques Intermationaux No. 239). Paris, Centre National de la Re- cherch Scientifique, 1977:215–8. 3. Control of the leishmaniases. Report of a WHO Expert Committee. Geneva, World Health Organization, 1990 (WHO Techni- cal Report Series No. 793). 4. Ozbet Y et al. Epidemiology, diagnosis and control of leishmaniasis in the Medi- terranean region. Annals of tropical medi- cine and parasitology, 1995, 89 (suppl. 1):89–93. 5. Nadim A, Faghih M. The epidemiology of cutaneous leishmaniasis in the Isfa- han province of Iran. I. The reservoir. II. The human disease. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1968, 62:534–42. 6. Nadim A, Seyedi-Rashti MA, Mesghali A. Epidemiology of cutaneous leishmaniasis in Turkeman Sahara, Iran. Journal of tropical medicine and hygiene, 1968, 71: 238–9. 7. Seyedi-Rashti M, Nadim A. Epidemiol- ogy of cutaneous leishmaniasis in Iran. B.Khorassan area part I: the reservoirs. Bulletin de la Societe de pathologie exot- ique, 1967, 60:510–8. 8. Seyedi-Rashti MA, Salehzadeh AA. New focus of cutaneous leishmaniasis near Tehran, Iran. Proceedings of the VIIth International Congress of Parasitology, Paris, France, 20–24 August. Bulletin de la Societe Francaise de Parasitologie, 1990, Suppl. 2:1145. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 477 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 9. Javadian E et al. Confirmation of Tat- era indica (Rodentia:Gerbillidae) as the main reservoir host of zoonotic cutaneous leishmaniasis in the west of Iran. Iranian journal of public health, 1998, 27(1/2):55– 60. 10. Javadian E. Reservoir host of cutaneous leishmaniasis in Iran. In: Abstracts of XIIth International Congress for Tropical Medi- cine and Malaria, 13 September 1988. Amsterdam, Netherlands, 1988:52. 11. Seyedi-Rashti MA, Nadim A. Cutane- ous leishmaniasis in Baluchistan, Iran. Abstract and poster. In: Volume XI. Abstracts of International Congress for Tropical Medicine and Malaria, 16–22 September. Calgary, Canada, 1984:124. 12. The leishmaniases. Report of a WHO Expert Committee. Geneva, World Health Organization, 1984 (Technical Report Series, No. 701). 13. Rassi Y et al. Confirmation of Meriones libycus (Rodentia; Gerbillidae) as the main reservoir host of zoonotic cutaneous leishmaniasis in Arsanjan, Fars province, south of Iran (1999–2000). Iranian journal of public health, 2001, 30:143–44. 14. Etemad E. [The mammals of Iran. Vol. 1. Rodentia]. Tehran, Islamic Republic of Iran, National Society for Protection of Natural Resources and Environment, 1978 [in Farsi]. 15. Noyes HA et al. A nested-PCR-based schizodeme method for identifying Leishmania kinetoplast minicircle classes directly from clinical samples and its appli- cation to the study of the epidemiology of Leishmania tropica in Pakistan. Journal of clinical microbiology, 1998, 36:2877–81. 16. Yaghoobi-Ershadi M R et al. Meriones libycus and Rhombomys opimus (Roden- tia: Gerbillidae) are the main reservoir hosts in a new focus of zoonotic cutane- ous leishmaniasis in Iran. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1996, 90:503–4. 17. Dejeux P. Information on the epidemiol- ogy and control of the leishmaniasis, by country or territory. Geneva, World Health Organization, 1991 (WHO/LEISH/91.30). 18. Ashford RW et al. Cutaneous leishmania- sis in the Libyan Arab Republic: prelimi- nary ecological finding. Annals of tropical medicine and parasitology, 1977, 71: 265–71. 19. Ibrahim EA et al. Meriones libycus (Ro- dentia:Gerbillidae), a possible reservoir host of zoonotic cutaneous leishmaniasis in Riyadh Province, Saudi Arabia. Trans- actions of the Royal Society of Tropical Medicine and Hygiene, 1994, 88(1):39. 20. Rassi Y et al. Epidemiological studies on zoonotic cutaneous leishmaniasis in Neiriz focus, Fars province, south of Iran (2001–2002). In: Abstracts of the 6th International Meeting on Microbial Epide- miological Markers (IMMEM6). August 27–30, 2003. Les Diableret, Switzerland, 2003. 478 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Short communication Antiperspirant use as a risk factor for breast cancer in Iraq S. Fakri,1 A.Al-Azzawi1and N. Al-Tawil1 1Department of Medicine, College of Medicine, Al-Nahrain University, Baghdad, Iraq (Correspondence to N. Al-Tawil: altaweeln@yahoo.com). Received: 19/05/04; accepted: 30/11/04 ABSTRACT Some internet communications have addressed the link between antiperspirant use and breast cancer. We studied the possible association between the use of antiperspirants and some other factors with the development of breast cancer in Al-Kadhmia teaching hospital. Thus, 54 cases of breast cancer and 50 controls were interviewed. We found 82.0% of the controls used antiperspirants compared with 51.8% of cases (P < 0.05). The use of antiperspirants had no association with the risk of breast cancer, while family history and oral contraceptives use were found to be associated. L’utilisation des antisudoraux comme facteur de risque de cancer du sein en Iraq Certaines communications électroniques sur l’Internet ont examiné le lien entre l’utilisation d’antisudo- raux et le cancer du sein. Nous avons étudié l’association éventuelle entre l'utilisation d’antisudoraux ainsi que certains autres facteurs et l'apparition d’un cancer du sein à l’hôpital universitaire Al-Kadhmia. Cinquante-quatre (54) cas de cancer du sein et 50 témoins ont donc été interrogés. Nous avons cons- taté que 82,0 % des témoins utilisaient des antisudoraux contre 51,8 % des cas (p < 0,05). Il n’y avait aucune association entre l'utilisation d’antisudoraux et le risque de cancer du sein, alors qu’on a trouvé une association avec les antécédents familiaux et l'utilisation de contraceptifs oraux. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 479 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction Breast cancer is considered one of the major types of cancers among women, hence one of the leading causes of death [1]. In Iraq, breast cancer cases have increased dramati- cally, especially in the 1990s, and constitut- ed 14.3% of all types of cancers in 1997 [1]. It has become a major public health prob- lem. The research question of this study arose after reading a letter submitted by Elizabeth Morin which linked breast cancer with antiperspirant (not deodorant) use [2]. The idea, as Morin said, is that antiperspi- rants prevent the body from perspiring, and thus prevent it from removing toxins from under the armpits. As toxins do not disap- pear spontaneously, the body deposits them in the lymph nodes below the arms instead. These lymph nodes are located in the upper outside quadrant of the breast area where almost all breast cancer tumours occur [2]. Considering the importance of breast cancer, we reviewed the literature that links breast cancer with antiperspirant use and found a reference that addresses this issue [3]. Our current study aimed to assess the possible association between the use of an- tiperspirants and breast cancer, and to iden- tify some other factors that are suspected of being associated with breast cancer. Methods All women (54) with breast cancer attending the oncology clinic of Al-Kadhmia teaching hospital from 1 September 2002 through 28 February 2003 were included as cases in the study. The inclusion criteria were any woman with breast cancer diagnosed histopathologically by excisional biopsy. Another group of 50 women, attending the general medicine clinic for various other complaints, not including breast problems, was considered as the control group. Wom- en attending the above-mentioned clinic and falling within the same 5-year age categories as the breast cancer cases were included in the control group. Only 50 controls could be recruited as a result of the invasion of Iraq in March 2003. We interviewed the cases using a self-designed questionnaire that included the following items: age, marital status, duration of the disease since diagno- sis, family history of breast cancer, smoking status, use of oral contraceptives, and the use of antiperspirants. Epi-Info, version 6 was used for data entry and analysis, and the chi-squared test of association was used to compare between observed and expected frequencies and between cases and controls. Results The mean age (standard deviation) of the cases was 43 (8.4) years, while that of the controls was 41.4 (15.1) years; the differ- ence between the 2 means was not statisti- cally significant (P > 0.05). Table 1 shows that there was a significant association between family history of breast cancer and use of oral contraceptives with the development of breast cancer (P < 0.05): 32.1% of the cases had a positive family his- tory of breast cancer compared with 8.0% of the controls and 38.9% of the cases had used oral contraceptives compared with only 10.0% of the controls. No significant as- sociation was found between either marital status or smoking habit and the develop- ment of breast cancer (P > 0.05). Table 2 shows that 82.0% of the control group used antiperspirants compared with 51.8% of the cases, and this difference was statistically significant (P = 0.00115). 480 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Discussion Recently spam messages on the internet, news and books have addressed the link between antiperspirant use and the risk of breast cancer. Darbre et al. carried out a study on 20 samples of human breast tumour to detect the level of parabens (cosmetic preservatives that can mimic the action of estrogen) [4]. In 4 of the 20 tumours, total paraben concentration was more than twice the average level. In spite of this finding, Darbre suggests more studies are needed to support or refute this hypothesis [4]. On the other hand, some experts think that perspi- ration does not eliminate toxins and there are in fact no toxins in sweat, which is made up of water, sodium, potassium, and magne- sium [5]. The relation between antiperspi- rant use and breast cancer is considered as a myth in another website [6]. Although the sample size was relatively small, our study failed to find a link between antiperspirant use and breast cancer. In fact our study showed that antiperspirant use was higher among the control group than the cancer cases. The proportion of women with a positive family history of breast can- cer among cases was fourfold the propor- tion among the controls. This is consistent with other findings. For example, it has been reported that women whose mothers Table 1 Comparison between cases and controls regarding marital status, family history of breast cancer, smoking, and use of oral contraceptives Variable Cases (n = 54) Controls (n = 50) Statistical data No. % No. % Marital status Married 45 83.3 39 78.0 χ2 = 0.48, P = 0.49 Single 9 16.7 11 22.0 Family history of breast cancera Present 17 32.1 4 8.0 χ2 = 9.19, P = 0.0024 Absent 36 67.9 46 92.0 Current smokinga Yes 6 11.3 8 16.0 χ2 = 0.48, P = 0.4885 No 47 88.7 42 84.0 Use of oral contraceptives User 21 38.9 5 10.0 χ2 = 11.6, P = 0.000675 Non-user 33 61.1 45 90.0 aData were missing for I case. Table 2 Use of antiperspirants among cases and controls Use of Cases (n = 54) Controls (n = 50) Statistical data antiperspirants No. % No. % User 28 51.9 41 82.0 χ2 = 10.57, P = 0.00115 Non-user 26 48.1 9 18.0 Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 481 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم or sisters have had breast cancer have a two- fold increased risk, and that women whose mother and sisters have breast cancer have a threefold increased risk [7]. Other studies report similar findings [8–11]. We found no association between cigarette smoking and breast cancer. In general this concurs with the results of epi- demiological studies throughout the world [12,13], although some of them do not show consistent results [14,15]. Analysis of the results of 53 epidemiological stud- ies showed that, after adjustment for the effect of alcohol, there was no association between smoking and breast cancer (rela- tive risk for ever smokers = 1.03, 95% CI = 0.98–1.07 and for current smokers = 0.99, 95% CI = 0.92–1.05) [13]. Band et al. carried out a study involving 318 pre- menopausal women and 340 controls [16]. The risk of breast cancer was significantly increased in women who had been pregnant and who started to smoke within 5 years of menarche (adjusted OR 1.69, 95% CI = 1.13–2.51), and in nulliparous women who smoked 20 cigarettes daily or more (OR = 7.08, 95% CI = 1.63–30.8) and had smoked for 20 cumulative pack-years or more (OR = 7.48, 95% CI = 1.59–35.2). On the other hand, postmenopausal women (700 breast cancer cases and 685 controls) whose body mass index increased from age 18 years to current and who started to smoke after a first full-term pregnancy had a significantly reduced risk of breast cancer (OR = 0.49, 95% CI = 0.27–0.89 [16]. Our study showed that there were more users of oral contraceptives among the cases of breast cancer compared with the controls. Other research has reported inconsistent findings regarding oral contraceptive use and breast cancer [7,17–19]. In conclusion, the use of antiperspi- rants was not associated with breast cancer. Family history of breast cancer and oral contraceptive pills use were found to be associated with breast cancer, while other variables such as marital status and smoking were not. References 1. Iraqi Cancer Board. Results of Iraqi can- cer registry 1995–1997. Baghdad, Minis- try of Health, 1997. 2. Morin E. Department of Medicinal Chem- istry. Merck Frosst Canada & Co. (a let- ter). 3. Erickson K. Drop-dead gorgeous: pro- tecting yourself from the hidden danger of cosmetics. New York, McGraw–Hill, 2002. 4. Darbre PH et al. Concentration of parabens in human breast tumours. Jour- nal of applied toxicology, 2004, 24(1):5– 13. 5. Dr Donnica.com. Breast cancer and an- tiperspirant use (http://www.drdonnica. com/display.asp?article=2379, accessed 21 January 2006). 6. Breast Cancer Health Centre. Breast cancer: detecting realities, not myths (http://health.yahoo.com/centers/breast_ cancer/104, accessed 21 January 2006). 7. Balaban DJ. Epidemiology and prevention of selected chronic illnesses. In: Cassens BJ, ed. Preventive medicine and public health, 2nd ed. Malvern, Pennsylvania, Harwal Publishing Company, 1992. 8. Tovar GV et al. Breast cancer in Mexican women: an epidemiological study with cervical cancer control. Revista de saúde pública, 2000, 34(2):113–9. 482 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 9. Calderon GAL et al. Risk factors of breast cancer in Mexican women. Salud pública de México, 2000, 42(1):26–33. 10. Arver B et al. Hereditary breast cancer: a review. Seminars in cancer biology, 2000, 10(4):271–88. 11. Brekelmans CT. Risk factors and risk reduction of breast and ovarian cancer. Current opinion in obstetrics & gynecol- ogy, 2003 15(1):63–8. 12. McPherson K, Steel CM, Dixon JM. Breast cancer epidemiology, risk factors, and ge- netics. In: Dixon JM, ed. ABC of breast disorders. London, BMJ publishing group, 1995:18–21. 13. Hamajima N et al. Alcohol, tobacco and breast cancer. British journal of cancer, 2002, 87(11):1234–45. 14. Li CI, Malone KE, Daling JR. The relation- ship between various measures of ciga- rette smoking and risk of breast cancer among older women 65–79 years of age (United States). Cancer causes & control: CCC, 2005, 16(8):975–85. 15. Johnson KC. Accumulating evidence on passive and active smoking and breast cancer risk. International journal of can- cer, 2005, 117(4):619–28. 16. Band PR et al. Carcinogenic and endo- crine disrupting effects of cigarette smoke and risk of breast cancer. Lancet, 2002, 360(9339):1044–9. 17. Deligeoroglou E, Michailidis E, Creatsas G. Oral contraceptives and reproductive system cancer. Annals of the New York Academy of Sciences, 2003, 997:199– 208. 18. Nkondjock A, Ghadirian P. Facteurs de risque du cancer du sein. [Risk factors and risk reduction.] Medecine sciences, 2005, 21(2):175–80. 19. Norsa’adah B et al. Risk factors of breast cancer in women in Kelantan, Malay- sia. Singapore medical journal, 2005, 46(12):698–705. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 483 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Short communication Inguinal hernias and genital abnormalities in young Jordanian males A.M.H. Ghazzal1 1Department of Surgery, King Hussein Medical Centre, Amman, Jordan (Correspondence to A.M.H. Ghazzal: asadghazzal@hotmail.com). Received: 26/05/04; accepted: 24/11/04 ABSTRACT This study was carried out to document the prevalence of inguinal hernia, hypospadias, undescended testis and varicocele in 3057 male applicants to the military wing of Mu’ta University in the south of Jordan. Age range was 17–20 years. A total of 250 men had one the 4 conditions: 93 (3.0%) had inguinal hernia; 15 (0.5%) had undescended testis (26.7% bilateral); 59 (1.9%) had hypospadias; 83 (2.7%) had varicocele (98.79% on the left side). Prevalence of inguinal hernia and undescended testis were comparable with international prevalence rates, while the rate for hypospadias was higher and that for varicocele lower. A birth defects registration system would help in planning preventive and treatment strategies. Hernies inguinales et anomalies génitales chez de jeunes Jordaniens RÉSUMÉ La présente étude a été réalisée pour documenter la prévalence de l’hernie inguinale, de l’hypospadias, de la cryptorchidie et de la varicocèle chez 3057 candidats à l’inscription dans la section militaire de l’Université Mu’ta dans le sud de la Jordanie. L’âge était compris entre 17 et 20 ans. Au total, 250 hommes avaient l’une des quatre affections suivantes : 93 (3,0 %) avaient une hernie in- guinale ; 15 (0,5 %) présentaient une cryptorchidie (bilatérale pour 26,7 %) ; 59 (1,9 %) avaient un hypospadias ; 83 (2,7 %) avaient une varicocèle (98,79 % du côté gauche). La prévalence de l’hernie inguinale et de la cryptorchidie était comparable aux taux de prévalence internationaux, tandis que le taux était plus élevé pour l’hypospadias et plus bas pour la varicocèle. Un système d’enregistrement des malformations congénitales permettrait de planifier les stratégies de prévention et de traitement. 484 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Introduction In any community, statistical studies of medical problems are very important as they can determine the size of the problem and help the health authorities to put ap- propriate plans in place to deal with them, especially for congenital conditions. Inguinal hernia in children and young adults is usually the result of patent proces- sus vaginalis. It can be life threatening, or can lead to loss of the testis or part of the intestine if strangulation occurs. Incidence of inguinal hernia ranges between 0.8% and 4.4% [1,2]. According to the American Academy of Pediatrics, 5 out of 100 chil- dren have inguinal hernias (more boys than girls), some may not have symptoms until adulthood [3]. Hypospadias is a congenital defect of the penis resulting in incomplete development of the penile urethra, the external urethral meatus may be anywhere along the ventral surface of the penis, ventral surface of the glans (glanular hypospadias), in the penis shaft distally (distal penile hypospadias) or proximally (proximal penile hypospadias), down to the scrotum (scrotal hypospadias) or even in the perineum (perineal). As the position of the external meatus becomes more proximal, ventral shortening and cur- vature during erection are more likely [4]. This may lead to sexual dysfunction in adulthood. In addition, the patient may be unable to urinate standing due to deviation of urine stream and may need to sit to uri- nate [5] and this will result in emotional and psychological stress for the patient and his family. Gallentine, Morey and Thompson found an incidence of 0.07% in a multiracial sample in the United States of America, with no racial difference [5]. Undescended testis is the failure of 1 or both testes to descend to the scrotum; this condition was first described in 1786 by Hunter [6]. In undescended testis there is increased incidence of infertility, torsion, malignancy and exposure to trauma. The presence of the testis in an obscure place may lead to delay in diagnosis of malig- nancy. Varicocele is pathologic dilatation, elongation and varix-like formation of the spermatic veins that form the pampiniform plexus [7]. It is considered a common cause for infertility as it elevates the temperature of the testis and this disturbs spermatogenesis and decreases its volume [7,8]. Varicocele occurs in 15% of men [9,10]. It is known that varicocele leads to functional disturbance of the testis and surgical treatment leads to improvement of semen quality [11]. Jordan, along with other developing countries, lacks a proper medical regis- tration system. There are, therefore, no official records documenting the incidence or prevalence of these 4 conditions. This has a negative effect on national health care programmes as such a system could provide medical researchers and health planning authorities with the statistical information necessary for future health strategies. Therefore, data were collated over 2 consecutive years for applicants to the mili- tary wing of Mu’ta University, who come from all geographic areas of the country. This provided an opportunity to document the prevalence of certain surgical conditions among young Jordanian males. It had been noticed that these were the 4 commonest conditions that were grounds for the univer- sity applicants to fail the medical check-up. Methods Data on inguinal hernia and 3 genital ab- normalities were collected during the medi- cal examinations for all applicants to the Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 485 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم military wing of Mu’ta University, Karak, Jordan. A total of 3057 male applicants were examined in 2 consecutive years, Au- gust 1992 and August 1993. Age range was 17–20 years. Applicants are categorized into 10 groups according to the father’s birthplace, so all areas of the country were represented (though not necessarily evenly represented as there is no limit for number of applicants). All applicants were examined clinically by the investigator for the presence of in- guinal hernia, hypospadias, undescended testis and varicocele, or for scars indicating their repair earlier in life (applicants in whom these conditions were found, i.e. not previously treated, were refused admission to the university). Results The results are shown in Table 1. Of the 3057 applicants, 250 (8.2%) had one of the conditions, either present when exam- ined or repaired earlier in life. Ninety three (3.0%) had inguinal hernia, bilateral in 13 (14.0%) cases; 59 (1.9%) had hypospadias, 48 (81.4%) of them glanular; 15 (0.5%) had undescended testis, bilateral in 4 (26.7%); and 83 (2.7%) had varicocele, only 1 (1.2%) on the right side. Discussion Inguinal hernias and genital abnormalities are common surgical problems in young males. Most can be managed easily, but if neglected, they can cause serious medical, social, psychological and economic prob- lems. The lifetime risk for developing inguinal hernia in men is 27% [12]. In Turkey, a prevalence of 1.45% was found among 19 750 schoolchildren [13]. In a study done on 1748 male elementary school students in the city of Aqaba in the south of Jordan, inguinal hernia was found in 13.44% [14], which is nearly 4 times the figure found in the present study. The results of this study may be more accurate because the sample was more representative of the Jordanian community as the applicants to the military wing of Mu’ta University come from all parts of Jordan. In Italy, an incidence of 0.36% was found for hypospadias [15]. In the Nether- lands the incidence was 0.38% of live births [16]. In British Colombia, the incidence was 0.444% of live births [17]. In Finland, 0.3% of boys were found to have hypospadias [18]. In Bahrain, prevalence was 0.76 per 1000 live births [19]. In Egypt a prevalence of 0.23% was found among 3000 consecu- Table 1 Prevalence of inguinal hernia and genital abnormalities in applicants to the military wing of Mu’ta University (N = 3057) Condition Total Right sided Left sided Bilateral No. % No. % No. % No. % Inguinal hernia 93 3.0 48 51.6 32 34.4 13 14.0 Hypospadias 59 1.9 – – – – – – Undescended testis 15 0.5 2 13.3 9 60.0 4 26.7 Varicocele 83 2.7 1 1.2 82 98.8 0 – 486 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم tive neonates [20]. In Aqaba, a prevalence of 0.74% was found [14]. In the present study, prevalence of hypospadias was 1.9%, so it is clear that this was substantially greater than international findings. This is supported by the high prevalence found in the Aqaba study [14]. More severe forms of hypospadias were not detected in this study. It is likely that a person with severe abnor- malities (where the deformity is obvious to the young man himself) would not apply to a military university as he would know that he would not pass the medical examination. This might explain why these forms of hypospadias were not detected. In the study done in Aqaba in southern Jordan, undescended testis was found in 2.12% of the sample [14]. In the United States of America, prevalence ranged from 3.7% at birth to 1.1% from age 1 year to adulthood [6]. In a comparative study done in Denmark and Finland, prevalence of undescended testis at birth was 9.0% in Denmark and 2.4% in Finland; at 3 months this fell to 1.9% in Denmark and 1.0% in Finland [21]. Internationally, prevalence range is 4.3%–4.9% at birth, 1%–1.5% at 3 months and 0.8%–2.5% at 9 months. [6,7]. In Nigerian children, the prevalence of un- descended testis was 0.5% [22]; in Turkey it was 0.9% [13]. In another Turkish study, undescended testis was found in 0.31% of 9078 elementary school students [1]. In Bahrain, prevalence was 0.65 per 1000 live births [19]. From this comparison, it is clear that the prevalence of undescended testis in developing countries, including Jordan in our study, is substantially lower (one quarter to one half) than that in some industrialized countries. This observation needs further investigation and assessment to be documented conclusively. The high prevalence reported in the previous Jor- danian study cannot be considered to be representative of Jordan as a whole as it was limited to 1 small city, Aqaba [14]. Varicocele is very rare under the age of 10; this might explain the very low prevalence of varicocele (0.46%) which was found in a study done in Aqaba, Jordan, as the age range of the sample was 6–12 years [14]. Some Italian studies showed a much higher prevalence: in a study carried on 9861 students aged 11–18 years, a preva- lence of 16% was found [23]. In a second study on 2400 male applicants for the Ital- ian Air Force Academy aged 18–22 years, varicocele was found in 8.16% [24]. In Greece, 3047 schoolboys aged 5–16 years were examined clinically by a urologist for varicocele while standing; left varicocele was present in 3.21% [25]. In Poland 2470 schoolboys aged 10–20 years were exam- ined, varicocele was found in 35% [26]. This showed that prevalence (2.7%) in our sample of young Jordanian men was lower than that in many similar studies. Conclusion Prevalence rates for inguinal hernia and undescended testis were comparable with the range found internationally, while the rate was lower for varicocele and higher for hypospadias. Conditions such as these, if left un- treated or not treated at the proper time, will lead to further complications. Some of these complications will have a negative physical, psychological, social and economic effect on the patient himself, his family and the whole society. For example, in our study those applicants in whom these conditions were found were rejected from the military wing of Mu’ta University (where study is completely free of charge) as they were considered not fit for military service. This Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 487 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم certainly changed the course of their careers and would have a psychological, social and economic impact on them and their families (and consequently on the community as a whole) compounded with the effect of the medical complications of these conditions. Screening of children through a national birth defects registration system would facilitate prevention and timely treatment of these conditions, and would reduce the medical, psychological, social and eco- nomic effects. References 1. Koltuksuz U et al. Congenital inguinal pathologies in Malataya school age children. Journal of Turgut Özal Medical Center, 1999, 6(1):9–12. 2. Lugo-Vicente H. Recurrent inguinal her- nias. Pediatric surgery update, 2003, 21(6). 3. Medline Plus Medical Encyclopedia. Hernia. Bethesda, Maryland, National In- stitutes of Health, (http://www.nlm.nih.gov/ medlineplus/ency/article/000960.htm, ac- cessed 29 October 2003). 4. Laurance B, Hiep TN. Center for the Study and Treatment of Hypospadias. San Francisco, University of California, San Francisco (http://urology.ucsf.edu/ clinicalRes/CRhypo.html, accessed 3 May 2002). 5. Gallentine ML, Morey AF, Thompson IM Jr. Hypospadias: a contemporary epi- demiologic assessment. Urology, 2001, 57(4):788–90. 6. Thomas FK. Cryptorchidism. Omaha, Nebraska, eMedicine, 2002 (http:// www.emedicine.com/med/topic2707.htm, accessed 3 May 2002). 7. Nicolaij D et al. Comparison of scrotal scintigraphy and thermography for the diagnosis of varicocele. European journal of nuclear medicine, 1983, 8:123–6. 8. Sawczuk IS et al. Varicoceles: effect on testicular volume in prepubertal and pubertal males. Urology, 1993, 41(5): 466–8. 9. Meacham RB et al. The incidence of varicoceles in the general population when evaluated by physical examination, gray scale sonography and color Doppler sonography. Journal of urology, 1994, 151(6):1535–8. 10. Sandlow J. Pathogenesis and treatment of varicoceles. British medical journal, 2004, 328(7454):967–8. 11. Belloli G et al. Fertility rates after success- ful correction of varicocele in adolescence and adulthood. European journal of pedi- atric surgery, 1995, 5(4):216–8. 12. Kingsnorth A. Treating inguinal hernias. British medical journal, 2004, 328(7431): 59–60. 13. Yucesan S et al. Prevalence of congenital abnormalities in Turkish school children. European journal of epidemiology, 1993, 9(4):373–80. 14. Al-Abbadi K, Smadi SA. Genital abnorm- alities and groin hernias in elementary- school children in Aqaba: an epidemiolog- ical study. Eastern Mediterranean health journal, 2000, 6(2–3):293–8. 15. Mondaini N et al. Hypospadias: incidence and effects on psychosexual develop- ment as evaluated with the Minnesota Multiphasic Personality Inventory test in a sample of 11 649 young Italian men. Uro- logia internationalis, 2002, 68(2):81–5. 16. Pierik FH et al. A high hypospadias rate in the Netherlands. Human reproduction, 2002, 17(4):1112–5. 17. Leung TJ, Baird PA, McGillivray B. Hypo- spadias in British Columbia. American journal of medical genetics, 1985,21(1): 39–50. 488 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم 18. Vrtanen HE et al. The birth rate of hypo- spadias in the Turku area in Finland. Acta pathologica, microbiologica, et im- munologica scandinavica, 2001, 109(2): 96–100. 19. Al-Arrayed SS. Epidemiology of con- genital abnormalities in Bahrain. Eastern Mediterranean health journal, 1995, 1(2): 248–52. 20. Temtamy SA et al. A genetic epidemio- logical study of malformations at birth in Egypt. Eastern Mediterranean health journal, 1998:4(2):252–9. 21. Boisen KA et al. Difference in prevalence of congenital cryptorchidism in infants be- tween two Nordic countries. Lancet, 2004, 363(9417):1264–9. 22. Onuora VC, Evbuomwan I. Abnormal findings associated with undescended testis in Nigerian children. Indian journal of pediatrics, 1989, 56(4):509–11. 23. Belloli G et al. Il varicocele in eta pedi- atrico-adolescenziale ed altre anomalie testicolari: studio epidemiologico [Vari- cocele in childhood and other testicular anomalies: an epidemiological study]. La Pediatria medica e chirurgica, 1993, 15(2):59–62. 24. Gioffre L et al. Indagine epidemiologica sulle patologie ed anomalie nella sfera genitale esterna maschile [Epidemiologi- cal study on pathology and abnormalities of the external male genitalia]. Il Giornale di chirurgia, 2002, 23(4):125–8. 25. Stavropoulos NE et al. Varicocele in schoolboys. Archives of andrology, 2002, 48(3):187–92. 26. Niedzielski J, Paduch D, Raczynski P. As- sessment of adolescent varicocele. Pedi- atric surgery international, 1997, 12(5–6): 410–3. Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 489 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم Case report Bilharzial infection of a uterine leiomyoma A.H. Al-Nakash1 and D.K. Al-Rahal2 1Department of Obstetrics and Gynecology, Al-Kindy Medical College, Al-Elweya Maternity Teaching Hospital; 2College of Medicine, Baghdad University, Baghdad, Iraq (Correspondence to A.H Al-Nakash: razaknakash@yahoo.com). Received: 04/08/04; accepted: 20/12/04 Introduction Schistosoma haematobium is endemic in Iraq, constituting an important health prob- lem in this country [1,2]. Boulanger in 1919 reported the geographical distribution of schistosomiasis in Mesopotamia [2]. More recent reports suggest that the reported in- cidence of schistosomiasis in the Iraqi adult population is 4.9% [3], and the incidence in autopsy materials in the Medical City Teaching Hospital in Baghdad is 4.4% [4]. Although S. haematobium usually af- fects the urinary system, involvement of the genital organs is not unusual in endemic zones, occurring via the vascular anasto- mosis between the bladder and the genital organs [5]. Aberrant nidation, spontaneous abortion and permanent sterility were the most reported complications of the genital schistosomiasis. It is also responsible for functional sequelae including pelvic ache and menstrual problems [6]. Other bil- harzial species have also been blamed for genital organ diseases in the areas where they are endemic, producing comparable symptoms [7,8]. We report a case of bilharzial infection of a uterine leiomyoma with other genital organs unaffected. Case report A 34-year-old grand multiparous woman from Baladros, north-east Baghdad, pre- sented with a lower abdominal mass that had been present for the last 2 years. Her menstrual cycle was regular, but recently she noticed that her menstrual flow became heavier and associated with symp- toms of congestive dysmenorrhea and deep dyspareunia. She had no urinary complaints and no previous history of haematuria. Abdominal examination revealed a firm, smooth and partly fixed central pelvic ab- dominal mass of about 16 weeks gestation size. It was tender on deep palpation. There were no other physical findings. Pelvic ex- amination showed an apparently normal va- gina and cervix. On bimanual examination a firm mass was felt, involving the uterus and limiting its movement. Ultrasound showed an anterofundal uterine myoma of about 11×11 cm. Her other organs were normal. Her husband and her 4 sons complained of urinary schistosomiasis and were on treatment, while her 4 daughters were symptom-free. In her district of Baghdad, schistosomiasis is endemic. However, blood tests on the woman were normal and 490 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 3/4, 2006 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم repeated urinary analysis (3 times) showed no bilharzial ova. Total abdominal hysterectomy was performed (with the patient’s agreement) leaving ovaries of normal appearance. The specimen showed a uterus with distorted shape and two fallopian tubes, measur- ing 11×12×16 cm at the widest diameter. Sectioning showed a nodular mass measur- ing about 11 cm in diameter involving the antero-fundal area of the uterus, whitish- grey in colour, with a firm whorled cut section. Microscopically, the benign leio- myoma showed multiple epitheloid granu- lomas with calcified bilharzial ova within the leiomyoma. No bilharzial lesions were present in other parts of the specimen (Fig- ures 1–3). Discussion The human is not the final host for the schistosome. It is the extreme inflammatory response to eggs deposited in the soft tis- sues that gives rise to chronic presentations of schistosomiasis [9,10]. Some of the eggs become calcified rather than resorbed and are generally surrounded by dense fibrosis which, as in our case, be seen long after the original infection. This case of bilharzial infection of a uterine myoma surprisingly spared other genital organs. We cannot offer a clear explanation for this occurrence; fibroid tissue is known to be less vascular than other uterine parts, and it seems that certain vascular connections had played a role in this situation. The resultant granulomatous inflammation had possibly influenced the size of the fibroid, explaining its relatively large size in this patient. Figure 1 An epithelioid granuloma within the leiomyoma Figure 2 An epithelioid granuloma with multiple calcified bilharzial ova Figure 3 Two calcified bilharzial ova within the leiomyoma Eastern Mediterranean Health Journal, Vol. 12, Nos 3/4, 2006 491 ٢٠٠٦ ،٤-٣
$دعل ،رشع (اثل دلجلم ،ةيلماعل ةحصل ةمظنم ،طسوتلم رشل ةيحصل ةلجلم [6] who recorded the involvement of genital organs as follows: cervix (42%), ovary (21%), fallopian tube (16%) and vulva, vagina and clitoris (21%). Unlike the other members of her fam- ily, our patient was free from the urinary manifestations of schistosomiasis, and her fertility was not affected. No anti-bilharzial treatment was given because it was evident that that the original infection had halted long before. Tawfikh et al. [2] reported on genital bilharziasis in Iraq, demonstrating distribu- tion of the disease in the genital organs. The fallopian tube was the commonest site of involvement (71.2%), followed by the cer- vix (13.5%) and the ovary (9.6%). Uterine, vulval and vaginal involvements were less frequent. Infertility was the commonest presentation (38.5%) and the rate of ectopic pregnancy was 8%. These figures are not consistent with that given by Gouzouv et al. 1. Boulanger GL. Report on bilharziasis in Mesopotamia. Indian journal of medical research, 1919, (7):8. 2. Tawfikh LE, Al-Wafa RO, Mukhlis GM. Schistosomiasis of the female genital tract in Iraq. Iraqi journal of community medicine, 1995, 1:37–42. 3. Report of investigation of endemic dis- ease. Baghdad, Iraq, Ministry of Health 1982. 4. Al-Saleem T, Alsh N, Tawfikh LE. Bladder cancer in Iraq: the histological subtypes and their relationship to schistosomiasis. Annals of Saudi medicine, 1990, 10:161– 4. 5. Morice P et al. Bilharzoise tubaire. [Tubal bilharziasis.] Journal de gynecologie, ob- stetrique et biologie de la reproduction, 1993, 22(8):848–50. 6. Gouzouv A, Baldassini B, Opa JF. Aspect anatomo-pathologique de la bilharziose genitale de la femme. [Anatomicopatho- logical aspects of genital bilharziasis in women.] Medecine tropicale: revue du Corps de sante colonial, 1984, 44(4): 331–7. 7. Richard-Lenoble D et al. Bilharziose a Schistosoma intercalatum bilharziose re- cente et oubliee. [Bilharziasis caused by Schistosoma intercalatum, a recent and forgotten form of schistosomiasis.] La Revue du praticien, 1993, 43(4):432–9. 8. Billy-Brissac R et al. Bilharziose genitale de la femme a Schistosoma mansoni: a propos de deux cas en Guadeloupe. [Genital Schistosoma mansoni bilhar- ziasis in women: apropos of 2 cases in Guadeloupe.] Medecine tropicale: re- vue du Corps de sante colonial, 1994, 54(4):345–8. 9. Helling-Giese G et al. Schistosomiasis in women: manifestations in the upper reproductive tract. Acta tropica, 1996, 62(4):225–38. 10. Ricosse JH, Emeric R, Courbil LJ. As- pects anatomo-pathologiques des bilharzioses (a propos de 286 pieces his- topathologiques). [Anatomopathological aspects of schistosomiasis. A study of 286 pathological specimens.] Medecine tropicale: revue du Corps de sante colo- nial, 1980, 40(1):77–94. References