Brief Communication
Accuracy of self-reporting of diabetes
mellitus
and
hypertension
and
its
determinants among Omani adults
Asya A. Al-Riyami, PhD, Mustafa M. Afifi, MMed, DrPH.
health surveys depend commonly on data
N ational
collected through self-administered questionnaires
due to the privilege of its lower costs.1 In several studies,
self-reported data was compared with medical records,
disease registries, or the results of clinical and laboratory
investigations. Some authors evaluate the accuracy of
self-reporting for both people who responded positively
and people who responded negatively to a specific
question regarding chronic disease, whereas others limit
their investigation to the positive responders or to people
who have the condition according to medical records or
clinical examination. Certain patient’s characteristics
are presumed to influence the accuracy of self-reported
data. In several studies, the associations have been
examined between gender, age and educational level.2
The aim of the present study is to investigate the
accuracy of Omani subjects’ on self-reporting of
diabetes mellitus (DM) and hypertension as compared
with the diagnosis of these diseases according to the
pre-set criteria; and to examine whether certain subject’s
characteristics influence the accuracy of self-reporting of
these chronic diseases in a community based survey
(National Health Survey, 2000). The survey adopted a
multi-stage, stratified probability-sampling design
representing the 10 regions of the Sultanate of Oman
according to proportional allocation of the population
size in each region. Sixteen willayates were selected out
of 59 (27%). The total number of households selected
was 1968 with a total of 7011 subjects aged >20 years.
The response rate varies from 77.5-91.5% according to
physical or laboratory measurement. Five thousand four
hundred and thirty-one Omani subjects were subjected to
data analysis to test the accuracy of self-reporting of DM
and 6414 were subjected to data analysis to test the
accuracy of self-reporting of hypertension. The tools
used in the survey were Household Health Status
questionnaire, which covers the demographic data and
includes
self-reporting
of
DM,
hypertension.
Measurements of blood pressure (BP), weight, height,
waist and hip circumference were registered in the
questionnaire. The World Health Organization (WHO)
procedures were used for taking the measurements.3 The
questionnaire also included items for the results of
laboratory investigations taken from fasting blood sugar,
and serum cholesterol. The WHO criteria (1999) for
diagnosis of hypertension, and glucose intolerance was
adopted. 3 Prevalence of hypertension was estimated
based on adding the subjects with self-reporting of
systolic or diastolic hypertension to the subjects with a
mean of 2 readings of 140 mm Hg systolic BP or 90 mm
Hg diastolic phase >5 BP. Diabetes prevalence was
estimated based on adding the subjects with
self-reporting of DM and subjects with fasting blood
glucose ≥7.0 mmol/l.
Data entry was carried out using EPI INFO version 6,
while analysis was carried out using SPSS 5.0. The
accuracy of the patients’ self-reports as compared with
the laboratory investigation or physical examination was
measured by using Cohen kappa. Step-wise logistic
regression was conducted to test the significant
associated factors with accuracy of self-reporting of DM
or hypertension.
The crude prevalence of DM and hypertension was
11.2% and 33.1%. Self-reporting of DM was low; only
4.2% of the studied population reported that they had
diabetes, and it was very low compared with the
prevalence of hypertension which is 6.1%. Table 1
shows the kappa statistic of agreement of self-reporting
of DM and hypertension compared with the results of
diagnosis due to the pre-set criteria. For DM, the kappa
was 0.56 for the whole sample, 0.50 for males, and 0.61
for females. Kappa was the highest among the elderly
(>60 years). For hypertension, the kappa was generally
lower than that of DM. The middle age group (40-59
years) had the highest kappa. The male gender and the
youngest age group (20-39) were more likely to report
inaccurate DM and hypertension than others. Logistic
regression was used to examine the variables that
increased the likelihood of accurate self-reporting of
DM or hypertension where the following variables were
included as independent; age groups, female gender,
Table 1 - Kappa statistic of agreement of self-reporting of diabetes
mellitus and hypertension with its diagnosis according to pre set
criteria, sex and age group wise.
Non-communicable disease
Kappa
p-value
Diabetes mellitus
Whole sample (N=5431)
Males (n=2668)
Females (n=2763)
0.56
0.50
0.61
0.00
0.00
0.00
Age group
20-39 years (n=3320)
40-59 years (n=1388)
60-120 years (n=723)
0.30
0.60
0.63
0.00
0.00
0.00
Hypertension
Whole sample (N=6414)
Males (n=3057)
Females (n=3357)
0.24
0.16
0.33
0.00
0.00
0.00
Age group
20-39 years (n=3932)
40-59 years (n=1658)
60-120 years (n=824)
0.12
0.27
0.20
0.00
0.00
0.00
www.smj.org.sa
Saudi Med J 2003; Vol. 24 (9)
1025
Accuracy of self-reporting of diabetes in Oman
being obese or centrally obese, level of urbanization,
having another chronic medical condition, educational
level, marital status, work status and smoking status. It
was found that ages >40, centrally obesity, and
hypertensive subjects were more likely to report DM
(odds ratio = 3.75, 1.82, 1.49 p<0.05). Those with
higher levels of cholesterol were less likely to report
diabetes accurately. As regards to self-reporting of
hypertension, females, age >40, obese subjects, and
with impaired fasting glucose were more likely to report
hypertensive accurately than others. Rural residents were
less likely to do that. The overall agreement above
chance was fair for DM while it was poor for
hypertension. From the results, we could notice that the
kappa statistics of self-reporting of DM was higher than
that of hypertension. Our finding is consistent with what
Bowlin et al4 who found in their study that self-reporting
of DM has a better validity than that of hypertension.
Awareness of having DM or being hypertensive was
positively associated in our study with older age group,
female gender, being obese or centrally obese, level of
urbanization, and having another chronic medical
condition. Misreporting of chronic medical condition in
our study did not differ by respondents’ level of
education, which is consistent with what Kriegsman et
al5 found in their study.
They found using the
multivariate analyses that educational level, and level of
urbanization had no influence on the level of accuracy.
An influence of gender, age and recent contact with the
general practitioner was shown for specific diseases.
We conclude that depending only on self-reporting
information of DM or hypertension, or both, would lead
to inaccurate estimates of their prevalence rates,
suggesting the need for including the clinical
ascertainment in any population based epidemiological
study.
Received 9th February 2003. Accepted for publication in final form 29th April
2003.
From the Department of Research & Studies, Ministry of Health, Oman.
Address correspondence and reprint requests to: Dr. Mustafa Afifi,
Department of Research & Studies, Ministry of Health, PO Box 393, PC 113,
Oman. Tel. +968 697551. Fax. +968 696702. E-mail: afifidr@yahoo.co.uk
References
1. Sherbourne CD, Meredith LS. Quality of self-report data: A
comparison of older and younger chronically ill patients. J
Gerontol 1992; 47: S204-S211.
2. Schrijvers CT, Stronks K, van de Mheen DH, Coebergh JW,
Mackenbach JP. Validation of cancer prevalence data from a
postal survey by comparison with cancer registry records. Am J
Epidemiol 1994; 139: 408-414.
3. King H, Minjoot-Preriera G. Diabetes and Non-Communicable
Disease Risk Factor Survey: a field guide. Geneva: WHO; 1999.
p. 7-15.
4. Bowlin SJ, Morrill BD, Nafziger AN, Lewis C, Pearson TA.
Reliability and changes in validity of self-reported cardiovascular
disease risk factors using dual response: the behavioral risk factor
survey. J Clin Epidemiol 1996; 49: 511-517.
5. Kriegsman DM, Penninx BW, van Eijk JT, Boeke AJ, Deeg DJ.
Self-reports and general practitioner information on the presence
of chronic diseases in community dwelling elderly. A study on
the accuracy of patients' self-reports and on determinants of
inaccuracy. Clin Epidemiol 1996; 49: 1407-1417.
1026
Saudi Med J 2003; Vol. 24 (9) www.smj.org.sa
Residents’ perception of the journal club
Shabih Manzar, FAAP.
club meetings have become a part and parcel
J ournal
of formal postgraduate medical education. It can be
1,2
defined as an educational meeting where a group of
individuals discuss articles, but it has been noted that it
has become a matter of skill presentation and this is due
to lack of critical appraisal. Postgraduate mentors and
faculty staff are striving constantly to make these journal
clubs as fruitful as possible by suggesting different
approaches. The recent article by Dwarakanath and
Khan3 is one of the good examples of these efforts.
Residents are the postgraduate trainees with both
educational and clinical commitments. In addition to
their day to day work and clinical responsibilities, they
are supposed to take active part in postgraduate teaching
activities with the journal club presentation as one of the
postgraduate scientific sessions. The main objective of
these journal club meetings is to provide the residents
with a forum to remain abreast with the current
literature.4 However, despite of this awareness, it has
been observed that residents lack the motivation.5 We
conducted this study to look further into this and to get
residents’view on the journal club.
The study was conducted in the Department of
Pediatrics at King Faisal University, Dammam,
Kingdom of Saudi Arabia. Residents at different level
of postgraduate training in pediatrics were asked to
respond to the 10-item questionnaire on what they think
of the present status of journal club meetings. Ten
residents completed the questionnaire. Table 1 depicts
the results of the questionnaire. Two items clearly had a
negative while 8 had a positive responses. Additional
comments, some residents thought that journal club
should be replaced with more grand rounds and case
discussion, some suggested that weekly journal club
meeting is too frequent. The study clearly demonstrated
that most of the residents had a positive attitudes
towards the journal club. In contradiction to the
assumption, only one resident chose presentation in
English as problem, so language was not thought to be a
barrier in the journal club presentation. Furthermore,
most residents voted for journal club meetings as no
waste of time and agreed that this meeting enhances
research understanding. However, majority thought that
it is of limited clinical use. That might be reflective of
their
preoccupation
with
laboratory-based
or
animal-based bench research articles.
Role of faculty (mentor). From the study findings, it
looked clearly that residents expect more support from
their mentors, as most of them voted strongly for item 3,
9 and 10. A solution to this problem could be a prior
consultation with their mentors before the presentation.
By doing that, the faculty can guide the residents not
only in proper article selection but also in making them
understand and present the article smoothly. The
Residents’ view of the journal club
Table 1 - Residents’ response to the questionnaire (N=10).
Items
Strongly
agree
%
Agree
%
Undecided
%
Strongly
disagree
%
Disagree
%
Conclusions
None
40
10
20
30
Yes, objectives of journal club are not clear
Guidelines not available
20
20
20
20
20
Equivocal response
No help from the faculty
20
40
20
10
10
Yes, no help from the faculty
Of limited clinical use
30
20
20
10
20
Yes, journal club are of limited clinical use
Waste of time
20
20
10
20
30
No, journal club is not a waste of time
Enhance research understanding*
10
30
20
20
10
Yes, journal club enhances research
thinking
Difficult to conduct in English
None
10
20
10
60
No, English is not a problem for journal
club
Articles difficult to find
None
50
10
None
40
Yes, articles for journal club are difficult to
find
Articles should be chosen by the faculty
40
30
20
10
None
Yes, faculty should chose article for journal
club
Lack of feedback
10
40
20
10
20
Yes, need feedback
Objectives unclear
*no response from one resident
problem or complaint regarding the poor feedback could
also eliminated by following this approach. Lastly,
residents’ view on difficulty in finding the journal
articles could be discussed and reported to the faculty, as
faculty can guide them for interesting, relevant and
recent articles. Also, many faculty members have their
own subscriptions of international highly rated journals,
which could be easily accessed if not found in the
library. Internet could also be used as rescue.
In conclusion, most of the residents thought that
journal club is a productive postgraduate activity and it
should continue with slight modifications and more
support from the faculty.
Received 18th January 2003. Accepted for publication in final form 5th May
2003.
From the Department of Pediatrics, Hamdard University Hospital, Karachi,
Pakistan.
Address correspondence and reprint requests to: Dr. Shabih
Manzar, PO Box 17730, Gulshan-e-Iqbal 75300, Karachi, Pakistan. Tel/Fax.
+92 (21) 4962038. E-mail: shabihman@hotmail.com
References
1. Sidorov J. How are the internal medicine residency journal clubs
organized, and what makes them successful? Arch Intern Med
1995; 155: 1193-1197.
2. Alguire PC. A review of journal clubs in postgraduate medical
education. J Gen Intern Med 1998; 13: 347-353.
3. Dwarakanath LS, Khan KS. Modernizing the journal club. Hosp
Med 2000; 61: 425-427.
4. Valentini RP, Daniels RS. The journal club. Postgrad Med J
1997; 73: 81-85.
5. Seelig CB. Affecting residents’ literature reading attitudes,
behaviors and knowledge through a journal club intervention. J
Gen Intern Med 1991; 6: 330-334.
-------------------------------------------------------------------ß-thalassemia major
Zakaria M. Al-Hawsawi, DCH, CABP,
Ghousia A. Ismail, MBBS, CABP,
Hanan A. Al-Harbi, MBBS, CABP,
Zaki R. Al-Sobhi, MBBS, CABP.
thalassemias are heterogeneous group of genetic
T he
disorders in which the production of normal
hemoglobin (Hb) is partly or completely suppressed due
to defective synthesis of one or more globin chains.
Several types of thalassemia have been described. The
most common type is ß-thalassemia in which ß-globin
synthesis is either reduced or totally absent.
ß-thalassemia major, historically known as Cooley
anemia, is the homozygous form of this disease. It has
been estimated that there are probably as many as
100,000 living patients with ß-thalassemia major in the
world. Madinah Maternity and Children’s Hospital
www.smj.org.sa
Saudi Med J 2003; Vol. 24 (9)
1027
ß-thalassemia major
(MMCH) in Madinah, Al-Munawara, Kingdom of Saudi
Arabia (KSA) has 400 beds, 200 of which are pediatric,
and it is the main referral hospital for the Madinah
region. The upper age limit for pediatric admission is 13
years. The approximate number of children served by
the hospital is 350,000 in an estimated population of
800,000. In 1992, the Thalassemia Center was
established in the Pediatric Section to provide
comprehensive Management of Children with
Thalassemia, which includes regular blood transfusion
(BT) at 2-4 weekly intervals with regular use of
subcutaneous desferrioxamine (DF). The upper age limit
for admission to thalassemia center is 20 years. The
objective of the study was to demonstrate our experience
in managing a group of children with thalassemia major.
The medical records of 67 ß-thalassemia major
patients, who had been managed and followed up in our
thalassemia center from January 1992 to December
2002, were retrospectively reviewed. Information
extracted from the records included the clinical data at
presentation,
demographic
characteristics,
anthropometric measurements, the pretransfusion and
post-transfusion Hb, general management undertaken
and the complications. The data was analyzed. The
diagnosis of ß-thalassemia major was based on a clinical
history of pallor, jaundice and hepatosplenomegaly with
Hb electrophoresis showing high HbF values (95-98%)
and raised HbA2 (3.5-5%) on cellulose acetate medium
at an alkaline pH 8.4. In addition, detection of
ß-thalassemia minor in both parents was of diagnostic
value. All patients were on a hypertransfusion regimen
receiving 10-15 ml/kg of packed red blood cells (RBCs)
at 2-4 weeks interval with the aim of maintaining the
mean pre-transfusion Hb at 9-10 gm/dl. Subcutaneous
infusion of DF at 20-40 mg/kg body weight daily and for
5 nights per week were started for all patients when
serum ferritin level reached 1000 ng/ml. Additional
intravenous DF (40 mg/kg body weight) was given at the
time of BT in the thalassemia center. Those who did not
comply with subcutaneous infusions of DF at home were
given up to 60-mg/kg body weight of intravenous DF
during BT. Patients who developed hypersplenism with
a need for packed (RBCs) transfusion of more than 250
ml/kg body weight per year underwent splenectomy. A
serum ferritin level measurement was used for
determination of body iron stores and was measured at 6
months intervals. All patients were screened for hepatitis
C virus (HCV) antibody by using a third generation
enzyme-linked immunosorbent assay (ELISA). Positive
result by ELISA was confirmed by recombinant
immunoblot assay. The presence of hepatitis B surface
antigen (HBsAg) was determined with appropriate
commercially available assay Auszyme monoclonal.
Cardiac evaluation by chest x-ray, electrocardiogram
(ECG), and echocardiogram were carried out routinely
for those over 10-year-old. There were 67 patients with
ß-thalassemia major attending regularly to the
thalassemia center. Thirty-nine (58%) were males and
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Saudi Med J 2003; Vol. 24 (9) www.smj.org.sa
28 (42%) were females. There were 30 Saudi patients
(45%) and 37 (55%) non-Saudi patients. Their age
ranged from 6 months to 20 years (mean 10 years).
Fifty-six patients (84%) presented to the center within
the first 2 years of life, and 45 patients (67%) had at least
one other sibling affected with thalassemia in the family.
The mean body weight and height were less than the
third percentiles for reference standards in 20 patients
(30%). Splenomegaly was present in 46 patients, and 23
patients had splenectomy. Hepatomegaly was noticed in
50 patients, abnormal facial configuration was observed
in 36 patients. Hepatitis C virus (HCV) antibodies were
detected in 33 patients, 15 patient had alanine
aminotransferase (ALT) of 100 Iu/l or more and only
one patient had HBsAg. The mean serum ferritin values
were more than 2000 ng/ml in 35 patients (52%).
Cardiac evaluations were carried out in 25 patients and 3
patients (12%) showed evidence of cardiomyopathy with
left ventricular dysfunction. There were 3 (4.5%) deaths
among our patients. Table 1 summarizes the clinical and
laboratory findings.
This is the first study in the Madinah region
highlighting the experience in managing children with
thalassemia major. ß-thalassemia is common in KSA
along the coastal strip of the Red Sea and in the Eastern
province around Jubail, Qatif, Dammam, and Hofuf.1 It
occurs mostly in the Mediterranean, Middle East region
and in countries were people from several areas have
migrated such as Madinah. Madinah Al-Munawara is a
holy city with mixed population; over the years, people
from various parts of Islamic and other countries have
migrated to Madinah. The exact prevalence of
Table 1 - The clinical features of 67 patients with ß-thalassemia.
Clinical features
Patients
n
(%)
Age of onset
< 2 years
> 2 years
56
11
(84)
(16)
Abnormal facial appearances
36
(54)
Splenomegaly
<5cm
>5cm
46
32
34
(69)
(47)
(50)
Splenectomy
23
(34)
Hepatomegaly
50
(78)
Mean serum ferritin level (ng/ml)
>2000
<2000
35
32
(52)
(48)
Hepatitis C infection
33
(49)
Hepatitis B infection
1
(1.5)
Hypoparathyroidism
2
(3)
ß-thalassemia major
ß-thalassemia is not known in Madinah region.
Splenomegaly were found in 69%, hepatomegaly in
78%, and abnormal facial configuration in 54%. These
findings indicate that our patients were receiving a
sub-optimal BT regimen. Although the patients were
maintain on hypertransfusion program but this could not
be applied to all patients as many had poor compliance
with the management protocol. Splenectomy was
performed on 34% of the patient; the indications were
increased transfusion requirements and massive
splenomegaly in all patients, except one with splenic
abscess. All our patients were over 5 years of age, and
none of the patients received polyvalent pneumococcal
and Haemophilus influenzae vaccines prior to
splenectomy, instead all received intramuscular
benzathine penicillin prophylaxis prior to surgery and
oral penicillin prophylaxis afterwards and none of the
patients developed post-splenectomy septicemia.
Therefore, we recommend that splenectomy can be
performed safely in children over 5 years of age with
thalassemia and that pre and postoperative penicillin can
be given prophylactically in the absence of the
recommended vaccines.
Gallstones in thalassemia major were not reported
previously, but one of our patient had gallstones, similar
case was reported recently by Krishna et al.2 Hepatitis C
virus antibodies were detected in 49% of our patients . A
lower prevalence was reported recently from the Eastern
province of KSA.3 Approximately 60-80% of HCV
infected children developed chronic hepatitis and almost
30% are prone to developed liver cirrhosis and
hepatocellular carcinoma, therefore, treatment for
chronic HCV infection is recommended to prevent
further complication. The recent report demonstrates a
high (72.2%) sustained biochemical and virological
response rate to combination treatment with alpha
interferon and Ribavirin despite infection with one type
of HCV (lb) genotype.4 Elevated ALT were observed in
45% of those with HCV infection and 75% of them had
raised serum ferritin (>2000 ng/ml), suggestive that
blood iron overloading and hepatitis C infection
contributed to liver damage in our thalassemic patients
whose compliance with DF therapy was less than
optimum, as 52% of our thalassemic patients had high
serum ferritin. Iron overload had a negative influence on
patients response to therapy and it has shown that
thalassemic patients with HCV infection had little
benefit from alpha interferon treatment. Two of our
patients had hypoparathyroidism with the prevalence of
3% lower than what reported by Chern et al.5 All the
patients had clinical symptoms of hypocalcemia and
none of the patients developed hypothyroidism. Cardiac
evaluation by x-ray, ECG, and echocardiogram were
carried out routinely to our patients after 10 years of age.
It revealed that 12% of investigated patients had
cardiomyopathy with left ventricular dysfunction. Three
of our patients (4.5%) died with cardiomyopathy at
approximately 20 years of age.
In conclusion, despite the use of iron chelation with
subcutaneous DF at earlier age but iron overload still the
major problem in thalassemia major and the leading
cause of death is cardiomyopathy. Tile oral chelation
agent becomes available, extensive education through
frequent workshops for patients and parents to improve
patients, compliance with DF is required. Recently, 2
workshops on compliance to treatment of thalassemia
were held in KSA by Thalassemia International
Federation, more of such workshops are required.
Finally, we recommend bone marrow transplantation for
children without organ impairment and further studies
are required to identify ß-thalassemia gene mutation in
Madinah region.
Received 8th February 2003. Accepted for publication in final form 7th June
2003.
From the Department of Pediatrics, Madinah Maternity & Children’s
Hospital, Madinah, Al-Munawara, Kingdom of Saudi Arabia. Address
correspondence and reprint requests to: Dr. Zakaria M. Al-Hawsawi,
Department of Pediatrics, Madinah Maternity & Children’s Hospital,
Madinah Al-Munawara, PO Box 6205, Kingdom of Saudi Arabia. Fax. +966
(4) 8368333. E-mail: zhawsawi@yahoo.com
References
1. Al-Awany BH. Thalassemia syndrome in Saudi Arabia
meta-analysis of local studies. Saudi Med J 2000; 21: 8-17.
2. Krishna KK, Diwan AG, Mithrea DK. Cholelithiasis in
thalassaemia major. J Indian Med Assoc 2002; 100: 258-259.
3. Al-Awamy BH, Al-Mulhim IA, Flemban SB, Al-Neem SA.
Evaluation of current management of homozygous
B-thalassaemia in Eastern Saudi Arabia. Saudi Med J 2002; 23:
1141-1142.
4. Li CK, Chan PK, Ling SC, Ha SY. Interferon and Ribavirin as
frontline treatment for chronic hepatitis-C infection in
thalassaemia major. Br J Haematol 2002; 117: 755-758.
5. Chern JP, Lin KH, Mitra DK. Hypoparathyroidism in
transfusion-dependent patients with beta-thalassemia. J Paediatr
Hematol Oncol 2002; 24: 291-293.
------------------------------------------------------------------------------------
Improving foot examination of diabetics
in primary care
Mohammed H. Al-Doghether, ABFM, SBFM.
mellitus is a common and serious problem in
D abetes
the Kingdom of Saudi Arabia (KSA) where
prevalence of diabetes approximately 12% of the
population as diabetic foot neglection leads to disability
of the patients as 50% of foot amputations are related to
diabetes.1 Due to several factors (peripheral neuropathy,
maculopathy and retinopathy) diabetics may not be
aware of their feet injuries. Early detection would save
patient’s life in terms of quality and quantity. For this
reason, diabetic foot examination has been considered as
part of many protocols for diabetic care.2 The aim of
www.smj.org.sa
Saudi Med J 2003; Vol. 24 (9)
1029
Improving foot examination of diabetics
Table 1 - Comparative outcome for the first and second periods.
Patient characteristics
Perform foot examination
Period 1
February - March 1999
N=282
n (%)
22
(7.8)
Period 2
July - August 1999
N=254
n (%)
Rate difference
95% Confidence interval
p value
134 (52.7)
-0.449 (0.382 - 0.515)
0.001
this study is to assess whether it is possible, by diabetic
foot reminder, to improve foot examination of diabetics
in primary health care centers (PHCC).
The data were collected in 2 periods with a 6 weeks
duration where diabetic patients were identified from
diabetic clinic register with 282 patients. Data was
collected from the annual checklist (which attached to
the file of diabetics) or from follow up sheets. If both
(annual checklist and follow up sheet) were not
including any document on foot examination, then this
would be considered as "no foot examination done".
The team (manager, nurses and general practitioners)
were circulated the data from the first period (Period 1
February-March 1999) along with the key articles from a
literature search on diabetic foot care.3
A practice
meeting was then held with doctors, nurses, and manager
of PHCC working in a small group to formulate an
evidence-based standard of diabetic foot care. Figures
from the literature were ranging from 45-70% of diabetic
patients had their feet examined.4 Seventy percent was
targeted by the team to be fulfilled in 4 months. An
evidence-based diabetic foot examination reminder was
designed to discuss the vascular, neurological, and
musculoskeletal status of the foot. The data was
collected by the same manner at the second period
(Period 2 July-August 1999) to check the effect of the
intervention tool (diabetic foot examination reminder) on
the results. During Period 1, a total of 22 diabetic
patients out of 282 (7.8%) had their feet examined in the
last 12 months, while 260 (92.2%) without foot
examination was carried out in the last 12 months.
During the second period, a total of 47 diabetics had
been registered, bringing a number of diabetics to 329
patients. Two hundred and fifty-four diabetics attended
the clinic during the fourth months period (between
Period 1 and 2). One hundred and thirty-four (52.7%)
of those attended the clinic had foot examination, while
120 diabetics (47.2%) had no foot examination. During
the Period 2, there had been a rise in achieving foot
examination from 7.8-52.7% of diabetic patients (Table
1).
The main findings from the study was that the diabetic
foot examination was almost neglected in Period 1,
which showed a considerable defect in quality of care for
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Saudi Med J 2003; Vol. 24 (9) www.smj.org.sa
diabetic patients and deficiency in applying a good
practice in PHCC. This poor quality of diabetic foot
care is not rare in primary health care settings.
However, foot examinations were performed at least in
85% of diabetic patients in other good practiced primary
care settings.5 Fifty-two percent of our diabetics had foot
examination over 4 months, which was a good
achievement. The study showed that there was a
dramatic improvement of performing foot examination
after using the reminder over 4 months. Further
improvement might be expected over applying the
reminder for a year or more. However, we feel that one
of the main reasons for the success in implementing the
diabetic foot examination reminder is that we employed
a multidisciplinary approach.
In conclusion, using a multidisciplinary diabetic foot
examination reminder, it is possible to increase the
performing of diabetic foot examination and quality of
diabetic foot care thereafter.
Received 8th February 2003. Accepted for publication in final form 7th June
2003.
From the Center of Postgraduate Studies in Family Medicine, Ministry of
Health, Riyadh, Kingdom of Saudi Arabia. Address correspondence and
reprint requests to: Dr. Mohammed H. Al-Doghether, Consultant Family
Medicine, Director, Center of Postgraduate Studies in Family Medicine,
Ministry of Health, PO Box 90945, Riyadh 11623, Kingdom of Saudi Arabia.
Tel. +966 (1) 4961860. Fax. +966 (1) 4970847. E-mail:
doghether@hotmail.com
References
1. Meshikhes AN, Al-Dhurais S, Al-Rasheed M, Al-Askar E,
Al-Kassab A. Diabetic foot: presentation and surgical
management at Dammam Central Hospital. Saudi Med J 1998;
19: 45-49.
2. Lavery LA, Armstrong DG, Vela SA, Quebedeaux TL, Fleischli
JG. Practical criteria for screening patients at high risk for
diabetic foot ulceration. Arch Intern Med 1998; 158: 157- 162.
3. Mayfield JA, Reiber Ge, Sanders LJ, Janisse D, Pogach LM.
Preventive foot care in people with diabetes. Diabetes Care
1998; 21: 2161-2177.
4. Wyile RJ, Walker EA, Shamoon H, Engel S, Basch C, Zybert P.
Assessment of documented foot examination for patients with
diabetes in inner-city primary care clinics. Arch Fam Med 1995;
4: 46-50.
5. Jensen T, Musaeus L, Molsing B, Lyholm B, Mandrup T.
Process measures and outcome research as tools for future
improvement of diabetes treatment quality. Diabetes Res Clin
Pract 2002; 56: 207-211.
Prevalence of HBV & HCV
Prevalence of hepatitis B virus and
hepatitis C virus in health workers in 3
major hospitals in Aden, Republic of
Yemen
Ahmed S. Al-Jarba, MBBS, MD,
Waleed M. Al-Sayyari, Dip (Lab).
B virus (HBV) and hepatitis C virus (HCV)
H epatitis
are common and serious viral infections affecting
the liver. In significant number of patients, the disease
develops into chronic liver disease, cirrhosis and
hepatocellular carcinoma. In HCV, for example, there is
a 20% chance of the affected person developing cirrhosis
or hepatocellular carcinoma after a mean period of
follow up of 20 years. Similar but less aggressive course
has been reported with HBV. As much as 44.5% of
cases of hepatic cancer are associated with HCV
according to a report from Germany. The major route of
transmission is blood, through blood transfusion or
intravenous drug abuse,1 or by contaminated parental
injections of medicaments as occurred in Egypt.
Hepatitis B virus is more infectious but its incidence has
dropped markedly with the use of vaccination. As the
blood route is essential, we felt that it would be useful to
investigate the prevalence rates of these 2 viral agents in
the workforce of 3 major hospitals in Aden, Republic of
Yemen.
Blood was extracted from 576 hospital employees in 3
major hospitals in Aden (Al-Gamhorria Teaching
Hospital, Aden General Hospital and Al-Wahdah
General Hospital). The total number of employees in
these hospitals was 1450 and we investigated 39.7%.
Aden is the second largest city in the Republic of Yemen
and it is the commercial capital. It has a population of
approximately 750,000 and its residents generally
represent the population of Yemen. The mean age was
31.1 years (range 16-57.8 years) and 51% were males.
The majority tested was nurses (298) followed by
doctors (94), technical staff (86), administrators (55) and
maintenance staff (43). The method used for detecting
HCV was enzyme immunoassay (enzyme-linked
immunosorbent assay, third generation). In our hands,
the sensitivity of the test was 92% and specificity was
100%. Hepatitis B virus was detected using enzyme
immunoassay method. For comparative analysis,
Student’s t-test was used. For non-comparable
parameter’s Chi-square test was applied.
The vast majority of the cohort studied was in the age
range of 20-39 years (80.5%). Virtually equal numbers
of males (51%) and females were studied (49%).
Interestingly, there were 2 peaks of HBV positivity at
the lower age range (10-19 years), higher age range
(6.6%) and 50-60 years age range (20%). In the middle
age range (20-39 years), the prevalence was only 3.8%.
By contrast, all the cases found to be HCV positive were
in the age range 39-49 years. Perhaps the opposite of
what would be expected, the lowest HBV prevalence
was found in the laboratory technician’s group, even
lower than that in the general population (1.3%). The
highest prevalences of 9% were found in the x-ray and
maintenance technicians. Doctors were 6.4%, nurses
were 3.1% and administrators 7.3%. Conversely, most of
the HCV positive found were in the doctors’and nurses’
groups (80%). The overall prevalences of HBV and
HCV were 5.5% and 1.3%. There was no effect of
gender on the prevalences of HCV. Similarly, there was
no effect of gender in the prevalence of HBV in our
study being 5% and 3.9% in males and females (p value
is not significant). A smaller group of hospital
employees were studied in 1997 for HBV prevalence
and found to be 3.4%. The increase to 5.5% in 2002 was
not statistically significant.
The incidence and prevalence of HBV and HCV are
variable from country to country. Hepatitis C virus
incidence has been reported to be particularly higher in
hemodialysis units in our countries, USA (8-36%),
Europe (1-54%), South America (39%) and Asia
(17-51%).
The prevalences for HBV are also
geographically variable (0.1-2%) in USA and Europe,
3-5% in Japan, Middle East and Latin America and
10-20% in China, Sub-Saharan Africa and South East
Asia.
The literature suggests that there is no increased
prevalence of HCV in health workers.3 However, needle
sticks injury is an independent risk factoring the
prediction of the presence of HCV.4 The average
seroconversion rate following an accidental needle stick
injury is 1.8-10%.5 Our findings confirm the low
prevalence in our health workers. The chances of an
HCV positive health worker infecting a patient is also
very low (0.002%).6 Standard precautions (formerly
known as universal precautions) should be used in all
patients. This should include wearing gloves whenever
handling blood or bodily secretions or excretions or
contaminated equipment or needles and so forth. A
mask, gown and eye protection gear should be used in
any procedure likely to be associated with splashing.
In conclusion, the prevalences of HBV (5.5%) and
HCV (1.3%) in the health workers in Aden are lower to
that in the general population and that there has been no
significant change since 1997. No differences were
detected in genders. There was a higher prevalence of
HCV in the middle age range and in the 2 ends of the
age ranges in HBV. The findings concerning age
distribution are similar to what has been reported
previously.
www.smj.org.sa
Saudi Med J 2003; Vol. 24 (9)
1031
Prevalence of HBV & HCV
Received 12th May 2003. Accepted for publication in final form 3rd June
2003.
From the Faculty of Medicine, University of Aden, Republic of Yemen.
Address correspondence and reprint requests to: Dr. Ahmed Al-Jarba, c/o Dr.
A. Al-Sayyari, Armed Forces Hospital, PO Box 7897, Riyadh 11159, Kingdom
of Saudi Arabia. Fax. +966 (1) 4791000 Ext. 3837.
References
1. Alter HJ, Purcell RH, Shih JW, Melpolder JC, Houghton M,
Choo QL et al. Detection of antibody to hepatitis C virus in
prospectively followed transfusion recipients with acute and
chronic non-A, non-B hepatitis. N Engl J Med 1989; 321:
1494-1500.
2. Schumunis Zickerf GA, Segura IL, Delpazo AE.
Transfusion-Transmitted Infectious Diseases in Argentina 1995
through 1997. Transfusion 2000; 40: 1048-1053.
3. Polish LB, Tong MJ, Co RL, Coleman PJ, Alter MJ. Risk
factors for hepatitis C virus infection among health care
personnel in a community hospital. Am J Infect Control 1993;
12: 196-200.
4. Recommendations for prevention and control of hepatitis C virus
(HCV) infection and HCV-related chronic disease. Centers for
Disease Control and Prevention. MMWR Recomm Rep 1998; 47
(RR-19): 1-39.
5. Mitsui T, Iwano K, Masuko K, Yamazaki C, Okamoto H, Tsuda
F. Hepatitis C virus infection in medical personnel after
needlestick accident. Hepatology 1992; 16: 1109-1114.
6. Ross RS, Viazov S, Roggendorf M. Risk of hepatitis C
transmission from infected medical staff to patients:
model-based calculations for surgical settings. Arch Intern Med
2000; 160: 2313-2316.
Erratum
In manuscript “Comparison of the growth standards between Saudi and American children aged 05 years” Saudi Medical Journal 2003; Vol. 24 (6): 598-602, the name of the co-author Mohamed K.
Khalil should have appeared in the footer section as follows:
Medical Education & Research Center, King Fahd Specialist Hospital, Buraidah, Kingdom of
Saudi Arabia.
Erratum
In manuscript “Strategy to improve road safety in developing countries” Saudi Medical Journal
2003; Vol. 24 (6): 603-608, in Table 4 the meaning of JD should have appeared as Jordanian Dinar.
1032
Saudi Med J 2003; Vol. 24 (9) www.smj.org.sa