Yagob Y. Al-Mazrou

Rift Valley Fever Epidemic in Saudi Arabia: Epidemiological, Clinical, and Laboratory Characteristics

This cohort descriptive study summarizes the epidemiological, clinical, and laboratory characteristics of the Rift Valley fever (RVF) epidemic that occurred in Saudi Arabia from 26 August 2000 through 22 September 2001. A total of 886 cases were reported. Of 834 reported cases for which laboratory results were available, 81.9% were laboratory confirmed, of which 51.1% were positive for only RVF immunoglobulin M, 35.7% were positive for only RVF antigen, and 13.2% were positive for both. The mean age (+/- standard deviation) was 46.9+/-19.4 years, and the ratio of male to female patients was 4:1. Clinical and laboratory features included fever (92.6% of patients), nausea (59.4%), vomiting (52.6%), abdominal pain (38.0%), diarrhea (22.1%), jaundice (18.1%), neurological manifestations (17.1%), hemorrhagic manifestations (7.1%), vision loss or scotomas (1.5%), elevated liver enzyme levels (98%), elevated lactate dehydrogenase level (60.2%), thrombocytopenia (38.4%), leukopenia (39.7%), renal impairment or failure (27.8%), elevated creatine kinase level (27.3%), and severe anemia (15.1%). The mortality rate was 13.9%. Bleeding, neurological manifestations, and jaundice were independently associated with a high mortality rate. Patients with leukopenia had significantly a lower mortality rate than did those with a normal or high leukocyte count (2.3% vs. 27.9%; odds ratio, 0.09; 95% confidence interval, 0.01-0.63).

Overweight and obesity in Saudi Arabian adult population, role of socio-demographic variables

The objectives of this Community-based National Epidemiological Household Survey, conducted between 1990–1993, were to estimate the prevalence of overweight and obesity in Saudi Arabia and to examine its association with the socio-demographic characteristics of the adult population. A sample of Saudis 20 years and over was selected using a multistage stratified cluster sampling technique with probability proportionate to size. The selected subjects were requested to visit primary health care centers in their localities. Physicians in these clinics took measurements of heights and weights and collected other relevant data. Obesity was measured by the Body Mass Index, using the Quetelet Index. The results showed the sample of 10,651 subjects of which 50.8% were males, had a mean age of 35.8 years (SD = 14.27 years). The prevalence of overweight was 31.2% (95% confidence interval: 30.3%, 32.1%); 33.1% for males and 29.4% for females. For obesity, the overall prevalence was 22.1%; males 17.8% and females 26.6%. The study design suggested that these estimates could be closer to the true values. The multiple logistic regression analysis showed that age, residential area, region, income, gender, and education are statistically significant predictors of obesity. The prevalence of obesity was higher in females than males, lower in subjects living in rural areas with traditional lifestyles than those in more urbanized environments, and increased with increasing age. The observed prevalence and pattern of overweight and obesity with age and gender is similar to those observed in the Arab community and some Western nations. There is a need for increased physical activity and better nutrition education programs to reduce the extent of obesity and to pre-vent the serious health consequences, especially, in the middle age group.

Prevalence of hypercholesterolemia in Saudi Arabia, epidemiological study

The objective of this study was to look at the pattern of serum total cholesterol concentration (TCC) distribution and the prevalence of hypercholesterolemia (HC) in Saudi Arabia. A cross-sectional national epidemiological household survey was carried out, consisting of 4539 Saudi subjects, over the age of 15 years. The sample was adjusted for gender, age, regional and residency, and urban versus rural population distribution. The following details were taken for each subject: height, weight, calculation of body mass index (BMI) and random blood samples for total cholesterol measurements. It was found that the mean TCC for all female subjects was significantly higher than for male subjects (4.24 versus 4 mmol/l). The mean TCC of female subjects, aged 40-59 years was higher, but not significantly so, than for male subjects (4.5 versus 4.4 mmol/l). There was a progressive increase in TCC with age, reaching a maximum at the fifth and sixth decades for male and female subjects, respectively. There was a progressive increase in mean TCC with increasing BMI values for male and female subjects with higher values of mean TCC for female subjects for any given BMI value. The prevalence of HC, 5.2-6.2 mmol/l was 9% and 11% for all male and female subjects, respectively (P = 0.74), whereas the prevalence of HC, > 6.2 mmol/l was 7% and 8% for male and female subjects, respectively (P = 0.52). The prevalence of HC 5.2-6.2 mmol/l for subjects aged 40-59 years was 14% and 10% for male and female subjects, respectively (P = 0.67), whereas the prevalence of HC > 6.2 mmol/l was 9% and 11% for male and female subjects, respectively (P = 0.6). There was a progressive increase in the prevalence of HC with age for male and female subjects. The prevalence of HC > 5.2 mmol/l increased with increasing BMI values. The prevalence of HC of female subjects was significantly higher than for male subjects among normal weight groups. The prevalence of HC (> 6.2 mmol/l) for female subjects was higher, however, not significant than for male subjects among overweight and obese groups. The prevalence of HC, whether for male or female subjects, was higher among diabetics when compared with non-diabetic subjects. The prevalence of HC (> 6.2 mmol/l) among male subjects was higher for smokers when compared with non-smokers. It was concluded that Saudi subjects have lower prevalence of HC than the European and American populations. This can partially be explained by the younger nature of the population. The prevalence of HC is likely to increase in the near future with the increasing percentage of the aged population in the community, and with the effects of a longer exposure to the acquired western life-style and nutritional habits, which is showing an impact with the increase in the prevalence of obesity. The cause of coronary heart disease is multifactorial, HC being one of the main contributors. Therefore, there is a need to study, in detail, the prevalence of other risk factors, such as: obesity, smoking, hypertension etc. There is a need to promote health awareness among the population with an emphasis on controlling weight and carrying out periodic cholesterol measurements.

HIV/AIDS epidemic features and trends in Saudi Arabia.

BACKGROUND More than 60 million persons have been infected since AIDS was described in 1981. By the end of 2003, an estimated 40 million individuals were living with HIV globally. The surveillance of HIV/AIDS still faces challenges in Saudi Arabia. This study describes the pattern and characteristics of HIV/AIDS cases in Saudi Arabia. METHODS This descriptive analytic study describes the reported HIV/AIDS data for all notifiable cases during the period 1984 to 2003 in the Kingdom of Saudi Arabia. Case definitions based on ELISA and Western Blot tests were used. Age, sex and regional distribution were studied in addition to survival rates. RESULTS As of 2003, 1743 Saudi nationals and 6064 non-Saudi HIV cases were reported. Among Saudis, 872 were AIDS cases. Males accounted for 1329 HIV infections, comprising 77%, with a male-to-female ratio of about 3:1. Adults 15–49 years constituted 78% of cases, including 46% of cases infected through sexual activity, while 33% of reported HIV seropositive cases had already died. Most cases (67%) were registered in Jeddah, Riyadh and Dammam. Infection through blood transfusion declined with no reported cases since 2001. CONCLUSION The number of reported HIV infections in KSA has increased in the last few years. Using the coverage rate estimating method, the number of Saudi HIV infections since the emergence of the epidemic was estimated to be 2640 cases as of the beginning of the year 2004. The estimated number of HIV infections is almost one and one-half times the reported number, indicating that a problem of underreporting of HIV/AIDS cases still exists.

Iodine deficiency in Saudi Arabia.

Data on the status of iodine deficiency in the Arabian peninsula is scarce. We have conducted a cross-sectional national epidemiological survey in Saudi Arabia to study the iodine status of Saudi schoolchildren, between eight and ten years, who were randomly selected, after taking into consideration the gender, provincial population and area distribution. Casual urine samples were collected and sent to the central laboratory for analysis. Clinical assessment for the presence of goiter was conducted in four areas with different geographical natures. The survey included 4638 subjects, and their median and mean (SD) of urinary iodine concentration was 18 and 17 m g/dL, respectively. We found provincial differences with respect to urinary iodine concentration and the percentage of subjects with urinary iodine concentration <10 m g/dL. The Southern province had the lowest median (11 m g/dL) and the highest percentage (45%) of subjects with urinary iodine concentration <10 m g/dL. On the other hand, subjects of the Western province had the highest median (24 m g/dL) and the lowest percentage (8%) of subjects with urinary iodine concentration <10 m g/dL. The clinical assessment revealed that the highest prevalence and more advanced grade of goiter (22%, 95% CI 19-25, grade 1; 8%, 95% CI 6-10, grade 2) was found in the Asir region, a high-altitude area in the Southern province. The lowest prevalence of goiter (4%, 95% CI 0.8-7.2, grade 1) was found in Gizan, an urban coastal community. There was a significant relationship between the prevalence of goiter and the urinary iodine concentration. The survey for iodine deficiency disorder (IDD) in Saudi Arabia has shown a mild degree of iodine deficiency in the Southern province. Odds ratio (OR) was used to study the statistical relationship between the prevalence of goiter and the urinary iodine concentration. There is a need to launch a control program to ensure the exclusive availability of iodized salt in Saudi Arabia, especially in the Southern province.

PATTERN AND FACTORS ASSOCIATED WITH GLYCEMIC CONTROL OF SAUDI DIABETIC PATIENTS

BACKGROUND The pattern and factors which can be associated with the glycemic control of Saudi adult diabetic patients were examined in this study. PATIENTS AND METHODS Confirmed diabetic patients from all regions of Saudi Arabia constituted the study population. Random blood glucose <10 mmol/L and >10 mmol/L was used to categorize patients into good and poor glycemic control patients, respectively. RESULTS There were 613 confirmed non-insulin dependent diabetic patients (NIDDM), 50% with good glycemic control. Patients with poor glycemic control were significantly older than patients with good glycemic control (51.5 vs. 47 years, P=0.0001). The insulin-treated diabetic population amounted to 13%, compared with 43% and 44% for oral agent and diet, respectively. The rate of insulin users among poor glycemic control diabetic population was 18%, compared with 50% for oral agents. There was a significant relationship between glycemic control and age, and treatment modalities of DM. Subjects who had good glycemic control of DM were younger and following a diet regimen, while those who had poor glycemic control were older and on insulin treatment. Multivariate analysis comprising 415 individuals was conducted to find out the factors that can potentially influence, or may be associated with, the control of DM. CONCLUSION The association of insulin therapy with poor glycemic control is not a cause-effect relationship. Insulin therapy in our study population is underutilized, given the high rate of poor glycemic control and high rate of relative occurrence of complication among the Saudi diabetic population. There is a need to address the importance of maintaining good glycemic control, and the reason for the low rate of insulin users. Close periodic monitoring of glycemic control, utilizing laboratories and home glucose monitoring devices, is required. Effective implementation of these measures, in addition to diabetes education, will have an impact on the future outcome of the Saudi diabetic population.

Haemophilus Type B Meningitis in Saudi Children under 5 Years Old

This study was designed to determine the magnitude of bacterial meningitis in general and Hib meningitis in particular among children below the age of 5 years. A population-based, prospective descriptive and analytical study was conducted in five regions, one each in northern, southern, eastern, western, and central parts of Saudi Arabia. Active surveillance for cases of bacterial meningitis among the study population, which comprised 171,818 children under 5 years of age, was implemented. A total of 208 cases of meningitis were identified, of which 141 (67.8 per cent) were identified with a definite causative organism. The remaining 67 cases (32 per cent) were labeled as aseptic meningitis. The overall incidence of meningitis was 60.53/10(5) in under-fives with a disease spectrum similar to that reported in studies conducted in other countries. The three leading causes of meningitis were Hib (Haemophilus influenzae type B), MCM (Neisseria menigitides) and SPN (Streptococcus pneumoniae). Hib meningitis constituted 28 per cent of cases with an incidence rate of 16.88/10(5) children. There was a marked regional variation in Hib incidence. MCM was the second leading cause (18 per cent) of meningitis with an incidence of 10.77/10(5) while SPN comprised 11 per cent of cases and its incidence was 9.69/10(5). Almost all MCM cases were related to meningitis outbreaks that occurred in Saudi Arabia during two successive Hajj seasons (2000-2001). Hib cases showed a bimodal seasonality, one peak during March-May, the other during September-November. The fact that this study is the first national base-line data on meningitis in general and Hib incidence in particular, has augmented further justification for introducing Hib vaccine within the national Expanded Program on Immunization (EPI). Based on the experience gained during this study regarding surveillance of meningitis disease, optimal methods to strengthen meningitis surveillance were identified. A model of Meningitis Diseases Surveillance was generated that can be tested and then generalized. The study has documented beyond doubt the impact of Hajj seasons on MCM disease occurrence and further justifies the rigorous control and preventive measures being taken in this aspect.

Breastfeeding and Weaning Practices in Saudi Arabia

A National Child Health Survey was conducted during 1987 for which a stratified multi-stage sampling was done. Out of the 8482 mothers interviewed 6131 had at least one live birth 5 years or less before the survey. Eighty-two per cent of the currently breastfed children, were less than 6 months of age, but only 55 per cent of the infants up to 1 month of age were breastfed without supplementation. The mean interval between supplementation and weaning for all age groups of mothers was 7.7 months. The predominant causes of weaning were child reaching suitable age and mother not having enough milk. This study establishes base line information about feeding practice on a nationwide basis in Saudi Arabia.

Screening of pregnant Saudi women for hepatitis B surface antigen.

Background The high prevalence of hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) in pregnant women is considered the most important factor contributing to the higher carrier rate of HBsAg in some populations, including Saudi Arabia. Universal hepatitis B vaccination in infancy was implemented in Saudi Arabia in 1990 to avoid early acquisition of infection. At the same time, another program was launched to vaccinate all school children at school entry as a second target group. The aim of this study was to evaluate the HBsAg prevalence rate in Saudi pregnant women 12 years after launching the program and to assess regional variation, if any. Methods In a cross-sectional study, 2664 pregnant Saudi women were recruited from the five main regions in Saudi Arabia. Blood samples were tested for HBsAg. Positive samples were tested also for HBeAg. Results Of 2664 pregnant Saudi women, 65 were positive for HBsAg (2.46%, 95% Cl=2.11 %– 2.69%). Four were positive for HBeAg (0.15%). The HBsAg prevalence rate was higher in Gizan (4.2%) and lower in Tabuk (1.4%) (P=0.035). Only one case was positive for HBsAg in women under the age of 20 years (1/186), a 0.5% positivity rate in this age group compared with 2.6% in the older age group (P=0.049 for the one-sided test). A history of surgical procedures was associated with a higher (3%), but not significantly higher rate of HBsAg positivity. No significant association was found between HBsAg positivity and a history of dental procedures or blood transfusion. Conclusion Although the HBsAg prevalence rate among Saudi pregnant women was lower than previously published data, the full impact of the hepatitis B vaccination program in infancy and childhood will take more years to decrease the prevalence rate in pregnant women. The MOH should continue to give the first dose of hepatitis B vaccine at birth to prevent early acquisition, but in the meantime a regional policy can be adopted to deal with the high prevalence rate of HBsAg among pregnant Saudi women.

Changing marriage age and consanguineous marriage in Saudi females.

Current marital age and consanguinity are not precisely known in Saudi Arabia. Saudi National Child Health Survey data were used to examine marital age, consanguinity, status and outcome of marriage of Saudi females. The survey (1987-88) involved interviewing 8482 ever-married urban and rural females by 120 female nurses. The results showed that 16% of young females and about 1% of young males were married before age 20. The rate of first marriage of females under 15 years of age decreased from 33% 20 years earlier to only 3.6% recently. The highest of 90% of females (35 to 39 years) and 98% of males (50 to 54 years) were currently married. Widowhood increased from 8% in the age group 40 to 44 to nearly 54% in those 70 over. Over all, nearly 0.5% of males and 3.4% of females remained widowed and 0.2% of males and 1.2% of females divorced. Thirty-four percent of all marriages were to first cousins in urban areas and 41% in rural areas. Thirty percent of marriages among literate groups and 39% in illiterate groups were consanguineous. Further research is needed to examine the causes and effects of (1) intercousin and (2) delayed marriage of females and (3) the welfare status of widowed and divorced females and their children.