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 1028 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 1030 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