Eastern Mediterranean Health Journal La Revue De Santé De La Méditerranée Orientale

Contents

Editorial

Improving evidence informed policy-making for health in the Eastern Mediterranean Region...... 793 Research articles

Independent prescription of medicines and diagnostic test advice by final year medical students in Punjab...... 795 Challenges impeding integration of oral health into primary health care...... 802 Eastern Mediterranean Caractérisation génétique du sous-groupe Maculipennis (Diptera : Culicidae) au Maroc : un outil fondamental pour lutter contre le paludisme...... 809 Health Journal Assessment of the quality of life in patients on haemodialysis in Iraq...... 815 Trend and seroprevalence of Epstein–Barr virus in Bahrain: 2001–2015...... 821 Investigation of breastfeeding training based on BASNEF model on the intensity of postpartum blues...... 830 La Revue de Santé de Volume 23 Number 12 Changes in dietary habits and physical activity and status of metabolic syndrome among expatriates la Méditerranée orientale in Saudi Arabia...... 836 Réflexionséthiques sur le principe de l’autonomie du patient...... 845 ...... 850

December 2017 تقييم فاعلية التطعيم ضدّ التهاب الكبد الفريويس البائي لدى مرىض نقل الدم املتكرر يف سوريا Commentary

The forgotten history of pre-modern epidemiology: contribution of Ibn An-Nafis in the Islamic golden era..... 854 WHO events addressing public health priorities

Redesigning the integrated approach to child health in line with the United Nations Sustainable Development Goals...... 858

A sound understanding of the context in which health systems must operate is essential in order to formulate effective policy-making, which can only be realized through the very best research evidence available, and is a priority for the many critical situations present in the Eastern Mediterranean Region.

املجلد الثالث والعرشون / عدد Volume 23 / No. 12 12 ديسمرب/كانون األول December/Décembre 2017

Cover 23-12.indd 5-7 2/26/2018 7:37:37 AM Members of the WHO Regional Committee for the Eastern Mediterranean املجلة الصحية لرشق املتوسط Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon هى املجلة الرسمية التى تصدر عن املكتب اإلقليمى لرشق املتوسط بمنظمة الصحة العاملية. وهى منرب لتقديم السياسات Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab واملبادرات اجلديدة ىف اخلدمات الصحية والرتويج هلا، ولتبادل اآلراء واملفاهيم واملعطيات الوبائية ونتائج األبحاث وغري Republic . Tunisia . United Arab Emirates . Yemen ذلك من املعلومات، وخاصة ما يتعلق منها بإقليم رشق املتوسط. وهى موجهة إىل كل أعضاء املهن الصحية، والكليات الطبية وسائر املعاهد التعليمية، وكذا املنظامت غري احلكومية املعنية، واملراكز املتعاونة مع منظمة الصحة العاملية واألفراد املهتمني بالصحة ىف اإلقليم وخارجه.

EASTERN MEDITERRANEAN HEALTH JOURNAL البلدان أعضاء اللجنة اإلقليمية ملنظمة الصحة العاملية لرشق املتوسط IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con- األردن . أفغانستان . اإلمارات العربية املتحدة . باكستان . البحرين . تونس . ليبيا . مجهورية إيران اإلسالمية .cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region اجلمهورية العربية السورية . اليمن . جيبويت . السودان . الصومال . العراق . عُ ام ن . فلسطني . قطر . الكويت . لبنان . مرص -It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col laborating Centres and individuals within and outside the Region. املغرب . اململكة العربية السعودية LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser‑vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres Membres du Comité régional de l’OMS pour la Méditerranée orientale informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collabora- Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran teurs de l’OMS et personnes concernés au sein et hors de la Région. Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne Somalie . Soudan . Tunisie . Yémen

EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/

EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). Correspondence

Editor-in-chief Eastern Mediterranean Health Journal © World Health Organization (WHO) 2017. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence WHO Regional Office for the Eastern Mediterranean (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). P.O. Box 7608 Nasr City, Cairo 11371 Disclaimer. Egypt The designations employed and the presentation of the material in this publication do not imply the expression of any opinion Tel: (+202) 2276 5000 whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning Fax: (+202) 2670 2492/(+202) 2670 2494 the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which Email: [email protected] there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the Subscriptions and Permissions interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Publications of the World Health Organization can be obtained from Knowledge Sharing The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, and Production, World Health Organization, Regional Office for the Eastern Mediterranean, decisions or policies of the institutions with which they are affiliated. PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 2670 2535, fax: +202 2670 2492; email: [email protected]). Requests for permission to reproduce, in part or in whole, or to If authors are staff members of the World Health Organization, the authors alone are responsible for the views expressed in this translate publications of WHO Regional Office for the Eastern Mediterranean – whether for publication and do not necessarily represent the decisions, policy or views of the World Health Organization. sale or for noncommercial distribution – should be addressed to WHO Regional Office for the Eastern Mediterranean, at the above address; email: [email protected].

ISSN 1020-3397

Cover 23-12.indd 8-10 2/26/2018 7:37:37 AM Eastern Mediterranean La Revue de Santé de Health Journal la Méditerranée orientale

املجلد الثالث والعرشون عدد Vol. 23 No. 12 • 2017 • 12 Contents

Editorial Improving evidence informed policy-making for health in the Eastern Mediterranean Region Arash Rashidian, Ahmed Mandil and Jaouad Mahjour...... 793 Research articles Independent prescription of medicines and diagnostic test advice by final year medical students in Punjab Kashif Aziz, Hafiz M. Aeymon and Saba Batool...... 795 Challenges impeding integration of oral health into primary health care Zahra Ghorbani, Mina Pakkhesal, Shahnam Arshi, Mohammad J. Eghbal, Marzieh Deghatipour, Marc Tennant and H. Malekafzali Ardakani...... 802 Caractérisation génétique du sous-groupe Maculipennis (Diptera : Culicidae) au Maroc : un outil fondamental pour lutter contre le paludisme Bouchra Trari et Mohamed Dakki...... 809 Assessment of the quality of life in patients on haemodialysis in Iraq Safauldeen A. Alhajim...... 815 Trend and seroprevalence of Epstein–Barr virus in Bahrain: 2001–2015 Eman Farid and Mohammed Al-Biltagi...... 821 Investigation of breastfeeding training based on BASNEF model on the intensity of postpartum blues Marzieh Akbarzadeh, Sima Kiani Rad, Marzieh Moattari and Najaf Zare...... 830 Changes in dietary habits and physical activity and status of metabolic syndrome among expatriates in Saudi Arabia Rasmieh A. Alzeidan, Fatemeh Rabiee, Ahmed A. Mandil, Ahmad S. Hersi and Anhar A. Ullah...... 836 Réflexions éthiques sur le principe de l’autonomie du patient Marianne Bracconi, Christian Hervé et Philippe Pirnay...... 845 تقييم فاعلية التطعيم ضدّ التهاب الكبد الفريويس البائي لدى مرىض نقل الدم املتكرر يف سوريا 850...... وداد يازجي، وفاء ّاحلبال، فوزة منعم Commentary The forgotten history of pre-modern epidemiology: contribution of Ibn An-Nafis in the Islamic golden era Ghazi Kayali...... 854 WHO events addressing public health priorities Redesigning the integrated approach to child health in line with the United Nations Sustainable Development Goals...... 858

Book 23-12.indb 791 3/4/2018 11:44:20 AM Jaouad Mahjour, Editor-in-Chief Arash Rashidian, Executive Editor Ahmed Mandil, Deputy Executive Editor Phillip Dingwall, Managing Editor Editorial Board Zulfiqar Bhutta Mahmoud Fahmy Fathalla Rita Giacaman Ahmed Mandil Ziad Memish Arash Rashidian Sameen Siddiqi Huda Zurayk International Advisory Panel Mansour M. Al-Nozha Fereidoun Azizi Rafik Boukhris Majid Ezzati Hans V. Hogerzeil Mohamed A. Ghoneim Alan Lopez Hossein Malekafzali El-Sheikh Mahgoub Hooman Momen Sania Nishtar Hikmat Shaarbaf Salman Rawaf Editorial assistants Nadia Abu-Saleh, Suhaib Al Asbahi (graphics), Diana Tawadros (graphics)

Editorial support Guy Penet (French editor) Eva Abdin, Fiona Curlet, Cathel Kerr, Marie-France Roux (Technical editors) Manar Abdel-Rahman, Ahmed Bahnassy, Abbas Rahimiforoushani (Statistics editors) Administration Yasmeen Sedky, Iman Fawzy, Dalya Mostafa

Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt

Cover photograph: © World Health Organization

Book 23-12.indb 792 3/4/2018 11:44:20 AM املجلة الصحية لرشق املتوسط املجلد الثالث والعرشون العدد الثاين عرش

Editorial Improving evidence informed policy-making for health in the Eastern Mediterranean Region Arash Rashidian 1, Ahmed Mandil 1 and Jaouad Mahjour 2

Health policies should be based on a scrutiny had made it important for evidence presented to them as irrelevant sound understanding of the problems, the politicians to demonstrate how to their context (12). With more issues and context in which they oper- they develop prudent policies, and research originating from the Region, ate, for which they require reliable data the effects of such policies on health this picture is about to change. At the and information for action (1,2). The outcomes. Also, increasing population same time, regional output on research policies should also be informed by the demand for health services and aging is challenged from two fronts. Over the best available research evidence (3), populations have resulted in increasing last decade, five countries of the Region which also helps in better capturing the health care costs, resulting in closer produced 80% of regional research problem, understanding existing trends scrutiny of health policies. Moreover, output in terms of peer-reviewed and patterns, and setting reasonable such conditions have also meant that publications. More noteworthy, the objectives that can be achieved using ministries of health are having more three leading universities of the Region effective interventions. More impor- success in putting ‘health’ on the agenda published over 10% of the total papers tantly, research can provide evidence of policy-makers outside the health published in indexed journals (11). The of comparative effectiveness of alter- sector. With increasing focus on social other relevant challenge is related to the native interventions for a given public determinants of health, and now the quality of research from the Region, and health issue; the costs and feasibility of Social Development Goals as a global its attention to public health issues 13( ). implementing each intervention; and agenda (10), health is more featured In both fronts, there has been some efficiency of the proposed interventions in the political discussions and hence, progress, but there remain important (policies) in comparison with alterna- further demand to support health policy limitations. tive interventions. These arguments decisions with research evidence. The third stream is related to the apply whether we are considering na- The second stream is related to institutional capacity of the ministries tional policies or focusing on policies availability, validity and relevance of of health (and other related public developed or advocated through inter- research evidence for health policy- institutions) in retrieving, assessing and national organizations, including the making. Different assessments have using research evidence. While there are World Health Organization (WHO) demonstrated a considerable increase many more ‘decision-oriented’ research (4,5). in the number of research outputs from studies being published every year (e.g. In the Eastern Mediterranean the countries of the region. While this systematic reviews), systematically Region (EMR), three parallel streams trend started from a handful of countries using such evidence in decision-making have shaped, and continue to shape, use in the last decade, it has affected more processes requires a level of institutional of research evidence in health policies. countries in the Region (11). This is capacity and technical expertise that First, there has been a growing interest important as this may partially alleviate a many ministries of health may lack. in the use of research evidence in major concern related to use of research Also, technical expertise on its own may health policies. The increasing demand evidence in decision-making. The not be sufficient for the expectations for research evidence has followed policy-makers’ concern has traditionally and processes of decision-making. Over national discourse in many countries, related to the fact that most research the years, WHO has advocated different where public policies – including health evidence presented to them actually structural approaches and technical policies – are increasingly assessed in a originated from high-income countries solutions for further use of research critical way (6-9). In recent years, health beyond the Region, which have a evidence in formulating key decisions. concerns are prominently featured in different set of priorities, challenges Health Technology Assessment political debates and national discourse and decision-making processes. Hence, programmes, and national plans for in several countries. This level of policy-makers perceived research adoption or development of clinical

1Department of Information, Evidence and Research; WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to: Arash Rashidian: [email protected]). 2Acting Regional Director, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt

793 https://doi.org/10.26719/2017.23.10.793

Book 23-12.indb 793 3/4/2018 11:44:20 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

public health guidelines are among (Islamabad, Pakistan; October 2017)1, To materialize these commitments, these (14). So far the progress on both in which ministers of health commit- systematic programmes are required fronts has been limited in the Region, ted themselves to “take necessary ac- to identify the priority health topics, as few countries have established such tion towards conducting public health establish research evidence review pro- mechanisms at the national level (15). research that is directed towards the cesses, and develop decision-making WHO also advocates development of requirements of health services and approaches that require the considera- policy briefs for key policy decisions that addresses people’s health needs; tion of research evidence. While these (16). Policy briefs can improve the and build national capacity to use evi- may sound difficult to a country with transparency of decision-making in health, as well as bringing forward dence from health research in national limited past experience or with complex benefits and challenges that might be policy-making for health”. The Member decision-making processes, in practice faced if policy-makers adopt one course States also requested WHO to “estab- there might be effective approaches that of action instead of others. lish regional mechanisms to support work for different scenarios with differ- In summary, there is a strong the bridging of gaps between relevant ent levels of capacity within the coun- political will in the EMR to enhance research institutions and policy-makers tries. WHO is committed to supporting use of research evidence in decision- and the translation of research evidence countries in their objective of improving making. This was demonstrated in into health policy statements, and health-related policies, and ultimately the Eastern Mediterranean Regional support the establishment of national improving health outcomes, through Committee Resolution EM/RC64/R.1 mechanisms.” evidence informed policy-making.

References

1. Alwan A, Ali M, Aly E, Badr A, Doctor H, Mandil A, et al. Mediterranean countries: views, practices, and contextual Strengthening national health information systems: challenges influences. BMC Health Serv Res. 2012 07 16;12(1):200. https:// and response. East Mediterr Health J. 2016 02 1;22(11):840–50. doi.org/10.1186/1472-6963-12-200 PMID:22799440 https://doi.org/10.26719/2016.22.11.840 PMID:28177115 10. World Health Organization. Health in 2015: from MDGs to 2. Eastern Mediterranean Region Framework for health SDGs. Geneva: World Health Organization; 2015 (http:// information systems and core indicators for monitoring www.who.int/gho/publications/mdgs-sdgs/en/). health situation and health system performance. Cairo: WHO 11. Tadmouri GO, Mandil A, Rashidian A. Development of an Regional Office for the Eastern Mediterranean; 2017. Eastern Mediterranean Region search strategy for biomedical 3. World Health Organization. The WHO strategy on research for citations indexed in PubMed. East Mediterr Health J. 2017 health. Geneva: World Health Organization; 2012. 11 19;23(9):619–29. https://doi.org/10.26719/2017.23.9.619 4. World Health Report 2013. Research for universal health PMID:29178119 coverage. Geneva: World Health Organization; 2013 (http:// 12. Yousefi-Nooraie R, Rashidian A, Nedjat S, Majdzadeh R, www.who.int/whr/2013/report/en/ ). Mortaz-Hedjri S, Etemadi A, et al. Promoting development and 5. Rashidian A. Policy and programme evaluation: principles and use of systematic reviews in a developing country. J Eval Clin objectives. East Mediterr Health J. 2017 02 21;23(1):3–4. https:// Pract. 2009 Dec;15(6):1029–34. https://doi.org/10.1111/j.1365- doi.org/10.26719/2017.23.1.3 PMID:28244054 2753.2009.01184.x PMID:20367702 6. Haq Z, Hafeez A, Zafar S, Ghaffar A. Dynamics of evidence- 13. Rashidian A, Jahanmehr N, Jabbour S, Zaidi S, Soleimani F, informed health policy making in Pakistan. Health Policy Plan. Bigdeli M. Bibliographic review of research publications on 2017 Dec 1;32(10):1449–56. https://doi.org/10.1093/heapol/ access to and use of medicines in low-income and middle- czx128 PMID:29045672 income countries in the Eastern Mediterranean Region: 7. Al Mawali AHN, Al Qasmi AM, Al Sabahi SMS, Idikula J, Elaty identifying the research gaps. BMJ Open 2013;3:10 e003332. MAA, Morsi M, et al. Oman Vision 2050 for Health Research: https://doi.org/10.1136/bmjopen-2013-003332. A Strategic Plan for the Future Based on the Past and Present 14. World Health Organization. WHO handbook for guideline Experience. Oman Med J. 2017 Mar;32(2):86–96. https://doi. development. 2nd ed. Geneva: World Health Organization; org/10.5001/omj.2017.18 PMID:28439378 2014. 8. Imani-Nasab MH, Seyedin H, Yazdizadeh B, Majdzadeh R. A 15. World Health Organization. 2015 Global Survey on Health qualitative assessment of the evidence utilization for health Technology Assessment by National Authorities. Main findings. policy-making on the basis of SUPPORT tools in a developing Geneva: World Health Organization; 2015. country. Int J Health Policy Manag. 2017 01 8;6(8):457–65. 16. World Health ORanization. SURE guides for preparing and https://doi.org/10.15171/ijhpm.2016.158 PMID:28812845 using evidence-based policy briefs. Version 2.1. Geneva: 9. El-Jardali F, Lavis JN, Ataya N, Jamal D, Ammar W, Raouf S. World Health Organization; 2011 (http://www.who.int/ Use of health systems evidence by policymakers in eastern evidence/sure/guides/en/).

1 Regional Committee for the Eastern Mediterranean. Sixty-fourth Session RC1/64 (http://applications.emro.who.int/docs/RC_ technical_papers_20094_1_2017_en.pdf?ua=1).

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Independent prescription of medicines and diagnostic test advice by final year medical students in Punjab Kashif Aziz 1, Hafiz M. Aeymon 2 and Saba Batool 3

وصــف األدويــة وتقديــم املشــورة بشــأن التحليــات التشــخيصية مــن جانــب طــاب الســنة النهائيــة يف الكليــات الطبيــة مــن تلقــاء أنفســهم يف إقليــم البنجــاب كاشف عزيز، حافظ حممد أيمن، صبا بتول اخللصــة:ال خيضــع بيــع األدويــة للمراقبــة الصارمــة يف باكســتان. وبالتــايل،يبــدأ طــاب الكليــات الطبيــة يف وصــف األدويــة وتقديــماملشــورة بشــأن حتليــات تشــخيصية قبــل خترجهــم. وعمــدت هــذه الدراســة املقطعيــة إىل التحقيــق يف تواتــر وصــف األدويــة مــن تلقــاء الــذات ملجموعــة مصنفــة لطبقــات وخمتــارة ًعشــوائيا مــن 180 ًطالبــا مــن طــاب ثــاث كليــات طــب عامــة يف إقليــم البنجــاب. وتــم مجــع البيانــات عــن طريــق اســتبيان مــدار ًذاتيــا. فتبــن أن 112 ًطالبــا ســبق وأن وصفــوا أدويــة مــن تلقــاء أنفســهم دون أي مراقبــة؛ و38 ًطالبــا أجــروا ًفحصــا ً بدنيــاقبــل وصــف األدويــة؛ و74 ًطالبــا ســبق وأن قدمــوا مشــورة بشــأن 44 49 حتليــات تشــخيصية؛ و ًطالبــا قامــوا بتفســري فحــوص تشــخيصية مــن تلقــاء أنفســهم. ّوتبــن أن ًطالبــا ســبق وأن قامــوا بحقــن أدويــة، ثلثهــا دون مطالعــة تاريــخ انتهــاء الرسيــان. وتضمنــت أكثــر األدويــة املوصوفــة األدويــة اللســتريودية املضــادة لللتهــاب )92 %( واملضــادات احليويــة )73 %(. وشــملت أكثــر الفحــوص التــي تــم النصــح هبــا حتليــل عــدد خليــا الــدم الكامــل واألشــعة الســينية وتقاريــر حتليــل البــول التفصيليــة. وأعــرب 127 ًمشــاركا عــن اعتقادهــم بــأن طلبــة كليــات الطــب ينبغــي أال يصفــوا أدويــة. ّوتبــن وجــود علقــة ذات داللــة بــن نــوع اجلنــس ودخــل األرسة وممارســات وصــف األدويــة. ّوتبــن أن كثــري مــن طــاب الســنة األخــرية يف الكليــات الطبيــة ســبق هلــم وصــف أدويــة أو قدمــوا املشــورة بشــأن حتليــات تشــخيصية قبــل التخــرج.

ABSTRACT Sale of medicines is not rigorously controlled in Pakistan. Therefore, medical students start prescribing drugs and advising diagnostic tests before they graduate. This cross-sectional study investigated the frequency of independent medical prescription by 180 stratified, randomly selected final year medical students from 3 public medical colleges in Punjab, Pakistan. Data were obtained by self-administered questionnaire. One hundred and twelve students had prescribed medicines independently without any supervision; 38 had performed a physical examination before prescribing; and 74 had advised and 49 interpreted diagnostic tests independently. Forty-four students had administered injectable drugs and one third of these were administered without seeing expiry dates. The most frequently prescribed drugs were nonsteroidal anti- inflammatory drugs (92%) and antibiotics (73%). The most frequently advised tests were complete blood cell count, chest X-ray and urine detailed reports. One hundred and twenty-seven participants thought that medical students should not prescribe drugs. There was a significant relationship between gender and household income and prescription practices. Many final year medical students had prescribed drugs and advised diagnostic tests before graduation.

Prescription indépendante de médicaments et recommandation de tests diagnostiques par des étudiants en dernière année de médecine au Pendjab

RÉSUMÉ La vente de médicaments n’est pas rigoureusement contrôlée au Pakistan. Ainsi, les étudiants en médecine commencent à prescrire des médicaments et à recommander des tests diagnostiques avant l’obtention de leur diplôme. La présente étude transversale a examiné la fréquence de la prescription indépendante de médicaments auprès de 180 étudiants en dernière année de médecine sélectionnés de façon aléatoire et stratifiée dans trois écoles de médecine publiques au Pendjab. Les données ont été obtenues au moyen d’un questionnaire auto-administré. Cent douze étudiants avaient prescrit des médicaments de façon indépendante et sans aucun contrôle ; 38 avaient procédé à un examen physique en amont de la prescription ; 74 avaient recommandé des tests diagnostiques et 49 avaient interprété lesdits tests de façon indépendante. Quarante-quatre étudiants avaient administré des médicaments injectables et un tiers de ces médicaments avaient été administrés sans consultation des dates de péremption. Les anti-inflammatoires non stéroïdiens (92 %) et les antibiotiques (73 %) étaient les médicaments le plus souvent prescrits. Un hémogramme complet, une radiographie pulmonaire et des rapports urinaires détaillés étaient les examens le plus souvent recommandés. Cent vingt-sept participants étaient d’avis que les étudiants en médecine ne devraient pas prescrire de médicaments. Il existait une relation significative entre le sexe, le revenu du foyer et les pratiques de prescription. De nombreux étudiants en dernière année de médecine avaient prescrit des médicaments et recommandé des tests diagnostiques avant l’obtention de leur diplôme.

1Aga Khan University Hospital, Karachi, Pakistan (Correspondence to: K. Aziz: [email protected]); 2Nishter Hospital, Multan, Pakistan; 3Allied Hospital, Faisalabad, Pakistan. Received: 16/06/16; accepted: 22/01/17 795 https://doi.org/10.26719/2017.23.12.795

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Introduction To explore this issue further and exclusion criterion was non-Pakistani establish the factors leading to such nationality but no students met this Prescription of drugs is regulated world- practices, we studied final year medical criterion. Among the 172 students, wide and only physicians are allowed students at 3 medical colleges in Punjab 109 (63%) were female and 63 (37%) to prescribe. Unfortunately, in develop- Province, Pakistan. We postulated that were male; 47 were from PMC, 69 from ing countries, there are other channels medical students start prescribing drugs NMC and 56 from QMC. from which drugs can be acquired. In after they have studied pharmacology in Data collection Pakistan, there is a statutory law called the 3rd year of their MBBS degree. The Allopathic System (Prevention of Data were collected through a self- Misuse) Rule 1968 that defines who reported questionnaire that was devel- can prescribe drugs, but informal drug Methods oped by the authors for an unpublished pilot study. Initially, 5 medical students distribution channels are still prevalent Study population (1). After graduation medical students were interviewed on prescription and must undergo 1 year supervised train- This was a cross-sectional study from diagnostic test advice practices, and the ing. This training period is termed a June 2013 to June 2014. In 2013 questionnaire was developed after con- house job/internship. After this year of there were 12 registered public sector tent analysis of these interviews. Then, medical colleges in Punjab. Three of supervised training doctors are certi- the aforementioned medical students these, Quaid E. Azam Medical College fied in Pakistan. The law requires that were given the questionnaire and inter- (QMC), Bahawalpur, Nishter Medical each prescription must be signed by a nal consistency was evaluated. Test– College (NMC), Multan, and Punjab medical practitioner and their registra- retest reliability was also checked by Medical College (PMC), Faisalabad, again administering the questionnaire tion number must be mentioned on the were randomly selected. We selected after 20 days. After this pilot study, the prescription (2). final year medical students who had questionnaire was finalized for inclusion Some pharmacists in Pakistan dis- already studied pharmacology and in the present study. pense drugs even without asking for a pathology. There was no previous refer- The questionnaire included general prescription. Many pharmacists and ence study for sample size estimation. demographic data (age, gender, rural or allied healthcare workers like nurses Therefore, to calculate the sample size, a urban residence and monthly income). and dispensers treat illnesses on their pilot study was done on 30 randomly se- Urban areas were defined according own and prescribe drugs (3,4). Due to lected medical students who were asked to the Pakistan National Statistical Of- this culture, medical students in Paki- about independent drug prescription. fice. Large cities of Lahore, Gujranwala, stan also start prescribing drugs before Twenty-four of them had prescribed in- Faisalabad, Rawalpindi, Multan, Sialkot, graduation (4). It can expose patients to dependently. We used these pilot study Sargodha, Bahawalpur, district head- unwanted drugs, create drug resistance, data (80% prescription rate) to estimate quarters and tehsil headquarters were and even contagious diseases can re- sample size, taking 5% as margin of er- classified as urban areas. All remaining main undetectable if a person has been ror and 95% confidence interval and areas were classified as rural. Monthly taking medication for symptomatic 600 was our population under study. income was recorded in Pakistani Ru- relief without proper evaluation (2). Sample size came out to be 175 and we pees and classified into 4 groups: < 10 Many studies have been done on decided to study 180 students. There 000, 10 000–25 000, 25 000–50 000 self-medication among medical and were 600 final year medical students in and > 50 000. Drugs were categorized nonmedical students. However, inde- all 3 medical colleges, thus, we decided into the following groups: analgesics, pendent prescription practices of medi- to take 30% of these. Weighted samples antibiotics, diuretics, vitamin supple- cal students are an unexplored area. Such were taken from each medical college ments, steroids, antipyretics, sleeping practices cannot thrive in developed according to enrolment. We selected pills, antiemetics, contraceptives, ho- countries because of strict pharmacy 30% of the enrolled final year medical meopathic medicines, antihistamines, regulations. However, in developing students from each institute. Overall H2 blockers and proton pump in- countries like Pakistan such practices ratio of male to female students was 2:3. hibitors. The following diagnostic tests can prevail due to loose legislation (5). A stratified random sampling technique were studied: X-rays, sputum culture, Only one study has investigated the pre- was used and stratification was based on computed tomography, pregnancy scription practices of medical students gender. Random numbers were gener- tests, blood cultures, complete blood in one city in Pakistan, which showed ated using Microsoft Excel version 10. count, lipid profile, magnetic resonance that medical students began prescribing One hundred and seventy-two of 180 imaging, renal function tests, urine before graduation (6). students agreed to participate. The sole detailed reports, electrocardiograms,

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ultrasonography and liver function tests. students who had prescribed, 14 (13%) students’ rural/urban residence and If the participants had prescribed other had prescribed on only 1 occasion, 47 prescription practices (P = 0.444). Stu- than the above-mentioned drugs/tests, (42%) had prescribed twice a year, 39 dents with low monthly household in- they were asked to name them. We (35%) had prescribed once monthly come (< 10 000 Pakistani Rupees) had asked the students about the number and 5 (4%) had prescribed every week. significantly higher prescription rates of times annually that each drug was Forty-five (26%) students had admin- (P = 0.03). There was also a significant prescribed. Seven structured questions istered injectable drugs in response to relationship between student house- were asked to inquire about attitude and a patient’s request (Table 2), and 30 hold income and diagnostic test advice perception of medical students toward of these students did not see the expiry (P = 0.008): the higher the student’s prescription practices. dates of the drug preparations. Anal- household income, the fewer tests were gesics and antibiotics were the most advised (Table 5). Data analysis frequently prescribed drugs (Table 3). Post-stratification analysis revealed Data were doubled entered in and ana- Seventy-four (43%) students ad- that there was a significant association lysed by SPSS version 17. Descriptive vised diagnostic tests independently of gender with the perception that analyses were performed. Data were (details of tests are shown in Table medical students could prescribe after stratified based on gender of partici- 4), and 44 did not perform any physi- passing pharmacology (P = 0.03) Fe- pant, their household income and their cal examination before advising tests. male students thought that just passing residence. The 2χ test was applied for Fifty (29%) students had interpreted pharmacology did not qualify a student significance, andP < 0.05 was taken as the diagnostic tests independently and to prescribe medication. There was sig- significant. The pilot study data were informed their patients that the results nificant association between gender not included in the final analysis. were normal. The most common tests and perception that medical students interpreted were complete blood count, should diagnose a disease in the absence Ethics urine detailed report, lipid profile, chest of a certified doctor P( = 0.004). Male Informed consent was obtained from X-ray and liver function test in descend- students were more inclined toward each participant before administering ing order. diagnosis of disease by students in the the questionnaire. Confidentiality was We asked several questions to deter- absence of a certified doctor. There was maintained. Ethical approval was ob- mine the attitude of the students toward a significant association of residence tained from each institute. independent medication. Forty-three with perception of disease diagnosis (25%) thought that medical students in the absence of a certified doctor (P can prescribe medication; 108 (62%) = 0.01). Urban students thought that Results thought that medical students could ad- they should not diagnose a disease in vise diagnostic tests; 36 (21%) thought the absence of a certified doctor. There Demographic details of the participants it right that medical students could treat was no significant association between are shown in Table 1. One hundred patients if certified medical practitioners monthly income of students and their and twelve (65%) students prescribed were not available; 144 (84%) knew attitude toward medical prescription. drugs independently without any super- about antibiotic resistance; 92 (53%) vision from a certified medical practi- did not know about the dangers of tioner. Prescription rates at the different self-medication; 140 (81%) thought it Discussion medical colleges are shown in Table 2. better for lay people to consult a medi- Twenty-two students prescribed volun- cal student instead of self-medicating Our study was a multicentre cross-sec- tarily, 74 were asked for a prescription themselves; and 78 (45%) thought if tional study on unique topic on the fre- and 16 prescribed as a result of family a medical student refused to prescribe quency of drug prescription by medical expectations. When we asked about the medication to lay people on their re- students before graduation. We found rationale behind independent prescrip- quest, they would be considered an that many students (112; 65%) were tion, 44 (40%) students did not give incompetent doctor. involved in this practice. About half of any reason and 28 (25%) said that they There was no significant differ- the students were unable to specify a prescribed because, in their opinion, ence in prescription rates among the reason for this practice. When asked the patient’s condition was trivial and 3 medical colleges (P = 0.077). Male about frequency of annual prescription, did not need any expert opinion. Six of students were significantly more likely most of the students had prescribed 112 (5%) students prescribed as part to prescribe independently than female only once or twice a year and only 4% of of first aid advice and then referred the students were (P = 0.001). There was them were prescribing almost weekly. patient to a hospital. Among the 112 no significant relationship between It was found that male students and

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Table 1 Demographic details Total, QMC PMC NMC n (%) n (%) n (%) n (%) Participants 172 56 47 69 Male 63 (37) 25 (45) 17 (36) 21 (30) Gender Female 109 (63) 31 (55) 30 (64) 48 (70) Mean age (SD), yr 22.5 (0.9) 22.5 (0.85) 22.5 (0.9) 22.6 (1.1) Rural 28 (16) 10 (18) 7 (15) 11(16) Residence Urban 144 (84) 46 (82) 40 (85) 58 (84) < 10 000 12 (7) 5 (8) 5 (11) 2 (3) Household income, 10 000–25 000 30 (17) 5 (8) 8 (17) 17 (25) Pakistani Rupees 25 000–50 000 62 (36) 21 (38) 22 (46) 19 (27) > 50 000 68 (40) 25 (46) 12 (26) 31 (45)

NMC = Nishter Medical College; PMC = Punjab Medical College; QMC = Quaid E Azam Medical College; SD = standard deviation.

students from low-income households finding was 65%. The most frequently than self-medication because patients were more likely to prescribe. prescribed medications were the same are consulting students rather than There has been much research on in both studies: antibiotics, antiallergics, qualified practitioners. One reason for self-medication but research on inde- antipyretics and analgesics. such practice is economics. Certified pendent prescription by medical stu- Prescription by medical students is doctors cost a lot of money, while seek- dents has not been done. Prescription prevalent in Pakistan because of loose ing help from a neighbouring medical by medical students is more dangerous regulation. Pharmacies dispense medi- student comes free of charge. Similar than self-medication because of the po- cation without prescription. A study by practices have been documented in tential dangers. This can result in anti- Hussain et al. in Sindh Province evalu- Kerala, India, where interns who are biotic resistance, masking of diagnoses, ated 371 community pharmacies and supposed to work under supervision, unnecessary exposure to medication none of them completely followed all run independent practices to make ex- and incorrect diagnoses. the regulations established by the Phar- tra money. (9). The study of Zafar et al. investigated macy Act 1967 (5). A survey by Haseeb Apart from the ethical questions, independent prescription by medical and Bilal in rural Karachi revealed that there is a need to evaluate whether fi- and nonmedical students in Karachi 85% of participants were using informal nal year medical students have enough (6). Our study differed in that we stud- ways of taking medication (7). The most knowledge to prescribe safely. This ied only medical students and only in common reasons evaluated were cost of question was addressed by a Nigerian their final year. We studied 3 different consultation (90.3%) and availability study (10). Thirty-one final year stu- medical colleges that were ~200 km of transport (81.0%) from rural areas dents were interviewed and it was found apart. Zafar et al. found that 53% of med- to healthcare facilities (8). Prescription that they all needed training to prescribe ical students had prescribed, while our by medical students is more dangerous safely. Another study in the United

Table 2 Study results Variable Cumulative QMC PMC NMC result (total 56) (total 47) (total 69) (total 172) n (%) n (%) n (%) n (%) Prescribed medicine All students 112 (65) 40 (71) 34 (72) 38 (55) Male students 51 21 15 15 Female students 61 19 19 23 Advised diagnostic tests All students 74 (43) 26 (46) 19 (40) 29 (42)

Interpreted diagnostic tests All students 50 (29) 14 (25) 16 (34) 20 (29) Administered injections All students 45 (26) 19 (34) 10 (21) 16 (23)

NMC = Nishter Medical College; PMC = Punjab Medical College; QMC = Quaid E. Azam Medical College.

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Table 3 Medicines prescribed by studentsa Medicine Cumulative result QMC PMC NMC (112 prescribed) (40 prescribed) (34 prescribed) (38 prescribed) n (%) n (%) n (%) n (%) Analgesics 104 (92) 38 (95) 31 (91) 35 (89) Antibiotics 83 (73) 29 (72) 28 (82) 26 (66) Multi vitamins 44 (39) 14 (35) 12 (35) 18 (46) Steroids 5 (4) 2 (5) 0 3 (7.7) Antipyretics 70 (62) 27 (67) 21 (61) 22 (56) Anxiolytics 18 (16) 5 (12) 3 (9) 10 (25) Antiemetics 34 (30) 11 (27) 11 (32) 12 (30) Contraceptives 4 (3) 3 (7.5) 0 1 (2) Antihistamines 58 (51) 25 (62.5) 15 (44) 18 (46) H2 receptor blockers 18 (16) 6 (15) 7 (20) 5 (12.8) Proton pump inhibitors 29 (26) 5(12.5) 13(38) 11(28) Diuretics 3 (2) 0 1 (3) 2 (5) Other 6 (4) 1 (2.5) 2 (6) 2 (5)

aPercentages are calculated among the students who prescribed medicines. NMC = Nishter Medical College; PMC = Punjab Medical College; QMC = Quaid E. Azam Medical College.

Kingdom investigated the readiness of year or foundation year is necessary. A patients who are poor and uninsured. graduating students to prescribe safely similar but more plausible concept in This improves medical students’ clini- (11). Many students felt underprepared the United States of America (USA) is cal experience and provides a medical to take responsibility for safe prescrip- student-run health clinics, where medi- service to a neglected stratum of society. tion. Therefore, a mandatory internship cal students care for underprivileged One important factor is that the clinics

Table 4 Diagnostic tests advised by studentsa Diagnostic test Cumulative result QMC PMC NMC (74 students advised (26 students advised (19 students advised (30 students advised tests) tests) tests) tests) n (%) n (%) n (%) n (%) X-ray 46 (61) 18 (69) 10 (52) 18 (60) Sputum test 13 (17) 5 (19) 4 (21) 4 (13) CT scan 10 (13) 3 (11) 2 (10) 5 (16) Pregnancy test 11 (12) 4 (15) 4 (4.8) 3 (10) Culture sensitivity 1 (1) 0 1 (5.3) 0 Complete blood count 49 (65) 18 (69) 12 (63) 19 (63) Lipid profile 20 (26) 3 (11) 9 (47) 8 (26) MRI 7 (9) 3 (11) 2 (10) 2 (6.7) Renal function tests 14 (18) 4 (11) 6 (31) 4 (13) Urine detailed report 34 (45) 14 (15) 7 (36) 13 (43) Electrocardiogram 15(20) 7 (26) 5 (26) 3 (10) Ultrasonography 29 (38) 9 (34) 10 (52) 10 (33) Liver function tests 21 (28) 7 (26) 8 (42) 6 (20) Other 8 (10) 1 (3) 4 (21) 3 (10)

aPercentages are calculated among the students who advised diagnostic tests. CT = computed tomography; MRI = magnetic resonance imaging; NMC = Nishter Medical College; PMC = Punjab Medical College; QMC = Quaid E. Azam Medical College.

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Table 5 Prescription practices cross tabulation could resolve this issue but they should Prescribed medicines P be shadowed by certified medical prac- Yes No titioners. Such clinics have also been College studied in Australia, with favourable PMC 39 13 0.077 outcomes (15). NMC 38 31 Our post-stratification analyses QMC 40 16 revealed that male medical students Gender prescribed more as compared to female Male 51 12 0.001 students. Female students thought that medical students were not capable of Female 61 48 Residence prescribing medication after passing Rural 20 8 0.444 pharmacology. Gender and safety of doctors are controversial, with studies Urban 92 52 Monthly income, Pakistani Rupees having conflicting results. A meta-analysis of 32 reports in 2015 revealed that < 10 000 11 1 0.03 male doctors had ~2.5 times the odds 24 6 10 000–25 000 of being subject to medicolegal action 37 25 25 000–50 000 thousands than female doctors had. Female doc- 40 28 > 50 000 tors seem to take less risk and therefore NMC = Nishter Medical College; PMC = Punjab Medical College; QMC = Quaid E. Azam Medical College. are less prone to medicolegal action (16). are managed by a certified physician schools. Medication errors should be Antibiotic resistance is on rise and who shadows all medical students included in the curriculum. much research is being done to curb this working in the clinic, which provides a In our study, medical students not issue (17). Our study showed that an- safety net against any inadvertent medi- only prescribed drugs but also advised tibiotics are among the most common cal errors. It is reported that the quality diagnostic tests and interpreted the drug prescribed, but alarmingly only 1 of services provided by such clinics has results. Advice for a diagnostic test is a of the 112 students advised a culture and sensitivity test. Medical students not been rigorously studied (12). complicated task. Medical students are not capable of choosing the appropriate are not equipped to guide adequate When we asked the medical stu- antibiotic therapy (18). dents about the reason for prescrib- test. Before giving appropriate diagnos- We found that 81% of all students ing, 16% revealed peer pressure and tic advice there is a need to take a proper who participated in our study thought family expectation. There is a need to history and perform a physical exami- that it was right to consult a medical stu- educate the population about the risk of nation (13). In our study, 73 students advised diagnostic tests but 44 of them dent instead of self-medication. There prescription by medical students. They did not perform a physical examination. is a need to correct this misconception. should counsel their family members A study by McGregor et al. also revealed Universities should include the harm to have a proper check-up by a certified that medical students are not capable of of independent prescription and self- doctor. Twenty-five percent of medi- accurate clinical decision-making (14). medication in their curricula. Medical cal students prescribed because they The same applies to interpretation of students should be advised to counsel thought that the patient’s condition was test results. Half of medical students people who approach them for a pre- not serious enough to refer to a doctor. who interpreted test results had not scription instead of entertaining them. However, as shown in previous stud- undertaken physical examinations. In a country like Pakistan, where ies11, medical students are not capable of We hypothesized that prescription per capita income is low, it is tempt- identifying subtle clinical signs and they practice of medical students from rural ing to adopt cheap illegal pathways can miss a diagnosis. areas would differ from that of urban ar- to take medication. Although there Thirty percent of the students in our eas but there were no significant differ- is government legislation, and drug study, who had administered inject- ences. There is a need to implement the inspectors are there to oversee drug able drugs, did not confirm the expiry same model as the clinics led by medical distribution channels, drugs can still be date. Medical students should be taught students in the USA. The population availed without a prescription from a about safe pharmacy practices and in Pakistan is unable to afford health certified doctor 1( ). There is a need for there is lack of such training in medical care, therefore, such student-led clinics a strict monitoring system to eradicate

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this issue. Pharmacies should be reg- students. A comparative study should approach is needed to resolve it. Further istered and should not be allowed to be done to see whether there is any dif- research is needed to investigate this sell medication without prescriptions. ference in prescribing practice between issue in other developing countries to There are free hospitals established first and final year medical students. see a global perspective. This practice by the government throughout Paki- Another limitation was that we only stan that provide free medication but studied 1 province. The study should can be transformed in a positive way by they are under-resourced. Free quality be replicated nationwide. We did not creating clinics led by medical students healthcare provision can also stop this study the patient perspective on this that are shadowed by physicians. problem. issue. Another study could be done to There were several limitations to determine whether patients would pre- this study. We only included public sec- fer to consult a nearby medical student Acknowledgements tor medical colleges. There are many or a certified doctor and the reasons for private sector medical colleges in Paki- such health-seeking behaviour. We are grateful to the students who stan and students at these institutions In conclusion, many undergraduate participated in the study and their in- should be investigated to establish any medical students prescribe medica- stitutions. difference from the public sector. We tion and advise diagnostic tests. Public assumed that final year medical students health scientists should further investi- Funding: None. would prescribe more than nonmedical gate the causes of this issue and a holistic Competing interests: None declared.

References

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Challenges impeding integration of oral health into primary health care Zahra Ghorbani 1,2, Mina Pakkhesal 2, Shahnam Arshi 3, Mohammad J. Eghbal 4, Marzieh Deghatipour 2, Marc Tennant 5 and H. Malekafzali Ardakani 6

التحديات التي تعوق إدماج صحة الفم يف الرعاية الصحية األولية زهرة قرباين، مينا باكخصال، شهنام عريش، حممد جعفر إقبال، مرضيه دقتي بور، مارك تينانت، حسي مالك أفضيل اردكاين اخللصــة: نجحــت خدمــات الرعايــة الصحيــة األوليــة يف مجهوريــة إيــران اإلســامية يف التصــدي الرتفــاع مســتويات األمــراض الســارية، إال أهنــا تبــدو أقــل قــدرة عــى التعامــل مــع أمــراض الفــم يف صفــوف األمهــات واألطفــال. ّــل ومتثاهلــدف مــن هــذه الدراســة يف النظــر يف املشــكلت القائمــة يف إدمــاج خدمــات صحــة الفــم يف الرعايــة الصحيــة األوليــة. وجــاءت كدارســة بحثيــة كينيــة تتألــف مــن مناقشــات مجاعيــة ومقابــات. فعقــدت مخــس مناقشــات مجاعيــة مــع قابــات، وممارســن يف جمــال الرعايــة الصحيــة األرسيــة، وعاملــن يفجمــال تقديــم الرعايــة الصحيــة يف الريــف، وأطبــاء أســنان يف جمــال الصحــة العامــة. ًوفضــا عــى ذلــك، ُن ِّظمــت مقابــات فرديــة مــع خــراء مــن أعضــاءهيئــة التدريــس يف جمــاالت مرتبطــة ومديريــن عارفــن وصنــاع قــرار، ُوعقــدت مقابــات ّمعمقــة مــع نســاء حوامــل يف أربعــة مراكــز لرعايــة الصحــة العامــة. وتــم تفريــغ التســجيلت الصوتيــة بعــد كل جلســة، وأجــرى حتليــل مواضيعــي كيفــي بشــأن البيانــات املجمعــة. وأســفر حتليــل البيانــات عــن أربعــة مواضيــع رئيســية تتعلــق بالتحديــات، وهــي: العوامــل الباجميــة البيئيــة والتعليميــة والتنظيميــة واملدرســية. وتوفــر هــذه الدراســة فهــا أوضــح للتحديــات التــي تواجــه إدمــاج خدمــات صحــة الفــم يف الرعايــة الصحيــة األوليــة.

ABSTRACT The primary healthcare (PHC) services in the Islamic Republic of Iran have succeeded in addressing high levels of communicable diseases; however, they seem less able to deal with maternal and paediatric oral diseases. The aim of this study was to examine problems in integrating oral health services into PHC. This was a qualitative research study comprising focus group discussions and interviews. Five focus-group discussions were held with midwives, family healthcare practitioners, rural PHC workers, duty-service dentists, and public health dentists. Also, individual interviews were organized with experts of faculty members in related fields, informant managers and policy makers, and in-depth interviews were done with pregnant women in four PHC centres. Audiotapes were transcribed following each session, and then a qualitative thematic analysis was carried out on gathered data. Data analysis resulted in 4 main themes relating to the challenges: environmental, educational, organizational and school-based programme factors. This study provides a clearer understanding of the challenges of integrating oral health services into PHC.

Les obstacles à l’intégration de la santé bucco-dentaire aux soins de santé primaires

RÉSUMÉ Les services de soins de santé primaires en République islamique d’Iran sont parvenus avec succès à traiter le nombre élevé de cas de maladies transmissibles. Néanmoins, il semblerait qu’ils soient moins performants dans la prise en charge des maladies bucco-dentaires de la mère et de l’enfant. La présente étude avait pour objectif d’examiner les obstacles à l’intégration de la santé bucco-dentaire aux services de soins de santé primaires. Il s’agissait d’une étude de recherche qualitative comprenant des groupes de discussion et des entretiens. Cinq groupes de discussion ont été tenus. Il réunissaient des sages-femmes, des médecins de famille, des agents de soins de santé primaires en milieu rural, des dentistes suppléants, et des dentistes en santé publique. Des entretiens individuels ont également été organisés avec des experts membres du corps enseignant des domaines concernés, des gestionnaires en charge de la planification et de la coordination et des responsables politiques. D’autre part, des entretiens approfondis ont été menés auprès de femmes enceintes dans quatre établissements de soins de santé primaires. Des cassettes audio ont été retranscrites à la suite de chaque session, et une analyse thématique qualitative a été menée sur les données recueillies. L’analyse des données a fait ressortir quatre types de problèmes principaux liés à des facteurs d’ordre environnemental et organisationnel, et concernant la formation des praticiens et les programmes scolaires. La présente étude permet une compréhension plus détaillée des obstacles à l’intégration des services de santé bucco-dentaires aux soins de santé primaires.

1Preventive Dentistry Research Center, Research Institute of Dental Sciences, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran. 2Community Oral Health Department, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to: M. Pakkhesal: [email protected]). 3Department of Public Health Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran. 4Dental Research Center, Iranian Center for Endodontic Research, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran. 5School of Anatomy, Physiology and Human Biology, University of Western Australia, Perth, WA, Australia. 6Epidemiology and Biostatistics Department, School of Public Health, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. Received: 05/10/16; accepted: 23/01/17 802 https://doi.org/10.26719/2017.23.12.802

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Introduction care into the nationwide PHC network dealt in the integration of oral health followed in 1997 (10). Oral health was care into PHC services. The focus Oral health is a critical component of integrated into the monitoring pro- groups provided detailed explanations overall health and well-being; yet, oral grammes for maternal and child care and examples of positive and negative disease remains a silent epidemic (1). through which the responsibility for experiences and views regarding oral Many children in developed and devel- oral health education, primary screen- healthcare integration into PHC. oping countries, especially those from ing and referral to the dentist was as- Semistructured interviews were deprived areas, are affected by dental signed to the PHC workers, including conducted with a convenience sample caries and suffer from pain and infection midwives, family health physicians and of 27 pregnant women seeking regular associated with their teeth and gums rural healthcare workers. About 60% maternal care in 4 selected PHC cen- (2). The prevalence of caries increases of PHC centres have an oral healthcare tres. A purposive sampling method was with age, especially in high-risk chil- unit with a dentist who is in charge of ba- initially used for selection of 4 PHC dren with limited access to oral health sic services, such as restoration, scaling centres with high levels of provision of services (3). Furthermore, dental caries and extraction, mainly for target groups maternal and paediatric services located in deciduous dentition predicts later consisting of children aged < 12 years, in 2 deprived regions of Tehran Prov- caries experience in adulthood (4). So, pregnant women and nursing mothers ince. Women were eligible for inclusion it seems that prevention and early initia- (9). The PHC services in the Islamic in the study if they were aged ≥ 20 years; tion of dental care, especially provided Republic of Iran have clearly succeeded were in 2nd or 3rd trimester of preg- in addressing high levels of communi- in a primary healthcare (PHC) setting, nancy; and were willing to participate in cable diseases and maternal and infant can lead to improved oral health out- the interview. They were asked whether mortality, but have been less effective comes and are both cost saving and they received any examination, service in dealing with maternal and paediatric effective 5( –7). or education regarding oral health in oral diseases. The aim of this study was their last maternal visit, and what oral Pregnancy represents a unique and to explore the considerable challenges health care did they expect to receive sensitive period of maternal oral health, of integrating oral health promotion via PHC. The average length of each in- and due to changes in hormonal levels, into PHC in Iran. terview was 20 minutes. The interviews pregnant women are more susceptible were transcribed individually and the to oral diseases. Possible adverse preg- sampling continued until data satura- nancy outcomes, including low birth Methods tion was reached. weight, preterm birth, pre-eclampsia Semistructured and individual in- and miscarriages have been reported Study design terviews were also conducted with 10 as consequences of oral diseases. It is experts lasting for 45 minutes to 2 hours. also widely accepted that poor maternal The present study used a qualitative The sample included experts from 3 oral health is a predictor of early child- research design consisting of 3 sources groups consisting of faculty members hood caries, and education of pregnant of data: focus group discussions, individual interviews with experts, and in related fields, informed managers women can effectively prevent early and policy makers in the Iranian health childhood caries (1). semistructured interviews with pregnant women. system using purposive sampling. The A majority of babies, young children participants were asked whether they and pregnant women do not undertake Focus group discussions and were aware of the history of the integra- regular dental visits; instead, they fre- interviews tion of oral health into PHC, and if they quently visit PHC providers for routine Five focus groups were held with mid- thought the programme was successful, check-ups. These check-ups provide an wives, family healthcare practitioners, and if not, what were the causes. opportunity to integrate oral health pro- rural PHC workers, duty-service den- The interview guide for each group motion into the practices of nondental tists and public health dentists. Each was developed from our literature re- staff in public health centres. Sharing focus group consisted of 10 participants view and after discussions among the the responsibility for child oral health and lasted 2–2.5 hours. Purposive sam- team members; these were then piloted care with PHC creates opportunities pling was used to select the members with an expert and a pregnant woman. for interprofessional efforts to target this of each focus group, since researchers Some questions were reworded to at-risk population (8,9). needed to consider who could best ad- make them clearer and some subques- Structured PHC in the Islamic Re- dress the research questions. A modera- tions were added to the interview guide public of Iran was established in the tor asked the participants to think about as a result of the piloting. Three authors 1970s, and integration of oral health the various challenges with which they (MP, ZG and MD) conducted the

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interviews and focus group discussions Shahid Beheshti University of Medical with clear protocols for managing some between July 2015 and February 2016. Sciences (number: IR.SBMU.RIDS. dental problems during pregnancy, and REC.1395.188). The participants were most of them were not covered by re- Data analysis clarified about the aims of the study sponsibility insurance. The pregnant Thematic analysis was used to analyse and verbal consent was obtained for women’s insufficient knowledge and and organize the collected data. First, 2 participation. It was confirmed that par- demand for oral health care were other researchers (MP and MD) read and re- ticipation in the study was completely challenges in this study. The pregnant read the text transcription of each focus voluntary, respecting the confidentiality women felt that poor oral health was group discussion and interview, inde- of the data. a normal outcome of pregnancy and pendently, to identify units of meaning there was no need to consult a dentist. related to the subject. Then, all of the units of meaning were categorized into Results Environmental factors initial themes. After matching the initial According to focus group participants, themes through informal discussion, Study participants nowadays, people go where they obtain the research team categorized the initial The characteristics of the 5 focus group good services. They usually go to the themes into overarching themes that members (n = 50), and experts (n = 10) clinics that have advanced technology were labelled as an inductive or bottom- participating in the study are shown in instead of to dispensaries where there up approach. The proposed labels Table 1. The educational background are limited equipment and facilities. for the main themes were discussed of the experts was dental sciences (n Some focus group participants also and achieved through consensus. The = 6), medical/health sciences (n = 3) reported that the physical infrastructure principal investigator (ZG) resolved and nursing care (n = 1). Mean age and available equipment, such as mod- any disagreement between the research (standard deviation) of the 27 pregnant ern dental chairs, instruments and ma- team by discussion and made the final women participating in the interviews terials, were not suitable to provide oral decision. was 28.6 (5.8) years, ranging from health education and dental screening. The robustness of the data should 20 to 40 years. Most of the pregnant Organizational factors be acknowledged because the research women had finished high school (41%) team attempted to maximize the va- and were in the 2nd trimester (63%), PHC providers consistently talked lidity of the study in 3 main ways: 1) experiencing their 2nd pregnancy about time limitation as a key barrier they attempted to take control of their (52%). Analysis of the data from the to providing oral health education and own perspectives and expectations; focus groups and interviews gave rise dental examination. They were involved 2) the transcripts were independently to 21 subthemes; later classified into 4 in the provision of vaccination and child analysed by 2 members of the research main themes in line with the methods and maternal care, leading to crowded team, and any disagreements were dis- (Table 2) related to environmental, clinic waiting areas. One midwife cussed by the team; and 3) to cover all educational, organizational and school- complained about insufficient human the viewpoints about the topic, we tried based programme factors. resources and high workload. Another reported that some mothers failed to to cover all the potential stakeholders. Educational factors We attempted to contact all partici- arrive on time for appointments, for Many PHC providers believed that pro- pants who had been involved in plan- various reasons, especially early in the viding preventive oral health services ning and/or provision of oral health morning, therefore, there was often was not their responsibility. Specifically, services delivered in PHC centres. The overcrowding in the middle of the day. midwives thought that they were not different stakeholders were selected to She reported that because of these time sufficiently qualified to assess oral health provide a wide range of views in the and human resource constraints, they nor to ask specific questions about it. oral health services that are delivered in were unable to counsel mothers regard- However, most of them expressed PHC centres, based on their perspec- ing oral health. interest and willingness to complete tives. It also allowed us to compare and Many of the focus group partici- appropriate training programmes. recognize the different perspectives of pants noted that using paper record- different stakeholders in this regard. Some dentists stated that they keeping instead of integrated electronic feared the legal consequences of po- records wasted a lot of time in the ma- Ethical issues tential complaints about their practice, jority of PHC centres. The existing This study was approved by the 27th and therefore avoided performing salary-based payment system for all Research Ethics Committee of the procedures on pregnant women. They PHC providers did not provide incen- Research Institute of Dental Sciences, expressed that they were not provided tives to improve their performance.

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Table 1 Characteristics of focus group members and experts participating in the study Variables Focus groups Interviews Rural primary Midwives Family Duty- service Public health Experts healthcare healthcare dentists dentists workers practitioners Sex Female 6 10 10 8 7 3 Male 4 0 0 2 3 7 Age (yr) 20–30 2 3 2 10 0 0 31–40 5 5 6 0 2 0 ≥ 41 3 2 2 0 8 10 Length of practice (yr) < 10 4 4 3 10 1 1 10–20 3 3 4 0 2 4 20–30 3 3 3 0 7 5 Total 10 10 10 10 10 10

Inadequate advocacy was another chal- This study revealed 4 main themes insufficient knowledge of PHC workers lenge noted by some experts, and that relating to the challenges of integration about oral health has been highlighted in powerful community individuals (such of oral health into PHC: educational, studies from other countries (20–24). as religious leaders and local govern- environmental, organizational and As a result, oral health is often neglected ment managers) were not involved in school-based factors. by maternal-care providers during pre- developing and disseminating health With regard to educational factors natal care, and is only discussed when programmes. and in agreement with our findings, initiated by pregnant women (21). The need for community-based education School-based programme many studies have shown that insuffi- of dental students is also noted in the factors cient knowledge and inappropriate perception among pregnant women about literature (25). With regard to the prob- Most focus group participants and ex- oral health are common causes of the lem of unclear guidelines for dentists perts reported inadequate support for decrease in dental care demand during about treatment of pregnant women, school-based oral health programmes. pregnancy (13–15). Also, the majority evidence-based guidelines have been They also believed that parents and of pregnant women believe that dental developed with a focus on tracking oral school staff were not involved in treatment during pregnancy might have health services, screening, and triaging developing school-based oral health a negative effect on pregnancy outcome prenatal patients for oral health risks to programmes and therefore not commit- (16). Many pregnant women still be- the mother, fetus and baby (26). Such ted to achieving the programme goals. lieve in the folk myth of “a tooth for a guidelines need to be reviewed and Some focus group participants were child”, which suggests an association customized according to the local and dissatisfied with inadequate physical between childbearing and loss of teeth, structural situations of each country. space in the schools for implementation On the topic of environmental fac- of oral health programmes. and they perceive that gingival bleed- ing does not indicate inflammatory tors, the need for increasing financial disease that requires professional help investment and human resources to de- Discussion (17). Mothers are unaware that vertical velop primary oral health care has been transmission of cariogenic microbes mentioned as an integral part of PHC This study used a qualitative research contributes to the development of den- (27). The time limitations for PHC pro- design to understand the challenges tal caries in children (17,18). They are viders to provide oral health education that impede integration of oral health also unaware about the importance of and screening have also been identified programmes into PHC. Qualitative cleaning deciduous teeth, proper feed- as a challenging barrier (8,24). methods seem to be an appropriate ing practices, and the important role With regard to organizational design for exploring complex phenom- of early-onset regular dental visits for factors, insufficient interprofessional ena about which little is known 11( ,12). their children (19). Furthermore, the collaboration has been considered

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Table 2 Recognized main themes and subthemes related to challenges in oral health integration into PHC Main themes Subthemes Educational factors Insufficient women’s attitudes and perceptions regarding oral health and dental care during pregnancy (FG 1,2,3,4,5, IPW) Insufficient PHC providers’ knowledge about oral health care (FG 1,2,3) Imperfect curriculum for undergraduate dental students to work with other areas of PHC (FG 2,3, IE) Unclear guidelines for dentists for treatment of pregnant women (FG 4,5, IE) Environmental factors Inappropriate facilities (FG 2,3,4,5) Inadequate physical clinic space (FG 2,3,4,5, IPW) Improper clinic waiting area (FG 2,3, IPW) Unstuitable equipment (FG 2,3,4,5) Organizational factors Insufficient interprofessional collaboration (IE) Little involvement of community leaders in developing and disseminating health programmes (IE) Insufficient human resources and high workload in PHC centres (FG 2,3, 5, IE) Insufficient time for provision of preventive services and oral health education (FG 1,2,3,4,5) Salary-based payment system with no financial incentives to motivate health workers (FG 2,3,4,5, IE) School-based programme factors Inadequate collaboration among healthcare workers and school staff (FG 1,2,3,5) Uncommitted school staff and parents with the programme goals (FG 1,2,3,5, IE) Imperfect relationship between dental staff and students (FG 2,5) Inadequate physical space in schools for oral health programmes (FG 1,2,3,4,5) Unspecified places to refer high-risk students to appropriate services (IE) Unhealthy nutrition of school children at school (FG 1,2,3,4,5, IE) Insufficient number of health counsellors in schools (FG 2,3,4,5) Inadequate coverage of oral health topics in school curriculum (IE) FG 1= focus group with rural primary healthcare workers; FG 2 = focus groups with midwives; FG 3 = focus group with family healthcare practitioners; FG 4 = focus group with duty-service dentists; FG 5 = focus group with public health dentists; IE = interview with experts; IPW = interview with pregnant women.

elsewhere (19) and has led to genera- of time and human resources for PHC local community leaders; and failure to tion of a model to educate dental and providers are another organizational provide quality services (31). medical practitioners about these fac- challenge that has been addressed to This study tried to gather the views tors. The model involves a system of some extent by using lay health workers of all potential stakeholders involved referral for comprehensive clinical care as the main facilitators of oral health in planning, providing and receiving of pregnant women, and an educa- programmes in some contexts (8). integrated oral health services. Despite tional guide for women about their oral In relation to school-based factors, the small number of participants in each health and that of their children. Such the Ottawa Charter for Health Promo- group, the sample size was appropriate programmes can help meet interpro- tion notes that schools can provide a considering the qualitative methodo- fessional accreditation standards and supportive environment for promoting logical approach, which emphasized encourage implementation of practice child health. The survey of Jurgensen the purposeful selection of information- guidelines (28). and Petersen has demonstrated the rich cases that provided in-depth data. Similar to our findings, a lack of important role of oral health educa- We selected participants according to provider capacity, training and expe- tion in promoting oral health among their experience of oral health care pro- rience for operating in the context of vided as PHC services and their ability school-aged children (31). The main cross-disciplinary or integrated settings to express their perspectives. However, factors identified as barriers for suc- is another challenge considered in the the most recent improvements in man- cessful implementation of school-based literature (22,23). It is also suggested agement and planning in the Iranian that integration of the PHC approach oral health programmes were: financial Ministry of Health have addressed to into the dental curriculum is crucial constraints; inadequate capacity and some extent some of the barriers found for training a competent workforce availability of human resources; lack of in this study. For instance, electronic (29). Given this situation, there is a collaboration at local level; inadequate health records have been recently need to provide the current and future policy framework; lack of high-level used in PHC centres, facilitating time PHC and dental workforce with the leadership and governance; poor atti- management among workers. Also, the skills needed to practice integrated oral tude, support and awareness among renovation of dental offices in PHC health services (23,30). The limitations school health team, parents and the settings has been emphasized in the past

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year, which could potentially improve to benefit from a mixed approach, by Institute of Dental Sciences, Dental dental care services (32). We should focusing on social factors (upstream) School, Shahid Beheshti University of also acknowledge that all the findings and simultaneously preventing modifi- Medical Sciences, Tehran, Islamic Re- might not be generalized to other coun- able risk factors at the individual level public of Iran. We would like to thank tries because of the distinct culture and (downstream), to tackle the serious the Vice Chancellor in Health Affairs of structure of the healthcare system in obstacles to achieving universal access Shahid Beheshti University of Medical the Islamic Republic of Iran. However, to integrated oral health services (33). Sciences, Dr. Bastani, Dr. Taheri, Dr. some of the findings will be helpful for In conclusion, since administrative Ghanbari, Dr. Ehdaeivand, Dr. Shahza- other countries to consider developing and clinical leadership support can be deh Fazeli and Dr. Khoshnevisan who their own integrated oral healthcare critical to the success of integrative ap- were involved at different stages of this systems. proaches, this study provides a better research. Finally, we express our grati- Our findings will serve as an initial understanding of the challenges around tude to the people who participated in step towards establishing evidence- integrating oral health services into focus group discussions and individual based interventions and identifying PHC, including environmental, educa- interviews with midwives, family health- potential gaps to guide future efforts. tional, organizational and school-based care practitioners, rural PHC workers, The next step will be identification and programme factors. dentists, experts, and pregnant women prioritization of solutions related to the for sharing their experiences and views barriers to integration of oral health care into the PHC system. The experi- Acknowledgements regarding oral healthcare integration ences from other countries can be used into PHC. in this regard. For instance, the Brazil- This study was supported by Preventive Funding: None. ian unified PHC system is suggested Dentistry Research Center, Research Competing interests: None declared.

References

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19. Ramos-Gomez FJ. A model for community-based pediatric 26. Stevens J. Lida H, Ingersoll G. Implementing an oral health pro- oral heath: implementation of an infant oral care program. Int J gram in a group prenatal practice. J Obstet Gynecol Neonatal Dent. 2014;2014:156821. PMID:24587803 Nurs. 2007 Nov–Dec;36(6):581–91. PMID:17973702 20. Wooten KT, Lee J, Jared H, Boggess K, Wilder RS. Nurse practi- 27. Honkala E. Primary oral health care. Med Princ Pract. tioners’ and certified nurse midwives’ knowledge, opinions and 2014;23(Suppl 1):17–23. PMID:24503932 practice behaviors regarding periodontal disease and adverse 28. Jackson JT, Quninonez RB, Kerns AK, Boggess K, Chuang A, pregnancy outcomes. J Dent Hyg. 2011 Spring;85(2):122–31. Eidson RS, et al. Implementing a prenatal oral health program PMID:21619740 through interprofessional collaboration. J Dent Educ. 2015 21. George A, Shamim S, Johnson M, Dahlen H, Ajwani S, Bhole S, Mar;79(3):241–8. PMID:25729017 et al. How do dental and prenatal care practitioners perceive 29. Mumghamba EG. Integrating a primary oral health care ap- dental care during pregnancy? Current evidence and implica- proach in the dental curriculum: a Tanzanian experience. Med tions. Birth. 2012 Sep;39(3):238–47. PMID:23281906 Princ Pract. 2014;23(Suppl 1):69–77. PMID:24246734 22. Rabiei S, Mohebbi SZ, Patja K, Virtanen JI. Physicians’ knowl- 30. Norwood CW, Maxey HL, Randolph C, Gano L, Koch- edge of and adherence to improving oral health. BMC Public har K. Administrative challenges to the integration of oral Health. 2012 Oct 9;12:855. PMID:23046660 health with primary care: a SWOT analysis of health care ex- 23. Sandhya MP, Shanthi M, Fareed N, Sudhir KM, Kumar RK. Ef- ecutives at federally qualified health centers. J Ambul Care fectiveness of oral health education among primary health care Manage. 2016 May 23; [Epub ahead of print] PMID:27218701 workers at the primary health center in Nellore district, Andhra 31. Jürgensen N, Petersen PE. Promoting oral health of chil- Pradesh. J Indian Assoc Public Health Dent. 2014;12(2):74–9. dren through schools – results from a WHO global survey 24. Rozier G, Sutton BK, Bawden JW, Haupt K, Slade GD, King RS. 2012. Community Dent Health. 2013 Dec;30(4):204–18. Prevention of early childhood caries in North Carolina medical PMID:24575523 practices: implications for research and practice. J Dent Educ. 32. Moradi-Lakeh M, Vossogh-Moghaddam A. Health sector 2003 Aug;67(8):876–85. PMID:12959161 evolution plan in Iran; equity and sustainability concerns. Int J 25. Mofidi M, Strauss R, Pitner LL, Sandler ES. Dental students’ Health Policy Manag. 2015 Aug 31;4:637–40. PMID:26673172 reflections on their community-based experiences: the use 33. Nascimento AC, Moysés ST, Werneck RI, Moysés SJ. Oral of critical incidents. J Dent Educ. 2003 May;67(5):515–23. health in the context of primary care in Brazil. Int Dent J. 2013 PMID:12809186 Oct;63(5):237–43. PMID:24074017

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Caractérisation génétique du sous-groupe Maculipennis (Diptera : Culicidae) au Maroc : un outil fondamental pour lutter contre le paludisme Bouchra Trari 1, 2 et Mohamed Dakki 3

التوصيف اجليني لزمرية مبقعات اجلناح )فصيلة البعوضيات( يف املغرب: أداة أساسية ملكافحة امللريا برشى اطراري، حممد داكي اخللصــة: تعــد بعوضــة (Anopheles labranchiae Falleroni 1926) إحــدى أعضــاء زمــرية مبقعــات اجلنــاح، وظلــت لفــرة طويلــة ً ســببايف انتقــال عــدوى امللريــا املتصــورة النشــيطة، التــي توطنــتيف املغــرب حتــى عــام 2010. وتــؤدي عوامــل تغــري املنــاخ وتزايد الســفر الــدويل ووجود ناقــل العــدوى بصــورة دائمــة إىل زيــادة خماطــر عــودة امللريــا للظهــور. وهتــدف هــذه الدراســة إىل حتديــد إمكانيــة وجــود أعضــاء آخريــن لزمــرية PCR مبقعــاتاجلنــاح يف املغــرب، باســتخدام تفاعــل البوليمــرياز التسلســيل ( )بــن البعــوض ّاملجمــع يف عــدة مناطــق، والتــي اختــريت ًوفقــا لنــوع املخاطــر حســب محددتــه وزارة الصحــة. وتــم حتليــل 86 عينــة مــن البعــوض باســتخدام تضخيــم تفاعــل البوليمــرياز التسلســ يللسلســلة احلمــض الريبــي ITS2. وقورنــت سلســل مفســاح ITS2 للبعــوض بسلســل 7 أنــواع مــن زمــ ة ريمبقعــات اجلنــاحاملتاحــة يف بنــك اجلينــات. وتؤكــد النتائــج املســتقاة وجــود األنوفيلــة اللبرانكيــة باعتبارهــا املمثــل الوحيــد هلــذه الزمــرية يف املغــرب. ومــن بــاب نقــل التكنولوجيــا، أتيحــت للمــرة األوىل إجــراءات اســتخ ص لاحلمــض النــووي وتضخيمــه، حيــث إن هــذه الطريقــة ال تــزال غــ ريمعروفــة لــدى عــدد مــناملختــرات املغربيــة.

RÉSUMÉ Le complexe maculipennis a été incriminé dans la transmission du paludisme, endémique au Maroc jusqu'en 2010. Le réchauffement climatique, l'intensification des voyages internationaux et la présence des vecteurs constituent un risque de réémergence de la maladie. L'étude a tenté d'identifier par PCR (Polymerase Chain Reaction), le complexe maculipennis dans plusieurs régions du Maroc, choisies en se basant sur la notion de risque. Quatre-vingt six (86) spécimens de moustiques ont été analysés en utilisant l'amplification par PCR de la séquence ITS2 (Internal Transcribed Spacer) de l'ADN ribosomique. Les séquences ITS2 des moustiques ont été comparées à celles des 7 espèces du groupe Maculipennis, disponibles dans GenBank. Les résultats obtenus confirment la présence d'An. labranchiae Falleroni, 1926. Aussi, dans un souci de transfert de technologie,les étapes d'extraction d'ADN et d'amplification sont exposées pour la première fois, en détail, étant donné que la PCR reste encore inconnue dans plusieurs laboratoires périphériques marocains.

Genetic characterization of the Anopheles maculipennis complex (Diptera: Culicidae) in Morocco: a fundamental tool for malaria control

ABSTRACT The Anopheles maculipennis complex has been implicated in the transmission of malaria, which was endemic in Morocco until 2010. Climate change, intensification of international travel and the permanent presence of the vector increase the risk of malaria re-emergence. Using polymerase chain reaction assay (PCR), this study attempts to identify the possible presence of the Maculipennis complex in several areas of Morocco, based on the concept of risk. Eighty-six mosquito specimens were analyzed using PCR amplification of the ITS2 (Internal Transcribed Spacer 2) sequence of ribosomal DNA. The ITS2 sequences of the mosquitoes were compared to those of the 7 species of the Maculipennis complex available in GenBank. The results obtained confirm the presence ofAnopheles labranchiae. In order to enable technology transfer, DNA extraction and amplification steps are presented for the first time in detail, given the fact that the technique is still unknown to several Moroccan peripheral laboratories.

1Unité de Recherche et Développement, Institut Supérieur des Professions infirmières et Techniques de Santé, Rabat (Maroc) (Correspondance à adresser à : [email protected]). 2Laboratoire de Zoologie et Biologie Générale, Faculté des Sciences, Université Mohamed V, Rabat (Maroc). 3Département de Zoologie et Écologie animale, Institut Scientifique, Université Mohamed V, Rabat (Maroc). Reçu : 14/06/15 ; accepté : 6/03/17

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Introduction importante variabilité au sein d’une augmenter le risque de transmission de même espèce, voire d’une même Plasmodium (25). La lutte antivectorielle reste le principal descendance, ce qui parfois peut rendre Le principal objectif de ce travail moyen de réduire la transmission du l’identification impossible. Il en est de est l’identification précise du sous- parasite responsable du paludisme, mais même pour l’analyse morphologique groupe Maculipennis au Maroc, au son succès repose en grande partie sur des stades larvaires, nymphaux et sein de trois régions représentatives une bonne connaissance du vecteur. imaginaux (10,11). La « variété » des situations épidémiologiques La plupart des vecteurs de An. sicaulti, décrite au Maroc près du paludisme dans le pays telles que Plasmodium appartiennent à des de Rabat par Roubaud (12), illustre définies par le ministère de la Santé, complexes d’espèces (1), groupes ou bien la confusion qui peut avoir lieu en vue d’y rechercher la présence sous-groupes, dont les membres sont à propos de ce sous-groupe (13- d’autres représentants susceptibles morphologiquement identiques mais 16). Depuis le travail de White qui de transmettre le Plasmodium. Aussi, génétiquement distincts (espèces reconnaissait neuf espèces (16), de étant donné que la technique PCR nombreux changements ont été opérés jumelles) et peuvent présenter est encore inconnue dans la plupart et concernent aussi bien l’appellation du des différences écologiques et des laboratoires périphériques qui sous-groupe Maculipennis (complexe, comportementales qui se répercutent assurent la surveillance entomologique groupe, sous-groupe) que le nombre et souvent au niveau épidémiologique. dans le cadre du programme de lutte le statut des espèces qui le composent. antipaludique, les étapes de la PCR sont Depuis la mise au point des À l’heure actuelle, et selon la dernière exposées en détail, dans un souci de techniques de biologie moléculaire (2), classification 17( ,18), dix espèces transfert de technologie. l’étude du polymorphisme des du sous-groupe Maculipennis sont populations anophéliennes par officiellement reconnues An.: artemievi, PCR (Polymerase Chain Reaction An. atroparvus, An. daciae, An. labranchiae, Méthodes – réaction de polymérisation en An. maculipennis, An. martinius, An. chaîne) n’a pas cessé de prouver melanoon, An. messeae, An. persiensis et Choix de la zone d’étude son efficacité pour l’étude des An. sacharovi. populations de vecteurs, aussi bien Tenant compte du risque de Au Maroc, la nécessité d’étudier la en région afrotropicale (complexe structure génétique des populations transmission du Plasmodium, le choix Anopheles gambiae) (3,4) qu’en naturelles des membres du sous- des sites étudiés a été effectué en région paléarctique (sous-groupe groupe Maculipennis a déjà été fonction de la classification établie par le Maculipennis) pour les régions qui soulignée (19). Des études génétiques ministère de la Santé (26) et permettant nous intéressent (5), pour devenir récentes montrent la présence d’An. de distinguer trois zones : haut risque, actuellement une technique de routine labranchiae comme seul représentant risque potentiel et faible risque. Cette dans la plupart des laboratoires du sous-groupe Maculipennis (20,21). stratification repose sur les données d’entomologie médicale à travers le Cependant, dans le contexte actuel épidémiologiques (notification monde. des changements climatiques et de récente de cas de paludisme Au Maroc, où le dernier cas de l’adaptation de nouvelles espèces, la autochtone), mais aussi sur les paludisme autochtone à Plasmodium présence éventuelle d’autres espèces notions de réceptivité (abondance vivax a été enregistré en 2004 (6) n’est pas à exclure, puisque certaines des gîtes anophéliens, présence et l’élimination a été certifiée par espèces du sous-groupe Maculipennis et densité du vecteur) et de l’Organisation mondiale de la Santé sont déjà signalées dans les pays voisins. vulnérabilité (mouvement des en 2010 (7), la transmission était Il s’agit de la présence d’An. sacharovi populations en relation avec les régions essentiellement due à An. labranchiae en Algérie (22) et d’An. atroparvus en ou les pays à risque) qui sont les Falleroni, 1926, membre du sous- Espagne (23). Cette dernière espèce deux critères de base pour définir le groupe Maculipennis. Celui-ci a été est très fréquente dans les rizières et « potentiel paludogène » d'une région. le premier « complexe d’espèces » les zones irriguées (1) et figure parmi Pour ce faire, nous nous sommes basés à avoir été découvert parmi les les plus importants vecteurs de sur les données des foyers récents moustiques (8,9). L’identification Plasmodium susceptibles d’étendre leur et anciens (27), sur la répartition morphologique précise des membres aire de distribution géographique (24). anophélienne déjà connue du sous- de ce sous-groupe reposait sur Il a été prouvé que les stratégies groupe Maculipennis (28) ainsi que l’ornementation des œufs (10). Ces d’aménagement de l’environnement sur les informations obtenues sur les derniers présentent toutefois une telles que l’irrigation peuvent zones de migration de population

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morphologiques (31), puis les spécimens triés du sous-groupe Maculipennis ont été conservés pour une identification plus précise à l’aide d’outils de biologie moléculaire. Chaque spécimen adulte a été sectionné en deux parties, conservées séparément, l’une comprenant l’abdomen ainsi que les pattes et les ailes du moustique servant pour les analyses PCR2 et l’autre le reste du corps (tête et thorax) pour des tests ELISA (Enzyme Linked Immunosorbent Assay) repas de sang. Les larves ont été conservées dans de l’alcool à 70° et les adultes ont été gardés en présence d’un dessicateur (gel de Figure 1 Localisation des sites étudiés silice). Extraction de l’ADN Pour les larves d’anophèles, chaque et d’aménagement hydroagricole 3) Région sud spécimen entier a été individuellement à risque (29). Trois chantiers • Zone à risque potentiel de paludisme : broyé dans 200 µL de CTAB 2 % (Cetyl géographiques correspondant à province d’Ouarzazate Trimethyl Ammonium Bromide 12 provinces ont alors été retenus dans – bromure d’hexadécyltriméthyl ce travail (Figure 1). • Zone à faible risque de paludisme : province de Tiznit ammonium) préalablement préparé et 1) Région nord conservé à température ambiante. Après Échantillonnage des cinq minutes au bain-marie à 65 °C, ce moustiques • Zone à haut risque de paludisme : broyat a été mélangé par inversion avec province de Chefchaouen1 Les anophèles ont été prélevés lors de 200 µL de chloroforme puis centrifugé • Zone à risque potentiel de paludisme : campagnes d’échantillonnage (larves pendant cinq minutes à 12 000 tr/ provinces de Larache et Khémisset et adultes) réalisées entre février 2004 min, à température ambiante (25 °C). et septembre 2005. Pour la région de La phase supérieure a été prélevée et • Zone à faible risque de paludisme : Rabat, les prélèvements ont eu lieu entre mise dans un autre tube, puis 200 µL provinces de Meknès, Oujda, Rabat décembre 2003 et septembre 2004. Les d’isopropanol ont été ajoutés à ce et Tétouan prélèvements larvaires, de type semi- surnageant ; le tout a été bien mélangé 2) Région centre quantitatif, ont été effectués à l’aide d’un par inversion avant d’être centrifugé filet Langeron et le nombre de coups pendant 15 minutes à 12 000 tr/min, • Zone à haut risque de paludisme : de filet a été variable selon la superficie à température ambiante. Par la suite, province de Khouribga du gîte. Les adultes ont été capturés l’isopropanol a été éliminé et égoutté, • Zone à risque potentiel de paludisme manuellement au repos, à l’intérieur des puis remplacé par de l’éthanol à 70 % : province de Settat habitations humaines ou des abris pour et le nouveau mélange a été centrifugé animaux, à l’aide d’aspirateurs à bouche. • Zone à faible risque de paludisme : pendant cinq minutes à 12 000 tr/ province de Marrakech min, à température ambiante. Après élimination de l’éthanol, le culot ainsi obtenu a été séché pendant cinq 1 Bien que la région de Chefchaouen Identification soit évaluée par certains auteurs morphologique comme une zone à faible risque et conservation 2 Les manipulations de biologie de paludisme (30), cette province des anophèles moléculaire ont eu lieu au Laboratoire continue, selon les critères établis de Lutte contre les Insectes par le ministère de la Santé (26), Nuisibles (LIN), Institut de Recherche d’être une zone où le risque demeure Les moustiques récoltés ont pour le Développement (IRD), relativement élevé. été identifiés sur la base de critères Montpellier (France).

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minutes au SpeedVac®, repris dans 86 spécimens (larves et adultes) niveau des provinces de Marrakech, 20 µL d’eau stérile et enfin gardé toute provenant de huit provinces Ouarzazate, Tiznit et Oujda. la nuit à température ambiante avant différentes (Tableau 1) ont pu être Les résultats des trois séries de d’être dilué au 1/50e pour être analysé analysés en trois séries de PCR : une PCR des 86 spécimens d’anophèles par PCR. première et une deuxième série pour analysés, obtenus par électrophorèse Pour les adultes, la PCR a été réalisée les adultes (18 et 24 échantillons), sur un gel d’agarose à 4 %, montrent que sans extraction d’ADN préalable et une troisième série pour les les séquences ITS2 de 72 anophèles mais directement sur les pattes de larves (44 échantillons). correspondent bien à celle d'An. moustiques (technique d’usage au Labranchiae ; deux ont dû être confirmés Laboratoire de Lutte contre les Insectes par séquençage, 14 spécimens étaient Nuisibles [LIN] de Montpellier, non Résultats négatifs et n’ont pu être amplifiés. publiée).

Amplification PCR Parmi les neuf espèces anophéliennes signalées au Maroc (28, 32), six ont Discussion La région ITS2 (Internal Transcribed pu être identifiées durant cette étude ; 2) de l’ADN ribosomal a été Spacer d’après les critères morphologiques, La caractérisation génétique du sous- amplifiée par PCR, en utilisant les elles appartiennent aux sous-genres groupe Maculipennis par PCR dans amorces décrites par Proft et al. (5). les sites étudiés montre bien qu’il Anopheles (An.) et Cellia (Cel.). Il Les conditions de PCR ainsi que le n’est représenté que par une seule s’agit de : An. (An.) labranchiae (huit programme d’amplification de l’ADN espèce, An. labranchiae ; c’est l’espèce provinces), An. (Cel.) sergentii et se sont déroulés conformément anophélienne la plus fréquente. Ces An. (Cel.) cinereus (quatre provinces), aux protocoles d’usage au LIN de résultats confirment les recherches puis ( ) ( ) Montpellier. Pour les anophèles adultes, An. An. algeriensis, An. An. précédentes (20,21) sur ce sous-groupe une patte issue de chaque spécimen marteri et An. (An.) ziemanni (deux au Maroc. Toutefois, étant donné la a été directement utilisée pour provinces) (Tableau 2). Les trois autres rareté de ces études, il serait intéressant de l’amplification de l’ADN. Concernant espèces, An. (An.) claviger, An. (Cel.) poursuivre les enquêtes en considérant les larves, la PCR a été pratiquée sur dthali et An. (Cel.) multicolor n’ont pas de nouvelles régions, en particulier les l’ADN préalablement obtenu par été trouvées dans nos échantillonnages. rizières, biotopes typiques ayant par le extraction à partir du moustique Aucun spécimen du sous-groupe passé favorisé la transmission de l’agent entier et dilué au 1/50e. Ainsi, au total, Maculipennis n’a été capturé au pathogène du paludisme au Maroc (33,

Tableau 1 Taille, provenance et identification des échantillons analysés Origine des moustiques Date du Stade Nombre de Espèces identifiées prélèvement spécimens analysés An. labranchiae Négatifs Chefchaouen septembre 2004 adulte 9 6 3

Larache mars 2005 adulte 12 8 4

Khémisset octobre 2004 adulte 4 2 2 octobre 2004 larve 15 15 0 mars 2005 larve 7 7 0

Meknès mai 2005 larve 2 2 0 juin 2005 larve 5 5 0 juin 2005 adulte 4 4 0

Rabat février 2004 larve 8 8 0

Tétouan juin 2005 adulte 11 5 6

Khouribga avril 2005 larve 5 5 0

Settat avril 2005 adulte 1 0 1 mai 2005 adulte 1 0 1 mai 2005 larve 2 2 0

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Tableau 2 Faune anophélienne des sites étudiés Espèce An. labranchiae An. sergentii An. cinereus An. algeriensis An. marteri An. ziemanni Province Chefchaouen + + + + + Khémisset + Larache + Meknès + Oujda + Rabat + Tétouan + + + + Khouribga + + + Marrakech Settat + + Tiznit + + + Ouarzazate

34) ainsi qu'en Espagne si bien que le risque de reprise de la transmission et la Montpellier (France) pour l’accueil au roi de Valencia avait interdit la culture réémergence du paludisme. LIN et pour l’aide dans la réalisation des du riz (35). En effet, les modifications de manipulations de biologie moléculaire, l’environnement telles que l’irrigation, Mme Btissam Ameur, M. Tachfine, s’ajoutant au nombre recrudescent de Remerciements M. Bouhrara et M. Nachi du Service cas de paludisme importé au Maroc (6) de Lutte antivectorielle, Direction de ainsi qu’aux changements climatiques Nous remercions M. Abdelaziz l’Épidémiologie et de Lutte contre actuels favorables à la transmission Agoumi, ancien Chef du Département les Maladies, Ministère de la Santé, de l’agent pathogène du paludisme, de Parasitologie, Faculté de médecine Rabat (Maroc) pour leur collaboration sont susceptibles d’influencer son et de pharmacie de Rabat (Maroc), concernant la capture des moustiques épidémiologie. Des mesures de de nous avoir permis de prendre en adultes. surveillance de l’importation de charge le projet SGS04/67, M. Didier Fontenille et Mme Cécile Brengues nouveaux vecteurs sont essentielles Financement : Organisation mondiale du Laboratoire de Lutte contre les pour préparer des opérations de lutte de la Santé (projet SGS04/67). antivectorielle adaptées et éviter le Insectes Nuisibles (LIN), Institut de Recherche pour le Développement , Intérêts concurrents : aucun déclaré.

Références

1. Mouchet J, Carnevale P, Coosemans M, Julvez J, Manguin S, 5. Proft J, Maier WA, Kampen H. Identification of six sibling Richard-Lenoble D et al. Biodiversité du paludisme dans le species of the Anopheles maculipennis complex (Diptera: monde. Montrouge: John Libbey Eurotext; 2004. 428 p. Culicidae) by a polymerase chain reaction assay. Parasitol 2. Saiki RK, Gelfand DH, Stoffel S, Scharf SJ, Higuchi R, Horn Res. 1999 Oct;85(10):837–43.doi: 10.1007/s004360050642 GT, et al. Primer-directed enzymatic amplification of DNA PMID:10494811 with a thermostable DNA polymerase. Science. 1988 Jan 6. Trari B, Carnevale P. De la préélimination à l’élimination du 29;239(4839):487–91.doi:10.1126/science.2448875 paludisme au Maroc. Quels risques pour l’avenir ? Bull Soc PMID:2448875 Pathol Exot. 2011 Oct;104(4):291–5. doi:10.1007/s13149-011- 0156-2. 3. Fontenille D, Faye O, Konate L, Sy N, Collins FH. Comparaison des techniques PCR et cytogénétiques pour la détermination 7. Eliminating malaria: learning from the past, looking ahead. des membres du complexe Anopheles gambiae au Sénégal. Progress & impact series, n. 8 (October 2011). Geneva: World Ann Parasitol Hum Comp. 1993;68(5-6):239–40.doi:10.1051/ Health Organization; 2011. 84 p. parasite/1993685239. 8. Falleroni D. Fauna anofelica italiana e suo “habitat” (paludi, 4. Fontenille D, Diatta M, Konate L, Lochouarn L, Lemasson JJ, risaie, canali). Metodi di lotta contra la malaria. Riv Malariol. Diagne N et al. Intérêt de l’utilisation des outils de biologie 1926;5(5-6):553–93. moléculaire dans l’étude de la transmission du paludisme : 9. Van Thiel PH. Sur l’origine des variations de taille de l’exemple des programmes conduits au Sénégal. Med l’Anopheles maculipennis dans les Pays-Bas. Bull Soc Pathol Trop.1995;55:52S–5S. Exot. 1927;20:366–90.

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10. Guy Y, Salières A, Boesiger E. Contribution à l’étude du « 23. Bueno-Marí R, Jiménez-Peydró R. Anophelism in a Former complexe maculipennis » (Diptera-Culicidae-Anophelinae). Malaria Area of Northeastern Spain. J Arthropod Borne Dis. Mise au point en 1975. Ann Biol. 1976;15(5-6):227–82. 2013;7(2):147–53. PMCID:PMC3875881 11. Deruaz D, Deruaz J, Pichot J. Correspondence analysis of 24. Sinka ME, Bangs MJ, Manguin S, Coetzee M, Mbogo CM, larval chaetotaxy in the « Anopheles maculipennis complex » Hemingway J, et al. The dominant Anopheles vectors of human (Diptera, Culicidae). Ann Parasitol Hum Comp. 1991;66(4):166– malaria in Africa, Europe and the Middle East: occurrence data, 72. doi:10.1051/parasite/1991664166. distribution maps and bionomic précis. Parasit Vectors. 2010 12. Roubaud E. Variété nouvelle de l’A. maculipennis au Maroc, A. Dec;3:117. doi: 10.1186/1756-3305-3-117 PMCID:PMC3016360 maculipennis sicaulti (n.var.). Bull Soc Pathol Exot. 1935;28:107– 25. Ghebreyesus TA, Haile M, Witten KH, Getachew A, Yohannes 11. AM, Yohannes M, et al. Incidence of malaria among children 13. Gaud J. Notes biogéographiques sur les Culicidés du Maroc. living near dams in northern Ethiopia: community based Arch Inst Pasteur Maroc. 1953;4:443–90. incidence survey. BMJ. 1999 Sep 11;319(7211):663–6. doi: 10.1136/bmj.319.7211.663 PMCID:PMC28216 14. Senevet G, Andarelli L, Sergent E. Les Anophèles de l'Afrique du Nord et du bassin méditerranéen. Encyclopédie 26. Stratégie d’élimination du paludisme au Maroc : plan et entomologique. Série A,33. Paris: P. Lechevalier;1956. 280 p. éléments d’évaluation. Rabat: Ministère de la Santé du Royaume du Maroc; 2001.41 p. 15. Stone A, Knight KL, Starcke H. A synoptic catalog of the mosquitoes of the world (Diptera, Culicidae). The Thomas Say 27. Données épidémiologiques des maladies sous surveillance. Foundation (Series),v. 6. Washington: Entomological Society of Bulletin épidémiologique1966-2004.Rabat: Ministère de la America;1959 (Supplements 1961 & 1963).358 p. Santé du Royaume du Maroc, Direction de l’Épidémiologie et de Lutte contre les Maladies. 16. White GB. Systematic reappraisal of the Anopheles maculipennis Complex. Mosq Syst. 1978;10(1):13–44 (http:// 28. Trari B, Harbach RE, Himmi O, Dakki MA, Agoumi A. An www.biodiversitylibrary.org/content/part/JAMCA/MS_V10_ inventory of the mosquitoes of Morocco. I. Genus Anopheles N1_P013-44.pdf) (Diptera: Culicidae). Eur Mosq Bull. 2004;18:1–19. 17. Harbach RE. Mosquito Taxonomic Inventory. Anopheles 29. Fenêtres sur le territoire marocain. Rabat: Ministère de classification (Updated 15 March 2017). http://mosquito- l’Aménagement du Territoire, de l’Urbanisme, de l’Habitat taxonomic-inventory.info/sites/mosquito-taxonomic- et de l’Environnement du Royaume du Maroc, Direction de inventory.info/files/Anopheles%20classification_48.pdf l’aménagement du territoire; 2002.147 p. (consulté le 11 juin 2017). 30. Faraj C, Adlaoui E, Ouahabi S, Rhajaoui M, Fontenille D, 18. 18. Linton Y. Systematics of the Holarctic maculipennis Lyagoubi M. Entomological investigations in the region of the complex. Systematics Symposium: 70th Annual Meeting of the last malaria focus in Morocco. Acta Trop. 2009;109(1):70–3. American Mosquito Control Association, Savannah, Georgia, doi: 10.1016/j.actatropica.2008.09.021 PMID:18992211 USA, 22-26 February 2004. 31. Bruhnes J, Rhaim A. Geoffroy B, Angel G, Hervy JP. Les 19. Trari B. Culicidae (Diptera): Catalogue raisonné des moustiques de l’Afrique méditerranéenne. Logiciel peuplements du Maroc et études typologiques de quelques d’identification et d’enseignement. Montpellier: Institut de gîtes du Gharb et de leurs communautés larvaires [Thèse]. Recherche pour le Développement (IRD) / Institut Pasteur de Rabat: Université Mohamed V, Faculté des Sciences;1991. Tunis (IPT) CD-Rom (Collection Didactiques); 2000. 20. Faraj C, Adlaoui E, Saaf N, Romi R, Boccolini D, Di Luca M et al. 32. Trari B, Dakki M, Harbach RE. An updated checklist of the Note sur le complexe Anopheles maculipennis au Maroc. Bull Culicidae (Diptera) of Morocco, with notes on species of Soc Pathol Exot. 2004;97(4):293–4 (http://www.pathexo.fr/ historical and current medical importance. J Vect Ecol. 2017 documents/articles-bull/T97-4-2648-2p.pdf). Jun;42(1):94-104.doi :10.1111/jvec.12243 21. Laboudi M, Faraj C, Sadak A, Harrat Z, Boubidi SC, Harbach RE, 33. Gaud J, Mechali D, Delrieu J. Riziculture et paludisme au et al. DNA barcodes confirm the presence of a single member Maroc. Bull Inst Hyg Maroc (NS). 1949;9(3-4):181–90. of the Anopheles maculipennis group in Morocco and Algeria: 34. Houel G. La lutte antipaludique dans les zones rizicoles du An. sicaulti is conspecific with An. labranchiae. Acta Trop. Maroc. Bull Inst Hyg Maroc (NS). 1954;14(1-2):43–90. 2011 Apr;118(1):6–13. doi: 10.1016/j.actatropica.2010.12.006 35. Rico-Avelló y Rico C. Aportación española a la historia del PMID:21172298 paludismo. Rev Sanid Hig Publica. 1947;21:483-733. 22. Boudemagh N, Bendali-Saoudi F, Soltani N. Inventory of Culicidae (Diptera: Nematocera) in the region of Collo (North- East Algeria). Ann Biol Res. 2013;4(2):94–9.

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Assessment of the quality of life in patients on haemodialysis in Iraq Safauldeen A. Alhajim 1

تقييم جودة احلياة ملرىض الغسيل الكلوي يف العراق صفاء الدين احلاجم اخللصــة: تتطلــب أمــراض الــكل املزمنــة عل ً جــاباالســتعاضة الكلويــة مــدى احليــاة، ومــا هــو مــن شــأنه أن يؤثــر تأثــري ًا ًبالغــا عــى جــودة حيــاة املرىض.ومتثــل الغــرض مــن هــذه الدراســة املقطعيــة يف تقييــم جــودة احليــاة بالنســبة ملــرىض الغســيل الكلــوي، والعوامــل التــي تؤثــر عليهــا، يف وحــدة غســيل الــكل بمستشــفى البــرة العــام. وشــملت الدراســة مــا جمموعــة 104أشــخاص يعانــون مــن مــرض كلــوي يف مراحلــه األخــرية ويتلقــون غســي ًل ً. كلويــاومجعــت البيانــات باســتخدام اســتبيان منظمــة الصحــة العامليــة جلــودة احليــاة. وتــم جتميــع بيانــات اجتمعية-ســكانية ورسيريــة. ومــناملــرىض البالــغ عددهــم 104 مــرىض، جــاء 57 % مــن الذكــور، و73 % يف الفئــة العمريــة األكــر مــن 45 ســنة، و87 % مــن وضــع اجتمعــي اقتصــادي متوســط أو منخفــض، و 70% ســبق هلــم تلقــي غســي ًل للــكل ألكثــر مــن ســنة، و74 % تلقــوا قســطرة وريديــة لعــاج الناســور الرشيــاين الوريــدي، و34 % كانــوا مصابــن بــداء الســكري، و48 % كانــوا مصابــن بفــريوس االلتهــاب الكبــدي. وتبــن تأثــر مجيــع جمــاالت جــودة احليــاة )الصحــة البدنيــة والنفســية والعلقــات االجتمعيــة والبيئــة(؛ كــاتأثــر املجــال البــدين ًتأثــرا ًبالغــا. وارتبطــت عوامــل تقــدم العمــر وانخفــاض الوضــع االجتمعــي واالقتصــادي وطــول فــرة العــاج بغســيل الــكل والقســطرة الوريديــة املركزيــة واإلصابــة بالســكري واإلصابــة بااللتهــاب الكبــدي ًارتباطــا ذا داللــة بانخفــاض جــودة احليــاة )p<0.05(.

ABSTRACT Chronic kidney disease requires life-long renal replacement therapy, which can greatly impair the quality of life (QOL) of patients. This cross-sectional study aimed to assess the QOL of patients on haemodialysis, and the factors affecting it, at the dialysis unit of Basra General Hospital. A total of 104 patients with end-stage renal disease on haemodialysis were included. Data were collected using the World Health Organization QOL questionnaire. Sociodemographic and clinical data were also collected. Of the 104 patients, 57% were male, 73% were older than 45 years, 87% were of middle and low socioeconomic status, 70% had been on dialysis for more than 1 year, 74% had arteriovenous fistula vascular access, 34% had diabetes and 48% were positive for hepatitis virus. All domains of QOL (physical health, psychological, social relationships and environment) were affected; the physical domain was the most severely affected. Older age, lower socioeconomic status, longer duration of dialysis, central line vascular access, having diabetes and positive hepatitis serology were significantly associated with lower QOL (P < 0.05).

Évaluation de la qualité de vie des patients sous hémodialyse en Iraq

RÉSUMÉ L’existence d’une maladie rénale chronique nécessite la mise en place d’une thérapie de remplacement rénal à vie, ce qui peut grandement impacter la qualité de vie des patients. La présente étude transversale avait pour objectif d’évaluer la qualité de vie des patients sous hémodialyse, ainsi que les facteurs de détérioration de la qualité de vie, à l’unité de dialyse de l’hôpital général de Bassora. Au total, 104 patients atteints de maladie rénale en phase terminale et sous hémodialyse ont été inclus à l’étude. Les données ont été collectées à l’aide du questionnaire d’évaluation de la qualité de vie de l’Organisation mondiale de la Santé. Des données socio- démographiques et cliniques ont également été recueillies. Sur les 104 patients, 57 % étaient des hommes, 73 % étaient âgés de plus de 45 ans, 87 % étaient issus de milieux socio-économiques moyen et faible, 70 % étaient sous dialyse depuis plus d’un an, 74 % disposaient d’un abord vasculaire de type fistule artério-veineuse, 34 % souffraient de diabète et 48 % avaient contracté le virus de l'hépatite. Tous les domaines de la qualité de vie (santé physique, psychologique, relations sociales et environnement) étaient affectés, le domaine physique étant celui le plus impacté. Un âge plus avancé, un statut socio-économique inférieur, une durée prolongée de la dialyse, un abord vasculaire par cathéter central, le fait d’être diabétique et d’avoir une sérologie positive au virus de l'hépatite étaient associés de façon significative à une diminution de la qualité de vie p( < 0,05).

1Department of Medicine, College of Medicine, University of Basra, Basra, Iraq (Correspondence to: Safauldeen A. Alhajim: safauldinhachim@ yahoo.com). Received: 28/12/15; accepted: 19/02/17 815 https://doi.org/10.26719/2017.23.12.815

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Introduction come for timely dialysis until severe co- (diabetes, hypertension and diabetes morbidities develop (8). Several studies and other co-morbidities, such as poly- Chronic kidney disease affects 5-10% of have shown that regular pre-dialysis cystic kidney disease and systemic lupus the world’s population; it is associated attendance helps to provide the patient erythematosus), type of vascular access with poor quality of life (QOL) and im- with proper education and thereby [arteriovenous fistula (AV-fistula) or poses a high economic burden (1–3). achieve better QOL 9( ). These findings central line], duration of haemodialysis, This is particularly true in the develop- were supported by the study of Lii et and hepatitis serology status (hepatitis ing world where resources are limited al. who concluded that patients who B and/or C positive, hepatitis B and C (4). The global prevalence of end-stage received psychosocial interventions negative). renal disease, which is associated with showed better QOL 10( ). Data were collected by interview considerable morbidity and mortality, Improvement in the QOL has during the dialysis session. It took about has increased in the past 2 decades. The become the major treatment goal in 30 minutes for each patient. The inter- treatment option at this stage is renal end-stage renal disease patients (8). view questionnaire was tested on a small replacement therapy, which includes Therefore, the aim of this study was to sample to assess any errors and bias that dialysis and kidney transplant (1,2). evaluate the QOL of patients on hae- could occur in explaining questions and According to various studies, the cost of modialysis in the dialysis unit of Basra to avoid suggestions by the interviewer. dialysis is between US$ 3 000 and 4 000 General Hospital, Iraq. Patients were divided into 3 sub- per month, and it is a lifelong treatment. It is very difficult for the average patient groups according to the duration of to afford dialysis and it is important Methods dialysis: group I were on dialysis for < 1 to ensure good QOL while on such year, group II for 1-3 years and group III expensive treatment (3). Study design and setting for > 3 years. Socioeconomic status of participating patients was categorized as The World Health Organization This was a cross-sectional study carried upper, middle, and lower socioeconom- (WHO) has defined QOL as “an in- out at the dialysis unit of Basra General ic status based on income, educational dividual’s perception of their position Hospital. This unit serves about 200 pa- level and type of employment (11). in life in the context of the culture and tients, providing an average of 3 dialysis value systems in which they live and sessions per week for each patient, free To assess the quality of life we in relation to their goals, expectations, of charge. adapted the WHOQOL-BREF as- standards and concerns” (4). Many sessment questionnaire (short form studies have evaluated QOL with ge- Study sample of WHO-100), which has been used neric as well as disease-specific instru- The sample was drawn from patients worldwide (4). This questionnaire has ments (5). The assessment of QOL registered at the unit. The inclusion 26 items, which assess 4 main domains: is an essential element of health care criteria were patients aged over 18 years physical health, psychological health, evaluation and helps suggest suitable who were diagnosed with end-stage re- social relationships and environment of measures to be taken to increase the nal disease and had completed at least 3 the patient. After recording all necessary QOL of patients with end-stage renal months on haemodialysis. Patients who items, a raw score is calculated for each disease. declined to answer the questionnaire, facet and each domain. Both facet and Haemodialysis is not a cure for those who had voluntarily withdrawn domain are scored through simple sum- chronic kidney disease but helps to from dialysis, those with severe illness mation of each item in that scale. Each prolong and improve a patient’s life or psychosis, and pregnant and lactating question contributes equally to the facet (6). However, patients on haemodi- women were excluded. score and each facet contributes equally alysis often experience complications to the domain score. Since each facet such as cardiovascular disease which Data collection has 4 items with response value of 1 to decrease their QOL. Furthermore, co- Data were collected from April to 5, the raw score for any facet has a mini- morbidities, such as anaemia, diabetes October 2013 using a data collection mum value of 4 and a maximum value of mellitus, hypertension, dyslipidaemia form. It included information on: so- 20. The next step involves transforming and thyroid disorders, greatly impair ciodemographic characteristics, prin- each raw scale score to a 0-100 scale the QOL of patients on haemodialysis, cipal diagnosis, co-morbid conditions using the formula below: negatively affecting their physical, social, financial and psychological well-being (Actual raw score —lowest possible raw score) Transformed scale = x 100 (7). Studies show that because of lack possible raw scrore range of awareness, patients often do not

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where the actual raw score is the as upper socioeconomic status, 44 roles and expectations are needed for value reached by summation, the lowest (42%) as middle and 47 (45%) as lower patients with end-stage renal disease, possible raw score is the lowest possible socioeconomic status. Regarding the which can also increase the stress level value that could be reached by summa- hepatitis serology status, 50 (48%) pa- and decrease QOL (14). In addition, tion (this value would be 4 for all facets), tients were positive for hepatitis virus caregivers also face many difficulties, and the possible raw score range is the and 54 (52%) were negative. such as changes in sleep patterns, health difference between the maximum pos- The overall QOL of patients on and social activities (15). In addition, sible raw score and the lowest possible haemodialysis was greatly impaired: the patients have to spend at least 3 days a raw score, i.e. 20–4 = 16 for all facets. mean (SD) score was 39.1 (16.1). The week on dialysis, often accompanied by This transformation converts the lowest QOL of 58 (56%) patients was greatly their caregivers, which imposes limita- and highest possible scores to zero and affected (score < 50), while 46 (44%) tions on social life and creates a feeling 100, respectively. patients were mildly affected (score ≥ of dependency on the dialysis centre. 50). So, both patients and caregivers have to Statistical analysis Table 1 shows effect of the studied make many modifications to their life Data obtained from the WHOQOL- variables on the QOL of the patients. styles (16). BREF questionnaire were analysed There was no significant effect of the pa- The present study showed that using SPSS, version 20.0. Descriptive tient’s gender on the QOL (P = 0.969). the physical domain of QOL was the analysis was done using mean and However, older age (P = 0.004), longer most affected, followed by psychologi- standard deviation (SD), and number duration of dialysis (P = 0.001), having cal, environmental and social domains. and percentage of each value. The chi- central line vascular access (P = 0.002), Similar results have been reported in squared test was used to compare the having diabetes and hypertension, or di- other studies (17,18). effect of different variables on QOL abetes co-morbidity (P = 0.001), lower According to various studies, male scores A P-value less than 0.05 was con- socioeconomic status (P = 0.003), and patients with end-stage renal disease sidered statistically significant. positive hepatitis serology (P = 0.0001) outnumber female patients. This may all negatively affected QOL (Table 1). Ethical considerations be because of the smoking and alcohol The transformed scores of the 4 habits of men, which might aggravate The study was approved by the ethics main domains of QOL were: physical renal failure (8,19). However, in the committee in Basra Medical College. (34%), psychological (40%), environ- present study, there was no significant ef- Written informed consent was obtained mental (48%) and social (53%). fect of gender on QOL, which is similar from all the participants. to a study from Egypt (20). Discussion Older patient age was negatively Results associated with QOL in our study, This study found that the quality of mainly in the physical domain. This A total of 104 patients met the inclusion life of patients on haemodialysis was finding is in line with several studies that criteria and were included in the study. significantly impaired. A similar effect showed similar results (21–24). The Of these, 59 (57%) were male. The on QOL was observed in other studies negative effect of the disease process on mean age of the patients was 49.7 (SD (12,13). the physical activity of patients, such as 13.1) years. With regard to duration of Common complications of dialysis, a decrease in haematocrit, and muscu- dialysis, 31 (30%) patients were on di- such as strict dietary restrictions, reduce loskeletal and neurological problems alysis for < 1 year, 40 (38%) for 1-3 years social and recreational activities. Medi- may contribute to this finding. Because and 33 (32%) for > 3 years. Most pa- cal complications, economic pressure, of a physiological decline from ageing, tients, 77 (74%), had AV-fistula access marital disputes, sexual dysfunction, the elderly experience a gradual and and 27 (26%) had central line access. emotional stress and anxiety result in progressive reduction in their functional Out of the 104 patients, 35 (34%) had further pressure on patients and their capacity. This may limit their daily ac- diabetes, 23 (22%) had hypertension caregivers that impair their QOL. tivities and result in worse QOL for and diabetes, while the remaining 46 Moreover, daily activities are also af- dimensions associated with physical (44%) had other co-morbidities such as fected by renal failure, including sleep- health (25). polycystic kidney disease and systemic ing, eating, working and planning a The duration of dialysis adversely lupus erythematosus. With regard to daily schedule, and these can become affects QOL in dialysis patients and socioeconomic status of the participat- a challenge for patients and their fami- was significantly associated with lower ing patients, 13 (13%) were categorized lies. Many permanent changes in family QOL in the patients in the present

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Table 1 Effect of the studied variables on the quality of life of patients (n = 104) Variable Quality of life P-value Badly affected Mildly affected No. (%) No. (%) Sex 0.969 Male 33 (56) 26 (44) Female 25 (56) 20 (44) Age (years) 0.004 18-45 9 (32) 19 (68) ˃ 45 49 (64) 27 (36) Duration of dialysis (years) 0.001 ˂ 1 9 (29) 22 (71) 1-3 25 (62) 15 (38) ˃ 3 24 (73) 9 (27) Vascular access 0.002 Arteriovenous fistula 36 (47) 41 (53) Central line 22 (81) 5 (19) Co-morbidities 0.001 Diabetes 22 (63) 13 (37) Diabetes and hypertension 19 (83) 4 (17) Other 17 (37) 29 (63) Socioeconomic status 0.003 Upper 2 (15) 11 (85) Middle 18 (41) 26 (59) Lower 40 (85) 7 (15) Hepatitis serology 0.0001 Negative 11 (20) 43 (80) Positive 47 (94) 3 (6)

study. QOL was better in patients with National Kidney Foundation’s Kidney make daily activities like bathing and a haemodialysis duration of less than Disease Outcomes Quality Initiative sleeping more difficult, and they may be 1 year compared with patients with a recommend early placement and use socially embarrassing and cosmetically dialysis duration 1-3 years, and both of an AV-fistula in at least 50% of inci- unaccepted (21). In this study, central groups had a better QOL than those on dent patients on haemodialysis (27). line access for haemodialysis adversely dialysis for more than 3 years. Initially, Referral of pre-dialysis patients to neph- affected the QOL of the patients. when patients start dialysis, they may rologists is usually late and a temporary The main cause of end-stage renal think that their kidneys will recover and access catheter is used as the primary disease in this study was diabetes mel- dialysis will be stopped, but with the access for dialysis. A study in Pakistan litus, which is similar to other national passage of time when they maintain reported late referral in 100% of dialysis and international studies (28,29). In their life on dialysis, their worries in- patients and temporary access catheter the present study, the QOL of diabetic crease and impair their QOL. A similar was used for dialysis in these patients patients on dialysis was poor compared observation has been made in another (28). Failure of AV-fistula in dialysis with patients without diabetes. Diabetes study in which QOL remained constant patients also contributes to the use of affects multiple organs in the body; it during the first year of dialysis 26( ). central lines. When catheters are used affects the eyes causing vision prob- AV-fistula is considered the best as the primary access for dialysis, they lems, and leads to cardiac problems, form of vascular access for those who affect not only QOL but also morbidity kidney failure, cerebrovascular events have end-stage renal disease and receive because they are a continuous source of and peripheral vascular disease, which haemodialysis. The clinical practice infection in the body. Furthermore, the may result in amputation and impaired guidelines for vascular access of the inconvenient site of central lines may QOL. All these problems limit daily

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activities and work capacity, lead to de- individual has a role in society and it Conclusion pendence on anti-diabetes drugs and contributes to improved self-esteem, disturbed sleep because of pain which which is an important aspect of QOL The results of the present study provide affects physical health. A similar pattern (24). Higher education also raises the evidence that the QOL of the haemodi- of poor QOL has been reported in QOL according to a study from Italy alysis patients is significantly impaired. other studies (30,31). Furthermore, in (33), and can raise awareness of chronic Gender had no significant effect on the present study, QOL was markedly diseases and help patients acquire better QOL. Increasing age, longer duration coping skills ( ). affected in patients with concomitant 24 of dialysis, diabetes and hypertension, diabetes and hypertension compared The QOL in haemodialysis patients central venous catheter as a vascular with patients with diabetes alone be- with positive hepatitis serology was sig- access for dialysis, lower socioeconomic cause of the additional complications nificantly impaired which may be due to status, and positive hepatitis serology imposed by hypertension. multiple factors such as social isolation, were all statistically significant factors Socioeconomic status was also sexual deprivation and the development that adversely affected QOL. Some significantly associated with QOL in of clinical features and complications of of these factors are modifiable, so we the present study; those of lower socio- hepatitis itself (24). should aim for better diabetes and economic status had a lower QOL. The The main limitation of our study hypertension control, encourage the findings of other studies, which found was the relatively small patient sample. use of AV-fistula rather than central that employed patients had a better We studied the correlation of QOL QOL than unemployed patients, sup- with dialysis-related factors and there catheter, and improve infection control port this finding 12,22( ). Demographic is a need for further study of health- for hepatitis viruses. factors such as unemployment, low ed- related domains of QOL in a much ucation and low socioeconomic status larger sample of patients with end-stage can impair QOL (32). This is because renal disease. The QOL questionnaire Acknowledgement financial independence may improve was completed when patients came I would like to acknowledge Dr Safaa A. QOL in working patient to some extent. for dialysis, where they may feel more Hneid for his help in the collection of Also, daily activity and work capacity secure and friendly to dialysis staff, may help to improve QOL (12). Hold- which may affects their how they are the data for this study. ing down a job certainly has a positive feeling and hence their responses when Funding: None. influence on the perception that an interviewed. Competing interests: None declared.

References

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13. Vasilieva IA. Quality of life in chronic hemodialysis patients sis in southern Brazil. Sao Paulo Med J. 2008 Sep;126(5):252-6. in Russia. Hemodial Int. 2006 Jul;10(3):274-8. https://doi. https://doi.org/10.1590/S1516-31802008000500002 org/10.1111/j.1542-4758.2006.00108.x PMID:16805889 PMID:19099157 14. Arslanian J, Binkley L, Hudson S, Hudson M, Kammerer J, Levin 25. Kusumoto L, Marques S, Haas V, Rodrigues RAP. Adult and N, et al. Core curriculum for dialysis technicians. USA: Amgen elderly on haemodialysis evaluation of health related quality of Inc.; 1992. life. Acta Paul Enferm. 2008;21:152-9. https://doi.org/10.1590/ 15. Fast J, Keating N. Informal caregivers in Canada: A snapshot. S0103-21002008000500003 Report to the Health Services Division. Edmonton: University 26. Hallinen T, Soini EJ, Martikainen JA, Ikäheimo R, Ryynänen OP. of Alberta; 2001. Costs and quality of life effects of the first year of renal replace- 16. Sezer MT, Eren I, Ozcankaya R, Civi I, Erturk J, Ozturk M. ment therapy in one Finnish treatment centre. J Med Econ. 2009 Psychological symptoms are greater in caregivers of patients Jun;12(2):136-40. https://doi.org/10.3111/13696990903119530 on hemodialysis than those of peritoneal dialysis. Hemo- PMID:19566482 dial Int. 2003 Oct 1;7(4):332-7. https://doi.org/10.1046/j.1492- 27. KDOQI Clinical practice guideline for hemodialysis adequacy: 7535.2003.00058.x PMID:19379384 2015 update. Am J Kidney Dis. 2015 Nov;66(5):884-930. 17. Park HC, Yoon HB, Son MJ, Jung ES, Joo KW, Chin HJ, et al. https://doi.org/10.1053/j.ajkd.2015.07.015 PMID:26498416 Depression and health-related quality of life in maintenance 28. Anees M, Mumtaz A, Nazir M, Ibrahim M, Rizwan SM, hemodialysis patients. Clin Nephrol. 2010 May;73(5):374-80. Kausar T. Referral pattern fof hemodialysis patients to neph- https://doi.org/10.5414/CNP73374 PMID:20420798 rologists. J Coll Physicians Surg Pak. 2007 Nov;17(11):671-4. 18. Merkus MP, Jager KJ, Dekker FW, De Haan RJ, Boeschoten EW, PMID:18070574 Krediet RT; NECOSAD Study Group. Quality of life over time in 29. United States Renal Data System. USRDS 2007 Annual Data dialysis: the Netherlands Cooperative Study on the Adequacy Report. Bethesda (MD): National Institute of Diabetes and Di- of Dialysis. Kidney Int. 1999 Aug;56(2):720-8. https://doi. gestive and Kidney Diseases, National Institutes of Health, US org/10.1046/j.1523-1755.1999.00563.x PMID:10432414 Department of Health and Human Services; 2007. 19. Abdel-Kader K, Myaskovsky L, Karpov I, Shah J, Hess R, Dew 30. Gumprecht J, Zelobowska K, Gosek K, Zywiec J, Adamski MA, et al. Individual quality of life in chronic kidney disease: M, Grzeszczak W. Quality of life among diabetic and non- influence of age and dialysis modality. Clin J Am Soc Nephrol. diabetic patients on maintenance haemodialysis. Exp Clin 2009 Apr;4(4):711-8. https://doi.org/10.2215/CJN.05191008 Endocrinol Diabetes. 2010 Mar;118(3):205-8. https://doi. PMID:19339411 org/10.1055/s-0029-1192023 PMID:19226477 20. Assal H, Emam H, Abd El-Ghaffar N. Health related quality 31. Sørensen VR, Mathiesen ER, Watt T, Bjorner JB, Andersen of life among Egyptian patients on haemodialysis. J Med Sci. MV, Feldt-Rasmussen B. Diabetic patients treated with di- 2006;6(3):314-20. https://doi.org/10.3923/jms.2006.314.320 alysis: complications and quality of life. Diabetologia. 2007 21. Mittal SK, Ahern L, Flaster E, Maesaka JK, Fishbane S. Self-as- Nov;50(11):2254-62. https://doi.org/10.1007/s00125-007- sessed physical and mental function of haemodialysis patients. 0810-1 PMID:17876568 Nephrol Dial Transplant. 2001 Jul;16(7):1387-94. https://doi. 32. Kalender B, Ozdemir AC, Dervisoglu E, Ozdemir O. Quality org/10.1093/ndt/16.7.1387 PMID:11427630 of life in chronic kidney disease: effects of treatment modal- 22. Frank A, Auslander GK, Weissgarten J. Quality of life of patients ity, depression, malnutrition and inflammation. Int J Clin with end-stage renal disease at various stages of the illness. Soc Pract. 2007 Apr;61(4):569-76. https://doi.org/10.1111/j.1742- Work Health Care. 2004;38(2):1-27. https://doi.org/10.1300/ 1241.2006.01251.x PMID:17263698 J010v38n02_01 PMID:15022732 33. Mingardi G, Cornalba L, Cortinovis E, Ruggiata R, Mosconi P, 23. Sabbah I, Drouby N, Sabbah S, Retel-Rude N, Mercier M. Qual- Apolone G; DIA-QOL Group. Health-related quality of life in ity of life in rural and urban populations in Lebanon using SF-36 dialysis patients. A report from an Italian study using the SF-36 health survey. Health Qual Life Outcomes. 2003 08 6;1(1):30. Health Survey. Nephrol Dial Transplant. 1999 Jun;14(6):1503- https://doi.org/10.1186/1477-7525-1-30 PMID:12952543 10. https://doi.org/10.1093/ndt/14.6.1503 PMID:10383015 24. Bohlke M, Nunes DL, Marini SS, Kitamura C, Andrade M, Von- Gysel MP. Predictors of quality of life among patients on dialy-

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Trend and seroprevalence of Epstein–Barr virus in Bahrain: 2001–2015 Eman Farid 1,2 and Mohammed Al-Biltagi 2,3

االجتاه العام واالنتشار املصيل لفريوس إبتشباين - بار يف البحرين: 2015-2011 إيمن فريد، حممد البلتاجي اخللصــة :تفتقــر البحريــن إىل املعلومــات الوبائيــة الكافيــة عــن معــدل اإلصابــة بفــريوس EBV، التــي مــن شــأهنا أن تســاعد يف إعــداد تدابــري للحميــة مــن العــدوى بالفــريوس. ولذلــك، يتمثــل اهلــدف مــن هــذه الدراســة يف ّتقــي االجتــاه العــام لعــدوى الفــريوس يف البحريــن خــال فــرة 15 ًعامــا، 2001- . 2015جــرى تقييــم النتائــج املصليــة ملــا جمموعــه 56010 ً مريضــاحيتمــل إصابتهــم بعــدوى فــريوس EBV. وأدرجــت العينــات املأخــوذة يف جممــوع الســلمنية الطبــي خــال الفــرة 2001- . 2015وســجل وجــود أو غيــاب اجللوبيولــن املناعــي G ملســتضدات ُقفيصــات الفــريوس EBV، واجللوبيولــن املناعــي M ملســتضدات ُقفيصــات الفــريوس، وأضــداد اجللوبيولــن املناعــي G للمســتضدات النوويــة للفــريوس EBV. مــن أصــل 56010 عينــة، بلــغ عــدد العينــات القابلــة للســتخدام 33310عينــة. وبلغــت نســبة العينــات اإلجيابيــة للمصــل 7.4 EBV 86.1 % مــع اجتــاه متزايــد للعــدوى بفــريوس خــال فــرة الدراســة. ّوتبــن وجــود عــدوى أوليــة بالفــريوس يف % مــن العينــات اإلجيابيــة للمصــل؛ 50 11 19 5 47.3 منهــا % يف الفئــة العمريــة مــا بــن و ســنة. ّوتبــن عــودة الفــريوس يف % مــن العينــات اإلجيابيــة للمصــل؛ منهــا % يف الفئــة العمريــة األصغــر مــن 25ســنة. وبلــغ عمــر أصغــر مريــض إجيــايب للمصــل 11 ً.شــهرا إن اإلصابــة بعــدوى فــريوس EBVشــائعة يف البحريــن. وحتــدث معظــم حــاالت العــدوى األوليــة يف الفئــة العمريــة مــا بــن ســنة و 5ســنوات يف حــن حتــدث معظــم حــاالت عــودة العــدوى بعــد ســن 25.

ABSTRACT In Bahrain, adequate epidemiological information is lacking concerning the rate of EBV infection, which could be helpful in order to develop measures to protect against EBV infections. The aim of this study, was to investigate the trend of EBV infection in Bahrain over a 15-year period, 2001–2015. The EBV serological results of 10 560 patients with possible EBV infection were evaluated. Samples taken at the Salmaniya Medical Complex ‎during 2001–2015 were included. The presence or absence of EBV viral capsid ‎antigen (VCA) IgG, VCA IgM and EBV nuclear antigen (EBNA) IgG antibodies was recorded. Of the 10 560 samples, ‎10 333 were usable; of these, 86.1% were seropositive with an increasing trend of EBV infection over the study period. Primary ‎EBV infection was found in 7.4% of the seropositive samples; of these, 47.3% were between 5 and 19 years. EBV reactivation ‎was found in 11% of the seropositive samples; of these, 50% were > 25 years of age. The youngest seropositive patient was 11 months old. EBV is a common viral infection in ‎Bahrain. Most primary infections occur between 1 and 5 years ‎while most reactivation infections occur after the age of 25 years. Serial surveillance of EBV infection is needed in Bahrain. Measures to protect against EBV infections should be implemented.

Tendance et séroprévalence du virus d’Epstein Barr à Bahreïn (2001–2015)

RÉSUMÉ À Bahreïn, il n'existe aucune information épidémiologique adéquate sur le taux d’infection par le virus Epstein Barr (EBV). Or, des données dans ce domaine pourraient permettre de mettre au point des mesures de protection contre les infections par EBV. La présente étude avait ainsi pour objectif d’examiner la tendance de l’infection par EBV à Bahreïn sur une période de 15 ans (2001-2015). Les résultats sérologiques de 10 560 patients ayant une infection par EBV suspecte ont été évalués. Les échantillons prélevés au centre médical de Salmaniya entre 2001 et 2015 ont été inclus. La présence ou l’absence des anticorps IgG de l’antigène de la capside virale de l’EBV, IgM de la capside virale, et IgG dirigés contre l’antigène nucléaire de l’EBV (EBNA) a été enregistrée. Sur les 10 560 échantillons, 10 333 étaient utilisables. Sur ce nombre, 86,1 % étaient séropositifs, et montraient une tendance à la hausse des cas d’infection par EBV sur la période couverte par l’étude. Une primo-infection à EBV a été trouvée pour 7,4 % des échantillons, et sur ce chiffre, 47,3 % des sujets avaient entre 5 et 19 ans. La réactivation de l’EBV a été observée dans 11 % des échantillons séropositifs. Sur ce nombre, 50 % des sujets avaient 25 ans ou plus. Le patient séropositif le plus jeune était âgé de 11 mois. L’EBV est une infection courante à Bahreïn. La plupart des infections ont lieu entre l’âge d’un et cinq ans, tandis que les cas de réactivation de l’infection apparaissent après l’âge de 25 ans. La surveillance en série de l'infection par EBV est requise à Bahreïn. Des mesures de protection contre cet type d'iinfection devraient être mises en place.

1Immunology Section, Saylmaniya Medical Center, Manama, Kingdom of Bahrain. 2Arabian Gulf University, Manama, Kingdom of Bahrain. 3Paediatrics Department, Faculty of Medicine, Tanta University, Tanta, Egypt (Correspondence to: Mohammed Al-Biltagi: [email protected]). Received: 25/04/16; accepted: 19/02/17

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Introduction serological diagnosis is important for were retrospectively collected from routine diagnostic laboratories (6). the Laboratory Information System Epstein-Barr virus (EBV) is a The use of only 3 parameters (VCA data and entered in a Microsoft Excel B-lymphotropic human herpesvirus IgG, VCA IgM and EBNA IgG) can database. The data were analysed which is widespread in the world. It can distinguish acute and past infections separately for the trend in EBV cause long-term immune damage and in immunocompetent people. The seropositive and seronegative status. has lifelong latency in the infected host. presence of VCA IgG and VCA IgM Seropositive results were further It is the etiologic agent for a number of in the absence of EBNA IgG indicates categorized into primary EBV infection, autoimmune diseases and malignancies acute infection, while the presence previous infection and reactivation (1). of VCA IgG and EBNA IgG in the infections according VCA IgM and VCA IgG positivity, and the presence or EBV is a globally prevalent virus and absence of VCA IgM is typical of past absence of serum EBVNA IgG. Serum over 90% of the world’s population is infection. However, some cases may EBVNA IgG and VCA IgG < 18 U/mL infected with the virus in adulthood. have different profiles that can create were considered negative, and ≥ 22 U/ Upon infection, the individual remains diagnostic doubts, such as the presence mL were considered positive. VCA IgM a lifelong carrier of the virus and remains of VCA IgG in the absence of VCA was considered negative if < 36 U/m without serious overt consequences IgM and EBNA IgG, the simultaneous and positive if ≥ 44 U/mL. Borderline in most cases. However, in some presence of VCA IgG, VCA IgM and results were considered equivocal and, individuals, the virus is implicated in the EBNA IgG, and the presence of EBNA IgG in the absence of VCA IgG and according to laboratory procedure, they development of malignancy (2). The are repeated after 1 week. Samples were rate and timing of primary infections IgM. In such circumstances, in addition to following up patients to assess any considered seronegative (no previous with EBV differ from one country to changes in the antibody profile, it is exposure) when serum EBVNA IgG, another. For instance, most children also useful to perform other laboratory VCA IgG and VCA IgM were negative in the developing world are infected tests (7). (Figure 1). Positive VCA IgM only, or during childhood, in contrast to most positive VCA IgM and VCA IgG with developed countries where most Baseline information of EBV infection in healthy populations is negative EBNA IgG were considered primary infections occur at a later age, acute primary EBV infection. Positive often in adolescence 3( ). The timing helpful in order to develop measures to protect against EBV infections. In VCA IgM and positive EBNA IgG of primary infection is important as it with or without positive VCA IgG was affects the host differently depending Bahrain, adequate epidemiological information about the rate of EBV considered EBV reactivation (8,9). on when it is acquired. For example, infection is lacking. The aim of this Patients with haemolysed samples or acquisition of primary EBV infection study, therefore, was to investigate the with equivocal results were not included in preadolescents is generally mild. trend of EBV infection in Bahrain over a in the data analysis. Inconclusive results However, acquisition in infancy is a risk 15-year period, 2001-2015. (could not be classified according to factor for later malignancy. The infection Table 1) were also excluded. in infants and children is usually less EBV VCA IgG, VCA IgM and severe than that of adults (4). Methods EBNA IgG antibodies were measured The clinical presentation of EBV by an advanced third-generation infection is challenging as it may be This study was a retrospective analysis of immunoassay system using an Immulite asymptomatic or indistinguishable the national data of both paediatric and 2000 machine (Siemens Healthcare from other mild, short-lived infections. adult patients that had been evaluated GmbH, Germany). Therefore, it is important to use the for the presence of EBV infection for The sex and nationality of the best diagnostic tests with a high degree various reasons in a major tertiary care patients were recorded, and they were of confidence (5). Several serological hospital in Bahrain during the 15-year divided into 6 age groups: < 5 years, tests can be used for diagnosing EBV period 2001-2015. The study included a 5–10 years, 11–15 years, 16–20 years, infections, such as indirect fluorescent total of 10 560 patients aged between 3 21–25 years and > 25 years. The data antibody, rapid monospot tests (for months and 91 years who were referred were analysed separately for the trend heterophile antibodies), and enzyme to the Salmaniya Medical Complex in the seroprevalence over the past 15 immune assay for detection of early (SMC) Laboratory with suspected years using TexaSoft, WINKS SDA antigens, the viral capsid antigens EBV infection. software 2007, 6th edition (Cedar (VCA) and the EBV nuclear antigen On all cases and the type of EBV Hill, Texas, USA). Mean differences (EBNA). Full automation of EBV infections over the past 15 years between subgroups were tested by the

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Student t-test. Comparison between ratios was done using the z-score test. P < 0.05 was considered statistically significant.

Ethical considerations The study was approved by the Ethics Committee of the Salmaniya Medical Center and the Secondary Health Care Research Subcommittee of the Ministry of Health, Bahrain, and was conducted in accordance with the Helsinki Declaration. No consent was obtained as it was a retrospective analysis of laboratory data which were

anonymized. Figure 1 Interpretation of Epstein–Barr virus (EBV) antibody serology (VCA: viral capsid antigens; EBNA: EBV nuclear antigen) Results

The study included 10 560 blood previous infection with EBV. Primary However, the numbers of samples EBV infection represented 40.3% and samples taken over a period of 15 years; without infection, with primary EBV EBV reactivation occurred in 59.7% of 90 samples were rejected because of infections or with reactivation of EBV the active infections. haemolysis or insufficient sample to infection over the study period did not test, and 137 samples gave equivocal Figure 2 shows the trend of EBV increase to the same degree. results. From the remaining 10 333 infection over the 15-year period. The valid samples, 13.9% were negative for number of screened samples increased Primary EBV infection was more EBV, while 6.4% showed primary EBV and consequently the number of common in males (M:F ratio = 1.86), infection, 9.4% showed reactivation the samples with previous infections while EBV infection reactivation was of EBV infection, and 70.3% showed increased from the year 2010 onwards. slightly more common in females (M:F

Table 1 Epstein–Barr virus (EBV) profile in all tested patients, 2001–2015 Year People screened EBV negative Primary infection Past infection Reactivation No. No. (%) No. (%) No. (%) No. (%) 2001 375 38 (10.1) 38 (10.1) 220 (58.7) 79 (21.1) 2002 350 34 (9.7) 30 (8.6) 216 (61.7) 70 (20.0) 2003 355 43 (12.1) 30 (8.5) 213 (60.0) 69 (19.4) 2004 409 46 (11.2) 39 (9.5) 243 (59.4) 81 (19.8) 2005 450 55 (12.2) 23 (5.1) 322 (71.5) 50 (11.1) 2006 577 99 (17.2) 45 (7.8) 314 (54.4) 119 (20.6) 2007 560 128 (22.9) 53 (9.5) 286 (51.0) 93 (16.6) 2008 554 139 (25.1) 45 (8.1) 290 (52.3) 80 (14.4) 2009 568 157 (27.6) 48 (8.5) 297 (52.3) 66 (11.6) 2010 572 135 (23.6) 59 (10.3) 322 (56.3) 56 (9.8) 2011 904 93 (10.3) 45 (5.1) 727 (80.4) 38 (4.2) 2012 1 153 109 (9.4) 40 (3.5) 964 (83.6) 40 (3.5) 2013 1 133 98 (8.6) 49 (4.3) 939 (82.9) 47 (4.1) 2014 1 324 153 (11.6) 67 (5.1) 1053 (79.5) 51 (3.9) 2015 1 054 110 (10.4) 53 (5.0) 856 (81.2) 35 (3.3) Total 10 338 1437 (13.9) 664 (6.4) 7262 (70.2) 974 (9.4)

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1400

1200 Total screened Negative for EBV infection 1000 Primary infection

800 Past infection

Reactivation 600 No. of cases

400

200

Figure 2 Trend of Epstein-Barr virus (EBV) infections in Bahrain: 2001-2015

ratio = 0.96). The majority of patients Bahraini, 87.8% and 81.6% respectively. in Tables 2 and 3 and Figures 3 and with both primary EBV infection The age trends for primary and 4. Overall, primary EBV infection was and reactivation EBV infection were reactivation EBV infections are shown most prevalent in age groups < 5 years

Table 2 Trend in primary Epstein-Barr virus infection from 2001 to 2015 according to age group, male: female ratio and nationality Year Total Age group (years) M:F Bahraini nationality < 5 5- 11- 16- 21- > 25 No. No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) % 2001 38 12 (31.6) 13 (34.2) 4 (10.5) 2 (5.3) 2 (5.3) 5 (13.2) 2.1 90.0 2002 30 5 (16.7) 17 (56.6) 4 (13.3) 1 (3.3) 1 (3.3) 2 (6.7) 2 90.0 2003 30 8 (26.7) 9 (30.0) 4 (13.3) 3 (10) 3 (10) 3 (10) 1.5 90.0 2004 39 18 (46.2) 14 (35.9) 4 (10.3) 1 (2.6) 1 (2.6) 1 (2.6) 3.3 9 7. 4 2005 23 5 (21.7) 10 (43.5) 2 (8.7) 0 2 (8.7) 4 (17.4) 2.3 82.6 2006 45 19 (42.2) 15 (33.3) 3 (6.7) 2 (4.4) 2 (4.4) 4 (8.9) 2.2 95.5 2007 53 21 (39.6) 15 (28.4) 4 (7.5) 4 (7.5) 1 (1.9) 8 (15.1) 1.4 83.0 2008 45 10 (22.2) 21 (46.7) 5 (11.1) 4 (8.9) 2 (4.4) 3 (6.7) 1.9 86.0 2009 48 10 (20.8) 24 (50) 4 (8.3) 3 (6.2) 2 (4.2) 5 (10.4) 1.7 86.0 2010 59 15 (25.4) 30 (50.8) 6 (10.2) 3 (5.1) 3 (5.1) 2 (3.4) 1.6 87.0 2011 45 0 31 (68.9) 8 (17.8) 2 (4.4) 1 (2.2) 3 (6.7) 1.42 84.7 2012 40 0 22 (55) 4 (10) 5 (12.5) 2 (5.0) 7 (17.5) 2.33 80.0 2013 49 6 (12.2) 36 (73.4) 4 (8.2) 1 (2.0) 2 (4.1) 0 1.33 94.0 2014 67 8 (11.9) 42 (62.7) 7 (10.4) 4 (6.0) 5 (7.4) 1 (1.5) 1.91 94.0 2015 53 24 (45.3) 21 (39.6) 5 (9.4) 2 (3.8) 0 1 (1.9) 1.79 7 7. 4 Mean 44.3 10.7 (24.2) 21.3 (47.3) 4.5 (10.4) 2.5 (5.5) 1.9 (4.6) 3.3 (6.2) 1.9 87.8

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Table 3 Trend in reactivation of Epstein-Barr virus infection from 2001 to 2015 according to age group, male: female ratio and nationality Year Total Age group (years) M:F Bahraini nationality < 5 5-10 11-15 16-20 21-25 > 25 No. No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) 2001 79 4 (5.1) 10 (12.7) 4 (5.1) 8 (10.1) 11 (13.9) 42 (53.2) 0.58 84.0 2002 70 3 (4.3) 5 (7.1) 0 6 (8.6) 7 (10) 49 (70) 0.46 83.0 2003 69 1 (1.4) 11 (15.9) 5 (7.2) 5 (7.2) 8 (11.6) 39 (56.5) 0.73 90.0 2004 81 8 (9.9) 9 (11.1) 4 (4.9) 9 (11.1) 12 (14.8) 39 (48.1) 0.95 80.4 2005 50 2 (4) 1 (2) 4 (8.0) 5 (10) 3 (6) 35 (70) 0.92 88 2006 119 3 (2.5) 17 (14.3) 4 (3.4) 16 (13.4) 20 (16.8) 59 (49.6) 1.05 78.1 2007 93 9 (9.7) 12 (12.9) 5 (5.4) 6 (6.5) 14 (15) 47 (50.5) 1.16 81.7 2008 80 4 (5) 11 (13.8) 4 (5) 7 (8.8) 19 (23.8) 35 (43.8) 1.2 75.0 2009 66 5 (7.6) 13 (19.7) 5 (7.6) 4 (6.1) 10 (15.1) 29 (43.9) 1.2 82.0 2010 56 7 (12.5) 11 (19.6) 4 (7.1) 3 (5.4) 6 (10.7) 25 (44.6) 0.9 84.0 2011 38 0 10 (26.3) 2 (5.3) 7 (18.4) 2 (5.3) 17 (44.7) 1.45 68.4 2012 40 0 12 (30) 7 (17.5) 4 (10) 2 (5) 15 (37.5) 1.35 77.5 2013 47 5 (10.6) 16 (34) 5 (10.6) 1 (2.2) 2 (4.3) 18 (38.3) 1.14 93.6 2014 51 7 (13.7) 13 (25.5) 5 (9.8) 1 (2) 8 (15.7) 17 (33.3) 0.76 78.4 2015 35 8 (22.9) 4 (11.4) 3 (8.6) 1 (2.9) 4 (11.4) 15 (42.9) 0.67 80.0 Mean 65 4.4 (6.8) 10.3 (15.8) 4.1 (6.3) 5.5 (8.5) 8.5 (13.1) 32.1 (49.3) 0.97 81.6

and 5–10 years (24.4% and 48.6% was associated with the presence of < 0.01)], and previous infection (134 respectively), while reactivation EBV vitamin D deficiency [75 cases (48.4%, cases (27.8%, P <0.001)]. infection was most prevalent in the age P < 0.01)], chemotherapy use [21 cases Table 4 shows a comparison of group > 25 years (45.3%) followed by (13.5%, P < 0.001)], steroid use [12 primary and reactivation EBV infections the age group 5–10 years (15.9%). The cases (7.7%, P > 0.05)], and previous with regard to sociodemographic youngest recorded case with primary hospitalization due to respiratory tract and clinical data. Significantly more infection was an 11-month-old Bahraini infection (15 cases (9.7%), P < 0.01]. pregnant women had reactivation of boy. Malaria was present in 3 boys (1.9%) a EBV infection than primary infection About 54% of cases with primary few months before reactivation of EBV. (P < 0.001). In addition, a significantly EBV infections occurred after 2008 P( Reactivation of EBV infection in the higher percentage of patients with < 0.01). Reactivation of EBV infection age group over 25 years was associated EBV reactivation had chronic diseases, such as chronic renal diseases, diabetes in the age group between 5 and 10 years with steroid use [95 cases (19.8%, P mellitus, malignancy, autoimmune diseases and chronic infections (tuberculosis, cytomegalovirus co- infection and HIV) than patients with primary infection. As regards clinical 7% 6%5% 24% < 5 yrs presentation, significantly more patients 10% 5-10 yrs with primary infection presented > 10-15 with lymphadenopathy, pharyngitis, 48% organomegaly and prolonged fever > 15-20 yrs than patients with reactivation of EBV > 20-25 yrs infection. On the other hand, abdominal > 25 yrs pain was significantly less common in primary infection than in reactivation Figure 3 Age distribution of patients with primary Epstein-Barr virus infection of EBV infection. The duration of EBV infection-related hospitalization was

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the age group 6–12 years with a higher 7% < 5 yrs 16% prevalence in those aged 12–19 years, which supported the need for EBV 49% 6% 5-10 yrs vaccination before 12 years of age (12). > 10-15 9% Our study showed a higher incidence > 15-20 yrs 13% of primary EBV infection in males than > 20-25 yrs in females. A Brazilian study reported a higher incidence of EBV-associated > 25 yrs childhood Burkitt lymphoma in male children than female children in south- Figure 4 Age distribution of patients with reactivation Epstein-Barr virus infection eastern Brazil (16). However, in our study the number of females with EBV reactivation infection was greater than significantly longer in patients with participants (12). The increased trend of with primary infection. This increase in primary infection than those with EBV primary EBV infection in Bahrain could reactivation infection among females reactivation. just be due to the increase in population may be due to increased silent primary numbers and hence increased the EBV infections among females. EBV numbers of patients. In addition, the tends to establish latency in the host Discussion ratio of Bahraini to non-Bahraini people as with other herpes viruses. Primary dropped from an average of 89% each infection leads to transitional viraemia, Primary EBV infection is often year in the first 9 years to an average followed by a strong T-cell adaptive asymptomatic but may result in lifelong of 86% in the following 6 years, which immune response, which keeps the infection, the course of which depends indicates a relative increase in the infection latent in immunocompetent on the host immune system. In some number of expatriates, which could be a individuals (17). cases, primary infection can result in reason. The reasons behind the increase The higher rate of EBV infection infectious mononucleosis (10). In our in primary EBV infection in Bahrain among Bahrainis than non-Bahrainis study, 86% of the tested patients were need be addressed. could be related to the relative increase positive for EBV infection. There was a A Malaysian study in 1987 showed in the number of the Bahraini citizens striking increase in the rate of primary that all the children had acquired primary and the easier access of Bahrainis to infection in children between 5 and 10 infection by the age of 8 years (13). This government medical facilities than non- years over the 15-year duration of the EBV infection in early life explained the Bahrainis. However, a study conducted study together with a relative increase in absence of infectious mononucleosis in the USA showed different prevalence the primary infection rate among males in the Malaysian population (13). A rates in different races; the prevalence than females. study in Espírito Santo, Brazil showed of primary EBV infection was more The prevalence and age distribution a higher prevalence of EBV antibodies common in non-Hispanic black children of this latent virus infection varies in in children and adolescents, with (74%), followed by Asian children different populations. In our study, more frequent infections occurring (62%), then multiracial children (54%), the trend of primary EBV infection in at a younger age in children from Hispanics (50%), and non-Hispanic Bahrain increased, especially during families of low socioeconomic status white children (26%). This marked the period 2010 to 2015. This was (14). Another study in the Islamic ethnicity variability of EBV prevalence also observed in Taiwan where the Republic of Iran between 2007 and could be explained by differences in prevalence of primary EBV infection 2011 showed that 91.5% of primary demographic and socioeconomic status increased with a seropositive rate > 50% EBV infections occurred by the age of of families, including education and at the age of 2 years, > 80% at the age of 10 years compared with 72.4% in our health care availability (18). However, 5–9 years and > 90% at age 10 years and study (15). However, a study in the socioeconomic position and factors above (11). This is in contrast with the USA found that about 50% of primary related to lifestyle explain only a part situation in the United States of America EBV infection in American children of the large ethnic differences in EBV (USA), where the EBV antibody occurred between 6 and 8 years of age seroprevalence (19). prevalence declined in individuals (12). The study was concerned with Unknown triggers can cause aged 6-19 years from 2003/2004 to antibody prevalence in Americans reactivation of EBV infection due to 2009/2010, mainly because of a aged 6–19 years from 2003 to 2010. stimulation of latently infected B cells. decrease among non-Hispanic white It showed a decreased prevalence in The virus can re-infect new B cells and

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Table 4 Comparison of primary and reactivation Epstein–Barr virus (EBV) infection over 15 years (2001 to 2015) according to sociodemographic and clinical data Variable Primary EBV infection Reactivation of EBV P-value (n = 664) infection (n = 974) (z -test) No. (%) No. (%) Age (years) < 5 161 (24.2) 66 (6.8) < 0.0001 5–10 320 (48.2) 155 (15.9) < 0.0001 11–15 68 (10.2) 61 (6.3) < 0.01 16–20 37 (5.57) 83 (8.5) < 0.05 21–25 29 (4.3) 128 (13.1) < 0.0001 > 25 49 (7.4) 481 (49.3) < 0.0001 Sex Male 435 (65.5) 481(49.4) < 0.0001 Female 229 (34.5) 493 (50.6) < 0.0001 Nationality Bahraini 583 (87.8) 796 (81.6) < 0.001 Non-Bahraini 81 (12.2) 178 (18.3) < 0.001 Pregnant women 20 (3.0) 69 (7.1) <0.001 History of chronic renal diseases 13 (2.0) 68 (7.0) <0.0001 History of diabetes mellitus 20 (3.0) 107 (11.0) <0.001 History of malignancy 7 (1.1) 49 (5.0) <0.0001 Associated chronic infection Tuberculosis 20 (3.0) 68 (7.0) < 0.001 Cytomegalovirus 73 (11.0) 263 (27.0) < 0.001 HIV 4 (0.6) 36 (3.7) < 0.001 Autoimmune diseases 13 (2) 64 (6.6) < 0.001 Clinical presentation Fever 611 (92.0) 828 (84.9) < 0.001 Duration of fever (weeks) > 1 230 (37.6) 300 (36.2) 0.3 < 1 381 (62.4) 528 (63.8) 0.4 Mean (SD) 7.2 (3.4) 6.4 (3.5) < 0.0001 Abdominal pain 299 (45.0) 536 (55.0) < 0.0001 Rash 126 (19.0) 69 (17.1) 0.3 Pharyngitis 598 (90.0) 819 (84.0) < 0.001 Lymphadenopathy 358 (53.9) 224 (23.0) < 0.0001 Organomegaly 212 (31.9) 243 (24.9) < 0.01 Laboratory data Erythrocyte sedimentation rate > 20 mm in first hour 412 (62.0) 624 (64.0) 0.4 C-reactive protein > 6 (mg/L) 359 (54.1) 692 (71.0) < 0.0001 White blood cell count (109/L) [mean (SD)] 12.4 (7.9) 10.1 (4.7) < 0.0001 Haemoglobin (g/L) [mean (SD)] 11.0 (1.2) 11.9 (3.7) < 0.0001 Platelet count (109/L) [mean (SD)] 256.7 (135.4) 294.5 (151.7) < 0.0001 Rate of hospitalization 64 (9.6) 44 (4.5) <0.0001 Duration of hospitalization, if any (weeks) > 1 30 (4.5) 20 (2.1) < 0.01 < 1 34 (5.1) 24 (2.5) < 0.01 Mean duration (SD) 7.1 (3.5) 5.2 (2.1) < 0.0001

SD = standard deviation.

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epithelial cells, becoming a source of in immunocompromised patients (24). infectious mononucleosis, such as the viral transmission initiating reactivated There were 3 cases of malaria infection male offspring of X-linked proliferative EBV infection (10). In our study, preceding reactivation of EBV in our syndrome carriers (27). reactivation was reported in 9.4% of the study. Malaria infection profoundly Our study had some limitations. total sample and 11.0% of the positive affects the B cell compartment, Being a retrospective study is a major samples compared with 6.4% and inducing polyclonal activation and limitation with inferior level of evidence 7.4% respectively with primary EBV hypergammaglobulinaemia. The compared with prospective studies. infections. Of the 1634 active infections, cystein-rich inter-domain region 1alpha The absence of available clinical data 40.3% were primary EBV infection and (CIDR1alpha) of the Plasmodium constitutes a clear limitation when 59.7% were EBV reactivation. The most falciparum membrane protein 1 acts attempting to compare our results with common age group for reactivation as a polyclonal B cell activator that the results of similar studies. Clinical was over 25 years followed by the preferentially activates the memory data are important to relate the EBV ages 5-10 years. In the 5-10 years age compartment, where EBV is known to infection positivity with clinical severity. group, vitamin D deficiency was found persist (25). At the same time, the difference in nearly half of the cases. Vitamin D At the same time, about 50% of the between the methods used in our study deficiency may increase the risk of EBV reactivation occurred after the compared with other studies made it certain viral infections, while it has been age of 25 years with nearly equal male difficult to compare results. We also shown to have some direct antiviral to female ratio. In a study by Nystad did not correlate EBV prevalence with effects (20). Chemotherapy use was and Myrmel, 42% of 43 patients with HLA typing and did not correlate EBV associated with EBV reactivation in suspected primary EBV infection had reactivation with the EBV viral DNA 13.5% of those aged 5-10 years. Certain late primary infection, while 49% had load. HLA typing could help to stratify chemotherapeutic drugs, including high-avidity IgG-antibodies, indicating the patients at risk of infection and gemcitabine, doxorubicin, cis-platinum an IgM response due to reactivation, even complications of EBV infection. and 5-fluorouracil, have been reported which agrees with our results (4). EBV to induce the lytic form of EBV infection High EBV viral loads are strongly reactivation essentially occurs in clinical in latently infected host cells and hence associated with current or impending situations associated with chronic EBV reactivation (21). At the same lymphoproliferative disorder. immunosuppression secondary to time, the use of steroids was associated systemic disease, viral superinfection with EBV reactivation in 7.7% of cases Conclusion of reactivation. Steroids are a common or specific treatments, as in the case of organ or bone marrow transplantation cause of EBV reactivation from latency, EBV is a common viral infection in the possibly directly by promoting viral (26). hospital setting in Bahrain, occurring in replication or alternatively by down- The importance of determining childhood as early as 1 year of age with regulating the ability of the memory the epidemiological status of EBV a high seroprevalence. The majority T-cell response to control the latent infection in the country is to estimate of primary infections occur in the age virus (22). Previous hospitalization the magnitude of the problem and range 1-5 years while most reactivation due to respiratory tract infection to help to decide the need for an infections occur after the age of 25 years. was reported in 9.7% of reactivation EBV vaccine. A vaccine against EBV The effect of these epidemiological cases. Hospitalization itself is a form would help to prevent primary EBV of stress, which in turn could stimulate infection and consequently EBV- findings on the prevalence of certain reactivation of herpesviruses including related malignancies. Such a vaccine diseases in Bahrain, mainly infectious EBV (23). A strong relation was found is still in clinical trials and must be mononucleosis, Burkitt lymphoma, in a study between cytomegalovirus given early in life before the peak of Hodgkin disease, nasopharyngeal super-infection and EBV reactivation seroconversion (as in our study) before carcinoma and B-cell lymphoma, needs leading the authors to suggest that the age of 5 years. It would also be to be explored. cytomegalovirus might be an important useful in seronegative organ transplant Funding: None. co-factor in EBV pathogenesis, especially recipients and those developing severe Competing interests: None declared.

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1. Goncharova EV, Senyuta NB, Smirnova KV, Shcherbak LN, 15. Moeini M, Ziyaeyan M, Asaei S, Behzadi MA. The incidence Gurtsevich VE. [Epstein-Barr virus (EBV) in Russia: infection of of epstein-barr virus primary infection among suspected the population and analysis of the LMP1 gene variants in patients patients referred to namazi hospital of shiraz, iran. Jundishapur with EBV-associated pathologies and healthy individuals]. J Microbiol. 2015 Apr 18;8(4):e16109. doi: 10.5812/ Vopr Virusol. 2015;60(2):11-7 [In Russian]. PMID:26182651 jjm.8(4)2015.16109. eCollection 2015. PMID: 26034534 2. Chijioke O1, Azzi T, Nadal D, Münz C. Innate immune 16. Hassan R, Klumb CE, Felisbino FE, Guiretti DM, White LR, responses against Epstein Barr virus infection. J Leukoc Biol. Stefanoff CG, et al. Clinical and demographic characteristics 2013 Dec;94(6):1185-90. doi: 10.1189/jlb.0313173. PMID: of Epstein-Barr virus-associated childhood Burkitt’s lymphoma 23812328 in Southeastern Brazil: epidemiological insights from an 3. Jayasooriya S, de Silva TI, Njie-jobe J, Sanyang C, Leese AM, intermediate risk region. Haematologica. 2008 May;93(5):780- Bell AI, et al. Early virological and immunological events in 3. 10.3324/haematol.12424 PMID:18367488 asymptomatic Epstein-Barr virus infection in African children. 17. Petrova M, Kamburov V. Epstein-Barr virus: silent companion PLoS Pathog. 2015 Mar 27;11(3):e1004746. doi: 10.1371/journal. or causative agent of chronic liver disease? World J ppat.1004746. eCollection 2015. PMID: 25816224 Gastroenterol. 2010 Sep 7;16(33):4130-4. 10.3748/wjg.v16. 4. Nystad TW, Myrmel H. Prevalence of primary versus reactivated i33.4130 PMID:20806428 Epstein-Barr virus infection in patients with VCA IgG-, VCA 18. Condon LM, Cederberg LE, Rabinovitch MD, Liebo RV, Go JC, IgM- and EBNA-1-antibodies and suspected infectious Delaney AS, et al. Age-specific prevalence of Epstein-Barr virus mononucleosis. J Clin Virol. 2007 Apr;38(4):292-7. 10.1016/j. infection among Minnesota children: effects of race/ethnicity jcv.2007.01.006 PMID:17336144 and family environment. Clin Infect Dis. 2014 Aug 15;59(4):501- 5. Pariente M, Bartolomé J, Lorente S, Crespo MD. Distribución 8. 10.1093/cid/ciu342 PMID:24820696 por edad de los patrones serológicos de infección por el 19. Jansen MA, van den Heuvel D, Bouthoorn SH, Jaddoe VW, virus de Epstein-Barr: revisión de resultados de un laboratorio Hooijkaas H, Raat H, et al. Determinants of Ethnic Differences de diagnóstico [Age distribution of serological profiles of in Cytomegalovirus, Epstein-Barr Virus, and Herpes Simplex Epstein-Barr virus infection: review of results from a diagnostic Virus Type 1 Seroprevalence in Childhood. J Pediatr. 2016 laboratory]. Enferm Infecc Microbiol Clin. 2007 Feb;25(2):108- Mar;170:126-34.e1-6. doi: 10.1016/j.jpeds.2015.11.014. PMID: 10. PMID:17288908 26707579 6. Koidl C, Riedl R, Schweighofer B, Fett S, Bozic M, Marth E. 20. Beard JA, Bearden A, Striker R. Vitamin D and the anti-viral state. Performance of new enzyme-linked fluorescent assays for J Clin Virol. 2011 Mar;50(3):194-200. 10.1016/j.jcv.2010.12.006 detection of Epstein-Barr virus specific antibodies in routine PMID:21242105 diagnostics. Wien Klin Wochenschr. 2011 Apr;123(7-8):230-4. 21. Feng WH, Cohen JI, Fischer S, Li L, Sneller M, Goldbach- 10.1007/s00508-011-1561-z PMID:21451951 Mansky R, et al. Reactivation of latent Epstein-Barr virus by 7. De Paschale M, Clerici.P. Serological diagnosis of Epstein-Barr methotrexate: a potential contributor to methotrexate- virus infection: Problems and solutions. World J Virol. 2012 Feb associated lymphomas. J Natl Cancer Inst. 2004 Nov 12;1(1):31-43. doi: 10.5501/wjv.v1.i1.31. PMID: 24175209 17;96(22):1691-702. 10.1093/jnci/djh313 PMID:15547182 8. De Paschale M, Clerici P. Serological diagnosis of Epstein-Barr 22. Cacopardo B1, Nunnari G, Mughini MT, Tosto S, Benanti F, virus infection: Problems and solutions. World J Virol. 2012 Feb Nigro L. Fatal hepatitis during Epstein-Barr virus reactivation. 12;1(1):31-43. 10.5501/wjv.v1.i1.31 PMID:24175209 Eur Rev Med Pharmacol Sci. 2003 Jul-Aug;7(4):107-9. PMID: 9. De Paschale M, Agrappi C, Manco MT, Mirri P, Viganò EF, 15068233 Clerici P. Seroepidemiology of EBV and interpretation of the 23. Coskun O, Sener K, Kilic S, Erdem H, Yaman H, Besirbellioglu “isolated VCA IgG” pattern. J Med Virol. 2009 Feb;81(2):325-31. AB, et al. Stress-related Epstein-Barr virus reactivation. Clin 10.1002/jmv.21373 PMID:19107979 Exp Med. 2010 Mar;10(1):15-20. 10.1007/s10238-009-0063-z 10. Odumade OA, Hogquist KA, Balfour HH Jr. Progress and PMID:19779966 problems in understanding and managing primary Epstein-Barr 24. Loutfy SA, Abo-Shadi MA, Fawzy M, El-Wakil M, Metwally SA, virus infections. Clin Microbiol Rev. 2011 Jan;24(1):193-209. Moneer MM, et al. Epstein-Barr virus and cytomegalovirus 10.1128/CMR.00044-10 PMID:21233512 infections and their clinical relevance in Egyptian leukemic 11. Chen C-Y, Shen J-H, Huang Y-C. P294 seroepidemiology pediatric patients. Virol J. 2017 Mar 6;14(1):46. doi: 10.1186/ of Epstein–Barr virus and herpes simplex virus-1 in Taiwan. s12985-017-0715-7. PMID: 28264674 Int J Antimicrob Ag, 2013; June; 42:S135·10.1016/S0924- 25. Chêne A, Donati D, Guerreiro-Cacais AO, Levitsky V, Chen Q, 8579(13)70535-1 Falk KI, et al. A molecular link between malaria and Epstein-Barr 12. Balfour HH Jr, Sifakis F, Sliman JA, Knight JA, Schmeling DO, virus reactivation. PLoS Pathog. 2007 Jun;3(6):e80. 10.1371/ Thomas W. Age-specific prevalence of Epstein-Barr virus journal.ppat.0030080 PMID:17559303 infection among individuals aged 6-19 years in the United 26. Keymeulen B, Candon S, Fafi-Kremer S, Ziegler A, Leruez-Ville States and factors affecting its acquisition. J Infect Dis. 2013 Oct M, Mathieu C, et al. Transient Epstein-Barr virus reactivation 15;208(8):1286-93. 10.1093/infdis/jit321 PMID:23868878 in CD3 monoclonal antibody-treated patients. Blood. 13. Yadav MS, Malliga N, Ablashi DV. Development of immunity to 2010 Feb 11;115(6):1145-55. 10.1182/blood-2009-02-204875 Epstein-Barr virus in Malaysian children. Microbiologica. 1987 PMID:20007541 Jan;10(1):29-35. PMID:3033449 27. Cohen JI, Mocarski ES, Raab-Traub N, Corey L, Nabel GJ. The 14. Figueira-Silva CM, Pereira FE. Prevalence of Epstein-Barr virus need and challenges for development of an Epstein-Barr virus antibodies in healthy children and adolescents in Vitória, State vaccine. Vaccine. 2013 Apr 18;31 Suppl 2:B194-6. 10.1016/j. of Espírito Santo, Brazil. Rev Soc Bras Med Trop. 2004 Sep- vaccine.2012.09.041 PMID:23598481 Oct;37(5):409-12. PMID:15361959

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Investigation of breastfeeding training based on BASNEF model on the intensity of postpartum blues Marzieh Akbarzadeh 1, Sima Kiani Rad 2, Marzieh Moattari 3 and Najaf Zare 4

ّ تقصأثر التدريب عىل الرضاعة الطبيعية - ً استناداإىل نموذج باسنف - عىل شدة الكآبة النفاسية مرضيه اكب زاده، سيم كياين راد، مرضيه معطري، نجف زارع اخللصــة: متثــل الكآبــة النفاســية أحــد أكــر عوامــل اخلطــر حلــدوث اكتئــاب مــا بعــد الــوالدة وانقطــاع الرضاعــة الطبيعيــة. وعمــدت هــذه الدراســة شــبه التجريبيــة إىل تقــي أثــر التدريــب عــى الرضاعــة الطبيعيــة - ً اســتناداإىل نمــوذج باســنف عــى شــدة الكآبــة النفاســية. ُوعقــدت أربــع جلســات تثقيفيــة منفصلة - ً إىلاســتنادا نمــوذج باســنف- لنســاءحوامــل وأمهاهتــنومحواهتــن وأزواجهــن. ّوتلقــت املجموعــة الضابطــة رعايــة روتينيــة يف العيــادة. وبعــد الوضــع، تــم تقييــم معلومــات النســاء بالكآبــة النفاســية واجتاهاهتــن نحوهــا باســتخدام مقيــاس زونــج للتصنيــف الــذايت للكتئــاب. ّوتبــن وجــود اختلفــات كبــرية بــن املجموعــات مــن حيــث متوســط درجــات املعرفــة وتقييــم األمهــات للمخرجــات الســلوكية واالجتاهــات والعوامــل التمكينيــة. كــا جاء متوســط درجــة الكآبة النفاســية أقــل بكثــ يفري املجموعــة التجريبيــة مقارنــة باملجموعــة الضابطــة. ًختامــا، ّ تبــنأن التدريــب القائــم عــىنمــوذح باســنف لــهأثــر إجيايب عــى معلومات األمهــات واجتاهاهتــنوبالتــايل شــدة االكتئــاب. ويتعــن إجــراء مزيــد مــن الدراســات لتحديــد مــدى موثوقيــة هــذه الطريقــة وفعاليتهــا.

ABSTRACT Postpartum blues is a major risk factor for the incidence of postpartum depression and disruption of breastfeeding. This semi-experimental study investigated the effect of breastfeeding training based on the BASNEF model on severity of postpartum blues in 2012. Four educational sessions based on the BASNEF model were held separately for pregnant women and their mothers, mothers-in-law and spouses. The control group received routine care at the clinic. After delivery, women’s knowledge of and attitude towards postpartum blues were evaluated using the Zung Self- Rating Depression Scale. There were significant differences between the groups regarding mean scores of knowledge, mothers’ evaluation of behaviour outcomes, attitude, and enabling factors. Also, the mean score for postpartum blues was significantly lower in the intervention group compared to the control group. In conclusion, training based on the BASNEF model had a positive effect on maternal knowledge and attitude and, consequently, the intensity of postpartum blues. Further studies are required to determine the reliability and effectiveness of this method.

Étude de l'impact d’une formation sur l’allaitement reposant sur le modèle BASNEF en matière d’intensité du baby blues

RÉSUMÉ Le baby blues constitue un facteur de risque majeur pour l’incidence de la dépression postpartum et de l’arrêt de l’allaitement au sein. La présente étude semi-expérimentale menée en 2012 avait pour objectif d’examiner l’influence d’une formation sur l’allaitement reposant sur le modèle BASNEF (modèle d’évaluation des croyances, des attitudes, des normes subjectives et des facteurs favorables) en matière de gravité du baby blues. Quatre sessions éducatives reposant sur le modèle BASNEF ont été organisées séparément pour les femmes enceintes et leurs mères, leurs belles-mères et leurs époux. Le groupe témoin a bénéficié de soins de routine à la clinique. Après l’accouchement, les connaissances et l’attitude des femmes en matière de baby blues ont été évaluées sur la base de l’échelle d'autoévaluation de la dépression de Zung. Des différences significatives ont été observées entre les groupes concernant les scores moyens portant sur les connaissances, l’évaluation des conséquences comportementales par les mères, leur attitude et les facteurs favorables. De même, le score moyen pour le baby blues était significativement moins élevé dans le groupe d’intervention que dans le groupe témoin. En conclusion, on peut dire que la formation reposant sur le modèle BASNEF a eu une influence positive sur les connaissances, les attitudes, et par conséquent l’intensité du baby blues des mères. D’autres études sont nécessaires afin de déterminer la fiabilité et l’efficacité de cette méthode.

1Maternal–fetal Medicine Research Centre, Department of Midwifery, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran (Correspondence to: A. Marzieh: [email protected]); 2Research Centre for Health Sciences, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran; 3Community Based Psychiatric Care Research Center, School of Nursing & Midwifery, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran; 4Department of Biostatistics, Infertility Research Centre, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran Received: 02/07/15; accepted: 23/01/17

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Introduction restlessness, weakness in concentration, women referred to gynaecology clinics anxiety, irritability and anger (7). On of the selected hospitals affiliated to Shi- Exclusive breastfeeding in the first 6 average, 50% (15.3–85%) of mothers raz University of Medical Sciences. The months of life has been recommended experience postpartum blues in the 1st inclusion criteria were: primiparity, no by many organizations, such as World week after delivery (8). However, lack of complications, gestational age 36–41 Health Organization (WHO) and diagnostic criteria and different research weeks, age 18–35 years, at least sec- American College of Obstetricians and methods have led to different preva- ondary school education, no serious Gynecologists (1). lence rates of postpartum blues (9). physical or mental disorders during Many factors affect the decision The postpartum period has the greatest the study, living in Shiraz, intending to to start and continue breastfeeding. probability for incidence of mood dis- breastfeed their infants, and willingness Continuation of breastfeeding can be orders, such as sadness, depression and to participate in the study. A sample encouraged by cultural, social and po- psychosis, which have negative effects size of 100 was determined based on litical factors, mass media, accessibility on women’s physical and mental health, previous results (α = 0.05, β = 0.2, P = of health services, social and health staff and consequently, their quality of life 0.8). One hundred pregnant women support (2), traditions, local beliefs and (10,11). were selected by purposive sampling familial factors (3). There is evidence of a significant de- and randomly divided into a control (n = 50) and an intervention (n = 50) Different educational programmes crease in postpartum depression up to 3 group using a table of random numbers. have been considered to increase ma- months after birth among women who exclusively breastfeed their infants for ternal interest and ability in breastfeed- Interventions ≥ 3 months ( ). In contrast, mothers ing. To achieve successful behavioural 12 who do not begin or continue breast- After selection of the mothers and change, the healthcare team should be feeding are more prone to depression completion of the demographic ques- aware of the effective factors in behav- after delivery. Also, mothers who experi- tionnaires, 4 educational intervention iour formation. The BASNEF model ence depression after delivery are less sessions of 90 minutes based on the is one of the comprehensive models interested in beginning and continuing BASNEF model were held for the used for identification of individuals with breastfeeding. Postpartum depres- mothers once weekly. These sessions changing behaviour (4). This model sion may occur following disruption included the advantages of breastfeed- focuses on the effect of knowledge, at- of breastfeeding (13). Nonpharmaco- ing; correct breastfeeding technique; titude and personal skills on behaviour logical methods are among the most role of breastfeeding in maternal health; change and is appropriate for use in effective ways of coping with stress and effect of breast milk on improvement of developing countries. The BASNEF depression. Breastfeeding may improve children’s physical and mental health; model comprises beliefs, attitude, sub- the quality of the maternal–infant rela- signs of sufficiency of milk such as -in jective norms and enabling factors (5). tionship, develop safe attachment at the fant weight gain, frequency of urination, Generally, individuals change their be- beginning of infancy, and provide a basis sleeping comfortably after breastfeed- haviour if they believe that it has health for reducing maternal stress. Therefore, ing; milking and storage techniques; and economic benefits. A combination the present study aimed to determine consultation with mothers and their of attitudes towards the behaviour and the effect of breastfeeding training based acquaintances regarding breastfeeding; subjective norms results in deciding on the BASNEF model on postpartum and effect of continuation of exclusive upon behaviour change (behavioural blues in women referred to gynaecology breastfeeding on children’s develop- intention). In this way, the messages clinics affiliated to Shiraz University of mental–physical indexes. These ses- affecting the individual’s knowledge and Medical Sciences, Islamic Republic of sions were presented through lectures, how they influence behavioural change Iran in 2012. group discussion, role play, educational are determined. Overall, this approach pictures, question and answer sessions, aims at identification of the factors that pamphlets and DVDs. An educational enable behavioural change (6). Methods pamphlet and a CD were also given to Postpartum blues is a transient phe- the mothers. In addition, 3 educational nomenon involving mood changes that Study population sessions were held separately for 20 may occur within the first few days after This semi-experimental study investi- mothers, 14 mothers-in-law and 19 delivery. This phenomenon is accom- gated the effect of breastfeeding training husbands. Both groups completed the panied by unstable mood fluctuating based on the BASNEF model on the se- BASNEF questionnaire before and between happiness and sadness, exces- verity of postpartum blues in 2012. The immediately, 1 month and 3 months sive sensitivity, crying without reason, study population included pregnant after the intervention. The mothers

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also completed the Zung Self-Rating Zung Self-Rating Depression to mothers in the last training session Depression Scale after the intervention. Scale and the first postpartum visit. Three months after giving birth, The Zung Self-Rating Depression Scale Data analysis mothers were invited by telephone to was published in 1965 and its reliability and validity have been confirmed in All data analyses were performed using the nearest clinic for evaluation of BAS- SPSS version 16 statistical software and various studies worldwide (15,16). This NEF model parameters. If mothers did analysed using independent t tests. The scale consists of 20 items measuring not attend on time, they were invited a significance level of α was 0.05. second time by telephone. different aspects of depression, scored from 1 to 4. In the present study, women Ethical considerations BASNEF questionnaire were required to mark the sentences that This research project was approved The reliability and validity of the BAS- best described their feelings during the by the local Ethics Committee of previous 2 weeks. The scores increased NEF questionnaire have been con- Shiraz University of Medical Sciences from left to right for positive feelings, firmed previously 14( ), and Cronbach’s (Proposal No. 91-4605) and written but from right to left for negative ones. informed consent was obtained from all α coefficients were the basis of the Scores < 50, 50–59, 60–69, and > 70 the participants. present study. In order to determine the represented normal mood without psy- reliability of the questionnaire, a pilot chopathology, mild to average depres- study was conducted on 20 individuals sion, average to severe depression, and Results and Cronbach’s α coefficients of 0.81, severe depression, respectively (17). 0.9, 0.78, 0.82 and 0.91 were obtained The mean age of the mothers was 23.86 The reliability of this scale was assessed (standard deviation 4.30) years in the for beliefs, attitudes, subjective norms by Khanjani et al. in the Islamic Repub- intervention group and 24.4 (4.18) and enabling factors, respectively. The lic of Iran using a test–retest method years in the control group. The age range BASNEF questionnaire was completed with a 15-day interval and a value of for the 2 groups was 18–34 years. Before by both groups before and immediately, 0.92 was obtained (18), which was the the intervention, no significant differ- 1 month and 3 months after the inter- basis of the current study. The Zhung ence was found between the 2 groups ventions. Self-Rating Depression Scale was given regarding age (P = 0.786), education

Table 1 Comparison of mean scores of knowledge, evaluation of behavioural outcomes, attitude towards behaviour, enabling factors before and immediately and 1 and 3 months after educational intervention Variables Groups Before After After 1 month 1 month 3 months intervention intervention intervention later later later Mean (SD) Mean (SD) Mean (SD) Knowledge Intervention 58.1 (14.4) 97.2 (4.3) 97.2 (4.3) 94.1 (5.1) 94.1 (5.1) 91.8 (6.5) P < 0.001 < 0.001 < 0.001 Control 55.7 (14.4) 61.1 (14.0) 61.1 (14) 58.1 (14.3) 58.1 (14.3) 57.4 (14.7) P 0.063 0.09 0.16 Evaluation of Intervention 64.8 (22) 97.2 (8.1) 97.2 (8.1) 88.4 (21) 88.4 (21) 90 (21.5) behavioural P < 0.001 0.004 0.399 outcomes Control 63.6 (13.2) 64.4 (13.6) 64.4 (13.6) 62.8 (22.5) 62.8 (22.5) 80.4 (24.4) P 0.159 0.598 < 0.001 Attitude Intervention 3.1 (0.4) 3.3 (0.4) 3.3 (0.4) 3.3 (0.3) 3.3 (0.3) 3.3 (0.3) towards the P < 0.001 0.380 0.5 behaviour Control 3.1 (0.42) 3.09 (0.4) 3.1(0.4) 3.1 (0.4) 3.1 (0.3) 3.04 (0.3) P 0.827 0.601 0.04 Enabling Intervention 31.2 (23.3) 96.3 (7.5) 96.3 (7.5) 94 (8.7) 94 (8.7) 95.2 (8.0) Factors P < 0.001 0.018 0.159 Control 30.9 (21) 35.6 (20.6) 35. 6 (20.6) 39.1 (19.8) 39.1 (19.8) 41 (20.4) P 0.019 0.003 0.013

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level (P = 0.852), and occupation (P = regarding the mean score of knowl- attitude is expressing one’s opinions and 0.952). edge about breastfeeding immediately watching others’ reactions. . There was no significant difference after intervention. This implied the -ef In the current study, the mean score in the control group’s mean scores of fectiveness of educational interven- of the intervention group’s evaluation knowledge immediately, 1 month and tion based on the BASNEF model on of behaviour outcomes immediately, 1 3 months after intervention (Table 1). increasing maternal knowledge, which month and 3 months after intervention For mean scores of evaluation of is consistent with other studies using the showed that the differences remained behaviour outcomes in the intervention BASNEF model (19). Also, the results significant over time. This result was group, there was a significant difference immediately, 1 month and 3 months similar to that of another study conduct- before and immediately after interven- after intervention indicated that the dif- ed on breastfeeding using the BASNEF tion, immediately and 1 month after ference remained significant over time. model (14). intervention, and 1 and 3 months after Similarly, Matvienko et al. showed that Our findings revealed a significant intervention (Table 1). In the control a 6-month educational intervention difference between the 2 groups regard- group, there was only a significant dif- improved the participants’ knowledge ing the mean score of enabling factors. ference between 1 and 3 months after level and prevented them from weight This might have resulted from acces- intervention. gain (20). The study also showed a sibility of the enabling factors, such as pamphlets, educational materials and The mean scores of attitude in the significant difference between the CDs, the researcher’s phone number intervention group were significantly intervention and control groups with and electric breast pumps (24). In a pre- different before and immediately after respect to the change in knowledge. An- vious study by Shakespeare et al., moth- intervention (Table 1). However, no other study was performed on maternal ers mentioned lack of access to health significant difference was found imme- knowledge and attitude towards breast- staff as a major problem in continuation diately and 1 month after intervention, feeding in Isfahan, Islamic Republic of Iran in 2008, which showed that the in- of breastfeeding (25). Furthermore, and 1 and 3 months after intervention. Laveist et al. proposed that the enabling In the control group, there was only a tervention and control groups differed significantly regarding knowledge but factors were more important than cul- significant difference between 1 and 3 tural and behavioural differences for months after intervention. not attitude (21). However, our current results were not in agreement with those changing behaviour (26). Similarly, a The mean scores of enabling factors obtained by Young et al. in a study of study in England demonstrated that in the intervention group were signifi- husbands’ support, acceptance of health education (22). Those two stud- cantly different before and immediately breastfeeding as a social norm, friends’ ies indicated no significant difference after intervention, and immediately and support, and taking part in educational between the intervention and control 1 month after intervention (Table 1). classes before and after delivery were groups with regards to knowledge and However, there was no significant dif- among the key factors for beginning attitude. The difference between those ference between 1 and 3 months after and continuation of breastfeeding (27). and our studies might have been due intervention. In contrast, the control Therefore, it is suggested that individu- group’s mean scores of enabling factors to the lack of any related models or als who are in close contact with the were significantly different before and theories in the design and execution mothers, such as grandmothers, sisters immediately after intervention, imme- of the educational programme, as well and husbands, can pass on their experi- diately and 1 month after intervention, as to the cultural and time differences ences and encourage breastfeeding. In and 1 and 3 months after intervention. between the studies. the present study, the control group’s The mean score of postpartum blues In our study, the intervention mean score for enabling factors was was significantly lower in the interven- group’s attitude towards breastfeeding also significantly different before and tion group [31.36 (7.98)] compared to improved and continued in the follow- after intervention, which indicates the the control group [37.61 (12.15)] after up period. Generally, attitude is not effectiveness of the healthcare staff in intervention (t = 3.005, P = 0.004). fixed and positive experiences can direct provision of training. Moreland and the individuals toward maintenance Coombs also emphasized the role of and improvement of positive attitudes family physicians and the healthcare Discussion (23). However, Charkazi et al. reported team in the success of breastfeeding no significant change in attitude (21). It (28). The results of the present study demon- should be noted that training is not suf- We revealed no significant differ- strated a significant difference between ficient for changing individual attitudes. ence between the intervention group’s the intervention and control groups One appropriate method for changing mean scores for subjective norms

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regarding husbands, mothers-in-law in multiparous women (33). Watkins which was to some extent eliminated by and friends before and after inter- et al. reported that women who had group training, reviewing the content in vention, but there was a significant not breastfed their infants were more each session, and role playing. One other difference in the subjective norms re- likely to experience depression within 2 limitation was utilization of a question- garding the mothers and healthcare months after delivery 34( ). naire for evaluation of the participants’ staff. However, no significant difference There is evidence that the hypo- real attitudes, which was somehow was found in the control group in this thalamic–pituitary–adrenal (HPA) controlled by coding the questionnaires regard. Bertini et al. stated that subjec- axis shows a weak response to stress to maintain the participants’ privacy. tive norms, including the viewpoints of in breastfeeding women. The function Moreover, not having access to the re- husbands, friends and healthcare per- of this axis and cortisol response are sults of related studies on breastfeeding sonnel were effective in beginning and associated with progress of depression and the BASNEF model caused us to continuing breastfeeding (27). One after delivery. Thus, breastfeeding re- compare our results to those of studies using this model in other areas. Hence, other study also demonstrated that the duces the response to stress and tension, further studies are required to achieve husbands’ support and proper attitude eventually decreasing the incidence towards breastfeeding were effective in more comparable results. of postpartum depression. Hormones breastfeeding premature infants (29). may also play a role in the relationship In conclusion, we showed the ef- Moreover, a study in England showed between breastfeeding and mental func- fectiveness of training based on the that conflict between one’s personal tion. For instance, oxytocin has shown BASNEF model in increasing maternal expectations and social norms led to knowledge and attitude, encouraging antidepressive and anxiolytic effects in social, physical and emotional isola- them towards breastfeeding and reduc- human and animal models. Prolactin tion in the mothers who intended to ing postpartum blues. Considering the may play a role in the relationship be- start breastfeeding their infants (30). importance of breastfeeding in maternal tween breastfeeding and depression Similarly, studies in Tanzania indicated and infant health and the effectiveness (33). One study assessed the correla- that the individuals around the mother of this model, it is recommended to tion between postpartum blues and ma- could play an active role in supporting replace routine training in gynaecology ternal emotional status before delivery, the mother and her decision for breast- clinics. feeding (31). Studies in developed readiness for delivery, and social sup- countries have demonstrated a positive port after delivery. Among the 131 study correlation between paternal support participants, 18.3% experienced depres- Acknowledgements and increase in breastfeeding. Studies sion throughout pregnancy, 61.8% ex- in the United States of America on the perienced postpartum blues, and 8.4% The present study was extracted from effectiveness of intervention and mental experienced postpartum depression. research project 91-4605. The authors health education based on the BASNEF In that study, postpartum blues was would like to thank Shiraz University of model have also revealed an increase negatively correlated to husbands’ and Medical Sciences, the Center for Devel- in the intervention group’s knowledge, social support, but positively related opment of Clinical Research of Nema- attitude and behavioural intention (32). to emotional status during pregnancy. zee Hospital, Shiraz and Dr. Nasrin The present study showed a signifi- However, no significant association was Shokrpour for editorial assistance. cant difference between the 2 groups found between readiness for delivery Funding: The study was financially with regard to postpartum blues. A and postpartum blues (35). supported by the Research Center for previous study indicated that initiation One of the limitations of the present Health Sciences, Shiraz University of of breastfeeding was accompanied by study was the lack of an appropriate Medical Sciences. a decrease in postpartum depression location for holding the training classes, Competing interests: None declared.

References

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Changes in dietary habits and physical activity and status of metabolic syndrome among expatriates in Saudi Arabia Rasmieh A. Alzeidan 1, Fatemeh Rabiee 2, Ahmed A. Mandil 3, Ahmad S. Hersi 1and Anhar A. Ullah 1

التغريات يف العادات الغذائية والنشاط البدين وحالة متلزمة التمثيل الغذائي بني الوافدين يف اململكة العربية السعودية رسمية الزيدان، فاطمة ربيع، أمحد منديل، أمحد هريس، أهناراهلل اخللصــة : قــد هدفنــا إىل تقييــم تأثــري املعيشــة يف اململكــة العربيــة الســعودية عــى املوظفــن الوافديــن وأرسهــم مــن حيــث عوامــل اخلطــر القلبيــة الوعائيــة 1437 الســلوكية املعرضــن هلــا، ودراســة العلقــة بــن التغــ ُّريات يف عوامــل اخلطــر هــذه ويف متلزمــة التمثيــل الغذائــي .أجريــت دراســة مقطعيــة عــى ًفــردا، عمرهــم أكــر مــن أو يســاوي 18 ســنة، مــن جامعــة امللــك ســعود، مدينــة الريــاض، اململكــة العربيــة الســعودية .واســتخدم الباحثــون اســتبيان اخلطــوات STEPS التدرجييــة لت ُّصــد األمــراض غــري الســارية ) ( ملنظمــة الصحــة العاملیــة لطــرح األســئلة مرتــن عــى كل مشــارك حــول عوامــل اخلطــر القلبيــة الوعائيــة الســلوكية: )1( للتعبــري عــن فــرة عيشــهم يف اململكــة العربيــة الســعودية؛ )2( لتســليط الضــوء عــى احليــاة يف بلدهــم األصــيل .بلــغ متوســط عمرهــم 40.9 1049 11 156 11.7 ± ) ( ســنة .وكان انتشــار عوامــل اخلطــر القلبيــة الوعائيــة الســلوكية عــى النحــو التــايل :اســتخدام التبــغ يف ًشــخصا ) ٪(، اخلمــول البــدين يف 26 378 88 1264 73 ًشــخصا ) ٪(، انخفــاض تنــاول الفواكــه واخلــروات يف ًشــخصا ) ٪(، متلزمــة التمثيــل الغذائــي يف ًشــخصا ) ٪(. وقــد قلــل املقيمــون يف اململكــة العربيــة الســعودية مــن النشــاط البــدين وتنــاول الفاكهــة واخلــروات، وكان هنــاك ًأيضــا زيــادة كبــرية يف اســتهلك الوجبــات الرسيعــة. لقــد كان للعيــش يف اململكــة العربيــة الســعودية تأثــريات كبــرية عــيل عوامــل اخلطــر القلبيــة الوعائيــة الســلوكية .ومــع ذلــك، مل يكــن هنــاك �ارتبـاط ذا داللـ�ة إحصائيـ�ة بــن التغــ ُّريات يف تنــاول الفاكهــة واخلــروات والنشــاط البــدين وحالــة متلزمــة التمثيــل الغذائــي.

ABSTRACT The aim of this paper is to assess the impact of living in Saudi Arabia on expatriate employees and their families’ behavioural cardiovascular risk factors (BCVRFs), and to examine the association between changes in BCVRFs and metabolic syndrome (MetS). A cross-sectional study was conducted on 1437 individuals, aged ≥ 18 years, from King Saud University in Riyadh, Saudi Arabia. We used the World Health Organization STEPS questionnaire to ask every participant questions about BCVRFs twice: (1) to reflect their period of living in Saudi Arabia and (2) to shed light upon life in their country of origin. Their mean age was 40.9 (11.7) years. The prevalence of BCVRFs was as follows: tobacco use in 156 (11%), physical inactivity in 1049 (73%) low intake of fruit and vegetables in 1264 (88%) and MetS in 378 (26%). Residing in Saudi Arabia had reduced physical activity and intake of fruit and vegetables. There was also a significant increase in the fast food consumption. In conclusion, living in Saudi Arabia had a significant negative effect on BCVRFs. However, there was nostatistically significant association between changes in fruit and vegetable intake and physical activity and MetS status, except that intake of fast food was lower among participants with MetS.

Changements concernant les habitudes alimentaires et l’activité physique, et situation du syndrome métabolique parmi les expatriés vivant en Arabie saoudite

La présente étude avait pour objectif d’évaluer l’impact de la vie en Arabie saoudite sur les employés expatriés, ainsi que les facteurs de risque cardio-vasculaire comportementaux de leurs familles, et d’examiner l’association entre les changements en termes de facteurs de risque de ce type et le syndrome métabolique. Une étude transversale a été menée auprès de 1437 individus âgés de 18 ans et plus à l’Université Roi Saoud de Riyad, en Arabie saoudite. Nous avons utilisé le questionnaire STEPS de l’Organisation mondiale de la Santé afin d’interroger chaque participant à deux reprises au sujet des facteurs de risque cardio-vasculaire comportementaux afin de refléter leurs comportements durant leur séjour en Arabie saoudite et d’apporter un éclairage sur leur habitudes de vie dans leur pays d’origine. L’âge moyen était 40,9 ans (ET 11,7). La prévalence des facteurs de risque cardio-vasculaire comportementaux était la suivante : tabagisme pour 156 individus (11 %), sédentarité pour 1049 (73 %), faible consommation de fruits et légumes pour 1264 d’entre eux (88 %) et présence de syndrome métabolique chez 378 des participants (26 %). Le fait de résider en Arabie saoudite avait réduit l’activité physique et la consommation de fruits et légumes. On observait également une augmentation significative de la consommation de fast food. Le fait de vivre en Arabie saoudite avait un impact négatif significatif sur les facteurs de risque cardio-vasculaire comportementaux. Néanmoins, il n’y avait pas d’association statistiquement significative entre les changements dans la consommation de fruits et légumes, l’activité physique et le syndrome métabolique, excepté que la consommation de fruits et légumes était plus faible chez les participants porteurs de syndrome métabolique.

1Cardiac Sciences Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia (Correspondence to: R.A. Alzeidan: ras_zeidan@hotmail. com). 2School of Health Sciences, Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, United Kingdom. 3Department of Epidemiology, High Institute of Public Health, Alexandria University, Alexandria, Egypt; WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt. Received: 15/11/16; accepted: 11/12/17 836 https://doi.org/10.26719/2017.23.12.836

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Introduction Worldwide, 6% (3.2 million) in BCVRFs and metabolic syndrome of deaths each year are attributed to (MetS). The Gulf Cooperation Council (GCC) physical inactivity, where physical countries, which came into existence inactivity is considered to be the fourth in 1981, include Bahrain, Saudi Arabia, most frequent cause of adult death (6). Methods Kuwait, Oman, Qatar and the United In wealthy GCC countries, particularly Arab Emirates (1). Following oil in Saudi Arabia, rapid socioeconomic Study design discovery in the Gulf region during transition and vast urbanization have led This was a cross-sectional study the 1950s, these countries including to a predominantly sedentary lifestyle conducted on KSU employees and Saudi Arabia lacked human resources, among the population. Consequently, their families over 9 months from 8 July, particularly in health professions. They physical inactivity has become a major 2013 to 30 April, 2014. The current have therefore attracted professionals public health concern in this region investigation was a substudy of a larger from all over the world seeking as well as in some other countries. study (n= 4500 subjects) and focused opportunities for employment and a Prevalence of physical inactivity varies only on non-Saudi employees and better standard of living 2( ). For this among the countries of the Eastern their families (n=1437). The details reason, the Saudi Arabian population Mediterranean, with the highest level of the larger study and participants’ profile has changed and, like other in Saudi Arabia (96%) and the lowest recruitment procedure are described GCC countries, enjoys a wide variety in the Syrian Arab Republic (31%) (7). elsewhere (14). of expatriates from diverse ethnic Globally, 2.8% (1.7 million) We used a modified version of the backgrounds. of deaths are attributable to low World Health Organization (WHO) The Annual Statistical Report from consumption of fruit and vegetables ( ). 8 STEPS questionnaire (15), version 2.1 the Saudi Ministry of Health indicates However, the worldwide consumption (both Arabic and English forms). This that 33% of the total inhabitants (30 of fruit and vegetables is still below questionnaire uses sequential steps, 770 375) in 2014 were expatriates. In the recommended intake of ≥ 5 five starting with a questionnaire (Step I), Riyadh, where the present study took servings per day (9). Likewise, in Saudi followed by physical measurements place, the expatriates represented 38% Arabia, a recent report shows that only (Step II) and biochemical of the total population (3). Also, an 3% of the population consumed the measurements (Step III). official statistical report form King recommended daily portions of fruit Saud University (KSU) showed that and vegetables (10). All participants personally reported expatriates constituted 23% of the total Substantial evidence worldwide their sociodemographic information, 1 university employees . demonstrates the phenomenon of such as age, sex, country of origin, The policies of most host acculturation, which has been simply marital status, educational level, job countries, including the GCC, defined as the gradual adoption of title, and length of residence in Saudi require all expatriates to undergo the host country’s cultural patterns, Arabia. Body weight and height and medical screening, and people who including attitudes, values, customs, waist and hip circumferences were have health issues are usually denied beliefs and behaviours by the migrants measured for all participants, as entry (4). Overall, new expatriates (11, 12). Furthermore, one of the well- described previously (14). Questions have good health status, however, it is established migration effects is dietary about lifestyle behaviour, including perceived that the health of expatriates acculturation, where the minority diet, physical activity and tobacco use, progressively deteriorates with their groups adopt the dietary practice of were asked twice: (1) to describe their duration of stay in a new host country. their host countries (12). In addition, current behaviour and (2) to report Such deterioration may be attributed acculturation influences the physical their behavioural habits before moving to cultural differences, psychosocial activity of migrants (13). to Saudi Arabia. The biochemical and socioeconomic changes, as well The present study estimated measurements in this study included: as lifestyle changes (including dietary the prevalence of behavioural glycosylated haemoglobin (HbA1C), habits and physical activity) with cardiovascular risk factors (BCVRFs), high-density lipoprotein–cholesterol migration, which may have negative including unhealthy diet and physical (HDL-C), low-density lipoprotein– impacts on health (5). inactivity, among expatriate employees cholesterol (LDL-C), total cholesterol and their families at KSU, to assess (TC) and triglyceride (TG).

1 Kingdom of Saudi Arabia Statistical the possible impact of living in Saudi Participants were instructed to fast for ≥ Report received via email (dfpa_es@ Arabia on expatriates’ BCVRFs, and 12 hours before they were subjected to ksu.edu.sa). Accessed May 2015. the association between the changes blood testing. 837

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MetS value < 0.05 was considered statistically Effect of living in Saudi Arabia Using the National Cholesterol significant. To compare changes in on BCVRFs Education Programme classification lifestyle behaviour, a 5-year cutoff point Tobacco use (16,17), participants were identified was used as it reflected the median There was a low rate of current daily as having MetS if they had ≥ 3 length of residence in Saudi Arabia. tobacco use (n = 156; 11%). The of the following 5 factors: (1) prevalence before and after residing in Ethical standards abdominal obesity measured by waist Saudi Arabia (using McNemar test) circumference; participants were This study was conducted according was 16% (n = 134) and 15.4% (n = considered to have abdominal obesity to the principles expressed in the 129) for men and 2.8% (n = 17) and if waist circumference was ≥ 102 cm Declaration of Helsinki. Furthermore, 3.1% (n = 18) for women, respectively. for men and ≥ 88 cm for women; (2) it was reviewed and approved by the Although this indicates that living in raised triglyceride ≥ 1.7 mmol/l ; (3) Institutional Review Board of KSU, Saudi Arabia had a small effect on the reduced HDL, ≤ 1.03 mmol/l for men College of Medicine; approval letter pattern of tobacco use (higher in men and ≤ 1.29 mmol/l for women; (4) number is 13-372. In addition, written and lower in women), the changes were raised fasting plasma glucose (≥ 5.6 informed consent was obtained from not statistically significant. mmol/l) or under treatment for and/ each participant prior to participation Dietary intake or previously diagnosed with diabetes; in the study. and (5) hypertension (systolic blood Table 2 presents the mean and SD pressure ≥ 130 mmHg and/or diastolic of number of days of eating fruit and blood pressure ≥ 85 mmHg or under Results vegetables, as well as the number of treatment for hypertension). servings per day before and after residing Sociodemographic in Saudi Arabia. There were significant Statistical analysis characteristics of the studied differences in both measures before and after coming to live in Saudi Arabia P( < Categorical data were summarized as population 0.001 for both comparisons). However, absolute numbers and percentages. There were 1437 expatriates in these differences, particularly reduced Numerical data were summarized with our study; 1091 (75.9%) were fruit consumption, were significantly means and standard deviations (SDs). non-Saudi Arabs, 37 (2.57%) were Categorical variables were compared higher among women and individuals from different nationalities, and 309 using the χ2 test or Fisher’s exact test, and who had resided > 5 years in Saudi (21.5%) were South Asians. The mean continuous variables were compared Arabia compared to their counterparts age of participants was 40.9 (SD ( < 0.001 and = 0.001, respectively) using independent sample t test or P P 11.7) years, and more details about (Table 3). In contrast, the consumption Mann–Whitney U test. To compare sociodemographic characteristics are the dietary habits and physical activity of fast food increased significantly almost shown in Table 1. patterns of participants before and after threefold during living in Saudi Arabia residing in Saudi Arabia, we used a paired (P < 0.001) (Table 2). This increased Prevalence of BCVRFs consumption was significantly higher sample t test. To study the association of duration of stay, gender and MetS with One hundred and fifty-six (11%) of among men than women (P < 0.001), changes of dietary habits and physical the participants were current tobacco and among newcomers (< 5 years activity patterns, a calculation was users; 1049 (73%) were physically residence) compared to those with done using the mean difference, and a inactive; and women were more longer length of stay (P < 0.001) (Table comparison between different groups physically inactive than men were 3). was conducted using an independent (Table 1). Moreover, 1264 (88%) of Physical activity sample t test or Mann–Whitney U test. the participants were reported to have Physical activity patterns in all domains, For testing the marginal homogeneity low intake of fruit and vegetables and such as travel to work, traveling to/ between tobacco use before and after women had a significantly higher rate from places or recreational activities residing in Saudi Arabia, the McNemar of low fruit and vegetable consumption were affected negatively by living in test was used, and the results presented compared to men (P < 001). Three Saudi Arabia. Thus, the number of days as text. hundred and seventy-eight (26%) and duration of physical activity were All analyses were performed using of the expatriates had MetS, but not decreased noticeably during residence SAS/STAT version 9.2 (SAS Institute statistically significant difference was in Saudi Arabia (Table 2). This decrease Inc., Cary, NC, USA). A 2-sided P observed between genders (P=0.08). was significantly higher in the first 5

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Table 1 Sociodemographic characteristics of expatriate population and prevalence of behavioural risk factors and MetS (n = 1437) Sociodemographic characteristics Total Men Women P n (%) n (%) 840 (58%) 597(42%) Age (yr); mean (SD) 40.9 (11.7) 41.9 (11.7) 39.1 (11.5) < 0.001 Educational level; n (%) Higher education (college and above) 1265 (88) 798(63) 467 (37) < 0.001 Essential educationa 168 (12) 42 (25) 126 (75) <0.001 Illiterate 4 (0.3) 0 4 (100) 0.005 Participant status in KSU; n (%) Employee 969 (67) 773 (80) 196 (20) < 0.001 Family member 468 (33) 67 (14) 401 (86) < 0.001 Occupation; n (%) Faculty staff 555 (37) 452 (81) 103 (19) < 0.001 Healthcare provider 96 (7) 39 (41) 57 (59) < 0.001 Technician 16 (1) 14 (88) 2 (13) < 0.001 Administrative 24 (2) 14 (58) 10 (42) < 0.001 Other KSU employee 278 (19) 254 (91) 24 (9) < 0.001 Marital status; n (%) Single 106 (7) 54 (51) 52(49) 0.01 Married 1321(92) 784 (59) 537(41) 0.01 Widowed / divorced 10 (1) 2 (20) 8 (80) 0.01 Behavioural risk factors; n (%) Tobacco use 156 (11) 134 (16) 22 (3) < 0.001 Physical inactivity 1049 (73) 539 (64) 510 (84) < 0.001 Low fruit/vegetable intake 1264 (88) 731 (87) 533 (89) 0.11 MetS according to NCEP-ATP III criteria; n (%) Total 378 (26) 233 (28) 145 (24) 0.08

aEssential education indicated completion of any school: elementary, preparatory or high school. KSU = King Saud University; MetS = metabolic syndrome; NCEP-ATP III = National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III); SD = standard deviation.

years of living in Saudi Arabia than in was significantly lower among people with the Saudi participants in the larger later years for both domains of physical with MetS (P = 0.001) (Table 3). study (14), as well as country-wide activity (work and sport), whereas not Furthermore, MetS was not associated population findings 18( ), and agrees statistically significant changes were with physical activity pattern changes in with other studies worldwide (19). reported between the lengths of stay all domains. Also noteworthy, in recent decades, and type of traveling (Table 4). A GCC nations have been influenced by a significant reduction in physical activity global trend towards high consumption in both work and recreational domains Discussion of fast food, which is thought to have was higher in men than in women. the following attributes: fast food Our findings indicate that non-Saudi is often quick, delicious, appealing Association between food participants demonstrated significant to all age groups and affordable to consumption and MetS negative effects on BCVRFs after their all socioeconomic classes (20). The intake of fruit and vegetables arrival in Saudi Arabia; namely, high rate Moreover, within Saudi Arabia, fast remained low in both groups, with of physical inactivity, high consumption food is generally available and easily or without MetS, and there was of fast food and low consumption of accessible throughout the year through no association between MetS and fruit and vegetables. a wide variety of global fast food chains, low intake of fruit and vegetables. The expatriates’ low consumption especially in food courts of modern However, consumption of fast food of fruit and vegetables is comparable shopping malls (21). This could also

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Table 2 Dietary and physical activity patterns among expatriates before and after residing in Saudi Arabia (n = 1437) Question Before living in After living in Mean P Saudi Arabia Saudi Arabia difference Dietary pattern, mean (SD) In a typical week, on how many days do you eat fruit? 4.59 (2.14) 4.81 (2.06) 0.22 < 0.001* How many servings of fruit do you eat a day? 1.95 (1.18) 1.92 (1.13) 0.03 < 0.001* In a typical week, on how many days do you eat vegetables? 5.17 (1.96) 5.10 (1.98) 0.07 < 0.001* How many servings of vegetables do you eat a day? 2.34 (1.35) 2.32 (1.32) 0.02 < 0.001* How many fast food meals per week do you eat that were not 1.27 (2.35) 3.42 (5.40) −2.14 < 0.001* prepared at home? Physical activities Work In a typical week, how many days do you do vigorous-intensity 0.50 (1.45) 0.30 (1.05) 0.20 < 0.001* activities as part of your work? How much time do you spend doing vigorous-intensity activities at 18.27 (57.07) 11.16 (42.10) 7.37 < 0.001* work on a typical day? (min) In a typical week, how many days do you do moderate-intensity 3.50 (2.82) 3.03 (2.62) 0.47 < 0.001* activities as part of your work? How much time do you spend doing moderate-intensity activities 75.49 (87.69) 54.36 (70.61) 21.13 < 0.001 at work on a typical day? (min) Travel to and from places In a typical week, on how many days do you do walk or cycle for ≥ 5.08 (2.72) 3.51 (2.92) 1.57 < 0.001* 10 min continuously to get to/from places? How much time do you spend walking or cycling for travel on a 78.28 (74.87) 36.95 (43.78) 44.33 < 0.001* typical day? (min) Recreational activities In a typical week, on how many days do you do vigorous-intensity 0.83 (1.68) 0.57 (1.38) 0.26 < 0.001 sports, fitness or recreational (leisure) activities? How much time do you spend doing vigorous-intensity sports, 23.04 (52.18) 13.59 (33.68) 9.11 < 0.001 fitness or recreational activities on a typical day? (min) In a typical week, on how many days do you do moderate-intensity 2.07 (2.59) 1.53 (2.18) 0.54 < 0.001* sports, fitness or recreational activities? How much time do you spend doing moderate-intensity sports, 33.94 (50.15) 21.92 (33.85) 12.021 < 0.001* fitness or recreational activities on a typical day? (min)

*Tests were done using Mann–Whitney U test. SD = standard deviation.

explain our reported significant increase living in Saudi Arabia. This transition physical activity of expatriate employees in fast food intake by expatriates during in nutritional habits and consumption and their families in this study during their residence in Saudi Arabia, which is usually associated with dietary their residence in Saudi Arabia. Such resembles that in the larger study (14) acculturation when the migrants adopt changes were more marked during the and the findings of prior Saudi and GCC the dietary practices of the host country first 5 years of residence. Moreover, studies (22, 23). Moreover, previous (11, 12, 27). these results are in line with findings studies have indicated that men Saudi Arabia, like other GCC from other Saudi and regional studies consume more fast food than women countries, has witnessed vast change in (18, 28, 29). do (24, 25), which is in accordance with wealth and subsequent urbanization the findings of our study. One reason over the past few decades. This led The significant changes in physical for this could be the greater number of to a sedentary lifestyle, in part due to activity levels were reported by male social activities for men (26). increased use of motorized commuting, participants, which indicates that Substantial evidence worldwide as well as changes to the nature of the expatriate men were more physically supports the results of the present work environment and facilities that active than women in their homeland study concerning the changes in require less physical activity (28). A (30). Nevertheless, overall women from dietary pattern among expatriates significant decline was observed in the the larger study (14) as well as expatriate

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Table 3 Association of dietary pattern changes with gender and length of stay in Saudi Arabia (n = 1437) Length of stay in Saudi Arabia Covariate < 5 yr, n = 634 ≥ 5 yr, n = 803 P Fruit/vegetable intake, mean (SD) Number of days eating fruit 0.39 (1.79) 0.09 (1.74) 0.001* Number of fruit servings/day change 0.08 (0.88) −0.11 (0.95) < 0.001 Number of days of ate Vegetables change −0.05 (1.54) −0.09 (1.29) 0.639* Number of Vegetable servings change −0.03 (0.93) −0.02 (0.82) 0.345* Fast food change 3.26 (6.66) 1.27 (3.84) < 0.001

Gender Male, n = 840 Female, n = 597 P Number of days eating fruit 0.43 (1.92) −0.07 (1.48) < 0.001* Number of fruit servings/day change 0.06 (0.93) −0.14 (0.91) < 0.001* Number of days of ate Vegetables change −0.06 (1.59) −0.09 (1.11) 0.698 Number of Vegetable servings change −0.02 (0.85) −0.04 (0.89) 0.334* Fast food change 3.32 (6.52) 0.49 (2.2) < 0.001*

MetS NCEP_ATPIII criteria Normal, n = 1059 MetS, n = 378 P Number of days eating fruit 0.23 (1.84) 0.22 (1.56) 0.933 Number of fruit servings/day change 0.0 (0.93) −0.09 (0.9) 0.097* Number of days of ate Vegetables change −0.07 (1.47) −0.09 (1.22) 0.886* Number of Vegetable servings change −0.01 (0.87) −0.08 (0.88) 0.369* Fast food change 2.42 (5.63) 1.36 (4.43) 0.001

*Tests performed by Mann–Whitney U test. MetS = metabolic syndrome; NCEP-ATP III = National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III); SD = standard deviation.

women in this study all reported higher an inverse correlation between fast cannot be generalized to the entire rates of physical inactivity compared food intake and MetS status. The only expatriate population in Saudi Arabia as to men, and this finding is strongly explanation is that participants with the sample was not randomly selected. consistent with previous reports from MetS were more aware of the negative Finally, due to its cross-sectional design, Saudi Arabia and the region (18, 28, effects of fast food on their health, hence the study does not allow us to assess 29). Reasons behind this phenomenon participants with MetS reported less whether MetS was prevalent or not among women could be due to the consumption (33). before entering Saudi Arabia. prevailing conservative social norms This study is one of the few to Despite the above limitations, this and restrictions on outdoor exercise explore the possible effects of living in was a comprehensive survey and the for women in Saudi Arabia. Another Saudi Arabia on BCVRFs of expatriate findings are expected to inform public possible contributing factor to such high employees and their families. It health policy and practice, to take rates of physical inactivity among all represents a comprehensive survey of further steps towards best interventions participants after living in Saudi Arabia is BCVRFs using a standardized WHO for changing adverse behavioural the hot arid climate in the Gulf Region, STEPwise approach; furthermore, data patterns in KSU, including among the which is present for a substantial part of were collected by well-trained research expatriate population. the year and restricts outdoor activities assistants under close supervision. (31). In addition, Saudi Arabia has a Nevertheless, the limitations scarcity of sidewalks, parks and facilities, of this study include the following. Conclusions and which is not conducive for walking and First, the answers to questions about recommendations sporting activities (32). behavioural risk factors, such as dietary We observed that there was no habits, physical inactivity and tobacco Our study indicated a high prevalence of association between the negative use were self-reported. In addition, BCVRFs among the study population. changes in physical activity pattern or relying on memories about past Non-Saudi participants showed a consumption of fruit and vegetables behaviour could have led to over- or higher rate of physical inactivity, higher and MetS status. However, there was under-reporting. Second, the results consumption of fast food and lower

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Table 4 Association of physical activity changes with gender and length of stay in Saudi Arabia (n = 1437) Covariate 0–5 yr, n = 634 ≥ 5 yr, n = 803 P Work Number of days of vigorous activity change −0.28 (1.11) −0.14 (1.04) < 0.001* Time consumed in vigorous change (in minutes) −9.32 (46.54) −5.85 (39.7) 0.012* Number of days of moderate activity change −0.67 (1.77) −0.31 (1.65) < 0.001* Time consumed in moderate change ( in minutes) −25.66 (60.2) −16.92 (65.0) 0.001* Travel to and from places Number of days of Walk change −1.64 (2.78) −1.55 (2.74) 0.573* Time consumed in Walk change ( in minutes) −41.5 (65.95) −41.94 (70.81) 0.246 Recreational activities Number of days of sport vigorous change −0.3 (1.53) −0.23 (1.44) 0.248 Time consumed in of sport vigorous change ( in minutes) −10.74 (44.76) −7.84 (48.14) 0.337* Number of days of sport moderate change −0.62 (2.34) −0.48 (2.18) 0.248 Time consumed in sport moderate change (in minutes) −13.07 (43.07) −10.83 (43.95) 0.337 Male, n = 840 Female, n = 597 P Work Number of days of vigorous activity change −0.25 (1.18) −0.14 (0.9) <0.001* Time consumed in vigorous change(in minutes) −8.96 (43.83) −5.1 (41.37) 0.001* Number of days of moderate activity change −0.57 (1.69) −0.32 (1.73) 0.001* Time consumed in moderate change (in minutes) −22.57 (58.95) −18.25 (8.44) 0.203 Travel to and from places −2.75 (3.12) Number of days of Walk change −0.77 (2.12) < 0.001* Time consumed in Walk change (in minutes) −43.42 (61.83) −39.42 (77.26) 0.05* Recreational activities Number of days of sport vigorous change −0.29 (1.55) −0.23 (1.39) 0.34* Time consumed in of sport vigorous change (in minutes) −12.39 (56.25) −4.51 (27.68) 0.011 Number of days of sport moderate change −0.52 (2.25) −0.57 (2.25) 0.689* Time consumed in sport moderate change (in minutes) −10.93 (43.01) −13.07 (44.35) 0.703*

Values are presented as mean (standard deviation). *Tested by Mann–Whitney U test

consumption of fruit and vegetables wellness among the university staff and Acknowledgements after their arrival in Saudi Arabia. their dependents. This should be done Living in Saudi Arabia had a different through the following. (1) A behavioural We would like to thank all heads of impact on gender. Among women a intervention programme focusing on concerned departments for their significant reduction was reported in promoting and sustaining a healthy diet support and approval and to the research assistants for their help with physical activity and intake of fruit and and active lifestyle at the university level vegetables, while men reported greater data collection. Special thanks are could prevent and reduce the burden fast food consumption. There was no directed to the participants of the study, of diet-related diseases. (2) Such a high association between the changes in without whom, this work would not rate of behavioural risk factors is enough physical activity or intake of fruit and have been possible. The funder had no vegetables and MetS, except that the to justify both population- and high- role in study design, data collection, data intake of fast food was lower among risk-based public health intervention analysis, decision or writing up of the participants with MetS. programmes and health promotion manuscript. Based on the findings of our study, we activities to prevent further increases, Funding: King Abdulaziz City for recommend building an effective public and to manage future cardiovascular Science and Technology (KACST), health strategy to prevent cardiovascular disease burden at both university and research grant number MS 34-5. events, and to improve cardiovascular national levels. Competing interests: None declared.

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References

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Réflexions éthiques sur le principe de l’autonomie du patient Marianne Bracconi, 1,2,3 Christian Hervé 1 et Philippe Pirnay 1,2,3,4

االنعكاسات األخلقية عىل مبدأ استقللية املريض ماريان براكوين، كريستيان هرييف، فيليب بريناي

اخللصــة : يف عــاملٍ منفتــح عــى ّتنقــل األشــخاص، ترتبــط األخلقيــات الطبيــة اليــوم بســلوك الطبيــب املرتبــط باملســاءلة ّواملوجــه ملــا يريــده املريــض، وعــى الرغــم مــن ّتطــور املفهــوم العاملــي الحــرام كرامــة الشــخص املريــض تبقــى ًأحيانــا بعــض ّالســلوكيات ّالرشعيــة دون أن تفــي ّمبد ًئيــا إىل تبعــات قانونيــة. إن أحــد املبــادئ األساســية يف احــرام موافقــة املريــض مبنــي عــى إعطائــه االســتقل ّلية يف ا ّختــاذ قــراره بنفســه ملــا يــراه مل ًئــا لعلجــه . ّوحيتــم ذلــك أن يكــون للمريــض ّحريــة ا ّختــاذ القــرار النهائــي يف األمــور التــي تعنيــه ومــا عــى الطبيــب إالّ احــرام هــذا القــرار .لذلــك عليــه أن يقبــل أن تكــون للمريــض قيــم خمتلفــة.

RÉSUMÉ Dans un monde ouvert à la circulation des personnes, on associe aujourd’hui à l’éthique médicale le domaine du comportement loyal du praticien, orienté dans l’intérêt du patient et la responsabilisation de chacun. La vision universelle du respect de la dignité de la personne souffrante progresse. Pourtant, bien des comportements restent parfois illégitimes sans être, en principe, répréhensibles juridiquement. L’un des principes essentiels marquant le respect du consentement du patient repose sur l’autonomie laissée au patient de décider pour lui-même ce qui lui semble être adapté à ses soins. Le patient doit alors être celui qui prend la décision finale sur les questions le concernant. Le soignant doit agir pour la respecter. C’est pourquoi il doit accepter que le patient puisse avoir un système de valeurs différent.

Ethical reflections on the principle of patient autonomy

ABSTRACT In a world open to the movement of people, medical ethics is today associated with the area of loyal behavior of the practitioner and oriented in the patient's interest and accountability of each. The universal vision of respect for the dignity of the sick person progresses. Yet, many behaviours are sometimes illegitimate, but not in principle legally reprehensible. One of the main principles marking the observance of patient consent is based on the autonomy given to the patient to decide for himself what appears to be adapted to his or her care. The patient must be the one who makes the final decision on issues concerning them and doctors must act to respect it. Therefore, they must accept that the patient has a different value system.

1Laboratoire d'éthique médicale et de médecine légale, Unité de recherche EA 4569, Faculté de médecine, Université Paris Descartes, Paris (France). 2Département de Santé publique, Faculté de chirurgie dentaire, Université Paris Descartes, Montrouge (France). 3Service d’odontologie, Hôpital Albert-Chenevier, Groupe hospitalier Henri-Mondor, Assistance publique-Hôpitaux de Paris, Créteil (France). 4 Expert en éthique auprès de l’Observatoire mondial d’éthique de l’UNESCO (Correspondance à adresser à Dr Philippe Pirnay : [email protected]). Reçu : 23/04/15 ; accepté: 7/03/17

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Introduction la notion d’autonomie d’un individu patient consistant pour le soignant à se à une liberté individuelle et admet un substituer à son patient dans la prise de Si le Code d'Hammourabi (1752 av. fonctionnement sociétal basé sur la décision au motif que le praticien agirait J.-C.) décline les premières dispositions négociation et la contractualisation (1). pour le bien de son patient. concernant la responsabilité du Les pays issus du droit romain ont Le préalable au respect de médecin, Hippocrate reste le adopté l’idée que l’autonomie s’exprime l'autonomie est d'offrir au patient précurseur des principes de l’éthique législativement, de façon universelle. une information qui soit de médicale. La relation médecin-malade Ainsi l’autonomie individuelle une qualité (complète, loyale, approximative était alors vue comme une rencontre fois exprimée se soumet à la volonté et en des termes intelligibles) et de entre une conscience et une confiance. générale. Aujourd’hui, le patient doit recueillir un consentement éclairé avant, Actuellement, il s’agit de la rencontre être celui qui prend la décision finale sur pendant et après les soins à chaque fois de deux confiances. L’éthique renforce les questions qui le concernent. Il s’agit qu'une intervention ou un soin devait ce lien et permet d’apprécier et de du respect pour chacun de disposer soi- être proposé(e)/prodigué(e). Ceci doit distinguer le bien du mal, c’est-à-dire même de sa santé et de choisir les options respecter la décision du patient même le soin du praticien qui sera bénéfique qui correspondent à ses souhaits, ses si celle-ci allait à l'encontre de l'avis du pour son patient de celui qui sera valeurs ou ses projets de vie. Le respect praticien (par exemple, en cas de refus nocif, par un questionnement, une de l’autonomie est la norme qui prescrit d’une sédation profonde d’un patient réflexion sur le comportement de la de respecter les capacités de prise de en fin de vie alors que le praticien est personne (Tableau 1). Or, ni les décision des personnes autonomes, en enclin à la lui proposer) ou de la loi, questions d’éthique appliquée ni celles connaissance de cause. lorsque celle-ci ne peut pas être mise de l’éthique théorique ne peuvent être C’est donc la capacité d’une en application. La France exige depuis traitées par le simple renvoi au droit personne à choisir son praticien, le 2 février 2016 la désignation d’une positif d’une région ou d’un pays, car à maîtriser sa volonté à consentir ou personne de confiance ou le recueil les lois en vigueur peuvent fort bien non à un traitement, à suivre ou non les de directives anticipées permettant de être condamnables d’un point de vue recommandations ou les conseils du connaître la volonté d’un patient qui éthique. La détermination de ce qui est soignant. Elle présuppose la capacité ne serait plus en état de donner son juste d’un point vue éthique ne se résume de juger, de prévoir, de choisir et la avis. Cependant, la mise en application donc pas à la détermination de ce qui est liberté de pouvoir agir, accepter ou s’avère extrêmement complexe, en accord avec la loi. Inversement, bien refuser en fonction de son jugement voire impossible dans de nombreux des comportements sont illégitimes, éclairé (2). Elle sous-tend le droit services hospitaliers qui doivent bien qu’ils ne soient en principe pas du patient à l’autodétermination. malgré tout rester à l’écoute du patient répréhensibles juridiquement. Aussi, Comme telle, l’autonomie s’oppose au et respecter sa volonté. Néanmoins, la recherche d’une éthique à portée paternalisme médical, lequel a été au lorsque le patient se présente dans un universelle est une préoccupation que cœur d’un type traditionnel de relation état comateux, la désignation de cette partagent aujourd’hui de nombreuses entre le prestataire de soins et son personne de confiance ou le respect des institutions régionales, nationales ou internationales, et en premier, l’Organisation mondiale de la Santé (OMS) et l’Organisation des La morale L’éthique Nations Unies pour l’éducation, la science et la culture (UNESCO). A une connotation religieuse Est plutôt de nature laïque

Elle comporte une notion L’autonomie comme Elle comporte une notion de d’autocontrôle. Elle part de principe éthique contrôle imposée de l’extérieur. l’intérieur de la personne.

L’autonomie du patient est reconnue Elle nous interpelle, crée des Elle nous fait réfléchir et nous partout dans le monde de la part des obligations. responsabilise. soignants comme une valeur. Ce principe d’autonomie émerge de deux philosophies qui s’opposent. Selon Tableau 1 Différences entre éthique et morale Rameix, le système anglo-saxon associe

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directives anticipées du patient permet américaine des droits et devoirs de Du point de vue de l’exercice de respecter son avis. l’homme du 30 avril 1948 suivie par médical, cette primauté de l’autonomie En cela, le principe d’autonomie des textes aussi célèbres que l’Acte final signifie donc que savoir mieux que le rejoint celui du respect de la dignité de la Conférence sur la sécurité et la sujet n’implique pas l’existence d’un humaine. La personne humaine coopération en Europe signé à Helsinki droit d’autorité du praticien sur le est considérée dès le XVIIIe siècle le 1er août 1975, la Déclaration puis patient. Selon Machat, l’interprétation comme étant la valeur suprême par la Convention des Nations Unies de la notion « d’autonomie » dans Locke « […] un état dans lequel, sans sur les droits de l’enfant ou même la le contexte médical est également demander de permission à personne, Déclaration des droits et libertés dépendante de la philosophie et sans dépendre de la volonté d'aucun fondamentaux adoptée par le Parlement adoptée (7). Dans un système libéral autre homme, ils peuvent faire ce européen le 12 avril 1989. On en déduit anglo-saxon, l’autonomie du patient qu'il leur plaît, et disposer de ce qu'ils plusieurs principes : la dignité de l’être sera interprétée comme purement possèdent et de leurs personnes » (3) et humain est intangible ; elle représente le individualiste, tout sera contrat entre Rousseau « Hommes, soyez humains, fondement de l’ordre politique et de la patient et praticien. Les responsabilités c’est votre premier devoir » […] paix sociale ; elle doit être protégée par seront parfaitement identifiées avant, « je lui veux donner un rang qu'il ne l’État et enfin, rien ne peut motiver son pendant et après la réalisation du puisse perdre, un rang qui l'honore abaissement. contrat. Dans un système universaliste, dans tous les temps ; je veux l'élever Pour atteindre cet objectif, la où l’idée d’un État protecteur domine, à l'état d'homme » (4), de sorte que reconnaissance de la dignité d’une l’autonomie individuelle se verra limitée Kant énonce en conséquence la théorie personne présuppose un respect actif par celle législativement exprimée (7). de la dignité inhérente à chaque être de ses droits de l’homme, de son estime De ce fait, si l’autonomie joue un rôle humain : « L'humanité elle-même est de soi et de son autonomie. Mais majeur dans certaines sociétés parce une dignité ; en effet, l'homme ne peut l’autonomie n’est pas seulement un droit, qu’elle implique une affirmation de soi, être utilisé par aucun homme (ni par c’est aussi une responsabilité partagée, en contrepartie, l’individu est surchargé autrui, ni par lui-même) simplement un choix issu d’une décision mutuelle, de responsabilités et d’épreuves qu’il comme un moyen, mais toujours car le patient n’est autonome que pour ne connaissait pas auparavant. Elle être traité en même temps comme prendre des décisions responsables, participe aussi à l’affaiblissement du une fin, et c'est en cela que consiste c’est-à-dire éclairées, légitimes et lien social (8). C’est pourquoi d’autres précisément sa dignité », « l’autonomie raisonnables. Le praticien doit rester approches, telles que la solidarité, la est donc un principe de la dignité de maître de son choix thérapeutique. responsabilité, l’autonomie intriquée, la nature humaine et de toute nature Aussi, le patient peut refuser l’option représentent la réalité de l’autonomie raisonnable » (5,6). La philosophie proposée par le prestataire de soins, dans beaucoup d’autres sociétés. moderne propose une acception laïque mais il ne peut pas prétendre à un Reste deux questions en suspens… de la dignité humaine, qu’elle associe traitement inutile, contre-indiqué ou progressivement à l’idée de droits de pouvant parfois être dangereux (en Comment s'assurer de la l’homme. chirurgie plastique, par exemple), ou valeur de l'autonomie ? L’un des principes de base de qui ne tiendrait pas compte des normes L’autonomie de décision du patient l’éthique de Kant – traiter autrui médicales du moment et des soins s’appuie sur la qualité de l’information toujours en même temps comme une disponibles (2). et la pertinence des recommandations fin, jamais simplement comme un La seule personne qui soit à données par le soignant. Elle tient moyen (impératif catégorique) – a même de décider pour le patient est le compte de toutes les sources été admis par la philosophie morale patient lui-même et il n’est pas dans les d’information du patient. Car l’ouverture et la politique moderne comme le prérogatives du praticien d’imposer sa au monde par les médias, l’élévation du fondement de la conception des droits propre échelle de valeurs. Le partenariat degré de formation des populations, de l’homme ; c’est, de ce point de vue, soignant/soigné découlant d’une l’augmentation des niveaux de vie font un principe fondateur. relation de confiance basée sur une que des situations autrefois admises Ainsi, de grandes déclarations information juste, compréhensible par sont de moins en moins supportées (9). de droits et de libertés essentiels des le soigné et vérifiée comme telle en reste L’autonomie doit ainsi amener le personnes y font depuis expressément le garant. Aussi, les patients gardent le patient à décider non pas de ce qui est référence : la Déclaration universelle des droit de refuser un traitement mais ils souhaitable, hypothétique, irréaliste, droits de l’homme des Nations Unies ne peuvent pas réclamer n’importe quel irrationnel, mais de « ce » qui est du 10 décembre 1948, la Déclaration traitement. parfaitement établi comme l’option

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thérapeutique adaptée au patient. Les convictions et des sensibilités personnelles de chaque patient ne doivent intervenir qu’après. En ce sens, il faut respecter la liberté individuelle de conscience tant qu’elle ne s’approprie pas la liberté d’autrui et être conscient que, dans la rencontre de deux libertés (liberté du soignant à proposer les options thérapeutiques et liberté du patient à choisir ses soins), le praticien ne peut vouloir faire toujours le bien Figure 1 La pyramide de l’éthique des soins d’une personne contre son gré au nom d’une solidarité humaine (10). Aussi, en privilégiant l’éducation permanente de son patient au cours des soins, le épidémie pourraient donc s’appliquer Les pays de la praticien contribue à compléter aux dépens du choix personnel du Méditerranée orientale l’autonomie de décision de son patient malade. Les libertés de choix du en compétence. praticien, de la chambre à l’hôpital, de Pour une large part de la population de Quelle limite accorder à circulation ou de visite des malades, etc., ces régions, la religion représente l’une l’autonomie ? seraient réduites au regard de la prise en des composantes de la réflexion, mais la réflexion éthique partage des valeurs L’autonomie n’est pleine et entière charge de l’épidémie. On passerait d’un que si le patient a été clairement et droit aux soins à une obligation de soins. communes en Occident comme loyalement informé et s’il a la capacité Pour les mêmes raisons, un patient ailleurs. Selon Chaoui et Legros, dans un monde ouvert à la circulation des et la liberté à consentir à des soins dangereux souffrant d’une maladie personnes, médecins ou malades, des justes. L’autonomie reste donc toujours mentale et adoptant un comportement biens médicaux et pharmaceutiques, encadrée par l’information d’une part et à risque pourrait se voir refuser ses choix le consentement d’autre part (Figure 1). des idées et des modèles de gestion, les s’il mettait la vie ou la sécurité d’autrui pays du Maghreb central ont essayé de Mais l’obligation du praticien de en jeu. conduire leurs systèmes de santé dans respecter la volonté du malade trouve Comment respecter l'autonomie de nouvelles directions en modifiant sa limite dans l’obligation qu’il a du patient qui n'a pas/plus ses capacités aussi de protéger la vie et la santé de les rapports entre public et privé et en l’individu. Il doit aussi tenir compte de de discernement, le laissant inapte à tentant de répondre avec des moyens la communauté car la notion de choix consentir ou en cas d’urgence vitale ? En limités à une demande de soins plus fondé sur l’intérêt du groupe est la l’absence d’une personne de confiance, massive et surtout renouvelée (11). base de l’équité. La santé publique est d’une déclaration anticipée de volonté, Pour Boustany, on peut distinguer importante. L’autonomie d’un individu d’un tuteur, etc., le choix du praticien, de d’une part, l’Algérie et le Maroc où le s’arrête là où commence celle des l’équipe soignante aidée par l’avis d’un statut personnel codifié met en forme un droit musulman traditionnel, et autres. Aussi, si nous sommes obligés comité d’éthique pluridisciplinaire doit d’autre part, l’Égypte, la Syrie et le Liban de respecter le libre arbitre et les valeurs alors guider la décision médicale. des autres, nous n’avons pas le droit qui sont des pays de pluralisme des Ces situations prouvent la de mettre en danger la santé d’autrui, statuts personnels (12). En Égypte et en complexité du respect de l’autonomie l’environnement, l’économie, etc. Ainsi, Syrie, le droit musulman bénéficie d’une la société devrait prendre en compte du patient et obligent les équipes certaine prééminence ; toutefois, les prioritairement l’intérêt général avant médicales à s’adapter au cas par cas juridictions communautaires doivent le malade présentant, par exemple, en menant une réflexion éthique qui respecter la procédure des juridictions une pathologie transmissible source tient compte du respect de la dignité du civiles. d'épidémie. En ce sens, les règles de malade dans la fidélité aux valeurs qui La Constitution libanaise fait une prévention et de traitement de cette fondent la médecine. obligation à l’État de respecter cette

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autonomie. Le contexte libanais ne délivrer une information et a prévu un duquel les patients prennent leurs spécifie pas particulièrement la réflexion modèle de recueil du consentement propres décisions quand il s’agit de leur éthique et limite souvent sa possibilité valable pour le secteur public et le propre dignité (15). Cela peut tenir de progression législative. secteur privé ; cette dernière décision compte aussi des valeurs religieuses. En Tunisie, les avis récents fut d'ailleurs fortement influencée par la Mais, pour Huriet, auteur de la première du Comité National d'Éthique loi française sur les droits du malade du loi éthique en France, « il n'y a pas Médicale (CNEM) vont tous dans 4 mars 2002. d'éthique universelle, car des références le sens de l'état de l'art et du respect D'un autre côté, le respect de culturelles, sociales, spirituelles, de l’autonomie du patient (13). Le l'autonomie ainsi que l'information et historiques, interviennent dans les Ministère de la Santé publique tunisien le consentement font partie des notions choix éthiques. L’expérience que j’ai a publié deux décisions en 2009 et en qui ont été rajoutées aux syllabus des acquise comme membre du Comité 2012 (14). La première a instauré une quatre facultés de médecine tunisiennes International de Bioéthique de l’Unesco charte du patient garantissant le respect depuis 2006. me l’a maintes fois confirmé. Mais des de la dignité du patient (y compris son principes éthiques fondamentaux sont autonomie), le respect de la décision universellement admis : l'autonomie de de refuser les soins et l'obligation du Conclusion la personne, à travers le consentement, praticien de délivrer une information la bienfaisance et la non-malfaisance, à et de collecter le consentement du Dans la mesure où la plupart des travers le rapport bénéfice/ risque, et patient qui remplissent toutes les trois patients se sentent dépendants des les conditions préalables au respect de médecins, il semble donc essentiel que l'équité et la justice, c'est-à-dire l'accès l'autonomie du patient. La deuxième ces derniers respectent l’autonomie aux soins. » (16). décision, intégrée dans la charte, a des patients ; il convient de délimiter Financement : aucun. rappelé l'obligation à tout médecin de un espace discrétionnaire à l’intérieur Intérêts concurrents : aucun déclaré.

Références

1. Rameix S. Fondements philosophiques de l’éthique médicale. 10. Comité Consultatif National d’Éthique pour les Sciences Paris: Ellipses; 1996. pp. 91–9. de la Vie et de la Santé. Refus de traitement et autonomie 2. Pirnay P. Responsabilités et exigences éthiques à l'égard du de la personne. Avis n° 87 du 14/04/2005. (http://www. chirurgien-dentiste. In: Tardivo D, Camilleri F, eds. Prévention ccne-ethique.fr/sites/default/files/publications/avis087.pdf, et gestion du risque contentieux en odontologie. Paris: Éditions consulté le 17 mai 2017). CdP; 2015. pp. 51-8. 11. Chaoui F, Legros M. Les systèmes de santé en Algérie, Maroc 3. Locke J. Two Treatises of Government. London: Awnsham et Tunisie - Défis nationaux et enjeux partagés. Les Notes Churchill; 1690. Traité du gouvernement civil. Paris : Garnier- IPEMED (Institut de Prospective Économique du Monde Flammarion, Deuxième édition corrigée, Collection Texte Méditerranéen), Études et Analyses. IPEMED. 2012;13 intégral (traduction de Davuk Mazel);1992. p.17 (http://www.ipemed.coop/adminIpemed/media/fich_ article/1336128563_LesNotesIPEMED_13_Sante_avril2012.pdf, 4. Rousseau JJ. Émile ou de l’éducation. Paris: Garnier- consulté le 17 mai 2017). Flammarion; 1966. p. 92. 12. Boustany FN. Bioéthique dans le monde arabe. Étude 5. Kant E. Fondements de la métaphysique des mœurs (1785). analytique et régulations. J Med Liban. 2011;59(1):7–11. Paris: Vrin; 1968. p. 140 13. République Tunisienne, Ministère de la Santé publique. Comité 6. Kant E. Fondements de la métaphysique des mœurs. Paris: National d’Éthique Médicale (http://www.comiteethique.rns. LGF/Livre de Poche, Classiques de la philosophie (trad. de tn/). l’allemand par V. Delbos), no 4622; 1993. p.115. 14. République Tunisienne, Ministère de la Santé publique. 7. Machat E. Principe d’autonomie et soins dentaires. In: Pirnay Charte du patient (http://www.santetunisie.rns.tn/images/ P, ed. L’éthique en médecine bucco-dentaire. Paris: Espace charteresume.pdf http://www.santetunisie.rns.tn/images/ ID; 2012. pp.109-12. articles/chartepatient.pdf, consulté le 6 juin 2017). 8. Ehrenberg A. Faire société à travers l’autonomie. 15. Organisation des Nations Unies pour l’éducation, la science et Recherche & formation. 2014;76(2):107-18. doi: 10.4000/ la culture (UNESCO). Cours de base de bioéthique, Section 1: rechercheformation.2256 Syllabus. Programme d’éducation en éthique; 2008 (http:// 9. Chaoui F, Legros M. Le Maghreb face aux nouveaux enjeux unesdoc.unesco.org/images/0016/001636/163613f.pdf, mondiaux - Les systèmes de santé en Algérie, au Maroc consulté le 18 mai 2017). et en Tunisie : des transitions inachevées. Note de l’Ifri. 16. Huriet C. Préface. In: Pirnay P, ed. L’éthique médicale en IFRI (Institut français des relations internationales); 2013 chirurgie dentaire : principes et applications. Espace ID; 2016. (https://www.ifri.org/sites/default/files/atoms/files/ p. 4. notedelifriocpchaouilegros.pdf, consulté le 15 mai 2017).

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Book 23-12.indb 849 3/4/2018 11:44:30 AM املجلة الصحية لرشق املتوسط املجلد الثالث والعرشون العدد الثاين عرش

تقييم فاعلية التطعيم ّ ضدالتهاب الكبد الفريويس البائي لدى مرىض نقل الدم املتكرر يف سوريا 1 2 1 وداد يازجي ، وفاء ّحبال ، فوزة منعم

اخللصة: تقدر هذه الدراسة املقطعية انتشار فريوس االلتهاب الكبدي البائي، وتقييم فاعلية التطعيم لدى مرىض نقل الدم املتكرر. اختب املصل يف 159 مريضاً يعانون من خمتلف األمراض اهليموجلوبينية، لوجود األجسام املضادة لفريوس االلتهاب الكبدي البائي وذلك باستعمل ELISA ، ثم قورنت النتائج املصلية مع الوثائق ذات الصلة يف السج ت لالطبية. واكتُشِ ف إجيابية املصل لفريوس التهاب الكبد البائي يف ثمن املرىض املشتكي يف الدراسة. واكتشفت املناعة املصلية يف نصف املرىض فقط، يف حي كان النصف اآلخر إما مصاباً أو غري حمصن. ويبدو أن التطعيم ضد التهاب الكبد البائي غري فعّال يف ما يقرب من نصف املرىض الذين لقحوا به، ومل يوثق التطعيم يف السجلت الطبية يف سدس املرىض. ومن ثم، فإن مرىض نقل الدم املتكرر معرضون خلطر اإلصابة بعدوى التهاب الكبد البائي. وينصح بشدة بتطبيق التطعيم الوقائي، وتوثيق جرعات اللقاح، ورصد االستجابة املناعية.

Evaluation of vaccination efficiency against HBV among Syrian multitransfused patients

ABSTRACT This cross-sectional study estimates HBV prevalence and evaluates vaccination efficiency among multitransfused patients. 159 patients with various hemoglobinopathies were tested for HBsAg, anti-HBs, and anti-HBc, using enzyme-linked immunosorbent assay (ELISA). The serological results were then compared with the relevant documentation in medical records. Seropositivity of HBV was detected in 1/8 of recruited patients. Serological immunity was found in only half of patients, while the other half were either infected or non-immune. The vaccination against HBV appeared inefficient in almost half of vaccinated patients and was not documented in the medical records of 1/6 of patients. Thus, multitransfused patients are at risk of acquiring hepatitis B infection. Applying prophylactic vaccination, documenting vaccine doses, and monitoring immune response are highly recommended.

Évaluation de l'efficacité de la vaccination contre le VHB chez des patients polytransfusés syriens

RÉSUMÉ La présente étude transversale vise à estimer la prévalence du VHB et à évaluer l'efficacité de la vaccination chez les patients polytransfusés ; 159 patients atteints de diverses hémoglobinopathies ont été testés à la recherche d’HBsAg, d’anti-HBs et d’anti-HBc en recourant à la méthode immuno-enzymatiqu (ELISA). Les résultats sérologiques ont ensuite été comparés avec les documents pertinents dans les dossiers médicaux. Une séropositivité au VHB a été détectée chez un patient recruté sur huit. Une immunité sérologique n'a été retrouvée que chez la moitié des patients, tandis que les autres étaient infectés ou non immuns. La vaccination contre le VHB semblait inefficace chez près de la moitié des patients vaccinés, et la vaccination n'a pas été documentée dans les dossiers médicaux d'un patient sur six. Les patients polytransfusés sont donc à risque de contracter une hépatite B. Il est vivement recommandé de pratiquer une vaccination prophylactique, de documenter les doses de vaccin, et d’effectuer le suivi de la réponse immunitaire.

1 قسم الكيمياء احليوية وامليكروبيولوجيا، كلية الصيدلة، جامعة دمشق، دمشق، سوريا )البيد االلكتوين: )[email protected](. 2قسم املختبات الطبية، مستشفى األسد، جامعة دمشق، دمشق، سوريا. االستلم: 10/03/16، القبول: 17/03/30 1Biochemistry and Microbiology Department, Faculty of Pharmacy, Damascus University, Damascus, Syrian Arab Republic. (Correspondence to: [email protected]). 2Clinical Laboratories Department, Al-Assad Hospital, Damascus University, Damascus, Syrian Arab Republic. Received: 10/03/16; accepted: 30/03/17

850 https://doi.org/10.26719/2017.23.12.850

Book 23-12.indb 850 3/4/2018 11:44:30 AM EMHJ • Vol. 23 No. 12 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

للقــاح )11(، ممــا قــد ينقــص قــدرة اللقــاح Sorbant Assay باســتخدام عتائــد Bioelisa املقدمة BioKit عــى تأمــن احلميــة اللزمــة هلــم مــن عــدوى )رشكــة ، إســبانيا(، ُوحســبت قيــم احلــد فــريوس التهــاب الكبــد البائــي. هدفــت هــذه الفاصــل cut-offبنــاء عــى تعليــات الرشكــة يعتــر نقــل الــدم ًتداخــا عل ًجيــا ًهامــا لــدى الدراســة إىل معرفــة انتشــار التهــاب الكبــد املصنعــة. صنــف املــرىض بنــاء عــى نتائجهــم مــرىض االعتــاالت اهليموغلوبينيــة، حيــث ُ ً البائــي لــدى مــرىض نقــل الــدم املتكــرر املصليــة إىل جمموعــة املتعرضــن لفــريوس حيتــاج هــؤالء املــرىض إىل نقــل الــدم املتكــرر وتقييــمنجاعــة التلقيــح يف هــذه املجموعــة ذات التهــاب الكبــد البائــي وهــم اإلجيابيــون جتــاه للحفــاظ عــى )بقائهــم عــى قيــد احليــاة( اخلطــورة العاليــة. املســتضد الســطحي لفــريوس التهــاب الكبــد البقيــا survivalوحتســن نمــط احليــاة )1(. البائــي و/أو ضــد املســتضد اللبــي للفــريوس، تعتــر عــدوى فريوســات التهــاب الكبــد HBV وجمموعــة املمنَّعــن ً مصليــاوهــم اإلجيابيــون ومنهــا فــريوس التهــاب الكبــد البائــي املواد والطرق جتــاه أضــداد املســتضد الســطحي للفــريوس مــن أهــم مضاعفــات نقــل الــدم )2(، الســيم وحــده، وجمموعــة غــري املمنعــن ًمصليــا وهــم يف ســوريا حيــث ينتــرش التهــاب الكبــد البائــي شــملت دراســتنا املقطعيــة 159 ًمريضــا الســلبيون جتــاه مجيــع الواســات املصليــة انتشــارا ً ًمتوســطا يبلــغ 5.62% )3(، ممــا يزيــد باعتــال هيموغلوبينــي مــن مراجعــي مركــز املدروســة. احتمليــة تعــرض مــرىض اعتــاالت اخلضــاب الثلســيميا الوطنــي ومستشــفى األطفــال ٍ الختطــار هــذه العــدوى؛ فقــد ذكــرت العديــد اجلامعــي يف مدينــة دمشــق بــن ترشيــن األول ُع ّــر عــن البيانــات ٍبنســب مئويــة مــع مــن الدراســات أن ارتفــاع نســب انتشــار 2012وكانــون األول .2013 خضــع مجيــع حســاب املتوســط واالنحــراف املعيــاري، Odds إجيابيــة املســتضد الســطحي لفــريوس التهــاب املــرىض لنقــل الــدم ثــاث مــرات عــى األقــل ُوحســبت قيمــة نســبة األرجحيــة Ratio الكبــد البائــي لــدى املتبعــن بالــدم ينعكــس قبــل االعتيــان، وكانــوا غــري موســومي أو مــن خــال اســتخدام موقــع http://www.medcalc.org/calc/ ًيف ارتفاعــانســب اإلصابــة لــدى املــرىض مصابــن بعــدوى كبديــة مســبقة، ومل يراجعــوا ) )odds_ratio.php املتلقــن للــدم املتكــرر )5،4(. وبالتــايل تكــون طبيــب األســنان أو جيــروا عمليــات جراحيــة واعتــرت قيمــة P< الوقايــة لــدى هــذه املجموعــة مــناملــرىض عــى يف األشــهر الثلثــة الســابقة للعتيــان. 0.05 ذات داللة إحصائية. قــدر بالــغ مــناألمهيــة، ويعتــر التمنيــع الفعــال ُأجريــت املقابــات الشــخصية مــع املــرىض immunization بلقــاح التهــاب الكبــد البائــي أو ذوهيــم وروجعــت ســجلهتم للحصــول النتائج قبــل التعــرض للفــريوس الطريقــة الفضــى عــى املعلومــات الشــخصية املتعلقــة للوقايــة مــن العــدوى )6) حيــث يــؤدي بالعمــر واجلنــس واحلالــة العائليــة واملهنيــة، شــملت جمموعــة الدراســة 88 ذكــرا ً )%55( تطبيقــه إىل تناقــص حــدوث العــدوى احلــادة وللحصــول عــى املعلومــات الطبيــة املتعلقــة و71 أنثــى )45%(. تــوزع املــرىض حســب منهــا واملزمنــة )7(. بتلقيهــم لقــاح التهــاب الكبــد البائــي. ًوتبعــا نــوع املــرض إىل 124 مريضــا ًمصابــا ً بمــرض ُأدرج لقــاح التهــاب الكبــد البائــي يف للتوثيــق يف الســجلت الطبيــة ُصنــف املــرىض الثل ّســيمية، و21 مريضــا مصابــا ً بمــرض بدايــة التســعينيات ضمــن برنامــج التلقيــح إىل جمموعتــن: جمموعــة املــرىض املتلقــن الثلســيمية املنجليــة، و7 مــرىض مصابــن بفقــر الوطنــي يف ســوريا ًوفقــا لنظــام مؤلــف مــن للقــاح وهــم مــن أمتُــوا جرعــات لقــاح الــدم املنجــيل، و 7مــرىض مصابــن بالناعــور. ± ثــاث جرعــات تعطــى بعــد الــوالدة ويف التهــاب الكبــد البائــي الثــاث مــع أو دون كان متوســط عمــر املشــاركي 9.25 17.11 الشــهر الثالــث ويف الشــهر الســابع )9،8( اجلرعــة الداعمــة وقــد وثقــت جرعاهتــم عــى عامــا ً )املجــال 52-1.5 ًعامــا(. حيــث تظهــر أضــداد املســتضد الســطحي الســجلت، وجمموعــة املــرىض الذيــن مل يوثــق تــوزع املــرىض حســب نتائجهــم املصليــة احلاميــة ضــد املســتضد الســطحي للفــريوس يف ســجلهتم أهنــم قــد تلقــوا اللقــاح. ّتــم إىل 21 )13.3%( مريضــا ً متعرضــا ً لفــريوس عنــد % 90مــن األشــخاص املؤهلــن ًمناعيــا احلصــول عــى املوافقــات املســتنرية مــن مجيــع التهــاب الكبــد البائــي وكان متوســط أعمرهــم ± immunocompetent بعــد اجلرعــات املــرىض أو ذوهيــم؛ كــا نالــت الدراســة موافقــة 10.59 23.76عامــا ً )املجــال 52-6 ًعاما(؛ الثــاث )6(. جلنــة األخلقيــات يف كليــة الصيدلــة، جامعــة ّأمــا غــري ّاملتعرضــن لفــريوس التهــاب الكبــد دمشــق. البائــي فتوزعــوا إىل 84 )52.8%) ًمريضــا يعتــر عيــار أضــداد املســتضد الســطحي ممنعــاً، و54 )33.9%( َمريضــا غــري ممنــع للفــريوس أعــى مــن 10 ميــيل وحــدة دوليــة ُمجــع 5مــل مــن الــدم املحيطــي مــن كل ًمصليــا وكان متوســط أعمرهــم 16.1±8.6 ً مــؤرشاعــى وجــود محايــة جتــاه العــدوى مريــض للحصــول عــى املصــل الــذي ُحفــظ عامــا ً )املجــال 48-1.5 ًعامــا(. وقــد زاد بفــريوس التهــاب الكبــد البائــي حيــث أن يف الدرجــة -°80 مئويــة إىل حــن إجــراء االختطــار بشــكل ّيعتــد بــه ًإحصائيــا لــدى العيــار بــن 100-10 ميــيل وحــدة دوليــة ّيــدل اختبــارات الكشــف عــن الواســات املصليــة الذيــن ولــدوا قبــل عــام 1993 مــا يقــارب عــى اســتجابة ضعيفــة، أمــا العيــار األكــر مــن املدروســة وهــي املســتضد الســطحي لفــريوس 7 مــرات عــن الذيــن ولــدوا بعــد عــام1993 100ميــيل وحــدة دوليــة ّيــدل عــى اســتجابة التهــاب الكبــد البائــي، وأضــداد املســتضد ) OR=7.48 P=0.0006، اجلدول 1(. قويــة )10(. ًونظــرا للتعديــات املناعيــة الناجتــة الســطحي للفــريوس، وأضــداد املســتضد اللبــي عــن فــرط محــل احلديــد لــدى مــرىض نقــل للفــريوس بتقنيــة مقايســة االمتــزاز املناعــي بينــت مراجعــة الســجلت أن 99 ًمريضــا Enzyme Linked Immuno� الــدم املتكــرر، ّفــإن ذلــك ُيضعــف اســتجابتهم املرتبـ�ط باإلنزيـمم مــن أصــل 159 )62%( ُو ّثــق يف ســجلهتم 851

Book 23-12.indb 851 3/4/2018 11:44:31 AM املجلة الصحية لرشق املتوسط املجلد الثالث والعرشون العدد الثاين عرش

تلقيهــم لقــاح التهــاب الكبــد البائــي بجرعاتــه املصليــة ) (12 والتــي يصعــب تفادهيــا رغــم املشــاركي يف الدراســة، بينــا كان املشــاركون الثــاث، ومل حيصــل أي منهــم عــى جرعــة االلتــزام بمعايــري منظمــة الصحــة العامليــة يف الباقــون إمــا مصابــن أو غــري ممنعــن ممــا داعمــة. تــوزع هــؤالء املــرىض حســب نتائجهم حتــري الــدم ومشــتقاته. يزيــد اختطــار تعرضهــم إىل اكتســاب العــدوى املصليــة إىل 13 ًمتعرضــا لفــريوس التهــاب بفــريوس التهــاب الكبــد البائــي مــع كل نقــل مــن جهــة أخــرى يشــكل مــرىض الكبــد البائــي، و30 غــري ممنعــن ًمصليــا، و دم جيرونــه ممــا يؤكــد عــى رضورة تلقيحهــم. االعتــاالت اهليموغلوبينيــة جمموعــة ذات 56ممنعــن ًمصليــا. أمــا ّالســتون الباقــون مــن اختطــار ٍعــال الكتســاب هــذه العــداوى مــن جهــة أخــرى ّوثقــت الســجلت تلقــي 159 ًمشــاركا )38%( مل يوثــق تلقيهــم اللقــاح الفريوســية بســبب احلاجــة املتكــررة لنقــل الــدم اللقــاح لــدى ثلثــي مــرىض دراســتنا رغــم عــدم يف الســجلت حيــث توزعــوا حســب نتائجهــم �immuni املصليــة إىل 8 متعرضــن، و24 غــري ممنعــن (13)، لذلــك يعتــر التمنيــع الفعــال نجاعــة التلقيــح لــدى جــزء منهــم وفــق نتائجنــا zation ًمصليــا، و 28ممنعــن ًمصليــا. بلقــاح التهــاب الكبــد البائــي الطريقــة املصليــة التــي أثبتــت أن %41.4 مــن هــؤالء الفضــى لوقايتهــم مــن العــدوى )6(. ودليــل كانــوا غــري ممنعــن ًمصليــا أو تعرضــوا لفــريوس ذلــك أن املــرىض األكــر ًســنا والذيــن ولــدوا التهــاب الكبــد البائــي. ويمكــن تفســري ذلــك املناقشة قبــل إدخــال لقــاح التهــاب الكبــد البائــي باإلصابــة بذريــة فريوســية حتمــل طفــرات عــى ضمــن برنامــج التلقيــح الوطنــي )عــام 1993) جــن املســتضد الســطحي Sيف مناطــق ارتبــاط تشــري النتائــج إىل ّأن أكثــر مــن ُث ُمــن املــرىض هــم يف اختطــار يزيــد ســبع مــرات لإلصابــة األضــداد ) (،16 أو بضعــفاالســتجابة املناعيــة املشــاركي يف هــذه الدراســة قــد تعرضــوا بالعــدوى ًعلــا أن تطبيــق اللقــاح ّخفــض ً أساســالــدى هــؤالء املــرىض بســبب فــرط محــل لعــدوى التهــاب الكبــد البائــي، ّويرجــح أن انتشــار املســتضد الســطحي لفــريوس التهــاب احلديــد الناتــج عــن نقــل الــدم املتكــرر )2(؛ يعــود ســبب انتقــال العــدوى هلــؤالء املــرىض الكبــد البائــي يف املجتمــع، وبالتــايل أنقــص وهــذا يؤكــد عــى رضورة مراقبــة االســتجابة إىل نقــل الــدم بعــد اســتبعادنا طــرق انتقــال اإلصابــة لــدى مــرىض نقــل الــدم املتكــرر املناعيــة لــدى جمموعــة مــرىض نقــل الــدم فــريوس التهــاب الكبــد البائــي األخــرى لــدى املتلقــن للقــاح كــا أشــارت دراســات ســابقة املتكــرر مــن خــال متابعــة مســتويات أضــداد جمموعــة الدراســة. قــد يكــون هــذا االنتقــال )15،14(. املســتضد الســطحي للفــريوس بعــد التلقيــح قــد تــم مــن خــال وحــدات دم مقطوفــة مــن لضــان وقايتهــم مــن العــدوى )10(. متبعــن يف مرحلــة النافــذة window period، عــى الرغــم مــن أمهيــة التلقيــح لــدى حيــث متثــل النافــذة املــدة الفاصلــة بــن وجــود هــذه املجموعــة فقــد بينــت النتائــج املصليــة أمــا ثلــث املــرىض الذيــن مل توثق ســجلهتم الفــريوس يف الــدم وظهــور أحــد الواســات أن املمنّعــن ًفعــا مل يشــكلوا أكثــر مــن نصــف تلقيهــم اللقــاح فقــد أثبتــت دراســتنا املصليــة

اجلدول 1 الصورة املصلية للمرىض املشاركني يف الدراسة ونتائج مراجعة السجلت الطبية الصورة املصلية الداللة عدد املرىض )%( تاريخ الوالدة توثيق التلقيح يف السجلت الطبية (+) املستضد السطحي لفريوس التهاب الكبد البائي متعرض 1 من 159 )%0.6( قبل 1993: 0 1 مريض ملقح 1 :1993 (–) ضد املستضد السطحي للفريوس بعد anti-HBc (–)

(–) املستضد السطحي لفريوس التهاب الكبد البائي متعرض 16 من 159 )%10.1( قبل 1993: 14 10 مرىض ملقحي 2 :1993 (+) ضد املستضد السطحي للفريوس بعد 1 مرىض غري ملقحي anti-HBc (+)

(–) املستضد السطحي لفريوس التهاب الكبد البائي متعرض 4 من 159 )%2.5( قبل 1993: 3 2 مريض ملقح 1 :1993 (–) ضد املستضد السطحي للفريوس بعد 2 مريض غري ملقح anti-HBc (+)

(–) املستضد السطحي لفريوس التهاب الكبد البائي ممنع 84 من 159 قبل 1993: 30 56 ًمريضا ًملقحا )52.8%( 54 :1993 (+) ضد املستضد السطحي للفريوس بعد 28 ًمريضا غري ملقح anti-HBc (–)

(–) املستضد السطحي لفريوس التهاب الكبد البائي غري ممنع 54 من 159 )%34( قبل 1993: 16 30 ًمريضا ًملقحا 38 :1993 (–) ضد املستضد السطحي للفريوس بعد 24 ًمريضا غري ملقح (–) ضد املستضد اللبي للفريوس

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أن نصفهــم كانــوا ممنعــن ًفعــا ًنظــرا لوجــود االستنتاجات اهليموغلوبينيــة، ويقتــي ذلــك َتلقيــح مجيــع أضــداد املســتضد الســطحي للفــريوس وحدهــا هــؤالء املــرىض مــع االلتــزام بتوثيــق اجلرعــات لدهيــم، ممــا يــدل عــى تلقيهــم اللقــاح يف فــرة إن التطبيــق الفعــال لبنامــج التلقيــح الوطنــي وتقييــم االســتجابة املناعيــة ومتابعتهــا لــدى مــا دون توثيــق ذلــك يف ســجلهتم وهــذا يؤكــد يســاهم يف ختفيــض اختطــار اإلصابــة بالتهــاب امللقحــن مــن خــال مقايســة مســتويات عــى أمهيــة التوثيــق بغــرض مناطــرة املــرىض. الكبــد البائــي لــدى مــرىض االعتــاالت أضــداد املســتضد الســطحي للفــريوس.

املراجع References

1. Soliman HH, Kabbash IA, El-Shanshory MR, Nagy HM, Abdou injuries among healthcare workers in Syria. J Glob Infect Dis. SH. Evaluation of immune status against hepatitis B in children 2010; 2(1):28-34. with thalassemia major in Egypt: A single center study. Journal 10. Chathuranga LS, Noordeen F, Abeykoon AM. Immune of microbiology and infectious diseases. 2012; 2(2):44-9. response to hepatitis B vaccine in a group of health care 2. Sharifi Z, Milani S, Shooshtari MM. Study on efficacy of hepatitis workers in Sri Lanka. Int J Infect Dis. 2013;17(11):1078-9. B immunization in vaccinated beta thalassemia children in 11. Froutan-Pishbijari H, Ghofrani H, Mirmomenm S, Kazemi-Asl Tehran. Iran J Pediatr. 2010; 20(2):211-5. S, Nassiri-Toosi M, Farahvash MJ et al. Immunogenicity of 3. Karim M, Laham H. Prevalence of viral hepatitis B and C in hepatitis B vaccine in multi-transfused thalassemic patients Syria. Syrian Epidemiological Bulttein. 2008; 2(3):9-11. with and without hepatitis C infection: a comparative study 4. Ansari SH, Shamsi TS, Khan MT, Perveen K, Farzana T, Erum with healthy controls. Med Sci Monit. 2004;10(12): CR679-83. S et al. Seropositivity of hepatitis C, hepatitis B and HIV in 12. Shyamala V. transfusion transmitted infections in thalassaemics: chronically transfused β-thalassaemia major patients. J coll need for reappraisal of blood screening strategy in India. Physicians Surg Pak. 2012; 22(9):610-1. transfus med. 2014;24(2):79-88. 5. Al-Sheyyab M, Batieha A, El-Khateeb M. The prevalence of 13. Azarkar Z, Sharifazdeh GHR. Efficacy of HBV vaccination in hepatitis B, hepatitis C and human immune deficiency virus children with thalassemia major, South Khorasan, Iran. Iran markers in multi-transfused patients. J Trop Pediatr. 2001; 47(4):239-42. Red Crescent Med J. 2009;14(3):318-20. 6. Filippelli M, Lionetti E, Gennaro A, Lanzafame A, Arrigo T, 14. Mirmomen S, Alavian SM, Hajarizadeh B, Kafaee J, Yektaparast Salpietro C et al. Hepatitis B vaccine by intradermal route in B, Zahedi MJ et al. Epidemiology of hepatitis B, hepatitis C, non responder patients: an update. World J Gastroenterol. and human immunodeficiency virus infecions in patients with 2014; 20(30):10383-94. beta-thalassemia in Iran: a multicenter study. Arch Iran Med. 2006;9(4):319-23. 7. McMahon BJ, Dentinger CM, Bruden D, Zanis C, Peters H, Hurlburt D et al. Antibody levels and protection after hepatitis 15. Vidja PJ, Vachhani JH, Sheikh SS, Santwani PM. Blood B vaccine: results of a 22-year follow-up study and response to transfusion transmitted infections in multiple blood transfused a booster dose. J Infect Dis. 2009; 200(9):1390-6. patients of beta thalassaemia. Indian J Hematol Blood Transfus. 8. . Damascus: Ministery of Health; 2015 (http:// 2011; 27(2):65-9. برنامج التلقيح الوطني www.moh.gov.sy/Default.aspx?tabid=414&language=ar-YE, 16. El-faramawyi AA, El-Rashidy OF, Tawfik PH, Hussein GH. accessed 04 Sep 2015). Transfusion transmitted hepatitis: where we do stand now? a 9. Yacoub R, Al Ali R, Moukeh G, Lahdo A, Mouhammad Y, one center study in upper Egypt. Hepat Mon. 2012;12(4):286- Nasser M. Hepatitis B vaccination status and needlestick 91.

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Commentary The forgotten history of pre-modern epidemiology: contribution of Ibn An-Nafis in the Islamic golden era Ghazi Kayali 1,2

Introduction a description of the disease prognosis tell what epidemic diseases will attack of several patients. Hence, this was the the city, either in summer or in winter, Hippocrates (around 460−370 BCE) first epidemiology work to present case and what each individual will be in dan- was a Greek physician and philosopher series, a modern design for observa- ger of experiencing from the change who is considered the father of mod- tional studies. For most of the cases, he of regimen”. Hence, he introduced the ern medicine (Figure 1). The history provided information about age, gen- concept of endemicity in contrast to of epidemiology typically starts with der, place of residence and the seasonal epidemic diseases that occur out of the Hippocrates in about 400 BCE but conditions at the time of onset of the routine. He associates endemicity with then more than 2000 years are skipped illness. After describing the symptoms, the climatic conditions of each region. until the birth of modern epidemiology Hippocrates described the outcome in Another important concept in this in the 17th century CE with the work terms of morbidity and mortality. He book is the association of place, water of John Graunt, followed by William also discussed disease modes of trans- and food with physical and emotional Farr and John Snow in the 19th cen- mission and recognized that certain health. Hippocrates observed that a tury (1). However, between the time of “genetic” predispositions could lead person’s diet and alcohol consumption Hippocrates and the 17th century, the to disease. This was evident when he were directly associated with disease. Islamic golden age of science occurred discussed the case of a feverish woman He further observed that people with (8th−16th century CE) (2). whose symptoms were brought on by sedentary lifestyles tended to be more This work attempts to fill this gap eating grapes and who had a “congenital obese and those who were obese typi- of 2000 years by tracing the contribu- tendency to phthisis”. Illness of another cally had reproductive health problems. tions of Muslim scientists to the field two cases was attributed to drinking and He directly attributed certain diseases of epidemiology. The epidemiological sexual indulgence. The case of Apol- to poor water quality. Stagnant waters concepts described by Hippocrates are lonius was clearly a foodborne episode were directly linked to the occurrence highlighted followed by a discussion of as Hippocrates states that, “Having of diarrhoea and dysentery, especially how his work influenced the work of eaten beef, and drunk unseasonably, in the summer, while consumption of Muslim scientists, in particular Ibn An- he became a little heated at first, and water with a high mineral content was Nafis, who preserved and advanced the betook himself to bed, and having used directly attributed to having kidney field until the European Renaissance. large quantities of milk, that of goats and problems. sheep, and both boiled and raw, with a Hippocrates bad diet otherwise, great mischief was Ibn An-Nafis occasioned by all these things.” In his book, Of the Epidemics (3), Hip- In another book, On Airs, Waters and The Muslim-Arab physician Alaa Al- pocrates introduced several concepts Places (4), Hippocrates presented the Din Ali Ibn Abi Al-Hazm Al-Qurashi of epidemiology that are considered the thesis that diseases should be studied in Al-Demashki Al-Masri El-Safii, better fundamentals of modern epidemiol- light of the season in which they happen, known as Ibn An-Nafis, was born in ogy. His main thesis was that disease the quality of the available water and the Damascus, Syria in 1210 CE (Figure 1) causality can be attributed to climate, prevailing environmental conditions. (5−7). He spent the first half of his life in seasonal variations and location. He Hippocrates drew a distinction between Damascus where he studied medicine. noted that habits, regimens and person- epidemic and endemic diseases. He He then settled in Cairo, Egypt where al pursuits are all factors associated with explained that a good physician, “as the he practised at its largest hospital at the disease occurrence. His book included season and the year advances, he can time, Al-Bimaristan Al-Nasiri (5). He

1Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas Health Sciences Center, Houston, Texas. 2Human Link, Hazmieh, Lebanon (Correspondence to: Ghazi Kayali: [email protected]). Received: 19/07/16; accepted: 12/02/17

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lived for 78 years and died in Cairo in Hippocrates and his most relevant work and 3). Ibn An-Nafis’ book was not a 1288 (5). His most influential work was A commentary on Hippocrates’ “Of mere translation of the original work was in the field of medicine and he is the Epidemics”. Ibn An-Nafis also wrote by Hippocrates but rather a critical ap- credited with discovering the pulmo- A commentary on Hippocrates’ Aphorisms praisal of it. nary blood circulation (2,6,7). He is also based on the Aphorisms of Hippocrates In the first constitution of Hippo- credited with early work in cardiology where both authors, each in his own crates’ Of the Epidemics, Hippocrates (8,9). However, his interests extended book, showed their prowess as early opens with the phrase: “In Thasus, beyond medicine and included epide- epidemiologists. about the autumn equinox, and under miology, nutrition, Islamic religion and the Pleiades…”. Ibn An-Nafis opened philosophy as evidenced by at least 24 his book by providing an explanation of books authored by him. why Hippocrates specified the location As a scholar, Ibn An-Nafis was A commentary on “Thasus” explaining that geographic influenced by the works of his prede- Hippocrates’ "Of the location and not only climate is impor- cessors. He studied the works of Ibn Epidemics" (Sharh Kitab tant when studying disease occurrence. Sina (Avicenna, about 980−1037 Al-Epidemia) (11) Both scholars embraced the notion CE), Al-Razi (Rhazes, about 865−925 that imbalances in temperature and CE), Galen (about 130−199 CE) and Hippocrates’ book Of the Epidemics humidity were causes of disease, an ac- Hippocrates (2,5,10). It is worthwhile was translated into Arabic by Ibn Ishaq, cepted biological dogma in their times. mentioning here that the vast majority based on which, Ibn An-Nafis wrote his However, Ibn An-Nafis tries to provide of the works of Hippocrates and Galen commentary on Of the Epidemics. An biological plausibility for this notion by were translated into Arabic, especially ancient Arabic copy of this book dated giving a potential biological mechanism, by the Christian-Arab scholars Hanin 1215 AH (1800−1801 CE) is available according to the accepted biological Ibn Ishaq, Yuhanna Ibn Al-Batriq and on microfilm at the Egyptian National concepts of the time, through which hu- Qusta Ibn Luqa (5). As an epidemi- Library and Archives in Cairo and was midity can cause disease. Both scholars ologist, Ibn An-Nafis was influenced by reviewed for this analysis (Figures 2 described the distribution of disease by

Figure 1 Hippocrates (left) and Ibn An-Nafis (right)

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demographic categories, but Ibn An- Nafis explained that people of different ages and genders have different biological processes and occupational hazards that contribute to the onset of disease. In his analysis of the second constitution, Ibn An-Nafis explained the exposure−outcome association laid down by Hippocrates. He provided a better definition of the seasons (exposure) using astrological signs, and then categorized outcome under several groups from mild to severe. An example here would be Ibn An-Nafis’ categorization of respiratory illness from mild colds to tuberculosis. In the explanation of the third constitution, the influence of Persian medical practice on Ibn An-Nafis is also evident. He uses the Persian term (bersam/sersam) to explain what Hippocrates meant by phrenitis (an inflammation of the body and mind). In this section, Hippocrates discussed seasonality of disease, changes in the elements, geographic distribution and associated risk factors and Ibn An-Nafis provided examples. A significant portion ofOf the Epidemics is dedicated to describing a series of cases of illness. Ibn An-Nafis provided some biological explanations for the disease prognosis for some of those cases. In addition, Ibn An-Nafis used what Hippocrates described to compare and contrasts cases and out- breaks of diseases that he handled. For example, Ibn An-Nafis compares an outbreak of malnutrition in Damascus to that described by Hippocrates. Both scholars clearly describe the location of cases as if drawing an outbreak map as Figure 2 First page of Ibn An-Nafis bookA commentary on Hippocrates’ "Of the Epidemics". An ancient Arabic language copy of this book, dated 1215 AH did John Snow hundreds of years later. (1800−1801 CE), at the Egyptian National Library and Archives in Cairo was In addition, Ibn An-Nafis described reviewed for this manuscript. cases of anthrax, linking incidence to climate and demonstrating that when a person has minor uncovered wounds, there is a risk of infection that typically ends with death.

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CE. Influenced by Hippocrates, these scholars, and in particular Ibn An-Nafis, moved the science of epidemiology forward. Hence, their work deserves to be credited. It becomes more plausible since the works of Hippocrates were preserved through their translation to Arabic and through the critical apprais- als of them by Muslim scholars. Renais- sance and modern era scientist then Figure 3 Last paragraph of Ibn An-Nafis bookA commentary on Hippocrates’ “Of the epidemics”. studied the Latin translations of Arabic works which led to the rise of modern epidemiology. Hence, the evolution of epidemiology, similar to other sciences, that different disease patterns occur in A commentary was a continuum that was contributed different locations due to differences on Hippocrates’ to by different civilizations in different not only in climate but also in the body Aphorisms (Sharh eras. types of people living in different loca- Fusul Bocrat) (5) tions, hence suggesting the role genetics in disease predisposition. Hippocrates’ Aphorisms was translated Acknowledgements by Ibn Ishaq and based on this transla- I am grateful to Dr Youssef Ziedan for tion Ibn An-Nafis wrote his commen- Conclusion tary. Hippocrates discussed the role his guidance. Dr Ziedan is an Egyptian of seasonality, changes in climate, rain Modern epidemiology was shaped scholar specializing in Arabic and Is- and wind on disease incidence. Ibn An- by the work of 16th century scientists. lamic studies. He has directed a number Nafis attempted to provide biological However, when discussing the history of of projects aimed at the delimitation plausibility to this by explaining how pre-modern epidemiology, discussing and preservation of Arabic manuscripts. these factors affect different organs. For the work of Hippocrates only is a com- His academic work on documenting example, Ibn An-Nafis explained that mon mistake. Hippocrates remains the the works of Ibn An-Nafis and other winds may carry diseases hence dem- father of epidemiology but the field was Muslim scientists was crucial to the onstrating the occurrence of airborne a scholarly topic for Muslim scientists preparation of this manuscript. respiratory illness. When discussing the who excelled during the Islamic golden Funding: None role of location, Ibn An-Nafis explained age between the 8th and 16th centuries Competing interests: None declared.

References 1. Prinicples of epidemiology in public health practice. Atlanta: 7. Loukas M, Lam R, Tubbs RS, Shoja MM, Apaydin N. Ibn al-Nafis Centers for Diesease Contriol and Prevention; 2012 (http:// (1210-1288): the first description of the pulmonary circulation. www.cdc.gov/ophss/csels/dsepd/ss1978/lesson1/section2. Am Surg. 2008 May;74(5):440–2. PMID:18481505 html, accessed 27 Ocober 2017). 8. Baharvand-Ahmadi B, Bahmani M, Zargaran A. Ibn Nafis 2. West JB. Ibn al-Nafis, the pulmonary circulation, and the Is- and the early description of the role of coronary arteries in lamic Golden Age. J Appl Physiol. 2008; 105(6):1877−80. blood supply of the heart. Int J Cardiol. 2016 Feb 1;204:131–2. 3. Hippocrates. Of the epidemics. Kessinger Legacy Reprints. PMID:26657607 Montana: Kessinger Publishing; 2012. 9. Numan MT. Ibn Al Nafis: his seminal contributions to cardiolo- 4. Hippocrates. On airs, waters and places. Kessinger Legacy Re- gy. Pediatr Cardiol. 2014 Oct;35(7):1088–90. PMID:25096906 prints. Montana: Kessinger Publishing; 2009. 10. Lakhtakia R. A trio of exemplars of medieval Islamic medicine: 5. Abdel Kader M, Zeedan Y. Sharh Fusul Bocrat [A commentary Al-razi, Avicenna and Ibn Al-Nafis. Sultan Qaboos Univ Med J. on Hippocrates aphorisms]. Cairo: Al-Dar Al-Masriah Al- 2014 Nov;14(4):e455–9. PMID:25364546 Lubnaniah; 1991 [In Arabic]. 11. Ibn An-Nafis A. Sharh Kitab Al-Epidemia [A commentary on 6. Akmal M, Zulkifle M, Ansari A. Ibn Nafis − a forgotten genius Hippocrates’ Of the epidemics. Cairo: Dar El-Kotob Al-Masri- in the discovery of pulmonary blood circulation. Heart Views. ah; before 1288 [In Arabic]. 2010 Mar;11(1):26–30. PMID:21042463

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WHO events addressing public health priorities

Redesigning the integrated approach to child health in line with the United Nations Sustainable Development Goals1

Key lessons learnt over the two decades since the imple- represented a unique platform to bring together all related mentation of the Integrated Management of Childhood Ill- programmes and concerned sectors along with United ness (IMCI) platform (1) have highlighted difficulties faced Nations agencies and nongovernmental organizations. In ad- by regional governments and partners in engaging the private dition, Dr Anirban Chatterjee, Regional Adviser, Health and sector in the implementation of the platform. Currently, there Nutrition, UNICEF Middle East and North Africa Regional has been a focus on training of health care providers only, Office (MENARO) reiterated UNICEF’s commitment to while investment in supervision has been inadequate and lim- advancing the issues of child and adolescent health in coordi- ited emphasis has been placed on community care. Country nation with WHO and other partners. level health systems have not been responsive to integrated management of childhood illness implementation needs (1). Summary of discussions In order to address these shortcomings, a consultative Global and regional overviews of the current status of meeting on redesigning the integrated approach to child child and adolescent health were presented by WHO head- health in line with the United Nations Sustainable Develop- quarters and EMRO representatives, respectively, followed ment Goals and other related global initiatives was held in by presentations on the outcomes of the WHO global child Cairo, Egypt, from 24 to 26 September 2017. A total of 28 survival and health strategic review and implications for the participants from ministries of health, the academic com- Region. munity, regional and global experts from the World Health To address the highlighted issues during the consulta- Organization (WHO) and the United Nations Children’s tion’s deliberations, participants proposed the following Fund (UNICEF), attended the meeting 2( ). priority actions (2): This consultative meeting aimed to discuss and agree • advocating for the redesigned package of child on future directions and a clear framework for action for health services within the regional framework; newborn, child and adolescent health in the Region. The objectives of the meeting were to analyse the implications of • identifying the package of services for children the findings of the IMCI global strategic review in countries of under 5 years to be included in the pre- and in- the Region. Thus, determine necessary action to be included service training of health providers; in the draft of the proposed regional framework for child and • agreeing on the multisectoral scope and roles of adolescent health and development 2018–2025. In addition, stakeholders; there was a review of the draft regional framework for child and adolescent health and development, taking into account • revitalizing/establishing national child health emerging newborn and child health issues, and propose steering committees; mechanisms of alignment with existing platforms, includ- • including the IMCI platform as part of country- ing the IMCI; propose concrete guidance on child health level mandatory continuous professional devel- programming in humanitarian contexts; and suggest practical steps to operationalize the guidance (2). opment and care-provider re-licensing; The inaugural speech of the late Dr Mahmoud Fikri, • engaging professional associations in IMCI Regional Director, WHO Regional Office for the Eastern training courses/evaluation/curricula updates; Mediterranean (WHO/EMRO), was presented on his • including the IMCI platform in national health behalf by Dr Maha Eladawy, Director, Health Protection insurance packages; and and Promotion (WHO/EMRO). In his opening remarks, Dr Fikri stated that the proposed regional framework for • using integrated supervisory checklists at country child and adolescent health and development 2018–2025 level.

1 This report is extracted from the Summary report on the Consultative meeting on redesigning the integrated approach to child health in line with the United Nations Sustainable Development Goals and other related global initiatives, Cairo, Egypt, 26–24 September 2017 (http://applications.emro.who.int/docs/IC_Meet_Rep_2017_EN_20198.pdf?ua=1, accessed 18 January 2018).

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In light of the draft WHO global conceptual framework • an inter-agency working group is needed to sup- to redesign child health in line with the United Nations Sus- port partnership and alignment, with an initial tainable Development Goals2, participants also discussed the global group leading the establishment of re- proposed regional framework for child and adolescent health gional groups; and development 2018–2025, along with regional child and adolescent health goals, targets and milestones with respect • child and adolescent health indicators must clas- to the Sustainable Development Goals, the United Nations sify information according to age and sex, and Global Strategy for Women’s, Children’s and Adolescent this should also be applied to all existing assess- Health 2016–2030, and the Roadmap of WHO’s work for ment tools; the Eastern Mediterranean Region 2017–2021 (3). • during emergencies, countries should make Discussions also addressed the current gaps in maternal, every attempt to maintain existing health sys- newborn, child and adolescent health in humanitarian crisis tems, but if this is not possible, then they should settings, and the role of the Regional Office in these settings, simplify the health indicators; and and concluded that health programme integration is vital in emergency settings 2( ). The following recommendations • build upon the successful experience of the nutri- were put forward: tion cluster in relation to emergency situations, • an essential package of services should be de- and the WHO Expanded Programme on Immu- fined for maternal, newborn child and adolescent nization (4) experience of developing a decision- health, and health kits should be developed for makers’ tool and programme implementation emergency settings; guidelines.

References

1. World Health Organization. Integrated management of child- 3. WHO Regional Office for the Eastern Mediterranean (EMRO. hood illness (IMCI) (http://www.who.int/maternal_child_ad- Roadmap of WHO’s work for the Eastern Mediterranean olescent/topics/child/imci/en/, accessed 18 January 2018). Region. Cairo: EMRO; 2017 (http://apps.who.int/iris/ 2. WHO Regional Office for the Eastern Mediterranean (EMRO). bitstream/10665/258986/1/EMROPUB_2017_19695_EN.pdf, Summary report on the Consultative meeting on redesigning accessed 18 January 2018). the integrated approach to child health in line with the United 4. World Health Organization. The expanded programme on Nations Sustainable Development Goals and other related immunization. Geneva: World Health Organization; 2013 global initiatives. Cairo: EMRO; 2017 (http://applications. (http://www.who.int/immunization/programmes_systems/ emro.who.int/docs/IC_Meet_Rep_2017_EN_20198.pdf?ua=1, supply_chain/benefits_of_immunization/en/, accessed 18 accessed 18 January 2018). January 2018).

2 SDG 3.2: By 20130, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under5- mortality to at least as low as 25 per 1000 live births.

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Book 23-12.indb 859 3/4/2018 11:44:32 AM Members of the WHO Regional Committee for the Eastern Mediterranean املجلة الصحية لرشق املتوسط Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon هى املجلة الرسمية التى تصدر عن املكتب اإلقليمى لرشق املتوسط بمنظمة الصحة العاملية. وهى منرب لتقديم السياسات Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab واملبادرات اجلديدة ىف اخلدمات الصحية والرتويج هلا، ولتبادل اآلراء واملفاهيم واملعطيات الوبائية ونتائج األبحاث وغري Republic . Tunisia . United Arab Emirates . Yemen ذلك من املعلومات، وخاصة ما يتعلق منها بإقليم رشق املتوسط. وهى موجهة إىل كل أعضاء املهن الصحية، والكليات الطبية وسائر املعاهد التعليمية، وكذا املنظامت غري احلكومية املعنية، واملراكز املتعاونة مع منظمة الصحة العاملية واألفراد املهتمني بالصحة ىف اإلقليم وخارجه.

ISSN 1020-3397

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Editorial

Improving evidence informed policy-making for health in the Eastern Mediterranean Region...... 793 Research articles

December 2017 تقييم فاعلية التطعيم ضدّ التهاب الكبد الفريويس البائي لدى مرىض نقل الدم املتكرر يف سوريا Commentary

The forgotten history of pre-modern epidemiology: contribution of Ibn An-Nafis in the Islamic golden era..... 854 WHO events addressing public health priorities

Redesigning the integrated approach to child health in line with the United Nations Sustainable Development Goals...... 858

املجلد الثالث والعرشون / عدد Volume 23 / No. 12 12 ديسمرب/كانون األول December/Décembre 2017

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