404 not found microsoft word gjphm-2020editorial.docx 107 global journal of public health medicine 2020, vol 2, issue 1 gggggglo editorial opinion the effects of predatory journals on quality of scientific research associate professor dr. hasanain faisal ghazi editor in chief, global journal of public health medicine * corresponding author: hasanain@gjphm.org predatory journals as defined by beall in 2012 are publishers “which publish counterfeit journals to exploit the open-access model in which the author pays” and also publishers that were "dishonest and lack transparency". any journal accepts the manuscript without any real and indepth evaluation by reviewers are considered as predatory journals. in recent years, many predatory journals have been published worldwide in many research fields. unfortunately, some of them found in the big and trustable research databases. they are only interested in financial profit. there is no real evaluation of the paper. once the fees are paid, the paper will be accepted and, in some cases, it can be accepted on the same day. the problem with this type of research paper when it gets indexed in those big databases and researchers start to cite all those unchecked and unevaluated researches. some of the strategies and recommendations by universities to overcome this phenomenon can be: § forming a committee at university level to follow up on predatory journals in reputable databases and creating a database that periodically updates for this purpose and can be made online so that researchers can view them and journals that included in them are the ones that do not create a real evaluation of the research and accept the paper quickly. § adopting personal correspondence between the researcher and the journal to approve research for scientific promotion to eliminate the phenomenon that agents or companies sending manuscripts to journals, and this in itself is a violation of scientific evaluation and ethics of scientific research. § adopting a minimum period between submitting the research and accepting it by the journal, so it is not possible to accept the paper within a short period as this means that the journal did not send the research to real reviewers and allow the researcher to answer the reviewers 'inquiries and make revisions to improve the research. some journals display the submission and acceptance date on published articles. the necessity of updating the lecturers periodically by their universities about the journals that discontinued from reputable databases such as scopus and clarivate analytics, as some do not know that the 108 global journal of public health medicine 2020, vol 2, issue 1 gggggglo journals were out form the database, as some journals are deliberately keeping the scopus logo on its website to make the researchers think that the journal is still indexed in scopus database. § the necessity of establishing a specialized research centre in every university called (research management centre). these centres aim to manage the research process at the university level and direct researchers to publish in reputable journals. the duties of these centres are as follows: o create a database for all research carried out by the university, whether at the undergraduate or graduate level. o responsibility to establish research grants for researchers and funding can be from the private sector through long-term partnerships. o conduct workshops periodically to develop researchers especially in the field of scientific publishing and select high-quality journals. o establishing an ethics committee to examine and approve all research that has direct contact with humans or even animals, before conducting them to avoid many of the mistakes that the researcher may make during the collection of samples and later when publishing the research findings. o making plans for scientific research for each faculty before the beginning of the academic year so each researcher can know what is required from him/her, such as the number of research and the number of articles that must be published in that academic year. o researchers are periodically updated for reputable journals and also discontinued journals from the scopus and clarivate analytics databases. as a conclusion, the revised definition of predatory journals should be any journal that does not follow the scientific procedure in submitting, evaluation and publishing the manuscript even if it was well indexed in big research databases. reference • predatory publishers are corrupting open access. beall j nature. 2012 sep 13; 489(7415):179. microsoft word gjphm-2020burger effect.docx 164 global journal of public health medicine 2020, special issue gggggglo review research review on the burger effect: beef industry and climate change rehab a. rayan department of epidemiology, high institute of public health, alexandria university. corresponding author: rayanr@alexu.edu.eg abstract the world needs to decrease emissions from agriculture, and fossil fuels to halt global warming adequately. animal-based meals are nourishing and very vital to livings and nutrition in developing nations, though they are a similarly incompetent source. producing beef is growing further dynamic, yet forests are still being cut down. people state they desire to consume more plants, although eating beef is yet increasing. consuming meat is among the main factors for global warming. provided that the globally growing market for meat, and the severe effect of manufacturing meat on the planet, cutting down animal protein regarded as public health and food security concern. a future with sustainable food would need a variety of approaches from the farmer to the consumer. this review explores the relation between producing beef and the emission of greenhouse gases (ghgs) and the debate of consuming more or fewer resources. it also displays the beneficial impact of cutting down beef consumption. finally, it suggests some methods to produce beef sustainably. keywords : sustainability, environmental health, climate change, global warming, beef. 165 global journal of public health medicine 2020, special issue gggggglo introduction growing beef production demands to expand land. modern grasslands are usually formed by cutting trees and thereby emitting the housed carbon dioxide in the woods. as cows and other ruminant animals such as sheep and goats feed on plants and grasses, they release methane (a strong greenhouse gas) in a process called enteric fermentation, and it is where the regurgitates of cows come from., methane is also released from compost. nitrous oxide (another potent greenhouse gas) is released from the wastes of ruminant animals on grasslands and synthetic fertilizers applied on farmed crops for feeding cattle (bryan et al., 2013). in 2019, the food and agriculture organization (fao) estimated that the cumulative emissions per year from animal agriculture were about 14.5% of all man’s emissions, of which beef contributed 41% (fao, 2019). the need for meat and other ruminant meats worldwide may grow by 88% from 2010 to 2050, adding immense burden on biodiversity, woods and the climate., grassland might yet extend approximately 400 million hectares to satisfy this increasing need. the resulting deforestation might raise greenhouse emissions, which can make the aim of limiting temperature rise by 1.5-2 ̊c unachievable (pendrill et al., 2019; us epa, 2019). producing beef consumes more or fewer resources ruminant animals have less reproducing and growing rates than poultry and pigs, therefore for each given meat, they need a larger quantity of pasture. beef consumes more manufacturing resources than other animal-derived foods, which intern consume more resources than plant-derived ones. beef needs more land and releases more gases for each dietary protein gram than that of traditional plant ones, like beans, most of the globe’s fields could not raise trees or crops as they heavily produce livestock. hence, the extra beef would intensify the pressure on woodlands (wirsenius, 2003). many statistics consider emissions from producing beef without these related to alteration in using the land. for instance: in 2017, the environmental protection agency in the u.s. determined that the entire u.s. farming emissions at just 8% of the total u.s. emissions; in 2017, a study published in the national academy of sciences proceedings estimated that eliminating all the u.s. agriculture animals could decrease u.s. emissions by 3%. in 2019, a study in agricultural systems estimated emissions from producing beef at just 3% of total u.s. emissions (us epa, 2019). in egypt, agricultural growth would cause environmental consequences involving increased demand on water, competition over land and climate change by ghgs, like methane, produced by livestock animals. every year, egypt consumes about 10 m tonnes of red meat. for egypt’s ghg emissions, the total emissions rise steadily with an average increase of 5.1% each year, and livestock agriculture is the second-largest producer of ghgs (fao, 2017). meanwhile, a land area dedicated to producing food might store much-added carbon with its natural plants or if left to become a forest. demanding beef is growing worldwide, and consumption by one country could lead to landuse consequences and emissions for another. for instance, a rise in consuming beef in the u.s. could derive deforestation for creating grassland in latin america and vice versa (rotz et al., 2019; white & hall, 2018). cutting down beef consumption many studies disclose the public unwillingness to cut down consuming meat for an ecological cause. furthermore, vegetarians consider environmental issues are just a rationale to argue for their diet habits rather than a genuine motive to abandon animal products. meanwhile, the current evidence demonstrates that environmental justifications are attractive for considerable numbers of meat-eaters to follow specific meat reduction plans such as meat-free days. such an attraction is further widespread between females and individuals with particular cultures (sanchez-sabate & sabaté, 2019). however, controlling climate change would not need everybody turning into vegetarian or vegan or quit consuming meat. in highly consuming nations, if eating bovine beef decreased by approximately 1.5 burgers for each individual weekly or 50 calories daily, this might almost drop the call for further agricultural enlargement and the related deforestation, yet in a world including 10 billion population. following 1970, u.s. beef consumption individually has dropped by one-third (willett et al., 2019). since poultry emits fewer greenhouse gases (ghgs), for their less enteric methane-producing rates than ruminant farm animals, it is regarded as environmentally friendly in relation to other sources for animal protein (poultryworld, 2016). 166 global journal of public health medicine 2020, special issue gggggglo the market for plant-derived substitutes is flourishing. for instance, mixed beef-plant alternatives and plant-derived burgers are steadily competing with traditional beef products on essential qualities such as cost and flavour. persuasive argues for switching to plant-derived diets is that consuming red meat is correlated to raised risks of colorectal cancer, stroke, heart diseases, and type 2 diabetes and that foods with greater healthy plant-derived components like legumes and nuts, vegetables and fruits and whole grains are correlated to fewer risks (willett et al., 2019). in high-income countries such as those in europe and north america, individuals eat more protein to fulfil the dietary requirements. in the developing nations, provided the expected future increase in meat demand, even if higher-income countries consume less beef, the world meat market would probably proceed to expand shortly. by 2050, it is anticipated that the universal consumption of ruminant meat will increase by 32%. growing consumption in countries like china will drive added trading opportunities in leading meat-producing nations. however, leading beef businesses are investing in the rapidly evolving protein alternative market. they are marketing for themselves as they operate to diminish emissions from producing beef in their supply chains through advanced production methods (gibson, 2017). sustainable beef production the intensity of emissions out of producing beef differs significantly all over the globe and enhancing the efficiency in producing farm animals could mostly minimize the utilized land and emissions for each meat pound. advancing pasture conditions and animal care, growing better animal breeds, which in turn produce milk and beef with increased productivity, and adopting enhanced control systems such as grazing rotationally could promote productivity and soil health meanwhile diminishing emissions (plumer, 2018). promoting productivity could reduce demand on tropical jungles by decreasing the need for grassland. for instance, in colombia, producing beef combines grasses and trees toward grasslands. hence, the land yields a higher amount of quality pasture. therefore, farmers could grow more bovine for each acre meantime considerably lessening emissions of methane for each meat pound. in kenya's dairy farms, improving the cattle's conventional food including better quality grass and high protein was found to fasten the growth of cattle, increase milk production and diminish emissions of methane for each milk litre from 8% to 60%. moreover, feeding additives could considerably decrease the cows' burping. better managing fertilizers and applying techniques to limit nitrogen in the waste of animals could additionally diminish farming emissions (bryan et al., 2013; byrnes et al., 2017; hristov et al., 2015). provided that the diet patterns are dynamic, and the mass media spotlight on sustainable nutrient systems and foods is growing, it is possible that environmental issues turn into a spark to at least modest cuts in eating meat for a bulk of the public, particularly those who are not encouraged by health or animal well-being, which could intern minimize the man-made touch considerably on the ecosystem. additionally, community health educators, nutritionists, policymakers, food manufacturers and mass media stations could as well regard ecological motives to boost sustainable and healthy foods (sanchez-sabate & sabaté, 2019). conclusion eventually, meat consumes more resources than other foods and affects the climate greatly. a future with sustainable food would need a variety of approaches from the farmer to the consumer. altering public dietary habits is challenging for habitual modification requires an individual's positive attitude derived by motives and justifications. similarly, as the population is increasing worldwide, food companies hold a role in decreasing emissions from meat. finally, we should work on policies to control climate change in agriculture and energy levels and more; along with using the best available information to reach decisions. conflicts of interest the author declare no conflicts of interest. references: • bryan, e., ringler, c., okoba, b., koo, j., herrero, m., & silvestri, s. (2013). can agriculture support climate change adaptation, greenhouse gas mitigation and rural livelihoods? insights from kenya. climatic change, 118(2), 151–165. https://doi.org/10.1007/s10584-012-0640-0. 167 global journal of public health medicine 2020, special issue gggggglo • byrnes, r. c., nùñez, j., arenas, l., rao, i., trujillo, c., alvarez, c., arango, j., rasche, f., & chirinda, n. (2017). biological nitrification inhibition by brachiaria grasses mitigates soil nitrous oxide emissions from bovine urine patches. soil biology and biochemistry, 107, 156–163. https://doi.org/10.1016/j.soilbio.2016.12.029 • fao. (2017). africa sustainable livestock 2050: country brief egypt (i7312en/1/05.17; p. 10). http://www.fao.org/inaction/asl2050/countries/egy/en/ • fao. (2019, december 13). fao news article: key facts and findings. http://www.fao.org/news/story/en/item/197623/i code/ • gibson, e. (2017, november 29). cutting down on cow burps to ease climate change. bloomberg.com. https://www.bloomberg.com/news/articles/201 7-11-29/cutting-down-on-cow-burps-to-easeclimate-change • hristov, a. n., oh, j., giallongo, f., frederick, t. w., harper, m. t., weeks, h. l., branco, a. f., moate, p. j., deighton, m. h., williams, s. r. o., kindermann, m., & duval, s. (2015). an inhibitor persistently decreased enteric methane emission from dairy cows with no negative effect on milk production. proceedings of the national academy of sciences of the united states of america, 112(34), 10663– 10668. https://doi.org/10.1073/pnas.1504124112 • pendrill, f., persson, u. m., godar, j., kastner, t., moran, d., schmidt, s., & wood, r. (2019). agricultural and forestry trade drives large share of tropical deforestation emissions. global environmental change, 56, 1–10. https://doi.org/10.1016/j.gloenvcha.2019.03.00 2. • plumer, b. (2018, december 5). can we grow more food on less land? we’ll have to, a new study finds. the new york times. https://www.nytimes.com/2018/12/05/climate/a griculture-food-global-warming.html. • poultryworld. (2016, march 9). poultry production and climate change. poultryworld. https://www.poultryworld.net/meat/articles/201 3/8/poultry-production-and-climate-change1327986w/ • rotz, c. a., asem-hiablie, s., place, s., & thoma, g. (2019). environmental footprints of beef cattle production in the united states. agricultural systems, 169, 1–13. https://doi.org/10.1016/j.agsy.2018.11.005 • sanchez-sabate, r., & sabaté, j. (2019). consumer attitudes towards environmental concerns of meat consumption: a systematic review. international journal of environmental research and public health, 16(7). https://doi.org/10.3390/ijerph16071220. • us epa, o. (2019, february 11). inventory of u.s. greenhouse gas emissions and sinks: 1990-2017 [reports and assessments]. us epa. https://www.epa.gov/ghgemissions/inventoryus-greenhouse-gas-emissions-and-sinks1990-2017. • white, r. r., & hall, m. b. (2018). reply to van meerbeek and svenning, emery, and springmann et al.: clarifying assumptions and objectives in evaluating effects of food system shifts on human diets. proceedings of the national academy of sciences, 115(8), e1706– e1708. https://doi.org/10.1073/pnas.1720895115. • willett, w., rockström, j., loken, b., springmann, m., lang, t., vermeulen, s., garnett, t., tilman, d., declerck, f., wood, a., jonell, m., clark, m., gordon, l. j., fanzo, j., hawkes, c., zurayk, r., rivera, j. a., vries, w. d., sibanda, l. m., … murray, c. j. l. (2019). food in the anthropocene: the eat–lancet commission on healthy diets from sustainable food systems. the lancet, 393(10170), 447– 492. https://doi.org/10.1016/s01406736(18)31788-4. • wirsenius, s. (2003). efficiencies and biomass appropriation of food commodities on global and regional levels. agricultural systems, 77(3), 219–255.https://doi.org/10.1016/s0308521x(02)00188-9. microsoft word gjphm-2021research notes.docx 409 global journal of public health medicine 2021, vol 3, issue 2 gggggglo research notes statistics & medicine: the exact link berghiche a laboratory science and technic of living, institute of agronomic and veterinary sciences, university of mohamed cherif messaâdia, souk ahras, algeria. *corresponding author: amine_berghiche@yahoo.com introduction statistics is the set of techniques and procedures used for the collection, description; analysis and interpretation of data, in the medicines’ there are many questions that can only be answered by statistics. (everitt & skrondal., 2002). in the field of medical science, clinicians are always required to understand and make judgements. by judging, we mean making decisions about causal relationships, diagnoses or therapeutic decisions, and making decisions based on knowledge of the facts and the underlying mechanisms. in effect, decision-making is the impact of medical research, and at this level we have defined epidemiology perfectly (zhou et al., 2009). according to (wunsh, 2010) in the social sciences, causal histories are "modelled" (theoretical approach) and one sees to what extent the model "fits" with the known facts, but in the biomedical sciences the approach is different; it starts with observation and ends with the "model". it is called inductive. scientific knowledge has accumulated more through "reason and intuition" than through empirical observation. indeed, observation alone is not scientific if it does not lead to a certain prediction obtained by a certain inductive logic. however, inductive logic is not everything because it often leads to error. on the other hand, deductive logic can be complete. for this, it must be linked to its natural environment. in fact, the history of the disease is derived by abstraction and generalisation from numerous concrete cases. this results in a picture of the disease with its common forms, clinical forms and complications. in order to do this, a maximum amount of data must be collected, which makes it possible to describe the picture of the disease and its spread. the basis of causal research is the emphasis on the temporal order: "the effect never precedes the cause" (davis, 1985). in this regard, the mathematical method is used to confirm or reject certain equivocal points. statistical analysis is of considerable value in causal research. its purpose is to ascertain the degree of connection between the effect and the cause, and if so, what the probability of this connection is (bagozzi & yi, 1988). thus, biostatistics does not define the cause, but that there are criteria for the causal link that can be formulated in terms of probability theory. statistical analysis does not deal with a case but with classes of facts or variables. it therefore assumes that the work of description has already been done. (holland, 1986). 410 global journal of public health medicine 2021, vol 3, issue 2 gggggglo epidemiology, like all sciences, aims to contribute to the establishment of scientific truth through the accurate representation of health phenomena. (polgar & thomas, 2011). in particular by ensuring the reduction and elimination of accidental and systematic errors (bias) in the presentation, processing and analysis of data with a view to their unbiased interpretation, processing and analysis of data with a view to their unbiased interpretation. (anderson et al., 2009). epidemiology should enable scientific reasoning by strengthening the criteria for clinical and community health judgment. in practical terms, the aims of epidemiology are to contribute to a better definition of diseases and to help classify them; to identify the extent of health problems and diseases and describe their characteristics; to contribute to the identification of causal relationships; to contribute to the evaluation of the effectiveness of health programmes (primary prevention, treatment, care, modification of health services, etc.); and to contribute to a better understanding of the impact of health services on the environment. (bonita et al., 2006). treatment, care, behavioural change, rehabilitation) and to conduct epidemiological surveillance, to study the long-term evolution of health phenomena under changing natural conditions. (hawley & altizer, 2011). the evolution of epidemiology requires a classification of epidemiological studies according to the purpose of the study. a general distinction can be made between observational epidemiological studies and interventional and/or experimental epidemiological studies, intervention and/or experimental studies. (röhrig, et al., 2009). descriptive studies are studies limited to the description of health phenomena and are fact-finding studies whose objective is to develop a research hypothesis, that are not research-oriented are surveillance studies surveillance studies, known as epidemiological surveillance. the second group of studies are analytical studies, which are start with a hypothesis and aim to test the validity of this hypothesis; this method consists of testing the relationship between a health condition and certain variables. (kim et al., 2017). epidemiological surveillance is not about knowing the health phenomenon. in this case the cause, the risk and the disease are known. the purpose of epidemiological surveillance is individual prevention. in this context, it is a continuous monitoring of individuals exposed to a particular risk, where all the data on risk factors and their possible effects are collected (declich & carter, 1994). the contribution of informatic tools is considerable; databases have been set up such as eurocat (congenital malformations), eurotransplant (database for organ donor identification), etc. (haux, 2006 ; pratschke et al., 2019). in an epidemiological survey, the choice of study subjects or a representative sample from the general population necessarily requires the systematic use of a random sampling method. (martínez-mesa et al., 2016). 411 global journal of public health medicine 2021, vol 3, issue 2 gggggglo a random sample is a probability method that is defined by the fact that that all the subjects that make up a given parent population must have the same probability of being the same probability of being part of the sample. (kothari, 2004) in technical terms, random surveys are based on the principle of drawing lots from the population, based on the principle of drawing lots from a number of subjects who can be considered who can be considered representative of the parent population and the draws must be carried out anonymously. (trochim & donnelly, 2001). in the random sampling method, the representativeness of the sample is a fundamental rule. fundamental rule; despite the strict observance of the random draw, the possibility of error is nevertheless envisaged in random surveys. however, despite the strict observance of the random draw, the possibility of error and of a non-representative sample is envisaged in random surveys representative sample. (dülmer, 2007). this is known as sampling error or accepted risk, which is fixed before the sample is taken and depends on its size. this risk is set before the sample is drawn and depends on its size: the larger the sample, the lower larger sample size, the lower the accepted risk and the better the accuracy of the survey; this technique makes it possible to use probability laws in the exploitation of data and to generalise the results and obtained on a sample to the whole population. (lemeshow et al., 1990 ; garthwaite et al., 2005). in fact, when interpreting the results recorded on a random sample and taking into account the accepted risk of error, the real values of the results obtained in the sample fluctuate within a certain interval (confidence interval), either around the average or around the percentage observed in this sample (neyman & pearson, 1928). in medicine, the maximum accepted risk is generally 5%, and different methods are used to construct which are random sample, simple random sampling, systematic sampling, multi-stage random sampling, cluster random sampling and stratified random sampling (smith et al., 2005). when designing a research protocol in an epidemiological study, and throughout its implementation and analysis, it is necessary to take into account factors that may lead to erroneous conclusions (althubaiti, 2016). for the association between a risk factor and a disease in an epidemiological study may be due to epidemiological study may be due to chance or to systematic error (bias); bias is considered to be a particular variety of error; it is a systematic error. it is defined as a distortion in the estimate of the measure of an association between exposure to a risk factor and the occurrence of a disease and the effect may be an overestimation or underestimation of the strength of the association, or a failure to appreciate the direction of the association. (pearce et al., 2007). a bias results from a systematic error in the selection of subjects for a study (selection bias) or in the collection of information about the selected subjects (information bias); biases are usually avoidable when designing a protocol and it is therefore important to anticipate the role they might play. two broad categories of bias can be distinguished, biases that can be avoided at the time of protocol design, but also taken into account during analysis: these are known as confounding biases; and that can be 412 global journal of public health medicine 2021, vol 3, issue 2 gggggglo avoided at the time of protocol design and study implementation, but which cannot be controlled for during analysis: these are selection bias and information bias (tripepi et al., 2010 ; tripepi et al., 2008). conclusion finally, it can be stated that the application and induction of mathematics, and more precisely statistics, in medicine has given a considerable step forward in research, especially in a very important field such as epidemiology. conflicts of interest: the author declares no conflicts of interest. references • althubaiti, a. (2016). information bias in health research: definition, pitfalls, and adjustment methods. journal of multidisciplinary healthcare, 9, 211. • anderson, s. r., auquier, a., hauck, w. w., oakes, d., vandaele, w., & weisberg, h. i. (2009). statistical methods for comparative studies: techniques for bias reduction (vol. 170). john wiley & sons. • bagozzi, r. p., & yi, y. (1988). on the evaluation of structural equation models. journal of the academy of marketing science, 16(1), 74-94. • bonita, r., beaglehole, r., & kjellström, t. (2006). basic epidemiology. world health organization. • davis, f. d. (1985). a technology acceptance model for empirically testing new end-user information systems: theory and results (doctoral dissertation, massachusetts institute of technology). • declich, s., & carter, a. o. (1994). public health surveillance: historical origins, methods and evaluation. bulletin of the world health organization, 72(2), 285. • dülmer, h. (2007). experimental plans in factorial surveys: random or quota design?. sociological methods & research, 35(3), 382-409. • everitt, b., & skrondal, a. (2002). the cambridge dictionary of statistics (vol. 106). cambridge: cambridge university press. • garthwaite, p. h., kadane, j. b., & o'hagan, a. (2005). statistical methods for eliciting probability distributions. journal of the american statistical association, 100(470), 680-701. • haux, r. (2006). health information systems–past, present, future. international journal of medical informatics, 75(3-4), 268-281. • hawley, d. m., & altizer, s. m. (2011). disease ecology meets ecological immunology: understanding the links between organismal immunity and infection dynamics in natural populations. functional ecology, 25(1), 48-60. • holland, p. w. (1986). statistics and causal inference. journal of the american statistical association, 81(396), 945-960. • kim, h., sefcik, j. s., & bradway, c. (2017). characteristics of qualitative descriptive studies: a systematic review. research in nursing & health, 40(1), 23-42. • kothari, c. r. (2004). research methodology: methods and techniques. new age international. • lemeshow, s., hosmer, d. w., klar, j., lwanga, s. k., & world health organization. (1990). adequacy of sample size in health studies. chichester: wiley. • martínez-mesa, j., gonzález-chica, d. a., duquia, r. p., bonamigo, r. r., & bastos, j. l. (2016). sampling: how to select participants in my research study?. anais brasileiros de dermatologia, 91(3), 326-330. • neyman, j., & pearson, e. s. (1928). on the use and interpretation of certain test criteria for purposes of statistical inference: part i. biometrika, 175-240. • pearce, n., checkoway, h., & kriebel, d. (2007). bias in occupational epidemiology studies. occupational and environmental medicine, 64(8), 562-568. • polgar, s., & thomas, s. a. (2011). introduction to research in the health sciences e-book. 413 global journal of public health medicine 2021, vol 3, issue 2 gggggglo elsevier health sciences. • pratschke, s., bender, a., boesch, f., andrassy, j., van rosmalen, m., samuel, u., ... & eurotransplant liver and intestine advisory committee (eliac). (2019). association between donor age and risk of graft failure after liver transplantation: an analysis of the eurotransplant database. transplant international, 32(3), 270-279. • röhrig, b., du prel, j. b., wachtlin, d., & blettner, m. (2009). types of study in medical research: part 3 of a series on evaluation of scientific publications. deutsches arzteblatt international, 106(15), 262. • smith, j. l., sturrock, h. j., olives, c., solomon, a. w., & brooker, s. j. (2013). comparing the performance of cluster random sampling and integrated threshold mapping for targeting trachoma control, using computer simulation. plos negl trop dis, 7(8), e2389. • tripepi, g., jager, k. j., dekker, f. w., & zoccali, c. (2010). selection bias and information bias in clinical research. nephron clinical practice, 115(2), c94-c99. • tripepi, g., jager, k. j., dekker, f. w., wanner, c., & zoccali, c. (2008). bias in clinical research. kidney international, 73(2), 148-153. • trochim, w. m., & donnelly, j. p. (2001). research methods knowledge base (vol. 2). atomic dog pub.. • wunsch, g., russo, f., & mouchart, m. (2010). do we necessarily need longitudinal data to infer causal relations?. bulletin of sociological methodology/bulletin de méthodologie sociologique, 106(1), 5-18. • zhou, x. h., mcclish, d. k., & obuchowski, n. a. (2009). statistical methods in diagnostic medicine (vol. 569). john wiley & sons. 11 global journal of public health medicine 2019, vol 1, issue 1 gggggglo the relationship between obesity and overweight with the intake of vitamin d and calcium rich foods among private university students in shah alam, malaysia tiba nezar hasan*, puteri farrah nadhira radhi corresponding author: dr.tibahasan@gmail.com international medical school, management and science university, selangor, malaysia abstract introduction: obesity and overweight are one of the health problems that critically increasing nowadays in worldwide including malaysia due to lifestyle changes such as inactive lifestyle as well as unhealthy eating habit. this study, therefore is to find if there is a relationship between obesity and overweight with the intake of vitamin d and calcium rich foods to see if there is any difference intake between normal, obesity and overweight group. methods: a cross-sectional study was conducted among 255 management and science university students (msu) who having a normal, overweight and obesity of body mass index. data was collected using self-administered questionnaire consisting of two part which is sociodemographic questions and food frequency questionnaire (ffq). result: for calcium intake, there is a significant association between body mass index (bmi) and calcium which is (p = 0.008) respectively and there is no significant association between bmi and vitamin d intake (p = 0.594) conclusion: the study found that there is a relationships between obesity and overweight with intake of calcium rich food and no relationship between obesity and overweight with the intake of vitamin d. further study are needed to build causal relationships and develop preventative measures. keywords: obesity, overweight, vitamin d, calcium, students, malaysia 12 global journal of public health medicine 2019, vol 1, issue 1 gggggglo introduction obesity results from consuming food that give high energy and calories that exceed the body needs in addition to low physical activity over long time (hill et al. 2010; daniels et al. 2005). during the growing years, the main causes of obesity are different with many factors, some of these factors are nonmodifiable and some are modifiable factors from the environment (lobstein et al. 2004; hill et al. 2003) and can sometimes worsen by biological growth factors during the rapid growth spurt at the time of puberty(siervogel et al. 2003). the most effective way of reducing weight or prevent weight gain come through healthy life style(daniels et al. 2005; hills et al. 2010), the practices of sedentary lifestyle and less physical activity such as watching television, computer and media used have high effect on obesity risk among populations in malaysia (epstein et al. 2008; sugiyama et al. 2008). bmi can be calculated by dividing a person’s weight in kilograms by the square of a person’s height in meters. the category of overweight and obesity is derive from data gathered from population-based epidemiology studies that examined the relationship between obesity and rates of mortality and morbidity that are adiposity related. it can be considered overweight if the bmi (kg/m2) is between 25 and 29.9. obesity is defined when the bmi is ≥ 30 and can be further classified into three classes beginning from class i till class iii. there is evidence to shows the risks of adiposity-related complications occur at lower bmis in asians. therefore, for obesity, china used a bmi of 28 and japan used a bmi cut-off of 25 kg/m2 for cut-off. the world health organization (who) has recommended that bmi > 27.5 kg/m2 be used as a cut off for asians, considering the increased risk of cardiovascular system problem at the bmi (fock et al. 2013). obesity is not considered as one of the psychiatric disorders. however, people who have a psychiatric disorder such as depression have a high risk of being obese. this increase in weight can be due to some medications such as antidepressants, antipsychotic medications antidiabetic drugs, anticonvulsants, beta blockers in addition to steroid hormones. weight gain also can be seen in people who quit smoking. it is also essential to note comorbidities associated with obesity including diabetes mellitus, high lipids profile, high blood pressure, and cardiovascular disease (fock et al. 2013). the basis of therapy for losing weight is dietary intervention and planning. it is suggested from most of the dietary regimens to have more concern on the content of energy and compositions of macronutrients in order to reduce weight. this energy content mainly affects the result and effectiveness of the dietary plans. the guidelines of obesity treatment that issued by the national institute health recommended that those who are overweight or with class i obesity with two or more risk factors should reduce their daily energy intake by 500 kcal while those with class ii and class iii obesity must reduce daily between 500-1000 kcal. weight loss of about 0.5 kg/week will result from reducing this 500 kcal/day of energy intake. it is crucial to calculate the daily requirement of energy for patient to give them diet that have lower energy and lead to loss of weight, this can be calculated using the harris benedict equation or the world health organ equation or american gastroenterological association dietary guidelines (klein et al. 2002). therefore, the aim of this study is to find the relationship between obesity and overweight with the intake of vitamin d and foods rich in calcium to see if there is any difference intake between normal, obesity and overweight group. methods the study design that have been used is cross sectional studies that was carry out to find the relationship between overweight and obesity with calcium and vitamin d intake among management and science university students in shah alam, selangor. the study was conducted in management and science university, shah alam, selangor. the study population was the students of management and science university in shah alam, selangor. sample was collected through convenience method. the respondents consist of male and female students aged 18 years and above. there are 255 respondents selected which is 85 have a normal body mass index (18.524.9), 85 have overweight body mass index (25-29.9) and 85 have obesity body mass index (≥ 30). those who refuse to participate in the research was exclude from the study. 13 global journal of public health medicine 2019, vol 1, issue 1 gggggglo data collection was done by using selfadministered questionnaires. it consists of two sections including part a sociodemographic details and part b food frequency questionnaire (ffq). all respondent need to recall back their dietary meal in one week. weight scale and stadiometer is used to measure the weight and height to get the bmi. the nutrition data was calculated by using a software called ‘nutritionist pro’ to get the total intake of calcium and vitamin d in one week. the collected data is entered and have been analyses by using spss version 25. one-way anova and t test is used to determine the association between obesity and overweight with the intake of vitamin d and calcium rich foods. all participants need signed the consent for before answering the questionnaires and full explanation of the study was given to them prior to enrolment. results a total of 255 students participate in this study or research which is 85 of students have a normal body mass index (bmi), 85 of students have an overweight bmi and the other 85 students have an obesity bmi. for the normal bmi, the mean intake of vitamin d is 18.83, overweight 23.68 and obesity is 25.68. the results shows that the highest average for the total intake of vitamin d is in obesity group which is 25.68. the minimum level of vitamin d intake for all group is .00. however, for the maximum level there is different between normal, overweight and obesity. the maximum level for vitamin d intake in a normal bmi is 97.41, overweight is 88.14 and obesity is 614.27. for the calcium intake, the mean intake for a normal bmi is 6192.25, overweight is 5928.64 and obesity is 4791.34. the highest average for the total intake of calcium is in a normal group which is 6192.25. the minimum level of calcium intake for a normal bmi is 1074.55, overweight is 1005.14 and for obesity is 736.04. for the maximum level in normal, the range is 22180.49, overweight is 23632.72 and obesity is 15094.38. results shows the association between bmi with vitamin d and calcium intake. the f score for the vitamin d is .522 and the significant level is .594. it shows that there is no significant between the bmi groups (normal, overweight and obesity) with the intake of vitamin d. the f score for calcium intake is 4.986 and the significant level is .008. it indicates that there is a significant level between the bmi groups (normal, overweight and obesity) with the intake of calcium. to be concluded, there is an association between obesity and overweight with the intake of calcium but there is no association between obesity and overweight with the intake of vitamin d in foods. this can be proved based on the p value which is < 0.05 (p = 0.008) that is means there is a significant in the calcium intake with obesity and overweight. however, for vitamin d, the p value is >0.05 which is p = .594. it indicates that there is no significant for the vitamin d intake with obesity and overweight. table1 vitamin d and calcium intake among male and female students mean sd vitamin d male 20.79 24.90 female 23.15 48.15 calcium male 5924. 73 3488. 28 female 5574. 17 3040.72 discussion the main finding of our current study is that high vitamin d intake among the bmi is 25.68 which in obesity group. the maximum intake of vitamin d in obesity group is 614.27. this results indicates that people with obesity bmi consumed more vitamin d in their meals compared with people who having normal and overweight bmi. 14 global journal of public health medicine 2019, vol 1, issue 1 gggggglo for the calcium intake, the high average is under a normal group of bmi which is 6192.26. however, the maximum calcium intake is 23632.72 which is under overweight group. the highest intake of calcium in the normal group is slightly less than those overweight group which is only 22180.49. both results for vitamin d and calcium have support from the previous research. in the population of northern norway, significant and positive association was founded between calcium intake and body mass index (bmi) in men, and negative significant associations were found between the intake of vitamin d and bmi in both sexes (kamycheva et al. 2004). results shows that the group statistics of male and female along with the bmi and the intake of vitamin d and calcium. the total of female respondents is high compared with male which is female 209 and male is 46. the total average for vitamin d intake in female is higher than male where is the total average for calcium intake in female is lower than male. there is no association between gender male and female with vitamin d and calcium intake. there have been previous human studies (zemel et al. 2000; carruth at al. 2001; heaney et al. 2003) that studied the association between dietary calcium and body weight and fat. in previous research by (zemel et al. 2003) examined epidemiological national health and nutrition examination survey iii data and revealed that after controlling for energy intake, the relative risk of being in the highest quartile of body fat was the highest for those consuming diets lowest in calcium. this reverse relationship between body fat and calcium intake was found for both men and women. conclusion this study was conducted to find out if there is a relationship between obesity and overweight with the intake of vitamin d and foods rich in calcium among msu students. a group of normal, overweight and obesity body mass index consists of male and female is randomly selected to answer the food frequency questionnaire. the findings of the study showed that there is relationship or association between the bmi with the calcium intake. however, there is no association between the bmi with the vitamin d intake. there is also no association between gender for each of bmi with the vitamin d and calcium intake. the null hypothesis is rejected for the calcium intake but the null hypothesis is accepted for the vitamin d intake. to be concludes, people is recommended to consume more calcium in their dietary meals as one of the prevention of obesity and overweight. references daniels sr, arnett dk, eckel rh, gidding ss, hayman ll, kumanyika s, et al. (2005) overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment. circulation;111:1999-2012. carruth br, s. j. (2001). the role of dietary calcium and other nutrients in moderating body fat in preschool children. int j obes relat metab disord,25(4), 559-566. epstein lh1, r. j., robinson jl, paluch ra, winiewicz dd, fuerch jh, & robinson tn. (2008). a randomized trial of the effects of reducing television viewing and computer use on body mass index in young children. arch pediatr adolesc med, 162(3), 239-245. doi:10.1001/archpediatrics.2007.45 fock km, k. j. (2013). diet and exercise in management of obesity and overweight. journal of gastroenterol and hepatology, 4, 59-63. doi:10.1111/jgh.12407 heaney rp, dowell ms, hale ca ,bendich a (2003)calcium absorption varies within the reference range for serum 25hydroxyvitamin d.j am coll nutr22: 142– 146 hill jo, w. h., reed gw, & peters jc. (2003). obesity and the environment: where do we go from here? science, 299(5608),853-855. doi:10.1126/science.1079857 hills ap, o. a., & baur la. (2010). addressing childhood obesity through increased physical activity. nat rev endocrinol, 6(10), 543-549. doi:10.1038/nrendo.2010.133 kamycheva e, s. j., & jorde r. (2004). serum parathyroid hormone level is associated with body mass index. eur j endocrino, 151(2), 167172. 15 global journal of public health medicine 2019, vol 1, issue 1 gggggglo klein s, wadden t, sugerman hj. (2002) aga technical review on obesity. gastroenterology. ; 123: 882 – 932. lobstein t1, b. l., & uauy r; iaso international obesity taskforce. (2004). obesity in children and young people: a crisis in public health. 1, 4104. doi:10.1111/j.1467-789x.2004.00133.x siervogel, rm, demerath, ew, schubert, c, et al. (2003) puberty and body composition. horm res. 2003; 60( suppl 1): 36‐ 45. sugiyama t, h. g., dunstan dw, salmon j, & owen n. (2008). is television viewing time a marker of a broader pattern of sedentary behavior? ann behav med, 35(2), 245-250. doi:10.1007/s12160-008-9017-z zemel mb, s. h., greer b, dirienzo d, & zemel pc. (2000). regulation of adiposity by dietary calcium. faseb j, 14(9), 1132-1138. microsoft word gjphm-2019perforated appendecitis.docx 90 global journal of public health medicine 2019, vol 1, issue 2 gggggglo the incidence of perforated appendicitis among pediatric patients in khartoum north teaching hospital, sudan ibrahim salih elkheir1, mohammed altyb alshykh2, ayman gafer mustafa3 1 consultant of paediatric surgery, head of the department of paediatric surgery in khartoum north teaching hospital and associate professor of paediatric surgery alzaiem alazhari university –sudan. 2 mbbs, alzaiem alazhari university –sudan. 3 mbbs, alzaiem alazhari university –sudan. corresponding author: dr.ibrahim5@hotmail.com abstract introduction: acute appendicitis is a common emergency condition in paediatrics with different ages. the perforated appendicitis is one of the most serious complications of acute appendicitis which may lead to peritonitis. the aim of our study is to calculate the incidence of perforated appendicitis. methods: this is a retrospective cross-sectional study has been conducted at khartoum north teaching hospital. the total number of patients was 214. results: the most common age in this study are 13 years old and the mean age is 11 years, 128 of cases were male 59.8% and 86 were females 40.2%. all cases of our study presented with fever 100%, 80.8% presented with right iliac fossa pain, and anorexia 100%. 50.5% of cases came within the first day of presentation and 26.6% of cases came in 4th day of presentation, all cases presented with right iliac fossa tenderness, 15.9% of cases presented with perforated acute appendicitis, 67.29% of cases operated after 6 hours, 5.61% operated in more than 6 hours and 27.1% operated after 6 weeks. conclusion: in this study the incidence of perforated acute appendicitis was 15.9% which is low in comparison with another study because there was no delay in appendectomy operation and the majority of patients came within the first day of the disease. keywords: incidence, perforated appendicitis, paediatrics, sudan. 91 global journal of public health medicine 2019, vol 1, issue 2 gggggglo introduction acute appendicitis is a common paediatrics surgical emergency, the admissions is about 12% of all paediatric surgical conditions (almaramhy, 2017) . the severity of acute appendicitis was classified as uncomplicated disease or complicated disease (perforated acute appendicitis, appendicular abscess) (omling et al., 2019) or inflammatory mass (guidaa et al., 2015). the diagnosis of this condition is challenging because of its symptoms are similar to another diseases such as gastroenteritis in which the patients presented with abdominal pain, vomiting nausea, diarrhea, or fever (wang et al., 2019) . or omental infarction(yang, 2010) which presented with the same symptoms of acute appendicitis. the classic presentation of symptoms are not usual in children (becker & bachur, 2007). the children have the higher rate of perforation, rather than the adults. (jha et al., 2017) the rate of treated perforated appendicitis about 37% among children(turela et al., 2019). in age of less than 5 years the rate of perforation is 30%. the rate of missed and delayed diagnosis in older paediatrics about 28% to 57% (çelik et al., 2019). the perforation is define as a fecalith in the abdomen or hole in the appendix (peter et al., 2008 ). the delayed of treatment of acute appendicitis will lead to progression of the disease to perforation which can cause complications such as peritonitis, abscess and partial bowel obstruction and this complications increase the rate of morbidity and mortality (ngim, 2014). the diagnosis of acute appendicitis by: 1-clinical examination (groseljgrenc et al., 2007), 2-or by using imaging ; in the case of children we request abdominal ultrasound u/s rather than computed tomography ct scan but the uses of it is less due to risk of exposure to ionizing radiation (phalke & das, 2018) 3-and other laboratory investigations such creactive protein crp, white cell count and bilirubin (mcgowan et al., 2013). the treatment of acute appendicitis are laparoscopic or open appendectomy. however, the role of laparoscopic appendectomy is controversial in management of complicated appendicitis in paediatrics (tsai et al., 2012 ). in new study; uncomplicated acute appendicitis may treated non-operatively and the patients get the clinical recovery after received of antibiotics (knaapen et al., 2019). postoperatively all patients with perforated acute appendicitis must receive intravenous antibiotics for 5 days minimally. (st. peter et al., 2008). the aim of this study is to calculate the incidence of perforated appendicitis in khartoum north teaching hospital. methods this is a retrospective cross-sectional study at khartoum north teaching hospital which is the one of reference hospital in sudan and it placed in bahri city. we was studied 214 patients who came with acute appendicitis which is one of the most common emergency condition in the paediatric surgery department. some of the data were collected from the record of patients who were operated and some from new patients came to us then diagnosed as acute appendicitis cases and was operated. duration of this study from november 2018 to august 2019. when the patients come to our emergency we take the history; assess and analyse the symptoms of acute appendicitis such as periumbilical pain, right iliac fossa pain (rif), nausea, vomiting, anorexia, fever, dysuria and, changes of bowel habits and previous history of similar abdominal pain; and the duration of all this symptoms. then we do the examination; firstly general examination such as temperature, pulse rate... etc. secondly abdominal examination searching for rif tenderness and rebound tenderness. then we do the investigations like complete blood count cbc, urine analysis and sometimes we need to do imaging to support our diagnosis using abdominal ultrasound or computed tomography ct scan. and we followed our patients after the operation until get well then discharged them and must be followed in refer clinic. the data have been collected by questionnaires and was analysed by spss application. we was consent all new patients and explained to them all the information will be kept in privacy and consent the hospital for collect the data from records. 92 global journal of public health medicine 2019, vol 1, issue 2 gggggglo results the most common age of cases were 13 years old which about 35.5 % and the mean age is 11 years. 59.8% of cases are male and 86 are females 40.2%, 52% of cases came from alhag yousif city. 15.9% of cases presented with perforated acute appendicitis, 18.7% presented with appendiceal abscess, 27.1% presented with appendiceal mass and 38.3% presented simply to moderately inflamed appendix (table 1). all cases of our study presented with fever 100%, about 78% of cases presented with vomiting, 80.8% presented with right iliac fossa pain, 56.5% presented with periumbilical pain, 35.5% the pain shifted to the right iliac fossa but 64.5% of cases the pain was not shifted, 93.9% of cases have no history of similar abdominal pain. all cases presented with anorexia 100%, 31% of cases presented with diarrhoea, 7.9% came with constipation and 77% of cases presented with no change in bowel habits (table 2). all cases presented with rif's tenderness, 58.9% of cases presented with rebound tenderness and the mean body temperature about 37.4 (17%). 88.8% of cases were received samixone (ceftriaxone) and 6.1% of cases were received samixone and diclofenac sodium injection. the mean twbcs in our patients with perforated appendicitis was 18 x103/ul (5.09%), mean platelets values 324.6 x103/ul (91.65%) and mean hemoglobin value 11.5 mg/dl (3.26 %) (table 3). 50.9% of cases have been diagnosed without imaging, 40.2% of cases have been diagnosed with the us and 8.9% of cases have been diagnosed with ct scan (table 4). 67.29% of cases operated within the first day of admission, 5.61% operated in the second day of admission and 27.1% operated after 6 weeks which explain the percentage of appendicular mass. table 1: socio-demographic data of the cases and the types of acute appendicitis variables n % age 9 years 15 7.0 11 years 70 32.7 12 years 53 24.8 13 years 76 35.5 gender male 128 59.8 female 86 40.2 types of appendicitis simple to moderate 82 38.3 appendiceal mass 58 27.1 appendiceal abscess 40 18.7 93 global journal of public health medicine 2019, vol 1, issue 2 gggggglo table 2: symptoms of acute appendicitis symptoms yes no n % n % anorexia 214 100% 0 0% nausea 87 40.7% 127 59.3% vomiting 167 78.0% 47 22.0% fever 214 100.0% 0 0.0% dysuria 0 0.0% 214 100.0% abdominal pain (rif) 173 80.8% 41 19.2% periumbilical pain 121 56.5% 93 43.5% shifting 76 35.5% 138 64.5% history of similar pain 13 6.1% 201 93.9% no history of similar pain 201 93.9% 13 6.1% diarrhoea 31 14.5% 183 85.5% constipation 17 7.9% 197 92.1% no change in bowel habits 166 77.6% 48 22.4% table 3: findings on examination specific to acute appendicitis, antibiotics was used and investigations variables n % sings rif tenderness 214 100% rebound tenderness 126 58.9% body temperature (mean) 37.4 c std. deviation= 0.42465 (17%) antibiotics samixone (ceftriaxone) 190 88.8% diclofenac sodium 11 5.1% samixone and vortrine 13 6.1% investigations twbcs mean 18 x103/ul std. deviation (3.70839) haemoglobin mean 11.5 mg/dl std. deviation (1.44201) platelets 324.6 x103/ul std. deviation (112.60253) 94 global journal of public health medicine 2019, vol 1, issue 2 gggggglo table 4: type of imaging done to patients imaging n % no imaging 109 50.9% ultrasound scan the us 86 40.2% a computed tomography ct scan 19 8.9% discussion appendicitis is an acute inflammatory disease may result from obstruction of the appendix lead to inflammation, perforation and necrosis.(veli avci, 2019 ).it is a one of the commonest surgical emergency in adults or paediatrics.(aneirosa et al. , 2019). we were conducted this study in khartoum north teaching hospital which is a one of the reference hospital in sudan which located in bahri city and contain one of the referral centre of the paediatric surgery in the sudan. highest incidence in of acute appendicitis in our study were in males rather than females but both at the similar age 11-13 years old and the mean age 11 years ( becker & bachur, 2007). the symptoms of acute appendicitis in our study were rif pain which was less in percentage than previous studies 94%(ngim, 2014) because of some cases were came to us before shifted of the pain to rif, the percentage of vomiting, absence of changed in bowel habits, tenderness and rebound tenderness in rif near to percentage in previous studies (ngim, 2014; becker & bachur, 2007). 50.5% of cases were came within the first day to our paediatric surgery emergency. the diagnosis of cases in our department depend on clinical examination so 50.9% diagnosed without imaging just 40.2% diagnosed by us. another investigations that we were did; complete blood count cbc and found that twbcs was high and the mean value was 37.4 (17%) which similar to another studies ( mcgowan et al., 2013) (groselj-grenc et al., 2007) (yang et al., 2010). in our study 88.8% of patients received antibiotic (ceftriaxone) before and after the operation. in recent study 15.9% of cases presented with perforated acute appendicitis and it's low in compare with other study which the rate of perforation about 52% ( ngim et al., 2014) because we operate all patients whom diagnosed with acute appendicitis without delay in time of operation and almost cases operated within the first day of admission (papandria et al., 2013) conclusion the incidence of perforated acute appendicitis was 15.9% which is low in our study in comparison with the previous study because there was no delayed in appendectomy operation in our department and the majority of patients come within the first day of the disease. that means the delayed operation increases the risk of perforated appendicitis. conflict of interest no one of authors has a conflict of interest. 95 global journal of public health medicine 2019, vol 1, issue 2 gggggglo references almaramhy, h. h. ( 2017). acute appendicitis in young children less than 5 years: review article. almaramhy italian journal of pediatrics, 43(15). aneirosa, i. c., araceli garcíaa, pedro yustea , eduardo ferreroa , andrés gómeza. (2019). pediatric appendicitis: age does make a difference. rev paul pediatr, 1-7. becker, t & bachur r. (2007). atypical clinical features of pediatric appendicitis. academic emergency medicine, 14, 124–129. çelik, h. n., mustafa özçatal,yasemin altuner torun. (2019). role of neutrophil-to-lymphocyte ratio and platelet -tolymphocyte ratio in identifying complicated appendicitis in the pediatric emergency department. ulus travma acil cerrahi derg, 25(3), 222-228. guidaa, f. p., massimo di graziab, daniela codricha, maria antonietta lemboa, maria grazia scarpaa, waifro rigamontia,. (2015). perforated appendix with abscess: immediate or interval appendectomy? some examples to explain our choice. international journal of surgery case reports, 12, 15–18. groselj-grenc, s. r., dubravka vidmar, metka derganc. ( 2007). clinical and laboratory methods in diagnosis of acute appendicitis in children. croat med j, 48, 353-361. knaapen, j. h. v. d. l., hugo a. heij, ernst l. w. van heurn, roel bakx, ramon r. gorter. (2019). clinical recovery in children with uncomplicated appendicitis undergoing non-operative treatment: secondary analysis of a prospective cohort study. european journal of pediatrics, 178, 235–242. jha k.k., s. s., shruti trehan, gregory e gilbert, aisha mohammed, moon hee hur, joseph uricchio, shama shirazi, pragya jha and romeen lavani. (2017). predictors of perforated appendix among children. jha et al., pediatr ther, 7(1). doi: 10.4172/2161-0665.1000310 mcgowan,dr, h. m. s., khawaja zia, mokthar uheba and irshad ahammed shaikh. (2013). the value of biochemical markers in predicting a perforation in acute appendicitis. anz j surg, 83 79–83. doi: 10.1111/ans.12032 ngim, k. f. q., amreeta dhanoa, joon joon khoo, muthualhagi vellusamy, and chen siew ng. (2014). pediatric appendicitis in a developing country: what are the clinical predictors and outcome of perforation? journal of tropical pediatrics, 60, 409-414. phalke, z. m., and samrat das,. (2018). utilization of imaging to identify a benign condition mimicking acute appendicitis in a child. journal of investigative medicine high impact case reports, 6, 1–4. doi: 10.1177/2324709618797989 papandria d, g. s., rhee d, salazar jh, arlikar j, gorgy a, zhang y, abdullah f. (2013). risk of perforation increases with delay in recognition and surgery for acute appendicitis. j surg res, 184(2), 723-729. doi: 10.1016/j.jss2012. 12.008. epub 2012 dec 27 omling , m. s., s. saluja , s. bergbrant, l. olsson, a. persson, j. björk and l. hagander. ( 2019). nationwide study of appendicitis in children. wiley online library. doi: 10.1002/bjs.11298 tsai ,c. s.-y. l., fu-chen huang (2012 ). laparoscopic versus open appendectomy in the management of all stages of acute appendicitis in children: a retrospective study. pediatrics and neonatology, 53, 289-294. turela, s. l. m., mine yuksela, aysenur ceylanc, bilge sumbul gultepec. (2019). perforated appendicitis in children: antimicrobial susceptibility andantimicrobial stewardship. journal of global antimicrobial resistance, 16, 159–161. st. peter, s. w. s., george w. holcomb iii, daniel j. ostlie. (2008 ). an evidence-based definition for perforated appendicitis derived from a prospective randomized trial. journal of pediatric surgery, 43, 2242–2245. veli avci, k. a. (2019 ). why is the rate of perforated appendicitis higher in girls in eastern turkey, unlike the literature? turk pediatri ars, 54(1), 40–43. doi: 10.14744/turkpediatriars.2019.82956 wang, j. y., yu-shui wang, yan liu,. (2019). diagnostic accuracy of pediatric atypical appendicitis. medicine, 98(13). yang , y.-h. h., mao-meng tiao, kuo-shu tang , fu-chen huang , shin-yi lee (2010). comparison of clinical characteristics and neutrophil values in omental infarction and acute appendicitis in children. pediatr neonatol, 51(3), 155−159. microsoft word gjphm-2019 breast cancer iraq copy.docx 33 global journal of public health medicine 2019, vol 1, issue 2 gggggglo survey of breast cancer in wasit province , iraq abduladheem turki jalil1 *, saja hussain dilfi2, aleksandr karevskiy1 corresponding author: abedalazeem799@gmail.com 1 faculty of biology and ecology, yanka kupala state university of grodno, belarus 2 department of histopathology, faculty of science, wasit university, iraq abstract introduction: cancer is one of the most common causes of death among females. in our research, cancer data were collected in wasit governorate for patients who were referred to al-zahra educational hospital for the period from february 2010 to february 2019. the results showed that breast cancer is the most common type of cancer in wasit governorate and by percentage (35.4%) with 341 out of 966 cases of cancer. methods: data were collected from data base between the year (2010 to 2019), with the highest rate of cases in 2013, which is around 139 cases , of these cases around 71 were breast cancer (51.07% recurrence). surprisingly the lowest cases were recorded in a year after (2014) with total cancer cases of 65 from them 21 cases of breast cancer only. results: about the relationship between breast cancer and gender, breast cancer recorded 95.60% of the cases in females, while percentage of men cases only 4.39%. conclusion: the higher percentage of the cases were around 4049 years old , 92 cases (27%) , 80 cases (23.5%) were in the age group (50-59 years) and 65 cases (19%) were in the age group (30-39 years) and 51 cases (15%) were in the age group (60-69 years) ). the lowest percentage of breast cancer was in the 10-19 age group, with only two cases (0.5%). keywords: breast cancer, women, wasit, age, gender 34 global journal of public health medicine 2019, vol 1, issue 2 gggggglo introduction breast cancer is one of the most common cancers among women, and one of the leading cause of death among female. there are several factors that lead to breast cancer: these factors are age, early menstruation, late pregnancy, obesity, oral contraceptives, hormone replacement therapy, diet, family history, decreased breastfeeding and history of pre-existing benign breast cancer. (bray et al., 2012) (brinton et al.,2018). breast cancer is the most commonly diagnosed cancer among women worldwide, accounting for 25% (over 1.5 million) women with cancer cases at all ages and a greater percentage among young women (torre et al.,2017).in america, it is estimated that 30% of all new cancer cases (252,710) among women are breast cancer (siegel, et.al .2016). in iraq, breast cancer is the most common type of cancer among females. according to the children's cancer research institute (ccri), it ranks first in female cancer, and accounting for about a third of all cancers registered according to the latest iraqi cancer register (iarc, 2013)breast cancer is a complex and multifactorial disease resulting in abnormal cell growth that leads to malignant tumour formation. it is the most common female cancer, affecting one in eight women during their lifetime. approximately 10% of all breast cancers are hereditary, most commonly caused by genetic variations transmitted in an autosomal dominant manner (howlader et al ., 2013 ) .simply being a woman is the main risk factor for developing breast cancer. men can develop breast cancer, but this disease is about 100 times more common among women than men (feng et al.,2018). the first physical symptoms of breast cancer include swelling of the breast, skin scrapping, pain in the nipple, secretions, redness, or skin scrapping of the nipple or breast (mangesi & zakarija-grkovic, 2016). the aim of the study is to find out the most common cancer and its relationship to age and gender. methods this study done by collection of cancer data for the years 2010 to february 2019 for the patients from histopathology unit in al-azahraa educational hospital in wasit governorate. who were diagnosed and confirmed having cancer by histopathological study data were collected from data base between the year (2010 to 2019), with the highest rate of cases in 2013, which is around 139 cases , of these cases around 71 were breast cancer (51.07% recurrence).surprisingly, the lowest cases were recorded in a year after (2014) with total cancer cases of 65 from them 21 cases of breast cancer only. the collected data for each patient include history of infection, age, gender, residential area. these statistics included all types of cancers and the study focused on data of breast cancer patients for the period mentioned. data were distributed according to years, gender and age. results the results of this study, as shown in table 1, showed that breast cancer recorded the highest percentage of cancers among the other cancers (35.4%). table 1: breast cancer prevalence rate type of cancer frequency of total cancer cases frequency of cancer cases percentage % breast cancer 966 341 35.4% 35 global journal of public health medicine 2019, vol 1, issue 2 gggggglo table 2 shows the distribution of breast cancer during the past 10 years, with the highest rate of cases in 2013. table 2:distribution of breast cancer according to years years no. of cancer cases no. of breast cancer cases percentage % 20102011 71 27 38.02 20112012 104 45 43.26 20122013 84 29 34.52 20132014 139 71 51.07 20142015 65 21 32.30 20152016 108 32 29.62 20162017 161 38 23.60 20172018 141 41 29.07 20182019 87 33 37.93 6 4 6.66 total 966 341 35.4% prevalence of breast cancer according to gender the results showed that breast cancer recorded 95.60% of the cases in females, while men had 4.39% of the disease. table 3: distribution of breast cancer according to gender years no. of breast cancer male percent % female percent % 2010-2011 27 0 0 27 100 2011-2012 45 4 8.88 41 91.11 2012-2013 29 0 0 29 100 2013-2014 71 7 9.85 64 90.14 2014-2015 21 0 0 21 100 2015-2016 32 1 3.12 31 96.87 2016-2017 38 2 5.26 36 94.73 2017-2018 41 1 2.43 40 97.56 2018-2019 33 0 0 33 100 2019(2months) 4 0 0 4 100 total 341 15 4.39 326 95.60 prevalence of breast cancer according to age figure 1 showing the relationship between breast cancer and age in this study revealed the distribution of patients in the age groups. figure 1: distribution of breast cancer according to gender 0 20 40 60 80 2010-2011 2012-2013 2014-2015 2016-2017 2018-2019 age ye ar s no. of bc 36 global journal of public health medicine 2019, vol 1, issue 2 gggggglo discussion overall prevalence of breast cancer in last years the total number of cancer cases during this period was 966 of cancers, and breast cancer recorded 341 cases and thus ranked first among the other types of cancers diagnosed in wasit governorate. the rate of deaths caused by the disease is 16% in all countries of the world, including iraq, where people suffers from the disease and other types of cancer most probably due to wars and environmental pollution in the large provinces, especially the south, where people exposed to different radioactive materials and weapons, as well as carcinogenic chemicals in some industries (fathi et al.,2013). prevalence of breast cancer according to years with 139 cases of cancer, of which 71 cases were breast cancer with a recurrence rate 51.07%.followed by 2011 with 104 cases of cancer, including 45 cases of breast cancer, a recurrence rate of 43.26%. while the lowest incidence rate was recorded in 2016 and 2019 with recurrence rate of 23.60%, 6.66% respectively. prevalence of breast cancer according to gender this means that females are more likely to have breast cancer, for several reasons including: pregnancy and exposure to hormone estrogen, which increases the incidence of the disease. there is also genetics factors, women who have relatives of the first degree (mother sister daughter) who have the disease are women are 5% to 10% more likely to develop the disease than others .there is a chemical factors such as medicines and that women deal with such as contraception treatments, alternative hormones taken by women after the age of menopause and hormones that cause obesity unhealthy diet, such as consuming foods high in fat. in developed countries, almost 99% of breast cancer cases are diagnosed in women; while men account for 5-15% of breast cancer cases in a few african countries that have the highest incidence of breast cancer in men. breast cancer is the highest cancer in women in iraq, with total number of cases in 2018 (according to world health organization figures) about 5141 (20.3%) of all cancers, followed by lung cancer. while lung cancer is the highest in men, 1573, and 13.9% of all cancers in men, followed by bladder cancer. the world health organization (who) forecast for the past five years of breast cancer is 1,3006. for all 2018 men and women in iraq, 25320 cases have a total of 54,809 deaths and a total of 14524 deaths in 2018.the males may develop breast cancer but with a much lower rate, one case in male compared to 100 cases in female this is because the low level of estrogen in male compared to female . the strongest risk factors for men are the diagnosis with klinefelter syndrome at birth, where the child is born with two x chromosome rather than one (xxy) rather than (xy), although men with klinefelter syndrome may develop breast hypertrophy, while breast enlargement is not associated with breast cancer in men. as with women, the risk factors for breast cancer in men increase with changes in the brca2 gene, alcoholism, chronic liver disease, and obesity may increase the risk of breast cancer. 37 global journal of public health medicine 2019, vol 1, issue 2 gggggglo prevalence of breast cancer according to age the most of the patients92 cases (27%) in the age group (40-49 years), 80 cases (23.5%), in the age group (50-59 years) and 65 cases (19%) were in the age group (30-39 years) and 51 cases (15%) were in the age group (60-69 years). were in the age group (10-19 years) where only two cases (0.5%). the other factor that has a role in disease is the age factor. it is known that breast cancer affects women after the age of 50, but recently in iraq and other countries the disease begin to appears in the young age between the age of (30-40) years and also few cases occur in age 20 years in this ages frequent deliveries and exercise allow the body of women to get rid of excess estrogen, but it is not related to estrogen only, but to the rest of the factors of this precaution and regular self-examination and early diagnosis ensures prevention and treatment dramatically when the signs of disease. the results of this study showed that the highest rate of cases was at the age (4049 years) and (50-59 years) and these results are consistent with the findings of alwan (2010), which was a study conducted in baghdad, where the results of this study that the highest rate of cases were in the age group (40-49 years) and (50-59 years), which recorded (31.9%) and (26.4%), respectively. another study finds similar result where the peak in this age group was recorded by the iraqi cancer register (icr, 2005). another iraqi study conducted by (mayada, 2013) showed that about 68.2% of the patients in the study were under the age of 50 years. the results of this study are also consistent with an egyptian study conducted by omar et al., (2003), which showed that the peak incidence of breast cancer was in the age group (40-59 years). these results coincide with a saudi study by elkhum (2007), noting that the average age of cases were 45 years. also our result agrees with rambau et al., (2011) who reports that patients with breast cancer mean age at diagnosis was 49 years. the results of this study agree with a study which is done by nyante et al., (2013) who find relationship between breast cancer type and age at first birth, and also agree with a study which is done by ozmen et al., (2009) observes that the (≥30) years age at first birth is associates with increased breast cancer risk. conclusion we concluded from this study that breast cancer is the most common cancer in wasit province, the highest rate of cases was in 2013, female are more likely to develop breast cancer than male and the most vulnerable age groups are between 40-60 years old. references • alwan, n.a. (2010). breast cancer: demographic characteristics and clinicopathological presentation of patients in iraq. em hj., 16: 1159-1164. • bray , f., ren, j.s., masuyer , e. , ferlay, j. (2012). global estimates of cancer prevalence for 27 sites in the adult population in 2008. int. j. cancer,132: 1133-1145. • brinton, l. a., brogan, d. r., coates, r. j., swanson, c. a., potischman, n., & stanford, j. l. (2018). breast cancer risk among women under 55 years of age by joint effects of usage of oral contraceptives and hormone replacement therapy. menopause, 25(11), 1195-1200. • elkum , n., dermime, s., ajarim, d., alzahrani, a., alsayed, a., tulbah, a. ( 2007 ) . being 40 or younger is an independent risk factor for relapse in operable breast cancer patients: the saudi arabia experience bmc cancer.7:222. 38 global journal of public health medicine 2019, vol 1, issue 2 gggggglo • fathi, r. a., matti, l. y., al-salih, h. s., & godbold, d. (2013). environmental pollution by depleted uranium in iraq with special reference to mosul and possible effects on cancer and birth defect rates. medicine, conflict and survival, 29(1), 7-25. • feng, y., spezia, m., huang, s., yuan, c., zeng, z., zhang, l., & liu, b. (2018). breast cancer development and progression: risk factors, cancer stem cells, signaling pathways, genomics, and molecular pathogenesis. genes & diseases, 5(2), 77106. • howlader, n ., noone, a. m. , krapcho, m., garshell, j. , miller, d. , et al. (eds.) (2013). seer cancer statistics review, 1975– 2010. bethesda, md: national cancer institute. • international agency for research on cancer (iarc), (2013). latest world cancer statistics global cancer burden rises to 14.1 million new cases in 2012: marked increase in breast cancers must be addressed. press release n° 223 pp1-2 • international agency for research on cancer (iarc), (2013). latest world cancer statistics global cancer burden rises to 14.1 million new cases in 2012: marked increase in breast cancers must be addressed. press release n° 223 pp1-2. • iraqi cancer registry (2005). results of the iraqi cancer registry.baghdad, iraqi cancer registry center, ministry of health. • mangesi, l., & zakarija-grkovic, i. (2016). treatments for breast engorgement during lactation. cochrane database of systematic reviews, (6). • mayada , i. y.( 2013). esterogen and progesterone receptors (er and pr) status of breast cancer cases in kurdistan and their correlation with pathologic prognostic variables. medical journal of babylon;10(1):75-84. • nyante, s. j., dallal, c.m., gierach, g.l., park, y., hollenbeck, a.r., brinton, l.a. (2013). risk factors for specific histopathological types of postmenopausal breast cancer in the nih-aarp diet and health study.american journal of epidemiology, 178:359-71. • omar , s., khaled, h., gaafar ,r., zekry, ar., eissa, s., el-khatib, o., et al. (2003) .breast cancer in egypt: a review of disease presentation and detection strategies. eastern mediterranean health journal may; 9(3):448-63. • ozmen, v., ozcinar, b., karanlik ,h.(2009). breast cancer risk factors in turkish women – a university hospital based nested case control study. world journal of surgical oncology: 7-37. • rambau, p. f., chalya, p. l., manyama, m. m. and kahima, j. k. (2011).pathological features of breast cancer seen in northwestern tanzania: a nine years retrospective study. bmc research notes 4, 214. • siegel, r. l., miller, k. d., & jemal, a. (2016). cancer statistics, 2016. ca: a cancer journal for clinicians, 66(1), 7-30. • torre, l.a., islami, f., siegel, r.l.,ward, e.m., jemal, a.(2017).global cancer in women: burden and trends. cancer epidemiol biomarkers prev.;26(4):444457. • who (2013). cancer control: knowledge into action: who guide for effective programmes: early detection. microsoft word gjphm-2020antibiotics.docx 125 global journal of public health medicine 2020, vol 2, issue 1 gggggglo original research magnitude of prescribed antibiotics in pediatric emergency department in basra hospital for maternity and children doaa qasim sabeeh1, noor mohammed abdulrahman2 & zaid abdul-ridha abass3 1 department of pharmacology and toxicology, college of pharmacy, university of basra, basra, iraq 2 department of clinical pharmacy, college of pharmacy, university of basra, basra, iraq 3 department of pharmacy, southern technical university, basra, iraq corresponding author: noormsc2014ph@gmail.com abstract introduction: antimicrobial agents are common employ in paediatric patients. emergency department make good place for known prescribing pattern of antibiotics with frequent use for disease that interfere in treatment between private pharmacy & hospital. the irrational and overuse of antibiotic in last decades did not follow the international guidelines and infectious strategy which if not controlled or minimize will lead to higher rates of mortality in human societies. the aim was to find the magnitude of antibiotics prescribing in children internal emergency department at basra hospital for maternity and children & showing relationship with misuse of it methods: the study was performed on 560 paediatrics patients aged (1 month -13 years) that seen in the (basra hospital for maternity and children) emergency department during 4 months from december 2017 to march 2018. these cases were dividing according to containment antibiotic and several parameters such as patient diagnosis and number of antibiotics prescribed. results: a total of 61% (n=342) patients were males. the average number of antibiotics per patient was 1.45 prescription did not contain antibiotics 28.57% (n=160) prescription contain antibiotics 71.42% (n =400) of all patient from total prescribed. most cases diagnosis for prescribing antibiotics are (24%) gastroenteritis (16.25%) bronchiolitis and (11.75%) pneumonia. conclusion: the dispensing of antibiotics is not following constant or international guidelines which will cause problems like resistance and economic side also. nearly almost the admitted patients received antibiotics regardless the culture results. keywords : antimicrobial, paediatric, irrational use, emergency department, magnitude , basra 126 global journal of public health medicine 2020, vol 2, issue 1 gggggglo introduction antibiotics, this class of drugs that are widely prescribed for podiatric patients, and in almost cases their dispensing is not being according true pathway (though checking the culture sensitivity) which make a big problem, that is bacterial resistance for almost antibiotics, even the broad spectrum one, for the coming years. such trouble will cause economical problem and large number of deaths by simple infections (pradeepkumar et al., 2017; sharma et al., 2016; thapaliya et al.,2015). irrational use of antibiotics will cause several problems; that are increase incidence of morbidity and mortality, toxic effect of some drugs, ineffective of these antibiotics due to new resistant strains of bacteria and higher morbidity and mortality rates (yusuf et al., 2017; baig et al., 2017 ; hameed et al., 2016). world health organization (who) puts an indicator for antibiotic uses to assess the percentage of its use. using of polypharmacy (more than one drug), using of antibiotic for non-infectious condition, wrong dose of antibiotics, using of injectable dosage form even the oral dosage form is present and the preferred and prescribe the drugs by generic name are some points prescribed in who indicator (el mahalli, 2012). some studies in iraq were made for evaluating the pattern of antibiotics use. in baghdad at 2017, a study was done in teaching hospital. this study shows the overuse of antibiotics either single or multiple drugs which in future will cause a big risk for individual and community (alwan et al., 2017). also, in karbala a research was done to assess the habit of antibiotic use and the result shows irrational use of antibiotics, as mentioned in obaid et al., (2017). in developing countries, antibiotics are taken by the patients directly from the pharmacy with-out prescription due to lack of laws that prevent their dispensing. these points will aid to develop high bacterial resistance and poor response to antibiotics. rapid and urgent changes are needed to overcome this problem (alhomoud et al., 2017 ; abuirmeileh et al.2014; mikhael, 2014; ronat et al., 2014; jamshed et al., 2018). in basra, this is the first study to assess the antibiotic use in paediatric hospital. the aim of this study is to evaluate the pattern and level of antibiotic use for paediatric patients in basra general hospital for paediatric and maternity. methods prospective study was done on paediatric patients admitted into hospital through emergency department. the study was performed on 560 paediatrics patients aged (1 month -13 years) randomly selected who visited basra hospital for maternity and children (bhmc) emergency department during 4 months from december 2017 to march 2018. their prescriptions were dividing according to containment antibiotic or not and several parameters recorded such as patient demographics, diagnosis and number of antibiotics prescribed. the data was collected by specific forma made for this study and statistical analysis was done by using excel 2010 and medcalc program. the ethical committee of scientific research in college of pharmacy was gotten. inclusion criteria: paediatric patient aged 1-15 years old admitted through emergency department exclusion criteria: any paediatric patient with chronic disease (cardiac, renal or respiratory disorder) 127 global journal of public health medicine 2020, vol 2, issue 1 gggggglo results table 1 shows the age distribution of the paediatric patients who included in this study. age groups are divided into five groups: less than one year (35.5%), 1-3 years (28.25%), 4-6 years (17.25%), 7-9 years (10%) and 10-12 years (9%). table 2 shows the number of patients who received antibiotics or not after admission into emergency department in hospital. patients who did not receive antibiotics account 160 patients, while who received antibiotics account 400 patients. 57.5% received one antibiotic and 47.5% received more than one antibiotic. table 3 describes the diagnosis of paediatric patients who enter emergency department of hospital. gastrointestinal infections account (24%), asthma (11.25%), pneumonia (11.75%), uti (4%), blood disorder (12.25%), bronchiolitis (16.25%), fever (4.75%), epilepsy (4.25%), dm (1.25%), septicaemia (1.75%), meningitis (2%), otitis media (1%), and undiagnosed cases (5.5%) table (4) explains the percent of prescribed antibiotics in emergency department. amoxicillin accounts the higher rate (40.5%) when compared to other antibiotics. cefotaxime accounts (17.6%), flucloxacillin (16.2%), metronidazole (19.7%), gentamicin (7.4%), ceftriaxone (4.5%) and vancomycin (2.9%). table (5) shows the frequency of combined antibiotics that prescribed for paediatric patients. these combinations are cefotaxime + flucloxacillin (12.8%), amoxicillin+ metronidazole (37.6%), amoxicillin + gentamicin (29.7%), flucloxacillin+ gentamicin (12.8%), ceftriaxone + flucloxacillin (7.9%), cefotaxime + amoxicillin (16.8%), cefotaxime + vancomycin (10.8%), ceftriaxone + vancomycin (5.9%), amoxicillin + flucloxacillin (19.8%), ceftriaxone + metronidazole (3.9%), amoxicillin +metronidazole+ flucloxacillin (8.9%) and finally cefotaxime+ flucloxacillin+ metronidazole (0.99%) table 1: frequency of pediatric patients’ admission into hospital during study period frequency and percentage for 4 months age 142 (35.5%) less 1yr. 113 (28.25%) 1-3yr. 69 (17.25%) 4-6yr 40 (10%) 7-9yr. 36 (9%) 10-12yr table2: evaluation antibiotics prescribed in hospital during work period did not received antibiotics received antibiotics 160 400 one antibiotics > one antibiotics 230 (57.5%) 170 (42.5%) 128 global journal of public health medicine 2020, vol 2, issue 1 gggggglo table 3: distribution of diagnosed admitted patients into emergency department in bhmc percentage and frequency diagnosis 96(24%) gastrointestinal infections 45 (11.25%) asthma 47 (11.75%) pneumonia 16 (4%) urinary tract infections 49(12.25%) blood disorder as prophylaxis 65 (16.25%) bronchiolitis 17(4.25%) epilepsy 19 (4.75%) fever 5 (1.25%) d.m* 7(1.75%) septicemia 8 (2%) meningitis 22(5.5%) undiagnosed cases 4 (1%) otitis media table 4: distribution of type of antibiotics prescribed in emergency paediatric department table5: frequency of combined antibiotic agents in paediatric department frequency and percentage (n=101) combination antimicrobial agent 13 (12.8%) cefotaxime + flucloxacillin 38 (37.6%) amoxicillin +metronidazole 30 (29.7%) amoxicillin + gentamicin 13 (12.8%) flucloxacillin + gentamicin 8 (7.9%) ceftriaxone + flucloxacillin 17 (16.8%) cefotaxime + amoxicillin 11 (10.8%) cefotaxime + vancomycin 6 (5.9%) ceftriaxone + vancomycin 20 (19.8%) amoxicillin + flucloxacillin 4 (3.9%) ceftriaxone + metronidazole 9 (8.9%) amoxicillin + metronidazole+ flucloxacillin 1 (0.99%) cefotaxime + flucloxacillin+ metronidazole discussion a total of 560 paediatric patients were reviewed during this study that admitted into emergency department and not admitted into hospital departments. all the information was collected using specific forma was made for this purpose to assess the patients’ characters, diagnosis and drugs prescribed. frequency and percentage (n=579) antimicrobial agents 235 (40.5%) amoxicillin 102 (17.6%) cefotaxime 94 (16.2%) flucloxacillin 62 (19.7%) metronidazole 43 (7.4%) gentamicin 26 (4.5%) ceftriaxone 17 (2.9%) vancomycin 129 global journal of public health medicine 2020, vol 2, issue 1 gggggglo antibiotic resistance is a growing problem in worldwide and need rapid and urgent plane to overcome it and avoid future mortality. in this study, about 400 paediatric patients were participated in this study who admitted into emergency department of basra hospital for maternity and children and received antibiotics, while 160 patients did not receive antibiotics; making the total number of patients are 560 patients. this study is designed to measure percent of antibiotic uses and the purposes for them to be prescribed and to evaluate if the dispensing is compatible with the diagnosis. in table 1, no. of paediatric patients who admitted into hospital. the higher age group who was less than one year age (35.5%), as the age becomes older; the percent of admission is being smaller. the age between 1-3 years, 28.25% was their percent, 4-6 years; about 17.25% was their admission percent. these age groups are more susceptible for infection and hospital admission. such results were also shown in a research done by thapaliya et al., 2015 and palikhe, 2008. this is a big problem due to complications that may these children will face in future, either as drug side effects or effect on their immunity (pomorska-mól & pejsak,2012). for future, it is necessary to ensure the right diagnosis before prescribing any antibiotic. in table 2, the data of 400 patients arranged as number of prescribing antibiotics. 57.5% of patients received one antibiotic during hospital admission, while 42.5% of patients received more than one antibiotic (may be double or triple). combination of antibiotics is good for several conditions such as meningitis, pneumonia, congenital heart disease, upper respiratory tract infection, etc. as seen in table 3, which shows the cases that admitted into hospital during research period. the higher percent was gastrointestinal infection (24%), then bronchiolitis, pneumonia and asthma were (16.25%), (11.75%) and (11.25%); respectively. such conditions, and the other which mentioned in table 3, are need for combination antibiotics, almost. using of combination of antibiotics should follow the guidelines of treatment in addition of culture sensitivity test, to overcome the causative agent and less side effects of agent will get, as seen in pradeepkumar et al.,2017 and alwan et al., 2017. some cases that mentioned in table 3 (like dm, fever, blood disorders) here the administration of antibiotic either prophylaxis to prevent any infection to occur due to these age group are immunocompromised patients, or to treat a serious infection for such patients. in table 4, the frequency of prescribed antibiotics was explained. amoxicillin with higher percent of dispensing (40.5%), and other antibiotics were (metronidazole 10.7% , flucloxacillin 16.2%, cefotaxime 17.6%, and ceftriaxone 4.5%). as we talk previously, the type of infections was serious and complicated that need combination in a lot of cases. pneumonia, meningitis, urinary tract infection are need to be amoxicillin or cefotaxime is one of the treatment guideline due to staphylococcus species are involve (husni et al.,2004). in this study, and as mentioned in table 3, gastroenteritis shows higher rate of admitted cases, then bronchiolitis and pneumonia, which can explain these percent of medications used. now in table 5, explains the type of combination of antibiotics. amoxicillin plus metronidazole shows higher percent of combination (37.6%). this combination can cover aerobic and non 130 global journal of public health medicine 2020, vol 2, issue 1 gggggglo aerobic microorganisms that are presents in children, like gastroenteritis which its prevalence is the highest among patients who participated in this study (yek et al., 2010). also, amoxicillin plus gentamicin shows high percent of patients (29.7%). this combination covers both gram positive and gram negative bacteria, in addition to synergistic effect on microorganism if this combination administered to the patients (darras-joly et al., 1996). amoxicillin plus flucloxacillin combination is useful for increasing area for covering microorganisms, the synergistic effect on bacteria (adam et al., 1983). conclusion: the dispensing of antibiotics is not following constant or international guidelines which will cause problems like resistance and economic side also. nearly almost the admitted patients received antibiotics regardless the culture results. this protocol need to be changed and make strict guidelines for prescribing antibiotics. conflicts of interest the author declare no conflicts of interest. references : • abuirmeileh, a., samara, s., alkhodari, a., bahnassi, a., talhouni, a., & hayallah, a. m. 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(2017). irrational antibiotic prescribing practice among children in critical care of tertiary hospitals. pakistan journal of pharmaceutical sciences, 30. • thapaliya, k., shrestha, s., bhattarai, s., basnet, d., & chaudhary, r. k. (2015). prescribing pattern of antibiotics in pediatric hospital in chitwan district in nepal. world j phar pharm sci, 4(11), 1631-41. • yek, e. c., cintan, s., topcuoglu, n., kulekci, g., i̇ssever, h., & kantarci, a. (2010). efficacy of amoxicillin and metronidazole combination for the management of generalized aggressive periodontitis. journal of periodontology, 81(7), 964-974. • yusuf, y., murni, i. k., & setyati, a. (2017). irrational use of antibiotics and clinical outcomes in children with pneumonia. paediatrica indonesiana, 57(4), 211-5. microsoft word gjphm-2020parasite 2.docx 151 global journal of public health medicine 2020, vol 2, issue 1 review research blood parasites affects local rabbits in iraq, a review hind d. hadi1, zainab a. makawi 1, farah a. abedulmujeeb2 1iraq natural history research center and museum, university of baghdad, baghdad, iraq 2 iraq national cancer research center, university of baghdad, baghdad, iraq *corresponding author: hinddhiaa86@gmail.com abstract rabbits are animals affected by many different species of parasites, infection lead to lower body weight gain compared with non-infected rabbits , while sever infection lead to death , although rabbits are less likely to develop epidemic diseases, but they are exposed to diseases of care and malnutrition, as well as parasitic diseases .turning to previous studies that dealt with the spread of blood parasites in rabbits is a protozoan parasite such as (scab body, babesia sp., theileria sp., anaplasma sp., trypanosom sp. ,plasmodium sp.). the current study aimed to defiend of blood parasite in rabbit in iraq . despite, the few of research on this subject for this study of blood parasites that infection of rabbits and suggestion development of a database of studies of blood parasites affecting rabbits in iraq. keywords: rabbits, blood parasites, babesia , theileria , anaplasma. 153 global journal of public health medicine 2020, vol 2, issue 1 introduction rabbits are one of the most common laboratory animals, used around the world in experiences to estimate various biological parameters, and this animal is either conventionally preserved in animal facilities for use in scientific research or is also obtainable in pet store s and in backyard settlements for commercial purposes (pinto et al., 2004). rabbits are susceptible to a number of parasites, among the parasitic diseases of rabbits, those which deserve special attention are coccidiosis, skin mange, ear mange or ear cancer and stomach-worm diseases. the common results are emaciation , weakness, wasting and death ,other parasitic affections , such as irritation caused by fleas, lice and intestinal worms of different types , although no noticeable symptoms are common in infected animals, they may gradually make them weak and unthrifty, making them more susceptible to other diseases due to their low vitality (schwartz and shook, 1931). the internal parasites of rabbits include very fine organisms known as protozoa and such tapeworms and round worms. they can cause loss of condition and ill health in rabbits as well as posing a risk to people. most pets have these, although it’s not always easy to tell if your rabbit is infested as often there aren’t any outward signs of ill health. symptoms are difficult to spot, but can include loss of condition, vomiting and diarrhea. by the time you notice these symptoms, these parasites can be damaging your rabbit’s health. (patton et al., 2008). as for the blood parasites of rabbits primary organisms that live and feed on animal blood where they are found within rbcs and wbcs or in plasma between blood cells and pose a significant risk to their life if the correct diagnosis and treatment are not made (ambrosio and dewaa, 1990). the most important of which are babesia theileria , plasmodium , anaplasma and trypanosome. babesia species: babesia is a genus of parasites that belongs to the phylum apicomplexa, babesiosis is transmitted through the bite of infected ixodes ticks, by blood transfusion or congenitally. in spite of fever is a hallmark of babesiosis, there are some no specified symptoms (vannier et al. 2015).the disease mostly occurs in the usa, but cases have also been reported in several european countries, in india, egypt, korea, taiwan, and south africa (nassar and richter, 2017). the main pathological event is lyses of red blood cells lead to hemolytic anaemia which in heavy cases may lead to organ failure and death, (gray et al., 2010). theileria species : theileria is a genus of parasites belonging to the group apicomplexa, and is closely related to plasmodium. theileria affects a variety of domestic and wild animals and is transmitted by tick ixodid from the genera amblyomma haemaphysalis, hyalomma and rhipicephalus. most of these ticks are famous for its large economic losses caused by the agricultural industry because of the spread of diseases and deaths and leathers damage and poor pet production. (bishop et al., 2004). the amplification and conservation of wildlife has make theileria of wildlife important theme for study. theileria can be categorized into "conversion" and "non-conversion" factions. parasite conversion of all groups in t. taurotragi clade (sivakumar et al., 2014), uncontrolled 153 global journal of public health medicine 2020, vol 2, issue 1 spread of schizonts results in diseases related with corridor disease (theileria parva), east coast fever (t. parva), malignant theileriosis (t. lestoquardi) in goats and sheep (bishop et al., 2004; mckeever, 2009). while, t. sp. (bougasvlei) , t. taurotragi, and t. sp. (buffalo) does not lead to diseases associated with schizot (bishop et al., 2004). theileria sp. that group within the antelope theileria causes lymphatic hypertrophy commonly related with the conversion of theileria (nijhof et al., 2005). this and the ability to culture schizonts indicate that not all the parasites converted share a monophyletic origin, which propose that schizonts transformation may happen on a larger scale than expected. the nonconversion theileria are benign but it can still cause infection due to plasma anemia induced by the piroplasm stage (sivakumar et al.,2014). plasmodium species: plasmodium falciparum (welch, 1897) is more famous in the tropics and subtropics area, stages of p. falciparum in the human host are (1) entering sporozoite (2) pre-erythrocytic schizont (3) asexual forms in the red blood cells and (4) gametocytes developing in the red blood cells . (p. ovale, p.vivax, , p. falciparum , p.malariae) reproduce asexually in man and sexually in anopheles mosquitoes .the infected mosquito injects sporozoites that enter liver parenchymal cell and undergo pre-erythrocytic schizogony to produce numerous merozoites. merozoites released into the blood stream enter erythrocytes and undergo schizogony to produce more merozoite (obado et al., 2016). asexual life cycle in red blood cells generally needs one to two days in p.falciparium ,two days in p.vivax and p. ovale. and three days in p. malariae. some merozoites that enter erythrocytes develop into macro and micro gametocytes that will initiate the sexual cycle if ingested by susceptible mosquito. malarial infection can be acquired by blood transfusion ,congenitally by organ transplant , and by the shared use of contaminated needles by intravenous drug users (coatney et al., 1971). pathology is primarily due to the erythrocytic stages and involves not only the red blood cells but also the spleen , liver, and other visceral organs in p.falciparum (frederick ,2002).malaria changes in the surface of the infected erythrocyte lead to hemostasis in the blood sinuses capillaries particularly in the brain , lung , coronary vessels and kidney (bartoloni and zammarchi, 2012). anaplasma species: anaplasma is one of the diseases of infectious blood parasites and is spread primarily by ticks and is not transmitted in direct contiguity. hot and underground areas. anaplasmosis is also transmitted by the ixodes tick which typically transmits lyme disease (yabsley et al., 2006). anaplasmosis is known as a disease spread by ticks. this can be contracted from tick bites that contain anaplasma phagocytosis. the most common bacterial tick that has bacteria is known as black-legged tick. this can be done by common deer tick. anaplasmosis can also be transmitted by blood transfusion, if the patient has contracted the disease unknowingly, then his blood is released. the infection can also be contracted by the recipient. it may also be spread through the use of unmodified surgical instruments, dehydration, castration, tattoo and needles under the skin. (capucille, 2011). ` 154 global journal of public health medicine 2020, vol 2, issue 1 trypanosomes species: wide range of blood parasites, which cause trypanosomiasis in both animals and humans (merino espinosa et al., 2016) like t.vivaxs, t.bruce ,t.rhodesiense, t. gambiense, t.congolense and t. evansi. trypanozoon evansi was first diagnosed and named by ‘griffith evans’ in 1880 in punjab / india by infected horses and camels, causing illness known as (surra). in iraq t.evansi first diagnosed by pioneer chadwick (1938) in the dogs (hoare., 1956). and in camels as an enzootic disease. trypanosome evansi also affected buffalo and cattle (leiper, 1956) . in humans, trypanosomiasis is known as african sleeping sickness. the main way of spreading these parasites is by a mechanical transmission. in another meaning , a kind of haematophagous insects, such as, tobanid flies can transfer infected blood to other healthy organisms. trypanosome species carried by tobanid flies, t.evansi remains monomorphic throughout its life cycle, while t. brucei subspecies presents different set of shapes during different points of her life cycle (hoare., 1972). encephalitozoon cuniculi : encephalitozoon cuniculi one of the microscopic parasites infecting the renal and central nervous system and causing infection to animals such as rabbits (oryctolagus cuniculus). (deplazes et al., 1996). it is a major disease of captive rabbits and has international recognition of its seroprevalence. most physicians mention vestibular disorder as one of the most frequently reported clinical signs. releated with chronic e. cuniculi infection . one of the most common species of the encephalitozoon genus and the phylum microsporidia genus is cuniculi (keeblem and shaw 2006). although a comprehensive review of the literature detects e-caused lesions. cuniculi are usually found in the central nervous system (cns) and these lesions are not consistent with clinical signs reported. the encephalitozoonosis pathogenesis and life cycle makes e. cuniculi escaping the serological titer association with the extent of the clinical disease, lacking humoral-mediated immunity in their rabbit host, remain unaffected by therapeutic attempts to reduce sporontaneous inflammation and escape therapeutic attempts in patients with chronic infection to eradicate germination, as e. cuniculi has been involved in immunocompromised humans as an opportunistic zoonotic agent, it becomes necessary to realize its true prevalence in the pet trade disease control and reduction of transmission are critical for veterinary and public health (mathis et al.,2005). review in the previous studies distribution of blood parasites from rabbits in iraq there are very few studies on this subject there are only two studies:first study abdulmajeed et al., (2007) in their study for some hematological and pathological changes in blood and liver of adult male rabbits experimentally infected with iraqi strain of trypanosome evansi they found the infection induced clinical symptoms of disease presented as acute and chronic phases depending on the duration of infection, leucocytosis due to marked lymphocytosis identified in the acute phase come after leucopenia through chronic phase . the major differences in the rbcs were the presence of 155 global journal of public health medicine 2020, vol 2, issue 1 large-size cells, howell-jolly bodies, sperm cells, target cells ,burr cells, and a significant platelets deficiency (thrombocytopenia) were monitored. the second study athraa, (2014) who study the prevalence of gastrointestinal and blood parasites with some histopathological changes of local rabbits in baghdad province ,who found some species of blood protozoa that infect local rabbits ,that the total infection rate of blood protozoa (38%) included (thieleria , babesia, anaplasma and plasmodium) in the percentage (23.75,5,6.25 and 25) respectively. dipeolu and ogunji (1977). in their study of the transfer of theileria annulata to a rabbit by the larvae of the tick hyalomma rufipes they found a white rabbit from new zealand on which larvae of hyalomma rufipes were fed died of theileriosis because of theileria annulata 22 days after the larvae had fed rufipes since its blood was free of theileria parasites before the larvae were fed ; . moreover, the blood of the rest of the rabbits rabbits, on which the nymphs and adults were feeding, was free of the theileria parasite . goethert and telford (2003) they recorded the rate of rabbits infected with babesia ranged from 11% to 29%, were examined over five transmission seasons. heidi and sam (2003).while studying enzootic transmission of anaplasma bovis in nantucket cotton tail rabbits they found that the prevalence of a. bovis in cotton tail rabbits ranged from 4 to 32% with a total average of 18% and they accounted for differences in prevalence that were not significant when evaluated on an annual basis but were significant when evaluated on a monthly basis.holman et al., (2005) the researchers reached through their study of isolating the babesia sp. from eastern cottontail rabbits that the nine samples were positive for babesias by pcr (88 total, 10.2% prevalence) during 2002 and three samples were positive (26 total, 11.5% prevalence) in 2003. yabsley et al., (2006). the researchers carried out a molecular survey of several tickborne pathogens in three types of rabbits to reveal anaplasma and babesia parasites in rabbits from georgia, usa and texas these results indicate the rate of rabbits infected with babesia (28%) and a. bovis (61%). qing et al., (2015) researchers, through their study of serological spread of encephalitozoon cuniculi and toxoplasma gondii in local rabbits (oryctolagus cuniculus) , found that e. cuniculi is found in rabbits on a large scale . the information about e. cuniculi serological spread is important not only because of on the animals potential from this parasite but also because the parasites can cause significant economic losses due to animal deaths of the hosts. conclusion rabbits have many parasites, including the hematomas, which lead to transitional diseases that affect humans and animals .the danger lies in its presence within rbcs and wbcs or in plasma between blood cells. therefore, the study focused on investigating the parasites that infect rabbits, including blood. conflict of interest the authors declare no conflicts of interest. 156 global journal of public health medicine 2020, vol 2, issue 1 references: • abdul-majeed, h. a. abbas, f. h. and abbood, h. f. 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(2006). detection of babesia and anaplasma species in rabbits from texas and georgia, usa. vector borne zoonotic dis ; 6(1):7-13. microsoft word gjphm-2020e health.docx 158 global journal of public health medicine 2020, special issue gggggglo review research e-health opportunities for the low and middle-income countries rehab a. rayan department of epidemiology, high institute of public health, alexandria university. corresponding author: rayanr@alexu.edu.eg abstract across the world, there is a critical expansion in digital technology through all fields, including health. electronic health (e-health) is the future of healthcare. e-health could help in building better healthcare systems since it can be adopted to enhance communications, train health workforce, assist in jobrelated tasks and supervision. additionally, precision medicine (pm), which is a modern approach in low and middle-income countries (lmics), could facilitate addressing chronic diseases. such techniques could promote innovative public health interventions that will improve population well-being worldwide to satisfy the indicators of sustainable development goal number-3 (sdg-3) that stresses on ensuring healthy lives and promoting welfare for all. however, e-health data could be both a gain and a challenge for lmics. a transformational and synergetic strategy is necessary to adopt these techniques as it would sustainably minimize the expanses of healthcare. yet, national adoption of ehealth is gradually progressing in several lmics. this review highlights the recent advances and future applications of mobile health and its impact on people's lives in the lmics. it also displays perceptiveness towards the best practice for scaling electronic health (e-health) initiatives in the lmics guided by adapted experience from real case studies and exploring the impact on designing and deploying future health initiatives, especially for improving the health workforce. finally, it suggests a structure for data governance policy to limit the hazards of breaching or abusing health data in e-health platforms. keywords : e-health, health workforce, health data, sdgs, low and middle-income countries. 159 global journal of public health medicine 2020, special issue gggggglo introduction unfortunately, not everyone can gain from nowadays technology. many have anyway been forgotten and the vulnerability is declining yet more for the economy, policy and society related outcomes of the quickly increasing disparity. large technical jumps are being made; however, the society and economyrelated profits stay geographically centred, mainly in the developed nations. quite often, the low and middle-income countries (lmics) are still away behind if not omitted entirely. this is because such countries keep confronting multiple and critical growth obstacles, encountering halts in their attempts to eliminate poverty, realize sustainable development and take part effectively in the progressively competing market worldwide. among the main reasons are structural limits and the apparent disparities between lmics and the others in fields like science, technology and innovation (sti). if such inequality are not addressed early enough, lmics would not be able to realize the 2030 agenda and its sustainable development goals (sdgs) ('utoikamanu, 2018). in the lmics, conventional strategies for growth supported by the premise that international investments and rising importations of capital products could derive, via disseminating technology and innovation, to developing profits, did not work as supposed. more significantly, reduced registration in higher education and therefore a shortage in the proficient workforce, reduced investment in research and development (r&d), and changeable or insufficient legal and political settings that could boost advancements, all lead to the deficient condition of science, technology and innovation. regarding the health sector, electronic health (e-health) can improve health systems, enhance the patientprovider relationship, empower novel paradigms of care, and transform the health systems to patient-centred healthcare in the low and middle-income countries (lmics). several digital initiatives have targeted healthcare challenges in the lmics, trying to promote both access to healthcare and the quality of services. ahead of piloting and exploration, such initiatives are targeting the call for practical scaling and integration to afford sustainable gains to the healthcare systems (mitchell & kan, 2019). lmics have endorsed the breakthrough in technology more than that in industry, yet, e-health is perceived with some doubts. hence, for adopting e-health initiatives, public and private sectors, as well as consumers, should play a significant role to adapt such technology (okwen, 2019). telemedicine and the shift in healthcare delivery health is a domain for innovative mobile solutions. examples of applying e-health include the rising adoption of telemedicine for remote diagnosis and management, standards to enhance the quality of care and more reliable access to services. smartphone technology is among the cutting-edge solutions in the lmics. factors such as the lower cost of the smartphone, and the united nations (un) promise to provide internet access in the lmics by 2020, which would afford smartphones for everyone. such technology has enhanced patient-provider communication, minimized costs, and boosted patients’ care. the potentials extend from affordable and fast medical training towards reaching the point-ofcare ultrasound. all the previously mentioned potentials are just a portion of what mobile solutions can offer to transform health universally. telemedicine is an ever-evolving circle of power that could fit the future of health worldwide (chung, 2016). precision medicine in lmic in contrast to high-income countries (hics), lmics are missing to some extent, a first field in precision medicine (pm) that is genomic studies. lmics, a significant percentage of the universe population, have access to fewer resources along with specific chronic illnesses and the related demand for durable care. hence, adopting the promising pm is challenging if not adequately tackled since it might largely broaden the disparity in health inequalities among hics and lmics (zgheib et al., 2020). in most lmics, the curve for chronic diseases, mainly cardiovascular diseases (cvds), diabetes mellitus, cancer, and chronic respiratory disease, steadily comply with that in the developed nations and resulting in prevalent premature mortality and morbidity and the accompanied undeniable economic load. moreover, an added significant issue is the growing drug-resistant microbes. in pm, subjective differences in genes, living and the environment for every individual is considered to manage and prevent illnesses. pm allows a personalized style where the proper therapy for the appropriate person at the appropriate timing. several developed nations have already implemented pm. however, the preliminary high cost, for the long-term, would minimize the health expenses by eliminating the incompetent therapeutic methods. in lmics, pm remains in its beginnings for problems like lacking 160 global journal of public health medicine 2020, special issue gggggglo experience and proficiency, the shortage of data on the population and the limited fiscal funding (haque et al., 2020). lately, genomic medicine has witnessed leading attempts in building capacities and partnerships in lmics. mindful adoption of pm in lmics with a cooperative, progressive designing and strategy would advance community health. for the elevated preliminary expenses, strict standards and interventions could be prioritized. for instance, they are regulating the cost of medicine to be affordable to as many people as possible. besides, the dynamic involvement of the private sector to endorse and boost pm might alleviate this load (haque et al., 2020). e-health potentials to advance health workforce several pieces of research have demonstrated the potential of digital technologies to enhance the health workforce all over the health system. in lmics, digital technology can build the capacity and promote the progress of the health workforce regarding training, stimulating, guiding, following up, and paying salaries, especially the health workers in distant or rural districts. research findings pointed out that a variety of e-health interventions for developing the health workforce has been examined and applied, for example, for training health workers, interacting among healthcare providers, professional networking, directing, and providing performance feedback to health workers. those are an indication of enhanced productivity and effectiveness in pilots or smallscale projects. in global health, however, there is an increasing need to go beyond small-scale projects and determine the initial and ongoing expenses of deploying and scaling-up e-health solutions, involving the return on investment. consequently, deciding, adapting, and executing the most promising e-health solutions for managing and developing the health workforce (long, pariyo, & kallander, 2018). moreover, there is a pressing demand to support progressing ahead small-scale evidently, showing which e-health interventions to pick, adopt, and execute at a larger scale. also, investigations are required to show how the states can improve their e-health administration and secure the tense invasion of web and mobile technologies to advance the lives of their people. the governments should also drive both the public and private sectors’ workers to fulfil substantial progress and safety by e-health interventions through improvements in technical areas like network speed and performance, data connectivity and analytics and cloud computing to promote healthcare workers’ capability and widen both access and quality of health services. eventually, a continuous hesitation to explore such greater concerns will drive wasted chances to maximize the striking capacities of innovative technologies on the healthcare system (long et al., 2018). successful cases from the lmics in lmics, implementing telemedicine is getting attention and expanding at the same time, shown by its several frameworks which are adopted and frequently led there (lemay et al., 2012). there is a growing acquisition of telemedicine tools such as the internet, mobile phones, and various information and communication technology devices. governments as well as developing and funding entities, have started to invest more in telemedicine. lately, grand challenges canada and the bill and melinda gates foundation have begun to fund and boost many creative proposals for telemedicine initiatives which enhance health outcomes in lmics. moreover, several cited telemedicine initiatives have demonstrated encouraging outcomes in perinatal care, for example in ghana, sony ericsson has sponsored the millennium village project; in albania, the world health organization (who) has sponsored both project optimize and program for appropriate technology in health (path); and in cameroon, grand challenges canada has sponsored the bornfyne project (okwen, 2019). furthermore, in malawi, airtel 321 brings data on maternal and child nutrition through mobile phones in the native language. in tanzania, a short message service (sms)-based application has been designed to attain the new-borns’ registration procedure more robust, cost-effective, and convenient for parents. in 2016, zipline, an interplay of high-tech start-up aircraft producer, logistics service provider, and public healthcare system experts, started utilizing aircraft to transfer medical equipment to distant health clinics in rwanda. zipline’s collaboration with the rwanda government has significantly minimized the need time to secure vital medical resources (‘utoikamanu, 2018). scaling e-health in the lmics universally, coordinated attempts for scaling and integrating e-health could allow creative approaches for patients and the healthcare 161 global journal of public health medicine 2020, special issue gggggglo workforce in the lmics. real case studies of scaling e-health in lmics have revealed some chief focus domains being crucial towards progress. initially, the inherent attributes of the program or initiative need to contribute real interests and approach an unmet demand, including input from the end-user. next, each stakeholder should be involved, qualified and encouraged to execute the novel initiative. also, the technological form of the initiative should be simple, interoperable and flexible. besides, the policy context where the e-health care initiative would be deployed should follow the broader healthcare system along with sustainable funding to maintain long-term extension, including private sector funding. sequentially, acknowledging the external environment, including the relevant infrastructure to promote adopting digital initiatives (labrique et al., 2018). e-health data governance consequently, the amount of big data worldwide has dramatically grown along with the fast rise in producing and consuming ehealth. such technical growth anticipates more potentials for data-driven and evidence-based health framework planning, control and evaluation. however, more chances to abuse such data or for data breaches to confidential individual data, particularly with the ease to access, transcript, move electronic data on automated hubs provided that missing proper controls. eventually, in the lmics, insecure people are more challenged in discussing digital protection and privacy. therefore, the likely gains in improving health systems and outcomes by the e-health context are coupled with the necessity to adopt robust data governance architectures and stressing on the ethical consumption of the gathered private data by the e-health platforms (tiffin, george, & lefevre, 2019). furthermore, the worldwide accelerated propagation of e-health meansincluding lmicsprovides much hope towards approaching significant gaps in healthcare systems. however, there is a specific duty for scientists, initiative administrators and workers to guarantee stable electronic data governance and relevant, approved utilization, there is as well a critical task on states and international parties to set and necessitate proper electronic data governance controls and balances meanwhile continuing initiatives. one governance structure for e-health data in healthcare systems research suggests principles regarding data governance at the micro-level where communications between subjects facilitate member safeguard by approval means and ethical commitment with private data; at the meso-level where parties like ethics review committees, donors and data access boards operate collectively to secure suitable data utilization; and at the macro-level where lawmakers and states determine how data governance need to be initiated to warrant the security of subjects (tiffin et al., 2019). the universal society would profit from the who leadership in that domain. meanwhile, state-level attempts are undertaken to drive higher responsibility and clarity in the data governance arrangements and standards schemes supporting electronic means being executed in the healthcare sector. in india, for example, the national health systems resource centre (nhsrc) has installed a community of research and practice for digital health that is generating unbiased criteria to evaluate electronic means for the front-line healthcare workforce, covering data governance and ethics. moreover, south to south cooperation of chief stakeholders is on the way to spread such proposals to south africa and stakeholders all over the neighbourhood to stimulate an evidence-based decision-making procedures for establishing the governance of scaling-up electronic means in the healthcare sector (tiffin et al., 2019). e-health and the future of healthcare systems the newly industrialized countries adopted foreign technologies to refresh their economy earlier to building their proper advancements in science and technology. meanwhile, this movement mandated a broad foundation of science-literate citizens to gain access to a trained and proficient workforce, which is vital to progressing sti. however, lmics are challenged with the shortage of high-speed connections and difficulties in equipment. insufficient connections hinder access to the most promising broadband applications for healthcare, education, economy and other industries, coupled with territorial and universal knowledge channels. most lmics cannot afford broadband internet access for everyone. innovative technologies have extraordinary futures to make gains for advancing the society and the economy of such countries. hence, substantial effort is needed to prepare and enable both the public and the private sectors with the facilities to achieve it (‘utoikamanu, 2018). regarding bold steps, in september 2017, the technology bank has signed the host country 162 global journal of public health medicine 2020, special issue gggggglo agreement between turkey and the un to endorse lmics in building capacities with respect to sti; nurture interior and innovative territorial contexts and homegrown r&d; enable market access and help with the shift towards proper technologies. the technology bank will start actions by collaborating with other agencies from the un to plan for evaluating the baseline sti and technology needs in five lmics—guinea, the sudan, haiti, uganda and timor-leste. additionally, after the year 2002, the technology bank in cooperation with research4life, a public-private alliance, has indeed employed "digital access to research", which has been operating in at least than 100 lmics (‘utoikamanu, 2018). consequently, in the lmics, although e-health is expected to imply a definite shift in delivering health services, there continue vital difficulties in both adoption and progress. unfortunately, the profited ones of the status quo will oppose such reforms notwithstanding the hope of more access and quality for the patient. technology will shift the power equilibrium between the patient and the provider, driving advances in the health workforce and the state functions. nevertheless, the global invasion of technology will make such moves inevitable. the initiatives’ administrators should apply such innovations for the public welfare and warrant that they serve all and not just the ones who can afford for the care or manage the health sector (mitchell & kan, 2019). conclusion it is probable for lmics to catch up with the modern developments in novel technology. cooperation between the public and the private sectors could achieve and prove that technology is not itself a destination but a precious facilitator along the way to realizing inclusive and sustainable development for all. ultimately, it is still pressing that the health society worldwide does not evolve mesmerized with technology as a destination itself, instead asserting that a technological breakthrough is a tool to overcome challenges, enhance healthcare, and save lives. through acknowledging the entire possibilities of ehealth, and ensuring proper stewardship, the world can boost realizing sdg-3, health for all. conflicts of interest the author declare no conflicts of interest. references: • chung, h. (2016). how smartphone technology is changing healthcare in developing countries. the journal of global health. retrieved from //www.ghjournal.org/how-smartphonetechnology-is-changing-healthcare-indeveloping-countries/ • haque, m., islam, t., sartelli, m., abdullah, a., & dhingra, s. (2020). prospects and challenges of precision medicine in lower and middle-income countries: a brief overview. bangladesh journal of medical science, 19(1), 32–47. https://doi.org/10.3329/bjms.v19i1.43871 • labrique, a. b., wadhwani, c., williams, k. a., lamptey, p., hesp, c., luk, r., & aerts, a. (2018). best practices in scaling digital health in low and middle income countries. globalization and health, 14(1), 103. https://doi.org/10.1186/s12992-018-0424-z • lemay, n. v., sullivan, t., jumbe, b., & perry, c. p. (2012). reaching remote health workers in malawi: baseline assessment of a pilot mhealth intervention. journal of health communication, 17 suppl 1, 105–117. https://doi.org/10.1080/10810730.2011.6491 06 • long, l.-a., pariyo, g., & kallander, k. (2018). digital technologies for health workforce development in lowand middle-income countries: a scoping review. global health: science and practice, 6(supplement 1), s41– s48. https://doi.org/10.9745/ghsp-d-1800167 • mitchell, m., & kan, l. (2019). digital technology and the future of health systems. health systems & reform, 5(2), 113–120. https://doi.org/10.1080/23288604.2019.1583 040. • okwen, p. (2019). mobile health at critical moments: how bold is global health? jbi evidence synthesis, 17(8), 1548–1549. https://doi.org/10.11124/jbisrir-d-1900243. • tiffin, n., george, a., & lefevre, a. e. (2019). how to use relevant data for maximal benefit with minimal risk: digital health data governance to protect 163 global journal of public health medicine 2020, special issue gggggglo vulnerable populations in low-income and middle-income countries. bmj global health, 4(2). https://doi.org/10.1136/bmjgh2019-001395 • ‘utoikamanu, f. (2018, december). closing the technology gap in least developed countries | un chronicle. retrieved 24 december 2019, from un chronicle website: https://unchronicle.un.org/article/closingtechnology-gap-least-developed-countries • zgheib, n. k., patrinos, g. p., akika, r., & mahfouz, r. (2020). precision medicine in lowand middle-income countries. clinical pharmacology & therapeutics, 107(1), 29– 32. https://doi.org/10.1002/cpt.1649 microsoft word gjphm-2020hydatiform.docx 118 global journal of public health medicine 2020, vol 2, issue 1 gggggglo original research descriptive study of hydatidiform mole according to type and age among patients in wasit province, iraq nawras najah mubark 1, abduladheem turki jalil 2 & saja hussain dilfi 1 1 department of biology,college of science,university of wasit , iraq. 2 department of microbiology, yanka kupala state university of grodno , belarus. corresponding author: abedalazeem799@gmail.com abstract introduction : hydatidiform mole is the most common among gestational trophoblastic diseases in women, which characterized by abnormal gestation, and subdivide to complete and partial hydatidiform mole. it continues to be a significant problem among women, because of complete h mole has a tendency to be a malignant. the diagnosis of this disease is very important because it has the potential to be transformed into choriocarcinoma and to differentiate it to a complete or partial. methods: in this study, data was collected from fifty-two patients selected randomly from al-karama teaching hospital and al-zahraa teaching hospital in wasit province. specialized histopathologists examined the sections with haematoxylin and eosin (h & e) to confirm the diagnosis. clinical information, clinical examination and histopathological parameter include type and age were obtained. the data collection period was from october 2018 to april 2019. results: the descriptive data showed that forty-eight percent of patients have a complete hydatidiform mole (chm) and fifty-two percent have a partial hydatidiform mole (phm). moreover, the same results demonstrated that the age group of patients between (14-21) and (22-29) years were more common than the other groups. conclusion: the age group under 30 years is the most common hydatidiform mole infected and partial hydatidiform mole was the most common type of hydatiform mole. keywords : hydatidiform mole, age, women, trophoblast cells, histopathology, iraq. 119 global journal of public health medicine 2020, vol 2, issue 1 gggggglo introduction the placental is a particular organ, which is capable of supporting life even if it is temporary. it serves as a lifeline for the physiological connection between the mother and the fetus during the pregnancy (ray,2010). "placenta is an interference organ between the fetus and mother during healthy pregnancy placenta has a crucial role to play while transporting the fetus ' oxygen and nutrients to the fetus for growth, development and disposal of wastes back to their mother's body. (um ,2004). placental pathology is known as a hydatiform mole for severe trophoblast invasiveness (savage et al.,2013). the unusual placenta features are the mass of tissue with grapelike, swollen, chorionic villi. the trophoblast shows an increased rate of proliferation and is very invasive. such high growth and invasion may lead to invasive trophoblastic gestational diseases (kars et al, 2009). "hydatidis derived from the greek word hydatis, which means watery vesicle, and mole comes from the latin word moles which means shapeless mass" (almahdili,2010). hydatidiform mole (hm) is the most common type of gestational trophoblastic disease (gtd), also called a molar pregnancy (wagneret al., 2008). hm is an unusual pregnancy with severe hydropic enlargement and trophoblastic factor proliferation affecting part or all of the chorionic villi. hms are subdivided into complete hm (chm) and partial hm (phm) based on clinical symptoms, histopathology and genetic differences (pakzad, et al.,2014). placenta comprises celllike vesicles (small sacs) of grapes normally visible to the naked eye. molar pregnancy or hm is an irregular pregnancy. the vesicles are caused by fluid, chorionic villi distention. hyperplasia of the trophoblastic tissue is noted when examined in the microscope (abbas and al-khafaji,2014). hm is distinguished by different degrees of trophoblast multiplication, (cytotrophoblast, syncytiotrophoblast and intermediate trophoblast) and vesicular swelling of the placental villi, connected to an absent embryo or irregular embryo (lurain,2010). given the spontaneous regression of the majority of hms after a suction evacuation, some may experience gestational trophoblastic neoplasia (gtn) and thus require chemotherapy. (cheung et al.,2004). grossly, the hydatidiform mole looks like masses of thin-walled, translucent, cystic, grape-like structures. there are two types of hydatidiform mole: complete hydatidiform mole (chm) and partial hydatidiform mole (phm). molar pregnancy incidence records vary according to a geographic area. for developing countries, the incidence is generally accepted to be very high. for women younger than 20 and over 40 years, the rate is higher (shazly et al.,2012). in low-economic patients and women who have inadequate food, folic and carotene diets, it is higher also in nulliparous women. (aghajanian et al., 2007). nutritional and socioeconomic factors have been attributed to the high incidence of molar pregnancy in some population. regions with a high incidence of molar pregnancy have been reported to correspond to geographic areas with a high vitamin a deficiency (loh et al.,2004). in iraq, the incidence is 1 in 221 women according to previous statistics. in basra, the incidence of molar pregnancy and choriocarcinoma was 1.7/1000 deliveries and 0.04/1000 deliveries, respectively (m chaied,,2007). 120 global journal of public health medicine 2020, vol 2, issue 1 gggggglo the incidence of gtds in maternity teaching hospital (in erbil city) 1 in 318 is comparable to the incidence in some middle east and far eastern countries(alalaf, and omer,2010). in nigeria, a high figure of 1 in 379 has also been reported (agboola, 2006). extreme maternal age and previous molar pregnancy are two known risk factors. late or very young maternal age has reliably associated with higher levels of complete hydatidiform mole. compared to women aged 21-35 years, the risk of the complete mole is 1.9 times higher for women both_35 years and_21 years as well as 7.5 times higher for women _40 years(sebire et al.,2002). risk factors for developing a molar pregnancy include advanced maternal age, teenage, inadequate nutrition, disturbed maternal immune mechanisms, cytogenetic abnormality, environmental factors and a history of hydatidiform mole (chandra,2015). the evidence for the role of other factors including diet, ethnicity, endogenous estrogen level, abo blood group, and environmental toxins is weak (cabill and wardle,2006). hydatidiform mole can be detected early by using ultrasound and serial monitoring of the serum human chorionic gonadotropin (hcg) hormones. however, hm and the remain products of conception (rpoc) can be difficult to be distinguished sonographically despite the presence of some specific sonographic features, that can differentiate hm and rpoc (betel et al.,2006). thus, in order to meet the gold standard for the diagnosis of hm, rpoc must be submitted for further histopathological analysis (horn et al.,2009). objective of the study detection the most affected age group as well as the most prevalent type. methods specimens of patients this study includes collecting fifty-two specimens randomly selected from patients infected with h mole with age range between 14 and 45 years, collection of blocks patients from (20092018 years). the study was submitted and approved by the faculty of college of science, the university of wasit in collaboration with alkarama and al-zahraa teaching hospitals, wasit, iraq. forty formalin-fixed paraffinembedded tissues section of hydatidiform mole patients with age range between 14 and 45 years were included in this study, 20 cases of complete hydatidiform mole and 20 cases of partial hydatidiform mole. all cases of patients were collected from al-zahraa teaching hospital and al-karama teaching hospital in wasit province, iraq. specialized histopathologists were examined the sections with haematoxylin and eosin ( h&m) . clinical information was obtained involving, clinical examination, and histopathological parameter includes (type and age). this study was carried out in laboratories of the all cases of patients were collected from alzahraa teaching hospital and al-karama teaching hospital. the collected data for each patient includes a history of infection, age. these statistics included all types of h mole for the period mentioned. data were distributed according to years and age. 121 global journal of public health medicine 2020, vol 2, issue 1 gggggglo results we colleted (52) specimen during the study period. the patients were grouped into four age groups (1-4) with an eight years interval. the first age group was 14-21 years, while the last age group was 38-45 years as shown in table 1. table 1: distribution of the hydatidiform mole patients according to age groups % n age group 38 20 14-21 years old 31 16 22-29 years old 14 7 30-37 years old 17 9 38-45 years old 100 52 total distribution of hydatidiform mole patients according to histological types out of fifty-two hydatidiform mole patients were taken randomly, 25 patients (48.08%) of them were found to have a complete hydatidiform mole (chm), and 27 patients (51.92%) have partial hydatidiform mole (phm) (table 2). table 2 : distribution of the hydatidiform mole patients according to histological types of disease. % n case 48 25 chm patients 52 27 phm patients 100 52 total discussion distribution of hydatidiform mole patients according to age group estimation of patients age group showed that 20 (38 %) patients with age group 1 (14-21), 16 (31 %) in age group 2(22-29), 7 (14 %) in age group 3 (30-37), 9 (17 %) in age group 4 (3845) . the minimum age was 14 years, while the maximum age was 45 years old. according to these results, the highest incidence rate been in the age group 1 (14-21). so we found that the incidence of hm in younger age patients is the most common. our result concord with the result of (ertiro et a , 2013) , when he found that the prevalence of hm was observed to be high (27.5%) in the age group below 20 years.whereas it is concluded that the age between 15-20 years was the only risk factor associated with the development of hydatidiform mole. also, our results were similar with the results of shazly et al., (2012), they clarified that the incidence in women under the age of 20 was higher and compared with them in that the 122 global journal of public health medicine 2020, vol 2, issue 1 gggggglo incidence in women over the age of 40 is. nevertheless, contrary to these findings, which also showed the risk of rising at age above 40 years, this trend was not observed in this sample, where it was found that the incidence rate in age groups 3 and 4 was small, likely due to early marriage in our community and by the age of 40 years, the majority of women completed their family. such conflicting results underline the need for further studies involving a broader patient population to create an absolute correlation between hm and advanced maternal age. the above findings also showed that the prevalence of the disease is also high in age group 2 (22-29), which indicates that this disease was more severe in reproductive age. jaffar et al. (2011 ), in his study, stated that in all regions and ethnic groups, the motherhood reproductive age is the risk factor most associated with hydatidiform mole. zh ,et al. (2019) also concluded that the molar pregnancies are more common at the extremes of reproductive age. however, the activity of sex hormone and maturation of ovum in the period between 1429 years maybe lead to the hydatidiform mole. there are two main risk factors that increase the probability of molar pregnancy: either the female is too young or too old to be pregnant (under 20 years, or over 35 years), and with past molar pregnancy history ( savage ,2008) . while not entirely clear aetiology of the disorder, possible risk factors can include ovaroid defects, uterine anomalies or nutritional shortcomings, including dietary protein, folic acid, and carotene. (jaffar ,2011). another study was done in singapore, karachi and nawabshah were suggested that hydatidiform mole arises as a consequence of defective ova (nizam et al., 2009). the low socioeconomic status of patients plays an important role in aetiology of this disease (jaffar,2011) . a study conducted by tham also found that the low socioeconomic status and malnutrition considered as the general reason for this disease (nizam et al., 2009). distribution of hydatidiform mole patients according to histological types it has been shown from the results, that the percentage of complete hydatidiform mole patients to partial hydatidiform mole patients was 48% to 52 % , where phm was higher as compare to chm . this result comes in contrast with results of (ertiro et a , 2013), who observed that the prevalence of partial hydatidiform mole and complete hydatidiform mole were 11.1% (20/180) and 1.7% (3/180), respectively. jaffar et al., (2011) were concluded that chm was higher as compared to phm , they found out of 60 cases of hydatidiform mole, 40 cases of complete hydatidiform mole and 20 cases of partial hydatidiform mole. the results above were in agreement with the results of abbas and al-khafaji ,(2014)(in baghdad \iraq ) , where the sixty cases of hydatidiform mole were obtained and classified for 30 patients to each complete and partial hydatidiform mole. also, gupta , et al.,(2012) found that the rate of chms patients was equal the phms in their study. another study was done by ali et al. (2018) during the period between jan 2011-jun 2013 in erbil\ iraq., on the pathology archives of the maternity teaching hospital & some private 123 global journal of public health medicine 2020, vol 2, issue 1 gggggglo histopathological laboratories demonstrated that the number of phm(n=24) same the number of chm ( n=24). conclusions: the age group under 30 years is the most common hydatidiform mole infected and partial hydatidiform mole was the most common type of hydatiform mole conflicts of interest the author declare no conflicts of interest. references : • abbas, r.k and al-khafaji ,k.r.(2014). expression of p57 immunohistochemical marker in complete and partial hydatidiform mole by using tissue microarray technique. iosr journal of applied chemistry (iosrjac) . 7( 5) :90-95. • agboola ,a . (2006).ttophoblastic tumours . text book of obstetrics and gynaecology for medical students , 2nded .ibadani heinemaun education books (nigerian) pic.;p.218-24. • aghajanian, p. 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(2004). the role of s6k1 in development and maintenance of nutrient homeostasis (doctoral dissertation, university_of_basel). • ertiro, b. t., twumasi-afriyie, s., blümmel, m., friesen, d., negera, d., worku, m., ... & kitenge, k. (2013). genetic variability of maize stover quality and the potential for genetic improvement of fodder value. field crops research, 153, 79-85. microsoft word gjphm-2020prolactindocx.docx 109 global journal of public health medicine 2020, vol 2, issue 1 gggggglo original research the frequency of elevated prolactin level in polycystic ovary syndrome women (pcos) and its' effect on pregnancy rate muhjah falah hassan department of anatomy, histology and clinical embryology, factuality of medicine, karbala university, iraq. corresponding author: doctor89muhjah@yahoo.com abstract introduction: prolactin is a hormone secreted from anterior pituitary gland which has different functions throughout the body of the fertile females. women with polycystic ovary syndrome (pcos) may exhibit a mild elevation of serum prolactin level. high prolactin level can affect the fertility potential causing ovulatory dysfunction. even those with normal ovulation, failure of producing a sufficient amount of progesterone after ovulation may occur which resulted in a deficient endometrium; less liable for embryo implantation( luteal phase defect). thus, this research is aimed to study the frequency of elevated prolactin in women with pcos and to evaluate its' effect on pregnancy rate. methods: fifty-three infertile females were included. they divided in to two major groups: group i: females with pcos and group ii: females with no pcos. both groups sub-divided in to two subgroups: group a with serum prolactin more than 20 ng/dl and group b with normal serum prolactin 2-20 ng/dl. all females were included in icsi program followed by assessment of pregnancy rate in both groups. results: the study was showed that 69.44% of women who suffered from pcos had an elevated serum prolactin level with a mean of 31.17±10.24. pregnancy rate was lower in the females with high serum prolactin level in both pcos and non-pcos women. conclusion: hyperprolactinemia is more frequent in the females with pcos than normal ovulatory females. elevated serum prolactin level negatively affects implantation and decreases the chance of getting a pregnancy following icsi. keywords : serum prolactin , pcos, icsi , pregnancy rate. 110 global journal of public health medicine 2020, vol 2, issue 1 gggggglo introduction polycystic ovary syndrome is a state of chronic anovulation affecting young women usually as a result of an imbalance of reproductive hormones (adam, 2014). women with pcos exhibit abnormal high serum androgen which results in failure of ovulation and reducing the chance of conception (alhindawi,2018) elevated prolactin level had been reported in pcos patients (apostolos,2018). there is an argument whether pcos and hyper prolactinemia share a common mechanism, coincidental, a cause-result relationship or both of them are distinct clinical entities(kemal et al., 2009). pcos usually result from improper steroidogenesis, hyper secretion of ovarian androgen, excess luteinizing hormone (lh) and hyper estrogenemia (susie et al., 2018). both hyper prolactinemia and pcos cause androgen excess but the source of androgen excess in hyper prolactinemia of adrenal origin which resolved on dopamine agonist medications while in pcos its mainly of ovarian source (gonen et al., 1989). some literatures documented an elevated prolactin level in females with polycystic ovaries (amir et al., 2016). the possible mechanism is an altered dopaminergic and opiodergic tones which has been observed in both conditions (perez et al., 2018). however, some postulated that the elevated prolactin level which has been recorded in pcos is transient and tends to be related to certain underlying factors most probably stress, drugs and associated hypothyroidism. so, any significant elevation of prolactin in pcos patients must be fully investigated (alpesh & mohd, 2018) and measuring serum prolactin level in such patients usually done because both disorders share certain clinical presentations (szosland et al., 2015). high prolactin level can affect the reproductive potential of the females through its inhibitory effect on gnrh neurons to inhibit gnrh secretion or affect the pituitary gland and decrease the secretion of gonadotropins resulting in ovulatory dysfunction (ursula, 2012). high serum prolactin also can interfere with the response of the uterine endometrium to the estrogen which is necessary for follicular growth and endometrial proliferation (daly et al., 1981). prolactin also may interfere with the luteal phase (ahmed et al., 2018). however the role of prolactin in the implantation and successful pregnancy is still uncertain (ioannidis et al., 2005). for successful embryo implantation, good quality embryo, adequately developed endometrium and a functional corpus luteum are essentials (perez et al., 2018). so, any factor which may interfere with implantation and decrease the chance of getting pregnancy should be fully investigated. 111 global journal of public health medicine 2020, vol 2, issue 1 gggggglo methods this is a prospective cohort study in which the infertile couples were taken from the fertility center, alsadr medical city, alnajaf al-ashraf/iraq. an oral consent was taken from all couples to be involved in the study. fifty three infertile females selected randomly were included and divided in to two major groups group i with pcos (n=36) and group ii without (normal ovulatory with or without tubal obstruction) (n=17) and all of them were subjected to intra cytoplasmic sperm injection(icsi) as a fertility treatment measure. the age of all females was 35 years old and less, all of them were stimulated by gnrh (gonadotropin releasing hormone) antagonist protocol + gonadotropins; (cetrorelix 0.25mg*1 + follitrope 75 iu*2 for approximately 7-14 days). the partners of those females had either normal semen parameters or with moderate impairment of semen quality according to who,2010. male partners with sever impairment of semen parameters and frozen sperms were excluded. other possible causes of elevated serum prolactin were also excluded eg., pituitary adenoma, drugsinduced and hypothyroidism. the female partners were evaluated by history, physical examination, anthropometric measure; weight, height and body mass index (bmi), hormonal profile and trans-vaginal ultrasound (tvus) for diagnosis of polycystic ovaries, antral follicles counts and endometrial thickness(et). blood was drawn at the morning of the day 2 of the menstrual cycle before 10.00 am. serum was obtained by centrifugation and tested by elisa using commercial kits(caa38264.1-mybiosource) to measure prolactin level. normal serum value in non-pregnant, non-lactating fertile female is 2-20 ng/dl(kathleen and timothy, 2017). cycle day 2(cd2) assessment of luteinizing hormone(lh), follicle stimulating hormone (fsh) and estrogen (e2) was also done. according to the level of serum prolactin, we subdivided the females of both groups in to two sub-groups: group a with normal prolactin level 2-20 ng/dl (n=11) and group b with high prolactin level more than 20 ng/dl (n=24). controlled ovarian stimulation by gnrh antagonist was done for all females. following ovulation trigger; pregnyl 10000 iu, oocyte retrieval was done by the gynecologist under general anesthesia and tvus when the woman had 8-14 follicles and their size more than 17 mm. at the same time the fresh ejaculated semen was prepared by sperm migration/direct swim-up from a pellet. icsi was commenced and embryo transfer was done at day 3. biochemical pregnancy was tested by human chorionic gonadotropin (hcg) assay 14 days following embryo transfer. pregnancy rate was calculated by dividing the number of women with positive hcg / the number of women whom embryo transfer was done*100%. the result were compared between both groups to predict the effect 112 global journal of public health medicine 2020, vol 2, issue 1 gggggglo of elevated serum prolactin level on pregnancy rate and implantation. analysis of the data was done by spss (version 24.0). the comparison for the mean ± sd was assessed by t-test and for the percentage by chi-square and the variation considered significant when pvalue ≤0.05. results from all 53 sub-fertile females, 36 females had pcos diagnosed according to rotterdam criteria (fauser et al., 2012) and 17 were normal ovulatory women whom attended the fertility clinic due to either tubal obstruction or mild-moderate male factor infertility. from 36 pcos women 25 ones had a mean serum prolactin level 31.17±10.24 and only 11 women had a mean serum prolactin15.17±4.51, so the percentage of pcos women with high serum prolactin (25/36) was 69.44%. the remaining 17 women were normal ovulatory women, nine had an elevated mean serum prolactin level 41.09±13.74 and 8 had a mean serum prolactin level 12.54±7.75. so, the percentage of normal ovulatory women having high serum prolactin (9/17) was 52.94%. so, the percentage women with high serum prolactin level was higher in pcos group 69.44 vs 52.94%. table 1: serum prolactin level in pcos and non-pcos groups. parameter pcos n (%) non-pcos n (%) women with high serum prolactin 25(69.44%) 9(52.94%) women with normal serum prolactin 11(30.56%) 8(47.06%) table 2 shows the demographic data of the females of pcos groups. there were no significant statistical differences regarding these parameters between both groups. p-value > 0.05. table2:demographic data comparison between both sub-groups within pcos group. parameter normal (n=11) mean ±sd high (n=25) mean ±sd pvalue age (years) 28.36±3.64 27.16±4.46 0.43 bmi (kg/m2) 28.88±2.12 29.96±4.80 0.48 duration(years) 6.18±2.82 6.84±3.26 0.56 113 global journal of public health medicine 2020, vol 2, issue 1 gggggglo table 3 compares cd2 hormonal profile and endometrial thickness (et) in both groups. there was no significant statistical variation regarding cycle day 2 in e2, fsh levels and et between females in both groups ( p-value = 0.50, 0.55 and 0.68 ) respectively. the only exception was cd2 serum lh which showed a significantly higher level in women with normal prolactin level with a mean of 5.72±3.50 vs 3.84±1.92 in women with high prolactin level ( p-value = 0.04). table 3: a comparison of cycle day 2 hormones and endometrial thickness within pcos sub-group. parameter normal (n=11) mean±sd high (n=25) mean±sd pvalue e2 (pg/ml) 44.63±30.17 39.44±20.16 0.54 lh (iu/l) 5.72±3.50 3.84±1.92 0.04 fsh (iu/l) 4.93±1.47 4.98±1.64 0.92 et (mm) 3.63±0.92 3.76±1.09 0.74 regarding to pregnancy rate, its best estimated in table(4). it was higher in females with normal serum prolactin level 27.27% in comparison with females with high serum prolactin 24%. table 4: pregnancy rate comparison between the pcos sub-groups parameter normal high p-value pregnant 3 (27.27%) 6 (24%) 0.2 not pregnant 8(72.73%) 19(76%) table 5 shows the demographic data of the females within non-pcos groups. there were no significant statistical differences regarding to these parameters between both sub-groups at p-value > 0.05 except bmi which is higher in women with normal serum prolactin at pvalue=0.03. table5:demographic data comparison between both sub-groups within nonpcos group. parameter normal (n=8) mean ±sd high (n=9) mean ±sd p-value age (years) 28.50±3.81 27.77±4.71 0.73 bmi (kg/m2) 28.16±4.34 24.17±2.39 0.03 duration(years) 5.50±4.89 7.77±3.23 0.27 table 6 compares cd2 hormonal profile and endometrial thickness (et) in both groups within non-pcos group. there was no significant statistical variation regarding cycle day 2 in e2, lh, fsh levels and et between females in both groups ( p-value = 0.84, 0.42, 0.73 and 0.93 ) respectively. table 6:a comparison of cycle day 2 hormones and endometrial thickness within non-pcos group. parameter normal (n=9) mean±sd high (n=8) mean±sd pvalue e2 (pg/ml) 33.71±15.21 35.46±19.69 0.84 lh (iu/l) 9.75±19..62 4.32±2.17 0.42 fsh (iu/l) 8.39±12.25 6.94±2.69 0.73 et (mm) 3.25±0.46 3.22±0.83 0.93 114 global journal of public health medicine 2020, vol 2, issue 1 gggggglo regarding to pregnancy rate in nonpcos group, its best estimated in table 7. it was higher in females with normal serum prolactin level 62.5% in comparison with females with high serum prolactin 55.55%. table 7: pregnancy rate comparison between the nonpcos sub-group: parameter high normal p-value pregnant 5(55.55%) 5(62.5%) 0.06 not pregnant 4(44.45%) 3(37.5%) discussion there is a controversy about the relation between polycystic ovary syndrome and hyper prolactinemia and weather pcos associated with hyper prolactinemia, hyper prolactinemia is a part of pcos pathophysiology or the abnormal hormonal environment of pcos lead to hyper prolactinemia is a matter of debate and a subject of a wide research (amir et al., 2016). the exact mechanism is still unknown, the theory of persistent hyper estrogenemia in polycystic ovary syndrome stimulates prolactin secretion is sometimes considered to be responsible (swathi and sujaya, 2015). about 5-30% of pcos exhibited a mild elevation in serum prolactin level (20-40 ng/dl) (baskind and balen, 2016) it has been reported that this mild elevation is transient and persistent elevation should be investigated by brain mri to exclude associated pituitary prolactinoma (sheehan, 2004). the study was showed that 69.44% of sub-fertile pcos patients had an elevated prolactin level (more than 20 ng/dl) in comparison with 52.94% in the normal ovulatory women. some was in agreement with this result and showed that serum prolactin level is higher than normal in pcos patients (sedighe et al., 2014). this could be explained by the hypothesis that some points of the pcos pathogenesis related to deficient hypothalamic dopaminergic activity which also responsible for elevated lh/fsh ratio and thyroid stimulating hormone (tsh) (anthony et al., 1984). many disagreed with this and states that serum prolactin level in pcos patients are normal and the association between pcos and high serum prolactin level is just an accidental finding (szosland et al., 2015). high serum prolactin (hyper prolactinemia) has been proven to negatively affect the outcome of icsi. studies had concluded that infertile females with normal serum prolactin showed a higher fertilization rate and pregnancy rate (del pozo, 1985) (reinthaller et al., 1987) (huang et al., 1991). other researches had found that the effect of an elevated serum prolactin on icsi tends to be insignificant (pattinson et al., 1990)(chang et al., 1993). meanwhile, subsequent studies had found a positive correlation between high serum prolactin and icsi outcomes (mendoz et al., 1997) (mendoz et al., 1999). 115 global journal of public health medicine 2020, vol 2, issue 1 gggggglo the current study showed that the pregnancy rate was less in the females who had high serum prolactin level. similar results were obtained from different studies which was reported that hyperprolactinemia decrease cleavage and pregnancy rate (ahmed et al., 2018). some researches tried to prove this by studying the icsi outcomes in infertile females with hyperprolactinemia after lowering serum prolactin by bromocriptine in the preceding cycle. they found a higher pregnancy rate and higher rate of developing good quality embryos which might responsible for the increased pregnancy rate(gonen et al., 1989). so, further studies about the possible factors which might be responsible for lowering pregnancy rate in hyper prolactinemic patients are suggested and studying the effect of high serum prolactin on embryo quality and further embryonic development is recommended conclusion: hyper prolactinemia is more frequent in the females with pcos than normal ovulatory females. elevated serum prolactin level negatively affects implantation and decreases the chance of getting a pregnancy following icsi. conflicts of interest the author declare no conflicts of interest. references : • adam, h. (2014). polycystic ovary syndrome, management–diagnosis and treatment. in : infertility in practice.4th ed. crc press is an imprint of taylor & francis group, an informa business., 201-236. • ahmed, k., ayman, a., mohamed, s., salwa, a., yahia, e., wafaa, r., & ahmed, m. (2018). changes in serum prolactin level during intra cytoplasmic sperm injection, and effect on clinical pregnancy rate: a prospective observational study.bmc pregnancy childbirth., 18:141. • al-hindawi, z.m. (2018). prevalence and ultrasound features of polycystic ovaries in kerbala-iraq. iraq medical journal.,2(4). • alpesh, g., & mohd, a.g. (2018). idiopathic hyperprolactinemia presenting as polycystic ovary syndrome in identical twin sisters : a case report and literature review.,10(7):e3004. • amir, h., hossein, m., & anoosh, n. (2016). comparison of the levels of lh, fsh, tsh, prolactin, progesterone and estradiol hormones between iranian infertile women with pcos and healthy women. int. j. of medical research and health sciences.,5(12):370-375. • anthony, a., frederick, k., & barry, m. (1984). hyper prolactinemia in polycystic ovary syndrome. the american fertility society.,41(5):719725. • apostolos, t. (2018) : polycystic ovary syndrome and early pregnancy loss : a review article. ec gynecology.,7(2) : 35-42. • baskind, n.e., & balen, a.h. (2016). hypothalamic-pituitary, ovarian and 116 global journal of public health medicine 2020, vol 2, issue 1 gggggglo adrenal contributions to polycystic ovary syndrome. best pract. res. clin. obstet. gynaecol.,37:80-97. • chang, s.p., ng, h.t., lan, t.l., chao, h.t., wei, t.c., yang, t.s., & ou-yang, x.r. 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(1991). transient hyperprolactinemia in infertile women with luteal phase deficiency. obstet. gynecol.,78(4):651-5. • ioannidis, g., sacks, g., reddy, n., seyani, l., margara, r., lavery, s., & trew, g. (2005). day 14 maternal serum progesterone levels predict pregnancy outcome in ivf/icsi treatment cycles: a prospective study. hum. reprod.,20:741-746. • jinno, m., katsumata, y., hoshiai, t., nakamura, y., matsumoto, k., & yoshimura, y. (1997). a therapeutic role of prolactin supplementation for in vitro fertilization : the bromocriptin-rebound method. j. clin. endocrinol. metab., 82(11):3603-11. • kathleen, p., & timothy, p. (2017). manual of diagnostic and laboratory tests. 6th ed. mosby's. • kemal, a., halis, y., ozgur, d., & sevim, g. (2009). hyper prolactinemia in polycystic ovary syndrome. endocrine abstracts.,20:653. • mendoz, c., cremades, n., ruizrequena, e., martinez, f., ortega, e., bernanabeu, s., & tesarik, j. (1999). relationship between fertilization results after intra cytoplasmic sperm injection, and intra follicular steroid, pituitary hormone and cytokine concentrations. hum. reorod.,14(3):628-35. • pattinson, h.a., taylor, p.j., fleetham, j.a., & servis, s.a. (1990). transient hyperprolactinemia has no effect on endocrine response and outcome in in vitro fertilization (ivf). j. in vitro fert. embryo trans., 7(2):89-93. • perez paulina, a., ceschin, alvaro, p., de moraes, m.p., oliveira, l.k., ceschin, n.i., & ichikawa, n. (2018). early serum progesterone and prolactin analysis at day 9 of oocyte retrieval as a predictor of success in fresh icsi cycles. jbra assisted reproduction.,22(2):9598. • reinthaller, a., deutinger, j., csaicsich, 117 global journal of public health medicine 2020, vol 2, issue 1 gggggglo p., riss, p., muller-tyl e., fischl, f., & janisch, h. (1987). effect of serum prolactin on cycle stimulation and fertilization of human oocytes. geburtschilfe frauenheilkd.,47(4):246-8. • sedighe, e., parvaneh, m., & maryam, g. (2014). the serum prolactin level in infertile women with polycystic ovary syndrome. j of babol university of medical sciences.,16(8):63-68. • sheehan, m.t. (2004). polycystic ovarian syndrome : diagnosis and management. clin. med. res., 2(1):1327. • susie, j., thomas, h., & adam, h. (2018). polycystic ovary syndrome and assisted reproduction. in : textbook of assisted reproductive techniques. david k. and colin m. (eds.).5th ed. crc press taylor & francis group.,762-772. • swathi, t., & sujaya, v. (2015). prevalence of hyper prolactinemia in pcos. ijsr.,6(11):185-187. • szosland, k., pawlowicz, p., & lewinski, a. (2015). prolactin secretion in polycystic ovary syndrome (pcos). neuro. endocrinol. lett., 36(1):53-8. • ursula, k. (2012). hyper prolactinemia and infertility: new insights. j clin. invest.,122(10):3467-3468 microsoft word gjphm-2021malaria (1).docx 467 global journal of public health medicine 2021, vol 3, issue 2 gggggglo review research a meta-analysis on the effectiveness of malaria community-based intervention norain ahmad1, nurul afzan aminuddin1, sharifah fazlinda syed nor1, mohd nazrin jamhari1, ahmad farid nazmi abdul halim1, hasanain faizal ghazi2, mohammed saffree jeffree3, syed sharizman syed abdul rahim3, norfazilah ahmad1, azmawati mohammed nawi1, mohd rohaizat hassan1* 1department of community health, faculty of medicine, universiti kebangsaan malaysia, kuala lumpur, malaysia. 2college of nursing, al-bayan university, baghdad, iraq 3faculty of medicine & health sciences, university malaysia sabah. *corresponding author: rohaizat@ppukm.ukm.edu.my abstract introduction: the community-based intervention was proven as one of the best approaches in combatting malaria. it is widely used to reduce malaria cases worldwide. a multisectoral approach must be made to ensure the success of the intervention. therefore, this study is aimed is to determine the effectiveness of community-based intervention for malaria based on recent findings. methods: a search strategy using pub med and cochrane database platform investigating the effectiveness of malaria community-based intervention. there are selected terms and words predefined to obtain a comprehensive search strategy that included text fields within records and medical subject headings (mesh terms). results: eight articles were selected for this study. this review identified six communitybased interventions for malaria and four outcome measures. most of the studies included a low risk of bias in each criterion except for random sequence and allocation of concealment. the meta-analysis found that the overall incidence difference of the included studies was significant (0.05 ci 0.02, 0.08), while the subgroup analysis of permethrin llin the i2 was reduced to 75%. however, the overall usage percentage difference in health education and community mobilization to improve intervention usage was not significant (0.28 ci -0.02, 0.58). conclusion: the community-based intervention approach is practical to fight malaria thus, to reduced mortality due to malaria. an integrated approach and engagement with multiagency will ensure outstanding achievement in fighting malaria. keywords: community-based, malaria, intervention, meta-analysis 468 global journal of public health medicine 2021, vol 3, issue 2 gggggglo introduction malaria is a vector borne disease caused plasmodium sp. parasites that transmitted to human bitten by the vector, infected female anopheles sp. mosquitoes. even though it is a life-threatening disease, it is preventable and curable. way back to malaria history globally, the malaria eradication programs that were launched in 1955 by the 8th world health assembly. since most of countries in the americas and europe, and in the majority of countries of asia and oceania initiated the program and very later after that was african region (world health organization, 2002). gratefully to know that the world data report in 2017 showed decreasing number of malarial cases from 2010 to 2017 however the difference not significant in the year 2015 to 2017. most malaria cases were reported from who african region (92%), followed by the who south-east asia region (5%) and the who eastern mediterranean region (2%)(world health organisation, 2018). it also reported that plasmodium falciparum is the most prevalent malaria parasite in the who african region, who regions of south-east asia, the eastern mediterranean and the western pacific. whereby in who region of americas is predominant by p. vivax representing the malaria cases. malaria infection is fatal if not treated accordingly. in 2017, there were an estimated 435 000 deaths from malaria globally and the african region accounted for the majority of the death (93%) , and children under five years are the most vulnerable to death (world health organisation, 2018). besides that, a pregnant woman is 3 times more likely to suffer severe disease after a malaria infection compared to non-pregnant women (tillotson & tillotson, 2009). nevertheless, the baby also prone to stillbirth, low birth weight and congenital malaria (de beaudrap et al.,2013; omer et al., 2017; schant-dunn, & nour, 2009). in other aspects, malaria burden the economics of the country. a study in zambia showed it was found the cost per rapid diagnostic tests (rdts) administered was estimated to be usd4.39, while the cost per artemetherlumefantrine (al) treatment administered was estimated to be usd34.74 (silumbe et al., 2015). it is much costly compared to the annual per capita cost of malaria control programme which only usd2.21 (shretta, avanceña & hatefi, 2016). therefore, the world health organization (who) with their tremendous efforts fighting malaria by series of programmes, guidelines, surveillances and intervention (world health organization, 2019). one of the best approaches in controlling and preventing malaria infection is by introducing the communitybased intervention. the types of community-based intervention that had been done are; i)insecticidetreated nets (itns), ii)indoor residual spraying (irs), iii) impregnated bed sheets, iv)intermittent preventive therapy (ipt), v)health education and vi)environmental management (owusu-addo e., 2014; salam et al., 2014). the study determines that most community-based interventions will give positive result in itns ownership and usage, parasitaemia, anaemia and other adverse health outcomes such as stunting, wasting, and stillbirth (salam et al., 2014). intervention combating malarial must be done in collaboration by multisectoral and agencies. it will include the elimination of breeding places, mobilizing supportive community participation, team building of healthcare staff, public health 469 global journal of public health medicine 2021, vol 3, issue 2 gggggglo department staff, general practitioners, youth club members and the co-operative societies. (shinde et al., 2015) . at our level of knowledge, the latest systematic review on community-based intervention for malaria was published in 2014 based on the articles of the 1990s to the early year of 2000s (salam et al., 2014). therefore, the objective of this present study is to determine the effectiveness of community-based intervention for malaria based on recent findings. methods literature search a systematic literature search of pub med and cochrane database platform was conducted in march 2019. there are selected terms and words that were predefined to obtain a comprehensive search strategy and that included text fields within records and medical subject headings (mesh terms). the keywords used are malaria or mesh word(malaria) or plasmodium and “community-based intervention”. the searching flow diagram is shown in figure 1. a total of 36 studies published from january 2000 until december 2018 were found using the key words mentioned. nine article was rejected because of duplication. only 11 articles selected after title screening in which were further filtered based on the inclusion and exclusion criteria. the inclusion criteria included were randomised controlled trials / experimental / quasi experimental studies on malaria interventions. observational studies, protocol, review papers, no full-text, non-english language articles and published before year 2000 were excluded from further analysis, which gave the total of 8 selected articles for full text review and further analysis. each article was reviewed by at least two reviewers using grade risk of bias checklist and if there was any disagreement between the 2 reviewers, third reviewer opinion will be sought and agreed upon. this study aimed to determine the effectiveness of community intervention of malaria. during the article search, the keyword use is not included in the outcome element to widen the exploration of the effectiveness element been studied. although there are several outcomes found including usage of llin, malaria incidence, knowledge toward malaria disease, care-seeking behaviour and compliance with imci, only two (2) outcomes were included in the meta-analysis which are malaria incidence and usage of llin. 470 global journal of public health medicine 2021, vol 3, issue 2 gggggglo figure 1: flow process data extraction the characteristics of the studies were extracted in a table. the information extracted include a) author and year of publication, b) country of study, c) the study design, d) sample population, e) intervention & duration, f) outcomes of the study, g) intervention group and h) control group. critical appraisal the studies were assessed based on six criteria; sequence allocation, allocation concealment, blinding, incomplete outcome data, selective reporting, and other sources of bias and will be decided as ‘low risk’ when there was no evidence of risk in the article, ‘high risk’ when there was obvious bias identified in the article and ‘unclear’ when there was insufficient evidence for conclusion of a bias. data analysis the effect size of this study was measured by calculating the prevalence difference of vaccination coverage and timeliness of vaccine intake between the intervention and the control group using 95% confidence interval (ci). the overall effect (pooled prevalence difference) was determined by z test 471 global journal of public health medicine 2021, vol 3, issue 2 gggggglo with p <0.05 was considered as significant. the heterogeneity was determined by x2 and i2 test, whereby p <0.1 and i2 >50% considered as heterogeneous. random effect model was used when there was evidence of heterogeneity as opposed to fixed effect model when there was evidence of homogeneity. publication bias was assessed by using funnel plot. analyses were done using review manager 5.3. results characteristics of reviewed articles a total of 8 articles that eligible to be included in this review whereby 6 studies are from india and 1 from each africa and vietnam as showed in table 1. the community-based intervention for malaria identified are: 1) supportive supervision & community mobilization (1 study), 2) llin – permethrin (2 studies) -deltamethrin (1 study), 3) llih (hammock) – permethrin (1 study), 4) permethrin plastic sheet (1 study), 5) health trainer (1 study), 6) household education and training (1 study). besides that, the outcomes measured are: 1) utilization or usage of llin (2 studies), 2) care seeking behaviour (1 study), 3) compliance to imci (1 study), 4) knowledge towards malaria disease (2 studies), 5) malaria incidence rate (1 study), malaria cumulative incidence (3 studies). risk of bias in the risk of bias assessment, most included studies contained a low risk of bias in each criterion except for random sequence and allocation of concealment. figure 2 showed four studies that did not meet the random sequence generation criteria whilst three studies did not meet the allocation of concealment risk criteria. one thing worth noted that almost all the studies did mention whether blinding of participants and personnel was carried out. 472 global journal of public health medicine 2021, vol 3, issue 2 gggggglo table 1: characteristics of the included studies author, year country study design sample population intervention & duration outcome intervention group control group (das et al., 2014) odisha, india. rct household supportive supervision & community mobilization 12 months consistent usage of llins care seeking behaviour 3571/4224 261/378 3219/4093 248/365 (winch et al., 2003) africa cluster rct carer of children in 10 health health trainer 3 months compliance with imci regime knowledge of malaria danger signs 109/152 100/145 29/134 44/143 duc et al., 2009) vietnam cluster rct 30 villages (population 18646) permethrin long lasting insecticidal hammocks (llih)24 months malaria incidence rate 92/9453.5 new cases per person sem 132/10706 new cases per person sem (sharma et al., 2009b) india cluster rct 3 village permethrin plastic sheet (zerofly) 8 months malaria cumulative incidence 13/330 51/382 (sharma et al., 2009a) india cluster rct 22 village permethrin llin 12 months malaria cumulative incidence 16/211 llin 48/265 untreated neat chourasia et al., 2014) india quasiexperimental 218 households in two villages household training vs. mass campaigns 4 months knowledge mean difference between the two groups was 0.547 (95% ci: 0.18–0.91) (pvalue of 0.004) proportion utilizing llin 57/108 27/110 (dev et al., 2010) assam india quasiexperimental village permethrin llin 10 months malaria cumulative incidence 36/2603 190/2950 (dev et al., 2011) india quasiexperimental village deltamethrin llin 9 months malaria cumulative incident mosquito mortality 31/2100 80/80 69/2068 7/80 473 global journal of public health medicine 2021, vol 3, issue 2 gggggglo figure 2: risk of bias result meta-analysis in the meta-analysis, the overall incidence difference of the included studies was significant (0.05 ci 0.02, 0.08) although there was high heterogeneity which was at 98% (figure 3). however, in the subgroup analysis of permethrin llin, the i2 was reduced to 75% and the result was also significant (0.07 ci 0.02, 0.12). 474 global journal of public health medicine 2021, vol 3, issue 2 gggggglo figure 3: effectiveness of community-based intervention in terms of malaria incidence in terms of the effectiveness of health education and community mobilization to improve intervention usage, the overall usage percentage difference was not significant (0.28 ci -0.02, 0.58) as pictured in figure 4. figure 4. effectiveness of health education and community mobilization to improve intervention usage the funnel plot for the studies included in the incidence analysis was visually symmetrical, meaning that there was unlikely any publication bias detected (figure 5). 475 global journal of public health medicine 2021, vol 3, issue 2 gggggglo figure 5 funnel plot discussion the meta-analysis result shows there is a significant difference in malaria incidence between intervention and control group. however, the results having high heterogeneity figure (98%). this may be due to the difference of population been studied, mainly from india and others country include africa and vietnam. the variety of population may result in a different geographical area, environment, social, and behavioural which may impact the study outcome. for example, duc et al studied the population live in the forest and like to sleep outside by using hammocks (duc et al., 2009). other studied populations are using llin inside their home ((dev et al., 2010, dev et al., 2011) and sharma et al studied the mobile population and used permethrin zero fly plastic sheet instead of llin (sharma et al., 2009a). the outcome measured differently across the studies such as duc et al used lab-test (rapid test p.falciparum specific, p.vivax and pan-malaria) and microscopic blood smear examination and measured incidence rate instead of cumulative incidence (duc et al., 2009). whereas other studies used only used malaria microscopic blood smear only to confirm the diagnosis (sharma et al., 2009a, sharma et al., 2009b). the study method to detect the malaria cases after intervention also differs, in example some study used passive surveillance (dev et al., 2010, duc et al., 2009) and other study performing active case detection (dev et al., 2011, sharma et al., 2009a, sharma et al., 2009b). the community intervention approach also varies, such as llin (2 types; deltamethrin and permethrin), llih (long lasting insecticide hammocks), permethrin plastic sheet (zerofly), health education with different approaches including household training, mass campaigns, health trainer, supportive supervision & community mobilization which have different degree of strength toward outcome measured in the study. 476 global journal of public health medicine 2021, vol 3, issue 2 gggggglo the other outcome that was analysed in this meta-analysis was the usage of intervention. it was noted health education and community mobilization do not affect on the usage of intervention. however, there are only three studies included in this analysis. it was also noted that there was high heterogeneity that could be due to different interventions applied in the three studies included. winch et al. (2003) implemented health education on integrated child management illness specifically for malaria whilst the intervention in das et al.(2014) was about community mobilization on good health behaviour. on the other hand, chourasia et al. (2014) intervention was about household training on the effective usage of llins. although all three studies included were about intervening health behaviour through health education and community mobilization, the implementation process differs so as the sample population involved. (winch et al., 2003) specifically targeted carers of children whereas chourasia et al.(2014) targeted the tribal population in the endemic regions which were quite similar to das et al. (2014). however, das et al. (2014) used a much larger sample size which gave weight to the result of the analysis. this study included the latest articles published since the year 2000 compared to a previous review article that included article less than years 2000 (salam et al., 2014). we used the cochrane search engine which is known to have high-quality paper and pubmed increase the search coverage. our study limitation is, we only used 2 search engines which may limit the coverage of article search. most of the studies are mainly from india and less from southeast asia and specifically from malaysia. by looking at the funnel plot, there is no evidence of publication bias however there is lacked smaller-scale studies evident by the missing gap in the base of the funnel. this could be explained by smaller studies were very rarely published in high impact journal making them not being picked up by the two search engines that were used. conclusion the community-based interventions showed effectiveness in reducing the incidence of malaria to achieve a successful malaria elimination program. it is recommended for integrating interventions and approach in maintaining effectiveness of the community-based intervention for malaria elimination program. acknowledgments we would like to thank the dean, faculty of medicine, university kebangsaan malaysia for his permission to publish this systematic review. conflicts of interest the author declares no conflicts of interest. 477 global journal of public health medicine 2021, vol 3, issue 2 gggggglo references • chourasia, m. k., abraham, v. j. & john, j. 2014. household training vs. mass campaigns: a better method of health communication for preventing malaria. trop doct, 44(4): 196-200. https://doi: 10.1177/0049475514545201 • das, a., friedman, j., kandpal, e., ramana, g. n., gupta, r. k. d., pradhan, m. m. & govindaraj, r. 2014. strengthening malaria service delivery through supportive supervision and community mobilization in an endemic indian setting: 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j. 2009. infectious diseases in obstetrics and gynecology. expert review of anti-infective therapy, 7(4): 413-414. https://doi:10.1586/eri.09.9 478 global journal of public health medicine 2021, vol 3, issue 2 gggggglo • winch, p. j., bagayoko, a., diawara, a., kane, m., thiero, f., gilroy, k., daou, z., berthe, z. & swedberg, e. 2003. increases in correct administration of chloroquine in the home and referral of sick children to health facilities through a community-based intervention in bougouni district, mali. transactions of the royal society of tropical medicine and hygiene, 97(5): 481-490. • world health organization. 2002. community involvement in rolling back malaria. http://www.paho.org/hq/index.php?gid=18295&option=com_docman&task=doc_view • world health organization. 2018. world malaria report 2018. world health organization. http://www.who.int/iris/handle/10665/275867 • world health organization. 2019. compendium of who malaria guidance. https://apps.who.int/iris/handle/10665/312082. microsoft word gjphm-2021acute diarrhea.docx 429 global journal of public health medicine 2021, vol 3, issue 2 gggggglo original research acute diarrhoea among under five years old children of underprivileged community in kota kinabalu, sabah mohd faizal madrim1, syed sharizman syed abdul rahim1, hasanain faisal ghazi 2, than myint1, khamisah awang lukman1, kamruddin ahmed3,4, mohd rohaizat hassan5, alabed ali a. alabed6 & mohammad saffree jeffree1,2* 1 department of community and family medicine, faculty of medicine and health sciences, university malaysia sabah, kota kinabalu, sabah, malaysia, 2 college of nursing, al-bayan university, baghdad, iraq 3 borneo medical and health research centre, university malaysia sabah, kota kinabalu, sabah, malaysia, 4 department of pathobiology and medical diagnostics, faculty of medicine and health sciences, university malaysia sabah, kota kinabalu, sabah, malaysia, 5 department of community health, faculty of medicine, universiti kebangsaan malaysia. 6 head of community medicine department, faculty of medicine, lincoln university college, 47301, petaling jaya, selangor, malaysia *corresponding author: saffree@ums.edu.my abstract the severity of childhood diarrhoea is linked with poor socioeconomic status, unhygienic living environment, and caregiver’s behaviour. this study is to determine the risk factors and economic burden associated with diarrhoea in children under 5 years of age. a case-control study using convenience sampling method with 105 cases and 105 controls was performed in menggatal health clinic, kota kinabalu, sabah between march-june 2017. younger caregivers, without formal education, poor knowledge, practice handwashing with water only and stopped breastfeeding were associated with diarrhoea. household with poor economic status, a family of five and more, crowded, with a pet, unsafe drinking water, no sanitary toilet, unsanitary garbage disposal and consuming street vendor food also associated with diarrhoea. the mean of total direct costs, total indirect costs and total incurred costs were (ringgit malaysia) rm 9.70, rm 59.40, and rm 14.30, respectively. as a conclusion, the risk factors for diarrhoea under 5 years of age still presents in sabah. environmental factors and hygienic practice are needed to control under 5 diarrhoea. keywords: diarrhoea; risk factors; household cost; children; underprivileged 430 global journal of public health medicine 2021, vol 3, issue 2 gggggglo introduction diarrhoeal disease is responsible for 1.7 billion morbidity and 760, 000 mortality of children every year (world health organization 2017). most of these deaths occur in developing countries. lack of access to safe drinking water and sanitary toilets, improper hand washing, poor environmental condition of household and modest health care system can worsen the severity of diarrhoea (godana and mengistie 2013). childhood and infant mortality rates are important components for the assessment of social development as well as health status assessment and the outcome of interactions of behavioural, socioeconomic and environmental factors (unicef 2012). explorations of these factors are essential to obtain a better picture of childhood morbidity. besides all these, diarrheal disease is an economic burden not only for the healthcare system, but also for patients’ families as well (burke et al. 2014). malaysia is a middle-income country in south east asia. despite tremendous progress in public health, the country still faces disparities among the population in different geographical locations. these are due to the inaccessibility of the places due to natural barriers such as dense tropical forests, mountains or remote islands. diarrheal disease is a challenge for the health care system in these areas. each year an estimated 16 outpatient clinic visits and 57 home-treated episodes per 1000 children under-5 with diarrhoea and costing about (ringgit malaysia) rm 10.8 million to the healthcare provider and about rm 15.8 million to society annually (loganathan et al. 2016). the economic impacts of acute diarrhoea among children include high medical expenses, productivity loss, and childcare adjustment. the economic burden of family is highest among children aged less than two years old for acute diarrhoea (diez-domingo et al. 2011). economically sabah ranked the lowest among all the states in malaysia (jamil and mat 2014). evaluating the known risk factors and economic outcome associated with acute diarrhoea have important policy implications for health intervention programs that subsequently will improve child health care in the study area and in the country in general. therefore, this study was done to determine the risk factors and household costs associated with acute diarrhoea of under five children visited a clinic serving underprivileged population in kota kinabalu, the capital of sabah, east malaysia. methods this is a clinic-based case-control study. the study was conducted at a suburban area of kota kinabalu containing many undocumented immigrants. it contributes the highest number of under-five diarrheal cases among all the primary health clinics. the study was conducted from march to june 2017. all under-five patients with diarrhoea attending at health clinic were enrolled in this study. 431 global journal of public health medicine 2021, vol 3, issue 2 gggggglo written informed consents were obtained from caregivers who agreed to participate in this study. children with acute diarrhoea were selected as cases and without diarrhoea as controls. under-five children with food intolerance, adverse effects of medicine, irritable bowel syndrome and any other intestinal diseases were excluded. sample size was calculated using the formula parker and bregman (parker and bregman 1986). required minimum sample size was 210 among them; 105 cases and 105 matched controls. a questionnaire based face-to-face interviews were conducted to collect data in the present study. the questionnaire was adopted from the who and translated into malay language. after that a pre-testing of questionnaires was conducted in urban area with 30 respondents which revealed good reliability chronbach’s alpha 0.82. the questionnaire contains both open and close-ended questions, and it was divided into four sections: a section on demographic and socioeconomic information; a section on environmental factors; a section on behavioural factors of caregiver; and a section on household cost of family. data were cleaned and analysed using ibm corp. released 2013. ibm spss statistics for windows, version 22.0. armonk, ny: ibm corp. it was analysed descriptively to identify demographic and socioeconomic characteristics of study population, environmental and behavioural factors that are potential risk factors for diarrhoea among under-five children. the household cost of family among those under-five children with acute diarrhoea was also calculated. the study was reviewed and approved by the national medical research registry (nmrr-16-224532787) and the medical ethics committee of universiti malaysia sabah medical ethics committee [jketika 1/17(1)]. all the consents for the study participants were collected from their parents. the parents were explained verbally and given a written guide by the assigned research assistant, parents were also asked to read the disclosure twice and asked if there were any uprising questions regarding the study prior to agreeing. results a total of 210 under-five children, aged 30.1±16.6 (mean±sd) months, were enrolled in this study. details of the demographic and social characteristics of the cases and controls are shown in table 1. the caregivers were at the mean age of 31.1±7.1 (range 17 to 63) years old. the mean monthly household income was rm 1833.62±1617.71 (range rm 300–11000). there is a statistically significant difference (p=0.02) of the monthly household income between the cases (1621.43±1374.21) and controls (2045.81±1811.00). children from households with pets, clean drinking water, using sanitary toilets, dispose garbage sanitary way, practice hand washing with soap, practice hand washing in critical time, had statistically significant less diarrhoea than households without pet, clean drinking water, not use sanitary toilets, not dispose garbage sanitary way, practice hand washing with water only, and do not practice hand washing in critical time (table 2). 432 global journal of public health medicine 2021, vol 3, issue 2 gggggglo in the association test for knowledge, attitude and practice of diarrhoea related components of this study, knowledge was the only component that showed significant association to under-five diarrheal morbidity. the odds of having acute diarrhoea in children of caregivers who had poor knowledge of diarrhoea are 2.3 times compared to those children of caregivers who had better knowledge of the disease (or=2.3; 95% ci 1.2 – 4.3; p<0.008). the total household costs of seeking care among underfive children with acute diarrhoea in this study are shown in table 3. the mean transport time consumed was 14±11 minutes. the main cost items that family suffer are consultations and medications (combined) cost being rm 8.00 (1.86 usd) ± 19.80 (82.5% of total direct costs). we found out that the mean monthly food expenses are rm 471.33 (109.66 usd). the mean cost per diarrhoeal episode is rm 14.30 (3.33 usd) which almost consumes 3% of the mean monthly food expenses. the economic status of household was divided into poor and not poor, based on the classification of economic status by economic planning unit of malaysian government. there were 57 families (61.3 %) in case group and 36 (38.7 %) in control group have poor household economic status (n=93). while 48 families (41.0 %) in case group and 69 (59.0 %) in control group have not poor household economic status (n=117). we found out that there is a statistically significant association between household economic status and under-five acute diarrhoea. the odds of having under-five acute diarrhoea among those with poor household economic status are 2.3 times compared to those with not poor household economic status (or=2.3; 95%ci 1.3 – 4.0; p<0.0004). the main source of funding for household costs for diarrhoea episodes was by using savings from monthly income with 64.8%. the other common source was cutting down on other expenses (29.5%), borrowing (3.8%) and donation from friends/relatives (1.0%). table 1: socio-demographic characteristics of children and caregivers variables cases (n=105) controls (n=105) gender of children male female 63 (60.0%) 42 (40.0%) 63 (60%) 42 (40%) age groups of children mean age (months) under 1 year 1-3 years 4-5 years 29.1 18 (17.1%) 51 (48.6%) 36 (34.3%) 31.2 17 (16.2%) 49 (46.7%) 39 (37.1%) age groups of caregivers under 20 years 20-40 years above 40 years 3 (2.9%) 93 (88.6%) 9 (8.6%) 95 (90.5%) 10 (9.5%) household income per month (rm) <rm1000 rm1000-rm3000 em3001-rm5000 >rm5000 34 (32.4%) 61 (58.1%) 8 (7.6%) 2 (1.9%) 25 (23.8%) 66 (62.9%) 10 (9.5%) 4 (3.8%) 433 global journal of public health medicine 2021, vol 3, issue 2 gggggglo table 2: associated risk factors between cases and controls variables cases (n=105) control (n=105) x2 or 95% ci mean age 29.26 33.03 3.99 p<0.001* education level of caregivers no formal education formal education 27 (25.7%) 78 (74.3%) 12 (11.4%) 93 (88.6%) 7.09 2.7 (1.3, 5.6) household economic status poor not poor 57 (54.3%) 48 (45.7%) 36 (34.3%) 69 (65.7%) 8.51 2.3 (1.3,4.0) crowding index overcrowded not overcrowded 79 (75.2%) 26 (24.8%) 58 (55.2%) 47 (44.8%) 12.82 2.9 (1.6,5.2) household size > 5 <5 87 (82.9%) 18 (17.1%) 65 (61.9%) 40 (38.1%) 11.53 3.0 (1.6,5.7) pet in house yes no 55 (52.4%) 50 (47.6%) 35 (33.3%) 70 (66.7%) 7.78 2.2 (1.3,3.8) drinking water unsafe safe 29 (27.6%) 76 (72.4%) 12 (11.4%) 93 (88.6%) 8.76 3.0 (1.4,6.2) sanitation facility unimproved improved 24 (22.8%) 81 (77.2%) 10 (9.5%) 95 (90.5%) 6.88 2.8 (1.3,6.2) household garbage disposal unsanitary sanitary 50 (47.6%) 55 (52.4%) 30 (28.6%) 75 (71.4%) 8.08 2.3 (1.3,4.0) knowledge on diarrhoea poor above poor 37 (35.2%) 68 (64.8%) 20 (19.0%) 85 (81.0%) 6.96 2.3 (1.2,4.3) handwashing method water only water and soap 35 (33.3%) 70 (66.7%) 10 (9.5%) 95 (90.5%) 17.68 4.8 (2.2,10.2) handwashing during all critical times not full full 32 (30.5%) 73 (69.5%) 13 (12.4%) 92 (87.6%) 10.21 3.1 (1.5,6.3) breastfeeding no yes 74 (70.5%) 31 (29.5%) 60 (57.1%) 45 (42.9%) 4.04 1.8 (1.0,3.2) recent street vendor food consumption yes no 32 (30.5%) 73 (69.5%) 15 (14.3%) 90 (85.7%) 7.92 2.6 (1.3,5.2) *p-value <0.05 is significant 434 global journal of public health medicine 2021, vol 3, issue 2 gggggglo table 3: total household costs of seeking healthcare among case group type of cost n mean + sd total direct cost (rm) 105 9.70 + 21.30 indirect costs (rm) 8 59.40 + 34.70 total incurred costs (rm) 105 14.30 + 28.10 discussion diarrhoeal disease is a widely recognized major contributor of morbidity and mortality in children. factors such as poor socio-economic status, low level of education, unsatisfactory environmental sanitation and poor hygienic practices account for a serious threat to human’s health, especially among children. in malaysia, diarrhoeal disease accounts for 4.52 % and 4.82 % of hospitalization and mortality respectively in 2015 (ministry of health malaysia 2016). risk factors for acute diarrhoea are mainly varied with child’s age, local environmental condition and behaviour of caregivers. this study is a supplement to not much pre-existing research that have been conducted so far in malaysia generally and sabah specifically. the highest rates of diarrhoea occurrence were among children aged six to 11 months old. diarrhoea occurrence rates maintained at a high level among the children aged one year old and reduced when children got older (molbak 2000). in this study, the number of males was higher than females in all age groups. the reason for this difference is not clear. however, for older children, boys are more active compared to girls (vale et al. 2010). the tendency of boys to move around and touch objects in the surrounding ground is higher than girls. girls have more tendency to stay close to their caregivers and play with more hygienic toys (arif and naheed 2012; eliot 2010; kuitunen 2005; yassin 2000). children from a poor socioeconomic background have higher risk to get acute diarrhoea. this finding is in line with the studies conducted in pakistan (alnawajha, bakry, and aljeesh 2015; arif and naheed 2012; dessalegn, kumie, and tefera 2011; kuitunen 2005; yassin 2000). perhaps lower income levels not only equated to poorer food safety and quality, but also less consumption of healthier foods like fruits and vegetables. furthermore, with poor economic status, there will be lack of resources such as availability of disinfectants in home cleaning and condition of the house surrounding. the caregivers with higher education have better chance of a child being spared of acute diarrhoea compared to lower education caregivers (alnawajha, bakry, and aljeesh 2015; dessalegn, kumie, and tefera 2011; gebru, taha, and kassahun 2014; sinmegn mihrete, asres alemie, and shimeka teferra 2014; siziya, muula, and rudatsikira 2013). education provides not only basic but also important information about personal and environmental hygiene, weaning and feeding practices, and disease signs and symptoms which boosts timely action on childhood illness. 435 global journal of public health medicine 2021, vol 3, issue 2 gggggglo children from households with more than two crowding indexes were more likely to develop diarrhoea compared to children from households with lower crowding index (siziya, muula, and rudatsikira 2013). children who live in a household with pet was having higher risk to get diarrhoea compared to household without pet. this may indicate possible zoonotic infections or hygienic condition associated with pet rearing in our study population (mamo and hailu 2014; seidu et al. 2013). children from households with improved drinking water source were less vulnerable to diarrhoea compared to children from households who use unimproved water source as well as availability of proper sanitation facility (dessalegn, kumie, and tefera 2011; godana and mengistie 2013). children of caregivers with good knowledge on general idea, signs and symptoms, causes, complications and preventive measures of diarrhoea were less likely to develop acute diarrhoea compared to those with poor knowledge. caregivers’ awareness of causes and general knowledge on how to prevent the disease are critical in the reduction of diarrhoea-related morbidity and mortality, which are, at present, unacceptably high (ansari, ibrahim, and shankar 2011; khalili et al. 2013; ogunrinde et al. 2012; wilson et al. 2012). diarrhoea causes economic burdens for families. even though the absolute number of household economic costs are relatively low for each childhood diarrhoea episode, but their cumulative impact is likely to be great. the small average costs also hide the continuous possibility that an episode will require more extensive and expensive care, resulting in not only indebtedness, but also selling of productive assets. furthermore, all the costs and other barriers to care may create or accentuate disparities in adverse outcomes including mortality (mendelsohn et al. 2008; weraphong et al. 2013). conclusion the risk factors for diarrhoea under 5 years of age still presents in sabah especially among the underprivileged population. environmental factors and hygienic practice are needed to control under 5 diarrhoea as it causes not only morbidity and mortality but detrimental effect on economy as well. limitations of this study include method in selecting the controls and lack of observational component in the study. this study indicates that there is a need to focus on comprehensive diarrheal disease control strategies, including improvement of water quality, hygiene, and sanitation, together with regular awareness talk on breastfeeding. acknowledgement we would like to thank the director general of health malaysia for his permission to publish this article. the authors would also like to express our gratitude to the sabah state health department. 436 global journal of public health medicine 2021, vol 3, issue 2 gggggglo conflicts of interest the author declares no conflicts of interest. references • alnawajha, samer khader, ghadeer abdo bakry, and yousef ibrahim aljeesh. 2015. “predictors of acute diarrhoea among hospitalized children in gaza governorates : a casecontrol study.” 33(1): 1–8. • ansari, mukhtar, mohamed izham mohamed ibrahim, and pathiyil ravi shankar. 2011. “a survey of mothers’ knowledge about childhood diarrhoea and its management among a 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http://www.ncbi.nlm.nih.gov/pubmed/11077937. microsoft word gjphm-2020climate change.docx 203 global journal of public health medicine 2020, vol 2, issue 2 gggggglo review research climate change actions: critical factors to achieve sustainable development goals narinderjeet kaur1, syed sharizman syed abdul rahim1*, zahir izuan azhar2, mohd yusof ibrahim1, mohammad saffree jeffree1, mohd rohaizat hassan3, rozita hod3 and azizan omar1,4 1 department of community and family medicine, faculty of medicine and health sciences, universiti malaysia sabah, 88400 kota kinabalu, sabah, malaysia 2 department of public health medicine, faculty of medicine, universiti teknologi mara (uitm), 47000, sungai buloh, selangor, malaysia 3 department of community health, faculty of medicine, universiti kebangsaan malaysia, 56000, bandar tun razak, cheras, kuala lumpur, malaysia 4 rural medical education center, faculty of medicine and health sciences, universiti malaysia sabah, 89050 kudat, sabah, malaysia corresponding author: syedsharizman@gmail.com abstract climate change has been deemed the biggest global health threat of the 21st century. multiple factors contribute to this global phenomenon including anthropogenic causes. this review is to explore causes of climate change and recognise the impacts on population health as well as to look at strategies to mitigate climate change. this narrative review included articles searched through databases of scopus, pubmed and proquest from the year 2006 to 2018. climate change is mainly due to man-made activities such as fossil fuels combustion, livestock farming and deforestation. the public health effects include increased vector-borne diseases, heat-related illnesses and respiratory illnesses. strategies such as strengthening the adaptations to climate-related hazards, climate change integration into national policies, education, awareness-raising, impact reduction and early warnings have been put in place to tackle this crisis. the climate change agenda has been given an important platform as it is the 13th goal of the 17 united nations sustainable developmental goals (sdg). in conclusion, climate change has been going on for decades and is threatening the earth. multi sectoral collaboration and working together towards a common goal is crucial as the wellbeing of our planet is our collective responsibility. keywords: climate change, global warming, health impact, sdg 204 global journal of public health medicine 2020, vol 2, issue 2 gggggglo introduction: climate change by definition is the change in the statistical distribution of weather patterns that occurs over an extended period of time regardless of the cause (schütte et al., 2017). another term widely used is global warming which refers to the increase in the surface temperature of the earth and appears to be synonymous with the term anthropogenic climate change (manmade causes). broadly, climate change includes global warming as well as every other reason for the change in weather patterns. it is therefore now widely used as a technical description of the process as well as a noun to describe the process. this change in climate has been something in the making for decades. the earth’s surface temperature has warmed by 0.85°c in the past 130 years. and since the year 1850, each decade appears to be warmer than the previous decade (smith, 2012). the 2°c increase is very crucial, because if earth’s temperature rises beyond 2 degrees then there is a risk of irreversible changes to the climate and the ecosystem (schütte et al., 2017). what is further worrying is that it has been recently projected that there will be an increase in temperature by 3.2°c by the year 2100 (rogelj et al., 2016). climate change effects include oceans getting warmer and sea levels rising. the arctic ice has been shrinking 1.07 km square every decade due to the increased temperatures at the poles (hák, janoušková, & moldan, 2016). sea levels have risen by 19 cm in a mere hundred years and it is predicted that by the year 2065, sea levels will rise by 24-30cm and 40-63cm by 2100. extreme weather patterns such as flash floods and typhoons, increasing number of infectious diseases and crop yield reductions are just some of the effects of climate change. these events will eventually cause social, demographic, economic and health disruption to the population (mcmichael, woodruff, & hales, 2006). by knowing the devastating repercussions of climate change, more policies need to be developed to ensure that there are adequate adaptation and mitigation strategies. the aim of this review is to understand the causes of climate change, especially on anthropogenic causes and to understand the impact of this phenomenon in contributing to individual and population health. this review looked into articles from 2006 to 2018. the focus of the review was on the causes, health effects and the strategies to mitigate climate change. the strategies reviewed were compared to the goals set under the 13th united nations sustainable developmental goal (sdg). methods: this is a narrative review that focuses on causes, health effects and mitigation strategies for climate change this review included articles searched through databases of scopus, pubmed and proquest. this review looked into articles in these databases from the year 2006 to 2018. keywords used were “climate change” and “health effects” and “mitigation”. the strategies reviewed were compared to the goals set under the 13th united nations sustainable developmental goal (sdg). the causes of climate change the causes of climate change can be explained via the forcing mechanisms which are divided into internal and external mechanisms. internal mechanisms are the natural processes that occur within the climate system itself. for example, the thermohaline circulation which is 205 global journal of public health medicine 2020, vol 2, issue 2 gggggglo part of the oceans circulation which is caused by density differences. it is commonly known as the global ocean conveyor or great ocean conveyor belt. this process drives warmer surface waters originating from the equator regions towards the north and south poles (yehudai et al., 2016). external mechanisms can be divided into natural and anthropogenic causes (man-made). natural causes are events such as volcano eruptions, changes in solar output, and the earth’s orbit. natural causes are rather difficult to predict and almost completely beyond our control. it has been anonymously concluded that human activities are the primary cause of climate change (mcmichael et al., 2006) as it leads to an increased emission of greenhouse gasses. the main contributions to the rising greenhouse gas levels are burning of fossil fuel, livestock farming, industrial activity and deforestation. this phenomenon is called the greenhouse effect. greenhouse gasses are carbon dioxide (co2), methane, chlorofluorocarbons (cfc) and nitrous oxide (schütte et al., 2017). climate change impact on public health a study conducted in 2017 concluded that by 2050, there would be a 257% increase in climate change related deaths (schütte et al., 2017). health impacts can be better understood based on events that occur due to climate change. the first is the disruption in the ecosystem. vector-borne diseases are very influenced by climatic conditions (campbelllendrum, manga, bagayoko, & sommerfeld, 2015). currently, vector-borne diseases are contributing significantly towards the global burden of disease. a change in climate will increase the transmission season of mosquitoes. previously, vectors were only active during the hot seasons, but with increasing temperatures, the hot seasons will be prolonged, allowing the mosquitoes to be active for a longer period. taking malaria as an example, due to the altered environment, which favours the agent by having more vectors (due to the increased range and period of transmission), the hosts become more susceptible. by the end of this century, 60% of the world’s population will be living in a malaria potential zone (andrew k, et al. 2000, campbell-lendrum et al. 2015, d.j rogers & s.e randolph 2006, badrul hisham a.s et al 2012). other effects of climate change include extreme weather events which range from heat waves to typhoons. these events are triggered and heightened by climate change (mcguire, 2012). these events can either affect health directly or indirectly. extreme high temperatures directly cause respiratory and cardiovascular diseases particularly among the elderly (levi & baldasseroni, 2017). this was evident when the heatwave in europe during the summer of 2003 claimed over 70 000 deaths (robine et al., 2008). higher temperatures have been known to cause a rise in the ozone gas which gives rise to respiratory and cardiovascular symptoms. elevated temperatures are usually accompanied by weak winds, causing air to stagnate, giving time for the air to rise in temperature and absorb more ozone. (zandalinas, mittler, balfagón, arbona, & gómez-cadenas, 2018). this also gives rise to increased circulation of allergens and pollens which gives rise to more allergies and bronchial asthma cases. bronchial asthma already affects 300 million people annually. the 206 global journal of public health medicine 2020, vol 2, issue 2 gggggglo indirect health effect of these extreme temperatures can be seen from a decrease in the yields of crops of staple foods. high temperatures year-long will make the soil dry, and even with irrigation, it won’t be able to sustain the moisture needed for crops like rice, wheat and corn to grow (caruso, petrarca, & ricciuti, 2016). this will further increase the number of deaths caused by malnutrition which is already at 3.1 million annually. this issue is bound to be most evident in the poorest regions of the world where agriculture is the main economy of the country. changing precipitation is also an effect of climate change which leads to more rainfall than normal. this increased rainfall leads to floods that are considered as an extreme weather event (mcguire, 2012). for example, in malaysia, the damages due to flooding cost of around 915 million ringgit (akasah & doraisamy, 2015). floods cause people to evacuate to temporary makeshift shelters that may not have facilities such as safe water. this can lead to water-borne disease such cholera and typhoid. it also causes an increase in vector-borne diseases like dengue as increase in stagnant water is perfect for mosquito breeding. besides that, other infectious diseases such as leptospirosis has shown to increase 2–3 weeks after heavy rainfall and flooding. aside from directly causing infectious diseases, flooding also causes physical injury and drowning. massive damage to properties and infrastructures such as roads and houses can occur. it is estimated that over 1 million ringgit is needed annually to restore and repair the roads that have been damaged by floods in one district (ismail & ghani, 2017). this damage also includes housing, schools and medical facilities which impacts millions of people. strategies to mitigate climate change countries are targeting for cleaner and more resilient economies. people are converting to renewable energy and various strategies were introduced to reduce emissions and increase adaptation efforts. however, the required actions need to be coordinated at the international level, in order to facilitate developing countries to move towards low carbon economy. to increase the global response to climate change threat, the paris agreement were adopted by many countries, at the cop21 in paris. this agreement went into force in 2016. this paris agreement states that all countries will work to limit global temperature rise to well below 20oc (paris agreement cop 21 2016). another strategy is to reduce energy usage. the international energy agency (iea) stated that by improving energy efficiency in buildings, industrial processes and transportation could reduce the world's energy needs in 2050 by one third. this will help reduce the global emissions of greenhouse gases for example carbon dioxide. in addition to reduction of energy usage, another strategy is to improve on the efficiency of energy. this include building insulation, energy saving electrical equipments and gadgets, as well as energy efficient public transport system (iea report 2019). the framework for the climate change policies have been made and policies have been implemented. however, there still lies many challenges regarding climate change policies. in regard to policy formation and construction, 207 global journal of public health medicine 2020, vol 2, issue 2 gggggglo a strong policy direction is needed to ensure that the goals towards reduced carbon emissions is achieved (schütte et al., 2017). the intergovernmental panel of climate change (ipcc) 5th assessment report 2014 states that given the current greenhouse emissions especially carbon dioxide, it is likely by the end of this century, the global mean temperature will continue to rise well above the pre-industrial level (ipcc 2014). in october 2018, the ipcc issued a special report on the impacts of the global warming of 1.50 celcius (ipcc 2018; climate summit 2019). sustainable developmental goal no 13 focuses on climate action. climate change is now affecting most countries of the world. the detrimental impacts are on the national economies, communities especially the vulnerable groups. there are increasing reports on changing weather patterns, sea level rise, extreme weather events becoming more frequent and the greenhouse gases emissions are at the highest level since history. without serious and concerted actions, the global ambient surface temperature is projected to surpass the 30c by the end of this century. if this happens, the most serious impacts will be upon the vulnerable groups such as the poor communities and the elderly (ipcc climate report 2018). challenge faced is the lack of expertise regarding climate change. there are not many noted environmentalist and experts on climate change, especially among the developing nations. this can be attributed to the fact that there is always lack of funding and research for climate change in developing countries (mcsweeney, new, lizcano, & lu, 2010) . ironically, due the dependence to natural resources, developing countries should have the most expertise. this leads them to rely on experts from other nations, which may delay the initiation of efforts in their own country. another limitation is following the public understanding and awareness towards climate change. there has not been much awareness and emphasis regarding climate change (tiew et al., 2019). this mindset of the public needs to change. people must understand that overconsumption and wastage of electricity leads to more power demands and this means more fossil fuel burning. another common misconception among the public is regarding the reduced use of plastic bags. plastic bags are detrimental, as they are mostly single use, nonbiodegradable and is commonly discarded into land fields, seas and ocean (wagner, 2017). this causes harm to the flora and fauna especially in the oceans. the manufacturing process of plastics also leads to many greenhouse gas emissions and other pollutants as plastic is made from petroleum based products (othman, adam, najafi, & mamat, 2017). there have been campaigns to ban the use of single use plastic bags and it is a great long-term strategy. however, the bigger concern currently is actually regarding the proper disposal of plastics. banning its use will not prevent ignorant people from throwing it into the seas and oceans. therefore, current public awareness regarding plastics should be more focused on the proper disposal and not just to limit its use. 208 global journal of public health medicine 2020, vol 2, issue 2 gggggglo another challenge regarding climate change policies are the issues of inequity in socioeconomic development. installing solar panels, for instance, is a way of using sustainable energy. however, it is costly to install solar panels in houses (kardooni, yusoff, kari, & moeenizadeh, 2018) . a household earning minimum wage may not be able to afford such methods. another issue is regarding the industries such as logging. the logging industry provides an income for many and especially in the rural areas (kaur, 2016). by shutting down the logging industries, these people will end up losing their livelihoods. the renewable energy industry has not reached the level where it can compensate and provide jobs to those who have lost jobs from logging in these affected countries. this matter, therefore, needs to be handled delicately and small steps need to be taken one at a time to ensure that the low and middle-income people do not suffer in the process. the number of countries pledging towards the climate change agenda is still not satisfactory. many nations still believe that climate change is not a big issue and that the repercussions are exaggerated (zhang, dai, lai, & wang, 2017) . in actuality, the health effects are detrimental. if actions are not taken early, these effects may become irreversible. all nations must be clear that if health is not prioritized, the economy and the whole nation will be affected. conclusion: from this review report, we can conclude that climate change is catastrophic, it has begun and will only get worse in years to come. unfortunately, the main cause of climate change is us, humans. cooperation between all the stakeholders is crucial in combating climate change. some success has been achieved but there is still a long road ahead. earth is our home and as inhabitants, we must take full responsibility and face this problem collectively to ensure that we do not cause further harm to our planet. conflicts of interest: the author declare no conflicts of interest. 209 global journal of public health medicine 2020, vol 2, issue 2 gggggglo references: • akasah, z. a., & doraisamy, s. v. 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(2017). u.s. withdrawal from the paris agreement: reasons, impacts, and china's response. advances in climate change research, 8(4), 220-225. doi:https://doi.org/10.1016/j.accre.2017.09. 002 microsoft word gjphm-2019pcos.docx 77 global journal of public health medicine 2019, vol 1, issue 2 gggggglo how polycystic ovary syndrome (pcos) affects the fertility potential of reproductive age females: review muhjah falah hassan 1 & rabab zahir al-yasiry2 ¹department of anatomy and embryology, faculty of medicine, kerbala university ,iraq. ²department of anatomy and histology, faculty of medicin, babylon university, iraq. corresponding author: doctor89muhjah@yahoo.com abstract polycystic ovary syndrome (pcos) is one of the major causes of decreased fertility in young females. multiple extraand intra-ovarian factors which are worked together or separately are responsible for sub-fertility. however, still, ovulatory dysfunction is the cornerstone that occurs as a result of hormonal dysfunction and consequently affects oocytes' quality, embryonic development and finally, implantation failure with a significant number of females seek assisted reproduction for getting pregnancy. keywords: pcos, sub-fertility, hormonal dysfunction, implantation failure and assisted reproduction. 78 global journal of public health medicine 2019, vol 1, issue 2 gggggglo introduction polycystic ovary syndrome is a condition of chronic anovulation which usually occurs as a result of an imbalance of reproductive hormones. women with pcos produce abnormally high androgen level which leads to failure of ovulation, skipping of menstrual period and difficulty in getting a pregnancy(mahesh et al., 2018). ovarian dysfunction represented by anovulation plays an important role in decreasing the fertility potential of the affected females (adam, 2014). however, multiple intra and extra ovarian factors could be considered (josefin et al., 2017). so, how pcos decrease the conception chance is a matter of debate and how could be bypass these factors is a matter of wide research. definition, diagnosis and clinical presentations of pcos the definition of the pcos has been much debated. the main pathophysiological abnormalities of the syndrome tend to be multi-factorial and poly-genic. still ovarian dysfunction plays a central role in the pathophysiology despite multiple extra-ovarian aspects (adam, 2014) at a joint european society of human reproduction and embryology (eshre) / american society for reproductive medicine (asrm) consensus meeting in rotterdam in 2004, pcos was diagnosed upon finding two from three criteria: 1. oligo and/or anovulation 2. clinical +/ biochemical sings of androgen excess and 3. polycystic ovaries by ultrasound, after the exclusion of other etiologies (fauser et al., 2012). the morphological features of polycystic ovary also were defined as an increased ovarian volume more than 10 cm3 and/or thickened stroma and appearance of 12 or more follicles measuring 2-9 mm in diameter distributed peripherally. either one or both ovaries may be involved (fulghesu et al.,2017). there is a variability in the expression of the syndrome among the patients and for a patient the sign and symptoms might be changed with time (mojgan, 2017). it may be clinically silent and the expression of it can be enhanced by multiple factors. increased weight is thought to be the most predominant one. however, clinical and biochemical factors which define pcos may not be exhibited in all women with polycystic ovaries. these are represented by disturbances of menstrual cycle, hirsutism, acne and alopecia; and biochemical abnormalities in form of increased concentrations of lh, testosterone and androstenedione in the serum. hyper-insulinaemia and obesity may associate although, only 40%–50% of females with polycystic ovary are overweight (adam, 2014) polycystic ovary syndrome presentation is usually variable in which either one, all, or a combination of the previously mentioned features can appear together with a polycystic ovaries picture during trans vaginal ultrasound examination (fritz & speroff, 2012). weight gain is associated with worsening of symptoms, whereas weight reduction enhances the endocrine, metabolic profile and the symptoms of the syndrome (josefin et al., 2017). although weight loss does not necessarily normalize the condition, it mainly improves the response to therapy, either for sub-fertility or for other abnormalities associated with the syndrome. the endocrine profile that many believe to be a diagnostic is elevated serum level of lh, testosterone and androstenedione together with normal or lower normal serum level of fsh and abnormal e2 production. (sudha et al., 2017). a non-invasive ultrasound scan is used for the assessment of total ovarian volume and morphology. the most relevant one that is used for the diagnosis of polycystic ovaries is trans-vaginal ultrasound (tvus). more recently, the threshold number of follicles should be 19 and serum concentration of anti-mullerian hormone (amh) is greater than 35 pml/l which is more precise than ultrasound features(yahia et al., 2013). so, the diagnosis is usually restricted for those females who show polycystic ovaries picture by ultrasound and display one clinical symptom or more with or without one or more biochemical abnormalities after the exclusion of certain underlying diseases that might 79 global journal of public health medicine 2019, vol 1, issue 2 gggggglo produce similar biochemical and ultrasound features such as pituitary and adrenal problems (arian et al., 2015). prevalence of pcos the exact prevalence of pcos is difficult to be determined definitively within the general population. it may show a considerable variation among the studied populations (amir et al., 2016). those who are selected upon the presence of clinical symptoms could be expected to have a greater prevalence than that exists in the general population. an estimated prevalence is approximately 4–8%, but it may be as high as 25% in some populations (susie et al., 2018). with increased rates and severity of symptoms in south-east asian women. around 22-33 % of women will show polycystic ovaries on ultrasound scan with no any associated symptom. those tend to be considered as normal variant and do not require further investigations or interventions (teede et al., 2010). pcos and infertility sub-fertility is a frequent complaint in pcos women and usually occurs as a result of anovulatory cycle due to the failure of normal ovarian function (kini, 2012). how pcos affects the fertility potential of the female is a controversial topic and usually results from multiple intra and extra ovarian factors which work together or separately and end in sub-fertility. despite multiple interlacing causes of sub-fertility in pcos women, ovulatory dysfunction is considered to be the most common cause. in fact, approximately 75% of all cases of anovulatory infertility have pcos (fritz & speroff, 2012). it has been showed that the effect of pcos which may result in sub-fertility acts at multiple levels : central ( hypothalamic-pituitary-ovarian axis ) results in anovulation, intra ovarian which adversely affects the quality of oocytes which in turn affects the quality of the resulting embryos or intrauterine level results in implantation failure and recurrent pregnancy loss (susie et al., 2018). pcos and chronic anovulation the precise mechanism is still not known but anovulation in pcos women most likely results from the inappropriate secretion of gonadotropins and change in the pulsatile secretion of gnrh which leads to excessive production of lh relative to fsh. whether the primary cause of pcos is the hypothalamus or pcos occurs secondary to abnormality in steroid hormones feedback is a matter of debate (hoffman et al., 2012). lh stimulates ovarian androgen production while the insufficient amount of fsh interferes with normal granulose cells aromatase activity and impairs androgen conversion to e2 (sudha et al., 2017). excessive circulating androgens also will enhance the aromatase conversion activity to produce e2 which is responsible for the chronic negative feedback to hypothalamus and pituitary gland in comparison to the normal fluctuations in the feedback which are observed in normal women as a result the of a dominant follicle presence and rapid change in e2 levels. insulin resistance might be considered as a potent contributor to follicular atresia in polycystic ovaries. impairment of normal follicular development leads to anovulation and subsequent oligo/amenorrhea in those patients (hoffman et al., 2012). effect of pcos on oocyte development as a result of dysfunctional ovarian steroid-genesis which is the main pathophysiological abnormalities in pcos women, theca cells from those patients will show an 1increased androgen secretion when they are cultured separately in vivo (walters & handelsman, 2016). this state of hyper androgenaemia will alter the microenvironment within the follicles leading to impaired folliculogenesis (yan et al., 2016). it might be possible that an elevated insulin level may also act as a contributing factor to excessive androgen production and will negatively affect proper oocyte development. high androgen level has a deleterious effect on folliculogenesis ends in follicular atresia. which tends to be 80 global journal of public health medicine 2019, vol 1, issue 2 gggggglo caused by androgens entrance into the granulose cells of pre-antral follicles, binding to intracellular receptors and leading to cellular apoptosis. the hyper androgenic state also leads to disturbed meiotic division as well as mitotic division of the oocytes and in turn results in improper maturation of the oocytes and developmental compromise (yan et al., 2016). maturation defects of the oocytes in the polycystic ovary are markedly still uncharacterized. there are inhibitory signals that hold meiosis in prophase i in the normal ovary (satin & rruce, 2008). successful ovulation to be occurred needs sufficient amounts of gonadotropins. both lh and fsh are necessary for enhancement of follicular growth and secretion of e2 and testosterone within a threshold level to oppose the inhibitory signals and allow oocytes initiate and complete meiosis. excess androgen in pcos stimulates multiple ovarian follicles in an equivalent time thus prevents the development of a single dominant follicle and leads to ovulation failure and relative resistance to gonadotropins (dumesic et al., 2015). intrinsic molecular defects within oocytes may also play a role. despite the abundant number of oocytes within polycystic ovaries, these oocytes have a reduced fertilizing ability and this leads to a decreased fertility in pcos patients and makes fertility treatment challenging (okohue et al., 2013). a raised concentration of lh, together with premature lh surge, may have an impact on follicle and oocyte development and are believed to be responsible for lowering pregnancy rate in those patients. a long time exposure of oocytes to high lh concentrations also leads to impairment of cytoplasmic maturity of oocytes. therefore it can be postulated that a prolonged pituitary suppression could be helpful in pcos patients. effect of pcos on embryo quality the quality of an embryo to a great extent depends on the quality of oocyte from which it was obtained. embryos with higher cell numbers, regular appearing cells, and little or no fragmentation have a higher overall chance of implantation (mina, 2013). in pcos patients, the increasing level of androgen leads to a decreased ovum potential to produce top-quality embryo. a high serum androgen level also has a negative impact on the quality of embryo itself and its quality gradually deteriorated with increased patients' age. the embryos of pcos women with high serum androgen and an age more than 35 years old, are usually at an increased risk of developmental arrest (baoli et al., 2015). pcos women with hyper androgenemia and obese women had shown a delayed early embryonic developmental stages. embryos which were derived from such women were characterized by delayed two pronuclus (2pn) formation post injection and delayed 4 cell stage up to 8 cell stage development (wissing et al., 2014). but this delay in the embryonic development had no significant bad impact on implantation and pregnancy rate (bellver et al., 2013). this will strengthen the concept that both the metabolic and hormonal state of pcos women will lead to derangement of early embryonic development with no significant clinical outcome (fancsovits et al.,2011). the effect of pcos on the embryo quality tends to be diverse as pcos women with normal androgen level still have an ability to produce developmentally normal embryos in synchronization with post injection time (bellver et al., 2013). the number of embryos which are produced by lab fertilization in such women are more when compared to women with normal ovary due to more oocytes which are produced. since the chance of a good quality embryo development would be increased and during arts, the probability of successful fertilization and successful conception is increased because of the ability of choosing oocytes and embryos with a good quality from all retrieved oocytes 81 global journal of public health medicine 2019, vol 1, issue 2 gggggglo and formed embryos (boomsma et al., 2006). effect of pcos on implantation of embryo and recurrent implantation failure implantation involves the adhesion of the embryo to the decidual layer of uterine endometrium with descent toward the basement membrane and its invasion to the stroma. this process is regulated by a complex system that involves interaction of hormones, growth factors, adhesion molecules, extracellular matrices and prostoglandins. although arts are able to achieve fertilization in 70-80 % of cases, the average live birth rate remains only 3040%. this could be explained by reduced endometrial receptivity and implantation failure (apostolos, 2018). the incidence of miscarriage in pcos patients is 30-40% which is three times higher than normal women. the mechanisms by which pcos causes a miscarriage are believed to be as a result of elevated androgen, elevated lh, increased insulin secretion and excess body weight (apostolos, 2018). impairment of endometrial blood flow, growth factors, adhesive molecules and cytokines are also likely to be candidates (cakmak & taylor, 2011). several studies suggested a link between hyper secretion of lh and early miscarriage. how an elevated lh concentration contributes to miscarriage till now is a matter of debate. a raised follicular level of lh can cause premature maturation of oocytes, release a physiologically aged oocytes and make viable embryos therefore unlikely to be produced (revelli et al., 2009). also elevated lh concentration can lead to impairment of endometrial receptivity and hence implantation failure, this was based on the discovery of lh receptors on the endometrium (duru et al., 2004). although recent studies have showed that there is no correlation between elevated lh and implantation failure, so depending on authors opinion, hyper secretion of lh is less likely responsible for making other endocrine and local factors to be considered instead(sudha et al., 2017). the mechanism by which high serum androgen level can cause implantation failure in pcos patients is mainly related to its bad effect on the normal uterine endometrial development (cocksedge et al., 2008). this concept depends on the fact that women with high androgen level have a reduced expression of the endometrial protein; placental protein (pp14) (glycodelin a) during the periimplantation period. in addition high androgen level also may have an adverse effect on the quality of oocytes and hence embryo viability and implantatio. furthermore, since hyper androgenism and hyper insulinaemia are usually accompanied to each other in pcos patients, hyper androgenism may indirectly affect insulin secretion via its effect on igf-1 receptors. the mechanism by which miscarriage may result is unclear. possibly, a raised insulin level is responsible for the decreasing serum glycodelin and insulin like growth factor -1 binding protein (igfbp-1) concentrations during the 1st trimester in pcos pregnant patients (stepto et al., 2013). low levels of these proteins leads to insufficient endometrial development during the peri-implantation period. two alternative mechanisms might also be responsible. firstly ; insulin resistance may lead to transport of excess amounts of glucose from the mother to the fetus resulting in the first trimester fetal loss. secondly, it was believed that there is a link between raised insulin concentrations and raised plasminogen activator inhibitor-1 (pai-1) concentrations. this will lead to placental insufficiency via increased thrombosis. glycodelin considered to be an important promising indicator of implantation. it plays a role in the processes pertaining to endometrial receptivity and implantation. its low levels during the mid-cycle fertile window are conducive to fertilization, while the higher levels during the midluteal implantation window (between day 19 and day 24 of the 28-day cycle) allow for implantation to take place. it has been demonstrated that the expression of glycodelin is increased in the endometrium during the implantation 82 global journal of public health medicine 2019, vol 1, issue 2 gggggglo window and late luteal phase. low serum and endometrial levels of glycodelin are observed in anovulatory cycles. this will lead to the impairment of endometrial functions making the pre-implantation environment is less suitable for implantation (sudha et al., 2017). thus, low glycodelin level leads to implantation failure, 1st trimester pregnancy loss, and recurrent pregnancy loss (selda et al., 2015). conclusions multiple intra and extra ovarian factors can affects the reproductive potentials in pcos women; increased body weight, hyper androgenemia, insulin resistance and excess lh production which may lead to failure of normal ovulation, alter the micro-follicular environment leading to produce bad quality oocytes and embryos and decrease uterine receptivity to the developed embryos which in turn decrease the chance of the women to get a spontaneous pregnancy. references adam, h. 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(2018). polycystic ovary syndrome and assisted reproduction. in : textbook of assisted reproductive techniques. david k. and colin m. (eds.).5th ed. crc press taylor & francis group.,762-772. teede, h., deeks, a., & moran, l. (2010). polycystic ovary syndrome: a complex condition with psychological, reproductive and metabolic manifestations that impacts on health across the lifespan. bmc med.,8:41. walters, k.a., & handelsman, d.j. (2016). androgen receptor splice variants and polycystic ovary syndrome: cause or effect?. asian j. androl.,18:442-443. 84 global journal of public health medicine 2019, vol 1, issue 2 gggggglo wissing, m.l., bjerge, m.r., hoest, t., & mikkeilsen, a.l. (2014). impact of pcos on early embryo cleavage kinetics. reproductive biomedicine online.,18:508514. yahia, w., mahmoud, s., & tamer, f. (2013). prediction of intracytoplasmic sperm injection outcome in patients with polycystic ovary syndrome using follicular anti-mullerian. aamj.,10(4)-supll 2. yan, z., lingyan, l., tai-lang, y., jing, y., & cheng-liang, x. (2016). follicular metabolic changes and effects on oocyte quality in polycystic ovary syndrome patients .oncotarget.,8(46):80472-80480 microsoft word gjphm-2021drugs error.docx 438 global journal of public health medicine 2021, vol 3, issue 2 gggggglo original research recognition and prevention of medication errors in pediatric inpatients: the role of clinical pharmacists mustafa b. al-khyat1, mohammed i. aladul2,3 1ibn al-atheer teaching hospital, nineveh health directorate, mosul, iraq, 41002. 2college of pharmacy, university of mosul. nineveh, iraq, 41002. 3college of pharmacy, ninevah university, nineveh, iraq, 41002. *corresponding author: m.i.m.aladul@uomosul.edu.iq abstract introduction: medication errors (mes) are considered preventable errors that may occur frequently during the treatment process with or without patient harm in addition to their economic consequence. mes occur during prescribing, dose calculation, dispensing, or administration of medicine which could be made by any healthcare professional as a physician, pharmacist or nurse, or by the patient himself. objective: to detect and report mes in pediatric inpatients’ medical records and potentially preventing these mes by making recommendations/suggestions for healthcare professionals about the proper action needed to be taken. methods: this was a prospective observational study, in which the medical records of admitted pediatric patients to ibn al-atheer teaching hospital, nineveh were reviewed to detect, report, and prevent mes between the 1st of january and the 30th of june 2019. results: out of 6964 medical records reviewed by clinical pharmacists during the study period, 119 mes were reported to healthcare professionals and prevented. 83% of detected mes were dosing errors. the results of the chi-square analysis showed that the highest percentage of dosing errors were associated with antibiotics (p=0.0493). furthermore, the results of chi-square analysis showed that the highest percentage of dosing errors were seen in infants and toddlers (p=0.011). conclusion: this study highlighted the role of clinical pharmacists in recognizing, reporting and preventing mes which are still occurring in every medical setting. dosing errors were the most commonly occurring errors and antibiotics were the most frequent group of medicines involved in mes. keywords: medication errors, pediatric, clinical pharmacist 439 global journal of public health medicine 2021, vol 3, issue 2 gggggglo introduction the treatment plan for each patient, is a multidisciplinary process involving prescribing, dispensing, administration of medicines and monitoring of the patient by healthcare professionals within the healthcare institute. this plan aims to promote patient’s health and saving lives (khowaja et al., 2008). however, medication errors (mes) may arise during any step of the treatment plan and may potentially lead to treatment failure and/or patient harm (ferner & aronson, 2006). according to the national coordinating council for medication error reporting and prevention (nccmerp), medication errors (mes) are defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in use” (karna et al., 2012). medication errors are multifactorial and might arise from (1) personal factors, such as lack of knowledge, prescribing problems, poor handwriting, inaccurate dose calculation, wrong strength or dosage form, incorrect method or route of administration, wrong patients order or dispense, mistakes in preparing & labelling, or unclear direction of use, (2) environmental factors, such as inappropriate environment as workload noise or tension, bad store as heat or light, invalid packaging (sinha et al., 2016; al-worafii, 2018). mes are not only made by physicians, all healthcare providers (pharmacists, dentists and nurses), medicine’s manufacturers and patients are involved in mes (karuppannan et al., 2013). the consequences of mes can range from simple unnoticeable errors to serious errors that lead to morbidity and mortality. in addition to the economic consequences of these errors that result from a prolonged hospital stay, need for further medical care and treatments, and decreased productivity (from time wasted in the hospital) (walsh et al., 2017). furthermore, mes has psychological consequences in which the patients’ confidence in their healthcare system would be compromised affecting patient’s compliance and adherence to their treatment (patanwala et al., 2010). medication errors are a very common problem worldwide. a recent study estimated that about 237million mes occurred during the last year in uk’s primary and secondary care settings and costs the uk national health service £98 million (elliott, et al., (2021). studies suggested that the incidence of mes are three times higher (1.1%) in the pediatric population in comparison with adults (0.35%) (kaushal et al., 2001; payne et al., 2007; baraki et al., 2018). since pediatric medications are prescribed based on the patient’s body weight or surface area that require precise dosage calculations. furthermore, the availability or unavailability of multiple dosage forms/strengths would lead to confusion and errors. in addition to the incomplete development of the metabolic and elimination functions in premature infants up to the age of six months which would increase the chance of errors or toxicity in these patients (kaushal et al., 2001). in hospitals, clinical pharmacists are the most reliable source of information about medicines. they are trained to design the best treatment regimen for every patient to improve the patient’s outcome and prevent mes (khayam, 2015). the importance of clinical pharmacist’s role lies by working directly (touring) with physicians and liaising with other healthcare professionals in hospital wards during the process of medicines prescribing, dose calculation, preparation and administration and to identify, report and prevent mes. clinical pharmacist’s role also involves direct observation and monitoring of prescribed medicines to the patient to ensure the proper utilization of medicine (karuppannan et al., 2013; dalton & byrne, 2017). identification of mes through a reporting system with analyzing the data 440 global journal of public health medicine 2021, vol 3, issue 2 gggggglo helps the healthcare system to rebuild a safer system by modification of their protocols accordingly improve patient safety (la pietra et al., 2005). the aims of this study is detect and report mes in pediatric inpatients’ medical records and potentially preventing these mes by making recommendations/suggestions for healthcare professionals about the proper action needed to be taken. methods this study was approved by the research ethical committee at nineveh health directorate, iraq (ref. 14866). this prospective observational study was conducted between the 1st of january and the 30th of june 2019 at ibn al-atheer teaching hospital, nineveh, iraq. this hospital is the main pediatric teaching hospital in nineveh province, with 220 beds, consist of two general medical wards, preterm infants ward, intensive care unit (icu), pediatric haematology and oncology ward and thalassemia ward. within the two main wards, preterm infants ward and icu (these wards would be collectively termed medical wards), where the study was conducted, twelve physicians were involved in prescribing medicines, while three clinical pharmacists were responsible for reviewing patients’ medical records and treatment regimen, medication dispensing and patient counselling for patient’s guardian or parents. pediatric patients aged from birth to 11 years admitted to the medical wards for at least two days during the study period were included in this study. outpatients or patients with haematological or oncological diseases were excluded from the study. pediatric patients were classified according to the international conference on harmonization of technical requirements for registration of pharmaceuticals for human use criteria: term newborn infants (0–27 days), infants and toddlers (28 days to 23 months), children (24 months to 11 years) (singh, 2015). data collection a special electronic form designed by the authors using microsoft excel 365 was used to collect data about reported mes including (patient’s name, age, gender, weight, date of admission, chief complaint, diagnosis, number of medications, dose, dosage form and time and route of administration, type of mes and the action taken for each me). reported mes were classified into four main categories according to the pharmaceutical care network europe foundation classification for mes (vm et al., 2018). these classes include (1) administration errors (in which the drug administered/used by a health professional/patient improperly), (2) dosing errors (in which doses used are either higher or lower than indicated for a particular patient), (3) interaction errors (in which a potential drug-drug and/or drug-food interaction are anticipated) and (4) prescribing errors (in which the prescribed drug, dosage form, route of administration or treatment duration are irrational). healthcare professionals were informed about the mes with a recommendation/ suggestion about the proper action needed to be taken to prevent mes. 441 global journal of public health medicine 2021, vol 3, issue 2 gggggglo data analysis collected data from the electronic from were transferred from microsoft excel to stata software for analysis. a descriptive statistical analysis (chi-square test) was performed using stata mp 13 software. p-values less than 0.05 were considered statistically significant. results during the study period, 6964 patients were admitted to the medical wards at ibn al-atheer teaching hospital, nineveh. more than half (55.6%) of the admitted patients were females, with a mean age of 4.57±2.55 years. the mean period between admission and discharge of the patients were 3.6±1.6 days. the main diagnosis/reason of admission of these patients were respiratory tract infections (39%), gastroenteritis (17%), urinary tract infections (2.9%), sepsis (2.5%), asthma (2%), meningitis (0.9%), cardiac diseases (0.6%) and other less common diseases. the medical records for these patients were checked by clinical pharmacists at the wards for potential mes. in these records, the clinical pharmacists have detected 119 mes in 119 patients’ records, with an error rate of 1.7%. the majority of these errors (63%) were detected in male patients. the mean age of these (119) patients with detected mes was 14.6±2.3 months and the mean weight was 8.45± 0.58kg. table 1 shows the type and frequency of medication errors detected in this study and the action suggested/performed according to the guidelines and references used in pediatric medicine. in more than half of the recorded errors are high prescribed doses (dosing errors) and the action was taken by the clinical pharmacists were decreasing the dose of the medications. table 1 types and frequencies of detected medication errors with suggested actions to prevent medication errors type of medication errors number frequency suggested actions to prevent medication errors administration errors 5 4% 2 changed to alternative medicines 3 changed the route of administration dosing errors (total) low dose high dose 99 34 65 83% 28.5% 54.5% 34 increased the dose accordingly 65 decreased the dose accordingly interaction errors 12 10% 2 stopped the treatment 6 changed to alternative 4 changed the treatment frequency to avoid concomitant administration prescribing errors 2 3% 1 stopped the medicine 1 changed to an alternative 442 global journal of public health medicine 2021, vol 3, issue 2 gggggglo table 2 shows the results of the chi-square tests. this test used to determine the independence of the characteristics of patients and their prescribed medications’ groups with the type of mes. amongst the types of mes, the highest percentage of mes were dosing errors. the chi-square analysis shows that the highest percentage of dosing errors were associated with the male gender (p=0.340). among the age groups, the results of chi-square analysis show that the highest percentage of dosing errors were seen in infants and toddlers (p=0.011). nine categories of medications were detected in this study, namely; antibiotics, antiepileptics, antipyretics, antivirals, bronchodilators, cardiac agents, fluids and electrolytes, gastrointestinal agents and steroids. the results of the chi-square analysis show that the highest percentage of dosing errors were associated with antibiotics (p=0.0493). characteristic s total administratio n dosing interactio n prescribin g chi-square tests of independenc e age groups child infant newborn 18 (15.12% ) 69 (57.98% ) 32 (26.89% ) 1 (20%) 4 (80%) 0 (0%) 15 (15.5%) 52 (52.53% ) 32 (32.32% ) 1 (8.3%) 11 (91.7) 0 (0%) 1 (33.3%) 2 (66.7%) 0 (0%) χ2= 21.3374 p=0.011* gender female male 41 (34.45% ) 78 (65.55% ) 3 (60%) 2 (40%) 33 (33.3%) 66 (66.7%) 3 (25%) 9 (75%) 2 (66.7%) 1 (33.3%) χ2= 3.3533 p=0.340 medicine groups antibiotics antiepileptics antipyretics antivirals bronchodilator s cardiac agents fluids and electrolytes gastrointestina l agents steroids 71 (59.66% ) 16 (13.44% ) 3 (2.5%) 4 (3.36%) 6 (5%) 1 (0.84%) 3 (2.5%) 10 (8.4%) 5 (4.2%) 4 (80%) 1 (20%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 60 (60.6%) 13 (13.1%) 2 (2%) 4 (4%) 4 (4%) 1 (1%) 2 (2%) 9 (9.3%) 4 (4%) 6 (50%) 2 (16.6%) 0 (0%) 0 (0%) 1 (8.3%) 0 (0%) 1 (8.3%) 1 (8.3%) 1 (8.3%) 1 (33.3%) 0 (0%) 1 (33.3%) 0 (0%) 1 (33.3%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) χ2= 23.3311 p=0.0493* table 2: comparison of patients' characteristics and their prescribed medication group and types of medication error 443 global journal of public health medicine 2021, vol 3, issue 2 gggggglo discussion the main reason behind medicines development is to improve the patient’s outcome and relieve the ailment. despite the rapid development in medicine production, therapeutic regimen designing and the introduction of electronic medical programs and applications within hospitals, mes are still common in the healthcare system and a big concern in developed and developing countries. drug-related complications like adverse events and side effects were further increased by mes and that may need or prolong hospitalization with further resources to be used (abubakar et al., 2014). the results of this study showed that the rate of mes are quite low (1.7%) in comparison with other national and international studies. in nori et al., (2014) study which was conducted in sulaimani pediatric teaching hospital, sulaimani, kurdistan region, iraq, showed that the percentage of mes was very high (85%) in 587 medication orders. similarly, al-jeraisy et al., (2011) study, which was conducted at king abdulaziz medical city, saudi arabia, recorded mes was also high (56%) in 2,380 medical records. furthermore, khayam et al., (2015) study, which was conducted in tertiary care teaching hospitals (rmi) at peshawar, pakistan, showed that the percentage of mes was 68% in 200 medical records. the reason for the low percentage of mes in the current study might be due to the presence of clinical pharmacists who work side by side with physicians and other healthcare professionals within the hospital to provide the best care for patients. although mes are more common among pediatric patients than in adult patients in hospitals because more calculation and dilution of the prescribed doses for pediatric patients based on body weight are associated with the chance of errors (fortescue et al., 2003). however, mosah et al., (2012) study, which was conducted in baquba teaching hospital, diyala, iraq, showed that the percentage of mes in adult patients was (8.7%) in 299 medication records, which is even higher than the results of this study. the results of this study showed that dosing errors were the most commonly detected errors among pediatric patients. this result was in line with nori et al., (2014), al-jeraisy et al., (2011) and ghaleb et al., (2006) studies. this was attributed to the wide variation in body weight of patients, which ranges from about two kilograms in preterm infants to tens of kilograms in older children, the narrow therapeutic range of the drugs used in paediatrics which requires doses to be calculated individually based on patient age, weight or body surface area, and clinical condition. this careful and precise dosing calculation in a crowded environment with a heavy workload for long working hours for physicians would increase the chance of dosing errors in a hospital setting (wong et al., 2004). barber et al., (1997) study showed that hospital pharmacists interventions for correcting/ amending dosing errors were much higher in paediatric wards in comparison to surgical, gynaecological and geriatric wards within a 10,000 beds’ hospital in the uk. several strategies were suggested to limit dosing errors in paediatric hospitals like computerized systems for prescribing (e.g., emis), electronic portable aids (e.g., tablets and mobiles), calculators and pre-calculated charts for each medicine containing the condition and the weight of the patients (kaufmann et al., 2012). refreshing lectures and summaries of paediatric medicine indications and doses for prescribers, and determination and follow up of the patient’s weight by the nurse at the time of admission and during the stay would also decrease the rate of dosing errors (foresman-capuzzi, 2011; merry & anderson, 2011). 444 global journal of public health medicine 2021, vol 3, issue 2 gggggglo the results of this study also showed that mes were higher in prescriptions for antibiotics than in other groups of medicines used. since antibiotics were the most commonly prescribed medicines in pediatric hospitals and associated with a high rate of mes even in developed countries like the uk and usa (neubert et al., 2008; condren et al., 2010; ghaleb et al., 2010). this result was in line with zeleke et al., (2014) study which found that mes and specifically dosing errors were higher (54%) in prescriptions for antibiotics (zeleke et al., 2014). in contrast, the result of this study was not in line with nori et al., (2014), al-jeraisy et al., (2011) studies, which found that mes errors were higher in prescriptions for bronchodilators and electrolytes and fluids respectively (al-jeraisy et al., 2011; nori et al., 2014). limitations of the study this study has several limitations: first; that this study was conducted in one hospital and therefore generalization of the result must be made cautiously. second; is that the study was conducted for six months which were the winter and spring season in the north of iraq, which associated with more respiratory tract infections and therefore the results were skewed towards these medicines, however, at the end of june 2019, refurbishment and reconstruction of different wards begun at the hospital and result in termination of the study. therefore, a longer duration of at least one year in different pediatric hospitals would give more precise and generalizable results. conclusion this study highlighted the role of clinical pharmacists in recognizing, reporting and preventing mes which are still occurring in every medical setting. the results suggested that dosing errors were the most common in this study, which can be limited by the inclusion of electronic aids and refreshing lectures and summaries that can be given by clinical pharmacists. antibiotics were the most frequent group of medicines involved in mes. this needs a more strict policy for antibiotic use and dosing in every hospital. the intertwined action of clinical pharmacists with physicians and other healthcare providers and with the patients would potentially eliminate mes and improve patients’ outcomes and eventually a successful treatment process. acknowledgements the authors would like to acknowledge the clinical pharmacists in the medical ward at ibn al-atheer teaching hospital for their support in this study, especially raghad salim, zahraa qusay, ataa abd aziz and others who helped in the process of monitoring, detection and reporting medication errors during the study period. conflicts of interest the author declares no conflicts of interest. 445 global journal of public health medicine 2021, vol 3, issue 2 gggggglo references • abubakar, a. r., chedi, b. a., simbak, n. b., & haque, m. 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(2014). medication prescribing errors and associated factors at the pediatric wards of dessie referral hospital, northeast ethiopia. international archives of medicine, 7(1), 1-6. microsoft word gjphm-2021ppd.docx 386 global journal of public health medicine 2021, vol 3, issue 2 gggggglo review research efficacy of complementary and alternative medicine in treatment of postpartum depression: a situation analysis bakhtawar m.hanif khowaja* & ghulam kubra rind department of obstetrics and gynecology, the aga khan university, stadium road, karachi , pakistan *corresponding author: bakhtawarshalwani92@gmail.com abstract postpartum depression is a major public health issue worldwide. it varies in prevalence across countries. pakistan remains highest to have the prevalence of postpartum depression among south asian countries. a number of complementary and alternative medicines can help in decreasing depressive symptoms in the postpartum period. the purpose of this article is to subject review the use of complementary and alternative medicine as a treatment for postpartum depression. a comprehensive review of the literature was conducted from articles using pubmed, cinahl, psycinfo, embase published since the last ten years. the findings of this review suggest that various complementary and alternative therapies may help in the treatment of postpartum depression. this literature review demonstrated the significant effectiveness of complementary and alternative medicine in the treatment of postpartum depression. as conclusion, the prevention and treatment of postpartum depression are essential for maternal as well as new-born health. complementary and alternative medicine has less side effects than antidepressants which can affect maternal and newborn health adversely. keywords: postpartum depression; complementary and alternative medicine; pakistan. 387 global journal of public health medicine 2021, vol 3, issue 2 gggggglo introduction postpartum depression postpartum depression, also called postnatal depression, is a type of mood disorder associated with childbirth. it is a major depressive disorder affecting 6.5-30% of postnatal women(stewart & vigod, 2016). the symptoms of postpartum depression include extreme grief, low-energy, anxiety, crying, irritability, and changes in sleeping or eating patterns(starr, 2017). the onset of ppd is usually between 7 days to 40 days following childbirth(kettunen & hintikka, 2017). the exact cause of ppd is not clear and includes a combination of factors like physical, emotional, genetic, and social factors (stewart & vigod, 2016) the hormonal changes in women following childbirth is identified to be a major cause of ppd (trifu, vladuti, popescu , 2019). the treatment for ppd is important to decrease the risk of chronic depression in postnatal mothers. postpartum depression was first identified as a disorder in the 16th century (ghaedrahmati,kazemi, kheirabadi, et al, 2017). since then, experimental treatments started as implementation for ppd. in the 20th century, it was included under the umbrella of mental illnesses. (starr, 2017) postpartum depression is a major public health issue worldwide. it varies in prevalence across countries (prabhu, george, shyamala, et al, 2019). evidence suggests that the global burden of ppd is around 17.7% (stewart & vigod, 2016). the low-middle income countries have the highest prevalence of ppd. (azale, fekadu, & hanlon, 2018). countries like singapore, denmark, and malaysia report a low prevalence of postpartum depression (0.5-9%), whereas, in countries like south africa, taiwan, and korea, there is a high prevalence of ppd (34-57%) (halbreich & karkun, 2006). the high prevalence of ppd in low-income countries is due to the low investment of these countries on maternal and mental health (dadi, miller & mwanri, 2020). most of the women with ppd in lowincome countries remain undetected due to ignored mental health and nearly 80% of women with ppd remain undiagnosed (learman, 2018). the prevalence of ppd in south asia ranges from 3.5% to 63.3%(aliani & khuwaja, 2017). pakistan remains highest to have the prevalence of ppd among south asian countries and accounts for ppd from 28% to 63%. (aliani & khuwaja, 2017) the health care expenditure on mental health in pakistan is only 0.4%(naaz, mehnaz, ansari, & amir, 2020). moreover, maternal health is also neglected in pakistan and the abandoned maternal and mental health in pakistan increases the risk of ppd in the country. the major risk factors for postpartum depression in pakistan include sociocultural factors involving gender bias, female mobility issues, postpartum customs and rituals, sociocultural traditions and the extended family system(naaz et al., 2020). 388 global journal of public health medicine 2021, vol 3, issue 2 gggggglo the treatment for ppd comprises a range of antidepressants(mccloskey & reno, 2019). the american academy of pediatrics considers antidepressants as a concern of postpartum treatment given to breastfeeding mothers. antidepressants can have negative effects on breastfeeding infants(bandoli, chambers, wells, & palmsten, 2020). a number of complementary and alternative medicines can help in decreasing depressive symptoms in the postpartum period. complementary and alternative medicine refers to therapies that range beyond conventional medical treatment. the term complementary refers to the treatment used as a combination with standard care and the term alternative refers to the therapies used as a replacement, other than standard conventional medications(weber & hopp, 2020). there are several cam therapies including dietary supplements, massage, yoga, exercise, and acupuncture that can help in the treatment of postpartum depression(weber & hopp, 2020). the purpose of this article is to subject review the approach of complementary and alternative medicine as a treatment for postpartum depression. methods a comprehensive review of literature for the subject review was conducted from articles using pubmed, cinahl, psycinfo, embase using terms such as postpartum depression, pakistan, south asia, complementary and alternative medicine, yoga, exercise, dietary supplementation, acupuncture, etcetera. moreover, links to “related articles” were accessed in electronic databases. inclusion criteria included only full-text papers in the english language published in the last ten years were preferred. research studies were selected that included risk factors of ppd, cam therapies, and cam therapies for depression, especially in pakistan. results the results of the literature review suggested that national center for complementary and integrative health defines complementary health approaches in two categories as natural products and mind/body practices(weber & hopp, 2020). natural products include herbal medicines, probiotics, minerals, and vitamins. mind and body practices involve a diverse group of techniques including acupuncture, massage therapy, meditation, relaxation therapies, and yoga(kinser, robins, & jallo, 2021). the findings of this review suggest that various complementary and alternative therapies may help in the treatment of postpartum depression. natural products according to national center for complementary and integrative health (nccih), natural health products include (e.g. omega-3 fatty acids), dietary supplements, probiotics, vitamins and minerals, botanicals, and herbal remedies(dennis, brown, & brown, 2019). the natural products have been proven to provide benefits in the treatment of postpartum depression. 389 global journal of public health medicine 2021, vol 3, issue 2 gggggglo nutraceuticals nutraceuticals are defined as non-prescribed natural health products. they are naturally occurring substances that include minerals, and vitamins (e.g. (acetyl-l-carnitine), tryptophan, inositol, folic acid, amino acids, alpha-lactalbumin, dehydroepiandrosterone (dhea), omega-3 fatty acids, and sadenosylmethionine (sam-e). (ravindran et al., 2018) they can be used alone or in combination with anti-depressants for the treatment of postpartum depression. omega-3 fatty acids omega 3 fatty acids are polyunsaturated fatty acids that originated from biological systems. they are formed of docosahexaenoic acid (dha), or cetyl esters of eicosapentaenoic acid (epa), or a combination of both. omega 3 fatty acids are involved in enhancing the serotonergic neurotransmission, regulation of corticotrophin-releasing factor, and changes that are related to the dopamine function. (lachance & ramsey, 2018) however, the mechanism of action requires more research to identify its role in the improvement of depression and stress (häberling, berger, schmeck, held, & walitza, 2019). one of the pilot trials found that women experiencing ppd had significant improvement by receiving omega-3 fatty acid intervention and had a reduction in their depressive symptoms. (mermer & şanlıer) a cross-sectional study reported that depressive disorders in women are mostly associated with low consumption of omega 3 fatty acids mostly found in seafood (young et al., 2017). several randomized controlled trials have been conducted that confirm omega 3 fatty acids to have a greater impact on depressive disorders. (nasab, pakseresht, & behbahani, 2019). there have been no short-term side-effects related to consumption of omega 3 fatty acids reported, however the long-term supplementation can cause increased risk for cancer due to oxidation products and added vitamin e (lange, nakamura, gosslau & li, 2019). folate folate is comprised of the one-carbon cycle and it works by modifying the production of neurotransmitters including serotonin, dopamine, and norepinephrine that reduces the depressive symptoms. (ng, nazir, & nault, 2020) a study on iranian women was conducted to determine the efficiency of iron supplementation among women who had undergone for c section. 37.1 % of mothers with ppd were found to have iron deficiency without anemia. a significant association was found with increase iron intake and decline in the edinburgh postnatal depression scale and 42.8 % improvement in ppd. (naaz et al., 2020). vitamin-d evidence suggests that vitamin-d is found to have a significant effect on brain development and its functioning. in the central nervous systems, there are special nuclear receptors for 1, 25-dihydroxy vitamin d along with vital enzymes for hydroxylation of vitamin d. thus, the brain activates vitamin d that leads to the prominence of vitamin d role in brain activities. (bahrami et al., 2018) it has been reported that a low level of 25-hydroxyvitamin d is linked to increased psychological symptoms including anxiety, depression, and decreased cognition. (gallone et al., 2017) evidence suggests that 390 global journal of public health medicine 2021, vol 3, issue 2 gggggglo consumption of vitamin d3 during late pregnancy is useful in reducing the post-partum depression level among women. another study was found to have significant results of the high dose of vitamin d among men and women who were depressed.(berlanga-taylor et al., 2017) herbal remedies herbs are derivates from plants and their extracts and include leaves, roots, flowers, berries, and bark. examples of herbs include crocus sativus, lavandula angustifolia, st. john’s wort (hypericum perforatum), and rhodiola rosea.(raheel, orabi, & el-masry, 2019) it has been reported that herbs alone or in combination provide a significant antidepressant effect as they control the neurotransmitters monoamine, inflammatory cytokines, and tcell mediators immune response(lee & bae, 2017). one of the studies conducted in iran showed that daily consumption of 30mg saffron decreased the severity of depression with no significant adverse outcome on the breastfeeding mothers(tabeshpour et al., 2017). however, few studies suggest the negative effects of herbs on embryos if taken during pregnancy (esmaeilzadeh & moradi, 2017). mind and body practices mind and body practices are considered the most common complementary health practices and are used to treat conditions like depression, anxiety, and stress. evidence suggests that more than 50% of people suffering from anxiety and depression, use some type of complementary health approach. these techniques can lift and energize the body(fulweiler & john, 2018). several mind and body practices are found to be effective in improving postpartum depression. these approaches have been discussed following. acupuncture considering the neuroendocrine disorder theory of depression, acupuncture reduces depressive symptoms by exerting effects through the hypothalamus-adrenal axis and hypothalamus-pituitarythyroid axis(crowley et al., 2018). acupuncture regulates the status of postpartum depression by improving hormone levels. several researches have been conducted to evaluate the effects of acupuncture on depression. a randomized controlled trial for the treatment of depression, conducted by university of york researchers found that there was a significant reduction in depressive symptoms with acupuncture without any adverse effects (li et al., 2019). acupuncture is effective as well as safe for patients with depression. another randomized controlled trial held in one of the hospitals from china concluded acupuncture with psychological intervention as effective as antidepressants without adverse effects for postpartum depression(zhang et al., 2020). massage therapy massage therapy helps in relieving physical distress. it improves blood circulation and slows down the production of the stress hormone, cortisol. one of the studies on the effects of massage found massage therapy in the reduction of cortisol level by 31%(nahayati et al., 2020). some studies on the effects of massage therapy confirm reducing depressive symptoms. massage therapy helps in increasing relaxation, pain relief, and sleep and in reducing swelling during the postpartum period. 391 global journal of public health medicine 2021, vol 3, issue 2 gggggglo massage therapy during pregnancy is proven to be beneficial for mothers in the postnatal period (haseli, ghiasi, & hashemzadeh, 2019). one of the studies demonstrated the effects of massage therapy during pregnancy on mothers and newborns. the newborns of these mothers have healthier birth weights and reduced cortisol levels. (álvarez et al., 2017) evidence suggests that massage therapy is not only beneficial to those diagnosed with postpartum depression, it also helps as a prevention to develop postpartum depression. mindfulness mindfulness is effective in reducing postpartum depression as it provides mothers with awareness and information about negative events such as sleep disorders, stress, and burdens. evidence suggests that mindfulness helps mothers to control negative feelings(azadi, manshaee, & golparvar, 2019). as hormonal changes during pregnancy and childbirth are considered to be a major cause of postpartum depression, mindfulness helps mothers in reducing depression by increasing awareness about psychological conditions. mindfulness facilitates mothers in the development of their coping strategies, in reducing impulsivity, and in reducing anxiety in postnatal mothers. (müller et al., 2020) several studies have shown prayer to be effective in reducing depressive symptoms and anxiety (johnson et al. 2009). centering prayer may hold promising results as an alternative intervention for improvement in chronic depression. yoga yoga is an ancient practice that originated from india. it is derived from a sanskrit word that means “to yoke or to unite”. postpartum mothers usually gain weight following childbirth and have poor psychological functioning due to changes in hormonal levels. yoga can help in the improvement of physical activity as well as psychological benefits that can help postpartum mothers. yoga helps in the improvement of conditions like agitation and anxiety through mindfulness. yoga provides antidepressive effects and promotes a sense of self-efficacy(müller et al., 2020). research evidence suggests the benefits of yoga in chronic health conditions including pain, stress, and insomnia. it also provides useful effects during labor pain and depression. (jahdi et al., 2017) music music therapy is known to reduce anxiety, stress and depression. according to quantitative research, many patients in hospital settings who were suffering from stress, anxiety, pain, and fear of death, were able to relieve their negative emotions with the help of music therapy (västfjäll, juslin, & hartig, 2012). clinical application of music therapy on clients with mental illnesses can have an intense effect on restoration. according to a survey by nizamie & tikka (2014), music therapy showed 45% effectiveness in clients with mental illnesses. when compared to antipsychotics, its side-effect profile was extremely safe whereas the latter developed 25% harmful side-effects in patients with mental diseases. thus, music therapy can decrease antipsychotics side-effects in patients if used in combination with pharmacological treatment. 392 global journal of public health medicine 2021, vol 3, issue 2 gggggglo discussion this literature review revealed the significant effectiveness of cam in the treatment of ppd. a number of studies including cross-sectional studies and randomized controlled trials have explored the role of natural products and mind/body practices in the treatment of postpartum depression. these studies have been conducted mostly in high-income countries. there is a nonexistence of researches on complementary and alternative therapies in south asian countries especially in pakistan where there is a high prevalence of postpartum depression. complementary and alternative therapies provide safe treatment as an alternative to antidepressants and provide better efficacy. these therapies not only provide treatment for postpartum depression but can also be used to prevent risks of developing postpartum depression. conclusion cam therapies including natural products and mind/body practices have demonstrated promising results in the prevention and treatment of postpartum depression. research evidence indicates that these effects have important clinical implications and they need to be studied further to implement these therapies in clinical settings. moreover, the health policy implications should be developed by health care authorities and providers to prevent postpartum depression. the prevention and treatment of postpartum depression are essential for maternal as well as new-born health. • a number of complementary and alternative medicines can help in decreasing depressive symptoms in the postpartum period. • complementary and alternative therapies provide safe treatment as an alternative to antidepressants and provide better efficacy. these therapies not only provide treatment for postpartum depression but they can also be used to prevent risks of developing postpartum depression. • research evidence indicates that these effects have important clinical implications and they need to be studied further especially in lmics like pakistan to implement these therapies in clinical settings where there is high burden of ppd. abbreviations • cam: complementary and alternative medicine; dhea: dehydroepiandrosterone; nncih: national center for complementary and integrative health; ppd: postpartum depression; sam-e: s-adenosylmethionine conflicts of interest: the authors declare no conflicts of interest. 393 global journal of public health medicine 2021, vol 3, issue 2 gggggglo references • aliani, r., & khuwaja, b. 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(2020). the effects of active acupuncture and placebo acupuncture on insomnia patients: a randomized controlled trial. psychology, health & medicine, 25(10), 1201-1215. microsoft word approved. gjphm-2020cytomegalovirus infection.edited.docx 269 global journal of public health medicine 2021, vol 3, issue 1 gggggglo original article prevalence and risk factors of cytomegalovirus infection among haemodialysis patients in southern gaza strip, palestine abed el kader y. elottol , akram m. altaher *, asma r. al-saqqa, ghadeer s. abu teba, amany s. al-jamal and nozha s. abu taha department of medical sciences, university college of science and technology-khan younis, gaza strip, palestine. *corresponding author: a.taher@ucst.edu.ps abstract introduction: end-stage renal disease patients (esrd) on maintenance haemodialysis (hd) are at high risk of acquiring cytomegalovirus (cmv). the aim of the study was to determine the prevalence and risk factors of cmv infection among hd patients from nasser's medical complex and abu yousef al najjar hospital southern gaza strip. methods: this study was an analytical cross-sectional from march to september 2019. serum samples were taken from 96 patients (51.1% of them from nasser medical complex and 48.9% of them from abu yousef al najjar hospital), analyzed for cmv-specific immunoglobulin g (igg) by using the chemiluminescence immunoassay (clia) techniques, questionnaire, and virological identification. results: cmv-igg was detected in 80 patients (83.3%), were 16 patients (16.7%) were cmv igg negative. the prominent risk factors were hd duration time, receiving injection, and previous blood transfusion. conclusion: the prevalence of cmv infection among hd patients in the southern gaza strip was very high. we recommend that hd patients should be vaccinated against cmv. keywords: cytomegalovirus, haemodialysis, gaza strip, palestine. 270 global journal of public health medicine 2021, vol 3, issue 1 gggggglo introduction cytomegalovirus (cmv), is an endemic herpes virus in all regions of the world, it is widespread and typically asymptomatic in otherwise healthy children and adults with cmv infections. the seroprevalence of the virus ranges from 45% to 100% in various countries in the general population (landolfo et al., 2003; cannon et al., 2010). when a human becomes infected, for the remainder of their life period, the cmv remains alive, but usually inactive, within the body of that person. unless the person's immune system is suppressed due to medicinal medications or disease, it seldom causes recurrent illness. therefore, cmv infection is not a serious concern for the vast majority of individuals (gold & nankervis, 1989; rosenthal et al., 1997). renal failure is described as a kidney function deficiency that is acute or chronic. it happens when it is unable for the kidneys to eliminate waste products, monitor electrolytes in the blood, and maintain fluid balance. for certain forms of end-stage renal disease (esrd), an alternative therapy is either dialysis or kidney transplantation. the most common renal replacement therapy treatment is haemodialysis (hd), where the dialysis process is used to remove excess fluids and toxic substances from the body (sepehrvand et al., 2010). cmv infections are a significant cause of disease and death in immunocompromised patients, including recipients of organ transplants, hd patients, cancer patients, patients receiving immunosuppressive agents, and patients infected with human immunodeficiency virus (hiv) (greene et al., 2000; mowatt et al., 2003; el sanousi et al., 2016). hd patients are at high risk of infection because the hd process involves long-term parenteral access in an environment where many patients undergo dialysis at the same time, so that the nosocomial transmission of infectious agents is repeatedly possible, directly or indirectly, through infected devices, equipment, hands or environmental surfaces (horl & williams, 1999). cmv infection is prevalent worldwide among hd patients, with a prevalence rate ranging from 55 percent to 90 percent (gianella et al., 2013). the incidence rate varies between different populations, depending on several variables, including age, gender, ethnicity, population density, socio-economic conditions, modes of transmission, personal immunity, chronic diseases, chemotherapy, blood transfusion frequency, as well as dialysis time and length (sepehrvand et al., 2010; akter & toods, 2011). cmv infection is an additional risk and health issue for hd patients at the local and national levels. the main objective of this research is to determine the prevalence of cmv infection and associated risk factors in the southern gaza strip of palestine among hd patients. methods this is an analytical cross-sectional study conducted on ninety-six dialysis patients in southern gaza strip centers from march to september 2019. multiple-choice questionnaires in the arabic language were adapted from previous studies and completely achieved by the researcher via a direct meeting with patients to assure excellent data collection and prevent any mistake, the collected data was included personal and socio-economical information's, hd units services, and medical history of the 271 global journal of public health medicine 2021, vol 3, issue 1 gggggglo patients (el-ottol et al., 2010). a pre-test was performed to ensure the construct validity of the questionnaire after its content validity was ensured by experts. the questionnaire was pre-tested among 30 esrd patients attending the two hd units. in the key sample, the respondents who participated in the pre-test were omitted. the findings showed the internal consistency of the products evaluated with a cronbach’s α value of 0.78. approximately five milliliter of blood were collected from each patient in a clean glass tube with no additives, serum was separated and tested within 2 hours and the remaining serum was frozen at -70 °c until reused if required (el-ottol et al., 2010). cmv antibodies were detected by chemiluminescence immunoassay cmv (clia) (ref 130212005m) according to the manufacture's instruction (shenzhen new industries biomedical engineering co, ltd). because there is no cmv igg universal standard material, the various manufacturer has different traceability chains. therefore, results from the test of other manufacturers cannot be used interchangeably. according to our kits result from less than 2 au/ml were treated as negative, results greater than or equal to 2 au/ treat as positive. statistical analysis: collected data were analyzed by using statistical package for the social sciences (spss) version 22 (ibm corp., armonk, n.y., usa), differences in proportions were been determined by a chi-square test, p-value ≤ 0.05 were been taken into consideration as statistically significant (altaher et al., 2020). ethical consideration: the study was been confirmed and approved by the university college of science and technology research (ucst) committee, and the palestinian ministry of health (moh). after clarifies the goals of the study, oral agreements were obtained from all patients, and all personal information of the study subjects and result were been process in high exclusiveness. results the study was conducted on hd patients attending hd units in south gaza strip. a total of forty-seven samples were collected from abu yousef al-najjar hospital out of 96 attending patients, and a total of 49 samples were collected from nasser medical complex out of 150 attending patients; two patents from abu yousef al-najjar hospital and one patient of nasser medical complex were not responded to the study and was neglected. a summary of the demography of respondents is seen in table1. 272 global journal of public health medicine 2021, vol 3, issue 1 gggggglo personal information. patient's age: the ages of the patients ranged from fifteen to eighty years; the mean age for all patients was 52.75 years with standard deviation (sd) ±15.84 years, thirty-four patients were over sixty years, one patient was less than nineteen years old sixty-one patients between nineteen and sixty years old. table 1: relationship between cmv infection and age, sex, education level, residence, and marital status among hd patients. *significant level at p < 0.05 patient's residence: patients of nasser's medical complex were from three regions of khan younis governorate, fifteen patients were from the center of the khan younis governorate, twenty-five were from east khan younis governorate, and nine patients were from the west khanyunis governorate. alnajar hospital patients were also from three regions of rafah governorate, twelve patients from the center of rafah governorate, seventeen patients from west rafah governorate, and eighteen patients of east rafah governorate. patient's education level: the degree of patient education was divided into five categories, unlettered, elementary, preparatory, secondary, and university. forty-one patients (42.7%) were secondary, which was the highest proportion of hd patients. patient’s marital status: we found that 82 patients were married from all the study population, which made (85.4%), while the remainder were single (14.6%). hd units services variable mcv positive mcv negative total p-value age mean age 53.7 ± 14.6 49.8 ± 17.8 0.31 patient sex male 44 6 50 0.46 female 37 9 46 education level unlettered 6 3 9 0.16 elementary 15 6 21 preparatory 5 0 5 secondary 36 5 41 university 18 2 20 marital status single 11 4 15 0.60 married 69 12 81 khan younis governorate residence west 7 2 9 0.22 east 23 2 25 middle 10 4 14 rafah governorate residence west 14 4 18 0.52 east 14 3 17 middle 12 1 13 273 global journal of public health medicine 2021, vol 3, issue 1 gggggglo hd time and duration: three shifts are served by hd centers; the first shift from 8 a.m. to 12 a.m., the second shift from 12 a.m. to 4 p.m., and the third shift are from 4 p.m. to 8 p.m. the study found that in the first shift there were 28 patients (29.2%), 60 patients, (62.5%) in the second shift, and 8 patients (8.3%) in the third shift. for each patient, doctors recommend the duration of hd sessions according to the health condition of the patient. two to four sessions a week are sufficient for most patients. we found that 26 patients (27.09%) received two hd sessions a week, 66 patients (68.75%) followed three hd sessions, and the minimum number of sessions was 4 sessions per week for 4 patients (4.16%). the length of each hd session is dependent on many factors, including the patient's age, weight, and response to treatment. the total length of time per session varied from 3 to 4 hours. in most patients, 82 patients (85.4%) underwent hd for three hours per session, followed by 14 patients (14.6%) for four hours per session. medical history of the patients history of blood transfusion: fifty-three patients (55.2%) received at least one blood unit transfusion out of the total study population. a positive history of blood transfusion was divided into three classes by the number of blood units received. the first group consisted of patients receiving fewer than 5 units of blood (83.02%), the second group consisted of 5 to 10 units of blood (15.09%), and the third group consisted of more than 10 units of blood (1.89%) as shown in table 2. history of surgical operation: one of the known risk factors for the transmission of cmv viruses are surgical operations. every patient underwent surgery to establish a fistula (shunting blood from an artery to a vein) as a requirement for the hd procedure. of the total study population, 23 (23.95%) of subjects had surgery before beginning hd, while the remaining 73 (76.05%) had just a fistula. history of treatment, surgical operation, and blood transfusion abroad: the data shows that 40 patients (41.67%) were treated abroad among the 96 patients tested. from them 24 patients (60%) had surgery abroad only, 8 patients (20%) had blood transfusions abroad only, and 1 patient (2.5%) had surgery and received blood abroad, 7 patients (17.5%) did not have an operation or received blood abroad (table2). history of receiving injection: from the total study population, 43 patients (44.8%) were injected prior to hd, while the remaining 53 patients (55.2%) were not injected prior to hd (table2). prevalence of cmv igg in the southern gaza strip: the overall prevalence of cmv among hd patients was found to be 83.33% (83.7% at the nasser medical complex and 83.0% at the abu-yousef al-najar hospital) (table2). 274 global journal of public health medicine 2021, vol 3, issue 1 gggggglo table2: relationship between cmv infection with hd centers, time duration on hd, blood transfusion, treatment abroad, and receiving an injection. *significant level at p < 0.05 relationship between the prevalence of cmv-igg antibodies and some personal and clinical characteristics. the mean age was 53.7 ± 14.6 years for cmv-positive patients, while the mean age was 49.8 ± 17.8 years for cmv negative patients, and there was no statistically relevant association between cmv and patient age (p=0.31) as shown in table 1. of the 96 patients tested, there are 50 (52.08%) male and 46 (47.92%) female, also no statistically significant association was found between the patient's sex and cmv infection (p=0.46). patients on hd have varying levels of learning. there was no statistically significant association between cmv infection and the level of education (p=0.16), with the majority of cmv patients at the secondary level (42.7%) followed by the universal level (20.8%). no statistically significant association was found between cmv infection and patient residence (p=0.22 and 0.5) for both khanyounis and rafah regions respectively, most cmv patients were found in the city of east khanyounis (26%) followed by the city of west rafah (17.7%). on the other hand, no important association between cmv infection and marital status has been identified (p=0.6) while married patients tend to be more exposed than single patients to cmv infection. there was also no statistically significant association between cmv infection and hd centers (p=0.57), with the highest positive prevalence of cmv in the nasser complex (83.7%) followed by (83.0%) in the al-najar region as shown in table 2. the varying amount of time spent on hd is between one month to 240 months. a slightly statistically significant relationship between cmv infection and hd duration time (p=0.5) was found, the probability risk of infection increases with the increased duration time. the mean period was 48.84± 42.21 months for negative cmv patients and 61.25±58.74 months for cmv-positive patients. variable cmv positive cmv negative p-value hd centers nasser medical complex 41 8 0.57 abu yousef al najjar hospital 39 8 blood transfusion 0 35 8 0.04 1-5 40 6 5-10 5 1 >10 1 0 duration time (month) meantime 61.25 ± 58.74 48.8 ± 42.21 0.50 no of the patients treated abroad yes 35 9 0.40 no 45 7 receiving injection yes 48 5 0.03 no 32 11 275 global journal of public health medicine 2021, vol 3, issue 1 gggggglo before or during hd, forty-four patients on hd were treated abroad. the bulk of treatments have been performed in neighboring arab countries, mainly in egypt. in countries such as occupied palestine and jordan, some patients have a history of a kidney transplant. it is also important to remember that certain cases have been handled in more than one country. a non-statistically significant relationship was found with treatment abroad (p=0.4). on the other hand, the study found a significant association between blood transfusion and mcv infection (p=0.04). the risk of infection increased with the increase in the number of blood units received. there is a statistically significant association between cmv infection and injection receiving, we found that patients receiving injection were more susceptible to cmv infection than non-injection receiving patients (p=0.03). discussion in patients with significant immune suppression, such as cancer, hiv, and renal failure, cmv disease may occur as an opportunistic infection (ljungman et al., 2016). in general, hd patients have an impaired immune system due to multiple transfusions and a reduced number of lymphocytes. there were numerous defects identified that could be attributed to intrinsic t cell abnormality rather than hd abnormality (mahmood et al., 2016). since hd was first carried out in 1956, the possibility of acquiring cmv infection has been apparent. a broad survey of the united states of america hd centers (1971) showed that cmv incidence rates among hd patients were 61.2% (agha, 2001). the prevalence of cmv among patients on hd was not previously examined in the gaza strip and its associated risk factors were not assessed. this research shows the prevalence of cmv using serological techniques among hd patients. it also attempts to establish risk factors currently involved in transmitting cmv to patients on hd. in this study, the overall prevalence of cmv in patients receiving hd in the southern gaza strip was 83.3% (83.7% at the nasser medical complex and 83.0% at the abu yousef al najjar hospital). this prevalence was higher than that in iran (71%), sudan (45.2%), and germany (56.7%) (sepehrvand et al., 2010; abd alla et al., 2015; lachmann et al., 2018) but lower than egypt (98%), iraq (95.6%) and croatia (90.7%) (el-sadek & morsy, 2008; salman et al., 2014; vilibic-cavlek et al., 2015). the two evaluated hd centers were diverse when comparing, the use of a disposable needle, dialysis equipment, type of machine for dialysis, sterilization and disinfectant process, type of dialysis rooms regarding infected patients, and so on. no statistically significant variations in prevalence between the two hd centers are evident (p<0.57), this was seen in the previous study reported in turkey (ocak et al., 2006). this small disparity in prevalence may be due to improvements in the degree to which universal precautions are applied to prevent the incidence of nosocomial transmissions, such as avoidance of exchanging multidose vials or blood contact equipment. a statistically significant relationship between cmv and the period on hd was found in our study, this finding was consistent with a previous report in turkey, egypt and iran (ocak et al., 2006; el-sadek & morsy, 2008; sepehrvand & khameneh, 2010). a statistically significant relationship between cmv and receiving injection (p=0.03) was found in our research and this finding was consistent with a previous report in egypt. (el-sadek & morsy, 2008). 276 global journal of public health medicine 2021, vol 3, issue 1 gggggglo in our study a statistically significant relationship was found between cmv and blood transfusion, this observation was in agreement with a previous report in turkey, egypt, and iran (ocak et al., 2006; elsadek & morsy, 2008; sepehrvand& khameneh, 2010). gaza strip was occupied by (israel) from 1967 to 1993 and the siege imposed on gaza by the israeli occupation since the year 2000, hampering the growth of health services in the strip. the majority of patients with chronic illnesses or in need of major surgery have been treated outside the strip, often in neighboring countries. some of them were treated in countries such as jordan and egypt (e.g., kidney transplantation patients). some patients have also undergone hd during their treatment, a non-statistically relevant association between outside treatment and infection with cmv (p=0.4) was found. in accordance with previous research among the general population in iraq, our findings also found no statistically significant association between the prevalence of cmv in hd patients and the sex of patients (salman et al., 2014). the study did not find any statistically significant correlation between the prevalence of cmv among hd patients and the level of education, residency, and marital status. a previous study in germany among the general population found that cmv is more popular among married and educated people (lachmann et al., 2018). limitations of the study the study was limited to two hd units in the southern of gaza strip, we hope that future work includes samples from a greater geographic area or be expanded to a multi-units analysis among all gaza strip. conclusion a high proportion of hd patients (83.3%) are seropositive to cmv, the results of this study indicate that for cmv infection risk factors including, duration of hd, receiving injection, and blood transfusion to be the major risk factors, other risk factors may including, treatment abroad countries which are associated with acquisition by nosocomial transmission, cmv prevalence was found lower among female patients, and higher among the secondary and highest level of education, and married patients. the study ultimately demonstrated the role of hd centers, receiving injection and blood transfusion in cmv transmission, and the urgent need for a rigorous infection management program to be implemented. recommendation implementation of a comprehensive infection control program, the components of such program include infection control practices specially designed for hd setting, including routine serological testing and immunization, surveillance, training, and education. these practices should be carried out routinely for all patients in the hd centers. 277 global journal of public health medicine 2021, vol 3, issue 1 gggggglo acknowledgments the authors of this study gratefully acknowledge the university college of science and technologykhan yunis, palestine for providing instruments, and chemicals for this research. conflicts of interest: the authors declare no conflicts of interest. references • abd alla, a. a. e., altayeb, a. a., alshareef, m. a., elboni, m. s., ali, s. e., abosalif, k. o., ... & elawad, h. e. 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(2015). prevalence and dynamics of cytomegalovirus infection among patients undergoing chronic hemodialysis. indian journal of nephrology, 25(2), 95. microsoft word gjphm-2021-kap.docx[18].docx 289 global journal of public health medicine 2021, vol 3, issue 1 gggggglo original article assessment of knowledge, attitudes and practice toward dengue fever among university students in malaysia mohammed abdelfatah alhoot1*, mohammed a. abdalqader1, mustafa fadil mohammed1, mohanad r. alwan1, fuzia elfituri muftah eltariki2, fatehah munirah binti aziz1, mohd noorhelmi bin bujang1, nurfitriana bt ahmad munir1, nur iwani binti abdul rahim1 1 international medical school (ims), management & science university (msu), shah alam, 40100, selangor, malaysia 2 post graduate centre (pgc), management & science university (msu), shah alam, selangor, malaysia *corresponding author: malhoot@hotmail.com abstract introduction: dengue fever is an acute febrile illness with a significant public health concern in tropical and subtropical countries. population knowledge and practice play an essential role in the transmission and prevention of the disease. this study aims to evaluate the level of knowledge, attitudes, and practice regarding dengue fever among malaysian university students. methods: a cross-sectional descriptive study was conducted in twenty-five randomly selected universities across malaysia. a total of 1520 respondents were approached by simple random sampling method. a previously validated and published questionnaire was used with little modification. the associations between the level of knowledge, attitudes, and practice with different risk factors were calculated statistically and the significant association was considered with a p-value <0.05. results: the data were analysed and showed that most of the students (56.3%, 46.2%, and 43.3%) has a moderate level of knowledge, attitude, and practice respectively toward dengue infection among the respondents. the result shows a significant association between the level of practice and knowledge (p-value <0.001) as well as between the level of practice and attitudes (p-value <0.001). conclusion: the significant association between the practice and knowledge along with attitudes indicates the more knowledge and attitudes lead to better practice. this study highlighted the important role of university students in dengue prevention-based programs. they should be exposed more to improve and transfer their knowledge and attitude to other community population to reduce the incidence of dengue not only in malaysia but globally. keywords: dengue fever, malaysia, knowledge, attitude, practice. 290 global journal of public health medicine 2021, vol 3, issue 1 gggggglo introduction dengue fever (df) is a disease that is not foreign anymore towards society worldwide nowadays. it is one of the most critical mosquitoes borne illnesses in the world. however, not everyone knows or cares about this disease. df is a significant cause of morbidity and mortality (cheah et al., 2014). clinical manifestations for df include three phases, which are the febrile phase, critical phase and recovery phase (kalayanarooj, 2011). briefly, for febrile phase, it includes dehydration, high fever that may cause neurological disturbances, and febrile seizures in young children. critical phase includes shock from plasma leakage, severe hemorrhage, and organ impairment. recovery phase includes hypervolemia that is only if intravenous fluid therapy has been excessive (kalayanarooj, 2011). in malaysia, dengue cases were first reported in 1901 in penang. since then, the disease became endemic throughout the country. the first case of dengue hemorrhagic fever (dhf) was reported in 1962 in malaysia. after this, a major outbreak of dhf occurred in 1973 when almost the whole nation was involved (poovaneswari, 1993). the destruction of disease bearing insects act (ddbia, 1975) was introduced in1975 (lam, 1994). recently, it has been estimated that 390 million dengue-infected people yearly, of which 67-136 million show clinically sever infections (world health organization, 2020). currently, over half of the world’s population live in areas potentially at risk for dengue transmission, making dengue one of the most crucial arbovirus disease transmitted to the human in terms of morbidity and mortality. dengue is endemic in more than 128 countries (brady et al., 2012) in whereby five out of the six who regions were involved compared to only nine countries in 1970 (world health organization, 2011b). approximately, 75% of the global dengue infection burden is in the who south-east asia and western pacific regions (world health organization, 2011a). the dengue cases in malaysia increases day by day. this increase gives us a big question mark why there is an increase in the number although the government had conducted many of the preventive measures. according to who, many factors lead to the rise in dengue cases nowadays, for example, it can be due to environmental factors that provide places for aedes mosquito to breed such as the exposed polystyrene and plastic containers and the used tires. the unlimited movement of patients who have been infected with the dengue virus would easily spread the virus to another person. society’s habit of litter and not well-managed garbage leads to the rise in dengue cases. lastly, the lack of awareness of the community to implement preventive measures, such as cleaning their surroundings and carry out the activities like "search and destroy" the breeding grounds for mosquitoes every week. it is essential to increase the health promotion activities to strengthen and improve the awareness and practices of dengue control among the malaysian society. it can form the basis for preventive practices as part of the strategy to control the dengue in the country, thus eliminating them to achieve a zero-dengue country in the future. preventive strategies are the only means of controlling the disease (baur, 2013; low et al., 2006). this study aims to determine the level of knowledge, attitudes, and practice (kap) regarding df among malaysian university students. furthermore, this study will highlight the role of university students’ as citizens in the collaboration the society together with the government to reduce the dengue transmission cycle. so, in the future, we can focus on those factors to increase awareness among the society. 291 global journal of public health medicine 2021, vol 3, issue 1 gggggglo methods an observational cross-sectional survey was conducted at selected universities in malaysia. students at the selected universities were recruited for this survey. the questionnaires were answered by convenience selection of the sample. simple random sampling was used to select twenty-five universities in the different states of malaysia to conduct this study. the sample size was calculated by statistical epi infotm version 7.1.3 program (centre for disease control, atlanta, usa) using 95% confidence level and 2.5 confidence interval with a total population of 1,174,579 local students in both public and private higher education institutions. accordingly, the sample size calculated was 1518 subjects. the inclusion of this study includes all the students at the selected universities. international students and students aged below 18 years were excluded from this study. a previously validated and published questionnaire was used for this study with little modification (shuaib et al., 2010). it is a quantitatively designed research whereby a survey was deliberated. the questionnaire has been written in bilingual (bahasa melayu and english) before being used to avoid any difficulty for the students to understand. it is contained a total of 72 questions. the questionnaire comprises four sections, in which part a, composed of ten questions on personal and demographical information. part b composed of 25 questions on the knowledge about df. the response option would be ‘yes’ or ‘no’. each correct answer was given one point, while no point for the incorrect answer. part c composed of 15 questions on the attitudes towards df prevention. the questions were comprised of awareness and responsibility as public in the prevention of df. the response options for this question will be ‘agree’ or ‘disagree’. a positive attitude will be given one point, and a negative attitude will be given no point. part d composed of 20 questions on the practice regarding df prevention. the questions were designed to assess the steps taken in the prevention of df. response option included ‘yes’ or ‘no’. if the answer was ‘yes’, one point is given and no points for the answer ‘no’. amendments have been made to the questionnaires to suit the researchers’ interests excluding the options ‘semirural’, for the ease of data calculation. ethics and consent the nature of the study was explained briefly to the students and written informed consent was obtained from all the participants. this study was approved by the ethics committee of management and science university (msu). the study methodology was reviewed and recommended for ethical approval by the institute for health behavioural research (ihbr) (nmrr id nmrr-15-1627-27280 s2 r0). data collection data collection began after the research committee granted the study approval at management and science university (msu). a cover letter was attached to the questionnaires to ensure the confidentiality of the participants’ information. patients were given a briefing before distributing the questionnaires. permission was taken directly from the students after agreed to participate and to fill the consent form. data were collected by answering a self-administered questionnaire. the questionnaire comprises of 292 global journal of public health medicine 2021, vol 3, issue 1 gggggglo close-ended questions. the session ended within half an hour. the study data was stored on the researcher’s personal computer. data analysis data were verified and analyzed using the ibm statistical package for the social sciences (spss) version 20.0 software for windows (ibm corp., armonk, ny, usa). descriptive analysis was used to compute the socio-demographic data (gender, age, residential area, race, monthly family income, relationship status, education level) in which the frequency and percentage of each variable were calculated. the descriptive analysis was also used to find out the prevalence of knowledge, awareness, and practice. for the analysis of the independent variables, the frequency and percentage of the categories were obtained. inferential analysis was used to analyze the association between the independent and the dependent variables. the chi-squared test and anova were used to determine the association between kap with socio-demographic information of the respondents whichever appropriate. the level of kap was categorized following scoring the right answers. then, the total score was calculated and converted to a percentage. finally, the sum score of each outcome was assessed based on bloom’s cut off point (bloom, 1956). based on the sum scores, level of knowledge was classified into low level knowledge (less than 60%), moderate level knowledge (60-80%), and high-level knowledge (80-100%). results this study was conducted among 1520 respondents with a response rate of 80%, to measure the level of knowledge, attitudes, and practice about df. results showed that most of the participants were have a moderate level of knowledge, 56.3%, whereas 24.1% of the study population have a low level of knowledge. for attitudes, 46.2% of the study population showed moderate attitudes than 30.3% with low attitudes. again 43.3% of the study population showed moderate practice toward df compared with 25.1% of those with low practice, as shown in table 1. table 1: the level of knowledge, attitudes, and practice about df among the respondents kap level knowledge n (%) attitude n (%) practice n (%) low 367(24.1) 460(30.3) 382(25.1) moderate 855(56.3) 702(46.2) 658(43.3) high 298(19.6) 298(19.6) 480(31.6) 293 global journal of public health medicine 2021, vol 3, issue 1 gggggglo as shown in table 2, the level of knowledge was significantly associated with gender, females showed a better level of knowledge. the race also showed significant association with knowledge, as the race malay had the highest level of knowledge. the age showed significant association knowledge, those aged 20-29 years majority under the moderate level of knowledge, while those more than 30 years majority had a higher level of knowledge. married had a significantly higher level of knowledge as compared to non-married. monthly family income and living area whether rural or urban did not show significant association with knowledge. educational level showed a significant association with the level of knowledge with p-value <0.001. table 2: the association between the level of knowledge and different demographical data variables low moderate high x² p-value n (%) n (%) n (%) gender male 138(28.3) 263(53.9) 87(17.8) 6.95 0.03 female 229(22.2) 592(57.4) 211(20.4) race malay 309(26.6) 686(59) 167(14.4) 97.05 <0.001 chinese 25(21.4) 58(49.6) 34(29.1) indian 22(15.0) 70(47.6) 55(37.4) others 11(11.7) 41(43.6) 42(44.7) age group (years) <20 44(26.2) 75(44.6) 49(29.2) 85.40 <0.001 20-24 271(24.7) 665(60.7) 159(14.5) 25-29 47(24.6) 86(45.0) 58(30.4) >30 5(7.6) 29(43.9) 32(48.5) marital status single 350(24.4) 817(57.0) 268(18.6) 16.77 0.002 married 17(20.0) 38(44.7) 30(35.3) monthly family income <3000rm 188(24.6) 435(56.9) 141(18.5) 1.30 0.52 >3000rm 179(23.7) 420(55.6) 157(20.8) living area rural 178(26.0) 384(56.1) 122(17.8) 3.80 0.14 urban 189(22.6) 471(56.3) 176(21.1) education level spm 62(34.1) 115(63.2) 5(2.7) 50.94 <0.001 diploma 83(22.5) 188(50.9) 98(26.6) degree 211(23.3) 518(57.2) 177(19.5) master 11(17.5) 34(54.0) 18(28.5) *level of significant at p value <0.05 table 3 shows the association with attitude level; males show a higher level of attitudes, p-value <0.001. the race showed a significant association with the level of attitudes with a p-value <0.001. the highest level of attitude was among those aged >30 years, and they showed a significant association. married showed a significantly higher level of attitude. those with higher income showed more level of attitude but was not significant. whether living in rural or urban also does not show a significant association. master level of education showed a higher level of knowledge. 294 global journal of public health medicine 2021, vol 3, issue 1 gggggglo table 3: the association between the attitude level and different demographical data variables level of attitude low moderate high x² p-value n (%) n (%) n (%) gender male 118(24.2) 257(52.7) 113(23.3) 15.37 <0.001 female 342(33.1) 445(43.1) 245(23.7) race malay 400(34.4) 538(46.3) 224(19.3) 82.72 <0.001 chinese 27(23.1) 60(51.3) 30(25.6) indian 16(10.9) 63(42.9) 68(46.3) others 17(18.1) 41(43.6) 36(38.3) age group (years) <20 43(25.6) 73(43.5) 52(31.0) 57.74 <0.001 20-24 378(34.5) 498(45.5) 219(20.0) 25-29 32(16.8) 100(52.4) 59(30.9) >30 7(10.6) 31(47.0) 28(42.4) marital status single 442(30.8) 667(46.5) 324(22.6) 14.35 0.006 married 17(20.0) 35(41.2) 33(38.8) monthly family income <3000rm 248(32.5) 348(45.5) 168(22.0) 4.17 0.124 >3000rm 212(28.0) 354(46.8) 190(25.1) living area rural 221(32.3) 300(43.9) 163(23.8) 3.21 0.200 urban 239(28.6) 402(48.1) 195(23.3) education level spm 69(37.9) 91(50.0) 22(12.1) 36.95 <0.001 diploma 83(22.5) 189(51.2) 97(26.3) degree 295(32.6) 397(43.8) 214(23.6) master 13(20.6) 25(39.7) 25(39.7) *level of significant at p value <0.05 table 4 shows no significant association between level of practice and gender, race, age group, marital status, monthly income, and living area. simultaneously, the relationship with the educational level was significant with p-value <0.001; those master level of education had a higher level of practice. the state where they live and the university, they study at showed significant association with practice toward df. 295 global journal of public health medicine 2021, vol 3, issue 1 gggggglo table 4: the association of level of practice towards df with different demographical data variables level of practice low moderate high x² p-value n (%) n (%) n (%) gender male 124(25.4) 208(42.6) 156(32.0) 0.13 0.937 female 258(25.0) 450(43.6) 324(31.4) race malay 289(24.9) 504(43.3) 369(31.8) 2.64 0.851 chinese 32(27.4) 52(44.4) 33(28.2) indian 33(22.4) 66(44.9) 48(32.7) others 28(29.8) 36(38.3) 30(31.9) age group (years) <20 40(23.8) 75(44.6) 53(31.5) 12.34 0.137 20-24 280(25.6) 481(43.9) 334(30.5) 25-29 44(23.0) 85(44.5) 63(32.5) >30 18(27.3) 17(25.8) 31(46.9) marital status single 364(25.4) 624(43.5) 445(31.1) 5.09 0.278 married 17(20.0) 33(38.8) 35(41.2) monthly family income <3000rm 181(23.7) 334(43.7) 249(32.6) 1.83 0.400 >3000rm 201(26.6) 324(42.9) 231(30.6) living area rural 162(23.7) 299(43.7) 223(32.6) 1.50 0.472 urban 220(26.3) 359(42.9) 257(30.7) education level spm 67(36.8) 80(44.0) 35(19.2) 25.64 <0.001 diploma 77(20.9) 165(44.7) 127(34.4) degree 226(24.9) 388(42.8) 292(32.2) master 12(19.0) 25(39.7) 26(41.3) *level of significant at p value <0.05 296 global journal of public health medicine 2021, vol 3, issue 1 gggggglo table 5 shows the association between the level of practice towards df and the level of knowledge and attitudes. table 5: the association of level of practice towards df with knowledge and attitudes variables n mean sd 95% confidence interval for mean lower bound upper bound practice low 367 12.96 3.340 12.62 13.31 moderate 855 13.70 3.608 13.46 13.94 high 298 14.59 3.616 14.17 15.00 total 1520 13.70 3.585 13.52 13.88 attitudes low 382 9.51 1.985 9.31 9.71 moderate 658 9.62 2.032 9.47 9.78 high 480 10.25 2.353 10.04 10.46 total 1520 9.79 2.149 9.68 9.90 discussion since the 21st century, df becomes the most crucial vector-borne disease toward human health that tends to morbidity and mortality, especially for those living in tropical and sub-tropical countries (wong et al., 2015). malaysian ministry of health reported an incidence rate of 397.71 for dengue in 2019 (ministry of health malaysia, 2020). yearly the incidence rate has been increased over the population and over the government target for df incidence, which is less than 50. there is no apparent reason to justify this increase. it could be due to climate changes, hot and humid weather; alternatively, the unplanned urbanization and community population behaviours make the environment very suitable for mosquitos breeding and growth. malaysia health technology assessment section (mahtas) published in 2015 that the dengue incidence rate is higher in the age group of 15 and above. most of the dengue cases reported were from urban areas (70% 80%). many factors such as high-density population, and rapid development favour dengue transmission could be involved (ministry of health malaysia & academy of medicine malaysia, 2015). with this sharp surge of dengue cases in malaysia, it is a must for the respondents to possess the right information, attitudes, and practice. therefore, this cross-sectional study was run to determine the knowledge, attitudes, and practice regarding df, especially among malaysian university students. our result shows that respondents were moderately knowledgeable in various aspects which are more or less corresponding with previous studies conducted in malaysia (al-zurfi et al., 2015; alhoot et al., 2017; hairi et al., 2003; leong, 2014; wong et al., 2015), laos (mayxay et al., 2013; nalongsack et al., 2009), nepal (dhimal et al., 2014), pakistan (itrat et al., 2008), philippines (yboa & labrague, 2013), sri lanka (gunasekara et al., 2015), jamaica (shuaib et al., 2010) and saudi arabia (ibrahim et al., 2009). in contrast, another study, that has been done in urban, semi-urban and rural communities in malaysia demonstrated a higher rate of knowledge (89.7%) towards df (al-dubai et al., 2013). this variation could be attributed to that different regions could have a different experience and the diverse 297 global journal of public health medicine 2021, vol 3, issue 1 gggggglo target population. interestingly, another study in the perak state in malaysia showed the highest rate (96.8%) of the public having a good knowledge of df (abdullah et al., 2013). this level of good knowledge was referred to the intensive education and awareness campaigns carried out by the government and various institutions to control the spread of the disease effectively. this can be shown clearly when we look at the significant association between practice and knowledge level (p-value < 0.001). the finding from this study is supporting the data obtained in 2015 by wong et al. where the student from the tertiary education level possessed a high level of knowledge related to dengue transmission (wong et al., 2015). the results show a good knowledge of preventing mosquitoes breeding by removing standing water, reducing the mosquitoes by cutting down bushes and killing mosquito larvae by pouring chemicals in standing water. this result similar to previous results showing blocked drains is the most suitable place for the mosquito breeding (rozita et al., 2006) and stagnant water is top mosquito breeding sites (al-dubai et al., 2013; alhoot et al., 2016; leong, 2014). when the students' attitudes are analysed, this study finds that university students have moderate positive attitudes, which should be reflected in their practice in preventing dengue. however, it is not reflected based on the data obtained. for example, there should be a significant association between the degrees of susceptibility for those previously affected or knew someone with their practice, since being infected with dengue virus for the second time will be much-severed reaction than the first one. thus, this study found that there was no significant association between those two. there should be a concern with their perception of susceptibility based on wong et al. findings (wong et al., 2015) some of the respondents state substantial body system decrease the chance of being infected. the most common practices used by respondents to prevent the dengue were the covering of water containers, cleaning water containers, and ditches around their homes. this finding was constant with previous results (abdullah et al., 2013; al-dubai et al., 2013; alhoot et al., 2017; leong, 2014). this study shows a significant association between the knowledge and the education level in which the master or higher education level has a higher level of knowledge than respondents with other educational levels. al-dubai et al. (2013) found a significant association between attitudes and both levels of education and employment status. it is like other study done by leong et al. (2014) where education level and ethnicity have a significant association with respondents. rozita et al. (2006) also found higher education level has positive attitudes towards df. finally, the result shows a significant association between knowledge and practice, unlike the earlier studies (abdullah et al., 2013; al-dubai et al., 2013; alhoot et al., 2017; leong, 2014). it indicates that people with good knowledge tend to act and be involved in preventing their surroundings from breeding mosquitoes and spread df. 298 global journal of public health medicine 2021, vol 3, issue 1 gggggglo conclusion this study highlighted university students' vital role in dengue prevention-based programs such as dengue campaigns, talks, school health programs, community collaboration activities. generally, they have a moderate knowledge of and attitude toward df. they should be exposed more to improve and transfer this knowledge to other community members. furthermore, it is essential to pollinate the seed of the right attitude and practice regarding dengue and its impact on the public. these programs should be started first at school levels to educate children at an early age. even though these activities established for some time ago, overall results could be achieved by the cooperation of individuals, community, government, and mass media. finally, everyone should play a role in eradicating dengue outbreak not only in malaysia but worldwide. acknowledgements thanks, are addressed to the different universities whom their students recruited to respond to the study questionnaire to achieve this study. conflicts of interest: the authors declare no conflicts of interest. funding this study was supported by management and science university (msu) seed grant number: sg379-0216-ims. the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. references • abdullah, m., azib, w., harun, m., & burhanuddin, m. 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(2010). knowledge, attitudes and practices regarding dengue infection in westmoreland, jamaica. west indian med j, 59(2), 139-146. http://www.ncbi.nlm.nih.gov/pubmed/21132094 • wong, l. p., shakir, s. m., atefi, n., & abubakar, s. (2015). factors affecting dengue prevention practices: nationwide survey of the malaysian public. plos one, 10(4), e0122890. https://doi.org/10.1371/journal.pone.0122890 300 global journal of public health medicine 2021, vol 3, issue 1 gggggglo • world health organization. (2011a). comprehensive guideline for prevention and control of dengue and dengue haemorrhagic fever. • world health organization. (2011b). dengue: call for urgent interventions for a rapidly expanding emerging disease. • world health organization. (2020). dengue and severe dengue. https://www.who.int/newsroom/fact-sheets/detail/dengue-and-severe-dengue • yboa, b. c., & labrague, l. j. (2013). dengue knowledge and preventive practices among rural residents in samar province, philippines. american journal of public health research, 1(2), 47-52. microsoft word gjphm-2021heparin 2.docx 374 global journal of public health medicine 2021, vol 3, issue 1 review research does heparin have an essential role in the treatment of the covid-19 pandemic? a review heba m. attash & luma m. al-obaidy department of clinical pharmacy, college of pharmacy, university of mosul, 81011, ninevah , iraq *corresponding author: l.m.saadallah@uomosul.edu.iq abstract coronavirus 2019 (covid-19), is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2). it was first reported in december 2019. the plasma markers of coagulation, like d-dimers and elevated prothrombin time (pt) are higher in patients with covid-19. the administration of anticoagulant is beneficial in those patients. heparins have many therapeutic functions that are important for the controlling of covid-19-associated clinical manifestations like, neutralization of inflammatory mediators and neutralization of extracellular cytotoxic histones. many observational studies in different countries have been done and large number of clinical trials have been designed and registered to evaluate efficacy and safety of heparin for patients with covid-19. the aim of this narrative review is to summarize all available data from previously published studies concerning the use of heparin in treatment of the covid-19 pandemic. keywords: heparin, covid-19, d-dimer, anticoagulant. 375 global journal of public health medicine 2021, vol 3, issue 1 introduction coronavirus 2019, is an infectious disease caused by sars-cov-2, was first reported in december 2019 (hippensteel et al., 2020). since the influenza pandemic of 1918, covid-19 was the most significant public health crisis all over the world (hippensteel et al., 2020; gozzo et al., 2020). according to large chinese epidemiological study, 4.7% from symptoms are critical, 13.8% severe and 80.9% mild. the fatality rate is 49% higher in patients with comorbidities like cardiovascular disease, chronic respiratory disease, diabetes mellitus and cancers (gozzo et al., 2020). the novel coronavirus caused respiratory disease with the symptoms usually affected the respiratory system and required 2 to 14 days to appear (sheikhi et al., 2020). the degree of symptoms ranged between very mild to very severe and even deaths. most patients experienced fever, cough, and shortness of breath and many of them are asymptomatic (kooraki et al., 2020). the plasma markers of coagulation, such as elevated d-dimers, increased pt and thrombocytopenia are higher in patients with covid-19 (van haren et al., 2020). one of the most important causes of morbidity and mortality in patients with covid-19 is coagulopathy. the survival is improved after the adminstration of anticoagulants (mattioli et al., 2020; paranjpe et al., 2020). many studies suggest that the use of unfractionated heparin(ufh) or low molecular weight heparin (lmwh) may improve outcome among patients with covid-19 (buijsers et al., 2020). heparins have many protective functions in addition to anticoagulant effect that are important for the controlling of clinical manifestations associated with covid-19 like, neutralization of inflammatory mediators, interfering with leukocyte trafficking and neutralization of extracellular cytotoxic histones (thachil, 2020). since heparin has many mechanisms of actions, it is unknown by which mechanism heparin could be beneficial for covid-19 patients (gozzo et al., 2020). the aim of this narrative review is to summarize all available data from previously published studies concerning the use of heparin in treatment of the covid-19 pandemic. 376 global journal of public health medicine 2021, vol 3, issue 1 pathophysiology of covid-19 systemic inflammatory response and coagulation system play an important role in the first host defense against pathogens in all types of acute infections including viral ones (fiusa et al., 2015). the process is multifactorial and complex and involves activation and recruitment of leukocytes through fibrinogen, fibrin and their degradation products to limit microbial dissemination and protect blood vessels (gozzo et al., 2020). the most important step of sars-cov-2 infection is the entry of the virus into host cells which is accomplished by binding of specific virus spike protein to angiotensin-converting enzyme 2 receptor and this process is an important determinant of viral infectivity and pathogenicity (shang et al., 2020). post sars-cov-2 entry, an immune response is triggered by host factors against the pathogen. this protective mechanism (if uncontrolled) may cause damaging to pulmonary tissues, atrophic changes to lymph nodes and spleen, reduction in lymphocytes in lymphoid organs, in addition to thrombosis, hypercoagulability, and damage to multiple organs (zabetakis et al., 2020). the inflammatory changes, especially the (cytokine storm syndrome) are responsible for the hypercoagulable state displayed by many covid-19 patients (porfidia & pola, 2020). the systemic inflammation caused impairment of fibrinolytic systems and pro-coagulant pathways which subsequently resulted in platelet activation and fibrin deposition (gozzo et al., 2020). the major coagulopathic changes related to covid-19 include an elevation in serum d-dimer and fibrinogen, reduction in platelets counts, prolongation of both pt and activated partial thromboplastin time (aptt) (hippensteel et al., 2020). heparin structure and types heparin is a preparation of highly sulfated heparan sulfate glycosaminoglycans extracted from the intestine of the porcine (hippensteel et al., 2020). since the 1930s, the highly sulfated glycosaminoglycan, heparin, has been employed as an antithrombotic and stays one of the drugs that most commonly prescribed nowadays (lindahl and li, 2020). heparin is selectively and strongly binds with an enormous number of proteins, the most important one is antithrombin-iii (at3) (an inhibitor of the serine protease) and this interaction is responsible for the anticoagulant activity of heparin (hippensteel et al., 2020). only a part of the polysaccharide chains in heparin preparations have the at3-binding penta saccharide structure, and therefore bind at3 with high affinity and exhibit significant anticoagulant activity (lindahl et al., 1980). 377 global journal of public health medicine 2021, vol 3, issue 1 hundreds of important protein-interactions with heparin have been explained further than at3 that has preceded the detection of an enormous number of potential positive and negative effects of heparin of undetermined clinical value (hippensteel et al., 2020). the molecular weight of lmwh is between 3500– 8000 daltons, in comparison with 15000 daltons in the ufh. lower molecular weight heparin molecules inhibit activated coagulation factor x more effectively than they inhibit thrombin (hull and pineo, 2000). the use of ufh does have practical topics, mostly concerning the necessity for regular monitoring by appt, even though it has been employed for several years. moreover, the use of ufh is considering problematical (much more than lmwh) (krishnaswamy et al., 2010). regardless of these topics, ufh may still be favored if there is evident renal damage or necessity for reversibility for an urgent intervention (garcia et al., 2012). because of its anti-inflammatory effect, lmwh is the most frequently used anticoagulants for the prevention of venous thrombo embolism (vte). in addition to that lmwh is more favored owing to its familiarity, the comfort of use, and not need laboratory monitoring. even though, the inquiry of whether the ufh therapeutic doses of lmwh or ufh must be considered for all persons is undetermined at present (mattioli et al., 2020). diagnosis of thrombosis in patients with covid-19 at present, very little is recognized on the exact occurrence of vte among hospitalized patients with covid-19 pneumonia, since the diagnostic tests cannot be simply done in those patients, another causes are deficiency of suitable protective individual equipment or patients are too unstable (porfidia & pola, 2020). coagulation abnormalities are gradually identified in hospitalized patients with covid-19, involving rising pt, elevated d-dimer, and raised fibrinogen. even though, an increased d-dimer concentration is the most characteristic finding in patients with covid-19 and a prothrombotic state (berger et al., 2020) d-dimer is a degradation product of cross-linked fibrin and is a sign of blood clot formation and its consequent fibrinolysis (oudkerk et al., 2020). several studies in patients with covid-19 have regularly revealed a very strong relationship between increased the levels of d-dimer and poor prognosis and/ or severe disease (tang et al., 2020). for asymptomatic deep vein thrombosis, screening ultrasound is not normally done in seriously ill patients. however, for seriously ill patients with a clinical suspicion for vte, lower extremity ultrasound is recommended. in general, screening ultrasound is associated with increased danger of employees exposure and resource utilization during the covid-19 pandemic (moores et al., 2020). 378 global journal of public health medicine 2021, vol 3, issue 1 rationale use of heparin in covid-19 heparin has many beneficial mechanisms of action in patients with covid-19 away from anticoagulation (buijsers et al., 2020). heparin has antiviral activity accomplished by binding the spike protein of the sarscov-2 and thus functioning as viral entry competitive inhibitor (kim et al., 2020). interestingly, lmwh did not bind the spike protein of the virus, and due to the lack of this competitive mechanism it may be less possible to have direct antiviral activity (hippensteel et al., 2020). the anti-inflammatory effect of heparin may be explained by its binding and modulating proteins such as cytotoxic peptides, chemokines, growth factors, cytokines, tissue destructive enzymes, adhesion molecules, and other proteins that involved in inflammation (gozzo et al., 2020). heparin has anti-coagulant effect (which is the most important action) mediated by several mechanisms, including catalyzing the action of at3, promoting tissue factor pathway inhibitor expression, endothelium releasing of tissue plasminogen activator, decreasing the expression of tissue factor, and through the release of tissue plasminogen activator by the endothelium (van haren et al., 2020). methods in this study a number of previously published studies in different countries were collected and summarized since the incidence of covid-19 till december 2020. studies involved anticoagulant interventions other than heparin were excluded. the included participants were patients infected with covid-19 from both sexes. some of these studies used ufh, the other used lmwh. also some of them used standard prophylactic doses while the other used higher therapeutic doses, as shown in table (1) 379 global journal of public health medicine 2021, vol 3, issue 1 table 1: summarized characteristics of included studies authors countr y drug number of participants gender age study design objectives of study outcomes of study comments (takayama et al, 2020) japan ufh 47 26 in therapeutic dose 21 in prophylactic dose 45 males 2 females median 57 years retrospective historical control study 1. comparison of in-hospital mortality between two groups. 2. to evaluate the anticoagulants adverse events. unfractionate d heparin at therapeutic doses is better than prophylactic doses for severe covid-19 patients. 1. this is a preprint study, which is not subjected to peer review 2. the sample size of this study is limited. (ayerbe et al., 2020) spain ufh 2075 persons 1734 received heparin 285 did not 1256 males 819 females mean 67.57 years observational to assess the mortality rate in patients who treated with heparin and patients who did not. the higher mortality rate was seen in patients who did not receive heparin the results of this study can be generalized due to the large sample size and multicenter. (stabile et al., 2020) italy lmwh 257 patients 131 received prophylactic dose 126 received therapeutic dose 174 males 83 females mean 69.3 years retrospective cohort study to assess inhospital mortality between patients treated with prophylactic doses versus therapeutic doses mortality was significantly higher in patients treated with prophylactic doses there is a potential selection bias and residual confounding in this study (stessel et al., 2020) belgium lmwh 72 patients 46 received pr-ophylactic dose of lmwh, the other received more aggressive do-ses 49 males 23 female s median 69.5 year s in prophylac tic dose group median 62 years in aggressiv a longitudinal controlled before-after study to assess onemonth mortality between two groups one-month mortality was lower in the patient s receiving the more aggres sive thromboprophylatic doses 1.unidentified confounders due to quasiexperimental study design 2. the results of this study cannot be generalized due to mono centric. . 380 global journal of public health medicine 2021, vol 3, issue 1 e dose group (mattioli et al., 2020) italy lmwh 105 patients treated with subcutaneous enoxaparin 61 males 44 females mean 73.7 years retrospective cohort study to determine the safety of intermediate dose of lmwh low rate of adverse events was detected in patients who received intermediate doses of lmwh there is a selection bias as a result of monocentric, limited sample size and there is no control group received standard therapy. (pesavento et al., 2020) italy lmwh ufh 324 patients 240 received subtherapeutic doses and 84 received higher doses of anticoagulants. 181 males, 143 femal es median 71 years retrospective to assess the incidence of bleeding between two groups. the rate of bleeding events was high in patients treated with subtherapeutic doses. there is no standardized approach for the detection of vte disorders 381 global journal of public health medicine 2021, vol 3, issue 1 heparin possible adverse and off-target effects the entire heparins adverse effects are connected to the extensive biological activities diversity, and the most critical safety matter is bleeding that be caused by the heparin potency as an anticoagulant (alban, 2012).there is a 10–15% risk of substantial bleeding when heparin use as a therapeutic anticoagulant (hippensteel, 2020). although the occurrence of bleeding is difficult to define, many factors may increase the risk. however, patients with renal failure, in addition to the elderly are usually individual baseline bleeding indicators in all patients taking antithrombotic therapy (middeldorp et al., 2020). moreover, pulmonary embolism, malignancy, surgery, recent bleeding or trauma, long hospital stay, raised cardiac biomarkers, and anemia are similarly related to the bleeding induced by heparin (lodigiani et al., 2020). another complication of heparin therapy is heparin-induced thrombocytopenia that is expected to occur in 0.2–3% of patients receiving heparin. this severe adverse effect is determined by the antibodies formation that is specific to the protein platelet factor iv which results in the inconsistent development of thrombosis and life-threatening thrombocytopenia (hippensteel, 2020). the correlation between osteoporosis and heparin therapy has been suspected for many years. both lmwh and ufh make a dosedependent decrease in cancellous bone volume by reducing bone formation. however, only ufh was established to enhance bone resorption as indicated by many studies (signorelli et al., 2019). the incidence of heparin-induced osteoporosis seemed to be closely associated with the dosage (15000 u or more daily), and the duration of treatment (more than 4–5 months), but the pathogenesis is inadequately comprehended (gennari et al., 1998). lastly, heparin may have various other unknown effects resulting from its heterogeneous structure. moreover, ufh is made up of a mix of distinctive biologically derived heparan sulfate polysaccharides, that exhibits a wide diversity of sulfation sequences, besides containing a penta saccharide sequence involved in the activation of the at3 (consequently anticoagulation). as a result, the non-anticoagulant sulfation sequences enable heparin to bind to many growth factors and possibly causing organ-harmful and organ-protecting influences (hippensteel et al., 2020). the use of heparin during pregnancy many risk factors cause thrombosis in pregnant women like thrombophilia, obesity, and prolonged immobilization (koyuncu et al., 2020). additionally, there is increased risk of thrombosis in pregnant women infected with covid-19 and the recommendations for thromboprophylaxis have been proposed by many international organizations for both pregnant and postpartum women infected with covid-19 (d’souza et al., 2020). however, how covid-19 infection caused a thromboembolic complication in pregnant woman and whether it is an indication for thromboprophylaxis is still unknown (koyuncu et al., 2020). 382 global journal of public health medicine 2021, vol 3, issue 1 on-going clinical trials about heparin: more than 3500 studies have been designed and registered to evaluate efficacy and safety of interventions for patients with covid-19 (tritschler et al., 2020). among these interventions is evaluating the effect of lmwh or ufh in hospitalized patients infected with covid-19 using different dosing regimens of anticoagulants as recommended by the world health organization guidelines (gozzo et al., 2020; tritschler et al., 2020). the main outcome measures of these trials are hard endpoints like survival or mortality (gozzo et al., 2020). a brief description of some of these trials: cohort (corimmuno-coag) in this protocol the safety and efficacy of tinzaparin or unfractionated heparin will be evaluated in covid19 patients (808 participants) using randomized open-label clinical trial where the patients will be randomly allocated to therapeutic anticoagulation group versus standard of care group using prophylactic doses of heparin (tritschler et al., 2020). eudract number 2020-001736-95 a multinational randomized open-label clinical trial will be done to compare the treatment with nebulized ufh plus standard care to standard care alone, and whether this combination will reduce the duration of mechanical ventilation in patients with covid-19, 1800 patients will participate in the overall study (van haren et al., 2020). conclusion coronavirus may affect many systems in the body other than the respiratory system like the coagulation system which is shifted toward the pro-coagulant state. heparin has a potential role in the treatment of the covid-19 since it has anticoagulant, ant inflammatory and antiviral activities, also the administration of heparin is associated with improved survival in those patients. in general, there are no significant differences between ufh and lmwh in the treatment of thrombosis. however, using the therapeutic doses shows advantages over the prophylactic doses both in reducing mortality and in decreasing the incidence of side effects. at the time of writing, many registered randomized controlled clinical trials in different countries are currently undertaken to evaluate the optimum doses and safety of ufh or lmwh used in patients with covid-19. recommendations for further studies randomized clinical trials about heparin use in covid-19 are immediately required, although there are various well-designed ongoing clinical trials awaiting completion. more information will be obtained in the future after the appropriate drug for treating covid-19 is found among the candidate drugs, with knowledge of the benefits and risks of these drugs. 383 global journal of public health medicine 2021, vol 3, issue 1 conflicts of interest: the authors declare no conflicts of interest. references ● alban s. 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(2020). covid-19: the inflammation link and the role of nutrition in potential mitigation. nutrients, 12(5), 1466. https://doi.org/10.3390/nu12051466 microsoft word gjphm-2019tyroid cancer (2).docx 96 global journal of public health medicine 2019, vol 1, issue 2 gggggglo an analytical, statistical study of thyroid cancer incidence in sudan during 2005-2015 abdelkareem a. ahmed1,5,7*, hassan h. musa2,7, taha h. musa3,7, idriss h. musa4, amal z. sifaldein1, mohammed elmujtba adam essa5, alfatih ismael adam6 1department of physiology and biochemistry, faculty of veterinary science, university of nyala,nyala, sudan 2department of medical microbiology, faculty of medical laboratory science, university of khartoum, khartoum, sudan 3key laboratory of environmental medicine engineering, ministry of education. department epidemiology and health statistics, school of public health, southeast university, nanjing, 210009, jiangsu province, china 3biomedical research institute, darfur university college, nyala, sudan 4sudan medical specialization boards, sudan 5 department of cancer research and awareness, medical and cancer research institute, nyala, sudan. 6 department of internal medicine, zalingei teaching hospital, zalingei, sudan. 7 darfur university college, nyala, sudan. *corresponding author: kareemo151@gmail.com 97 global journal of public health medicine 2019, vol 1, issue 2 gggggglo abstract introduction: sudan, the most diverse country in the african continent, is experiencing growing cancers problems. however, little is known about thyroid cancer epidemiology and patterns. the study aimed to analyse and describe the epidemiological characteristics and trends of thyroid cancer in, in the period1st january 2005 and 31st december 2015. methods: this is retrospective population and hospital-based study. we analysed epidemiological data for digital medical records at both radiation and isotope centre khartoum (rick), and soba university hospital, khartoum, sudan were reviewed. results: in total, 1,062 cases were reported during 1st january 2005 and 31st december 2015. of these, (360; 33.9%) were male and (702; 66.1%) were female. the highest number of cases was in the 25-54-yearold age group (451; 42.5%), and more than 65-year-old age (331; 31.2%). the most predominant type of thyroid cancer among the sudanese population was papillary carcinoma (734; 69.1%) followed by follicular carcinoma 178(16.8%) and medullary carcinoma (150; 14.1%). there were significant differences in gender, age groups and types of thyroid cancer (p=0.001). based on geographical distribution thyroid cancer showed high prevalence in khartoum, north kurdufan, river nile, kassala, north darfur, northern, and south kurdufan. whereas, low distribution is seen in red sea, west darfur, west kurdufan, east darfur, al gadarif, and the blue nile. conclusion: our results suggest that thyroid cancer continuous presenting alarming challenge with an increasing the prevalence in females. papillary carcinoma is the most common type among sudanese populations. further epidemiological studies are required in policy strategies for control and prevention strategies of thyroid cancer in sudan. keywords: epidemiology, sudan, thyroid cancer 16 global journal of public health medicine 2019, vol 1, issue 2 gggggglo introduction thyroid cancer comprises approximately two percent of all cancers types diagnosed global and 95% of all endocrine cancers (sipos & mazzaferri, 2010). recent studies indicate a continuous increase in thyroid tumours occurrence worldwide. in some geographical regions, this increase exceeds 100% (kilfoy et al., 2009). however, small decreases in the incidence of thyroid cancer were reported in a few regions (kilfoy et al., 2009). it has been proposed that this generally steady trend of increasing thyroid cancer incidence present in all continents except africa, where the diagnosis detection is possibly inadequate (pellegriti et al.,2013). several factors such as genetic factors, environmental factor (ilias et al.,2002), nutritional status (dal maso et al.,2009), and availability of medical care (yabroff et al.,2019) might contribute in the thyroid cancer incidence by ethnicity and geographic area. based on recent reports, thyroid cancer is the fifth most frequent cancer in female (siegel et al., 2014) and it is the second most common cancer in women below 45 years old in italy (dal maso et al., 2011). a few countries such as norway and sweden are capable to decrease the incidence of thyroid cancer(kilfoy et al., 2009). however, relevant information in sudan is missing. despite of the gradually increased incidence, thyroid cancer mortality rate is reported constant at approximately 0.5 cases per 100,000 patients (liu et al., 2017; olson et al.,2019). compared with other types (including colon-rectum, breast, prostate cancer, and lung) whose mortality rate has decreased in the last two decades, thyroid cancer mortality rate is slightly increased (pellegriti, et al., 2013).explanations for the thyroid cancer incidence increase worldwide are controversial (ito et al., 2013). some scientists believe that the increase is due to the increased diagnostic tools (davies & welch, 2006; grodski et al., 2009), whereas other scientists believe that the real increase is due to lifestyle (mack et al., 2002) and environment changes(fiore et al., 2019; nettore et al., 2018). the problem is of socioeconomic (zevallos et al., 2014) and medical relevance(lin et al., 2017). the financial cost of thyroid cancer over diagnosis patient can vary from hundreds to thousands of dollars, based on the extent of the laboratory examinations been done and the complexity of the intervention and follow up (boltz et al., 2013; schlumberger et al., 2011) recent reports indicate that the treatment and follow-up costs of thyroid cancer can be reduced in low-risk tumours by selective, simplified procedures (ahmed & essa, 2019; alexander & larsen, 2012; schlumberger et al., 2012). currently, this is the most suitable approach, depending on the judgment of different prognostic factors which affect the patient outcome. sudan does not have a cancer registry-based on national population. the most important 17 global journal of public health medicine 2019, vol 1, issue 2 gggggglo sources of cancer statistics are the hospitalbased case series. there are only two centres in the country, both located in central sudan, the area with a high density of population. for instance the radiation and isotope centre in khartoum (rick), khartoum state (figure 1), and the national cancer institute of the university of gezira (nci-ug) in wad medani, gezira state (previously “institute of nuclear medicine molecular biology & oncology”, inmo). additionally, in the 1960s to 1980s, there was the sudan cancer registry (scr), which was mainly based on histopathological diagnosed confirmation. it was under the national health laboratories authority. currently, rick is the main source for the cancer registry in sudan. the description of epidemiological characteristics and trends of thyroid cancer in sudan has not been reported. moreover, it remains unknown whether women are affected earlier than men and, therefore, suffer greater professional, economic, and social impacts. consequently, the study aimed to analyse and describe the epidemiological characteristics and trends of thyroid cancer in, in the period1st january 2005 and 31st december 2015. methods there were two main types of cancer registry in sudan: hospital-based and population-based cancer registries. estimated cancer cases were unknown in sudan because of the absence of the population-base cancer registry. the first cancer registry was practical from the early sixties (1960s) to the early eighties (1980s). it was based on histopathologically confirmed cases diagnosed mostly at the national health laboratories of public health in khartoum (stack). today, radiation and isotope centre khartoum (rick) is the main source of hospitalbased cancer registry in sudan. this is a retrospective study conducted by using the digital records at both rick and soba university hospital from 2005-2015. these registries were created by the ministry of federal health for the diagnosis, treatment and epidemiological surveillance of all cancer types in sudan. the data used in this study contains 1,062thyroid cancer patients, including the sex of the patients, age, geographical region and type of thyroid cancer were reported. each thyroid cancer diagnosis start from the outpatient clinic where relevant history and clinical examination have been done, in addition to lab and imaging investigation which include, complete blood count (cbc), thyroid function test (tft), renal profile, calcium blood level, liver function test, thyroid ultra sound, computer tomography (ct) for the thyroid gland and fine needle aspiration (fna) from thyroid gland tissues for histopathology, and the final confirmation of the diagnosis made by clinical oncologist but no gene test was available. we found that almost every thyroid cancer patients from all regions of sudan transferred to the rick and hospital for more confirmation and treatment. this database was the data source for the present population-based report. 18 global journal of public health medicine 2019, vol 1, issue 2 gggggglo statistical analysis the collected data were stored using the computer program. nominal data are expressed as frequency or proportion. all statistical analysis was performed using the statistical analysis package for social science (spss, v.22.0 chicago, illinois, usa) with a level of the significant set at (p<0.05). results the frequency differences between males and females within different types of thyroid cancer were presented in figure 2. a total of 1062 cases were investigated by thyroid cancer in sudan from1january 2005 to 31 december 2015. of these, (360; 33.90%) were males, and(702; 66.10%) were females cases were diagnosed and confirmed by the types of thyroid cancer. papillary carcinoma reports high frequency in follicular carcinoma (178; 16.76%), and medullary carcinoma (150; 14.12%) were reported. where age 25-54 years are more infected group by thyroid cancer (451; 42.47%).the high prevalence of thyroid cancer was reported in the age group 25-54 years as 451(42.5%), and the lower incidencewas noticed in aged 15-24 years as (58; 5.5%). another fact that papillary carcinoma (734; 69.1%) is a large type of thyroid cancer reported among sudanese population. females were showed high affected groups compared to male groups. the finding seen that thyroid cancer had most common in female than male patients. within 10 years, the monitoring assessment of thyroid cancer cases showed that significant differences (p=0.001) difference between male and female, age groups (p=0.001), and between the different types of thyroid cancer (p=0.001) as presented in table 1. the trend of thyroid cancer cases by sex, age group, and type of thyroid cancer during the tenyears were presented in table 2.khartoum, gazira, north kurdufan, river nile,kassala, and north darfur were reported higher cases of thyroid cancer compared with other cities during the study period figure 3. discussion thyroid cancer comprises approximately 2% of all cancers diagnosed worldwide and 95% of all endocrine cancers (drabe et al., 2016; nguyen et al., 2015). recent reports indicate that there is a progressive increase in thyroid malignancy worldwide in 2013 (pellegriti et al., 2013). in the present study, we observed an increasing trend in the incidence of thyroid cancer in sudan. this trend seems to be similar to that of worldwide (pellegriti et al., 2013). the increases of thyroid cancer could be attributed to the environmental factors such as pollution (awadelkarim, et al., 2012), exposure to radiation (miyakawa, 2014) as well as iodine deficiency. in the present study, we have reported for the first time the epidemiology of thyroid cancer in sudan. women are more affected by thyroid cancer than men. this may explain gender differences (yao et al., 2011). table 1: characteristic of the study population variables no. (%) p-value gender 19 global journal of public health medicine 2019, vol 1, issue 2 gggggglo male 360 33.9 0.001 female 702 66.1 total 1062 age groups (years) 15-24 58 5.5 0.001 25-54 451 42.5 55-64 222 20.9 <65 331 31.2 type of thyroid cancer follicular 178 16.8 0.001 papillary 734 69.1 medullary 150 14.1 table 2: the trendof thyroid cancer cases by gender, age group during the period 2005-2015. variables 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 gender males 6 37 38 19 21 22 24 43 52 24 74 females 10 58 70 64 39 33 86 75 99 48 120 total 16 95 108 83 60 55 110 118 151 72 194 age groups 15-24 0 6 9 5 3 5 8 6 9 1 6 25-54 6 43 41 41 27 24 53 52 59 26 79 55-64 4 15 18 19 18 11 21 27 31 19 39 <65 6 31 40 18 12 15 28 33 52 26 70 type of thyroid cancer follicular 3 17 14 12 11 6 12 18 15 5 65 papillary 10 64 77 62 44 45 90 91 122 64 65 medullary 3 14 17 9 5 4 8 9 14 3 64 20 global journal of public health medicine 2019, vol 1, issue 2 gggggglo figure 1: map of sudan after referendum (retrieved from https://images.app.goo.gl/4x1jk3di7ow7kz38a) figure 2: frequency distribution of type of thyroid cancer by gender figure 3: frequency distribution rate of thyroid cancer by cities among sudanese population 21 global journal of public health medicine 2019, vol 1, issue 2 gggggglo hormonal factor (horn-ross, et al., 2011), dietary factor (choi & kim, 2014) employment factor (kuzmickiene & stukonis, 2010) or economic status (kim et al., 2014). thus, women are suffering greater professional, economic, and social impacts in sudan. in the present study, ethnic cancer risk factors were seen in some sudanese ethnic groups was more affected than others. our findings are agreed with previous reports that the incidence of thyroid cancer associated with the ethnic group (finlayson et al., 2014a). in the present study, the time trends analysis indicated a stable increase in the incidence of thyroid cancer in sudan. this trend is widespread in many national and international geographical areas (pellegriti et al., 2013), which may be due to the worldwide increase in the number of new cases of thyroid cancer reported in a number of publications. however, it is not unknown whether this is a real increase in incidence due to that some areas in sudan polluted with pesticides exposure (awadelkarim et al., 2012) or whether it reflects a general insufficiency of technological means and expertise employed to detect small thyroid malignancies, that in the past may not have discovered(liu et al., 2017). in the current study, the incidence of thyroid cancer was influenced by several factors, including age, gender, and geographical area. these findings are in line with previous reports that cancer disease is affected by the above mentioned factors (dorak & karpuzoglu, 2012; finlayson et al., 2014b; jonklaas et al., 2012). conclusion our data reveal an increasing trend in the incidence of thyroid cancer in sudan. female are affected more than male and hence , may imply the greater professional, economic, and social impacts. some ethnic groups were more affected by thyroid cancer. further studies are required to elucidate the mechanism underlying the vulnerability among those infected age group within a different geographical area. acknowledgement this work was supported by the ministry of higher education and scientific research. special thanks to sami at radiation and isotopes centre khartoum (rick). ethics approval and consent to participate the study was approved by the university of cape town, faculty of health sciences human research ethics committee and by the western cape health research committee. references ahmed, a. a., & essa, m. e. a. 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(2014). the impact of socioeconomic status on the use of adjuvant radioactive iodine for papillary thyroid cancer. thyroid, 24(4), 758-763. doi:10.1089/thy.2013.0409. microsoft word gjphm-2021vaccination.docx 447 global journal of public health medicine 2021, vol 3, issue 2 gggggglo review research a comprehensive review of a race of vaccination against covid 19 virus: the recent vaccines developed maimonah q. yahya1, zena s. hamed2, seema m. kasim3 1department of clinical laboratory science, college of pharmacy, mosul university, mosul, iraq 2department of pharmacology and toxicology, college of pharmacy, mosul university, mosul, iraq 3department of pharmaceutical chemistry, college of pharmacy, mosul university, mosul, iraq *corresponding author: pharm.maymona@uomosul.edu.iq abstract vaccines are urgently needed at the present time to protect humanity from covid-19, which is caused by the coronavirus 2 that causes severe acute respiratory syndrome. large quantities of antibodies which have high affinity virus-neutralizing capability were induced by vaccines may optimally prevent infection and avoid unfavourable effects. during the progression of the vaccine, different vaccine models were assessed by disparate groups. this review summarizes the currently approved covid19 vaccines with late-stage clinical results. the currently authorized sars-cov-2 vaccines with late stage clinical data are summarized in this review. thrombosis may be related in some way to the vaccine, but the direct link has not yet been established. it was stressed that the probability of developing strokes is very small and does not compare with the benefit gained from using the vaccine at all. keywords: covid-19, vaccines, viral vector vaccine, mrna vaccine, inactivated vaccine 448 global journal of public health medicine 2021, vol 3, issue 2 gggggglo introduction covid-19 (2019-novel beta coronavirus) is a disease caused by sars-cov-2, newly discovered in china and spread to all over the world that reported as epidemics by world health organization (who)(zhu et al., 2020). such disease has emerged in late 2019, which has spread globally with, at time of writing, overall, 150,110,310 confirmed cases of covid-19 have been reported to who since 2:41 pm cest on 30 april 2021, including 3,158,792 deaths. a total of 1,011,457,859 doses of vaccines were administered as at 29 april 2021. (world health organization,2021). it has caused an emergency on international public health especially among the elderly and those with underlying illnesses who are vulnerable to acute respiratory distress syndrome (ards)( koirala et al., 2020). corona viruses are members of the coronaviridae (subfamily coronavirinae) family of viruses infecting a wide range of organisms, causing many symptoms depending on host immunity, varying from a flu virus to severe and ultimately fatal illnesses like sars( severe acute respiratory syndrome ) , mers (middle east respiratory syndrome), and novel coronavirus disease 2019 (2019-ncov) (dhama et al., 2020; boopathi et al., 2020 ). coronaviruses have single-stranded (ss) positive-sense rna genome that is not segmented. nucleocapsid (n), membrane (m), spike (s) and envelop (e) are four structural proteins those with others non-structural proteins (nsp) are the result of encoding the virus genome (sarma et al., 2020). coronavirus s protein attached to ace2 (angiotensin converting enzyme 2) receptors present on many human cells including lung cells permitting virus entry. host protease (i.e. furin and trypsin) rupture spike s protein leads to release the fusion peptide which in turn activates membrane fusion mechanism. blocking virus entry is targeting for treatment option (bian et al., 2020). the n-protein present inside the capsid has an effective n-terminal that bind with viral rna causing cells to be hijacked. once the virus enters the cell, the rna genetic material of the virus is transferred into the cytoplasm. the replication / transcription complex (rtc), which is made up of non-structural proteins, plays a very important role in viral rtc by coating the viral rna genome with n-proteins (nsp). preventing such contact is targeting for effective drug to stop viral replication and transcription (chowdhury et al., 2020). finally, special insights are sended from infected cells by transported through smooth vesicles present in the cell membrane and secreted outside the cell via exocytosis process become ready to infect other cells (dhama et al., 2020). while certain therapeutic options for covid-19 have shown efficacy in vitro studies, they have yet to be tested in randomized animal or human clinical trials, limiting their realistic applicability in the current pandemic. (abubakar et al., 2020). the requirement of sars-cov-2 vaccines is urgently needed as a result of its rapid spread and infection between people as well as unavailability of antiviral therapeutic agents. 449 global journal of public health medicine 2021, vol 3, issue 2 gggggglo methods since the occurrence of covid-19 until december 2020, a number of previously published studies from various countries were collected and summarized in this study, with a focus on the discovered vaccines that have already been used in most countries around the world, as well as how these vaccines work in preventing the disease and other details. studies that included statistics on vaccinated people in each country were excluded. an evaluation in sars-cov-2 patients found that the primary targets for the receptor binding domain of the s1 subunit were binding and neutralizing antimicrobials. the spike protein especially in its original configuration was established, as the virus's immune antigen shortly after sars-cov-2 emerged at the end of 2019 (huang et al., 2020). once this alleged vaccine target was identified, the next challenge was determining how to obtain the highest possible immune system response to it (the vaccine-induced response that, paradoxically, worsens disease severity in the face of a viral challenge). this response has the following characteristics: neutralizing anticorps, t-cell generative, and immunological disease prevention (the vaccine-induced response that paradoxically increased disease severity upon viral challenge) (wang et al., 2020). various vaccine designs were evaluated by various groups during the development of the sars-cov2 vaccine. the following are the currently authorized sars-cov-2 vaccines with late-stage clinical data: 1-viral vector vaccines a.sputnik v (gam-covid-vac) on august 11, 2020, russia's president vladimir putin was announce the world's first vaccine against the covid-19 pandemic, which russia successfully developed after two months testing on human. the vaccine was developed by the gamaleya national research centre for epidemiology and microbiology in moscow. it is known as “sputnik v,” after the first orbital satellite launched in 1957 by the soviet union , which sparked the global space race. (shervani et al., 2020). the vaccine contains two components, one with the recombinant adenovirus vector based on the human adenovirus type 26 and another with the adenovirus vector based on the human adenovirus type 5, both containing sars-cov-2 s protein gene (rawat et al., 2020). the russian researchers expect more immune response and more prolonged response by using two different vectors (uddin et al., 2021). adenovirus serves as a "shell" for delivering the coronavirus gene to cells and initiating the synthesis of the new envelope made up from coronavirus's proteins, thus exposing the immune system to a possible threat. the sputnik v (gam-covid-vac) vaccine aims to shorten the time it takes for sars-cov-2, the virus that caused the covid-19 pandemic, to establish immunity(ahn et al., 2020). the rad26-s/rad5-s vaccine regimen consists of an initial ad26-based sars-cov-2 s vaccination accompanied by an ad5-sars-cov-2 s booster vaccination after twenty one days (lundstrom, 2020). the dose is 1011 viral particles/dose for each recombinant adenovirus (creech et al., 2021). storage must be at (–18◦c in liquid form) but can be stored at (2-8◦c in freeze dried) up to 6 months (logunov et al., 2020). 450 global journal of public health medicine 2021, vol 3, issue 2 gggggglo the results of a phase i and ii trial were released a few weeks after the approval, followed by the results of a phase iii trial. the efficacy of vaccine was 91.6% according to interim results from a phase iii trial which indicating that in healthy adult volunteers, the vaccine is well tolerated, safe and does not lead to serious health problems (logunov et al., 2021). it induces strong humoral and cellular immune responses in all healthy volunteers and it is highly immunogenic , with antibody titers in vaccinated participants higher than those in convalescent plasma (logunov et al.,2020; klasse et al.,2021). the post-registration phase iii trial is currently underway in russia and belarus, with over 40000 participants, and the plan is to carry out the phase iii trial of sputnik v in various other countries such as the uae, india, venezuela, egypt, and brazil (rawat et al., 2020). at least 20 countries have approved the inoculation for use including russia, belarus, argentina, serbia, uae, algeria, palestine and azerbaijan (logunov et al.,2021;fairgrieve et al., 2020). b. azd1222 a vaccine based on a chimp adenovirus (chadox1/azd1222) encoding the spike glycoprotein of sars-cov-2 was developed by the british-swedish company astrazeneca and the university of oxford (uddin et al.,2021; poland et al., 2020). it is composed of dna that codes for the s protein and is encased in a capsid from a chimpanzee adenovirus. the adenovirus with the accompanying dna is brought into the cell by endocytosis, the dna is released into the cytoplasm, migrates to the cell nucleus where it is transcribed creating mrna that codes for the s protein. the s protein is processed and presented by the mhc i and mhc ii complexes by non-immune and immune antigen presenting cells, respectively (liu, 2019). the dose is 5×1010 viral particles, given in two doses twenty eight days apart (creech et al.,2021), storage must be at 2-8 c for 6 months (logunov et al., 2021). one of the important advantages over moderna and pfizer, covid-19 vaccines of oxford-astrazeneca is the fact that it is possible to store and distribute at 2-8°c (nguyen et al., 2020). a phase i and ii trial with 543 individuals receiving the azd1222 vaccine tested a prime and a primeboost schedule. phase iii were published with an efficacy 82.4% (nguyen et al., 2020). the study found that the first dose of vaccine triggered humoral responses, characterized by anti-spike igg and neutralizing antibodies, as well as ifn t-cell responses in the majority of recipients, and that the second dose of vaccine triggered an additional increase in humoral immune outcomes. (poland et al., 2020). adverse events such as tenderness and pain at the injection site, fever, chills, headache, fatigue, malaise, muscle aches, and nausea were mostly mild and occurred within 4–5 days of vaccination. the protocol included the use of paracetamol as a preventative measure, which reduced both local and systemic reactions to the vaccine. (poland et al., 2020). the vaccine has not yet obtained an authorization for emergency use in the usa, but it has been authorized for emergency use in several others. it was added to the list of emergency uses by the world health organization in february 2021 (nguyen et al., 2020). britain, india and mexico used such vaccines as an emergency (longunov et al., 2021;nguyen et al., 2020). 451 global journal of public health medicine 2021, vol 3, issue 2 gggggglo the news of the oxford-astrazeneca vaccine, which has been linked to blood clots, has made us even more wary (wise,2021). thromboembolic events associated with this vaccine were reviewed by the european medicines agency's (ema) pharmacovigilance risk assessment committee (prac). this pandemic has humbled us and continues to present new challenges. a safety signal does not mean that the vaccination campaign should be halted, but it does mean that further investigation is required, as recognized by the ema. formal paraphrase according to world health organization statements, the specific vaccine has been given a green light; however, these side effects need to be studied further(wise, 2021). c. jnj78436735 or ad26.cov2.s the janssen pharmaceutical companies of johnson & johnson developing a coronavirus vaccine known as jnj78436735 or ad26.cov2.s at beth israel deaconess medical center in boston (rai et al., 2021). it is a recombinant, replication-incompetent adenovirus serotype 26 (ad26) vector vaccine that encodes the stabilized perfusion spike glycoprotein of sars-cov-2, the virus responsible for covid-19(oliver et al., 2021). ad26-based vaccines are generally safe and highly immunogenic, and the vaccine was developed from the first clinical isolate of the wuhan strain(sadoff et al., 2021). it is given in a single dose 5×1010 viral particle intramuscularly (creech et al., 2021). this candidate vaccine requires storage at (– 20°c) and can be stored at 2–8°c for three months (logunov et al., 2020; poland et al., 2020). phase iii trial showed that the vaccine was 66% effective overall in the prevention of moderate to intense covid-19 infection occurs twenty-eight days after vaccination. but it proved less effective in south africa, where a new variant of the virus has appeared, offering just 57% protection from moderate to severe infection there (95% of cases were due to infection from the variant). the level of protection in the u.s. was 72% and it was 66% in latin america (rai et al., 2021; funk et al., 2021). ad26.cov2.s vaccine has been showed to be 100% effective against sever covid-19 after forty nine days. emergency use authorization process initiated in usa and bahrain (logunov et al., 2021) following news that six women out of more than 6.8 million of administered doses in the united states developed rare and severe type of blood clots, 6 to 13 days after receiving the coronavirus vaccine, johnson & johnson has decided to postpone its introduction in europe (chadwick, 2021). 2-mrna vaccines a.bnt162b2: a series of mrna-based covid-19 vaccines has also been produced by pfizer and biontech (bnt162b1 and bnt162b2). bnt162b2 developed a higher value of t-cell responses in phase i and ii trials and had a beneficial safety profile, so it was chosen as the candidate vaccine for evaluation in phase iii trials, which are currently enrolling over 44,000 volunteers. (poland et al., 2020). all clinical trials in phases i, ii, and iii were published. bnt162b2 is made up of a nucleoside-modified messenger rna (modrna) that encodes an optimized viral full-length spike (s) glycoprotein of the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) that serves as the target of virus neutralizing antibodies(polack et al., 2020). messenger rna (mrna) is encapsulated with lipid 452 global journal of public health medicine 2021, vol 3, issue 2 gggggglo nanoparticles (lnps), which allow it to enter host cells by shielding naked mrna from rnases after injection and enhancing endocytosis into cells surrounding the injection site. thus, the formulation of lnps allows for the expression of the s protein as well as the induction of antibody and cellular immune responses(balakrishnan, 2020). when the lipid nanoparticle is injected, its phospholipid membrane fuses with the host membrane, releasing the mrna into the cytoplasm of the target cell. the s protein mrna is then translated at the rough endoplasmic reticulum, resulting in the s protein being present in the cytoplasm. major histocompatibility complex i (mhc i) and ii (mhc ii) degrade and express the s protein. after binding to the s protein fragment, a t-helper cell releases interleukins, causing b cells to proliferate and differentiate into plasma cells. these plasma cells then produce antibodies against the s protein fragment(liu, 2019). the dose is 30g, administered intramuscularly in two doses 21 days apart (creech et al., 2021). the pfizer and biontech vaccine has unique storage requirements, as it must be kept at -70°c but can also be kept at 2-8°c for 30 days or at room temperature for 2 hours (logunov et al., 2021,sereviante et al., 2020). the vaccine was found to be 95 percent effective in preventing covid-19 in phase iii trials involving 43,538 participants, with 170 confirmed cases of covid-19 in the first twenty-eight days (162 cases observed in the control group versus eight in the vaccinated group). furthermore, while pfizer has reported no significant safety concerns to date, the vaccine's medium and long-term safety remains unknown (badiani et al., 2020). it was authorized by fda, ema and uk and current approved in many countries like us, eu and uk (logunov et al., 2021). b. mrna-1273: in collaboration with moderna, the national institute of allergy and infectious diseases (niaid) in the united states has begun research to develop mrna-1273, an mrna vaccine (pandey et al., 2020). the nucleoside-modified mrna vaccine is delivered in the form of lipid particles. it, like the mechanisms of bnt162b2 vaccines, allows delivery of nucleoside-modified mrna into host cells to enable expression of the sars-cov-2 s antigen. specialized antigen presenting cells (apcs) engulf mrna virus vaccine and activate thelper cells which in turn enable b cells to make antibodies that can block the virus from infecting cells and will remember how to fight the virus that causes covid-19 if infected the body in the future (meo et al., 2021). furthermore, it is regarded as reasonably safe because it is composed of neither the inactivated pathogen nor the live pathogen's subunits(tu et al., 2020). the regimen is 100µg in 2 shots, given twenty eight days apart by injection in the intramuscular-deltoid muscle (meo et al., 2021). the requirement for a storage temperature of –20°c for 30 days, 2-8°c for 30 days, and room temperature for 2 hours is one potential issue for vaccine deployment(logunov et al., 2021; poland et al., 2020). moderna announced the findings of an interim analysis of their phase iii trial is ongoing involving more than 30,000 participants. all phases i, ii and iii clinical trials were published. they found their vaccine candidate mrna-1273 to be safe and well tolerated and to have a vaccine efficacy of 94.5% (35pain at the injection site, chills, nausea, myalgia, and fever are both moderate local and systemic side effects that occur within a few days of vaccination (meo et al., 2021). it was emergency authorized by fda, 453 global journal of public health medicine 2021, vol 3, issue 2 gggggglo ema and uk and current approvals in us, eu, canada, israel, switzerland and uk (logunov et al., 2021). 3inactivated coronavirus vaccine: coronavac and bbibp cor-v china national biotec group (cnbg), a joint venture between sinopharm, a state-owned corporation, and sinovac, a private chinese company, is well ahead of the curve in coronavirus vaccine trials (uddin, 2021). sinopharm has created two whole-virus inactivated vaccines. the wuhan institute of biological products created the first vaccine candidate, new crown covid-19 (inactivated cno2 strain of sarscov-2 created from vero cells). the beijing institute of biological products developed the second vaccine candidate, bbibp cor-v (inactivated hbo2 strain of sars-cov-2 created from vero cells)(logunov et al., 2020; poland et al, 2020). sinovac biotech developed an inactivated vaccine called (coronavac.) (uddin, 2021). inactivated vaccines are viruses that have been physiochemically treated to reduce their pathogenicity. when inactivated viruses are injected, they are engulfed by antigen-presenting cells, and different epitopes are presented to the immune system. they also have a good safety profile because the virus cannot cause disease; however, they require a booster strategy to develop immune memory(yu et al,2020). the vaccines are given in two doses intramuscularly with aluminum hydroxide adjuvant. new crown covid-19 vaccine dose is 5 µg in 2 doses. bbibp cor-v vaccine dose is 4 µg in 2 doses twenty one days apart, while corona-vac vaccine dose is 3µg in 2 doses fourteen days apart (creech et al., 2021). one potential issue with vaccine deployment is that it requires a storage temperature of 2-8 c; the lifespan is unknown(creech et al., 2021). the new crown covid-19 vaccine has been shown to be safe and immunogenic in a randomized, double-blind and placebo controlled phase i and ii trials that published with no phase iii published data (40). its efficacy is 86% in uae with 31000 volunteers and 70% in china. it was approved in china, uae, bahrain, serbia, peru, zimbabwe and morocco with limited use in china, egypt, jordan and uae (logunov et al., 2021; wise, 2021). while the efficacy of corona-vac is 50.38% in brazil, 91% in turkey and 65% in indonesia(poland et al., 2020). it is currently approved for use in brazil, uruguay, columbia, bolivia, china, turkey, azerbaijan and indonesia with limited use in china and indonesia and emergency use in turkey(logunov et al., 2021;poland et al., 2020). the adverse effects of these vaccines may include localize pain, headache, muscle ache, and hyperthermia (logunov et al., 2021). conclusion vaccines are an important component of public health and have been shown to prevent serious diseases. they, like any other medications, have the ability to cause harmful effects which must be balanced against the likelihood of developing a serious or even fatal disease like covid-19. your participation by taking the vaccine will increase the safety of covid-19 vaccines evaluation. but, using a face mask, good hand hygiene, and maintaining a safe physical distance are still important. the greater the similarity between the vaccine action and the immune system triggering action, the more effective and multi-step protective mechanisms the immune system is developing and provides multilevel protection, increase the effectiveness of the vaccine. the european medicines agency (ema) 454 global journal of public health medicine 2021, vol 3, issue 2 gggggglo indicated that clots can be considered a very rare side effect of the vaccine, and confirmed that the benefits of using the vaccine are much greater than the risks of the corona virus, and that it will continue to recommend its use according to controls. recommendations for further studies suggestions for further investigation despite the fact that many well-designed ongoing clinical trials are nearing completion, randomized clinical trials on the effectiveness of vaccine use in covid-19 are desperately needed. conflicts of interest the author declares no conflicts of interest. references • abubakar, a. r., sani, i. h., godman, b., kumar, s., islam, s., jahan, i., & haque, m. 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(2020). a novel coronavirus from patients with pneumonia in china, 2019. new england journal of medicine. doi: 10.1056/nejmoa2001017. microsoft word gjphm-2019-hcq copy.docx 52 global journal of public health medicine 2019, vol 1, issue 2 gggggglo the role of hydroxychloroquine as monotherapy in managing early undifferentiated arthritis: a prospective hospital-based study ziryab imad taha mahmoud1,2 , mustafa mohamed ali hussein1,3, mohammed elmujtba adam essa adam1,3*,sherihan mohammed elkundi osman3,4, mutwaly defealla yousif haron1,3, mohammed altyb alshykh5,elnour mohammed elagib6, abdelkareem abdallah. ahmed1,7. 1 department of clinical medicine, medical and cancer research institute (mcri), nyala, sudan. 2 department of internal medicine and rheumatology, faculty of medicine, university of bahri, khartoum, sudan. 3 department of health, faculty of medicine, al fashir university, al fashir, sudan. 4 department of molecular medicine, institute of endemic diseases, university of khartoum, khartoum, sudan. 5 faculty of medicine, alzaim alazhari university, khartoum, sudan 6 department of internal medicine and rheumatology, omdurman military hospital, khartoum, sudan. 7 department of physiology and biochemistry, faculty of veterinary science, university of nyala, nyala, sudan. * corresponding author:awadali818@yahoo.com abstract introduction: early undifferentiated arthritis (eua) is a common form of arthritis comprising, joint pain, stiffness and swelling with no definitive diagnosis. patients of eua can progress to other forms of rheumatic arthropathies such as rheumatoid arthritis or remain in the same form or spontaneously disappear. the main focus of this study is to explore the potential effect of hydroxychloroquine (hcq) in management of eua as a monotherapy treatment. methods: this is a prospective hospital-based study which was conducted in almwada hospital in khartoum, sudan. the study included thirty patients of eua. full clinical examination and history were done by a rheumatologist, and all the related investigations were obtained, and they all received hcq after eua diagnosis has been established. result: the study shows that 96% of the patients responded well to the treatment and 10% had their duration of treatment doubled to show a favorable response. we also found that female patients were more commonly affected than male ones with higher incidence among middle aged as compared to others. after treatment with hcq, 86.6% of the patients showed average mean decrease in erythrocyte sedimentation rate (esr) by 44%, the other 13.4%, even though they were symptoms free after treatment they showed increased level of esr by 30% average. conclusion: in the present study we found out most of the eua patients are well responded to the hcq treatment, and most of them respond from the first course of treatment, the study also shows higher incidence among female in compared to male. key words: early undifferentiated arthritis, middle age group, hydroxychloroquine, monotherapy. 53 global journal of public health medicine 2019, vol 1, issue 2 gggggglo introduction early undifferentiated arthritis is an inflammatory polyarthritis or monarthritis with no definitive diagnosis that has a duration of less than three months and do not categorized under any connective tissues or rheumatic disease (combe et al., 2017; dixon & symmons, 2005; wevers-de boer, heimans, huizinga, & allaart, 2013), patients with early undifferentiated arthritis minimally should have one tender joint or swelling (aletaha et al., 2010), eua can be initial presentations of many rheumatic diseases including rheumatoid arthritis(combe et al., 2017; dixon & symmons, 2005; vaidya, baral, & nakarmi, 2018). after the 2010 eular/acr updated the classification criteria (aletaha et al., 2010) many cases of eua can be diagnosed as early rheumatoid arthritis (era). many patients of early scleroderma, rheumatoid arthritis or lupus are presented as eua and their diagnosis becomes more obvious after a period of one year and sometimes months (suresh, 2004), about one third of eua patients will achieved spontaneous remission(stockman et al., 2006), a third will remain as eua and the rest will progress to rheumatoid arthritis (ra)(hazes & luime, 2011). there is no standard management for eua, most of the treatments are off-label such as steroids or non-steroids anti-inflammatory drugs, until the patient exhibited apparent features of chronicity then others alternative drugs like disease modifying anti rheumatic drugs (dmards) are used(van dongen et al., 2007). current evidence proved that it is unjustifiable to wait until erosions or chronicity to initiate dmards (bosello et al., 2011; joshua, edmonds, & lassere, 2006; sudolszopinska et al., 2013), and the goal of management is to reduce the risk of chronicity and complications of the disease (combe et al., 2017; smolen et al., 2016), if the patient doesn’t reach significant improvement, then the therapeutic agent is upgraded as needed in a form of combination of methotrexate, hydroxychloroquine and sulfasalazine with dmerds according to the patient tolerance and side effect profile, in spite of the efforts and the studies on eua, until now no clear pathophysiology has been identified. the current study aims to explore the effectiveness of using hydroxychloroquine as monotherapy for treatment of eua patients. methods this is a hospital-based study which was conducted in almwada hospital, khartoum, sudan, where we screened and selected prospectively a number of 30 patients according to specific criteria in the outpatient department of medicine in the period of april 2017april 2018. all patients have been examined (musculoskeletal examination) with detailed history taken by specialist (dr. ziryab imad taha mahmoud) to achieve the final result after reviewing the lab investigation. the study is focusing on the effect of hydroxychloroquine (hcq) on undifferentiated arthritis patients after fulfill the inclusion criteria which includes only patients regardless of the age and gender, complaining of multiple tender joint pain in duration lees than six weeks , and the exclusion criteria is patients complaining of joints pain associated with any of the following: swelling, stiffness, deformity, fever, duration more than six weeks, any other systemic symptoms. we collected the data from the patients and they were given a discharge summary card for their regular follow up, the card contains the date of every follow up meeting for checkup of the renal function test, esr level and general wellbeing, the initial clinical presentation, all the relevant investigation such as the esr, rheumatoid factor (rf), anti-cyclic citrullinated peptide (anti ccp), antinuclear antibodies (anas), blood urea (bu), serum creatinine, liver enzymes and bilirubin level, complete blood count (cbc), and urine microscopic examination. finding of the clinical examining, duration of the disease, medication patterns, assessment various organs involvement, gender, age, ethnic and geographical distribution, were also been recorded to include in data sheet. modified disease activity score 28 (das28), is being used to establish the diagnosis and the treatment outcome. the therapeutic approach was initiated by using the hcq as monotherapyin management of eua at a dose of 400 mg daily, divided twice, in tablet form, for a period of 3 months, and another three months in the cases where a poor was noticed according to das28 criteria. 54 global journal of public health medicine 2019, vol 1, issue 2 gggggglo analysis the collected data were stored using the computer program. nominal data are expressed as frequency or proportion. all statistical analysis was performed using the statistical analysis package for social science (spss, v.22.0 chicago, illinois, usa), an independent t test and one-way anova are tested with a level of the significant set at (p<0.05) . results in this study we found that female has the higher prevalence among our patients in a percentage of 86.7% and male patients represented the remaining 13.3 % (fig 1). regarding age group, we classified the patients into three categories, age 20 years and less than 40years, 40 to less than 60 and 60-80years (table 1). the middle age group patients which are between 4059 years are the most affected group (46.7%), followed by 36.7% for the group between 20 years and less than 40 years, and the last age group which is the group between 60-80 years represent the remaining 16.7% (table 1). further analysis showed that response to treatment is 96.7%, while the remaining 3.3% of the patients shows no treatment response (fig2). also, we noted that 90% of the patients were responsive to treatment from the first course which is 3 month, while the other 10% had their duration of treatment doubled (fig 3). regarding the treatment effect on erythrocyte sedimentation test (esr), they were categorized into three groups, 86.6% of the patients had their average mean decreased to 44% after they receiving the treatment, 3.3% of the patients had their esr decreased to 13% after the treatment, the remaining 13.4% of the patients showed increase in esr level by 30% even after treatment but their complains disappeared (fig 4). the std deviation of the age and sex are 0.71 and 0.34 respectively (fig 5), the age groups, esr, gender, duration and treatment dosage, clinical presentation, outcome and investigations all have been showed in table (2). the initial das28 of the patients at the time of diagnosis shows that 73.3% of the patients has a high score and 26.7% with moderate score, after receiving treatment with hcq for three months, the high score group had 50% lower das28 score and 45.4% of them became moderate score and 4.6% achieved total remission. among those 45.4% with moderate das 28 score after receiving three months treatment, 20% of them received another three months treatment and achieved 100% remission. the second group with moderate das28 at the time of diagnosis after three months of treatment also showed 50% lower score, 37.5% remission and the remainder 12.5% showed no decrease in das28 score until they received another three months treatment to end by having 100% remission (fig 6) (table3). according to sheer's equation results showed that the mean size of zro2 nanoparticles molecules under study were 29.8 nanometers. the results were compared with (vasaikar et al., 2017). they showed that the size of the particles (20 nanometers) when measured according to the shearer equation and the highest value of the x-ray oxides measured by xrd. while (arefian et al., 2015) the xrd value of zro2 was 35 nanometers. the xrd measurement is used to identify the crystallization of molecules. in some cases, the crystallization of these molecules is not perfect, due to the insufficient thermal processor and time during the preparation process. the results of x-ray diffraction analysis show the crystallization or calcification of zirconium, and the removal of the protein improves the biopolymerization of zirconium (haghi et al., 2012). it is also used to detect the nature of particulate matter.(gowri, gandhi and sundrarajan., 2014) the results of this study showed that the molecules of zinc oxide have a crystalline nature. table 1: socio-demographic variables and response to treatment variables no. (%) pvalue gender male 4 13.3% <0.05 female 26 86.7% total 30 age groups (years) 20-39 11 36.7% <0.05 39-60 14 46.7% 60-80 4 16.7% response to treatment responded 29 96.7% <0.05 not responded 1 3.3% 55 global journal of public health medicine 2019, vol 1, issue 2 gggggglo table 2: patients variation age, gender, treatment duration, clinical presentation and clinical investigations a ge baseline esr gen der duration of treatment course of treatment clinical presentation outcome esr after 3 months from treatment accp, ug ana, rft lft, cbc 60 55 fem ale 3 months 1 tender multiple joint pain not responde d 86 nonsignificant 45 25 fem ale 3 months 1 tender multiple joint pain respond ed 30 nonsignificant 42 25 fem ale 3 months 1 tender multiple joint pain respond ed 26 nonsignificant 50 75 mal e 3 months 1 tender multiple joint pain respond ed 35 nonsignificant 36 52 mal e 3 months 1 tender multiple joint pain respond ed 45 nonsignificant 40 75 fem ale 3 months 1 tender multiple joint pain respond ed 45 nonsignificant 30 75 fem ale 3 months 1 tender multiple joint pain respond ed 60 nonsignificant 70 70 fem ale 3 months 1 tender multiple joint pain respond ed 55 nonsignificant 55 60 mal e 3 months 1 tender multiple joint pain respond ed 30 nonsignificant 38 35 fem ale 6 months 2 tender multiple joint pain respond ed 25/20 nonsignificant 45 25 mal e 3 months 1 tender multiple joint pain respond ed 30 nonsignificant 37 75 fem ale 3 months 1 tender multiple joint pain respond ed 50 nonsignificant 22 65 fem ale 3 months 1 tender multiple joint pain respond ed 55 nonsignificant 50 55 fem ale 3 months 1 tender multiple joint pain respond ed 40 nonsignificant 40 50 fem ale 3 months 1 tender multiple joint pain respond ed 40 nonsignificant 39 75 fem ale 3 months 1 tender multiple joint pain respond ed 65 nonsignificant 55 75 fem ale 3 months 1 tender multiple joint pain respond ed 65 nonsignificant 42 62 fem ale 3 months 1 tender multiple joint pain respond ed 30 nonsignificant 39 50 fem ale 3 months 1 tender multiple joint pain respond ed 30 nonsignificant 60 55 fem ale 6 months 2 tender multiple joint pain respond ed 48/30 nonsignificant 40 30 fem ale 3 months 1 tender multiple joint pain respond ed 10 nonsignificant 27 65 fem ale 3 months 1 tender multiple joint pain respond ed 40 nonsignificant 35 55 fem ale 3 months 1 tender multiple joint pain respond ed 35 nonsignificant 60 30 fem ale 3 months 1 tender multiple joint pain respond ed 15 nonsignificant 25 20 fem ale 3 months 1 tender multiple joint pain respond ed 5 nonsignificant 30 70 fem ale 3 months 1 tender multiple joint pain respond ed 20 nonsignificant 44 60 fem ale 3 months 1 tender multiple joint pain respond ed 40 nonsignificant 80 70 fem ale 3 months 1 tender multiple joint pain respond ed 30 nonsignificant 50 60 fem ale 6 months 2 tender multiple joint pain respond ed 40/10 nonsignificant 40 60 fem ale 3 months 1 tender multiple joint pain respond ed 40 nonsignificant 56 global journal of public health medicine 2019, vol 1, issue 2 gggggglo table 3: das28 score of the patients at the time of diagnosis and after treatment. no initial das28 severity das28 after three months treatment severity das28 after six months treatment severity 1 4.6 moderate 2.8 low 2 4.6 moderate 2.84 low 3 5.1 high 3.6 moderate 4 5.7 high 3.05 low 5 5.1 high 3.2 moderate 6 5.3 high 3.2 moderate 7 5.3 high 3.5 moderate 8 5.4 high 2.8 low 9 5.2 high 2.8 low 10 4.9 moderate 4.7 moderate 2.1 remission 11 4.6 moderate 2.8 low 12 5.6 high 3.3 moderate 13 5.6 high 3.5 moderate 14 5.51 high 3.2 moderate 15 5.3 high 3.14 low 16 5.8 high 3.6 moderate 17 5.2 high 2.8 low 18 5.09 moderate 2.8 low 19 5.16 high 5.09 moderate 2.38 remission 20 4.7 moderate 1,16 remission 21 5.27 high 3 low 22 5.16 high 2.9 low 23 4.59 moderate 1.9 remission 24 4.3 moderate 1.3 remission 25 5.6 high 2.1 remission 26 5.22 high 3.14 low 27 5.78 high 2.8 low 28 5.22 high 4.9 moderate 1.6 remission 29 5.22 high 3 low 30 5.12 high 2.96 low 57 global journal of public health medicine 2019, vol 1, issue 2 gggggglo figure 1: demonstrates male to female ratio figure 2: patients response to the treatment figure 3: patients response to the treatment 13.30% 86.70% 0.00% 20.00% 40.00% 60.00% 80.00% 100.00% male femalet he p er ec en ta ge o f bo th s ex tr ea te d w it h h c q male to female ratio %96.7 %3.3 treatment responce responed to treatment resisted 90% 10% numbers of treatment course single course treatment double course tretment 58 global journal of public health medicine 2019, vol 1, issue 2 gggggglo figure 4: the average mean of the esr after treatment figure 5: age and sex statistics 86.60% 3.30% 13.40% -44% -13% 30% -100.00% -50.00% 0.00% 50.00% 100.00% a b c esr result after treatment patients esr 1.8 0.71438 0.13043 1.8667 0.34575 0.06312 0 0.5 1 1.5 2 2.5 mean std. deviation std. error mean statistical analysis of age and sex age sex 59 global journal of public health medicine 2019, vol 1, issue 2 gggggglo figure 6: modified das28 score percentage of the patients before and after treatment discussion: this study is the first of its kind to explore the use of hcq as a monotherapy in treatment of eua in sudan. many studies have shown that vast majority of eua are self-limiting especially those of viral etiology (cacoub et al., 1999; dendooven et al., 2006). we only focused on using hcq and no other drugs for treatment of eua. hcq is an anti-malarial drug used in combination with other drugs to treat a wide variety of rheumatologic diseases such as systemic lupus erythematosus (sle)(spinelli et al., 2018), ra(schapink, van den ende, gevers, van ede, & den broeder, 2019), primary sjogren's syndrome (wang, zhang, wei, & hua, 2017) and osteoarthritis (lee et al., 2018), and until now its therapeutic potential and pharmacokinetic has not been identified and explored in depth (hanaoka, iida, kiyokawa, takakuwa, & kawahata, 2019), records show no studies regarding the use and efficacy of hcq as monotherapy in eua as the drug carry less side effect and complications compared to other drugs used in treatment of the same disease such as methotrexate which has a negative impact on the bone marrow (yuncu, bukucu, bayat, sencar, & tarakcioglu, 2015) and gastro intestinal system (attar, 2010). biologic treatment has less side effects with good outcome (zavvar et al., 2019) but as most of the patients from the developing centuries have no affordability for the treatment and its need for regular follow up, hcq provides a better option. regarding male to female ratio there are only few studies that estimated the sex difference in eua, they also carry similar findings of this study as all of them showed that female constituted more than two thirds of total eua patients (o16 aetiology of early undifferentiated arthritis in india, 2009; shankar s, 2010), no clear explanation have been identified yet but as eua is an immunological disease (foocharoen, nanagara, suwannaroj, & mahakkanukrauh, 2011), recent evidence suggest that female hormones such as estrogen have strong role in development of autoimmune diseases(somers & richardson, 2014). the study shows patients at the age of forties and fifties are the most commonly affected by the disease, the findings are directly in line with previous result with same sample size of this study (shankar s, 2010), it remains unclear why exactly the middle age people are das 28 at the time of diagnosis 26.7% of the patients have moderate score three months hcq treatment 50% low 37.50% remission 12.5% moderate all received another three months treatment 100% remission 73.3% of the patients have high score three months hcq treatment 45.4% moderate 20% of them received another three months treatment 100% remission 50% low 4.6% remission 60 global journal of public health medicine 2019, vol 1, issue 2 gggggglo more likely to be affected rather than those at old age who tend to be vulnerable due to their weak immune system(merani, pawelec, kuchel, & mcelhaney, 2017), but we postulate that this might be due to female sex hormones(marder, vinet, & somers, 2015; somers & richardson, 2014) and also the menopausal change occured at this age (su & freeman, 2009). the management of eua is controversy as no standard treatment protocol is present, and around 30-60% of all the patients of eua has self-limiting disease(olivieri et al., 2012), so many questions been asked by us. should we treat every patient? however, our primary focus was on the effectively of hcq alone in the treatment of eua and deliver significantly good result with 96.7% fully response, no comparable studies have been found in the literature neither an explanation. das 28 score classify patient’s well-being into three categories, high for those who score above 5.1, moderate for the patients who score between 5.1 and more than 3.2, low between 3.2 and more than 2.6, remission for and 2.6.and below. the score calculation depends on the number of joints involved, swelling of the joints, the global health assessment of the patient, and either the crp or esr (van riel & renskers, 2016). half of the patients who received three months hcq treatment with high score das28 their score turned to low, the other half had complete remission or became moderate. those with six months duration of treatment their outcome ended by complete remission. as the used calculating score is modified to eua patients, no available reviews or similar study were founded with same result, and no clear explanation has found the limitation of this study is the sample size which is relatively low, early undifferentiated arthritis is not widely common, another limitation is the lack of the long term follow up for the patients to explore the total efficacy of the management and whether there is any recurrence of the previous complains and this lack of follow up is strongly due to patients factor as most of them were from rural and remote areas so 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(2019). gene therapy in rheumatoid arthritis: strategies to select therapeutic genes. j cell physiol. doi: 10.1002/jcp.28392 microsoft word gjphm-2021attitude leprosy_edited (1).docx 396 global journal of public health medicine 2021, vol 3, issue 2 gggggglo original research factors associated with perceived stigma among community members living close to leprosy centre in malaysia noor amani mohamad pakhurdin.1,2, qistina mohd ghazali1, azmawati mohammed nawi*1 1department of community medicine, faculty of medicine, national university of malaysia, jalan yaacob latif, bandar tun razak, 56000 kuala lumpur malaysia 2training institude of ministry of health malaysia, jalan hospital, 47000 sungai buloh, selangor, malaysia. *corresponding author: azmawati@ppukm.ukm.edu.my abstract introduction: stigma is strongly associated with leprosy that affects the social status of leprosy patients. the main problem of leprosy is that it presents a negative stigma and a very poor image to the patient. stigma is a sign that represents unwanted traits that are contrary to one's personality within the community. stigma is also a social process that results in the patient being unwanted. the purpose of this study was to determine perceived stigma among community members living close to leprosy center in malaysia. methods: a cross-sectional study was conducted among the communities around leprosy center from june to october 2019. a total of 260 persons were selected by simple random sampling to answer question on demographic, socioeconomic status, placement distance, information source, infected family, knowledge, attitude and stigma. data were analyzed using pearson correlation, independent t-test and multiple linear regression. results: the mean stigma score obtained was 11.41 (sd=5.38). negative attitude among community were significantly correlated with higher stigma scores (aor 0.365, 95% ci 0.20, 0.53). conclusion: the stigma scores obtained in this study were lower compare to other countries and negative attitudes are a major contributing factor to the stigma toward leprosy patients. this negative attitude can be avoided by raising awareness of leprosy among community living nearby to leprosy center. key words: attitude, community, leprosy centre, leprosy, stigma 398 global journal of public health medicine 2021, vol 3, issue 2 gggggglo introduction leprosy is a chronic dermatological infection that has afflicted at least 100,000 people in the past. however, to date, the disease still affects millions in the form of new diagnoses and neurological defects (lastoria et al., 2014). the disease is manifested in several types based on the clinical pathology spectrum of tuberculoid, lepromatous, paucibacillary or multibacillary in skin lesions (eichelmam et al., 2012). leprosy is still remaining endemic in most countries. in 2014, it was reported that 1000 new cases were detected from 14 countries. the three countries, india, brazil and indonesia, account for about 81% of all leprosy cases in the world. at the end of 2014, the world recorded a total of 213 899 new cases of leprosy, 3.8 cases per 100,000 inhabitants (world health organization [who], 2016). leprosy is more associated with social illness than the term medical illness. this is because there is a misconception in society that there is a false perception of the reality of the disease since it was detected (heynders, 2000). although leprosy can be completely cured by the treatment of drugs, the misconceptions persist (calcraft, 2006). in nepal, the stigma against leprosy is still enduring. this condition exacerbates the psychosocial effects of being in the community after being diagnosed as the patient receives the physical effect of the disease on them (van brakel, 2003). the disease has a physical effect on the patient who is later diagnosed and causes complications for physical disability. misconceptions about the effects of leprosy lead to profound social stigma on leprosy patients. visible deformities is one of the major contributing factors for stigma and further exacerbated by an attitude due to perceived fear of potential discrimination (marahatta et al., 2018). previous studies have shown that stigma causes infected patients to conceal the disease without seeking treatment to cause permanent disability (rafferty, 2005). leprosy-related social stigma is experienced by patients characterized as social exclusion, unacceptable in society, shameful and uncooperative in society (ibikunle, & nwokeji, 2017). it is generally known that there are many factors that interact and influence the level of stigma of the community against leprosy patients. when you know a person is infected with leprosy, there are various stigmas about the disease and negatively affect the patient. although many studies have been done on the effects of this stigma, it is still not enough to correct the misconception of leprosy patients. studies on the stigma of people with leprosy are still underway in malaysia. this situation leads to the need for research because the stigma against leprosy still exists and will not disappear as leprosy is cured. this is because leprosy has a very negative image and the stigma against it is a problem for leprosy patients (barth-jaeggi et al., 2016). however, in malaysia there is still no published data on the study of community stigma against leprosy patients especially in the community around the leprosy centre which is very close to leprosy patients. the stigma of this society needs to be studied to improve understanding of knowledge, correct misconceptions about leprosy, non-discriminatory attitudes of leprosy patients, correct beliefs and practices in the practice that distinguish or isolate leprosy patients. by understanding this study, information about the stigma towards leprosy can be 399 global journal of public health medicine 2021, vol 3, issue 2 gggggglo passed on to the general public and change the stigma against leprosy patients. increased awareness of the effects of stigma should be done to help patients with leprosy, shy, marginalized and discredited. this study will determine the level of society's stigma score on leprosy patients in national leprosy centre (pusat kawalan kusta negara), by identifying the factors associated with the society's stigma score. methods a cross-sectional study was conducted among the communities around the leprosy centre in sungai buloh as aman puri village, bukit rahman putra, damansara damai and valencia from june to october 2019. a total of 260 persons were selected as respondents using sample random sampling for this three area. respondent were adult aged 18 years and above who live near the pusat kawalan kusta negara in sungai buloh, selangor in which within 4 kilometres of the centre. an individual from each selected family answered the survey questionnaire after obtaining consent to participate. next face-to-face interviews are conducted. the questionaire in malay language and consists of information on demographic (age, gender, ethnicity, marital status), sosioeconomic (education level, occupation, household income), environmental factors (location distance, family history of leprosy), knowledge, attitude and stigma score using validated emic questionnaire. the pilot study was conducted to determine the validity of the questionnaire used with cronbach alpha of 0.65, 0,81 and 0.66 for knowledge, attitude and stigma (overall cronbach alpha 0.75). those who are selected but do not want to cooperate or get infected are excluded and new individuals will be selected within the family. inclusion criteria and exclusion criteria were defined for this study. the inclusion criteria were individuals living around the leprosy center, sungai buloh, selangor, individuals 18 years of age and above for both sexes and malaysian. exclusion criteria were individuals living temporarily around the leprosy center, sungai buloh, individuals who do not want to cooperate and provide information, people with leprosy and individuals who cannot speak malay or english. research approval has been obtained from the secretariat for medical research and innovation, national university of malaysia medical centre. approval of the study was obtained with ff project code 2019 -250. respondents were first informed of the background and purpose of the study and the confidentiality of the information provided in the questionnaire form. respondents were also asked to sign the consent form as a voluntary sign to participate in the study. the sample size were calculated based on on kish formula with 216 individuals after added 20% drop up. the data were analysis using pearson correlation, independent t-test and multiple linear regression to determine the factors associated with stigma score. results the mean age of respondents was 25.49 (5.96) years. more than half of the respondents were found to be male (54.6%), malays (73.1%) and not married (75%). most of them were higher education status (82.4%), unemployed (53.2%) and had household income less than rm3860 a month (67.2%). in environment status, the mean placement distance for all respondents was 2.21 (1.27) kilometres. 84.3% of respondents received information about leprosy. it was found that the highest percentage of 400 global journal of public health medicine 2021, vol 3, issue 2 gggggglo 66.5% of respondents received information from health centre followed by 11.5% of information from friends or family. the other 22% sources refer to information received from television or radio. whereas information about the immediate family of the infected indicates that 100% of the relatives of the leper are not infected. knowledge score majority of respondents had a high knowledge of leprosy (95.8%). a high percentage of this knowledge was related to knowledge of the cause of leprosy (79.2%), disease caused by bacteria or other organisms (77.4%), and contagious leprosy (88%). while the transmission of leprosy (74.5%) was caused by leprosy patients (87.6%). the highest percentage was non-chronic leprosy (92.1%) followed by severe leprosy (82.9%). however, knowing the signs and symptoms of leprosy was only (68.2%) which is a relatively low percentage. it is known that leprosy is a serious disease and leprosy is not a disease of 80% (91.7%) and (88%). the mean community attitude score for leprosy patients obtained in this study was 16.79 (4.55) out of a maximum of 28. all 7 attitude items showed mean score scores above 2 (> 2). the highest mean score is 2.89 which is for the attitude item “how do you feel about allowing someone like pn. salmah to be your nanny for a few hours? whereas the lowest mean score is 2.09 which is for the item "how would you feel if you had a neighbour like pn. salmah?". the mean community stigma score for leprosy patients was 11.41 (5.38) out of the maximum number of stigma scores in the questionnaire form 30. it was found, and only 4 items had a mean score less than one (<1). the item "do family members worry if one family is infected with leprosy?" was the highest mean of 1.44 while the lowest mean of 0.13 was for the item "would you look down on this patient's leprosy family?". (table 1). only attitude showed a significant correlation with stigma score. then interpret value of adjusted or (0.365) (table 2 and table 3). 401 global journal of public health medicine 2021, vol 3, issue 2 gggggglo table 1 demographic, environment, knowledge, attitude and stigma score among community members living around leprosy center characteristics mean (sd) n (%) (n=260) socio-demographic factors age (years) 25.49 (5.96) gender male 142 (54.6%) female 118 (45.4%) race malay 190 (73.1%) chinese indian 29 (11.1%) 26 (10.2%) others 15 (5.6%) marital status not married 195 (75.0%) married 65 (25.0%) socio-economic factors education status low 46 (17.6%) high 214 (82.4%) occupational status employed 122 (46.8%) unemployed 138 (53.2%) household income low (< rm3860) 175 (67.2%) high (≥ rm 3860) 85 (32.8%) environment factors placement distance (km) 2.21(1.27) receiving information about leprosy yes 219 (84.3%) no 41 (15.7%) source of information health centre 173 (66.5%) friends / family 30 (11.5%) other (tv / radio) 57 (22%) the nearest family is infected yes 0 (0 %) no 260 (100%) knowledge do you know the cause of leprosy? yes 206 (79.2%) no 54 (20.8%) source of infection microorganism 206 (79.2%) others 54 (20.8%) did you know, leprosy can infectious? yes 229 (88%) no 31 (12%) do you know the transmission of leprosy? yes 194 (74.5%) no 66 (25.5%) 402 global journal of public health medicine 2021, vol 3, issue 2 gggggglo the transmission leprosy patient 228 (87.6%) contaminated environment 26 (9.9%) mosquito 5 (1.9%) others 1 (0.6%) do you think leprosy is difficult to treat? yes 216 (82.9%) no 44 (17.1%) do you think leprosy is a common disease? yes 21 (7.9%) no 239 (92.1%) do you know the signs and symptoms of leprosy? yes 177 (68.2%) no 83 (31.5%) sign and simptom grouped skin 88 (33.8%) sensitive grouped skin 90 (34.5%) weak foot and eyelids nervous 16 (6.1%) painless pain 17 (6.8%) various 49 (18.9%) is leprosy a bad disease? yes 238 (91.7%) no 22 (8.3%) is leprosy a disease of divine punishment? yes 13 (12%) no 229 (88%) knowledge score low (<50) 10 (4.2%) high (≥50) 250 (95.8%) attitude how do you feel about renting a room in your house to someone like pn. salmah? 2.20 (0.77) how would you feel if you were a colleague like pn. salmah? 2.12 (0.72) how would you feel if you had a neighbor like pn. salmah? 2.09 (0.73) how do you feel about allowing someone like pn. salmah to be your children's nanny for a few hours? 2.89 (0.97) what if one of your children wants to marry someone like pn. salmah? 2.79 (0.92) are you going to introduce someone like pn. salmah to one of your male friends? 2.50 (0.85) would you recommend someone like pn. salmah to work at your friend's company? 2.20 (0.84) attitude score 16.79 (4.55) stigma score if necessary, is a person infected with leprosy hidden from other people's knowledge? 0.49 (0.82) if one of your family members is infected with leprosy, do you feel inferior? 0.37 (0.72) does this leprosy cause you embarrassment in society? 0.84 (0.93) 403 global journal of public health medicine 2021, vol 3, issue 2 gggggglo do others look down on those with leprosy? 0.99 (0.90) does knowing someone with leprosy harm others? 0.18 (0.55) will you stay away from this leper? 0.63 (0.84) would anyone avoid visiting a leper's home? 0.86 (0.89) are you going to look down on this leprosy family? 0.13 (0.46) will leprosy cause problems for their families? 0.57 (0.83) do family members worry about having one family infected with leprosy? 1.44 (0.76) does the patient have problems getting married if the patient is not married? 0.96 (0.86) will leprosy suffer from problems in the household for married patients? 0.60 (0.84) will leprosy cause problems for other family members to get married? 1.02 (0.84) will leprosy patients have problems finding a job? 1.11 (0.96) don't you like buying food from leprosy? 1.20 (0.82) total stigma score 11.41 (5.38) table 2 factors associated to stigma among community members living close to leprosy center characteristic factors score stigma mean (sd) t value p value socio-demographic age (years) 25.49 (5.96) -0.005a 0.937b gender male 11.26 (5.45) -0.434 0.665 female 11.58 (5.32) race malay 11.61 (5.34) 0.925 0.357 nonmalay 10.84 (5.44) marital status not married 11.70 (5.35) -1.405 0.161 married 10.52 (5.43) socio -economic education status low 12.24 (5.45) 1.047 0.296 high 11.23 (5.35) occupational status employed 11.63 (5.24) 0.578 0.564 unemployed 11.21 (5.52) household income low (< rm3860) 11.59 (5.31) 1.331 0.266 404 global journal of public health medicine 2021, vol 3, issue 2 gggggglo high (≥ rm 3860) 11.03 (5.55) environment placement distance (km) 2.21 (1.27) 0.025a 0.714b receiving information about leprosy yes 11.47 (5.38) 0.411 0.820 no 11.06 (5.44) knowledge of leprosy -1.063 0.316 low (<50) high (≥50) 9.67 (5.00) 11.48 (5.39) attitude scores on leprosy patients 0.352a 0.001b a correletion coeficien value (r) bpearson’s correletion table 3 multiple linear regression analysis of factors associated on stigma among community members living close to leprosy centre factors slra mlrb crude b (95% ci) p value adj. b (95% ci) p value age -0.005 (-0.13, 0.12) 0.937 gender 0.319 (-1.13, 1.77) 0.665 race -0.925 (-2.59, 0.74) 0.275 marital status 2.031 (-0.27, 4.34) 0.084 education status -1.332 (-3.26, 0.60) 0.175 occupational -1.348 (-3.20, 0.50) 0.152 household income -0.370 (-2.63, 1.89) 0.746 placement distance 0.201 (-0.39, 0.78) 0.499 information of leprosy -0.476 (-2.50, 1.55) 0.643 knowledge 0.373 (-0.09, 0.83) 0.110 attitude 0.399 (0.249, 0.55) <0.001 0.365 (0.20, 0.53) <0.001 a. simple linear regression b. multiple linear regression. (r2= 0.129, the model is fix.: assumption of model fulfilled: no interaction between independent variables and no multicollinearity problem 405 global journal of public health medicine 2021, vol 3, issue 2 gggggglo discussion the mean stigma scores among community living near to leprosy centre was 11.41 out of a maximum of 30. this shows that there is a perceived stigma in the community even though the disease has been around for a long time and the leprosy centre has grown. however, studies in some countries show higher stigma scores than this study. similar studies conducted in brazil show that stigma scores are 12.4 (schutten, 2018) and in india are 13.8 (rense et al., 2011). both studies used emic to measure stigma scores in the study population. a study conducted in five regions in indonesia also used emic-css and found that the mean stigma score was higher than this study which is between 13 – 16 (van brakel et al., 2012). another study in the district of cirebon, west java, indonesia also gave the highest mean score of 15.4 (peters et al., 2014). the results of this study were lower than those of other countries because the study was concentrated only within 4 kilometer radius of the leprosy centre. the area cannot reflect the overall population of people living further than this study area. one-fourth of the area is also covered by the bukit lagong recreation area where no respondents are found in the area. in addition, it is possible that respondents did not answer every question that was provided due to time constraints. although the time had been ample, the respondent was in a hurry. this creates a bias in the information obtained. furthermore, this study requires researchers to devote more time to sampling throughout a wider area than the area around the leprosy centre to obtain information that is not possible due to time constraints. these findings also indicate that stigma items that contribute most to stigma scores are from dislike of food from leprosy patients. this study shows results consistent with studies conducted in indonesia (sermrittirong & van brakel, 2014). this is evidenced by a study (adhikari et al., 2014) in nepal, showing that a person's fear of infection leads to higher stigma. while the difficulty of getting a job is also seen as contributing to high scores. this is illustrated by findings consistent with a study conducted in nonsomboon, thailand (kaehler et al., 2013) where patients were required to leave their jobs due to leprosy. similar results were also obtained from the results of a study conducted in nepal (adhikari et al., 2014). that is, other family members are difficult to marry because they are influenced by leprosy conditions, which results from a study consistent with research done in thailand (kaehler et al., 2015). the findings of this study found that only attitude factors influence the level stigma scores on leprosy patients. respondents with high attitude scores had a negative attitude and had a stigma against leprosy patients. these findings are in line with some previous studies. studies in indonesia and nigeria indicate that attitude factors are the major contributing factors to high stigma scores (ibikunle, & nwokeji, 2017; peters et al., 2014). the results of this survey also found that majority of respondents had a negative attitude towards leprosy, which showed findings consistent with previous studies, as reported in ethopia (tesema, & beriso, 2015) and in india (danturty et al., 2016). similarly, higher stigma is found in people with a negative attitude toward leprosy. they think leprosy is a chronic disease, difficult to treat and a highly contagious infectious disease. negative attitudes 406 global journal of public health medicine 2021, vol 3, issue 2 gggggglo toward leprosy were found to be strongly associated with stigma in a study conducted in eastern nepal (de stigter et al., 2012). negative attitudes and high stigma are also shown in number of other diseases besides leprosy as tuberculosis (sermrittirong et al., 2015). the results of a recent study conducted in thailand and india show a high negative attitude and stigma against tuberculosis which is considered to be a highly contagious disease in the community and cannot be cured (soonthorndhana et al., 2000) while occupational health shows high stigma and negative attitudes toward tuberculosis patients (wu, 2010). however, the study found that the stigma against leprosy was higher compared to the stigma against tuberculosis. this is because isolation of leprosy patients is performed while tuberculosis patients are not isolated (mwasuka et al., 2018). leprosy also involves the problem of finding a partner but has not been reported for tuberculosis. therefore, the stigma of tuberculosis is less serious than the stigma of leprosy (soonthorndhana et al., 2000). they argued that lepers would hide their disease, aimed at preventing it from being excluded by society. attitudes to hide the disease can only be avoided if the public is provided with an accurate education of leprosy that can help the leper to be socially accepted and promote early treatment and prevent permanent disability. several limitations have been identified in this study. this study is limited to respondents who can speak malay and english only. therefore, information cannot be obtained primarily from respondents who are chinese or indian who can only speak chinese or indian. similarly, chinese or indian respondents who are not fluent in malay or english, the bias in the delivery of information can occur. this study also is focused around a 4 kilometres radius of the pusat kawalan kusta negara. this study area cannot reflect the overall population of people living further than this study area. onefourth of the area is also covered by the bukit lagong recreational forest area where no respondents are found in the area. conclusion stigma scores among community living in leprosy centre in malaysia are lower compare to other countries. negative attitude factors contribute to society's stigma against leprosy patients around the national leprosy centre. this negative attitude is driven by the notion that leprosy is a chronic and easily contagious chronic disease. although knowledge of leprosy is caused by microorganisms, there is still a negative attitude towards the patient. 407 global journal of public health medicine 2021, vol 3, issue 2 gggggglo acknowledgement we would like to thank the all community members for their help and cooperation in facilitating this research. conflict of interests the authors declared no potential conflicts of interest. references • adhikari, b., shrestha, k., kaehler, n., raut, s., & chapman, s. r. 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(2010). knowledge and attitudes of health care workers towards tuberculosis patients and the experiences of tuberculosis patients regarding health care workers in vellore district, tamil nadu, south india. vu university, amsterdam. microsoft word gjphm-2020healthy diet.docx 140 global journal of public health medicine 2020, vol 2, issue 1 original research assessment of dietary habits and their influence on serum lipid profile among yong adults from palestine akram m. altaher, abed el kader y. elottol, belal i. alastal, abed almalek i. alhobi & mohamed i. shihada department of medical sciences, university collage of science and technology-khanyounis, gaza strip, palestine corresponding author: a.taher@cst.ps abstract introduction: hyperlipidemia increases the risk of many diseases including coronary artery disease and atherosclerosis. nutritional knowledge may act as a deterrent against unhealthy nutrition trend which is strongly associated with hyperlipidemia. we aim to evaluate the dietary habits and their influence on serum lipid profiles among university students. methods: this study was an analytical descriptive design that started in june and finished in september 2018. a total of 200 students (100 males and 100 females), aged between 18-22 years were evaluated. sociodemographic data and health-related data situations, lifestyle practices, and eating habits of the study population were reported by an interview questionnaire. the biochemical evaluation for total cholesterol (tc), low-density lipoprotein cholesterol (ldl), high-density lipoprotein cholesterol (hdl), and triglycerides (tg) was carried out. a significant result means that the p-value for the hypothesis tests was less than 0.05 at confidence intervals 95%. results: male students were more likely to be healthier eating habits compared to female students in terms of regular breakfast intake, regular lunch intake, and regular dinner intake. the majority of students (67.5%) eat two to three meals per day. most students (60.0%) thought that eating meats, vegetables and other variety of foods are the keys to point of a balanced diet. on the other hand, the prevalence of hypercholesterolemia was significantly higher in male students than females and, the prevalence of elevated ldl was higher in female students than males. conclusion: despite the students having some unhealthy eating habits, however, their eating habits were non significantly associated with a higher prevalence of the three hyperlipidemias. keywords : eating habits, lipids profile, students, gaza strip. 141 global journal of public health medicine 2020, vol 2, issue 1 introduction the major cause of death in developed and developing countries were the cardiovascular disease (cvd) (van minh et al., 2003). the risk factors for cvd i.e. hyperlipidemia, sedentary lifestyle and unhealthy eating habits are originating in the childhood and may develops in the adulthood (ericksson et al., 2001). hyperlipidemia has been criminalized as a potential risk in coronary heart diseases (chd), atherosclerosis, diabetes mellitus (al-taher, et al., 2017). metabolic syndrom is the main risk factor for cvd & dm (altaher, et al., 2019a). according to the american diabetic association (ada) lipid profiles (lp) are blood test used to determine the blood levels of triglycerides (tg), total cholesterol (tc), low-density lipoprotein (ldl), and high-density lipoprotein (hdl) (ada, 2013). for chd diagnosis and monitoring; the lp test is used (ada, 2013). the increased in saturated fats consumption especially cholesterol leads to elevated tc, which resulting in increased danger of cvd (ye and kwiterovich, 2000). animal or vegetable originally saturated fats adhere to the blood vessel wall by forming a clot and blocking blood flow (ighosotu and tonukari, 2010). it is important to mention that foods with elevated fiber content, such as fruits and vegetables, have been reported to be useful in reducing plasma tc concentrations, while foods with low soluble fibers are ineffective in lowering of plasma tc levels (ericksson et al., 2001). however, there are numerous genetic influences on the metabolism of lipoproteins that can make certain people in the same population "nutritional responsive" or "nonresponsive" to fat consumption (ye and kwiterovich, 2000). data gathered from a lp test can help to recommend modifications in lifestyle and dietary behaviors to take the lipids and lipoprotiens serum concentrations back to the normal range and thus will reduce the occurrence of cvd (altaher, et al., 2016). the ongoing urbanization of the developing countries including palestine state has bring accelerated changes in the lifestyle and the dietary behaviors (namely; typical mediterranean diet) among the university students toward consumption of fast food and, high caloric diets pattern and inactive lifestyle. these changes have a strong impact on the onset of cvd diseases and other chronic diseases related to urbanization. dietary awareness of palestinian college students can survive as a protective measure to the fast-food trend among them, which in order contributes to decreasing cvd risks among the students. nationally, there have been no prior studies linked to this subject to date, and this is the firsttime college young students in gaza strip have participates in this type of studies. in many countries around the world, there have been several studies dealing with this topic. these surveys, however, have disclosed, inconclusive or contradictory findings, and this is due to variations in the type of food consumption and nutritional patterns from country to country. however, this study aimed to assess the dietary habits and their influence on serum lipid profile among college students from khanyunis, palestine. methods the research was a descriptive-analytical design that began in june and was completed in october 2018. the total samples of this study were 200 college students, out of them (100 subjects) were males and the other 100 were females, aged between 18-22 years and 142 global journal of public health medicine 2020, vol 2, issue 1 collected by simple random method from the university college of sciences and technology (ucst)-khanyunis governorate, gaza strip. students with chronic disease such as: diabetes mellitus, hypertension, and other diseases were excluded. all formal letter of approval to conduct the study was obtained from related authority and every subject in the study was given a consent form about the study and received the report of the results of their biochemical examinations after the end of the study. the students were requested to complete an interview questionnaire relevant to their eating, drinking, and smoking habits. the questionnaire was adapted from earlier research in which researchers standardized its use among university learners (yahia et al., 2008). the questionnaire consisted of three items: sociodemographic data (name, age, gender, educational status, etc.), health-related data (following a regime, smoking situation, etc.), and lifestyle practices (eating habits, meal patterns, consumption of fruit and vegetables, and fried food, etc.). approximately 3 ml venous blood specimen in fasting state (14 to 16 hr.) were withdrawn from each student in a test tube without anticoagulation and the specimens were permitted to clot then the sera were isolated at room temperature by centrifugation using the 80-1 fuhua, china at 3500 rotate/minute for 10 minutes. serum was used to measure the concentrations for tc, tg, and hdl by spectrophotometer device (stat fax 1904+, usa) using qca clinical kit, spain and the calculation of colorimetric tests for tc, tg, and hdl were performed according to beer's law. while the ldl was calculated by the formula of friedewald: [ldl = tc – (hdl) – tg/5 (mg/dl)] (friedewald et al., 1972). all biochemical tests were conducted in the biochemistry laboratory off the university college of science and technology – khanyunis. the spss vr. 22 was used for statistical analysis of data. descriptive statistics and chi-square test were carried out. at confidence interval equal 95.0%; p-value of less than 0.05 for the tested hypothesis was considered statistically significant. results the finding showed that the mean of age among the males group was 21.21 years whereas, the mean ± sd of age was 21.23 among the females group. however, there is no statistically significant difference between the study subjects with respect to mean of age in years (p=0.947). the following table shows the comparative distribution of the study subjects according to their inhabited governorate, education level in university and monthly income (table 1). after using of chi-square test; there was a statistical difference among the study subjects with respect to education levels in the university, family monthly income and smoking status (p<0.000, <0.000 & = 0.024 respectively) (table 1). the table below (table 2) reveals the student's response to questions related to their dietary practices i.e. eating habits, meal patterns, fried food consumptions, fruits and vegetables intake, meats (white and red) intake, and gas drinks drinking by gender. it shows that the majority of male students (72.0%) vs. (34.0%) of female students were taking their breakfast regularly (p<0.000), and the most of 143 global journal of public health medicine 2020, vol 2, issue 1 students (86.0%) vs. (65.0%) of female students were taking their lunch regularly (p=0.001), while (57.0%) of male students vs. (22.0% of female students were taking their dinner regularly (p<0.000). consequently, male students showed healthier eating habits compared to female students in terms of regular breakfast intake, regular lunch intake and regular dinner intake (p ≤ 0.05 for all) (table 2). also, the majority of students (67.5%) reported eating two to three meals per day. among males, 69.0% reported eating two to three meals per day as compared to 66.0% females. however, there was a significant gender difference in the number of meal intake (p = 0.015) (table 2). as well as, about 60.0% of students (62.0% male students and 57.0% female students) think that eating of meats, vegetables and other variety of foods are the key to achieve balanced diet (table 2). table 1: distribution of the population general characteristics by gender t the unhealthy eating practice was indicated by the fact that the majority (57.5%) of the students reported eating fried food at least three times per week. among females, 71.0% reported eating fried food daily or three to four times per week compared to 44.0% males. however, there was a gender difference according to eating fried food (p<0.000) (table 2). concerning to the frequency of gas drinks drinking per week; table 2 indicates that the majority of students (59.0%) drank 1 or 2 cups of gas drinks per week (61.0% of males vs. 57.0% of females). however, there was a gender difference according to the frequency of gas drinks drinking per week (p=0.001) (table 2). p-value female (n=100) male (n = 100) variables 0.947 21.23±1.5 21.21±1.4 age (mean±sd) 0.663 governorate (63.0%) (60.0%) khanyunies (37.0%) (40.0%) rafah <0.001 education level in the university (14.0%) (11.0%) level 1 (55.0%) (20.0%) level 2 (10.0%) (18.0%) level 3 (18.0%) (47.0%) level 4 (3.0%) (4.0%) level 5 <0.001 monthly income (nis) (79.0%) (30.0%) < 15000 (14.0%) (43.0%) 1500 < 2500 (6.0%) (24.0%) 2500 < 4000 (1.0%) (3.0%) > 4000 <0.024 smoking status (0.0%) (5.0%) yes (100%) (95.0%) no 144 global journal of public health medicine 2020, vol 2, issue 1 table 2: student's response to questions related to their dietary practices p-value total gender variables female male 0.000 do you take your breakfast regularly? 106 (53.0%) 34 (34.0%) 72 (72.0%) yes 94 (47.0%) 66 (66.0%) 28 (28.0%) n o 0.001 do you take your lunch regularly? 151 (75.5%) 65 (65.0%) 86 (86.0%) yes 49 (24.5%) 35 (35.0%) 14 (14.0%) n o <0.001 do you take your dinner regularly? 79 (39.5%) 22 (22.0%) 57 (57.0%) yes 121 (60.5%) 78 (78.0%) 43 (43.0%) n o 0.015 how many meals do you eat except snacks? 50 (25.0%) 31 (31.0%) 19 (19.0%) one meal 135 (67.5%) 66 (66.0%) 69 (69.0%) 2-3 meals 15 (7.5%) 3 (3.0%) 12 (12.0%) more than 3 meals 0.135 how often do you take snacks apart from regular meals? 69 (34.5%) 39 (39.0%) 30 (30.0%) daily 65 (32.5%) 34 (34.0%) 31 (31.0%) 3 or 4 times per week 10( 5.0%) 2 (2.0%) 8 8.0%) 1 or 2 per week 56 (28.0%) 25 (25.0%) 31 (31.0%) rarely 0.055 what type of food do you think you should eat to have balanced nutrition? 25 (12.5%) 9 (9.0%) 16 (16.0%) mainly meats 56 (28.0%) 34 (34.0%) 22 (22.0%) mainly vegetables 92 (46.0%) 49 (49.0%) 43 (43.0%) meats & vegetables 27 (13.5%) 8 (8.0%) 19 (19.0%) other <0.001 how often do you eat fried food? 24 (12.0%) 16 (16.0%) 8 (8.0%) daily 91 (45.5%) 55 (55.0%) 36 (36.0%) 3 or 4 times per week 85 (42.5%) 29 (29.0%) 56 (56.0%) 1 or 2 per week 0.542 how often do you eat fruit and vegetables? 3 (1.5%) 2 (34.0%) 1 (1.0%) daily 87 (43.5%) 40 (40.0%) 47 (47.0%) 3 or 4 times per week 110 (55.0%) 58 (58.0%) 52 (52.0%) 1 or 2 per week 0.072 how often do you eat meats (white and red) per week? 77 (38.5%) 42 (42.0%) 35 (35.0%) one time 98 (49.0%) 43 (95.0%) 55 (55.0%) two times 25 (12.5%) 15 (15.0%) 10 (10.0%) three times & more 0.001 how many cups of gas drinks do you drink per week? (cup=330ml) 44 (22.0%) 32 (32.0%) 12 (12.0%) i don't drink it 118 (59.0%) 57 (57.0%) 61 (61.0%) 1 or 2 cups 38 (19.0%) 11 (11.0%) 27 (27.0%) 3 cups or more 200 100.0% 100 100.0% 100 100.0% n total % 145 global journal of public health medicine 2020, vol 2, issue 1 table 3: lipid profile levels based on who category by gender the table above (3) illustrates lipid profile levels of students based on who category by gender. the prevalence of hypercholesterolemia was significantly higher in male students than females (p = 0.000) but the prevalence of high ldl was higher in female students than males (p = 0.001). on the other hand, there were no statistically significant differences among the study population according to triglycerides and hdl levels by gender (p = 0.352 and 0.294 respectively) (table 3). the prevalence of high levels of tc, tg or ldl in the different eating habits of students is shown in table 4. students who take their breakfast regularly have a higher prevalence of high tc (6.0%), tg (3.0%), and ldl (19.0%) levels as compared to those who don’t take it regularly. but this difference doesn't reach a statistically significant level (p < 0.05 for all) (table 4). as same as, students who take their lunch regularly have a higher prevalence of high tc (8.0%), tg (4.5%), and ldl (27.0%) levels as compared to those who don’t take it regularly. but these differences also don't reach a statistically significant level (p < 0.05 for all) (table 4). in contrast, students who don’t take their dinner regularly have a higher prevalence of high cholesterol (5.0%), tg (3.0%), and ldl (20.0%) levels as compared to those who take it regularly. but these differences also don't reach a statistically significant level (p < 0.05 for all) (table 4). in addition, participants who reportedly consumed 2 or 3 meals except for snacks per day had a higher incidence of high tc (6.5%), tg (3.5%) and ldl (26.0%) levels as compared to those consumed one meal. but these differences also don't reach a statistically significant level (p < 0.05 for all) (table 4). furthermore, students who take snacks daily had a higher incidence of high tc (3.5%), tg (2.0%) and ldl (11.5%) levels as compared to those consumed it one to four times per week. but these differences also don't reach a statistically significant level (p < 0.05 for all) (table 4). in the same context, students who prefer to take sweets as snacks have a higher prevalence of high cholesterol (5.0%), tg (2.0%), and ldl (11.0%) levels as compared to those who don’t prefer to take it. p-value total gender variables 0.000 200 (100%) female male total cholesterol (mg/dl) 182 (91.0%) 99 (49.5%) 83 (41.5%) less than 200 18 (9.0%) 1 (0.5%) 17 (8.5%) 200 or more 0.001 ldl (mg/dl) 133 (66.5%) 78 (39.0%) 55 (27.5%) less than 130 67 (33.5%) 22 (11.0%) 45 (22.5%) 130 or more 0.294 hdl (mg/dl) 133 (66.5%) 70 (35.0%) 63 (31.5%) less than 40 67 (33.5%) 30 (15.0%) 37 (18.5%) 40 or more 0.352 triglycerides (mg/dl) 189 (94.5%) 96 (48.0%) 93 (46.5%) less than 150 11 (5.5%) 4 (2.0%) 7 (3.5%) 150 or more 146 global journal of public health medicine 2020, vol 2, issue 1 table 4: relationship of lipid profile levels with eating habits high ldl-c (%) hypertriglyceridemia (%) hypercholesterolemia (%) do you take your breakfast regularly? 38 (19.0%) 6 (3.0%) 12 (6.0%) yes 29 (14.5%) 5 (2.5%) 6 (3.0%) n o 0.455 0.916 0.223 p-value do you take your lunch regularly? 54 (27.0%) 9 (4.5%) 16 (8.0%) yes 13 (6.5%) 2 (1.0%) 2 (1.0%) n o 0.234 0.616 0.166 p-value do you take your dinner regularly? 27 (13.5%) 5 (2.5%) 8 (4.0%) yes 40 (20.0%) 6 (3.0%) 10 (5.0%) n o 0.870 0.294 0.563 p-value how many meals do you eat except snacks per day? 10 (5.0%) 4 (2.0%) 3 (1.5%) one meal 52 (26.0%) 7 (3.5%) 13 (6.5%) 2-3 meals 5 (2.5%) 0 (0.0%) 2 (1.0%) more 3 meals 0.060 0.472 0.619 p-value how often do you take snacks apart from regular meals? 23 (11.5%) 4 (2.0%) 7 (3.5%) daily 22 (11.0%) 4 (2.0%) 6 (3.0%) 3 or 4 times/ week 22 (11.0%) 3 (1.4%) 5 (2.5%) 1 or 2 times/ week 0.933 0.914 0.870 p-value what type of food do you think you should eat to have balanced nutrition? 17 (8.5%) 3 (1.5%) 2 (1.0%) mainly meats 22 (11.0%) 4 (2.0%) 10 (5.0%) mainly vegetables 14 (7.0%) 2 (1.0%) 3 (1.5%) meats & vegetables 14 (7.0%) 2 (1.0%) 3 (1.5%) other 0.053 0.954 0.096 p-value how often do you eat fried food? 32 (16.0%) 7 (3.5%) 9 (4.5%) daily 30 (15.0%) 4 (2.0%) 7 (3.5%) 3 or 4 times/ week 5 (2.5%) 0 (0.0%) 2 (1.0%) 1 or 2/week 0.302 0.310 0.922 p-value how often do you eat fruit and vegetables? 39 (19.5%) 5 (2.5%) 8 (4.0%) daily 27 (13.5%) 6 (3.0%) 9 (4.5%) 3 or 4 times/ week 0.5%) ( 1 0 (0.0%) 1 (0.5%) 1 or 2 per week 0.808 0.707 0.251 p-value how often do you eat meats (white and red) per week? 25 (12.5%) 4 (2.0%) 5 (2.5%) one time 32 (16.0%) 6 (3.0%) 10 (5.0%) two times 4.0%) ( 8 1 (0.5%) 3 (1.5%) 3 times & more 0.908 0.883 0.683 p-value how many cups of gas drinks do you drink per week? (cup=330ml) 13 (6.5%) 1 (0.5%) 2 (1.0%) i don't drink it 38 (19.0%) 9 (4.5%) 11 (5.5%) 1 or 2 cups 8.0%) ( 16 1 (0.5%) 5 (2.5%) 3 cups or more 0.436 0.285 0.390 p-value 147 global journal of public health medicine 2020, vol 2, issue 1 however, these differences don't reach a statistically significant level (p < 0.05 for all) (table 4). likewise, consumption of fried food, frequency of fruits and vegetable consumption, frequency of meats consumption per weeks, and the number of gas drink cups drank per week were non significantly associated with the higher prevalence of the three hyperlipidemias (p < 0.05 for all) (table 4). discussion in terms of dietary practices, university students usually do not pursue good nutritional habits. students at universities often prefer fast food because of its availability and short preparation period compared to conventional food. fast food e.g. falafel, luncheon meat, sausage pancakes, shawarma, hamburger, etc.. generally high in fat, tc, simple sugar and calories. in the current study, after comparison of student's dietary practices between males group and females group; the findings showed that the majority of students (53.0%) were taking their breakfast regularly, and the most of students (75.5%) were taking their lunch regularly, while only (39.5%) of students were taking their dinner regularly. however, male students showed healthier eating habits compared to female students in terms of regular breakfast intake, regular lunch intake & regular dinner intake (p ≤ 0.05 for all). in addition, the majority of students (67.5%) reported eating two to three meals per day. however, there was a significant gender difference in the number of meal intake (p = 0.015). similar result was found by the crosssectional study that was conducted in students from the lebanese american university (in beirut) to evaluate their eating practice. the study found that the majority of students (58.9%) eat meals regularly and (53.3%) of them eat breakfast daily or three to four times per week (yahia, et al., 2008). as well, 52.7% of the students eat meals two times per day. however, there was a significant gender difference in the frequency of meal intake in the studied sample (p = 0.001) (yahia, et al., 2008). in contrast to the current study findings, another cross-sectional study by al-rethaiaa et al. aimed to determine eating habits among college students in saudi arabia. the findings of this research observed that 63.3% of students reported irregular meal intake. in addition, only 49.0% of students intake breakfast daily (al-rethaiaa et al., 2010). furthermore, most of the students (87.1%) were ate two or three meals per day and these results were in the line with our findings (alrethaiaa et al., 2010). regarding to the type of food which students think that they should eat to have balanced nutrition, our findings showed that about 60.0% of students think that intake of meats, vegetables and other variety of foods will provide them with a balanced diet. these findings were in line with other researches that indicated that the majority of university students believe it is essential to consume meat, vegetables and other less fatty foods to achieve a balanced diet (al-rethaiaa et al., 2010; yahia, et al., 2008; davy et al., 2006; wardle and haase, 2004). as anticipated, the consumption of fruits and vegetables among the study population was also prevalent, and this behavior should be encouraged and enhanced the energy content of fruits and vegetables is low because it contains more water and fiber than other food kinds. however, adding them to a student diet therefore decreases the total consumption of energy, therefore assisting in management of weight and serum lipids, and lipoprotein (rolls, et al., 148 global journal of public health medicine 2020, vol 2, issue 1 2004). on the other side, the unhealthy eating styles were stated by the reality that most (57.5 %) of the students were intake fried food at least three times a week, 59.0 % were drinking 1 or 2 cups of gas beverages a week (61.0 % of men vs. 57.0 % of women) and 67.0 % were eating snacks at least three times a week. there have been gender differences, however, depending on intake of fried food and the frequency of drinking gas beverages per week (p<0.000 & =0.001). snacks are described as all foods and beverages taken outside of the three primary meals (de graaf, 2006). while enhanced consumption of snacks is often accused with enhanced incidence of hyperlipidemia, a visible cutting relationship between snacking and hyperlipidemia is still unclear (spanos & hankey 2010). a one study discovered a link between obesity and hyperlipidemia with gas beverage intake (gibson, 2008). regarding to the associations of dietary habits with hyperlipidemia, to the best of our knowledge, unfortunately, there are no large-scale studies have identified the cvd risk factors especially hyperlipidemia among adult college students in palestine. furthermore, considering the absence of adequate sources available in the literature, we could not discover a survey analyzing the impact of gender or nutritional and/or lifestyle patterns on the palestinian population's hyperlipidemia status. this has prevented us from reaching a significant conclusion on how these parameters interact with hyperlipidemia. as found in the current study, the prevalence of hypercholesterolemia was significantly higher in male students than females, but the prevalence of high ldl was higher in female students than males. compared with other countries, the prevalence of hypercholesterolemia in the current study is similar to that in turkey and the guadeloupe (erem et al., 2008; foucan et al., 2000), but lower than that in england (primatesta, 2000). this reduced incidence in women may indicate that female sex hormones, particularly estrogen, protect against increased tc or tg levels. this protective function for estrogen has been noted earlier, but is still disputed (oh & park, 2015; li, et al., 2017). regarding the relationship of lp with eating practices, changed serum tc, ldl, hdl, tgs concentrations are identified as risk factors for cvd and, meal pattern affects these variables (farshchi, et al., 2004). the present findings found that the irregular meal frequency was not associated with higher lipid profiles levels. this finding in the current study did not coincide with the majority of latest research which reporting that irregular meal frequency causes hyperlipidemia to develop (farshchi, et al., 2004; samuelson, 2000; murata, 2000). moreover, the results of the present study reported that consumption of fast foods and fried food were none significantly associated with a greater incidence of the three hyperlipidemias. these results do not agree with the results of kelishadi et al. (2004), which reported a considerable direct correlation between the dyslipidemia of adolescents and the intake frequency of fried foods and fast foods.(p < 0.05). the difference in findings between the current study and previous studies stems from the fact that alternation in blood lipid levels need a long-term follow up to be observed in addition to a large number of participants. however, health program must be developed to encourage improve dietary habits, healthier lifestyle, promote exercise, discourage smoking, avoid complications of 149 global journal of public health medicine 2020, vol 2, issue 1 diabetes and appropriately handle chronic diseases (altaher, et al., 2019b). conclusion male students showed healthier eating habits compared to female students in terms of regular breakfast intake, regular lunch intake and regular dinner intake. the frequency of hypercholesterolemia in male students was considerably greater than in women but the frequency of elevated ldl in female students was greater than in male students. students eating habits were non significantly associated with higher occurrence of the three hyperlipidemias (tc, tg, ldl) recommendation despite the eating patterns of students, none were substantially correlated with the greater incidence of the three hyperlipidemias; university students especially males, should benefit from a nutrition and health promotion program to decrease the tendency among them to obesity and dyslipidemia, furthermore, the finding that most students were unaware of their lipid profile status mandates warrants public education initiatives. in addition, extra screening studies in the same topic with larger sample size is strongly recommended. acknowledgements the authors of this study gratefully acknowledge to the university college of science and technology-khanyunis, palestine for providing instruments, and chemicals for this research. references • al-taher, a. m., aljboor, h. s., alshaer, s. i., & soboh, m. m. 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(2000). influence of genetic polymorphisms on responsiveness to dietary fat and cholesterol. the american journal of clinical nutrition, 72(5), 1275s-1284s. microsoft word edited-gjphm-2021adult immunization.docx 496 global journal of public health medicine 2021, vol 3, issue 2 gggggglo original research development and construct validation of questionnaire assessing the adult immunisation perceptions among malaysian population siti nor mat, shamsul azhar shah, syafiq taib, norzaher ismail & mohd rohaizat hassan department of community health, faculty of medicine, universiti kebangsaan malaysia, 56000 cheras, kuala lumpur, malaysia *corresponding author: sitinor.mat@gmail.com abstract introduction: immunisations are one of the most effective public health interventions, reducing or eliminating the burden of many infectious diseases. this study aims to establish the construct validity of a newly developed adult immunisation perceptions questionnaire among malaysians. methods: the adult immunisation perceptions-questionnaire (aip-q) was created following literature reviews on the health belief model. primarily, 64 questions were pooled, followed by face validity by experts, pretested via 20 healthcare personnel and later translate into the malay language. a total of 305 respondents were selected for the construct validation process. varimax rotation method used in the analysis for exploratory factor analysis (efa) and confirmatory factor analysis (cfa) done using amos software. results: ten constructs were produced as predicted in efa: health believes, experience, knowledge, attitude, perceived severity, perceived susceptibility, perceived benefits, perceived barriers, and 2 cues for action. thirteen items with low factor loading and unrelated to the recovered domains were removed from being included in cfa. in path analysis, the scale fitted χ2/df=1.943 (n=305) =p<0.001, cfi=0.908, ifi=0.909, tli=0.901 and rmsea=0.056. strong factor loading was found across the final items, ranged from 0.53 to 0.94 with a good reliability test (cronbach alpha, ave and cr values) for all constructs. conclusion: the final aip-q consists of 10 domains with 45 items that give a promising psychometric property. this questionnaire can measure the perceptions of adult immunisation among the malaysian population and can be utilized for the nationwide study. keywords: adult immunisation perception questionnaire, factor analysis, construct validation 497 global journal of public health medicine 2021, vol 3, issue 2 gggggglo introduction immunisations are one of the greatest public health achievements of the twentieth century (alexa et al.,2016). adult immunisation is not commonly practiced in most countries as well as in malaysia. even though there are significant morbidity and mortality due to vaccine-preventable diseases (vpd) within this age group, the awareness of the benefits of immunisation for adults is still lacking (malaysia adult immunisation guideline, 2014). hence, less attention has been given to adult immunisation, even in developed countries with strong public health infrastructures (levine et al.,2011). data from the ministry of health malaysia, 2011 showed that vpd are still commonly encountered in malaysia, as the incidence rates for measles, hepatitis b and pertussis were 5.42, 4.32, 0.86 per 100,000 populations respectively (malaysia adult immunisation guideline, 2014). whereas in singapore, the proportion of influenza-associated deaths was 11.3 times higher in persons aged 65 years and above (singapore report, 2014). meanwhile, in the united states, the vpd caused death in approximately 50,000 adults every year: 36,000 from influenza, over 6,000 from invasive pneumococcal disease and 5,000 from hepatitis b (us report, 2009). however, fewer than 500 children die from vpd in the united states each year. various factors have been recognized to influence the perception towards adult immunisation and vaccine preference comprising socio-demographic, socio-economic, health-related factors, social impacts, disease/vaccine-related factors, common attitudes towards health and vaccines, custom, awareness and knowledge, real-world barriers and promoters, and humanity (wheelock et al.,2013). although strategies have been identified and few programmes have been initiated to encounter the low vaccine coverage in adults (poland et al.,2010), little progress has been achieved. this study aims to determine its reliability and validity based on structural equation modeling (sem) within a cfa which provide reliable instrument and valid measurement for components of health belief. in addition this questionnaire should provide a useful tool to measure the perceptions of adult immunisation among malaysian population with age group 18 and above. methods respondents this is a cross-sectional study, recruiting 305 respondents aged ≥18 years in april 2018. the study involved two health clinics in gombak district, selangor among people who are attending the health clinics regardless of patient or caregiver. all the respondents who fulfilled the criteria of (1) age 18 years and above (2) understand english or malay language, and (3) willing to participate in the survey, were invited to participate in this study. the researcher cross-checks the answer thoroughly, ensuring no missing responses of the items and respondents allowed to verify the difficult or confusing questions. the respondents were told if they felt that they did not have enough information or knowledge about any of the items to select the best answer closest to their perception. this is an important element of the instructions so that the respondents would feel comfortable about answering the questions. instruments the initial 64 items of the adult immunisation perception scale (aips) were generated to fill the gap in perception and its associated factors about adult immunisation among malaysians. the health belief model was used in developing items in the questionnaire where it includes the health belief model domains: susceptibility, severity, barriers, benefits, and cues to action as well as its associated factors including health belief, past medical experience, knowledge, and attitude towards adult immunisations. there are 4 steps to generate the items which are: (1) identify appropriate constructs, (2) form item pool, (3) define a format for measurement, and (4) all item pool should be revised by experts, and later pre-tested. (de vellis, 2003) description for each step is summarized as follow: 1) identifying appropriate constructs the questions were generated after wide exploration from quantitative and qualitative literature on knowledge, attitude, and perception about adult immunisations. several instruments for measuring knowledge, attitude and perception regarding immunizations have been developed in various countries 498 global journal of public health medicine 2021, vol 3, issue 2 gggggglo at different times [rashwan et al.,2011; antoinette et al.,2012; halperin et al.,2015; donadiki et al.,2014 & halperin et al.,2015]. the framework was based on health belief model and any questionnaire related to perceptions with or without the health belief model were used. development of instrument items to measure the constructs in this study is based on the lazarsfeld scheme which involves four stages namely imaginary concept, specification concept, index selection and index construction. 2) generating item pool originally, the item pool consisted of 64 items, in which five items to measure health belief, six items to measure past experience, 15 items measuring knowledge, six items measuring attitude and 32 items to measure perception which include four items to measure susceptibility, six items to measure severity, four items measuring benefits, four items measuring barriers, 11 items measuring cues for action. 3) define format for measurement items were scored on a tenth-point agreement level; using likert scale; 1 = strongly disagree to 10 = strongly agree. according to zainudin et al.,2015, to determine how much agree or disagree of the respondent towards particular questions, the long scale such as 10 points is way better than the short scale. the respondents have also been told to choose the best answer closest to their perception about the topic even though they do not have enough knowledge or information about it. this instruction was important to make the respondents feel comfortable while answering the questions. 4) experts review three experts were chosen among public health consultant from ministry of health malaysia and local universities to review the scale and content validity. according to rosnah et al.,2013, the experts are better from healthcare professionals since they have enough information and updated with the objective and conceptual basis measure. they were evaluating the clarity of the items, decide whether they are relevant to the domain, and justify whether the items should remain in the pool or not. the assessment of the questionnaire was continued pretested by selected 20 healthcare workers at a health clinic. they were asked to constructively comment on each item by evaluating its objective, suggest items for deletion, alteration, or recommend new items. all their perceptive thinking and probing results were recorded. finally, the item pool was translated from english to malay using the simplified back-translation method (brislin, 1976). analysis of data the efa used to assess items for its psychometrically, replicating naing’s suggestion (naing, 2010). the efa was commenced using principal component analysis (pca) and promax rotation with eigenvalues more than 1; factor loading <0.40 was removed. it was then followed by an examination of rating scale quality and later by cfa. analysis was performed using ibm spss statistics version 22. the value of the score scale groups was observed to create; (i) the group regularities exhibited a steady distribution (i.e., uniform, normal, bimodal, or slightly skewed), (ii) at least ≥10 responses per group item, (iii) the adjacent threshold distance between 1.4 and 5.0 logits, (iv) the regular measures increased monotonically through the score scale, (v) a different probability curve graph in each response group, and (vi) the outfit was <2 to measure the suitability of the ten-point likert scale response group. the analysis replicated rasch model analysis using winstep (bond & fox, 2015). maximum likelihood estimate used in assessing model fitness to the covariance matrix of the confirm data set, namely comparative fit index (cfi) > 0.9, goodness of fit index (gfi)> 0.9, normed fit index (nfi)> 0.9, root mean square error of approximation (rmsea) range 0.05 to 0.1, and chi-square difference (chisq/df) <5.0 (zainudin, 2012). the items that persistently stable after efa and cfa analysis were reserved (hair et al.,2010). 499 global journal of public health medicine 2021, vol 3, issue 2 gggggglo results respondents total of 305 respondents involved in validity and reliability study. since this study was conducted using one-to-one interview, the response rate was 100%. respondents age was between 18 to 71 years old, with mean (±s.d.) of 30.67 (+10.73) years. female respondents were 190 (62.3%) compared to 115 (37.7%) males. the majority of the respondents were malay, 257 (87.0%). in terms of work, 186 (61.1%) of them were working while 109(35.7 %) were unemployed and the rest were retired. 248 (81.3%) stayed in city area (table 1). table 1: details of socio-demographic characteristics of respondent participated in the validation study of adult immunisation perception-questionnaires (aip-q) characteristics frequency (n) percentage (%) age (years) mean (+sd): 30.67 (+10.73) gender male female 115 190 37.7 62.3 race malay chinese indian bumiputera sarawak bumiputera sabah 257 26 17 1 4 84.3 8.5 5.6 0.3 1.3 marital status single married divorced 118 186 1 38.7 61.0 0.3 education level illiterate primary secondary tertiary 1 4 62 238 0.3 1.3 20.3 78.0 working status yes no pensioner 186 109 10 61.0 35.7 3.3 working sector government private self-employment unemployed student 55 104 39 55 52 18.0 34.1 12.8 18.0 17.0 monthly income <rm999 rm1000 – rm2999 rm3000 – rm6900 >rm7000 107 112 70 16 35.1 36.7 23.0 5.2 place of living urban rural 248 57 81.3 18.7 medical illness yes no 47 258 15.4 84.6 500 global journal of public health medicine 2021, vol 3, issue 2 gggggglo exploratory factor analysis a preliminary pca was carried out to explore the data set. the result was divided into 2 subgroups: 1) adult immunisation perception scale and 2) adult immunisation domain scale. the kaiser-meyer-olkin (kmo) of domain scale and perception scale was 0.859 and 0.887 respectively with bartlett’s test of sphericity was significant at p <0.001. it showed that this data is suitable and useful to proceed with factor analysis. initially,8 components with eigenvalues above 1.0 were generated in domain scale whereas 7 components generated in perception scale. a total of 15 constructs were not exhibited an unacceptable reliability alpha of 0.7, as well as the items representing five other constructs also failed to be theoretically meaningful. the deleted item in domain scale and perception scale are shown in tables 2 and 3. table 2: the initial factors extraction by the efa using pca extraction method with promax rotation and reliability analysis of each construct. item mean (±sd) perceived suscep tibiity perceived severity perceived benefits perceived barriers cues 1 cues 2 itc iic cronbach alpha f1i 6.01 (2.363) 0.967 0.796 0.580.85 0.865 f1ii 5.97 (2.255) 0.942 0.824 0.620.85 f1iii 6.18 (2.228) 0.683 0.623 0.580.62 f1iv 6.12 (2.303) item deleted f2i 5.55 (2.393) 0.777 0.769 0.590.89 0.934 f2ii 5.68 (2.290) 0.804 0.836 0.620.89 f2iii 5.49 (2.416) 0.921 0.816 0.630.80 f2iv 5.64 (2.402) 0.938 0.841 0.650.80 f2v 5.92 (2.411) 0.904 0.833 0.640.80 f2vi 5.53 (2.576) 0.823 0.727 0.590.69 f3i 7.24 (2.300) 0.891 0.686 0.570.67 0.905 f3ii 7.41 (1.972) 0.824 0.833 0.660.78 f3iii 7.60 (1.873) 0.850 0.837 0.670.79 f3iv 7.40 (1.936) 0.805 0.777 0.570.77 f4i 7.83 (2.205) 0.812 0.657 0.440.64 0.829 f4ii 7.41 (2.420) 0.798 0.636 0.480.64 f4iii 5.89 (2.658) item deleted f4iv 5.30 (2.642) item deleted f4v 7.50 (2.397) 0.789 0.632 0.440.67 501 global journal of public health medicine 2021, vol 3, issue 2 gggggglo f4vi 7.90 (2.232) 0.839 0.693 0.480.67 f5i 7.89 (2.320) item deleted 0.885 f5ii 6.88 (2.054) 0.554 0.540 0.390.50 f5iii 6.71 (1.887) 0.837 0.715 0.460.74 f5iv 6.37 (1.880) 0.758 0.636 0.430.74 f5v 7.52 (1.947) 0.730 0.746 0.430.79 f5vi 7.24 (2.143) 0.886 0.817 0.450.86 f5vii 7.26 (2.133) 0.869 0.742 0.390.86 f6i 7.09 (2.451) 0.690 0.531 0.390.48 0.824 f6ii 7.31 (2.171) 0.758 0.621 0.390.55 f6iii 6.56 (2.286) 0.836 0.627 0.430.52 f6iv 7.44 (2.075) 0.742 0.639 0.410.58 f6v 7.70 (2.008) 0.658 0.659 0.460.58 table 3: the initial factors extraction by the efa using pca extraction method with promax rotation and reliability analysis of each construct. item mean (sd) health believe past experience attitute general knowledge itc iic cronbach alpha b2i 4.51 (1.892) 0.633 0.297 0.16-0.29 0.571 b2ii 6.66 (2.566) 0.711 0.502 0.22-0.48 b2iii 5.02 (2.420) 0.629 0.238 0.16-0.22 b2iv 5.21 (2.317) item deleted b2v 6.46 (2.772) 0.645 0.412 0.16-0.48 c1i 8.57 (1.787) 0.859 0.738 0.49-0.78 0.874 c1ii 8.44 (1.951) 0.888 0.765 0.58-0.78 c1iii 7.40 (2.127) item deleted c2i 8.70 (1.750) 0.863 0.754 0.61-0.68 c2ii 8.38 (2.027) 0.783 0.655 0.49-0.68 c2iii 7.48 (2.084) item deleted e1 6.32 (2.832) item deleted 0.706 e2 6.94 (2.066) 0.734 0.557 0.32-0.58 502 global journal of public health medicine 2021, vol 3, issue 2 gggggglo e3 7.42 (1.906) 0.557 0.593 0.32-0.58 e4 6.46 (2.534) 0.865 0.389 0.24-0.37 e5 7.28 (2.212) item deleted e6 7.38 (2.125) 0.500 0.407 0.24-0.43 d1 7.85 (1.800) 0.901 0.779 0.45-0.78 0.941 d2 7.84 (1.808) 0.885 0.768 0.40-0.74 d3 7.96 (1.727) 0.844 0.765 0.48-0.75 d4 7.86 (1.882) 0.892 0.802 0.51-0.75 d5 8.14 (1.806) 0.755 0.774 0.48-0.71 d6 7.28 (2.194) item deleted d7 6.81 (2.187) item deleted d8 6.04 (2.901) item deleted d9 8.22 (1.796) 0.622 0.717 0.47-0.65 d10 3.82 (2.536) item deleted d11 8.07 (1.889) 0.712 0.671 0.40-0.66 d12 7.85 (1.862) 0.852 0.786 0.51-0.88 d13 7.87 (1.780) 0.884 0.829 0.49-0.88 d14 7.61 (1.866) 0.684 0.697 0.44-0.70 d15 7.94 (1.772) 0.650 0.598 0.44-0.55 note: • initial total items were 64, 13 items were deleted during efa. only 51 items left for cfa. • the item with bold text was removed from being included in the cfa to further ensure that the efa process to be accurate, the scale of reliability analysis of those 10 constructs were performed to the remaining 51 items which had factor loading >0.4. the reliability test showed that the itc and iic values of each item towards their respective constructs were acceptable except for items b2i and b2iii. however, this item remained since it has good factor loading (>0.6) with an acceptable cronbach alpha value of 0.57. scale reliability was 0.89 with good subscale reliability ranging from 0.57 to 0.94 (table 2 and 3). confirmatory factor analysis the cfa was performed to test the exploratory factor structure using amos software. cfa was conducted on the 51 items identified in the exploratory data set and was found to provide an acceptable, but relatively poor fit based on the goodness of fit statistics: χ2/df=2.674 (n=305) = p<0.001, cfi=0.810, ifi=0.811, tli=0.800 and rmsea=0.074 (figure 1). 503 global journal of public health medicine 2021, vol 3, issue 2 gggggglo figure 1: the path analysis of the cfa showing standardized estimates of the correlations between the five second order constructs (ellipse), six first order constructs (ellipse) and the fifty-one items (rectangle), and their respective residuals (circle). the numbers on the double headed arrows indicate the calculated correlation values by the path analysis. note: certain fitness indexes do not achieve the required level. upon examination, items b2i, b2iii, e4, f5ii, f5iv had low factor loading and item deleted. according to zainudin, 2012, a discriminant validity which other criteria for measurement model, the items must be free from redundancy. any identified items with a high value of modification index (mi) were either deleted or constrained as “free parameter estimate”. the measurement model was run again after mi assessment was carried out since fitness index still not acceptable even after removing items with low factor loading. finally, the result showed a significant improvement, and fit the 45-item model over the 51-item model, better chi-squared value, and goodness of fit statistics. the shown model was estimated against the recent data sets and produced χ2/df=1.943 (n=305) =p<0.001, cfi=0.908, ifi=0.909, tli=0.901 and rmsea=0.056 (figure 2). strong factor loadings were found across the 45 items, ranging from 0.53 to 0.94 (table 4). 504 global journal of public health medicine 2021, vol 3, issue 2 gggggglo figure 2: the final measurement model of adult immunisation perception questionnaires (aipq) another crucial requirement of discriminant validity is the value of correlation between exogenous constructs must not >0.85 (zainudin, 2012). four out of five factors were managed to get out correlation values below 0.85 but only one factor just having slightly above the limit value which is between knowledge and perception (0.86). overall, the exogenous constructs were not redundant or had a multicollinearity issue. figure 2 explains the five domains; assumed to cause variation and covariation in the measurement of perception. there is a double-headed arrow between the five domains, indicates that the five domains are correlated. 505 global journal of public health medicine 2021, vol 3, issue 2 gggggglo table 4: the cfa report for every construct in the measurement model with factor loadings of each item towards respective domainaverage variance extracted and composite reliability. construct item factor loading cronbach alpha composite reliability (cr) average variance extracted (ave) health belief b2i b2ii b2iii b2v item deleted 0.75 item deleted 0.64 0.645 0.65 0.49 past experience c1i c1ii c2i c2ii 0.91 0.85 0.72 0.70 0.871 0.88 0.64 attitude e2 e3 e4 e6 0.65 0.86 item deleted 0.53 0.699 0.73 0.48 knowledge d1 d2 d3 d4 d5 d9 d11 d13 d14 d15 0.81 0.82 0.80 0.83 0.81 0.76 0.67 0.80 0.70 0.63 0.933 0.93 0.59 perception p. susceptibility p. severity p. benefit p. barrier cues to action 1 cues to action 2 0.46 0.31 0.88 0.26 0.71 0.60 0.67 0.33 perceived susceptibility f1i f1ii f1iii 0.89 0.94 0.66 0.865 0.88 0.70 perceived severity f2i f2ii f2iii f2iv f2v f2vi item deleted 0.80 0.88 0.90 0.89 0.76 0.925 0.93 0.72 perceived benefit f3i f3ii f3iii f3iv 0.72 0.90 0.89 0.86 0.900 0.91 0.72 perceived barrier f4i f4ii f4v f4vi 0.62 0.57 0.77 0.88 0.827 0.81 0.52 cues to action 1 f5ii f5iii f5iv f5v f5vi f5vii item deleted 0.71 item deleted 0.89 0.87 0.73 0.894 0.88 0.65 cues to action 2 f6i f6ii f6iii f6iv f6v 0.58 0.69 0.67 0.74 0.78 0.819 0.82 0.48 506 global journal of public health medicine 2021, vol 3, issue 2 gggggglo cronbach’s alpha for the aip-q was beyond 0.6 in all domains, representing adequate level of internal consistency. table 4 showed that internal consistency for all factors is supported by composite reliability (cr) and the average variance extracted (ave). in order to achieve the cr, the value should be >0.6. as for ave, it indicates the average percentage of variation explained by the measuring item for a latent construct. the value of ave must be >0.5 for every individual construct. discussion immunisation can prevent infectious diseases, decrease morbidity as well as mortality of some diseases. at present, there are 26 infectious diseases that can be protected by vaccines (andre, 2003). nevertheless, adult immunisations often remain under-utilized when most of them consider those vaccines are recommended but not required (us report, 2000). several factors influenced the immunisation perception in adult population. by recognizing the factors and groups that give unsatisfactory feedback in adult immunisation, appropriate communications and delivery of messaging can be tailor specifically to those groups. numerous tools for assessing knowledge, attitude and perception about immunisations have been established in many countries at different times (rashwan et al.,2011; antoinette et al.,2012). by using these tools and/or comparing them with few research, it can provide interesting results but it must be done with careful supervision. it is due to many factors that can influence knowledge, attitudes, and their perception regarding adult immunisation where it should be taken into consideration, such as their different socioeconomic background, cultural and religious beliefs of different populations, epidemiological differences, and policy support (ammar et al.,2014). the developed questionnaire (in the english language) was translated into bahasa melayu, the common spoken language of malaysians. the skilful bilingual translator then certified that the translation was precise and correct by review on both versions (english and malay). the development and validation of the original items made the questionnaire relatively simple and practical to use among the malaysian population. ten points likert scale were used in this questionnaire compared to normal 5 or 7 points. according to zainudin et al., 2015, to determine how much agree or disagree of the respondent towards particular questions, the long scale such as 10 points is way better than the short scale. the scale of measurement is supposedly reflecting the actual intention of the respondent towards the question submitted. since this study is using sem for validation, both measurement and structural models can be assessed successfully with 10 points of likert scale in determining the construct validity. the statistical indices from sem were used for a final version questionnaire which consists of 45 items in order to get a suitable degree of reliability and validity (hafizah et al.,2002). the malay version of aip-q from this study also indicate that it has acceptable psychometric properties to measure the knowledge, attitude, and perception among adult population in malaysia regarding immunisation. the overall observations were adequate; ensuring stability during the efa, where its able to produce usable results from 64 items to 51 items. according to william et al.,2012, it is considered necessary for the item to have a rotated factor loading of at least 0.4 (meaning >+0.4 or <−0.4) to make it significant. therefore, if the item was shown not to have validity even after some additional criteria had been measured, the items were eliminated if the factor loading constantly less than 0.4 (costello, 2009). since there was no previous model to test against this model, absolute fit indices were used in this study (schermelleh et al.,2003). the cfa is a method to identify certain variables that belongs to certain factors and it is likely to identify further which factor items are loaded to. meanwhile, factor analysis allows the factor scores to be explained by common factors which only contain variance (williams, 2012). thus, the effect of measurement error can be removed by calculating the factor scores and putting them into path analysis, fortunately, this is the principle of sem which offers several advantages in performing cfa (schermelleh et al.,2003). the reliability testing was higher than acceptable values indicate that an acceptable internal consistency was observed in the full model of aip-q. the reliability assessment of every construct based on cronbach's alpha, ave and cr shows acceptable internal consistency tested among adult population. 507 global journal of public health medicine 2021, vol 3, issue 2 gggggglo the reasons of good internal consistency in most of the factors could be due to respondent had a good understanding of the item (hair et al.,2010; tabachnik & fidell, 2001), hence less random error. several strengths were recognized throughout this validation. preliminary evidence shows its initial reliability and validity towards developing a new questionnaire among malaysian concerning perceptions towards adult immunisations. even though there are few existing questionnaires already developed based on the five-health belief domains, but this questionnaire is a new tool covering the whole spectrum of adult immunisation and design specifically for a malaysian population. it is essential to find out their perceptions in general rather than specific vaccination since most of malaysians had minimal exposure to adult immunisation. therefore, this new questionnaire fills a gap of knowing their knowledge, attitude, and perceptions towards adult immunisation. there are few limitations in this validation study which is lack of test-retest reliability assessment of the instrument and it remains to be further tested in future studies. besides, no concurrent validity evaluation to show its correlation to other measures, such as the health behaviour measure. they might be a connection of recorded vaccine uptake with the immunisation perception which need to be prioritized in future studies. meanwhile, perceptions may change over the time and represent a snapshot of the study period. hence, search for respondents who are very similar can be done, but for one specific domain or variable could be difficult to find. conclusion the self-administered adult immunisation perception-questionnaire (aip-q) is a valid and reliable instrument for providing psychometric properties. it is a valid measurement for components of health belief, experience, knowledge, attitude, perceived severity, perceived susceptibility, perceived benefits, perceived barriers, and cues for action. this questionnaire should provide a useful tool to measure the perceptions of adult immunisation among malaysian population with age group 18 and above. acknowledgement the research was funded by the dana fundamental ppukm (ff-2017-342) and ethically approved by the national medical research centre of malaysia (nmrr-18-1617-40854 (iir)). a special thanks to those direct and indirectly involved in the research. list of abbreviation adult immunisation perceptions-questionnaire (aip-q) exploratory factor analysis (efa) confirmatory factor analysis (cfa) principal component analysis (pca) goodness of fit indexes (gfi) modification indices (mi) comparative fit indexes (cfi) inter total correlation (itc) composite reliability (cr) inter item correlation (iic) root mean square error of approximation (rmsea) average variance extracted (ave) vaccine-preventable diseases (vpd) structural equation modelling (sem) conflicts of interest the author declares no conflicts of interest. 508 global journal of public health medicine 2021, vol 3, issue 2 gggggglo references • adult immunisation guideline (malaysia) 2nd edition 2014 • alexa m. sevin, cristina romeo, brittany gagne, nicole v. brown, & jennifer l. rodis. 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(2012). a handbook on structural equation modeling (sem) using amos. bangi: mpws publication sdn bhd. microsoft word gjphm-2021-validity.edited (reviewed).docx 301 global journal of public health medicine 2021, vol 3, issue 1 gggggglo original article validity and reliability of biopsychosocial-related measurement scales among low-income malaysian smoker fadzrul hafiz johani, shamsul azhar shah*, nazarudin safian department of community health, faculty of medicine, university kebangsaan malaysia, kuala lumpur, malaysia. *corresponding author: drsham@ppukm.ukm.edu.my abstract introduction: tobacco is the only legal product that kills a large proportion of its consumers when used as intended by its manufacturer. the effect of nicotine as a driving substance on smoking has been established for decades. still, very little is known on how the biopsychosocial determinants relationship affects levels of nicotine addiction in smokers, especially in the urban low-income population. the study aimed to validate measurement scales related to biopsychosocial factors that will be used in the future study to evaluate biopsychosocial components that influence nicotine addiction among urban poor smokers. methods: exploratory factor analysis (efa) using the principal component analysis with varimax rotation and kaiser normalization was used to assess the factor structure. then, the confirmatory factor analysis (cfa) was conducted to assess the unidimensionality, validity, and reliability of the latent construct. results: efa showed extraction of factors according to their original scales with all factor loading and communality's values were above 0.5. during cfa, factor loading less than 0.6 was deleted. convergent validity verified by computing the average variance extracted (ave) for every construct range between 0.528 – 0.801. the fitness indexes achieved the required level (rmsea=0.05, cfi=0.937, chisq/df=1.7). meanwhile, the discriminant validity index range between 0.75-0.89, which is higher than the correlation coefficient value. internal consistency assessed from composite reliability range between 0.714-0.965. conclusion: the measurement scales are valid and reliable to assess the intended constructs among low-income male smokers in the urban area. keywords: biopsychosocial, factor analysis, reliability, smoking, validity. 302 global journal of public health medicine 2021, vol 3, issue 1 gggggglo introduction tobacco is the only legal product that kills a large proportion of its consumers when used as intended by its manufacturer (who, 2013). the world health organization (who) has estimated that around 6 million people die from tobacco use each year. the number of tobacco-related direct and indirect death is projected to increase to 8 million by 2030 if no strong tobacco control measures are put in place (who, 2015). the most commonly used form of tobacco is cigarette smoking (eriksen, mackay, schluger, islami, & drope, 2015; who, 2020). currently, around 80% of smokers worldwide live in low and middle-income countries, and in most countries, tobacco use is more concentrated in the lowincome population (us national cancer institute & who, 2016). in malaysia, 40.5% of men age 15 years and above were smokers compared to only 1.2% smokers among women (institute for public health, 2020) which warrants specific and targeted intervention among male smokers. more than half of the low-income group in malaysia which is also known as category b40 reside in the urban area, living in high-density housing and facing multiple issues including non-conducive living conditions and rising cost of living (economic planning unit, 2017). they are said to be vulnerable to economic shock as the majority of them depended on a single source of income and encounter various health challenges related to non-communicable diseases which smoking becomes one of the important risk factors. the urbanization factor, migration of low-income groups from rural to urban areas, the influx of foreign workers, and the rising costs of living have contributed to the increase of urban poor in malaysia (zainal, kaur, ahmad, & khalili, 2012). the effect of nicotine as a driving substance on smoking has been established for decades (american psychiatric association, 1996; royal college of physicians, 2000; who, 2001). nicotine which is as addictive as heroin and cocaine acts as a central nervous system stimulant to give a perceived calming effect that may be what nicotine users find reinforcing (handa, kour, & khurana, 2017; maisto, galizio, & connors, 2014). behavioral components influenced by psychological and socio-environment factors also contribute to the progression and maintenance of an addiction. the available evidence suggests that interaction between biological, psychological, and social factors is the core principle of the biopsychosocial model of addiction (pfeffer, wigginton, gartner, & morphett, 2017). therefore, this study aims to validate measurement scales related to biopsychosocial factors that will be used in future research to evaluate biopsychosocial components that influence nicotine addiction among urban poor male smokers. methods study design and participant this study was a cross-sectional study design. a purposive sample of hard-to-reach cigarette smokers from the low-income neighborhood was recruited through street outreach and word of mouth from an impoverished neighborhood in one of the randomly selected public housing areas in kuala lumpur. the participant must be 1) male, 2) age 18 years old and above, 3) current smoker, 4) b40 group category 303 global journal of public health medicine 2021, vol 3, issue 1 gggggglo as defined for low-income population in malaysia, and 5) could communicate, read and write in the malay language independently. the sample size for factor analysis was calculated based on gorsuch (1988) who suggested a minimum of 50 observations or the total number of items in the measurement scale is multiplied by five, and the resulting number gives the required sample for the study (gorsuch, 1988). for reliability testing, cronbach’s alpha formula was used to calculate the sample size (bonett, 2002). the higher value of the two calculations was taken as the final sample size. the current study required a minimum of 60 sample sizes for factor analysis while for reliability testing, the calculated sample size was 52. therefore, we recruited 60 participants in the study. measurement scales there are five sets of measurement scales that underwent validation. first, neighbourhood-level cohesion and disorder scale (ncds) was developed by cagney et al. (cagney et al., 2009) to assess the neighborhood condition. the ncds is an 8-item scale measuring two dimensions of neighborhood context i) social trust and ii) sign of physical neglect in the neighborhood environment. the items were measures on a 7-point likert-type scale from 1 'very strongly disagree' to 7 'very strongly agree'. the higher the score indicates higher social cohesion and physical environment care. second, workplace stress was measured using the workplace stress survey (wss) (the american institute of stress, 2018) developed by the american institute of stress as a simple screening measure to identify stressful experiences at the workplace. the wss has 10-item using a 10-point likert-type scale from 1 'strongly disagree' to 10 'strongly agree'. third, financial wellness was measured using financial well-being scale (fws) developed by prawitz et al. (prawitz et al., 2006). fws is a brief scale that consists of only eight items measured on a 10-point likert-type scale arrange as a continuum extending from negative to a positive feeling. fourth, the perceived stress of the respondents was measured using perceived stress scale 10 (pss-10), which was adopted from sheldon cohen (cohen, 1988). the pss-10 assesses perceived stressful experiences or stress response over the previous month using a 5-point likert-type scale from 0 'never' to 4 'very often'. individual's scores on the pss-10 can range from 0 to 40 with higher scores indicating higher perceived stress. lastly, the work and family balance was measured using the work-family conflict questionnaire (wfcq) measurement scale developed by kelloway et al. (kelloway, gottlieb, & barham, 1999). the original measurement scale consisted of 22items with a likert-type answer range from 1 ‘strongly disagree to 5 ‘strongly agree’. the measurement scale covers four dimensions: time-based work-interfere-family, strain-based work-interfere-family, time-based family-interfere-work, and strain-based family-interfere-work. to shorten the measurement scale, we adapted two of four dimensions from the measurement scale i.e. strain-based work-interfere-family and strain-based family-interfere-work, which consisted of 12-items. 304 global journal of public health medicine 2021, vol 3, issue 1 gggggglo translation process neighborhood-level cohesion and disorder scale (ncds) and workplace stress survey (wss) were the only measurement scales that went through the translation process. the english version of the ncds and wss was translated into malay by a postgraduate student who possesses a strong command of english and the malay language. then the malay version was back-translated into the english language by another postgraduate student who does not know the original scale to ensure face validity of the scale. the english back-translated version was compared to the original english version to identify problematic words or phrases. the malay translated version was read through and checked thoroughly to ensure proper use of words and grammar. these processes were repeated until a final version of the malay translated version of the neighbourhood-level cohesion and disorder scale (ncds-m), and the malay translated version of workplace stress survey (wss-m) were derived. the malay language version of the financial well-being scale (kamaluddin et al., 2018), perceived stress scale 10 (al-dubai, alshagga, rampal, & sulaiman, 2012) and work-family conflict questionnaire (sanaz, syaqirah, & khadijah, 2014) were adopted from the existing malay translated measurement scales data collection the data was collected at a public housing area situated in kuala lumpur, malaysia. the selected participants were informed of the objectives of the current study and relevant information. written consent was obtained from the participants prior to questionnaire distribution once they agreed to participate. each participant was given a set of malay-translated versions of each measurement scale with the sociodemographic section. the average time taken to complete all measurement scales was 10 minutes. analysis the data were analyzed using ibm spss statistic version 22 with amos graphic for descriptive statistics, factor, and reliability analyses. the socio-demographic variable of the participants was summarized using descriptive statistics while the preliminary analysis such as kaiser-meyer-olkin (kmo) measure of sampling adequacy (≥0.5), and bartlett's test of sphericity (p<0.05) was observed for sample adequacy and appropriateness for factor analysis (williams, onsman, & brown, 2010). subsequently, exploratory factor analysis (efa) was conducted. principal component analysis (pca) using the rotational method of varimax rotation with kaiser normalization was used to assess the factor structure. the item with factor loading values >0.50 was considered as indicators of significant factorial contribution (comrey & lee, 2013; hair, black, babin, anderson, & tatham, 1998). then, the confirmatory factor analysis (cfa) was conducted to assess the unidimensionality, validity, and reliability of the latent construct. the cfa processes were done by combining all constructs known as pooled-cfa, and the cfa procedure was executed at once. the cfa for pooled measurement tools is more efficient and highly suggested (awang, 2015). the cfa test whether the measures of a construct are consistent with the researcher’s understanding of the nature of that construct. the cfa 305 global journal of public health medicine 2021, vol 3, issue 1 gggggglo assess the uni-dimensionality, three types of validity (namely convergent, discriminant and construct validity), and reliability of the latent construct (afthanorhan, awang, salleh, ghazali, & rashid, 2018; asnawi, awang, afthanorhan, mohamad, & karim, 2019; awang, 2015; awang, hui, & zainudin, 2018). uni-dimensionality is achieved when all measuring items have acceptable factor loading of 0.6 or higher for the respective latent construct. any item with a low factor loading was deleted. the deletion process was made one item at a time with the lowest factor loading item were deleted first. the three types of validity assessed during cfa are i) convergent validity, ii) discriminant validity, and iii) construct validity (a. mahfouz, awang, muda, & suriawaty bahkia, 2020; aziz, afthanorhan, & awang, 2016; raza & awang, 2020; yusof, awang, jusoff, & ibrahim, 2017). convergent validity is verified by computing average variance extracted (ave) for every construct. the value of ave of 0.5 or higher indicates that this validity is achieved (awang, 2015; awang et al., 2018). ensuring discriminant validity indicates that the measurement model of a construct is free from redundant items and multicollinearity problems. a redundant construct occurs when any pair of constructs in the model are highly correlated. the items redundancy in the model were identified through a discrepancy measure called modification indices (mi) (>15) and correlation value between exogenous constructs exceeding 0.85 (awang, 2015; awang et al., 2018). the discriminant validity index was also developed to determine the discriminant validity. construct validity in cfa is achieved when the fitness indexes for a measurement model reached the required level in all three model fit categories namely absolute fit (root mean square of error approximation (rmsea) <0.08) (browne & cudeck, 1993), incremental fit (comparative fit index (cfi) > 0.9) (bentler, 1990), and parsimonious fit (chisq/df <3.0) (marsh & hocevar, 1985). apart from the validity assessment, the reliability of the constructs was also measured during cfa. the evaluation for reliability for the measurement model was made using composite reliability (cr) calculated using the formula cr = (∑κ )2 / [( ∑κ )2 + ( ∑1-k2 )] where k is factor loading of every item (awang, 2015). a value of cr ≥ 0.6 is required in order to achieve composite reliability for the construct. ethics approval the study had successfully obtained ethical approval from the research ethics committee of university kebangsaan malaysia (reference number: ukm ppi/111/8/jep-2018-671) and registered under the national medical research register (reference number: nmrr-18-2318-44070). results sociodemographic characteristic the normality assessment is made by assessing the measure of skewness for every item. the absolute value of skewness was within the range between -1.0 to 1.0 which indicates normally distributed data (awang, 2015; awang et al., 2018). table 1 illustrates the sociodemographic characteristic of the 60 male smokers who participated in the validation study. the mean age of the respondents was 33.80 306 global journal of public health medicine 2021, vol 3, issue 1 gggggglo years old (sd = 10.10). the majority of the respondents were malay (83.3%), married (55.0%), attained high school education (46.7%), work as a private employee (75.0%), and had mean household monthly income rm 2402.32 (sd = 877.37). the mean year of living in the neighborhood was 10.42 years (sd = 6.97). table 1 socio-demographic characteristic of the participants variable n (%) mean (sd) age (years) 33.8 (10.10) ethnicity malay 50 (83.3) chinese 4 (6.7) indian 6 (10.0) marital status married 33 (55.0) single 22 (36.7) divorced 5 (8.3) education level bachelor’s degree/ degree/ phd 3 (5.0) stpm/ certificate/ diploma 28 (46.7) pmr/ spm 24 (40.0) upsr 5 (8.4) working sector government employee 15 (25.0) private employee 45 (75.0) household income (rm) 2402.32 (877.37) duration living in the neighborhood (years) 10.42 (6.97) exploratory factor analysis (efa) based on table.2, the kaiser-meyer-olkin value of the study range between 0.761 to 0.918 (>0.5), which indicates the adequacy of the sample, while all bartlett’s test of sphericity was significant (p<0.001), suggesting that the items were appropriate for factor analysis. the exploratory factor analysis using the principal component analysis with varimax rotation of the item on each scales result in extraction of one factor (76.4% variance) for financial well-being scale, two factors (69.7% variance) for perceived stress scale-10, two factors (70.7% variance) for neighbourhood-level cohesion and disorder scale, one factor (75.6% variance) for workplace stress survey, and two factors (68.0% variance) for work-family conflict. all the factor loading values were above 0.5. table 3 shows communalities values in each measurement scale. all the communality’s values were above 0.5. table 2. factor loading of each measurement scale used in the study. scale fws pss10 ncds wss wfc item fac 1 fac 1 fac 2 fac 1 fac 2 fac 1 fac 1 fac 2 h3 0.939 h7 0.901 h2 0.894 h8 0.888 307 global journal of public health medicine 2021, vol 3, issue 1 gggggglo h1 0.886 h4 0.878 h6 0.842 h5 0.755 j3 0.869 j1 0.793 j2 0.740 j9 0.654 j6 0.653 j10 0.597 j4r 0.826 j5r 0.822 j7r 0.755 j8r 0.738 k7 0.851 k3 0.839 k1 0.813 k5 0.799 k4 0.922 k6 0.812 k8 0.775 k2 0.736 m1 0.908 m4 0.899 m3 0.896 m6 0.894 m2 0.893 m5 0.877 m9 0.863 m10 0.845 m8 0.821 m7 0.789 n11 0.869 n12 0.863 n8 0.855 n9 0.840 n10 0.780 n7 0.603 n1 0.820 n3 0.796 n4 0.777 n2 0.711 n6 0.623 n5 0.540 variance (%) 76.4 58.8 10.9 49.8 20.9 75.6 54.8 13.2 kmo-msa 0.918 0.888 0.778 0.761 0.833 bartlett’s test x2(df) χ2(28) =480.5 χ2(45) =371.2 χ2(28) = 249.4 χ2(45) =783.8 χ2(66) =516.8 p-value <0.001 <0.001 <0.001 <0.001 <0.001 note: : fac: factor, fws: financial well-being scale, pss-10: perceived stress scale 10, ncds: neighbourhood-level cohesion and disorder scale, wss: workplace stress survey, wfc: workfamily conflict, kmo-msa: kaiser-meyer-olkin measure of sampling adequacy 308 global journal of public health medicine 2021, vol 3, issue 1 gggggglo table 3 communalities value for each item in measurement scale item 1 2 3 4 5 6 7 8 9 10 11 12 fws .651 .735 .793 .682 .540 .629 .663 .760 ncds .595 .640 .667 .646 .702 .705 .687 .593 pss .566 .653 .712 .748 .770 .610 .763 .708 .634 .662 wss .728 .796 .729 .819 .783 .864 .768 .810 .742 .794 wfc .740 .703 .661 .629 .670 .590 .648 .740 .775 .699 .766 .778 note: fws: financial well-being scale, pss-10: perceived stress scale 10, ncds: neighbourhoodlevel cohesion and disorder scale, wss: workplace stress survey, wfc: work-family conflict confirmatory factor analysis (cfa) a. uni-dimensionality pooled-cfa analysis (figure 1) showed that item m1, and m3 for workplace stress construct and item j4, j5, j7, and j8 for perceived stress constructs were deleted for having factor loading less than 0.6. otherwise, other items show satisfactory factor loading. b. convergent validity the average variance extracted (ave) for all the constructs was computed and presented in table 4. the results showed that all constructs had an ave value of at least 0.5. thus, the convergent validity for the measurement model is achieved. c. discriminant validity the redundant pairs (e6 & e7, e9 & e10, e40 & e26, e45 & e46, e15 & e16) were constraint as ‘free parameter estimate’ to overcome the high modification indices (mi) while correlation values between exogenous constructs does not exceeding 0.85 as shown in figure 1. besides, the discriminant validity for all construct is achieved when the discriminant validity index (value in its diagonal) is higher than the correlation coefficient value (value in its row and column) between the pair of the respective construct as shown in table 5. d. construct validity the fitness indexes for the measurement model achieved the required level in all three model fit categories. the absolute fit category namely root mean square error of approximation (rmsea) is 0.05 (achieved the threshold of less than 0.08), the incremental fit category namely comparative fit index (cfi) is 0.937 (achieved the threshold of greater than 0.90), and the parsimonious fit category, namely the ratio of chisq/df is 1.70 (achieved the threshold of less than 3.0) are as shown in figure 1. 309 global journal of public health medicine 2021, vol 3, issue 1 gggggglo table 4. internal consistency for each construct construct composite reliability (cr) average variance extracted (ave) work-family conflict 0.890 0.801 work-family strain 0.897 0.592 family-work strain 0.929 0.684 neighbor 0.714 0.556 social cohesion 0.829 0.549 physical disorder 0.817 0.528 workplace stress 0.965 0.773 perceived stress 0.882 0.556 financial stress 0.931 0.630 table 5 the discriminant validity index for the latent construct construct work-family conflict neighbour workplace stress perceived stress financial wellness work-family conflict 0.89 neighbor -0.33 0.76 workplace stress 0.54 -0.18 0.88 perceived stress 0.65 -0.61 0.26 0.75 financial stress -0.45 0.37 -0.19 -0.61 0.79 note: the discriminant validity index value in bold internal consistency based on table 4, all the constructs had achieved the minimum requirement (cr ≥ 0.6) for their reliability. 310 global journal of public health medicine 2021, vol 3, issue 1 gggggglo figure 1: pooled confirmatory factor analysis discussion despite using a purposive sampling technique to get hard-to-reach male cigarette smokers respondents from a low-income population, it is still able to provide reliable and robust data even tested against random probability sampling (campbell, 1955; karmel & jain, 1987; tongco, 2007; topp, barker, & degenhardt, 2004). these demographic epidemiological findings are similar to a study by abd rashid et al. who enrolled their participant from a home-to-home survey using a universal sampling method in two public housing areas in kuala lumpur (abd rashid et al., 2019). each of the measurement scales was tested for their validity and reliability in exploratory factor analysis before proceeds with confirmatory factor analysis. prior to conducting the validity test, three components that need to be assessed to determine the appropriateness of the data for factor analysis including sample size, factorability of the correlation matrix, and the kaiser-meyer-olkin (kmo) measure of sampling adequacy or barlett’s test of sphericity (bts). regarding sample size, maccallum et al (1999) suggested that the number of sample sizes should be at least five times the number of variables for factor analysis. since the highest number of items in the measurement scales that we used was 10, thus we enrolled a total of 60 participants involved in this validation study. meanwhile, the kmo value of the study for each measurement scale was more than 0.6 (range between 0.761 to 0.918), and all the bts was significant (p<0.001). according to hair et al (2010), tabachnick & fidell (2007), and pallant (2007), to determine sampling adequacy and factorability of the correlation matrix, they suggested that the kmo value must be greater than 0.6 and 311 global journal of public health medicine 2021, vol 3, issue 1 gggggglo the bts must be significant at p<0.05 (hair, black, & babin, 2010; pallant, 2000; tabachnick & fidell, 2007). in essence; the kmo test and bts determine whether the sampling was adequate to proceed with factor analysis. thus, based on these findings, our sampling was sufficient and appropriate for factor analysis. during exploratory factor analysis using principal component analysis with varimax rotation of the items, each scale results in the extraction of factors similar to the original version of measurement scales. in assessing the factor loading, the recommendation of factor loading cut-off point is different based on sample size and significant level (guadagnoli & velicer, 1988; stevens, 2012). as a general rule, peter samuels (2017) suggested that factor loading less than 0.3 should be suppressed while the retained factors should have at least three items with factor loading greater than 0.4 (samuels, 2017). the current study finding showed that factor loading in each scale was above 0.5, indicating statistically meaningful to retain the factors. communalities is the estimated proportion of an item’s unique variance to its shared variance in the matrix (samuels, 2017). since dimension reduction techniques were to identify items with a shared variance and explain the variance through the common factors, it is suggested that a communality score less than 0.2 (child, 2006) should be eliminated from the analysis. thus, we retained all our items in each measurement scale as the communality’s values were above 0.5. since all factors were valid during efa, we proceed with our analysis with cfa without eliminating any factors and items in efa to evaluate whether the chosen factors and items are significant. we combined all measurement scales to form pooled-cfa so that the cfa procedure was executed at once and more efficiently (awang, 2015). during the uni-dimensional assessment, we deleted some of the items since they had a factor loading less than 0.6 as suggested (awang, 2015). the minimum requirement for the measurement validity, including convergent validity, construct validity, and discriminant validity was achieved. in the assessment of reliability, it is adequate for the study to assess the composite reliability (cr) since it replaced the traditional method of computing the cronbach alpha for analysis using structural equation modeling (sem) (awang, 2015; awang et al., 2018). all the constructs were considered reliable since the cr value ≥ 0.6 (awang, 2015). all composite reliability values for each measurement scale that measure reliability assessment were above 0.7, which indicates good internal consistency. conclusion the finding of this study suggested that the malay translated version of neighbourhood-level cohesion and disorder scale (ncds), workplace stress survey (wss), financial well-being scale (fws), perceived stress scale 10, and work-family conflict questionnaire (wfcq) are valid and reliable measurement scales to be used among malaysian low-income male smokers in the urban area. 312 global journal of public health medicine 2021, vol 3, issue 1 gggggglo acknowledgment the authors would like to express their gratitude and thanks to the department of community health, university kebangsaan malaysia for the support. conflicts of interest: the authors declare no conflicts of interest. references • a. mahfouz, s., awang, z., muda, h., & suriawaty bahkia, a. 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(2012). housing conditions and quality of life of the urban poor in malaysia. procedia-social and behavioral sciences, 50, 827-838. microsoft word gjphm-2021alterations in biochemical markers (3).docx 327 global journal of public health medicine 2021, vol 3, issue 1 gggggglo review research alterations in biochemical markers of covid-19 and using it as diagnostic and prognostic tools athraa sami department of clinical laboratory science, faculty of pharmacy, university of kufa, alnajaf al-ashraf, iraq *corresponding author: athraas.alshebani@uokufa.edu.iq abstract biochemical markers (bm) play an important role in the early identification of covid-19 and monitoring of infected people in order to evaluate the severity of infection and providing the proper care and optimum management to decrease mortality rate and disease progression. prognostic tools are consider the essential approaches for making a decision in patient management and treatment for patients with covid-19 infection. in this review, we determine the most important biomarkers of immunity, coagulation, cardiac and renal dysfunction as a highly valuable laboratory tools for diagnostic, monitoring, predicting the progressive complications of coronavirus infectious disease in order to give the effective treatment and for more efficiently control the pandemic. keywords: biochemical markers, covid-19, disease progression, renal dysfunction. 328 global journal of public health medicine 2021, vol 3, issue 1 gggggglo introduction the rapid spread of the covid-19 pandemic worldwide has prompted the health science community to investigate the appropriate, fast and accurate diagnostic and prognostic tools (bano et al., 2020). these tools will assist risk classification, guide interventional reports to target infected patients at increased risk of development severe infection and identify allocation of limited technical and human resources in the current outbreak (henry et al., 2020). moreover, laboratory biomarker is one of the most critical factor in prediction of progression and detection of complications of covid-19 (gallo marin et al., 2020). signs and symptoms are also used in the early diagnosis of covid-19 infection and involve:1) fever more than 37.8°c, 2) headache, 3) dry cough.4) breathless on light effort ,5) diarrhea ,6) loss of sense of taste and smell. while symptoms of severe condition during infection include:1) high respiratory rate (more than 20 breaths/minute), 2)breathing difficulty, 3) high heart rate (more than 100 beats /minute), 4) loss of appetite,5) chest tightness, 6) confusion, 7) temperature more than 38°c,8), hypoxia (emperador & dittrich, 2020). bm have been referred to a measurement variable that is based on the results of the progression of the disease (ballman, 2015). a measurable alterations can be assessed as a sign of normal, abnormal biological processes or pharmacological reactions to treatment intervention leading to an understanding the causes of disease, methods to diagnose it, regression, progression, and the outcome of management of disease (kinja & gupta, 2011). immunoassays and real-time pcr (rt-pcr) are the main methods that used in the diagnosis of covid-19, which can be performed through a variety of clinical samples, including nasal and pharyngeal swabs, sputum, feces or blood (whetton et al., 2020). although the role of bm in screening patients that are infected with covid-19 has not been accurately established as compared to rt-pcr, but the alteration in its values can be used to detect the result of coronavirus test and prediction of covid-19 patients especially when it linked to clinical feature (mardani et al., 2020). in addition, a high costs and the limited medical resources of rt-pcr resulted in restriction to their application, therefore the appropriate and the effective approaches are urgently required in the diagnostic process as well as to evaluate the severity of disease(peng et al., 2020). bm are divided into two main types: 1) biomarkers of disease that are utilized in diagnosis and monitoring the progression of diseases, 2) biomarkers of exposure that are utilized in risk prediction (mayeux, 2004) . the study reviewed a correlation between the alterations in bm and the severity of covid-19 in addition to their diagnostic role. bm that measured and used clinically in evaluation of covid-19 were wbc count, lymphocytes, eosinophils, neutrophils, d-dimer, fibrin degradation product, interleukin-6 (il-6), antithrombin, platelets, creatine phosphokinase, cardiac troponin and renal biomarkers (kermali et al., 2020). 329 global journal of public health medicine 2021, vol 3, issue 1 gggggglo corona virus attacks various systems in the body, firstly through inhalation of virus-filled particles which entered into the nasopharynx and exert its effect on the pulmonary arteries by targeting ace2 receptors and initiating a series of micro-thrombi formation leading to consequent hypoxemic damage to many systems especially the immune system, blood vessels and gastrointestinal system because of the availability of ace2 receptors. the immune response to a viral infection lead to formation of cells such as t helper cells and the natural killer (nk) cells that contribute in the destruction of lymph nodes, spleen, thymus and liver (garg et al., 2020). bm of immunity dysfunction the potential mechanisms of immune defect in patients infected with covid-19 is induce the depletion and promote the exhaustion of lymphocytes especially t cells, however decreasing the level of t cell which is inversely related with il-6, il-10 and tnfα levels (proinflammatory cytokines) is associated with an elevating in inflammatory cytokine levels (yang et al., 2020). lymphopenia in covid-19 patients may be occur as a result of the inhibition of cell proliferation by acidosis, recruitment of monocytes and lymphocytes from circulation into the site of infection, prevention of t cell recirculation under the influence of tnf-α 2 which stimulate the connection of these cells to the of lymphatic organs, also lymphocytopenia may be present due to activation prompted cell death of t cell by the influence of cytokine il-6 (fouladseresht et al., 2020). il-6 gene expression is typically increased in response to a variety of infections especially viral infection and also observed in the state of hypoxia, therefore the circulating levels of il-6 (pro-inflammatory cytokine) are noticed to be higher in patients with covid-19 (mcelvaney et al., 2020). furthermore, measuring the il-6 levels is consider a good biomarker in the prediction and evaluation the progression of covid19 patients (changsong wang et al., 2020). several studies used in analysing the immune response in covid-19 patients and showed an enhancing in inflammatory cytokine (luo et al., 2020; liu fang, et al., 2020) and decline in lymphocyte count (wagner et al., 2020; zhang et al., 2020; guan et al., 2020). eosinophils less than 100 cells/mm3 is called as an eosinopenia which represent a valuable diagnostic method that help to identify patients with covid-19 infection especially if the imaging resources has been lacking. moreover, many studies (djangang et al., 2020; sun et al., 2020; tan et al., 2020; gong et al., 2020; qin et al., 2020) found that eosinopenia may be occur as a result of the inflammatory state and the migration of eosinophils from the bone marrow into the peripheral tissues or decreased their production. neutrophilia is a part of abnormal immune responses and act as a biomarkers for predicting covid-19 disease. this is consistent with prior findings showing that patients with covid-19 exhibiting a higher neutrophil count through the period of disease ( wang et al., 2020; kong et al., 2020; extracellular & drive, 2020; zhao et al., 2020). like neutrophils, wbc count are also parameter that used as an indicator of inflammatory state. several studies found that leukocytosis are associated with cytokine storm due to virus invasion in the human body (yuan et al., 2020; zhao et al., 2020; he et al., 2020) (table 1 & 2) 330 global journal of public health medicine 2021, vol 3, issue 1 gggggglo table 1: research articles that commonly use biochemical markers as diagnostic tool comments type of alteration biomarker sample size study period authors leukocytosis may reflect a state of severe inflammation in lung and other organs that occur due to aggravation of the covid-19 disease by be a cytokine storm increased wbc count 45 january 23february 13, 2020 (changzheng wang et al., 2020) 117 february 15march 30, 2020 (yuan et al., 2020) 619 february 3-march 3, ( zhao et al., 2020) 2020 288 jan 15-mar 10, 2020 (he et al., 2020) lymphocyte count has a laboratory value aiding physicians in managing covid-19 infection and used as diagnostic tool decreased lymphocytes 57 january 3 january 5, 2020 (wagner et al., 2020) 78 december 30, ( liu et al., 2020) 2019january 15, 2020 242 january 16( jin zhang et al., 2020) 3-feb-20 1099 december 11, 2019 january 29, 2020 (guan et al., 2020) 331 global journal of public health medicine 2021, vol 3, issue 1 gggggglo comments type of alteration biomarker sample size study period authors sensitivity of eosinophils for the detection of covid-19 are more than lymphocytes in the term of disease diagnosis, it was markedly decreased in majority of peoples infected with covid-19 at their disease onset decreased eosinophils 174 march 1031 march, 2020 (ndieugnou djangang et al., 2020) 116 january 19february 20, 2020 (sun et al., 2020) 40 january 30 february 30, 2020 (tan et al., 2020) jan 28-mar (gong et al., 2020) 26, 2020 452 10 january 12 february 2020 (qin et al., 2020) excessive neutrophils act as a biomarkers for predicting covid-19 disease increased neutrophils 55 january 23march 15, 2020. ( wang et al., 2020) 210 27 january 9 march 2020 (kong et al., 2020) (extracellular & drive, 2020) 539 january ( zhao et al., 2020) 13-march 4, 2020 332 global journal of public health medicine 2021, vol 3, issue 1 gggggglo bm of coagulation abnormalities covid-19 infection stimulates the immune-hemostatic response, therefore triggering an excessive inflammation, thrombotic complications and tissue damage and leading to many complications such as respiratory dysfunction, acute lung injury, many organ failure and the highest mortality rate. a wide range of laboratory tests including the coagulation parameter was reported in peoples with covid-19 and appeared abnormalities, including d-dimer, fibrinogen degradation products, antithrombin, platelet count and prothrombin time (fei et al., 2020). all these biochemical parameters are prognostic markers for the severity of the pathological condition for patients who have admitted to covid-19 infection (yao et al., 2020). d-dimer could be an effective and helpful biomarker to improve management and treatment of covid19 patients (zhang et al., 2020). in addition increasing d-dimer level was related to a hazard ratio for death due to the underlying thromboembolic burden and increased mortality among those patients (naymagon et al., 2020). moreover, d-dimer is a reflective of high thrombotic activity and may not only be a biomarker of prothrombotic state and a hypercoagulability but may contribute in pathogenesis of acute pulmonary dysfunction (berger et al., 2020). elevated fibrin degradation products has been reported in several studies leading to serious condition caused by disseminated intravascular coagulation, which requires continuous attention and prompt intervention (terpos et al., 2020; zheng et al., 2020). while the reduction in antithrombin levels in patients with covid-19 are also appear to have an important role in patient prognosis through both arterial and venous thrombotic complications (liao et al., 2020; christensen et al., 2020). like antithrombin, a low platelet count is accompanying by fivefold increased risk of disease and mortality in covid-19 patients and therefore should used as prognostic indicator of worsening disease during hospitalization (lippi et al., 2020). many studies revealed a thrombocytopenia in groups of patients with severe covid-19 and associated with increasing the mortality many times higher than in patients without thrombocytopenia ( liu et al., 2020; zhao et al., 2020). . bm of cardiac complications covid-19 usually presents as viral pneumonia that may resulting in acute respiratory distress syndrome and it has a signifcant effect on the cardiovascular system through severe systemic inflammatory response, hypoxia, direct myocardial damage, lung injury and the major cardiac complications are myocardial infarction, acute myocarditis, arrhythmia and abnormal clotting (bandyopadhyay et al., 2020). creatine phosphokinase and cardiac troponin are a prognostic tool that utilized as a circulating cardiac injury marker, and a patients with higher levels of these biomarkers are associated with increased severity of covid-19 death (qin et al., 2020; masetti et al., 2020; izquierdo et al., 2020; salvatici et al., 2020; shah et al., 2020). (table 2) 333 global journal of public health medicine 2021, vol 3, issue 1 gggggglo table 2: study details of research articles that commonly used biochemical markers as prognostic tools comment type of alteration biomarker sample size study period authors the apoptotic processes of virus triggered coagulopathy by targeting the vascular endothelial cells, so that a greater level of d-dimer on admission was correlated to a worse prognosis of disease. increased d-dimer 343 january 12march 15, 2020 ( zhang et al., 2020) 2032 march 1 april 1, 2020 (naymagon et al., 2020) 2377 march 1 april 08, 2020 (berger et al., 2020) elevated fibrin degradation products leading to serious condition caused by disseminated intravascular coagulation increased fibrin degradation product (terpos et al., 2020) 55 february 15th, 2020 (zheng et al., 2020) reduction antithrombin activity is associated with the increasing the severity of covid-19 and mortality decreased antithrombin 466 jan 23 feb 23, 2020 (liao et al., 2020) n/a (christensen et al., 2020) 334 global journal of public health medicine 2021, vol 3, issue 1 gggggglo comment type of alteration biomarker sample size study period authors platelet count is readily available biomarker,could distinguish covid-19 patients with severe disease. decreased platelets 383 january 2 march 1, 2020. ( liu et al., 2020) 1066 january 7february 28, 2020 ( zhao et al., 2020) creatine phosphokinase is a prognostic tool using as a circulating cardiac injury marker increased creatine phosphokinase 3219 december 31, 2019 march 4, 2020 (qin et al., 2020) 229 28 february 10 april 2020 (masetti et al., 2020) 872 february 27 -april 7, 2020 (izquierdo et al., 2020) cardiac troponin is a useful biomarker of myocardial injury and the elevation in its concentration associated with increased mortality rate in patients with worse clinical outcomes in covid-19 infection. increased cardiac troponin 523 1 march14 april 2020 (salvatici et al., 2020) 309 march 2june 7, 2020 (shah et al., 2020) blood urea nitrogen is consider an important marker for predicting, estimation of renal function and represent a valuable prognostic factor of covid-19 severity increased blood urea nitrogen 305 8 february 11 march 2020 ( cheng et al., 2020) 210 january 23 february 29, 2020 (gao et al., 2020) 335 global journal of public health medicine 2021, vol 3, issue 1 gggggglo creatinine measurements is a very useful prognostic tool in the early detection of kidney injury increased creatinine 701 january 28february 11 2020, ( cheng et al., 2020) 333 january 28 february 9, 2020 (pei et al., 2020) 370 march 10 may 13, 2020 (nimkar et al., 2020) high level of il6 mayreflect a state of acute inflammatory cytokine storm indicating disease progression increased interleukin-6 69 january 21 february 16, 2020 ( liu et al., 2020) 80 january 21 february 16, 2020 ( liu tao et al., 2020) 140 january 18march 12, 2020 ( liu fang, et al., 2020) 15 january 275 march 2020 (luo et al., 2020) bm of renal failure recent studies show that renal injury is commonly occur in coronavirus patients because of a highly presented ace2 receptors in the renal cells which making them targeted and infected by the coronavirus (valizadeh et al., 2020). however, the possible mechanisms for the kidney manifestations of covid-19 are:1) renal dysfunction due to viral replication, 2) systemic inflammatory response for the cytokine storm, 3) disturbance in renin angiotensin aldosterone system homeostasis (kunutsor & laukkanen, 2020). increased level of blood urea nitrogen is a risk factors for poor prognosis of coronavirus especially when it infected the elderly patients with comorbidities (cheng et al., 2020; gao et al., 2020). the occurrence of acute renal injury as a one complication of covid-19 infection is a partly detected through measuring creatinine levels, because of the diagnosis of renal injury is generally depend on the acute changes in the levels of creatinine in the serum which has a substantial effect on detection rate ( cheng et al., 2020; pei et al., 2020; nimkar et al., 2020). 336 global journal of public health medicine 2021, vol 3, issue 1 gggggglo conclusion in conclusion, we found that there are many biochemical markers that play an important roles in predicting of covid-19 infection with a clear evidence of how their levels may alter according to the severity of covid-19. this may be ultimately helped the clinicians in their clinical practice to guide management and to determine the necessity for admission to icu in order to decrease the mortality rates. recommendation to illustrate that a biomarkers are predictive of management and treatment benefit, the study requires biomarkers status on all patients preferably in the context of a randomized study and to determine whether a biomarkers are purely prognostic, it requires to be demonstrated that there is a significant correlation between the biomarkers and outcome. conflicts of interest: the authors declare no conflicts of interest. references • ballman, k. v. 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kinabalu sabah malaysia *corresponding author: syedsharizman@ums.edu.my abstract introduction: lymphatic filariasis (lf) is a disease caused by filarial parasites transmitted to human by mosquitoes and infecting 120 million people worldwide. mass drug administration (mda) involves delivering treatment to every person living in a defined geographical area, is the current practice in place and has shown to be very useful in reducing the global transmission of lf. this review aims to explore into the effectiveness of mda in interrupting the transmission of lf in terms of the types of mda, number of cycles, coverage, and percentage of transmission reduction. methods: a systematic search via scopus, pubmed, and cochrane was done for articles published from 2015 to 2019 by using the preferred reporting items for systematic reviews and meta-analyses (prisma) checklist. the articles identified from the databases searched and any that appeared to relate to the research questions were included. a total number of 14 articles fulfilled the criteria for review. results: overall, the review showed a reduction in lf indices of more than 50% and up to 100% post-mda in endemic communities with high prevalence. the entomological assessment revealed a reduction in lf transmission post-mda, which strongly supported the reduction of lf indices. biannual mda conducted further showed a marked reduction in lf indices compared to annual mda. double therapy of mda significantly reduced the transmission indices to almost nil compared to single therapy. conclusion: review of mda showed promising effects in which it reduced the prevalence microfilaraemia (mf) and circulating filarial antigen (cfa) from baseline, as well as the clinical prevalence and entomological indices. combination therapy showed better outcome compared to single therapy. therefore, complementary vector control is suggested in addition to mda, as well as education delivery to the endemic communities. keywords: lymphatic filariasis, mass drug administration, systematic review, transmission assessment survey 415 global journal of public health medicine 2021, vol 3, issue 2 gggggglo introduction lymphatic filariasis (lf) is a disease caused by filarial parasites that are transmitted to human by mosquitoes. this infection is usually obtained during childhood and can damage the lymphatic system in the body. as the disease progresses over the years, the patients will present with swelling over bilateral limbs, as well as scrotum. the appearance of lower limb swelling looks similar to elephant leg; thus, this disease is also known as elephantiasis. despite being considered as a neglected tropical disease, lf has infected 120 million people worldwide, with 886 million people in 72 countries living in prone areas (world health organization, 2021). there are three species of filarial parasites responsible for causing this disease. in most areas in the world, it is caused by wuchereria bancrofti. two other parasites, namely brugia malayi and brugia timori affect those in the asia region (cdc, 2021). these parasites are transmitted by a wide range of mosquitoes, such as anopheles, culex, mansonia, and aedes. the types of mosquito species involved are highly dependent on their geographic distribution. for example, anopheles is commonly found in rural areas, culex is found in urban and semi-urban areas, and mansonia and aedes are the common vectors in the pacific islands and asia (world health organization, 2021). an adult filarial parasite lives in the human lymphatic system and reproduces microfilariae. due to its small size, the mf can enter blood vessels and then circulates. when a mosquito bites a human, the mf will enter into mosquito’s gut and grows in it. the mf will then be passed to another human when the mosquito bites them before entering the lymphatic system and growing into an adult worm. it will stay in the lymph vessels for five to six years, before mating and releasing more mf (cdc, 2021). the presence of adult worms can block the lymph vessels and cause limb and genitalia swelling. the mf will present at the blood capillaries at night-time so that it can be taken by the mosquito during the bite. majority of the patients are asymptomatic, whereby the clinical manifestation usually appears in chronic infection due to lymphatic damage. the patients will have lymphoedema of the limbs, hydrocele, and chylocele. recurrent acute attacks are also common, such as acute adenolymphangitis, which is characterised by fever associated with swelling and pain of the lymph nodes and vessels (cdc, 2021; world health organization, 2021). in 2000, world health organisation (who) launched the global programme to eliminate lymphatic filariasis (gpelf) in response to the quest to eliminate lf worldwide. elimination of lf is achieved when mf rate is less than 1% and less than 1/1000 children infected over five cumulative years (noordin, 2007). two objectives were highlighted in this programme: (i) to interrupt the transmission of lf, and (1) to control the morbidity caused by lf. endemic areas were mapped, and community-wide treatment programmes were administered. patients with morbidity were included in morbidity management and 416 global journal of public health medicine 2021, vol 3, issue 2 gggggglo disability prevention (mmdp) programme and they were taught on the care of lymphoedema and hydrocele (world health organization, 2021). mass drug administration (mda) is a programme designed to treat the entire population at risk by delivering treatment to every person living in a defined geographical area. this programme is implemented using the smallest administrative unit, which is called the implementation unit (iu) (2). every person in the iu, excluding children under two years old and pregnant ladies, is given either 6 mg/kg of body weight diethylcarbamazine citrate (dec) + 400 mg albendazole, or 150 µg/kg of body weight ivermectin + 400 mg albendazole annually for at least five years. the coverage of annual mda must be at least 65% of total population (world health organization, 2018). after completing the mda rounds, transmission assessment survey (tas) is done to quantify the impact of mda on the prevalence of mf in the iu. once the prevalence is very low and there is no risk of new transmission, the programme can be stopped. since the gpelf has been set up to eliminate lf by 2020, many countries have scaled up mda in their endemic districts, such as in the african region. a who progress report in 2017 stated that 87% of ius conducting mda globally had achieved effective coverage of more than 65% (world health organization, 2018). despite having a good coverage for mda, the number of people who suffers from the complications of lf are still increasing in trend (molyneux, 2018). it is agreed that mda is very useful in reducing the transmission of lf. however, some countries have reported an increasing resistance towards the antihelminthic drugs used in mda. the prolonged exposure to these drugs can cause drug pressure on the parasites and trigger the production of drugresistant strains (cobo, 2016). therefore, it is important to evaluate the impact of mda conducted globally. this review will look into the effectiveness of mda in interrupting the transmission of lf globally in terms of the types of mda, number of cycles, coverage, and percentage of transmission reduction. methods literature search a systematic search for relevant published articles with three major search engines, namely scopus, pubmed, and cochrane were conducted. to yield the most current studies, retrieval was restricted to articles published from the year 2015 to 2019. the systematic review is performed using the prisma checklist (moher et al., 2015) in which the workflow of publication search is presented in figure 1. the three major selected databases were accessed using the following keywords: “filariasis*” or “elephantiasis*” and “mass drug administration” or “chemoprevention” or “antibiotic prophylaxis” and “effectiveness” or “impact” or “outcome”. for the articles identified from the database search, the titles were screened according to those which were relevant to the research questions. any articles that appeared to provide an answer to the research questions were also included. then, articles that were duplicated in the pool of screened articles were discarded and the total number of articles left after 417 global journal of public health medicine 2021, vol 3, issue 2 duplication were assessed for eligibility. the eligible articles were retrieved and evaluated based on the inclusion and exclusion criteria. inclusion criteria were: (a) community-based study, (b) epidemiological or entomological assessment as the outcome, (c) included studies that were done all over the world, and (d) availability of baseline information. the studies were excluded based on: (a) non-lymphatic filariasis, (b) review or clinical trial, and (c) vector surveillance. articles were also excluded if the english version of the full text was not available. the three electronic database searches revealed a total number of 14 articles that fulfilled the aforementioned criteria for review (table 1). the selected articles were assessed for quality using the newcastle-ottawa quality assessment scale in which the reviewers consisted of three medical doctors with public health background. s c r e e n in g in c lu d e d e li g ib il it y i d e n ti fi c a ti o n records identified through database searching (n =232) records screened for relevant topics (n =59) records after duplicate were removed (n = 43) records duplicated (n = 16) full-text articles assessed for eligibility (n=43) full-text articles excluded, with reasons (n =29) • 2 studies on review • 15 studies on lymphatic filariasis treatment (individual) • 2 studies on nonlymphatic filariasis • 2 studies on economic impact • 2 studies on prevalence lf • 1 study on vector surveillance • 1 study on insecticidal nets • 1 study on protocol • 1 clinical trial study with predicted modelling • 2 studies without baseline information studies included in qualitative synthesis (n =14) figure 1: workflow showing process of articles selection for the review irrelevant topics (n =173) 418 global journal of public health medicine 2021, vol 3, issue 2 gggggglo results characteristics of studies as mentioned in the methodology section, the systematic review included studies from the year 2015 to 2019 from various countries in the world, which were prominently from the endemic region of african countries and other regions including south asia, southeast asia, and oceania. all of the studies used the observational type of quantitative study, whereby 13 studies were cross-sectional, and one was cohort/longitudinal in design. sample population involved in the studies were from various range of ages, including both children and adults. most of the studies used thousands of sample size and the quality of the selected articles was fair to good quality based on the newcastle-ottawa quality assessment scale. epidemiological assessments such as cfa and mf were carried out as an outcome impact in most studies, while only two studies assessed entomological indices as an outcome impact. results are further specified according to the type of mda conducted and outcome reduction (table 2). impact of mda all of the studies showed a reduction in lf indices, namely cfa and mf of more than 50% and up to 100% post-mda in the community over endemic regions with a high prevalence of lf infection. few studies also demonstrated the reduction of both cfa and mf prevalence to 0% after five to six rounds of mda (allen et al., 2017). the entomological assessment also revealed a reduction in lf transmission post-mda, which strongly supported the reduction of lf indices. biannual mda that was previously conducted also showed a marked reduction in lf indices compared to annual mda (supali et al., 2019). on top of this, single therapy of mda (diethylcarbamazine alone) showed higher transmission rates compared to the double therapy of mda (diethylcarbamazine plus albendazole), whereby the double therapy of mda significantly reduced the transmission indices to almost nil compared to single therapy (sunish et al., 2015). however, in both comparisons of mda frequency (annual versus biannual) and type of mda prescribed to the community (double versus single therapy), more studies needed to be included for comparative review. for this study, the objective and keywords in the search engines should be expanded accordingly. in the systematic review, one study was included for an assessment of mda effectiveness in the vulnerable group, which was individual with hiv (human immunodeficiency virus) co-infection (pitter, mgeni, mabuye, kowuor, & mwingira, 2016). in the study, they found that the effectiveness of mda was not reduced by concomitant hiv infection. again, the effectiveness of mda towards the vulnerable population needs to be systematically reviewed using different operational keywords in order to capture more related studies and make more comparisons. 419 global journal of public health medicine 2021, vol 3, issue 2 gggggglo table 1: characteristics of studies reviewed article & author/year study population/country study design mass drug administration (mda) other intervention outcome impact barriers (if applicable) lymphatic filariasis transmission in rufiji district, south-eastern tanzania: infection status of the human population and mosquito vectors after twelve rounds of mass drug administration jones et al. 2018 population in rufiji district, south-eastern tanzania n=854 communitybased crosssectional study (7 months post 12th annual mda round april 2015) 12 annual rounds of mda (ivermectin and albendazole) between 20022014 with 5494% of coverage drug uptake among respondents ranging from 70% to 83% none reduction of cfa prevalence from baseline 49% to 1.1% and mf prevalence from baseline 18% to 0.1% reduction of hydrocele prevalence from baseline 12% to 4.8% and elephantiasis prevalence from baseline 4% to 2.9% none of the indoor filarial vectors was found to be infected with w. bancrofti an estimated w. bancrofti infection rate of 0.1% among outdoor filarial vectors individuals who did not participate in any of the previous rounds of mda were significantly more infected (cfa) compared with those with a recent history of participating in mda not stated progress on the elimination of lymphatic filariasis in sierra leone koroma et al. 2018 population in all 12 districts of sierra leone n=4230 community survey using selected sentinel and spot-check sites (2013) 5 annual rounds of mda (ivermectin and albendazole) in 2008-2012 with coverage >65% none reduction of mf prevalence from baseline 2.6% to 0.3% at midterm 2011 and slightly increase to not stated 420 global journal of public health medicine 2021, vol 3, issue 2 gggggglo 0.54% in the current study mapping and modelling the impact of mass drug administration on filariasis prevalence in myanmar aye et al. 2018 12 provinces (45 districts) in myanmar with high endemicity status of lf transmission n=4660 communitybased survey; tas via sentinel and spot-check sites in districts with at least 5 rounds of mda annual mda conducted in a stepwise manner over 13 years period from 2001 2013 with coverage 6098% none only 5 provinces (22 districts) completed tas post 5 rounds mda reduction of mf prevalence from 1.55.2% to 0.22.8%. challenges: drug supply, local conflict interrupted mda in some districts the interruption of onchocerca volvulus and wuchereria bancrofti transmission by integrated chemotherapy in the obongi focus, northwestern uganda luroni et al. 2017* population in obongi focus in moyo district, northwestern uganda n=1532 communitybased survey (2014) using selected sentinel sites and tas 5 annual rounds of mda (ivermectin and albendazole) in 2006-2011 with 70% coverage malaria prevention (long-lasting insecticidetreated nets) reduction of mf prevalence from premda 2.5% to 0.8% in 2011 and 0% in 2014 tas among children aged 6-7 years old in 2014 revealed negative (0.0%) for antibodies of w. bancrofti not stated persistent ‘hotspots’ of lymphatic filariasis microfilaraemia (mf) despite 14 years of mass drug administration in ghana. biritwum et al. 2016 98 endemic districts in ghana • 29 hotspots • 69 stopped mda districts n=not stated community based survey 14 annual rounds of mda 2001-2014 with coverage 75% (hotspots) 10 annual rounds of mda 2001-2012 with coverage 77.5% (stopped mda) *type not specified 1. average llin coverage (sd) • hotspots: 19.7 (1.5) • stopped mda: 20.1 (12.2) hotspots: reduction of mf prevalence from baseline (2000-2004) 41.6% to 11.5% at midterm (2003-2009) to 0.7% during recent study (20092014) stopped mda: reduction of mf prevalence from baseline (2000-2004) 4.7% to 2.0% at midterm (2003-2009) to 0.1% during recent study (20092014) not stated impact of mass drug administration for elimination of lymphatic filariasis in nepal. 10 selected districts in nepal n=9495 communitybased survey (pre-tas; post 5 annual mda 5 annual rounds of mda (dec and albendazole) in 2010-2014 6 districts achieved mda none reduction of mf prevalence from baseline 1.06-20% to <2% at pretas not stated 421 global journal of public health medicine 2021, vol 3, issue 2 gggggglo ojha et al. 2017* rounds 2014) (tas in 2015) coverage of 65% tas mf prevalence: all 6 districts achieved the prevalence threshold (<1%) effect of 3 years of biannual mass drug administration with albendazole on lymphatic filariasis and soil-transmitted helminthic infections: a communitybased study in republic of the congo pion et al. 2017 seke pembe, a village located in mabombo health district (bouenza division) in republic of the congo n=1574 communitybased survey (2015) biannually (6 rounds) mda with albendazole in 2012-2015 mda coverage: 77-83% coverage bednet usage: 76% reduction of cfa prevalence from 17.3% (2012) to 4.7% (2015) reduction of mf prevalence from 5.3% (2012) to 0.3% (2015) 72.8% reduction in cfa prevalence and 94.3% reduction in mf prevalence not stated reaching endpoints for lymphatic filariasis elimination results from mass drug administration and nocturnal blood surveys, south gujarat, india. modi et al. 2017* 5 districts in south gujarat region n=17551 communitybased survey (20102015) 10 annual rounds of mda from 2005-2015 with coverage of 89.2-96.7% for the last 5 years (20102015) *type of mda not specified none reduction of mf prevalence from 1.4% (2005) to 0.44% (2015) not stated comparison of the impact of annual and semi-annual mass drug administration on lymphatic filariasis prevalence in flores island, indonesia. supali et al. 2019 3 villages in sikka district, flores island, indonesia n=2804 (2104) communitybased survey (2014) mda with dec combined with alb in 20112013 no. of mda rounds: • paga and lewomada: 3 (annual) • pruda: 5 (semiannual) none 1. baseline mf prevalence: • paga: 3.9% • lewomada: 5.0% • pruda: 14.2% 2. current mf prevalence: • paga: 0.0% • lewomada: 0.3% • pruda: 1.2% not stated the first evidence of lymphatic filariasis transmission interruption in cameroon: progress towards elimination. north and far north regions of cameroon; 5 health districts divided into 3 evaluation unit (eu) • mokolo • ngong/poli • tchollire/rey-bouba n=5292 community based tas in 2014 6 annual mda rounds in 2008 – 2013 none baseline cfa prevalence in 2007 was 2.7% current cfa prevalence: • eu #1: 0.13% • eu #2: 0.57% • eu #3: 0.45% not stated 422 global journal of public health medicine 2021, vol 3, issue 2 gggggglo nana-djeunga et al. 2017* • overall: 0.40% impact of the lymphatic filariasis control program towards the elimination of filariasis in vanuatu, 1997–2006 allen et al. 2017* 51 villages throughout the 6 provinces of vanuatu n=4363 communitybased survey (2005/2006) 5 annual rounds of mda from 2000 to 2004 with coverage of 75.5-81.5% none reduction of mf prevalence from baseline (1997/1998) 2.48% to 0% (current study) reduction of cfa prevalence from baseline (1997/1998) 4.79% to 0.16% (current study) not stated prevalence of lymphatic filariasis and treatment effectiveness of albendazole/ ivermectin in individuals with hiv coinfection in southwesttanzania kroidl et al. 2016 population in the kyela district/ mbeya region southwest tanzania (aged 0–94 years) n=2104 communitybased crosssectional study (part of cohortstudy; surveillance of lymphatic filariasis) *6 months post 2nd round of mda 2 annual rounds of mda (ivermectin and albendazole) from 2007-2009 *coverage not specified in article none prevalence cfa reduced from 21.6% to 19.7% after 2 rounds of annual mda (relative drop of 8.8%, mcnemar´s exact p = 0.036) * the effectiveness of mda was not reduced by concomitant hiv-infection not stated the impact of six annual rounds of mass drug administration on wuchereria bancrofti infections in humans and mosquitoes in mali coulibaly et al. 2015 6 endemic villages in sikasso, mali n=1334 communitybased crosssectional study between 2002-2008 six consecutive annual mda albendazole and ivermectin from 2002 to 2007 with coverage of 69% to 89% none adults: reduction of mf prevalence from 21.4% (pre-mda) to 0% (12 months post 6th round of mda) children: reduction of cfa from 53% (premda) to 0% (12 months post 6th round of mda) number of infective bites/ human/ year decreased from 4.8 in 2002 (premda) to 0.04 not stated 423 global journal of public health medicine 2021, vol 3, issue 2 gggggglo in 2007(postmda). only one mosquito containing a single infective larva was observed 12 months post a final round of mda decline in lymphatic filariasis transmission with annual mda using dec with and without albendazole over a 10-year period in india sunish et al. 2015 endemic districts (revenue blocks) in tamil nadu state, south india. n=not stated longitudinal study from 2001-2009 6 rounds of annual mda carried out over a period of 10 years (2001, 2002, 2003, 2004, 2007 and 2009) tirukoilur block (dec + albendazole) mugaiyur block (dec alone). none entomological indices derived from the collection of indoor resting adult female mosquitoes; -99% reduction in tti for dce + albendazole -72% reduction in tti for dec alone -86% reduction in infectivity rate for dce + albendazole -54% reduction in infectivity rate for dec alone dec alone arm showed higher transmission rates, compared to the dec + alb arm. albendazole along with dec has significantly reduced the transmission indices to almost nil level, compared to dec alone mda not conducted in 2005. 2006, 2008 due to administrative reason *good quality study using newcastle ottawa scale assessment, tti= transmission intensity index 424 global journal of public health medicine 2021, vol 3, issue 2 gggggglo table 2: outcome reduction in relation to the type of mda therapy type of mda therapy outcome articles combination dec/ ivermectin with albendazole annual mda ≥ 5 rounds of mda reduction of 98% cfa prevalence reduction of 88100% mf prevalence reduction of 99% tti and 86% infectivity rate jones et al. 2018 dolo et al. 2015; jones et al. 2018; koroma et al. 2018; luroni et al. 2017; ojha et al. 2017 sunish et al. 2015 < 5 rounds of mda reduction of 8.8% cfa prevalence reduction of 94% mf prevalence kroidl et al. 2016 supali et al. 2019 biannual mda ≥ 5 rounds of mda reduction of 91.5% mf prevalence supali et al. 2019 < 5 rounds of mda albendazole alone/ dec alone annual mda ≥ 5 rounds of mda reduction of 72% tti and 54% infectivity rate sunish et al. 2015 < 5 rounds of mda biannual mda ≥ 5 rounds of mda reduction of 72.8% cfa prevalence and 94% mf prevalence pion et al. 2017 < 5 rounds of mda not specified ≥ 5 rounds of mda reduction of more than 80% cfa prevalence and more than 50% mf prevalence allen et al. 2017; aye et al. 2018; biritwum et al. 2016; modi et al. 2017; nana-djeunga et al. 2017 tti= transmission intensity index discussion single mda vs double mda most of the studies revealed a reduction in either microfilariae count, cfa by using double therapy and employing a combination of either albendazole or dec (sunish et al., 2015; supali et al., 2019) or albendazole and ivermectin (coulibaly et al., 2015; jones et al., 2018; koroma et al., 2018; kroidl et al., 2016; luroni et al., 2017). using a single therapy of albendazole alone as per is due to its delayed use in central africa as a result of the risk of serious adverse events in subjects with loiasis. using single-dose therapy shows a reduction in the mf count and cfa, however, they are not significant (bastien et al., 2015). nevertheless, the use of a single dose is still promising as it reduces the geometric mean mf count and the hookworm infection rate in the community. a double-blind study in south india by has shown no difference between single dose in terms of its efficacy in the clearance of microfilaria and the overall incidence of adverse reactions (pani et al., 2002). by contrast, another communitybased study in india showed higher and sustained benefits with regard to filarial and soil-transmitted helminthic infections for the combination therapy (rajendran et al., 2006). this review showed that 425 global journal of public health medicine 2021, vol 3, issue 2 gggggglo combination therapy was better in the reduction of transmission intensity index and infectivity rate compared to single therapy, which could be due to the positive effect of the drug combination. additional control the articles included using mda mainly of three drugs, which were albendazole, dec, and ivermectin, whether as a single therapy or in combination. besides, the insecticide net was mentioned in addition to pharmacotherapy (bastien et al., 2015; n.-k. biritwum et al., 2016; luroni et al., 2017) as a part of vector control. to achieve lf elimination, a suggestion that supplementary vector control needs to be added alongside mass therapy due to persistent transmission in villages in the study (sunish et al., 2015). annual vs semi-annual a randomised clinical trial in egypt showed that multi-dose dec/alb was significantly more effective than single-dose therapy for reducing and clearing microfilaraemia. it can be used to quickly reduce the community mf loads and transmission rates, especially in endemic places (el setouhy et al., 2004). a study conducted in indonesia has also stated that the annual mda rounds are sufficient in areas with low to moderate baseline prevalence compared to more frequent biannual rounds (supali et al., 2019). however, the study showed that in areas of higher endemicity, semi-annual mda was useful for rapidly reducing of the microfilariae prevalence. a study in congo as mentioned earlier showed semi-annual use of albendazole could reduce both the cfa and mf. in this review, both annual and semi-annual mda outcomes were almost the same. round of treatment in this review, the rounds of treatment were from two rounds up to 12 rounds in annual mda, while five to six rounds were done in semi-annual mda. meanwhile, an ecology study in ghana stated the average number of mda rounds in hotspots was 11.5 (n.-k. biritwum et al., 2016). one round of mda has been reported to have a reduction of microfilariae prevalence by 26% to 41%, five to six rounds led to 88%– 90% reduction (ramaiah & ottesen, 2014). generally, in the included articles, more or equal to five rounds of treatment look promising in reducing the circulating filarial antigen for annual combination mda, however, this is not conclusive and needs further comparison. the required rounds of annual mda increase with higher baseline endemicity and lower mda coverage (jambulingam, subramanian, de vlas, vinubala, & stolk, 2016). if the mda coverage rate is high, a higher treatment index can be achieved in the early rounds of the programme, and fewer rounds of mda may be required to maximise both impact and cost-effectiveness. coverage of mda the coverage in the articles is only from 54% up to 98%, showing that the coverage of mda is not 100%. it can be due to geographical reasons, logistics such as drug supply and local conflict (aye et al., 2018), and country capacities. a review (ramaiah & ottesen, 2014) has also stated that all at-risk countries and all regions within these countries have not yet reached 100% geographic mda coverage. 426 global journal of public health medicine 2021, vol 3, issue 2 gggggglo this review cannot compare between coverage in terms of the outcome as the studies included have used a range of coverage that is not a discrete value, while some did not mention the coverage level. it is crucial to achieve a 100% mda coverage in order to eliminate filariasis in endemic countries. programmes in india implementing the global programme for elimination of lymphatic filariasis (gpelf) are an example to increase the coverage. method of detection the included studies showed many methods of assessment and evaluation of microfilaria. the most common method is cfa (allen et al., 2017; coulibaly et al., 2015; jones et al., 2018; kroidl et al., 2016; nana-djeunga et al., 2017; ojha et al., 2017; pion et al., 2017) and microfilaria prevalence (aye et al., 2018; n.-k. biritwum et al., 2016; coulibaly et al., 2015; koroma et al., 2018; luroni et al., 2017; modi et al., 2017; ojha et al., 2017). meanwhile, other methods are vector or entomological indices like mosquito transmission indices (sunish et al., 2015), mosquito infectivity rate, mosquito containing a single infective larva (coulibaly et al., 2015; jones et al., 2018), number of infective bites/ human/year, clinical signs such as hydrocele and lymphoedema (jones et al., 2018), and transmission assessment survey (tas) (aye et al., 2018; luroni et al., 2017; ojha et al., 2017). the gpelf diagnostic principles are simple and efficient: diagnostic techniques for field diagnosis of infection by simple, finger-prick, anytime-of-day antigen-detection tests and for clinical diagnosis by ultrasound identification of living adult parasites (ottesen, hooper, bradley, & biswas, 2008). conclusion from all of the studies included, mda showed promising effect in which it reduced the prevalence of mf and cfa from baseline, the clinical prevalence, and entomological indices. combination therapy showed better outcome compared to single therapy. however, most of the studies did not eliminate the prevalence by a total of 100%. this can be due to the incomplete coverage of the mda programme. besides, vector control is required, in addition to mass therapy and education to the endemic communities. limitation this review is only a scoping review and does not compare the information statistically. we recommend using a metanalysis of the outcomes of the included studies. the review also 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(2018). world health organization. 2018. global programme to eliminate lymphatic filariasis: progress report, 2017. retrieved from ttps://www.who.int/lymphatic_filariasis/resources/who_wer9344/en/ proof_gjphm-2021sys review final_new rohaizat 16-9-2021.pdf 1.1 screening 1.2 included eligibility identification microsoft word response letter,1st round revision, mj.docx 354 global journal of public health medicine 2021, vol 3, issue 1 gggggglo original article assessment of thyroid hormones and testosterone among tramadol-abusers in gaza strip-palestine alaa mudalala1, saleh mwafy2, fadel ashour3, and majed jebril*4 1 department of laboratory medicine, faculty of applied medical sciences, al-azhar university of gaza, gaza strip, palestine. 2 department of biology, faculty of science, al-azhar university of gaza, gaza strip, palestine. 3 psychiatric mid, psychiatric hospital gaza, palestine. 4 global health institute, school of public health, xi’an jiaotong university, health science center, xi'an, shaanxi, china. *corresponding author: majed.jebril2021@gmail.com abstract introduction: tramadol is a prescription opioid used to treat moderate pain. but among tramadolabusers in gaza strip, little is known regarding tramadol's effect on their body functions such as levels of thyroid hormones and testosterone. the aim of the study was to investigate the effect of tramadol abuse on the level of thyroid hormones and testosterone among tramadol-abusers in gaza strip. methods: this study used a prospective case-control design performed on a population of tramadol overdosed patients, aged 18 to 35 years old who were admitted to psychiatric clinics in the gaza strip. questionnaires on sociodemographic and clinical data were collected from 196 males (98 cases from tramadol abusers who followed before pre-detoxification and one-month later post detoxification and an equal number of healthy individuals with matching age as control. tsh, ft4, ft3, and testosterone levels were measured, statistically analyzed. results: there was an association between tramadol abuser's pre-treatment and healthy subjects for thyroid parameters and testosterone. t-test showed tramadol abusers pre-detoxification were significantly increased in tsh levels than controls (p<0.001) conversely, they were significantly decreased in serum ft4, ft3, and testosterone levels than controls also paired t-test illustrated level of tsh for pre-detoxification were significantly higher than postdetoxification. additionally, there is no significant correlation between controls and tramadol abusers' groups (pre & post-treatment) in hematological profile (p>0.05) except in red cell distribution width (rdw) that showed a positive significant correlation between controls and tramadol abusers groups in both pre & post-treatment (p=0.021). conclusion: the study concluded that tramadol abusing have a significantly decreased level of testosterone, ft4, and ft3 levels and a significantly high level of tsh, also we conclude that the level of testosterone, t3, and t4 in pre detoxification of tramadol abusers was significantly lower than controls and significantly lower than its results after detoxification. keywords: opioids, tramadol, thyroid function, testosterone, gaza strip 355 global journal of public health medicine 2021, vol 3, issue 1 gggggglo introduction tramadol (tramal tm) is a synthetic opioid analgesic (painkiller) that is frequently prescribed to manage moderate to severe levels of pain such as that experienced after surgery or in chronic conditions like arthritis (gay-escoda et al., 2019). there has been an increasing rate of recognizing problems connected to prolong use of opioids (rhodin et al., 2010), these opioids including narcotics, opium, morphine, meperidine, and tramadol which have high rate consumption around the world (lewis et al., 1997). in present days tramadol is widely used for the treatment of different pain disorders and it is the most commonly prescribed opioid in the world (rosenblum et al., 2008). it is considered a centrally effective drug used for the treatment of moderate to severe pain, including cancer pain, the pain of surgery, muscle and joint pains, its effectiveness is less than morphine and pethidine and is stronger than ibuprofen, it is distributed in the body with a mean distribution half-life of 1.7 hours (macintyre et al., 2010). according to australian studies, tramadol use has increased almost 10 times between 1998 and 2004 (mehrpour et al., 2015). it has been approved for use in many countries for many years such as the united states since 1995 and in france since 1997 (shadnia et al., 2008). nowadays tramadol has a clear prevalence in various arabic countries such as egypt. it is noticed that tramadol abuse in the egyptian community was increased in the last years (fawzi, 2011). other neighboring countries suffer from this problem increasingly alarming phenomenon of tramadol such as the united arab emirates which has been on the top in the phenomenon of selling and trafficking of tramadol since january 2010. also, tramadol abuse has been heavily demonstrated in gaza, it is the most used one (fawzi, 2011a; progler, 2010). rough estimates suggested that there are 15,000 addicted males to tramadol in gaza (30% of males between 14 and 30 years old). even israeli reports noted “some supplies of the drug are smuggled into gaza from egypt through tunnels, tramadol being the most used one (fawzi, 2011b). tramadol is currently available as tablets, oral drops, and solutions for injection. tramadol is completely and rapidly absorbed after oral use (shilo et al., 2008). despite being a centrally acting analgesic agent, increasing the rate of opioids consumption especially tramadol is one of the major challenges in most countries. it is considered one of the most common causes of poisoning in people especially in adult male patients with a previous history of drug addiction and psychological problems which is considered the cause of mortality and morbidity in many countries (mehrpour et al., 2015). there are limited data available about its side effects and manifestations in overdose cases. the side effects of poisoning with the tramadol are drowsiness, nausea, vomiting, restlessness, headache, constipation, and some rare side effects related to the respiratory system, liver, and kidney (subedi et al., 2019). many medications especially morphine in overdose states affect 356 global journal of public health medicine 2021, vol 3, issue 1 gggggglo the body because of its toxicity and many of it affect thyroid hormones and testosterone (caplan et al.,2007) the effect of long-term consumption of tramadol on endocrine systems especially the thyroid and testosterone hormones have not investigated so much (katz & mazer, 2009). some researches shows a direct effect of tramadol abuse with hormonal secretions, such as thyroid hormones, testosterone, lh and fsh which thus interferes with the menstrual cycle in women and decrease of the normal pulsatile release of lh leading to a negative effect on the testes of males caused by the decrease of testosterone levels (mehrpour et al., 2015). since tramadol-abusers are highly prevalent in the gaza population (diab et al., 2020) assessment of the effect of thyroid hormones and testosterone among tramadol-abusers in such a population may help to determine the potential effects of tramadol-abusers metabolism (tafesh, 2013). this study aimed to investigate the effect of tramadol abuse on the level of thyroid hormones and testosterone among tramadol-abusers in gaza strip. methods the present study is a prospective case-control study, with inclusion criteria of known patients with tramadol abuse, with age between 18-35 years, further a period of poisoning is more than three years. patients who received other types of opioids, take hormone replacement therapy or corticosteroid therapy, and patients with a history of thyroid gland disease or fertility problems were excluded from this study. the sample of the study consisted of 196 males as participants divided equally into two groups: (cases group) consisted of 98 with tramadol abuse problems, aged from 18 to 35 years old who followed before treatment (pre-detoxification) and one-month later post detoxification and an equal number of healthy individuals with matching age as control. the researcher conducted face-to-face interviews with the participants, which were used for filling the questionnaires designed for matching the study need of the study population. most questions are designed as yes/no questions, which offers a dichotomous choice (biner & kidd, 1994). the questionnaire included questions on sociodemographic data (age, education, governorates, marital status, smoking, and employment status), also clinical data (route of poisoning, time of the poisoning, the dosage of poisoning, and clinical findings). blood samples (5 ml each) drawn into a vacationer blood collection tube from the study groups' cases and control. about 2 ml of blood was placed into an ethylene diamine tetraacetic acid (edta) vacutainer tube to perform complete blood count (cbc) for cases and controls. serum samples were obtained to determine the biochemical parameters. cbc of cases and control was determined using orphee for analysis depending on the electrical impedance principle. a complete system of reagents of control and calibrator according to standard protocols (orphee for analysis, mythic 18). the hormones serum samples included tsh, free t4, free t3, and 357 global journal of public health medicine 2021, vol 3, issue 1 gggggglo testosterone were measured quantitatively by elisa technique (enzyme-linked immune sorbent assay) using biorex reagent kit according to (szaniawska & spencer, 1995). treatment of addiction to tramadol goes through three consecutive stages; the first stage depended on the process of detoxification (withdrawal of tramadol), the second stage of psychological specialist, and the third stage of behavioral and cognitive therapy. the first stage included the period of withdrawal of the drug from the body, which spends a period of 7 days to 12 days according to the dose used in the past and the duration of the use of drugs. for most tramadol addiction, most cases can treat at home but in some cases, it may be necessary to enter the hospital to control the withdrawal symptoms. this phase treated suddenly with the patient giving some drugs that relieve withdrawal symptoms (such as drugs that help to sleep using antidepressants which called strong benzodiazepine such as xanax, lorocare, or clonazepam) in addition to spasmolytic drugs also the medicines of the digestive system (mcquay et al., 2016). the second stage included the use of antidot for opiates such as naltrexone 50 mg orally. the third stage included encouragement and increased motivation to continue treatment and non-return of drugs. this stage is carried out by a psychiatrist or psychologist and the time after finishing directly from the phase of detoxification (mcquay et al., 2016). ethical and administrative considerations the approval letter was obtained from the helsinki committee in the gaza strip-palestine. for ethical consideration, the necessary approval to conduct this study was obtained from the helsinki committee with ethical approval number phrc/hc/115/16 in gaza strip. also, an approval letter to conduct the study was obtained from the ministry of health (moh). before filling the questionnaire, assurance of voluntary participation was maintained, then the interviewer described the study aims, and explained all the questions for the participants. informed consent was obtained from the participants with their signatures. statistical analysis data were computer analyzed using spss (statistical package for the social science version 20). the sample distribution of the study variables and the cross-tabulation were applied. chisquare (x2) was used to identify the significance of the relations associations, and interactions among various variables. the paired and student t-test, pearson's correlation test, and correlation graphs plotting were applied. the results in all the above-mentioned procedures were accepted as statistically significant when the p-value was less than 5% (p<0.05). 358 global journal of public health medicine 2021, vol 3, issue 1 gggggglo results the study population comprised 196 participants divided equally into two groups: (case group) consisted of 98 with tramadol abuse problems, aged from 18 to 35 years old who followed before treatment (pre-detoxification) and one-month later post detoxification and equal number healthy individuals. the age was matched between cases and controls; with mean age 27.5±4.3 years in controls whereas that of chronic users of tramadol cases was 27.9±4.0 years (p>0.05). table 1 shows the sociodemographic data among the study population. the number of controls from gaza, deir el-balah, khan younis, and rafah governorates were 46 (46.9%), 3 (3.1%), 39 (39.8%), 10 (10.2%), respectively. in addition, the number of tramadol abusers from gaza, deir el-balah, khan younis and rafah governorates were 28 (28.6%), 23 (23.5%), 30 (30.6%), 17 (17.3%), respectively, with statistically significant differences (c2 = 22.75, p< 0.001). analysis of the educational status of the controls and tramadol abusers showed that 37.8% and 71.4% have high education, 43.9% and 23.5% have finished secondary school, 18.3 %, and 5.1% have passed the primary school, respectively. the high educational level was associated with chronic users of tramadol (c2 = 23.59, p< 0.001). regarding employment status, 64.3% controls and 79.6% cases reported that they were employed compared to 35.7 controls and 20.4 cases who had not, respectively. chi-square test showed employed in cases higher statistically significant than controls (c2 = 5.69, p> 0.05). the numbers of single, married, widow and divorced in controls were 44 (44.9%), 45 (45.9%), 3 (3.1%), 6 (6.1%) and 49 (32.6%), respectively whereas in cases they were 15 (15.3%), 64 (65.3%), 10 (10.2%) and 9 (9.2%), respectively. there was a statistically significant association between different groups (c2=21.94, p< 0.001). the prevalence of smoking was higher statistically significant in cases than controls (92 (93.9%) vs. 82 (83.7%), respectively, c2 = 5.12 and p= 0.024. 359 global journal of public health medicine 2021, vol 3, issue 1 gggggglo table 1:baseline information among the study population (n=98) sociodemographic controls cases statistical test p-value governorates n (%) gaza 46 (46.9) 28 (28.6) c2 = 22.75 <0.001* deir el-balah 3 (3.1) 23 (23.5) khan younis 39 (39.8) 30 (30.6) rafah 10 (10.2) 17 (17.3) education n (%) higher education 37 (37.8) 70 (71.4) c2 = 23.59 <0.001* secondary school 43 (43.9) 23 (23.5) primary school 18 (18.3) 5 (5.1) employment status n (%) employed 63 (64.3) 78 (79.6) c2 = 5.69 0.017* unemployed 35 (35.7) 20 (20.4) marital status n (%) single 44 (44.9) 15 (15.3) c2 = 21.94 <0.001* married 45 (45.9) 64 (65.3) widowed 3 (3.1) 10 (10.2) divorced 6 (6.1) 9 (9.2) smoking n (%) smokers 82 (83.7) 92 (93.9) c2 = 5.12 0.024* non-smokers 16 (16.3) 6 (6.1) age (years) mean±sd (min-max) 27.5±4.3 (18-35) 27.9±4.0 (18-35) t = 0.71 0.479 c2: chi-square test; t: student's t-test; *p-value significant at p ≤ 0.05. clinical data among tramadol abusers were presented in (table 2) rote of administration in all cases was by tablet. the average duration of using tramadol among cases was 5.7±1.8 years and a dose of tramadol was 3.8±2.2 tablets per day. 360 global journal of public health medicine 2021, vol 3, issue 1 gggggglo table 2: clinical data among cases (n=98) clinical data cases rote of administration n (%) tablet 98 (100) oral drops 0 (0.0) injection 0 (0.0) period of using (years) mean±sd (min-max) 5.7±1.8 (4-10) dose (tablet/day) mean±sd (min-max) 3.8±2.2 (1-17) sd: standard deviation table 3 illustrate the mean values of hematological parameters among controls and tramadol abusers (pre-and post-treatment). the mean values of wbcs, hb, rbcs, mcv, mch, mchc, rdw, and plt demonstrate that there were no statistically significant differences between controls and pre-treatment and post-treatment of tramadol abusers showed by student's t-test (p> 0.05). the results illustrate that there was no association between hematological parameters studied between the controls and tramadol abusers pre-and post-treatment. 361 global journal of public health medicine 2021, vol 3, issue 1 gggggglo table 3: haematological parameters among controls and tramadol abusers parameters control cases % change p-value pre-treatment post-treatment wbcs (k/µl) (min-max) 6.9±1.6 (4.6-10.4) 7.0±2.0 (3.9-12.5) 7.2±2.1 (3.9-12.3) 1.44 0.721 a 4.26 0.263 b 2.82 0.225 c rbc (m/µl) (min-max) 4.9±0.4 (4.3-6) 4.9±0.6 (3.4-6.2) 5.0±0.6 (3.8-6.6) 0.00 0.957 a 2.04 0.425 b 2.04 0.421 c hb (g/dl) (min-max) 14.6±0.9 (13.5-16.5) 14.3±1.5 (10.2-16.7) 14.5±1.4 (10.5-17.3) -2.05 0.130 a -0.69 0.344 b 1.39 0.187 c hct (%) (min-max) 42.8±2.8 (38.3-48.5) 42.4±3.9 (29.5-51.4) 42.7±3.4 (34.3-50.4) -0.94 0.479 a -0.23 0.858 b 0.71 0.485 c mcv (fl) (min-max) 86.9±5.2 (76.4-96.4) 86.7±9.6 (62.9-105.5) 86.4±10.7 (67.5-110.8) -0.23 0.856 a -0.58 0.658 b -0.35 0.790 c mch (pg) (min-max) 29.7±1.7 (26.5-32.6) 29.3±3.8 (20.8-38.2) 29.2±3.6 (23.4-39.8) -1.36 0.386 a -1.70 0.202 b -0.34 0.730 c mchc (%) (min-max) 34.2±0.7 (33.0-36.0) 33.9±3.2 (27.1-43.8) 34±3.5 (26.2-43.7) -0.88 0.430 a -0.59 0.564 b 0.29 0.872 c rdw (%) (min-max) 13.3±0.9 (11.3-14.6) 13.3±1.2 (10.4-15.8) 13.3±1.1 (10.5-15.7) 0.00 0.813 a 0.00 0.590 b 0.00 0.604 c plt (k/µl) (min-max) 238.6±62.1 (152-446) 241.4±71.5 (133-508) 238.7±57.6 (135-450) 1.17 0.771 a 0.04 0.987 b -1.12 0.401 c rbc=red blood cell; hgb=hemoglobin; hct=hematocrit; mcv=mean corpuscular volume; mch=mean corpuscular hemoglobin; mchc=mean corpuscular hemoglobin concentration; rdw=red cell distribution width. all values were expressed as the mean ±sd. k/µl=thousand cells per microliter; m/µl= million cells per microliter. a, b the significance of difference was checked by independent-sample t-test (compare all vs. control), significant at p≤0.05. c the difference in tramadol abusers were checked by pairedsample t-test (compare post vs. pre-treatment), significant at p≤0.05. table 4 and figure 1 shows the mean values tsh, ft4, ft3, and testosterone among controls and tramadol abusers pre& post-treatment. the mean levels of tsh were significantly increased (2.8±2.0 vs. 1.9±1.0 miu/l, % of change = 47.4, p< 0.001, respectively) in tramadol abuser before treatment compared to control. in contrast, the mean levels of serum ft4, ft3, and testosterone were significantly decreased in tramadol abuser before treatment compared to control (1.1±0.3 vs. 1.4±0.3 ng/ml, 2.6±0.8 vs. 2.8±0.8 ng/ml, and 4.4±1.2 vs. 5.1±1.1 pg/ml, respectively p≤ 0.05). 362 global journal of public health medicine 2021, vol 3, issue 1 gggggglo the mean levels of ft4 were significantly higher in the post-treatment tramadol abusers group than control (1.5±0.5 vs. 1.4±0.3 ng/ml, % change= -7.14, p≤ 0.05). meanwhile, there was no significant difference in the mean of tsh, ft3, and testosterone among post-treatment of tramadol abusers compared to control (1.9±1.0 vs. 2.0±1.0 miu/l, 2.8±0.8 vs. 2.9±1.2 ng/ml, 5.1±1.1 vs. 4.9±1.5 pg/ml, p> 0.05, respectively). clearly, paired t-test illustrated that the mean levels of tsh in tramadol abuser post-treatment were significantly decreased compared to tramadol abuser pre-treatment (2.0±1.0 vs. 2.8±2.0 miu/l, % change = -28.6, p= 0.036, respectively). while, the mean levels of ft4, ft3, and testosterone for tramadol abuser posttreatment were significantly increased compared to tramadol abuser pre-treatment with percent of change 36.37%, 11.54%, and 11.36%, respectively. table 4: serum levels of tsh, ft4, ft3, and testosterone among controls and tramadol abusers (pre & post-treatment) (n=98) hormones controls tramadol abusers % change p-value pre-treatment post-treatment tsh (miu/l) (min-max) 1.9±1.0 (0.5-4.2) 2.8±2.0 (0.6-9.5) 2.0±1.0 (0.4-5.0) 47.4 0.001 a * 5.3 0.396 b -28.6 0.036 c * ft4 (ng/ml) (min-max) 1.4±0.3 (0.8-1.8) 1.1±0.3 (0.1-1.9) 1.5±0.5 (0.3-3.0) -21.4 0.001 a * 7.14 0.003 b* 36.37 0.001 c * ft3 (ng/ml) (min-max) 2.8±0.8 (1.8-4.3) 2.6±0.8 (0.8-4.4) 2.9±1.2 (0.8-5.8) -7.14 0.026 a * 3.57 0.617 b 11.54 0.04 c * testosterone (pg/ml) (min-max) 5.1±1.1 (3.4-8.5) 4.4±1.2 (1.9-7.5) 4.9±1.5 (1.9-9.0) -13.72 0.001 a * -3.92 0.346 b 11.36 0.001 c * sd: standard deviation; tsh: thyroid-stimulating hormone; ft4: free thyroxine; ft3: free triiodothyronine. all values were expressed as the mean ±sd a,b the significance of difference was checked by the independent-sample t-test (compare all vs. control), significant at p≤0.05. c the difference in tramadol abusers were checked by pairedsample t-test (compare post vs. pre-treatment), significant at p≤0.05. 363 global journal of public health medicine 2021, vol 3, issue 1 gggggglo figure 1: serum levels of tsh, ft4, ft3, and testosterone among controls and tramadol abusers (pre & post-treatment). the correlation between hormonal and haematological parameters studied in the study population in table 5. pearson correlation showed a significant positive correlation between tsh levels and plt counts in the study population (r = 0.169, p = 0.018; fig. 2). on the other hand, no significant correlation was found between tsh levels and wbcs (r= 0.033, p= 0.645), rbc (r= 0.022, p= 0.763), hb (r= -0.017, p= 0.815), hct (r= -0.012, p= 0.867), mcv (r= 0.049, p= 0.493), mch (r= -0.054, p= 0.449), mchc (r= 0.008, p= 0.911); and rdw (r= 0.028, p= 0.699). obviously, pearson correlation of the present study showed positive significant correlations between ft4 levels and hb concentrations (r= 0.150, p= 0.036; fig. 2). in comparison, no significant relation between ft4 levels and wbcs (r= 0.11, p= 0.125), rbc (r= 0.135, p= 0.059), hct (r= 0.136, p= 0.057), mcv (r= -0.054, p= 0.451), mch (r= -0.021, p= 0.768), mchc (r= 0.023, p= 0.751), rdw (r= 0.094, p= 0.19); and plt (r= -0.048, p= 0.506). as can be expected, there was no significant correlation between ft3 levels and hematological parameters studied; wbcs (r= -0.063, p= 0.38), rbc (r= -0.024, p= 0.743), hb (r= 0.11, p= 0.124), hct (r= 0.073, p= 0.312), mcv (r= 0.097, p= 0.178), mch (r= 0.123, p= 0.086), mchc (r= 0.051, p= 0.48), rdw (r= 0.105, p= 0.144) and plt (r= -0.022, p= 0.755). after all, testosterone levels revealed a significant positive correlation with rdw (r= 0.164, p= 0.021; fig. 2), nevertheless there is no significant correlation in testosterone levels with wbcs (r= 0.007, p= 0.923), rbc (r= 0.008, p= 0.914), hb (r= 0.114, p= 0.112), hct (r= 0.031, p= 0.671), mcv (r= 0.019, p= 0.791), mch (r= 0.095, p= 0.187), mchc (r= 0.098, p= 0.171), and plt 364 global journal of public health medicine 2021, vol 3, issue 1 gggggglo (r= -0.07, p= 0.329). in brief, the present study showed no significant correlation between hormonal and hematological parameters studied except positive significant correlation between tsh levels & plt counts, ft4 levels & hb concentrations; and testosterone levels & rdw. table 5: the correlation between hormonal and haematological parameters among the study population. parameters tsh (miu/l) ft4 (ng/ml) ft3 (ng/ml) testosterone (pg/ml) r p-value r p-value r p-value r p-value wbcs (k/µl) 0.033 0.645 0.110 0.125 -0.063 0.380 0.007 0.923 rbc (m/µl) 0.022 0.763 0.135 0.059 -0.024 0.743 0.008 0.914 hb (g/dl) -0.017 0.815 0.150 0.036* 0.110 0.124 0.114 0.112 hct (%) -0.012 0.867 0.136 0.057 0.073 0.312 0.031 0.671 mcv (fl) -0.049 0.493 -0.054 0.451 0.097 0.178 0.019 0.791 mch (pg) -0.054 0.449 -0.021 0.768 0.123 0.086 0.095 0.187 mchc (%) 0.008 0.911 0.023 0.751 0.051 0.480 0.098 0.171 rdw (%) 0.028 0.699 0.094 0.190 0.105 0.144 0.164 0.021* plt (k/µl) 0.169 0.018* -0.048 0.506 -0.022 0.755 -0.070 0.329 r: pearson correlation; *p-value significant at p≤ 0.05. 365 global journal of public health medicine 2021, vol 3, issue 1 gggggglo figure 2: the correlation between hormonal and haematological parameters studied in the study population between a) tsh and plt; b) ft4 and hb; and c) testosterone and rdw (c ) (a) (b) (c) 366 global journal of public health medicine 2021, vol 3, issue 1 gggggglo the correlation between tsh, ft4, ft3, and testosterone are pointed out in table 6. serum tsh levels exhibited negative correlation with ft4 (r = -0.375, p< 0.001; fig. 3); ft3 (r= -0.309, p< 0.001; fig. 3) and testosterone (r = -0.455, p< 0.001; figure 3). on the contrary, serum ft4 levels showed positive correlation with ft3 (r = 0.502, p<0.001; fig. 3) and testosterone (r = 0.610, p<0.001; fig. 3). likewise, there was a positive correlation between ft3 and testosterone (r= 0.713, p<0.001; fig. 3). summarily, a negative significant association was found between serum tsh and other studied hormones (ft4, ft3, and testosterone). in contrast, ft4 was positive relations between ft3 and testosterone. also, there were positive relations between ft3and testosterone. table 6: the correlation between studied hormones in the study population hormones tsh (miu/l) ft4 (ng/ml) ft3 (ng/ml) testosterone (pg/ml) r p-value r p-value r p-value r p-value tsh (miu/l) -0.375 <0.001* -0.309 <0.001* -0.455 <0.001* ft4 (ng/ml) -0.375 <0.001* 0.502 <0.001* 0.610 <0.001* ft3 (ng/ml) -0.309 <0.001* 0.502 <0.001* 0.713 <0.001* testosterone (pg/ml) -0.455 <0.001* 0.610 <0.001* 0.713 <0.001* r: pearson correlation *p-value significant at p≤ 0.05. 367 global journal of public health medicine 2021, vol 3, issue 1 gggggglo figure 3: the correlation between tsh, thyroid hormones, and testosterone among the study population (a): the correlation between tsh and ft4 among the study population (b): the negative correlation between tsh and ft3 among the study population (c): the negative correlation between tsh and testosterone among the study population (d): the positive correlation between ft4 and ft3 among the study population (e): the positive correlation between ft4 and testosterone among the study population (f): the positive correlation between ft3 and testosterone among the study population (c) (f) a b c d e f 368 global journal of public health medicine 2021, vol 3, issue 1 gggggglo table 7 illustrated the relation between dose of poisoning and studied parameters (hematological and hormonal). pearson correlation test revealed negative significant correlations between dose of poisoning and ft4 (r= -0.218, p= 0.031) and ft3 (r= -0.211, p= 0.037). however, there was no significant correlation between dose of poisoning and others parameters (wbcs (r= -0.042, p= 0.68), rbc (r= -0.021, p= 0.841), hb (r= -0.176, p= 0.083), hct (r= -0.133, p= 0.193), mcv (r= -0.093, p= 0.364), mch (r= -0.137, p= 0.18), mchc (r= -0.07, p= 0.492), rdw (r=-0.035, p= 0.730), plt (r= 0.008, p= 0.935), tsh (r= -0.027, p= 0.794) and testosterone (r= -0.136, p= 0.182)). obviously, duration of poisoning was no significant correlation with either hematological or hormonal parameters in the study parameters ( r= 0.011, p= 0.913 for wbcs; r= 0.1, p= 0.325 for rbc; r= 0.056, p= 0.585 for hb; r= 0.063, p= 0.54 for hct; r= -0.055, p= 0.593 for mcv; r= -0.052, p= 0.610 for mch; r= 0.001, p= 0.994 for mchc; r= -0.106, p= 0.298 for rdw; r= 0.035, p= 0.732 for plt , r= 0.035, p= 0.735 for tsh; r= 0.118, p= 0.247 for ft4; r= -0.093, p= 0.364 for ft3; and r=-0.142, p= 0.163 for testosterone). therefore, neither hematological nor hormonal affected by duration of poisoning. table 7: the relationships of poisoning duration and dose with studied parameters parameters dose of poisoning (tablet/day) duration of poisoning (years) r p-value r p-value wbcs (k/µl) -0.042 0.680 0.011 0.913 rbc (m/µl) -0.021 0.841 0.100 0.325 hb (g/dl) -0.176 0.083 0.056 0.585 hct (%) -0.133 0.193 0.063 0.540 mcv (fl) -0.093 0.364 -0.055 0.593 mch (pg) -0.137 0.180 -0.052 0.610 mchc (%) -0.070 0.492 0.001 0.994 rdw (%) -0.035 0.730 -0.106 0.298 plt (k/µl) -0.008 0.935 0.035 0.732 tsh (miu/l) -0.027 0.794 0.035 0.735 ft4 (ng/ml) -0.218 0.031* 0.118 0.247 ft3 (ng/ml) -0.211 0.037* -0.093 0.364 testosterone (pg/ml) -0.136 0.182 -0.142 0.163 r: pearson correlation; *p-value significant at p≤ 0.05. 369 global journal of public health medicine 2021, vol 3, issue 1 gggggglo table 8 illustrated the hematological profile correlation between studied tramadol abusers (postand pre-treatment). pearson correlation showed positive significant correlation between preand posttreatment of tramadol abusers in wbcs (r = 0.661, p< 0.001), rbcs (r = 0.391, p< 0.001), hgb (r = 0.848, p< 0.001), hct (r = 0.486, p< 0.001), mcv (r = 0.271, p= 0.007), mch (r = 0.315, p= 0.002), mchc (r= 0.483, p< 0.001), rdw (r = 0.753, p< 0.001) and plt (r = 0.906, p<0.001) fig. 11. meanwhile, there is no significant correlation between controls and tramadol abusers groups (pre & post-treatment) in hematological profile (p>0.05) except in rdw that showed positive significant correlation between controls and tramadol abusers groups in both pre & post treatment (p<0.05). table 8: the correlation between hematological profiles among the study population r: pearson correlation; *p-value significant at p≤ 0.05. discussion tramadol as being one of the opioids which are widely used for the treatment of different degree of pain disorders (ibrahim, 2018), it is considered the most commonly prescribed opioids in the world (fischer et al., 2019; rodieux et al., 2018), but by a long term of tramadol abusing it became the most common causes of drug poisoning in people leading to psychological problems which are considered the causes of mortality and morbidity in many countries (kunzler et al., 2018). many medications that belong to opioids especially morphine in overdose states affect the body because of its toxicity and many of its effects on thyroid hormones and testosterone (sikka & bartolome, 2018). it is noteworthy that tramadol has been being one of the most common scenes of drug poisoning due to drug abuse, notably among adult males worldwide (bamigbade & langford, 1998), as well in the gaza strip, and elsewhere in the middle east. when overdosed, it is, as believed, associated with significant morbidity and mortality (elmanama et al., 2015). parameters post& pre-treatment pre-treatment & controls post-treatment & controls r p-value r p-value r p-value wbcs (k/µl) 0.661 <0.001* -0.140 0.169 -0.125 0.221 rbc (m/µl) 0.391 <0.001* -0.071 0.487 0.014 0.888 hb (g/dl) 0.848 <0.001* -0.155 0.127 -0.103 0.312 hct (%) 0.486 <0.001* -0.032 0.756 -0.075 0.461 mcv (fl) 0.271 0.007 -0.106 0.297 0.023 0.822 mch (pg) 0.315 0.002 -0.059 0.566 0.103 0.314 mchc (%) 0.483 <0.001* -0.003 0.978 -0.101 0.324 rdw (%) 0.753 <0.001* 0.527 <0.001* 0.748 <0.001* plt (k/µl) 0.906 <0.001* 0.112 0.270 0.148 0.147 370 global journal of public health medicine 2021, vol 3, issue 1 gggggglo the present study demonstrated that there was an association between some socio-demographic characteristics and tramadol abusing which included age, smoking, the governorates, employment status, and marital status. this indicates that the socio-demographic characteristics affected results as confiding. there was a matching between tramadol abusing and controls in most of these characteristics. in our results, there was an association between marital status and tramadol abusing and that may be due to the use of tramadol as a way for treating premature ejaculation (abdel-hamid et al., 2016). also, in the present study, tramadol abusers' data showed that about (71.4%) of the abusers were a high educational level this percentage is critical especially with the difficult socioeconomic status along with a life of hardship and unemployment. the results showed that the gaza governorate had a high percentage of tramadol abusing this may be due to area or patient selection also this study demonstrated that the route of ingestion of tramadol was the oral route of intoxication; this is probably because tablets are widely available in gaza strip, cheapest and easiest to use. dispersion of injectable forms of tramadol is limited to non-private or private pharmacies and hospitals (leppert, 2009). this is in agreement with a study performed in iran, showing that the majority of people seeking tramadol from pharmacies are young adults taking tramadol orally, with the criteria for drug addiction (zabihi et al., 2011). most patients were addicted to a tramadol dose of more than 500 mg using opioid overdose according to previously published data that considered the total daily dose should not exceed 400mg for adult therapeutic blood levels of 0.1-0.8 mg/l (clarot et al., 2003). to the best of our knowledge, there are no studies aimed to assess the hematological parameters for follow up of tramadol administration, neither other opioids, until the date of the writing of this manuscript. it was found that the drug abuse exhibited no significant observations in the mean level of wbcs, rbcs, hb, and hct mcv, mch, mchc, and plt parameters. this is probably explained as the drug has no side effect on either hemopoiesis or iron metabolism by any means. our current results showed that the mean levels of tsh were significantly higher among tramadol abusers at baseline compared to control (p≤ 0.05) also it is demonstrated that tsh after treatment was significantly lower than before treatment. this study is the first to test thyroid hormones on tramadol abusers in gaza strip, and the results show similarity to other studies at the tsh levels due to reduction of thyroid function, which in turn led to decreased ft3 and ft4, because of the known consequences of mu opioid peptide (mop) receptor agonists, which affects the neuroendocrine system causing reduced hypothalamic-pituitary-gonadal axis (rhodin et al., 2010). from other previous studies, the administration of opioids showed an altered hypothalamus-thyroid axis similar results were documented (gozashti et al., 2014). 371 global journal of public health medicine 2021, vol 3, issue 1 gggggglo the mean levels of free t4 and free t3 were significantly lower among tramadol abusers compared to control at baseline. while after detoxification treatment the mean levels were significantly higher compared to the baseline of the study. when studying thyroid hormones, there were significant alterations in the thyroid axis. ft3 and ft4 were lowered, whereas tsh was increased in addicted patients compared to their pretreatment results and control cases. from other previous studies, the administration of opioids showed an altered hypothalamus-thyroid axis (gozashti et al., 2014). studies on morphine and heroin showed lowered hypothalamus-thyroid axis activity (gozashti et al., 2014). a recent study on opium showed different findings, for instance, ft3 and total t3 were decreased, whereas ft4 and total t4 were increased and so tsh (gozashti et al., 2014). studying testosterone showed significantly lowered levels of the hormone among drug abusers compared to their pretreatment results and the control group (table 6). this finding in agreement with (ahmed & kurkar, 2014); (abdellatief et al., 2015) who found significantly reduced plasma levels of testosterone in albino adult male rats which were subcutaneously injected with 40 mg/kg of tramadol, three times per week for 8 weeks compared with the control group. these results were somehow predicted at the time other studies on opioids showed similar results (handa et al., 1994), which also can be explained as a result of the reduction of the hypothalamicpituitary-gonadal axis. conclusion: finally, we conclude that serum hormonal levels of tsh, ft4, ft3, and testosterone exhibited a positive correlation between tramadol abuser's pre-detoxification and post detoxification, where the level of testosterone in pre detoxification of tramadol abusers was significantly lower than controls and was significantly lower than its results after detoxification. there is no significant correlation between controls and tramadol abusers' groups (pre & post-treatment) in hematological profile except in rdw that showed a positive significant correlation between controls and tramadol abusers' groups in both pre & post-treatment. there was no significant correlation between the duration of poisoning and hematological or hormonal parameters in the study parameters. the hormones level including (tsh, testosterone, ft4, and ft4) should be testing as monitoring for tramadol abusers. more research concerning other hormone tests may be performed to increase awareness for people about the toxic effects of tramadol. our study has some limitations: first, sample collection was relatively difficult as many patients refuse to participate in the study and difficulty obtaining samples from females due to the very limited of female tramadol abusers. second, the delay of performing some hormonal and biochemical parameters into some days due to unavailability of kits reagents. third, the delay of some samples due to electricity off. and four, the lack of relevant studies made the comparison somewhat difficult. acknowledgments we would like to thank the participants who participated in the data collection, with many thanks to the ministry of health in gaza strip for their cooperation. conflicts of interest: the authors declare no conflicts of interest. 372 global journal of public health medicine 2021, vol 3, issue 1 gggggglo references • abdel-hamid, i. a., andersson, k.-e., waldinger, m. d., & anis, t. h. 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(2011). potential for tramadol abuse by patients visiting pharmacies in northern iran. in: sage publications sage uk: london, england. microsoft word gjphm-2021periodontal diseases .docx 341 global journal of public health medicine 2021, vol 3, issue 1 gggggglo review research covid-19 pandemic and perspective convergence with periodontal diseases asem mohamed kamel1, ibrahim m. mwafey1, ibrahim h. ibrahim1, ahmed hussein gaber2 1department of oral medicine, periodontology, oral diagnosis and dental radiology, faculty of dental medicine al-azhar university (assiut branch) assiut, egypt 2department of oral pathology faculty of dental medicine al-azhar university (assiut branch) assiut, egypt *corresponding author: asemali.dent.ast.b@azhar.edu.eg abstract this review aim to discuss the important components of coronavirus disease (covid-19) and possible correlations, interactions with oral/periodontal structures. with the beginning of the announcement of the transformation of covid-19 from an epidemic into a pandemic, it was necessary to realize the injury of several million people infected with this disease and others will become infected soon and its impact on public health as well as the adverse effect of chronic diseases and their causes for the spread of covid-19. chronic periodontal diseases are one of the most widespread diseases around the globe and one of their supposed causes is the presence of many microbial plaques, including bacteria and viruses. presence of coronavirus receptors on the cells of the oral mucosa, and cells of the periodontal pockets, may give a way to adhere the virus and spread inside the body through the periodontium. sars-cov-2 virus was found in some saliva samples. a conceivable relevance between periodontitis and covid-19 has been hypothesized. defense against covid-19 in dental clinical consist of three ascending levels. it is advised to utilize a mouth rinse against sars-cov-2. at end of this review, oral health providers and periodontists will gain essential knowledge to the successful confrontation against the coronavirus disease (covid-19). keywords: sars-cov-2, covid-19, periodontal diseases, pandemic. 342 global journal of public health medicine 2021, vol 3, issue 1 gggggglo introduction in association with specific bacterial pathogens like red complex bacteria, etiopathogenesis of periodontal diseases may include many viruses as active herpesviruses, and it associated with unbalanced immune restraint including pro/anti-inflammatory cytokines (slots 2015). some viruses like herpesviruses act by infect or alter periodontium components and immune cells within periodontium and thereby decease efficiency of periodontal tissues to overcome bacterial overloads (contreras et al., 2014). synergistic effects of viruses enhance microbial replication or infectivity of another microbes. the human immunodeficiency virus (hiv) with specific epstein-barr virus (ebv) progenies show growing replication within cd-4 cells (zhang et al. 1997). with assisting of herpes simplex virus (hsv)-1, hiv can enter keratinocytes, which are commonly avoider to invasion as these cells don't have the cd4 molecule (heng et al., 1994). the aftermost evidence for a possible microbial correlation between human herpesvirus 4 (ebv) and some periodontpathogenomic bacteria in periodontal etiopathogenesis was reported in observations suggested that butyric acid by-product of periodontal bacteria have the capacity to target epstein-barr virus reactivation in the periodontium of ebv-infected individuals and control switching from latency to reactivation considered as an initial step in ebv infection (imai & ogata, 2020). redondoviridae, a family of tiny, annular dna viruses newly located in metagenomic series map, can assist and persist the inflammation status associated with periodontal diseases and contribute to disease aggression via their infection and replication (abbas et al., 2019) (figure.1). acute virally infected patients are showing high accretion of bacterial invasions. the study of influenza outbreaks in humans gives the clearest and strongest clue of the effect of viral infections on the spread of bacterial diseases. streptococcus pneumonia and staphylococcus aureus bacterial super infections result in altitude of morbidity and mortality during influenza epidemics (abramson & mills, 1988) (figure.1). 343 global journal of public health medicine 2021, vol 3, issue 1 gggggglo figure.1 showing potential sites of coronavirus (sars-cov-2) in oral cavity and possible polymicrobial interactions between bacteria and viruses which leading to synergism, stability, coinfection, bacterial superinfection. abbreviations; (gcf, gingival crevicular fluid), by the beginning of 2020, “world health organization” (who) termed the virus severe respiratory syndrome-coronavirus-2 (sars-cov-2), constructing it as major outrage for acute respiratory distress syndrome (ards), and the malady was termed “coronavirus disease 2019 (covid-19)”. by the time, a state of covid-19 became pandemic, and it was known as a public health contingency of international disquiet (j. wong et al., 2020;khongsai et al., 2020). coronaviruses are determined as the massive group of viruses, which being owned by the nidovirales order, including coronaviridae (alpha, beta, gamma, and delta), arteriviridae, and roniviridae families. their main structures are coated, undivided positive-sense rna. digestive and respiratory sickness in animals, and fatal respiratory distress in persons can be caused as manifestations of coronavirus infection (fehr & perlman, 2015). as members of coronaviridae family, severe acute respiratory syndrome coronavirus (sars-cov), specified in 2002, and the middle east respiratory syndrome coronavirus (mers-cov), specified in 2012 (wax & christian, 2020). newly incoming betacoronavirus (sars-cov-2) has resemblance to coronavirus species habituated in bats and pangolins, supporting the zoonotic essence of this recent wandering viral-mediated disease (zhou et al., 2020; wahba et al., 2020;pandey et al., 2020) the components of sars-cov-2 structure include a nucleocapsid(n) with a single stranded rna core, a spherical lipoprotein envelope(e) and matrix protein(m) with protruding spike shape proteins (s), which are adhering to specific receptors of the host cells to be infected (gorbalenya et al., 2020) (figure.2). sars-cov-2 needs incubation period from 1 to 14 days to be contagious in its latency interval (pereira et al., 2020). its replication cycle was correlated with the harmful impacts, appearing as cellular lesions and increased cell death (earar et al. 2020). viruses have stealth capacity to escape 344 global journal of public health medicine 2021, vol 3, issue 1 gggggglo from host immune defense and to inactivate the host interferon system which interfering with pattern recognition receptors (prrs) alerting routes to evade host defense (kindler et al., 2016). the sars-cov n proteins inhibit retinoic-acid inducible gene i (rig-i) conjunction with ubiquitin and thus decrease the emission of type i ifn (interferon) (hu et al., 2017). m proteins restrains tnfrassociated factor/ tank-binding kinase (traf3/ tbk1) complex formation and blocks activation of interferon regulatory factor 3 / interferon regulatory factor 7 (irf3/irf7) transcription factors (siu et al., 2009). the sars-cov nonstructural protein (nsp1) prohibits host mrna translation and initiates host mrna degradation [(tanaka et al., 2012;huang et al., 2011). three routes of the sars-cov transmission have been found. firstly, contact transmission: when someone touches an infected object and subsequently touches his mouth, nose or eyes. secondly, droplets transmission: when the droplets generated by cough and sneezes are ingested or inhaled. finally, airborne transmission: when air contaminated by droplets, creating aerosols that results in infection if inbreathed (adhikari et al., 2020; harte, 2010) . fecal-oral transmission is considered possible as well (zhang et al., 2020). figure 2. showing fictional form for coronavirus (sars-cov-2) and its structures; also, possible host cell membrane receptors. 345 global journal of public health medicine 2021, vol 3, issue 1 gggggglo during the massive spread of pandemic covid-19, attention to use tele-communication or teledentistry prior periodontal management to estimate the patient status also to diminish the risk of virus spread, quizzing if sickly person has common cold/ bronchitis symptoms and have went abroad national or internationally. in this significance, the treating team members necessarily use clinical judgment remotely and every possible precaution must be taken to prevent disease transmission (pereira et al., 2020). in dental clinics, many necessary and successive measures must be taken during the rapid spread of the covid-19 epidemic as follows; waiting room for one patient only , strict adherence to the infection control procedures, ideal steps of wearing and taking off all personal protective equipment (ppe), including protection tools for all exposed skin, eyes, mouth, face and hands (pereira et al., 2020). before beginning of treatment, a patient rinsing with 1% or 1.5% hydrogen peroxide or 0.2% povidone also he should wear goggles and apron until ending of procedure (pereira et al., 2020). aerosols generation must be limited through using manual instruments and high-suction for saliva during the periodontal therapy and avoiding 3-in-1 chip syringe (kharma et al., 2015). sars-cov-2 colonization into periodontal pockets a periodontal pocket is a unique isolated site in the human body, presenting qualified biotic dynamics, with bidirectional linkage with the oral environment via periodontal crevicular fluid exudate on one direction and systemic circulation via gingival peripheral blood capillary networks on the other hand (badran et al., 2020). initial viral infection of periodontal tissues have occurred through direct contact of gingival epithelial cells exposed to the oral cavity with virus, or virus wandering and entrance via the blood supply or virally affected defense cells in the periodontal inflammatory transudate (c. s. miller, 2014). the viral observations in periodontal pocket, have been affirmed such as herpes simplex virus (hsv) type 1, type 4 (ebv) and type 5(hcmv) (cappuyns et al., 2005). the main gate of coronavirus is proposed to be by emerged droplets results in a former nexus and habitation of cells in the oral environment (lo giudice, 2020). the main receptors to this virus are angiotensin converting enzyme-2 (ace-2) (zou et al., 2020) , furin (proprotein convertase) (izaguirre, 2019) and cluster of differentiation 147 (cd 147) (k. wang et al., 2020) ; these receptors were highly expressed in fibroblasts of periodontium ligaments (santos et al., 2015) , in oral epithelial cells (zhong et al., 2020) and the sulcular epithelium of periodontal pocket (feldman et al., 2011). coronavirus’ conjugation to membrane receptors, are suitable with an assumed attachment to periodontal pocket. this could encompass the sulcular/gingival epithelial lining also the gingival/periodontal fibroblasts (badran et al., 2020) . by different pathway, sars-cov can invade and reproduce in mononuclear cells (infecting t-lymphocytes) but for a short span (x. wang et al., 2020). also, the invasion of endothelial cells by sars-cov-2 seems conceivable (varga et al., 2020). it was hypothesized that periodontal pocket could represent a repository of sars-cov-2 depending on harmonious and feasible surveillances (badran et al., 2020). 346 global journal of public health medicine 2021, vol 3, issue 1 gggggglo blatant pandemic covid-19 and calm pandemic periodontitis one of pathophysiological mechanisms of covid-19 was introduced to be correlated to a ‘cytokine storm’ which appearing as supreme serum levels of proinflammatory interleukins. clinical studies in covid-19 patients showed that manifestations of the cytokine storm matched up raised th17 pathway (wu & yang, 2020). periodontal disease has a sophisticated interlace pathophysiology with increased affirmations of immunological participations; demonstrating that patients suffering from periodontal disease, having increased aggregate of interleukin-17 (il-17) in the serum as well as rise il-17 output cells in gingival tissue (graves, 2008). a probable consortium between periodontal diseases and covid-19 related detrimental consequences has been hypothesized. future and present recognition of this correlation emphasizes the significance of maintaining periodontal conditions with continuous screening and the importance of keeping exacting oral hygiene in the covid-19 interval and beyond. this probable association also tip across the potency of the existence of periodontal disease as catalyzer towards covid-19 related detrimental effects (sahni & gupta, 2020). virtual existence of sars-cov-2 in saliva during periodontal diseases the salivaomics motif which constituting from genomics, transcriptomics, proteomics, metabonomics and microrna (mirna) screening was proposed by wong in 2012 to appear from nowhere to existence ( wong, 2012;santosh et al., 2020) . many salivary mediators have been used for the scientific periodontal disease’s assessment. porphyromonas gingivalis salivary kit which is depended on an enzyme-linked immunosorbent assay (elisa) has been introduced and endued rapid results within 90 seconds with high sensitivity and a specificity (o’brien-simpson et al., 2015). as periodontal diseases can be associated with more than 70 genes (karimbux et al., 2012), salivary genomics represent recent appealing way for the periodontal diagnosis. after analyzing salivary dna, it was legitimized that il-6 genetic mutations are one of considerable hazards for chronic periodontitis (song et al., 2013). recently, viral infections identification by salivary biomarkers, such as viral dna, rna, antigens and antibodies was broadly used. moreover, saliva considered to be more sensitive than serum in the assessment of human herpesvirus-6 or human cytomegalovirus (nefzi et al., 2015).for detecting the hepatitis c virus, oraquick® hepatitis c virus rapid antibody test was used via a saliva samples (parisi et al., 2014). covid-19 disease is very prevalent and super-contagious even to those who have all the means of protection and precautions from members of medical teams, especially at the beginning of diagnosis and diagnostic sampling via nasopharyngeal or oropharyngeal specimens, as a result of close proximity to potentially diseased individuals. in patients with condition such as thrombocytopenia, 347 global journal of public health medicine 2021, vol 3, issue 1 gggggglo nasopharyngeal or oropharyngeal swabs could result in discomfort and provoke bleeding (chan et al., 2020). in hong kong public health laboratory services branch, saliva from twelve confirmed covid19 patients was gathered and submitted to nucleic acid extraction and real-time reverse transcriptionquantitative polymerase chain reaction. virus was detected in 91.7% of the initial saliva samples. in 33 recovered patients, both nasopharyngeal and saliva specimens tested negative for covid-19 (to et al., 2020). extraction of viral rna from salivary fluid was a potent gateway for covid-19 diagnosis and has the same fulfillment to the advisable swab-based collection specimens. with the universal insufficiency of swabs for diagnosis and huge increased covid-19 patients, salivary swabbing will be useful, and will be dimming the demand of health care specialists to round up samples (anjum, 2020). potential diagnostic and prognostic biomarkers for covid-19 disease, could be including salivary elisa of antibodies against sars-cov-2, sars-cov-2 double-membrane extracellular vesicles (evs) isolation, anti-sars-cov-2 surface proteins, viral titers load, cd4+/cd8+ t cells derived evs, and proinflammatory cytokines. indeed, an ideal indoor saliva test would be a nonreturnable ready device used by patients, avoiding contact to a prospect environmental virus infection hazard (han & ivanovski 2020). potential relevance between covid-19 and periodontal diseases gingiva that possesses angiotensin-converting enzyme 2 (ace2) sensors would be given a conceivable track for sars-coronavirus-2 entrance (xu et al., 2020) (balaji et al., 2020). in chronic periodontitis, gingival cells have established much amount of osteopontin, which resulting in elevated the protease furin level (sharma & pradeep, 2007; kumar et al., 2010) . besides furin, cathepsin l level is also heightened (trabandt et al. 1995). by assistance of furin and cathepsin, sars-coronavirus-2 enable to invade the host cells. furin divides the s protein of the virus into s1 and s2 subunits (zhong et al., 2020) (hoffmann et al., 2020), then s1 subunit coheres to the angiotensin-converting enzyme 2 (ace2) located at cell surfaces (xia et al., 2020). then final fusion occurs via two ways, cysteine proteases cathepsin b/l participation for endosomal fusion or serine protease participation for plasma membrane fusion (xia et al., 2020). it can be assumed that the massive protease amount in chronic periodontitis could imaginably maximize endangering of an oral mediated sars cov-2 infection (xu et al., 2020). 348 global journal of public health medicine 2021, vol 3, issue 1 gggggglo periodontal diseases as reflex of general health on covid-19 reported hospital-acquired pneumonia complications in periodontally diseased patients are more likely to be developed because respiratory pathogens, including chlamydia pneumoniae were hiding in oral cavity (almeida-da-silva et al., 2019; scannapieco, 1999, 2006). adequacy of oral microbes to aggravate lung contagions may be explained; via (1) entrance of oral microbes inside the lower respiratory tract, predominantly in debilitating patients (2) changes of mucosal cells throughout the length of the respiratory system by actions of salivary enzymes, which thereby favoriting pathogens habitation (3) pro-inflammatory cytokines discharge through periodontal diseases, which enhancing coalescence to respiratory epithelium and settlement by respiratory microbes (gomes-filho et al., 2010; varanat et al., 2017). oral status amelioration and refined regular periodontal interest diminish the succession or initiation of respiratory diseases, seriously in the senescent age and very ill patients (azarpazhooh & leake, 2006). this population is also at extreme hazard for incubating critical complications concerned to covid-19 (boccardi et al., 2020; swiss, 2020). ameliorative periodontal condition in people of any age will diminish their endangering of developing any systemic diseases and this may eliminate the ailment of covid-19 (botros et al., 2020). massive effects of covid-19 on oral/periodontal conditions appear to be multi-directional, immunerelated and supposedly indirect, expressed by several pathways, representing the pathological severity of coronavirus invasion/ stealth via mucosal surfaces (dziedzic & wojtyczka, 2020). periodontal treatment and covid-19 aerosols with contaminated saliva that generated by any dental procedure, can seriously elevate airborne contamination with microbes (micik et al., 1971). aerosols are defined as tiny diameter airborne particles with lesser 50-micron which persisting as suspensor for extended time and increase incidence of circumferential dirtiness and gets pathway into respiratory system. beside aerosols, airborne matters with oversized than 50-micron diameter which too large to persist as suspensor in air for protracted periods, are known as splatters. splatters are considered as droplets get out vigorously in a defamatory way like a missile until they contact a subject (harrel & molinari, 2004; miller et al., 1971). with talking, cough or sneeze, scattered virus can sustain for a longer interval as suspensor in surrounding area and may be prevailed via breathing in or communicate with infectious individuals. in 25-28 celsius degrees, sars-cov-2 sticks on surfaces (inanimate flatness) across nine days, but its vitality is determined by the nature of the surfaces. it still infectious for several hours, 2-3 days, 5 days and more than 5 days in aluminum and copper, stainless steel and plastic, ceramics, and paper and glass respectively (kampf et al., 2020). selected aerosol paradigms showed that virion integrity can reach up to 16 hours pended in air under scanning electron microscope (fears et al., 2020). 349 global journal of public health medicine 2021, vol 3, issue 1 gggggglo the mechanism of defense against covid-19 in dental clinical consist of three levels. the primary level is private preservative kit such as gloves, eyeglasses and masks. the secondary level is oral rinsing with antiseptics and the tripartite level is the use of high-speed suction and adjunctive high efficiency particulate air (hepa) filters (bauchner et al., 2020). by contact time fifteen second, 0.25% to 0.5% povidone-iodine (pvp-i) showed prompt viricidal activity against sars-cov-2 (‘coronavirus’) to lessen the danger of propagation of the infection in the practical field. therefore, the 10% (pvp-i) antiseptic formula should be diluted by 1:20, employing mixture of 0.5 cubic centimeter of 10% povidone iodine and 9.5 cubic centimeter of sterile water for single use at 0.5% povidone iodine concentration (bidra et al., 2020). oxidizing agents such as citrox (flavonoids as coronaviral chymotrypsin-like protease inhibitors) is used as mouth wash to constrict the virus’s tonnage, encompassing potential sars-cov-2 transit. these oxidizing mouth rinses that comprise cyclodextrins combined with citrox could supply beneficial adjunctive periodontal therapy. locally administered delivery systems that containing cyclodextrins combined with citrox or 0.5% povidone iodine, could diminish the sars-cov-2 virus’s tonnage and minify the nasopharyngeal microbes, through coating aerosol and droplets throughout its rush from mouth (carrouel et al., 2020). currently, the effects of covid-19 around our planet are worsening continuously (kassaw & pandey, 2020). medical and scientific research community learns more about covid-19 with more blinded, randomized clinical trials will be performed. more future knowledge about novel coronavirus pathogenesis and its effect on periodontal tissue, microbiome interactions and possible genome/epigenome will open horizons in the relationship between covid-19 and periodontal diseases. conclusion as coronavirus was detected in saliva and epithelial cells of periodontal pocket have receptors to coronavirus attachment, this review concluded that there is close convergence between periodontal diseases and covid-19. conflicts of interest: the authors declare no conflicts of interest. references • abbas, a. a., taylor, l. j., dothard, m. i., leiby, j. s., fitzgerald, a. s., khatib, l. a., collman, r. g., & bushman, f. d. 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(2020). single-cell rna-seq data analysis on the receptor ace2 expression reveals the potential risk of different human organs vulnerable to 2019-ncov infection. frontiers of medicine, 1–8. microsoft word gjphm-2020-europe 2.docx 179 global journal of public health medicine 2020, special issue review research covid-19 most affected age groups and lethality in europe abduladheem turki jalil faculty of biology and ecology , yanka kupala state university of grodno corresponding author: abedalazeem799@gmail.com abstract introduction: the outbreak of a novel coronavirus disease (covid-19; previously known as 2019ncov) was the beginning of one of the largest and most critical covid-19 clusters in the world since late december 2019. despite intensive prevention measures, the epidemic tends to propagate and the number of patients infected is growing. the case-fatality incidence was very high and is driven by very elderly people. methods: in this study, we collected data from the (covidgraph.com) database as the number of infection cases in the world reached 2736188 infections and the number of recovery cases reached 751805 and the number of deaths reached 191423. results: it turns out that the virus infects older people and the older a person is, the higher the chance of infection with the virus. results from this analysis the mean age of death is 78 years. data from 106,399 cases and 12,550 deaths in italy, to 2 april. in spain, they are based on 7 april, 88,144 cases, and 3,479 deaths. there were less than 80 deaths in patients younger than 50 years of age. conclusion: coronavirus is a global epidemic, and it's hard to control, and it's not enough to prevent people from spreading the virus. the age groups most vulnerable to lethality are shown in this paper, in italy, the virus destroys people over 75 years of age, in spain, however, the virus destroys people aged over 85 taking into account numerous comorbidities, including psychiatric, cerebrovascular, endocrine, metabolic, and respiratory disorders. keywords : covid-19, epidemic, europe, lethality, patients 180 global journal of public health medicine 2020, special issue introduction the novel coronavirus disease (covid-19) triggered pneumonia in 2019 is an extremely contagious disease and the current epidemic has been proclaimed a global public health emergency by the who (lai et al., 2020). and in december 2019, covid-19 pneumonia was first recorded in wuhan, hubei province, china, preceded by an epidemic province of hubei, and other parts of the world (surveillances, v. 2020). continued coronavirus disease outbreak 2019 (covid-19) is a major public health issue in europe. several european countries registered cases of covid-19 imported from italy, the european epicenter for some european countries’ local transmission of covid-19 has been reported. as of 10 march 2020, reported cases of covid-19 in italy reached 10,000, in spain, france and germany surpassed 1,000, and in other european countries rose rapidly. (who, 2020). to date, most affected patients with sars-cov-2 have experienced minor symptoms include dry coughing, sore throat, and fever (xu, x. w et al.,2020). and many situations have been settled naturally. however, some fatal incidents have resulted, organ collapse, septic shock, lung edema, severe pneumonia, and acute respiratory distress syndrome (ards) involved (docea et al.,2020). and in-vitro studies have shown that chloroquine, an immunomodulant drug widely used to treat malaria, has been effective in reducing viral replication in some infections, including sars (cov) and merscov associated with coronavirus. (cortegiani et al.,2020). also for those afflicted with sarscov-2, 54.3 percent are males for average age 56. patients who needed urgent care were, also, older and had many comorbidities, including psychiatric, cerebrovascular, endocrine, metabolic, and respiratory disorders (wang et al.,2020). and the patients who sought intensive care were also more likely to suffer dyspnoea, dizziness, stomach pain, and anorexia. also, covid-20 (coronavirus disease-2019) is a public health epidemic around the world. patients with a serious form of disease-account for about 15 percent of accidents. since that time no single, effective, recorded pharmacological treatment has been established (kahn 2020). the research aims to determine the ages most vulnerable to coronavirus infection, and also to research the most lethal ages in europe due to covid-19. methods this study was carried out by collecting data from (covidgraph.com) people who were infected with coronavirus when the virus appeared worldwide in 2019. cases of patients that were diagnosed and confirmed to be infected with coronavirus in the world, the number of patients reached 2736188 and the number of recovery cases reached 751805 and the death toll reached 191423.the data are based to april 7, 2020, the study includes data regarding the deadliest age groups due to coronavirus. data was distributed according to age. in this study, in terms of the most infected age groups and those most vulnerable to covid-19, we discussed data for those infected in italy and spain. 181 global journal of public health medicine 2020, special issue results as a result, it turns out that the virus infects older people and the older a person is, the higher the chance of infection with the virus. results from this analysis are seen as seen in figure 1and 2, the mean age of death is 78 years. data from 106,399 cases and 12,550 deaths in italy, to 2 april. in spain, they are based on 7 april, 88,144 cases, and 3,479 deaths. there were less than 80 deaths in patients younger than 50 years of age. figure 1: patient age groups and age relation in italy and the percentage of lethality shown source: https://covidgraph.com (accessed on april 7 , 2020) 182 global journal of public health medicine 2020, special issue figure 2: patient age groups and age relation in spain and the percentage of lethality shown source: https://covidgraph.com (accessed on april 2 , 2020) 183 global journal of public health medicine 2020, special issue discussion in december 2019 in wuhan, hubei province, china, a group of patients with pneumonia of unknown cause is reported to be infected with a novel coronavirus, known as 2019-ncov, that had not previously been identified in humans or animals (xu, x. w et al.,2020).the median age of death is 78 years old. data based on 106.399 cases and 12.550 deaths in italy where the patients were divided based on age groups from (0-9) to (80-89) and more than 90 years, and in (70-79) 21.8% and in (80-89) 30.9% and in ages over 90 for a year, the lethality rate was 28.7%, and the lethal rate among the age groups was 11.8%,and the highest incidence of coronavirus among the following age groups (60-69) (70-79) (50-59) was 17.0%, 18.1%, 19.7%. choosing to describe covid-19 death in this way may have contributed to an overestimation of the rate of case-lethality. ischemic heart disease, diabetes, cancer, atrial fibrillation, dementia, stroke history. the presence of these comorbidities may have raised the risk of mortality independent of infection with covid-19(onder, g., et al 2020). the incidence of caselethality was very high and is dominated by very old patients (livingston, e., & bucher, k. 2020). in spain, the data are based on april 7, 88,144 cases, and 3,479 deaths. less than 80 deaths occurred in patients younger than 50 years of age, divided by age group and lethality by coronavirus, the mortality rate was 0.20 percent, 0.20 percent, 0.20 percent, 0.40 percent, 0.90 percent, 2.80 percent, 9.50 percent, and 19.10 percent, respectively. the lethality was very high in people over 90 years of age and was 23.20 percent higher than the rest, the highly contagious nature of the virus and the large number of asymptomatic people infected and the absence of a vaccine, implies that social distancing is critical in fighting the spread of the virus and preventing a health system collapse. social distancing can be accomplished by the cooperation of the community and voluntary compliance. this, however, needs high amounts of altruism – internalizing the social distancing harm for the good of society at high (amat et al., 2020). in figure 2, the largest age groups infected with the coronavirus were 16.2%, 16.9%, 18.8% in the following age groups (70-79), (60-69), (5059). given the recent rapid rise for spain and france, recent cases covid-19, transmissibility in real-time, and control of mortality are a concern. since the epidemic covid-19 remains a major concern in germany, it is important to read the interventions on low mortality. many european countries will continue to prepare and respond to covid-19 and will learn about various preventive and control measures from italy, spain, france and germany (yuan, j et al., 2020). the recommendation given that the hubei region in china has a marginally smaller population than italy (about 50 million in hubei and 60 million in italy), the most successful way of suppressing this viral epidemic in european countries is possible to prevent direct interaction at the individual level and social meetings in each group. (remuzzi et al.,2020). stricter surveillance and control steps to limit the spread of covid-19 are recommended in some countries. locking-out findings in italy remain unclear. in new cases of covid-19, quarantining hubei province including the epicenter of wuhan city, proved successful in slowing the drastic rise. continued tracking in addition, new cases of covid-19 reported in italy are needed to help assess the effect of the italian lockdown. the hubei province quarantine also prevented covid-19 from spreading to other areas of china and across the globe. active surveillance of new cases of covid-19 found in other european countries would enable european and local authorities to better understand the consequences of lockups outside italy. (yuan et al., 2020). conclusion coronavirus is a global epidemic, and it's hard to control, and it's not enough to prevent people from spreading the virus. the age groups most vulnerable to lethality are shown in this paper, in italy, the virus destroys people over 75 years 184 global journal of public health medicine 2020, special issue of age, in spain, however, the virus destroys people aged over 85 taking into account numerous comorbidities, including psychiatric, cerebrovascular, endocrine, metabolic, and respiratory disorders. conflicts of interest the author declare no conflicts of interest. references: • amat, f., arenas, a., falcó-gimeno, a., & muñoz, j. (2020). pandemics meet democracy. experimental evidence from the covid-19 crisis in spain. • cortegiani, a., ingoglia, g., ippolito, m., giarratano, a., & einav, s. 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(2020). clinical findings in a group of patients infected with the 2019 novel coronavirus (sars-cov-2) outside of wuhan, china: retrospective case series. bmj, 368. • yuan, j., li, m., lv, g., & lu, z. k. (2020). monitoring transmissibility and mortality of covid-19 in europe. international journal of infectious diseases. 16 global journal of public health medicine 2019, vol 1, issue 1 gggggglo improving the antibacterial activity by the combination of zirconium oxide nanoparticles (zro2) and ceftazidime against klebsiella pneumoniae sarah naji aziz 1* ,karrar jasim al-sallami 1,2 ,suhad yassein abd 1 ,ali muhsin ali al-musawi 1 murtadha adnan mohammed 1 ,al-maamoon h. abed 1 & sundus qasim mohammed 1 1college of science, mustansiryiah university, baghdad, iraq 2college of science, mansuora university, egypt corresponding author: sarahnaji2015@gmail.com abstract introduction: klebsilla pneumoniae is one of must opportunistic pathogens that causes nosocomial infection, uti, respiratory tract infections and blood infections. zro2 nanoparticles have antimicrobial activity against some pathogenic bacteria and fungi. ceftazidime is one of third generation cephalosporins groups of antibiotecs, characterized by its broad spectrum on bacteria in general and particularly on enterobacteriaceae family like klebsiella spp. method: diverse clinical samples of klebsilla pneumoniae were isolated from several hospitals in baghdad – iraq and zro2 nanoparticles was investigated against it. ceftazidime was also investigated against k. pneumoniae. both of zro2 nanoparticles and ceftazidime were mixed together and investigated against k. pneumoniae. results: the result showed that zro2 nanoparticles were effectivity on inhibiting opportunistic pathogens. by using zirconium oxide nanoparticles on klebsiella pneumonia isolates in 24h. of incubation time, inhibition zones were (38,34,10,10,8,0) mm respectively on agar plates. by using ceftazidime alone against the same bacteria inhibition zones were (40,32,10,9,8,0) mm. respectively. conclusion:the present study results that the antibacterial activity of ceftazidime against bacteria was increased when combination between zro2 nanoparticles and the antibiotic had done, because, inhibition zones in case of mixing both of zro2 nanoparticles and ceftazidime were (43,40,12,12,10,0) mm respectively. so that we can conclude that the combination of zirconium oxide nanoparticles (zro2) and ceftazidime was a useful method for the treatment of klebsilla pneumonia that cause nosocomial infection, uti, respiratory tract infections and blood infections. keywords: zro2 nanoparticles, klebsiella pneumoniae, antibacterial activity, ceftazidime. 17 global journal of public health medicine 2019, vol 1, issue 1 gggggglo introduction klebsilla pneumonia, a part of enterobacteriaceae family, a gram-negative, motile rod-shaped bacteria. typical klebsiella pneumoniae is an opportunistic bacteria that cause nosocomial infections, urinary tract infections, respiratory tract and blood infections (vasaikar et al., 2017). this bacteria found in the skin, mouth and intestines, as well as in hospital settings and medical devices. nanoparticles are particles with a diameter of 10-9 mm. because of their small size and other uniq ue mechanical, chemical, electric and magnetic features, these particles can easily enter the cell and interfere in its metabolic natural process (arefian et al., 2015). nanomaterials were used in biomedicine, pharmaceuticals and many biotechnologies (gowri, gandhi and sundrarajan.,2014). silver nanoparticles were used as antibacterial for both gram negative and positive bacteria, and silver nanoparticles can affect about 16 species of bacteria, including e. coli. nanoparticles were used in the manufacture of teeth and in coating of medical devices (sondi. and salopek-sondi, 2004). nanomaterials were used in personal care products, food containers, clothing washing materials, paintings tools, household appliances as well as water treatment, medical, gene delivery, bone delivery, artificial limbs and implantable materials, sensors devices (yang et al., 2013). it was found that the use of oxide nanoparticles can eliminate several diseases that caused by pathogenic bacteria such as klebsiella spp. staphylococcus spp. salmonella spp.(ravikumar and gokulakrishnan., 2012) zro2 nanoparticles were reported as broad spectrum bioactivity agents and safety, with compared with superior and heat resistance when compared with traditional antibacterial agents (sant et al., 2012). in previous study, (bansal et al., 2004) researchers founded that zro2 nanoparticles have antifungal activity on fusarium oxysporum, which causes plant diseases as well as its effectiveness against e. coli, s. aureus, c. albicans and a. niger. zro2 is a nontoxic, efficient, environmentally friendly and low-cost. (gowri, gandhi and sundrarajan., 2014), thus this study aimed to detect the fact that there are antibacterial activity produced by the combination of zro2 and ceftazidime against klebsiella pneumonia bacteria. ceftazidime, one of third generation cephalosporins groups of antibiotecs that characterized by its broad spectrum on grampositive, gram-negative and aerobic bacteria in general and is particularly antibacterial activity on enterobacteriaceae family like klebsiella spp. (richards and brogden.,1986). methods diagnosis of bacteria the samples were collected from different diseases cases (infections of burns, wounds, blood). the isolates were diagnosed using traditional specific culture media and biochemical test imvic and api 20e test that done according to directives of the company (biomeriux/france). preparation of nanoparticles solutions zro2 nanoparticles were suspended in distilled water by using ultrasound device for 15 min. that prepared (1g /100 ml) in concentration (haghi et al., 2012). preparation of ceftazidime concentration a stock buffer solution of ceftazidime were prepared by dissolving 1g of the ceftazidime powder in 100 ml of the distilled water, sterilized the antibiotic had happened by millipore filter to get (1g / 100 ml) in concentration. (olaleye 2007) preparation of combination of nanoparticles solution and ceftazidime antibiotic 1ml of zro2 nanoparticles were suspended with 1ml of ceftazidime by using ultrasound device for 15 min. that prepared (1g /100 ml) in concentration (haghi et al., 2012). studying of inhibitory activity agar wells diffusion method used by the agar wells diffusion method to study the effect of both nanoparticles and ceftazidime alone and when mixed together. (olaleye 2007) fourier transform infrared spectroscopy (ft-ir) the ft-ir spectroscopy to the zro2 nanoparticles solutions under study were carried out by using (perkin 8300 ft-ir shimadzu spectrophotometer) where the spectrum wavelength ranges in 400 cm-1 to 4000 cm-1. x-ray diffraction analysis (xrd) analysis zro2 powder used for measuring the x-ray diffraction (xrd) by using (shimadzu xrd6000) and the analysis had run in the university of baghdad. 18 global journal of public health medicine 2019, vol 1, issue 1 gggggglo transmission electron microscopy (tem) technique zro2 nanoparticles composition was also studied by tem (fig.) by using (jem-2100 electron microscope) in mansoura university to determine the shape, size and distribution of nanoparticles. there are two different shapes for the zro2 nanoparticles, the first one is rod-shaped or nanotubes long narrow closed at the both ends, while the other shape looks smaller and clustered "flower shape". supposedly the small clusters of the zro2 nanoparticles grow to show nanotubes that could be observed in tem image. results antibacterial activities of zro2 nanoparticles had studied against six isolates of klebsiella pneumonia bacteria and results showed that five isolates of k. pneumonia had inhibition zones (38,34,10,10,8,0) mm, and the antibacterial activities of ceftazidime had tested against the same isolates of k. pneumonia, results showed the following inhibition zones (40,32,10,9,8,0) mm. respectively. when a combination between zro2 nanoparticles and ceftazidime antibiotic had done, results showed a protective effect against these five isolates of klebsiella spp. the diameters of the inhibition zone in mixed were (43,40,12,12,10,0) mm respectively as shown in table 1 and fig. 1. table 1: diameters of inhibition zone for zro2 nanoparticles alone, ceftazidime alone, and mixed of zro2 nanoparticles on klebsiella pneumonia isolat es of k. pneu monia diameter of inhibition zone in (mm) zro2 nanopa rticles ceftaz idime combi nation of ceftazi dime zro2 nanopa rticles con trol (d. w) k. 1 38 40 43 0 k2 34 32 40 0 k. 3 10 10 12 0 k. 4 10 9 12 0 k. 5 8 8 10 0 k.6 0 0 0 0 figure 1: inhibition zone for zro2 nanoparticles alone, ceftazidime alone, and mixed of zro2 nanoparticles on klebsiella pneumonia the analysis of (ft-ir) to zro2 nanoparticles showed that this solution contains chloride group at (592 cm-1), amide cn group at (1637 cm-1), o2 group at (2065 cm-1) and oh hydroxide group at (3448 cm-1) as shown in fig. 2 figure 2: (ft-ir) to zro2 nanoparticles solution. the analysis of (ft-ir) to ceftazidime showed that this solution contains chloride group at (584 cm-1), amines group at (1637 cm-1), o2 group at (2065 cm-1), and alcohol group (1223 cm-1) and (1039 cm-1) as shown in fig. 3 figure 3: (ft-ir) to ceftazidime solution 19 global journal of public health medicine 2019, vol 1, issue 1 gggggglo the analysis of (ft-ir) of zro2 nanoparticles and ceftazidime showed that this solution contains chloride group at (596 cm-1), amide cn group at (1633 cm-1), o2 group at (2073 cm-1), amine group at (3429 cm-1), alcohol group at (1215 cm-1) and the alkyl nitro groups group at (1367 cm-1). the analysis of the xrd analytical technique to zro2 nanoparticles were performed and results of x-ray diffraction analysis show the crystallization or calcification of zirconium. figure 4: (ft-ir) to the mixed zro2 nanoparticles and ceftazidime solution figure 5: shows x-ray diffraction patterns of zro2 nanoparticles and its intensity. discussion these results of inhibition zones in our study seem concurrence with (gangra et al 2012) which proved that zro2 nanoparticles was effective against both gram-negative and gram-positive bacteria. in addition, zro2 nanoparticles was effective against fungi, including a. niger. the difference in effectiveness of zro2 nanoparticles against different bacterial species is due to the arrangement of atoms on the surface of the cells, which results in a difference in the shape of the molecule. the results of (ft-ir) analysis were agreed with (gowri, gandhi and sundrarajan.,2014) because they found that -oh group in the zro2 nanoparticles solution when measuring the ftir and amide links between the amino acids and the carbonyl groups (c = o) and the co group associated with the polyphenolic compound and the oh group found in the carboxylic acid phenolic groups and the carbonyl group of amino acids and proteins, which have a strong ability to bind metals that cover nanoparticles to prevent aggregation and thus play biological molecules as a hydrogenation agent for nanosecond. while (haghi et al., 2012) was found in infrared spectroscopy of zirconium oxide containing zro-zr at the frequency of cm-1 (613) and cm-1 (819) accompanied by disappearance of protein amide. some studies have shown that there is special interest in nanocrystalline nanoparticles due to its highly stable mechanical and electronic properties. therefore, it is used in many applications as a reduction agent, anti-bacterial and anti-oxidant (gowri, gandhi and sundrarajan., 2014) zro2 nanoparticles was exposure to the xrd analytical technique that performed as shown in figure 5. the diffraction peaks indicated the small size of these crystals. average size of these particles can be simply calculated by using scherrer equation (langford et al 1978) where: k= shearer constant with a value of 0.9-1 (form factor) λ = wavelength of x-ray (1.5418 å) β = peak width of xrd in the middle of the length θ = bragg angle d is the particle size according to sheer's equation results showed that the mean size of zro2 nanoparticles molecules under study were 29.8 nanometers. the results were compared with (vasaikar et al., 2017). they showed that the size of the particles (20 nanometers) when measured according to the shearer equation and the highest value of the x-ray oxides measured by xrd. while (arefian et al., 2015) the xrd value of zro2 was 35 nanometers. the xrd measurement is used to identify the crystallization of molecules. in some cases, the crystallization of these molecules is not perfect, due to the insufficient thermal processor and time during the preparation process. the results of x-ray diffraction analysis show the crystallization or calcification of zirconium, and the removal of the protein improves the biopolymerization of zirconium (haghi et al., 2012). it is also used to detect the nature of particulate matter.(gowri, gandhi and sundrarajan., 2014) the results of this study showed that the molecules of zinc oxide have a crystalline nature. d =k λ / β cos θ 20 global journal of public health medicine 2019, vol 1, issue 1 gggggglo conclusion the present study results that the use of the zro2 nanoparticles as antibacterial agent are successfully effective with wide range of microorganisms. the combination of both zro2 nanoparticles and ceftazidime had caused increasing the activity of ceftazidime against klebsilla pneumonia which proved a useful method for this bacteria that causes nosocomial infection, uti, respiratory tract infections and blood infections. the difference in effectiveness of zro2 nanoparticles against different bacterial species because of the differential arrangement of atoms on the surface of cells references arefian, z.; pishbin, f.; negahdary,m. and ajdary,m (2015) potential toxic effects of zirconium oxide nanoparticles on liver and kidney factors. biomedical research. 26 (1): 89-97. bansal, v.; rautaray, d.; ahmad, a. and sastry, m (2004) biosynthesis of zirconium nanoparticles using the fungus fusarium oxysporum. j. mater. chem. 1(4): 3303 – 3305. doi 10.1039/b407904c gangra. s. l.; stalin, k.; dilbaghi, n.; kumar, s.; tawale, j.; singh, s.p. and pasricha, r (2012) antimicrobial activity of zirconium (zro2) nanoparticles and zirconium complexes. j. nanosci. nanotechnol. 12(9):7105. doi: 10.1166/jnn.2012.6574 gowri, s.; gandhi, r.r. and sundrarajan, m (2014) structural, optical, antibacterial and antifungal properties of zirconium nanoparticles by biobased protocol. j. mater. sci. technol. 30(8), 782790. doi: 10.1016/j.jmst.2014.03.002 haghi, m.; hekmatafshar, m.; janipour, m.b.; gholizadeh, s. s.; faraz, m. k.; sayyadifar, f. and ghaedi, m (2012) antibacterial effect of tio2 nanoparticles on pathogenic strain of e. coli. international journal of advanced biotechology and research. 3(3):621-624 jesline, a.; john, n.p.; vani, c. and nurugan, s. (2015) antimicrobial activity of zinc and titanium dioxide nanoparticles against biofilm– producing methicillin resistant, applied nanoscience 5(30): 157–162. doi 10.1007/s13204-014-0301-x langford, j. i. and wilson, a. j. c. 1978. scherrer after sixty years: a survey and some new results in the determination of crystallite size, j. appl. cryst; 11: 102-113 olaleye, m. t (2007) cytotoxicity and antibacterial activity of methodic extract of hibiscus sabdariffia. j. of medicinal plant. 1:913 ravikumar and gokulakrishnan., ravikumar, s. and gokulakrishnan, r (2012) the inhibitory effect of metal oxide nanoparticles against poultry pathogens .international journal of pharmaceutical sciences and drug research. 4 (2): 157-159 richards dm and brogden rn (1986) ceftazidime. a review of its antibacterial activity, pharmacokinetic properties and therapeutic use. drug evaluation 29(2): 105– 16. doi: 10.2165/00003495-198529020-00002 sant la jangra, k. stalin, neeraj dilbaghi, sandeep kumar, jai tawale, surinder p. singh, and renu pasricha (2012) antimicrobial activity of zirconia (zro2) nanoparticles and zirconium complexes journal of nanoscience and nanotechnology 12(9):7105-12. doi: 10.1166/jnn.2012.6574 sondi, i and salopek-sondi, b (2004) silver nanoparticles as antimicrobial agent: a case study on e. coli as a model for gram-negative bacteria. j colloid interface sci. jul (1). 275(1):177-82. doi:10.1016/j.jcis.2004.02.012 vasaikar, s.; obi, l.; morobe, i. and bisijohnson, m. (2017). molecular characteristics and antibiotic resistance profiles of klebsiella isolates in mthatha, eastern cape province, south africa. int. j. microbiol. 42: 1-7. doi: 10.1155/2017/8486742 yang, y.; wang, j.; xiu, z. and al varez, p.j.j. impacts of silver nanoparticles on cellular and transcriptional activity of nitrogencycling bacteria. environmental toxicology and chemistry. 32(7): 1488–1494. doi: 10.1002/etc.2230 zro2 nanoparticles composition was also studied by tem (fig.) by using (jem-2100 electron microscope) in mansoura university to determine the shape, size and distribution of nanoparticles. microsoft word gjphm-2020body shape.docx 229 global journal of public health medicine 2020, vol 2, issue 2 gggggglo original article the impact of social media on body comparison tendency, body-esteem and sleep quality among female students in a private university in shah alam/ malaysia mohammed a. abdalqader*, sabrina alfred joseph international medical school, management and science university, malaysia corresponding author: mohd_abdalqader@msu.edu.my abstract introduction: based on many studies probing the spectrums of social media, it has become evident that social media has changed a variety of human interactive activities such as communication, shopping, source of influence on perception, and even search for knowledge. the study aims to find the relationship between social media usage with the body comparison tendency, body esteem levels, and sleep quality. methodology: a cross-sectional study design using quantitative data conducted among female students of a private university with a sample size of 267 and using a self-administered questionnaire for data collection. a convenience sampling was used from different faculties of the university. results: it was found that excessive use of social media significantly predicted that participants engage in body comparison behaviours p< 0.001. it was also found that social media use influenced body esteem levels significantly. higher social media use influences sleep quality significantly, as well. conclusion: the results showed that social media use for more than 3 hours had a significant impact on body comparison tendencies among those female university students. it was also concluded that body esteem levels among those that fell into this category who used social media for more than 3 hours were lower compared to those who used social media for lesser than 3 hours in general. in evaluating the impact of social media on sleep quality, it was found that nearly half is at high risk of suffering from insomnia or sleep-related disorders. keywords: social media, body comparison tendency, body esteem, and sleep quality 230 global journal of public health medicine 2020, vol 2, issue 2 gggggglo introduction: the world as it is today has been subjected to tremendous changes over the last two decades, primarily due to the advancements of technology. these changes have had a significant impact on the social structure of societies everywhere on the planet as indicated by numerous researchers such as (bank & tat, 2014; amedie, 2015; siddiqui & singh, 2016) currently, social media is utilized by billions of people around the globe commonly referred to as ‘netizens’, a netizen is defined as ‘a frequent user of the internet’, and according to (walton, 2017) the impact that social media has on individuals from a health perspective (mental & physical) is largely negative. social media has transformed itself into a platform that provides a multitude of opportunities for the current 'digital generation' to access information and the knowledge that is easily shared by each other via text, videos, and images. the motivation for sharing such information publicly varies in a form that ranges from social support, social status, personal experiences, and personal achievements (oh & syn, 2015). this sharing of personal information has led to a trend among netizens globally who have gradually increased their use of social media not just to communicate and merely share information and knowledge, but also to compare themselves with others from various perspectives as indicated by (panger et al., 2014; vogel et al., 2015). with their personal physical appearances compared to multiple other users and often spend substantial amounts of time on social media to enhance their virtual presence on these platforms. there has been a wide array of research that has contributed to the knowledge that social media increases the tendency for body comparison and body-esteem, especially among women. apart from these two elements that often cause stress (low esteem and confidence), social media has also been identified as a major sleep disruptor impacting sleep quality that eventually leads to various other ailments, both mentally and physically. the proliferation of social media has gained momentum, and how this phenomenon is affecting the global population is an evolutionary question that needs to be addressed more frequently and thoroughly that it is now. it is not precise or clear about the position of social media harm with regards to if it is doing more harm than good. understanding the relationship between social media and social comparisons and its subsequent impact on sleep is a critical topic that needs to be pursued as frequently as possible based on the fact that the last known study on the subject was conducted in 2015 by vogel et.al and there has been a significant number of changes in applications and technological devices since 2015, requiring the subject to be examined closer to home which is the purpose of this study that focuses on body comparison tendency, body esteem levels and sleep quality due to social media. the objective is to study the impact of social media on body comparison tendency, body esteem, and sleep quality among female students in a private university. 231 global journal of public health medicine 2020, vol 2, issue 2 gggggglo methods: a cross-sectional study design was conducted using convenience sampling of the students from different faculties in that private university. the data were obtained via a self-administered survey questionnaire which is used before and validated containing five sections with five items on the first part that was targeted at extracting demographic data. the second part of the survey questionnaire was aimed at gathering information on the use of social media containing two items. the 3rd part of the questionnaire contained six items that were aimed at obtaining information on body comparison tendencies among women that use social media. in contrast, the 4th part was a section containing 14 items that were intended to assess the level of body esteem among women that use social media. the final section of the questionnaire contained ten items that was focused on evaluating the impact of social media on sleep quality. sections 3, 4, and 5 were attached to a likert scale selection structure that presented students with five options with each option representing a numeric value starting from 1 to 5. the sample size was 267 participants, and inclusion criteria were for those aged between 21 and 35 years old from various faculties. those who refused to participate and males are excluded from this study. ethical approval was granted from the university ethics committee before conducting the data collection. the analysis of the data was done via the spss statistical software version 24 (ibm spss statistics), which provided an assessment of various statistical figures in a quantitative format. the analysis was focused on demographic variables followed by the analysis of the impact that social media had on each of the three variables (body comparison tendency, body esteem, and sleep quality). descriptive statistics and inferential statistics using oneway anova, t-test, and correlation analysis was used for the statistical test analysis of the study objectives and hypothesis testing. results: the response rate was 95%, which was covered by the 20% of the non-response rate, which was added to the original calculated sample size. the total number of respondents was 267 from different faculties of that private university, with a minimum age 18, maximum age of 28, and mean age of 21 years old. the majority are malay 58.4%, followed by indians 36.7%, then chinese 3% and others 1.5%. the majority of the respondents are among the international medical school, 28.8%. it was found that 65.2% have more comparison tendencies, followed by 17% with medium and 17.8% with less body comparison tendencies. the younger the age group, the higher the duration of social media use. based on the data-set output, it was revealed that about half the sample population is likely to have sleep disorders 49.4%. table1: the association between time spent on social media/hour with body comparison 233 global journal of public health medicine 2020, vol 2, issue 2 gggggglo n mean std. deviation t test p value body comparison/more comparison 160 8.2 1.65 3.57 < 0.001 body comparison/less comparison 107 5.7 2.86 table2: the association between time spent on social media/hour with self-esteem n mean std. deviation t test p value self-esteem/high 152 4.9 1.23 2.8 < 0.001 self-esteem/low 115 7.8 2.07 also, it was found that excessive use of social media significantly predicted that participants engage in body comparison behaviours with p< 0.001. it was also found that body esteem has a significant p < 0.05. it was revealed that social media use influenced body esteem levels and the conclusion there is a positive relationship between social media usage and body-esteem levels, body esteem levels were lower among those who spent an average of 3 hours or more each day on social media. the results also revealed that body comparison tendencies were significantly higher among indians and malays. higher social media use influences sleep quality, it was demonstrated that p < 0.001 which indicates there is a direct relationship between social media use durations and sleep quality with the conclusion that social media use impacts sleep quality. discussion: in the study, it was found that excessive use of social media significantly predicted that participants engage in body comparison behaviours with p< 0.001 and that is supported by (fardouly & vartanian, 2015) in which they found in their study there is a positive relationship between social media platforms such as facebook and body dissatisfaction and body comparison. it was also found that body esteem has a significant p < 0.05. it was revealed that social media use influenced body esteem levels and the conclusion there is a positive relationship between social media usage and body-esteem levels, and that was consistent with the findings of another study in which they concluded the social media using related to a sharp drop in body esteem levels for females between the ages of 16 to 25. however, the studies also revealed that this trend reverses as women draw nearer to the age of 30 (anderson & jiang, 233 global journal of public health medicine 2020, vol 2, issue 2 gggggglo 2018) & (amedie, 2015). in general, most females ‘accept’ the way they are only around the age of 24 (nelson et al., 2018). nevertheless, elements of their experiences with body esteem are eventually carried on and reflected in the level of their confidence and character in the long run. in the current study, higher social media use influences sleep quality, in which it was noticed a direct relationship between social media use durations and sleep quality and that is parallel to another study which declared that the social media had been found to be among the major causes behind sleep deficiency among young adults which has a negative impact on cognitive functioning, immune system, cardiovascular risk, metabolism, weight, and as well as temperament as indicated by (mullington et al., 2009). this study findings of adolescents who used social media more were more experienced poorer sleep quality, lower self-esteem, and higher levels of anxiety and depression are consistent with a study done by (woods et al., 2016). the study limitation was doing a random sampling for better generalization of the findings; the short time frame was another limitation. the implications of findings for future research to aware those teenagers and young adults about the effect of the extra use of social media on health, sleep and mental health competency to balance their lifestyle, benefits and harms of social media use. conclusion it is showed that social media use for more than 3 hours had a significant impact on body comparison tendencies among women, especially those between the ages of 18 to 27. the results also indicated that body esteem levels among those that fell into this category who used social media for more than 3 hours were lower compared to those who used social media for lesser than 3 hours in general. in evaluating the impact of social media on sleep quality, it was found that nearly half the sample population is at high risk of suffering from insomnia or sleep-related disorders. we recommend future research to include different groups of adolescents and young adults and not only from universities to compare social media use among those from different backgrounds. conflicts of interest: the author declare no conflicts of interest. references: amedie, j. (2015). the impact of social media on society. advanced writing: pop culture intersections, 1-20. anderson, m., & jiang, j. j. (2018). teens, social media & technology 2018. internet & technology. bank, n. z., & tat, u. (2014). social media & its effects on individuals and social systems. portoroz, slovenia international conference (pp. 1183-1190). human capital without borders. fardouly, j., & vartanian, l. r. (2015). negative comparisons about one's appearance. body image , 82-88. nelson, sarah, c., frisen, moin, & syed. (2018). identity and the body: trajectories of body esteem from adolescence to emerging adulthood. american psychological association, 1159-1171. 234 global journal of public health medicine 2020, vol 2, issue 2 gggggglo systems. portoroz, slovenia international conference (pp. 1183-1190). human capital without borders. oh, s., & syn, s. y. (2015). motivations for sharing information and social support in social media: a comparative analysis of facebook, twitter, delicious, youtube, and flickr. journal of the association for information science and technology, 66(10), 2045-2060. panger, g. (2014). social comparison in social media:. work-in-progress: one of a chind, 2095-2100. siddiqui, s., & singh, t. (2016). social media its impact with positive and negative aspects. international journal of computer applications technology and research, 5(2), 71-75. vogel, e. a., rose, j. p., okdie, b. m., eckles, k., & franz, b. (2015). who compares and despairs? the effect of social comparison orientation. personality and individual differences, 249-256. walton, a. g. (2017, june 30). 6 ways social media affects our mental health. forbes magazine. woods hc, scott h. # sleepyteens: social media use in adolescence is associated with poor sleep quality, anxiety, depression and low self-esteem. j adolesc. 2016;51:41–9. microsoft word gjphm-2020-sdg.docx 196 global journal of public health medicine 2020, special issue gggggglo original research knowledge regarding sustainable development goals (sdg) among medical students at a private university in shah alam, malaysia hasanain faisal ghazi, mohammed a. abdalqader, mohammed faez baobaid, tiba nezar hasan, mustafa fadil mohammed, hesham abdelaziz shebl, hana chen wei jun, haitham assem abdalrazak & hassan omar ads. international medical school, management & science university, selangor, malaysia corresponding author: mohd_abdalqader@msu.edu.my abstract introduction : sustainable development goals are big challenge to the nation and they represent a critical encounter to be achieved with the current unsustainable condition worldwide the aim of the current study was to find out the level of knowledge regarding sustainable development goals (sdg) among medical students at a private university in shah alam, malaysia. methods: a cross-sectional study was conducted among 203 medical students at a private university in selangor malaysia using convince sampling method. results: only (77.8%) of the respondents heard of sustainable development goals (sdg) and the main source of information was internet (35.5%). two-thirds of them knew that sdg should be achieved by year 2030. only half of the respondents knew the correct numbers of sdg which is 17 goals and (45.3%) knew that sdg consist of 169 targets. conclusion: as a conclusion, medical students have adequate knowledge regarding sustainable development goals, but more education and promotion are needed, especially for future medical doctors as they will be the frontlines in achieving those goals. keywords : knowledge, sustainable development goals, medical students 197 global journal of public health medicine 2020, special issue gggggglo introduction sustainable development goals (sdg) emerged after the millennium development goals (mdg) as an update and upgraded version, it is also known as the agenda 2030, as refer to the year where the sdg shall be achieved in 2030 (un, 2015). the mdgs, although it lasted as a motivation of the human's and global growing plan and carried about real collaboration, partnerships and significant expansion to both developing and developed countries (un, 2015). the sdg signifies an additional comprehensive programme than the mdgs with seventeen goals, 169 targets and well above 200 indicators (iaeg-sdg 2016). the sdg includes a five “ps” outline: people, prosperity, planet, peace and partnership and these five “ps” are for all nations and peoples of the world (un, 2015, iaeg-sdg 2016). before the sdg was set in motion, universal discussions were held between various administrations / sectors, civil society organisations, the private sector, experts, academics and individual populations. the education sector was therefore not excluded from its design. in order to achieve the sdg, the position of education (with clarification of sdg as the focus) is crucial. equally important is primary health education. the organization for education and science (unesco) distinguishes that educational education is a key tool for the sustainable development of its announcement: "not technological solutions, political regulation or financial instruments alone can achieve sustainable development. we must change our way of thinking and acting. good education and learning for all will be needed for sustainable development (unesco, 2017). possibly the delay affects to the mdg was possibly not irrelated with the reduced alertness and information on the mdgs between the general public. it is conceivable if the societal understanding is elevated, different sponsors of many fields able to contest governments in order to apply worldwide progressive plans nationally. universities are the higher education body regularly considered as the pillars of taught, and accordingly, it is essential that the level of knowledge and understanding on the sdg have to be discovered in the high level of education platform so that any defects would be diagnosed. the higher education settings is constructed of many teaching and learning methods like lecturers who give the knowledge, students who absorb and administrative staff who shows caring to both students and staff. the education on the sdg are thus crucial in the university setting, to all members including the academic employments, students and the supporting staff as its so important to all to know about it and implement in these sdg (omisore et al., 2017). the "sustainable development goals," or the transformation of our world, and the global goals: the 2030 agenda, tackles specific concerns related to sustainable development for countries, such as poverty eradication, hunger, healthy health and education, environmental disparities, etc. by 2030, the 193 member states agreed to achieve the brand new targets; these 17 targets are further divided into 169 numerical goals, best measured by 40 198 global journal of public health medicine 2020, special issue gggggglo observable metrics. the main focus of the sdg is health. the three aims are precisely healthrelated and other objectives are related to health-related elements (sdg, 2015). the agenda 2030 with its 17 sustainable development goals (sdg) provides the path towards the global development and cooperation among all united nation (un) members. achieving this agenda depends crucially on whether civilization can optimize synergies and overcome established trade-offs between the sdgs (kroll et al., 2019). previous studies (pradhan, 2016; schmidt et al., 2015) has relate the interlinkages between the 17 goals. pradhan (2016 ) indicated that the sdg 1 (no poverty) is linked to several goals in synergy, while the sdg 12 (liability in consumption and production), in particular economic growth, is linked with trade-offs. sdg interaction factors were also established in other research, including energy (sdg 7) and other sdg. interactions (nerini et al., 2018). nevertheless, it will rely critically on achieving agenda 2030 to reduce trade-offs across the entire goals of the sdg and simultaneously to optimize synergies between objectives. the purpose of this study was to find out how much knowledge medical students at a private university in shah alam, malaysia have about sustainable development goals (sdg's). methods a cross-sectional study was conducted among 203 medical students at a private university in selangor, malaysia using convince sampling method. data collection was done throughout october to december 2019. questionnaires consist of part a, b and c. part a about socio-demographic characteristics such as age, gender, educational level, working status. while part b is about sustainable development goals (sdg) such as how many goals, how many targets, launching year, should be achieved which year and how many goals related to health. part c regarding student’s perception regarding the sdg and whether they are better than millennium development goals (mdg). data were analysed using jasp version 0.10 software. all respondents signed the consent form prior to answering the questionnaires. ethical approval was obtained by management and science university. 199 global journal of public health medicine 2020, special issue gggggglo results a total of 203 medical students participated in the current study. majority of the respondents were females (57.6%) with bachelor’s degree (86.7%) currently studying (86.7%) and only (7.8%) currently working. the mean age was 23.73 ± 3.57 years as shown in table 1. table 2 shows the knowledge of the respondents. only (77.8%) of the respondents heard of sustainable development goals (sdg) and the main source of information was internet (35.5%) followed by tv (30.0%) and education (26.6%). regarding the sdg knowledge question, twothirds of them knew that sdg should be achieved by year 2030. only half of the respondents knew the correct numbers of sdg which is 17 goals and (45.3%) knew that sdgs consist of 169 targets. regarding the indicators, only (17.2%) knew the correct numbers which is 241. majority knew the correct launching date which in 2015 (60.6 %). a total of (56.2%) of the respondents knew the correct numbers of countries that signed the sdg and only 46.8% answered correctly the numbers of sustainable development goals (sdg) that is related to health which is 6 as shown in table 2. table 3 shows student’s perception regarding the sustainable development goals sdg, as two-thirds of them (74.4 %) think that sdg will be achieved by year 2030 and almost everyone (98.5%) think that sdg is better than the millennium development goals (mdg) table 1: socio-demographic characteristics of the respondents n % gender male 86 42.4 female 117 57.6 educational level bachelor 176 86.7 diploma 14 6.9 postgraduate level 8 3.9 others 5 2.4 currently studying no 27 13.3 yes 176 86.7 currently working no 187 92.2 yes 16 7.8 min max mean sd age 19 41 23.73 3.57 table 2: knowledge about sustainable development goals (sdg) n % you heard about sustainable development goals (sdg) before? no 45 22.2 yes 158 77.8 source of information regarding sdg internet 72 35.5 education 54 26.6 tv 61 30.0 newspaper 16 7.9 sdg should be achieved by? 2020 47 23.1 2025 33 16.3 *2030 123 60.6 how many sdg goals 10 30 14.8 15 18 8.9 *17 109 53.7 20 46 22.7 200 global journal of public health medicine 2020, special issue gggggglo how many targets in sdg 160 19 9.3 165 29 14.3 *169 92 45.3 170 63 31.1 how many indicators listed in sdg? 200 19 9.4 *241 35 17.2 244 119 58.6 250 30 14.8 sdg were launched in *2015 123 60.6 2016 46 22.7 2017 34 16.7 how many countries signed the sdg? *193 114 56.2 195 35 17.2 200 54 26.6 how many sdg goals related to health? 5 33 16.3 *6 95 46.8 9 41 20.2 10 34 16.7 *indicate correct answer table 3: respondent’s perception towards sdg n % do you think that sdg goals will be achieved? no 52 25.6 yes 151 74.4 do you think that sdg is better than mdg no 3 1.5 yes 200 98.5 discussion sustainable development goals are big challenge to the nation and it is a critical encounter to be achieved with the current unsustainable condition worldwide. unsustainable condition has contributed to resource exhaustion, environmental pollution and climate change problems that we face today. the current study found different ranges of knowledge among the private university students, overall moderate to high level of knowledge was found and this finding is in line with another study done in malaysia, in selangor among university students as well, in which they found high level of knowledge but moderate level of attitude and practice among the students. (nurul ruwaidah & mariani, 2018) while our study finding showed that 77% of our respondents have heard about the sustainable development goals and this finding was not in line with another study done in nigeria in which they found different finding to us, they discovered that only 43% of the respondents did hear about the sdg goals and only 4.2% had a good level of knowledge. (omisore et al., 2017) our study found that the internet is the main source of information regarding the sustainable development goals, that finding was parallel with the selangor study in which they discovered social media is the number one source of developing knowledge for them. (nurul ruwaidah & mariani, 2018) 201 global journal of public health medicine 2020, special issue gggggglo in the current study the mean age was 23, while the mean of age for another study subjects in a university community in southwestern nigeria was 26 years. (omisore et al. 2017) our respondents were mostly with high knowledge and with bachelor level of study and that’s somehow consistent with the study in nigeria in which majority of respondents who having good knowledge of sdg were either from the academia or they do personal revision or study on the sdg or through other ways (omisore et al., 2017). that brings to the attention that sdg and related knowledge should be part of the educational settings materials and to enhance the academic curricular modifications (akinlolu et al., 2017). while another study in anand district, india showed mean age of peripheral health workers (phws) was 36.459 ± 7.58, among them the highest sex group of 138 (86.6%) were female and minority were males. the main marital status was those married with 134 (84.4%) and these findings are slightly same to our findings in terms of the majority sex was among females as well but with only 57.6% (talpada & sarate, 2019). in relation to the level of knowledge, a study in the district of anand in india found that 96.9 percent had average knowledge and no good knowledge of sdg from the peripheral health professionals and found no significant correlation between knowledge score and demographic variable (talpada & sarate, 2019). in china, an online survey data of 4128 valid subjects, they study and investigated the main predictors that affected the public support for sdg and describes how the people create a supportive attitudes. they found evidences in china that public support is mostly affected by demographic factors (sex, age, and level of education), and the level of sdg-relevant knowledge. they found as well that the chinese public considers the use of sdg as a part of the development policy rather than environmental policy (guan et al., 2019). conclusion in conclusion, medical students have adequate knowledge regarding sustainable development goals, but more education and promotion are needed, especially for future medical doctors as they will be the frontlines in achieving those goals. conflicts of interest the authors declare no conflicts of interest. references • guan t, ke meng, wei liu, lan xue. (2019). public attitudes toward sustainable development goals: evidence from five chinese cities. sustainability. 11(20), 5793; https://doi.org/10.3390/su11205793 • kroll, c., warchold, a. pradhan, p. (2019). sustainable development goals (sdgs): are we successful in turning trade-offs into synergies? palgrave communication 5 (140): 0335-5. • nurul ruwaidah ahamad & mariani ariffin (2018). assessment of knowledge, attitude and practice towards sustainable consumption among university students in selangor, malaysia. sustainable development and consumption; 16: 88-98. https://doi.org/10.1016/j.spc.2018.06.006 • nerini, f.f., tomei, j. to, l.s. bisaga, i. parikh, p. black, m. borrion, a. spataru, c. broto, v.c. anandarajah, g. milligan, b. mulugetta, y. 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(2019). a study to assess the knowledge and attitude regarding selected sustainable development goals among peripheral health workers working in selected phcs of anand district. scientific research ;06 (01): doi 10.4236/oalib.1105131 • united nations. transforming our world: the 2030 agenda for sustainable development. 2015. accessed march 25, 2017. available at https://sustainabledevelopment.un.org/content/ documents/21252030%20agenda%20for%20 sustainable%20development%20web.pdf • united nations. the millennium development goals report. 2015 • inter-agency and expert group on sdg indicators (iaeg-sdgs). final list of proposed sustainable development goal indicators. march 2016 accessed on 12/12/2016. available at http://unstats.un.org/sdgs/indicators/official%2 0list%20of%20proposed%20sdg%20indicat ors.pdf • undp nigeria. 2030 agenda for sustainable development. accessed on 12/12/2016. available at: http://www.ng.undp.org/content/nigeria/en/hom e/post-2015/sdg-overview.html • unesco. education for sustainable development. accessed 20th march, 2017. available at http://en.unesco.org/themes/educationsustainable-development • sustainable development knowledge platform (2015) transforming our world: the 2030 agenda for sustainable development. https://sustainabledevelopment. un.org/post2015/tran sformingourworld 28 global journal of public health medicine 2019, vol 1, issue 1 health status and lifestyle related risk factors among migrant workers in shah alam, malaysia aisyah binti abdul jabar, khin hla hla thein, hasanain faisal ghazi, mohammed a. abdalqader, hesham shebl &mohammed faez baobaid corresponding author: hasanain@msu.edu.my international medical school, management and science university, selangor, malaysia abstract introduction: in malaysia, it’s about 4-5 million of the migrant’s workers that involve in occupation that seriously give and effect to their health, which is in construction, manufacturing, agriculture, services, and domestic work. thus, study is conducted to identify the noncommunicable disease (ncds) risk factor among the migrant workers in migrant workers in shah alam of both genders. methods: a crosssectional study was conducted among 50 migrant workers in shah alam using convenience sampling method. both questionnaires and measurement were used in data collection. the questionnaire included sociodemographic data, behavioral and lifestyle data and medical history. results: a total of 32% of migrant workers either oversight or obese. 56% of them are involve in vigorous activity. most of them are not a smoker person which is about 86%. 20(40%) of them have history of hypertension only 6(12%) of them have diabetes conclusion: the main findings of our study that, 32% of the migrant workers either overweight or obese. more health promotion and regular screening are required especially, for people with high risk or having hypertension and diabetes history. keywords: migrant workers , non-communicable disease , obesity, health mailto:hasanain@msu.edu.my 29 global journal of public health medicine 2019, vol 1, issue 1 introduction non communicable disease is one of the highest challenges in all of the countries. especially in high income countries community where it ethnically and culturally diverse due the migration of international group (agyemang & van den born,2018). in malaysia, it’s about 4 5 million of the migrant’s workers that involve in occupation that seriously give and effect to their health, which is in construction, manufacturing, agriculture, services, and domestic work. most of the risk factor of the non-communicable disease (ncd) are strongly related with their changes in unhealthy lifestyle, ageing and the changes in the urbanization. besides that, the increasing of the blood glucose, abnormal serum cholesterol, overweight and obesity are the risk factor of the ncds in malaysia and this cause the increasing number of deaths among the migrant every year (misra et el., 2014). the world health organization (who) introduce the steps to make a survey which is to control the risk factor of the ncds in the countries and handling a correct interfere. the steps is a simple, standardized method for collecting, analysing and disseminating the data used to make a survey of the risk factor of ncds (misra et el., 2014). cardiovascular disease (cvds), chronic respiratory disease, 8 cancers and diabetes mellitus are known as the major ncds that trouble in the region (mclennan & jayaweera, 2014). chronic conditions such as oral diseases (oral cancers, periodontal diseases and dental caries), thalassaemia, renal, endocrine, mental, neurological, haematological, gastroenterological, hepatic musculoskeletal, skin and genetic disorders also are fully devoted to the trouble of the ncds. the ncds will be highly increased according to the morbidity and increasing of the mortality (mclennan & jayaweera, 2014socioeconomic or household income level are also one of the reasons that linked to with the ncds to be attributed among the migrants workers. in the high-income countries, people at younger age are in high risk to get the ncds, around 7.9 million deaths annually attributed to ncds, 34% happens to people at age of 60 years old mortality (mclennan & jayaweera, 2014). this shows that the socioeconomic is one of the causes that contribute to the health change due to the macroeconomic level. the drop of the economic with rising cost for the health-care will lead to increase of the ncds mortality. the aim of current study was to identify non communicable disease (ncds) risk factor among the migrant workers in shah alam. methods a cross-sectional study was conducted among 50 migrant workers in shah alam using convenience sampling method. this study was carried out at the public area around shah alam, selangor, malaysia which is among the migration workers. the study was conducted over a period from january 2019 to march 2019. medical health interview also has been asked at the migrant workers for health data. questionnaire was distributed to them, the questionnaire is divided into few parts which is demographics data, behavioral measurement, physical activity, travel to and from places, sports, history of high blood pressure, history of diabetes, and lastly the physical measurement. both questionnaires and measurement were used in data collection. the questionnaire included sociodemographic data, behavioural and lifestyle data and medical history. data analysis was done using spss software version 24.0. all respondents sign the consent form prior to data collection and ethics approval was obtain form management and science university ethics committee. results a total of 50 respondents participated in our results. majority were from indonesia (52.0%) followed by bangladesh (36.0%) table 1 shows that 7(14%) of them are underweight, 27(54%) of them have normal weight, 12(24%) of them are overweight and 4(8%) are obese. table 1: body mass index (bmi) among migrant workers in shah alam n % underweight 7 14.0 normal 27 54.0 overweight 12 24.0 obese 4 8.0 30 global journal of public health medicine 2019, vol 1, issue 1 table 2 shows that migrant workers have different lifestyle and medical health history. 56% of them are involve in vigorous activity but 44% did not involve with vigorous activity. while for the moderate activity, 88% of them are involve with it but 12% did not involve. but most of them are not a smoker person which is about 86% of them and 14% of them are smoked. alcohol consumption among the migrant workers is actually are common, but base on the data collected only 16% of them are in alcohol use and the rest did not consume any alcohol which is 84% of them. moreover, they also have a history of their medical health which is hypertension and diabetes. from the 50 participants, only 20(40%) of them have history of hypertension and another 30(60%) of them did not have hypertension. besides that, for the diabetes only 6(12%) of them have diabetes and 44(88%) of them did not have diabetes. in their life, majority of them in one week almost every day they have a fruit in their diet, same with the vegetables intake. but basically, they not prefer to have an outside meal. maximum in one week only 3 times they have an outside meal. table 2: lifestyle characteristics among migrant workers in shah alam for the systolic blood pressure reading, 174 are the maximum reading among them but minimum is 93. for the diastolic blood pressure, maximum reading is 100 and minimum reading is 63. most of them have high heart rate at 103 per minute but some of them have reading of heart rate at 50 per minute. highest reading for glucose reading among them is 66.1 mmol/l while the minimum is 3.6 mmol/l. next is regarding maximum waist measurement among them is 118 centimetre but minimum in 30 centimetre. maximum hip circumference measurements is 126 centimetre but minimum at 29 centimetre. the height for them which is migrant workers is maximum at 180.10 centimetre and minimum at 139.40 centimetre. maximum weight among the migrant workers is 89 kilogram and minimum is 45 kilogram. between all of them, 14(28%) are in blood group a+, 4(8%) blood group ab+, 13(26%) blood group b+, and 21(42%) of them are blood group o+ as shown in table 3. history of hypertension yes 20 40.0 no 30 60.0 history of diabetes yes 6 12.0 no 44 88.0 min max mean sd intake of fruits 0 7 2.20 2.44 intake of vegetables 0 7 4.60 2.29 outside meals per day 0 3 1.94 0.86 n % vigorous activity yes 28 56.0 no 22 44.0 moderate activity yes 44 88.0 no 6 12.0 smoking yes 7 14.0 no 43 86.0 alcohol consumption yes 8 16.0 no 42 84.0 31 global journal of public health medicine 2019, vol 1, issue 1 table 3: medical health data of the migrant workers in shah alam min max mea n sd systolic bp 93 174. 0 122. 04 15.5 2 diastolic bp 63 100 80.1 2 8.30 glucose (mmol/l) 3.6 66.1 6.64 8.6 heart rate 50.0 103. 0 78.9 0 11.8 4 weight 45.0 89.0 64.3 1 12.2 0 height 139.40 180. 10 158. 34 8.77 waist circumfere nce 30.0 118. 0 83.5 1 17.6 4 hip circumfere nce 29.0 126. 0 93.5 3 18.6 8 blood group n % a+ 14 28.0 0 ab+ 2 4.00 b+ 13 26.0 0 o+ 21 42.0 0 visual acuity right 6/6 42 84.0 6/15 4 8.0 6/60 2 4.0 6/9 1 2.0 visual acuity left 6/6 40 80.0 6/15 3 6.0 6/60 1 2.0 6/9 4 8.0 6/30 1 2.0 6/20 1 2.0 color vision norma l 50 100. 00 pupil reflex (rapd) negati ve 46 92.0 positiv e left eye 1 2.0 positiv e right eye 3 6.0 red reflex right prese nt 49.0 98.0 reduc ed 1.0 2.0 red reflex left prese nt 49.0 98.0 reduc ed 1.0 2.0 discussion the main findings of our study that, 32% of the migrant workers either overweight or obese. based on the previous study in 2011, the migration represents the higher risk of having overweight and obesity. migrant workers who migrate from low income country to high income country are tend to have high risk of obesity rather than those who from the origin country kilaf, & kirchengast (2011). unhealthy weight gain also will represent in the huge level of overweight fleshiness rates among migrant appear mostly in the period of 10 to fifteen years after migration. besides that, nutrient availability, income, beliefs relating to food, religious belief and "food laws", and the generation and historic period of immigrants are one of the feeding habit among the migrant workers that effect their daily dietary ( goulão, et al. ,2015). in particular, people from first gear to spiritualist -income body politic who have migrated to reside in high-income countries, appear to be more susceptible to overweight and obesity than their local anaesthetic counterparts (delavari, et al. 2013). diabetes rates among migrant workers are triple higher rather indigenous universe (montesi et al. 2016). in europeans, around 90% of males group and are higher more in female group which is 120%, this is equally 32 global journal of public health medicine 2019, vol 1, issue 1 same with the survey that have been done in asian country. conclusion the main findings of our study that, 32% of the migrant workers either overweight or obese. more health promotion and regular screening are required especially, for people with high risk or having hypertension and diabetes history. references agyemang, b.j. van den born (2018). non communicable diseases in migrants: an expert review, j. travel med. https://doi.org/10.1093/jtm/tay107. delavari, m., sønderlund, a. l., swinburn, b., mellor, d., & renzaho, a. (2013). acculturation and obesity among migrant populations in high income countries--a systematic review. bmc public health, 13, 458. doi:10.1186/1471-2458 13-458 goulão, beatriz, santos, osvaldo, & carmo, isabel do. (2015). the impact of migration on body weight: a review. cadernos de saúde pública, 31(2), 229-245. kilaf, e. & kirchengast, s. (2011) socio economic position and obesity among turkish migrant women in vienna, austria. life science journal 3, 107–116. mclennan ak, jayaweera h. (2014). non communicable diseases and risk factors in migrants from south asian countries. uk: oxford university. misra, p. j., mini, g. k., & thankappan, k. r. (2014). risk factor profile for non communicable diseases among mishing tribes in assam, india: results from a who steps survey. the indian journal of medical research, 140(3), 370–378. montesi, l., caletti, m. t., & marchesini, g. (2016). diabetes in migrants and ethnic minorities in a changing world. world journal of diabetes, 7(3), 34–44. doi:10.4239/wjd.v7.i3.34 aisyah binti abdul jabar, khin hla hla thein, hasanain faisal ghazi, mohammed a. abdalqader, hesham shebl &mohammed faez baobaid abstract introduction methods results table 1: body mass index (bmi) among migrant workers in shah alam table 2: lifestyle characteristics among migrant workers in shah alam table 3: medical health data of the migrant workers in shah alam conclusion references microsoft word gjphm-2020elderly.docx 185 global journal of public health medicine 2020, special issue gggggglo review research why covid-19 is lethal to elderly and chronically ill? berghiche amine laboratory of science and technic of living, institute of agronomic and veterinarian sciences, university of mohamed cherrif messaâdia, souk ahras, algeria corresponding author: a.berghiche@univ-soukahras.dz abstract our work consists of a systematic statistical approach and analysis of the pathophysiological literature review of the coronavirus 2019.firstly, we have given a realistic view of the re-emerging disease caused by the coronavirus through the detailed information available, and secondly, we have given probable explanations based on old literature and research on the specific immune profile and the dangers related to age and chronic diseases. systematic analysis of the data shows the relationship between age and chronic disease with covid 19 mortality, the closest explanation for this relationship is the phenomenon of the 'cytokine storm', where the immune system acts reversibly on older people or people with chronic diseases. the suggestion obtained from this study is that at this point for this pandemic it is necessary to work only on the symptomatic treatment of cytokine shock in this population because even after having a vaccination for the virus the risk remains significant for them. keywords : covid-19, age, chronic diseases, cytokine storm 186 global journal of public health medicine 2020, special issue gggggglo introduction coronaviruses were named based on the crown-shaped aspect of their virions as viewed under electron microscopy. these viruses are the second commonest cause of the common cold, with rhinoviruses being the primary culprit. (stadler et al., 2003) it has also been reported that coronaviruses induce gastroenteritis in children and adults (clarke et al., 1979); in 2002 severe coronavirus associated with acute respiratory syndrome (sars) (goldsmith et al., 2004) and (sars-cov 2) is a newly described coronavirus in 2019. (lai et al., 2020; berghiche, 2020 ). the virus produces atypical pneumonia, serious illness, and potentially fatal viral infection in humans, it is strictly confined to the mucosal cells of the airway. (poon et al., 2004). the virus generally causes infections of the superior respiratory tract, as the optimal temperature for virus replication is 37-38°c. the envelope contains (a) viral binding protein e2, (b) matrix protein e1, and (c) nucleocapsid protein n1. in the early phase of infection produces rna polymerase; the late phase produces non-structural proteins from a negativesense rna template. covid 19 causes an airway infection by binding to angiotensin-2 converting enzyme receptors on the surface of the respiratory epithelium. (shereen el al., 2020;memish et al., 2020; han et al., 2020). this causes an alteration of the water balance and leads to the development of alveolar space edema, which diffuse edema leading to hypoxia is characteristic of pneumonia caused by this virus, we must note that the infections caused by coronaviruses produce a brief immunity, but reinfection may occur. (jin et al., 2020; piccoli, 2020; kuljić-kapulica,2020). inflammation is the set of reactive defense mechanisms by which the body recognizes, destroys, and eliminates all foreign substances. the inflammatory reaction sometimes exceeds its objectives, causing deleterious effects, but this is the price the body sometimes has to pay to maintain its integrity. grodzinsky et al., 2020). the causes of inflammation are many and varied: infectious agent, inert foreign substance, physical agent, post-traumatic lesion of cyto-tissues, etc. inflammation begins with a "recognition" reaction involving certain cells in the body (monocytes, macrophages, lymphocytes) or circulating proteins (antibodies, complement proteins, hageman factor, etc.) (goldstein et al., 1992). the recognition phase is followed by the sequential involvement of a whole set of cells and mediators whose order of intervention is complex and variable. some mediators, such as prostaglandins and cytokines, are produced by different cell types, act on several cell types, and sometimes control their production by retroactive regulation. this shows the complexity of the mechanisms of the inflammatory reaction, which prevents the description of an overall pattern and requires an analytical and individual description of the cells and the mediators that make it up. (sedger et al., 2014). 187 global journal of public health medicine 2020, special issue gggggglo the cytokine is a low molecular weight secreted proteins that regulate the intensity and duration of innate and acquired immune responses with multiple biological properties on different cells pleiotropy as synergy and antagonism its action (outcome) depends on receptor being present it can be autocrine, paracrine or endocrine. (klasing and korver, 1997;janeway et al., 1999). broad categories of cytokine function are cytokines that mediate and regulate innate immunity; cytokines that mediate and regulate specific or adaptive immunity and cytokines that stimulate hematopoiesis. (abbas et al.,1997). the immune system is our defense. in addition to its protective role against external aggressions, the immune system plays a key role in the internal balance of the organism. unfortunately, this system sometimes gets it wrong and attacks the body's constituents. (nicholson, 2016). the elderly is more prone than the young to suffering from an illness (for example, pneumonia) and have a high mortality rate. (gardner,1980) measles, myelin, poliomyelitis, and covid 19 are examples of diseases that cause more serious clinical problems. the inflammatory reaction sometimes exceeds its objectives, causing deleterious effects (siegrist, 2007), but this is the price the body sometimes has to pay to maintain its integrity, could this be due to a more active immune response in an adult that causes increased tissue damage? current status data using data from the report of the joint whochina mission (who, 2019) and the article from the chinese cdc (ccdc, 2020), these two sources we provide the following statistics on age and comorbidity (worlodmeter, 2020). fatality ratio = (number of deaths / number of cases) = odds of mortality in case of virus infection (%). the graphical representation shows that mortality is very directly related to the age where most deaths are over 50 years old and the very high rate corresponds to people over 80 years old. this probability differs depending on a preexisting condition. the interpretation of this graph shows that all the dead cases have a chronic disease, the highest rate for cardiovascular diseases, followed by diabetics, chronic respiratory diseases, and cancer patients. the previous results give us three questions to answer: *why mortality rates among the elderly are the highest? *how chronic diseases lead to a higher mortality rate for those affected? *immunity can have a negative role among elderly and chronically ill? 188 global journal of public health medicine 2020, special issue gggggglo figure 1: mortality rates by covid-19 classified by age figure 2: covid-19 mortality rate by comorbidity death rate = (number of deaths/number of cases) no pre-existing conditions 0, 9 cance r 5, 6 7, 6 hypertensio n 6 8, 4 chronic respiratory disease 6, 3 diabete s 8 7, 3 cardiovascular disease 9,2 10, 5 13, 2 0 2 4 6 8 10 12 14 death rate % (all cases) death rate % (confirmed cases) 189 global journal of public health medicine 2020, special issue gggggglo age and immunity immunosenescence is the process of deterioration of the immune system over time; studies show that immune aging is associated with a higher frequency of infections, cancers, and autoimmune diseases. (pera et al., 2015) immunosenescence has been linked to an increase in respiratory and urinary infections, endocarditis and sepsis (the presence of bacteria in the bloodstream) in the elderly, in cases where the infection is due to an intracellular microorganism, such as tuberculosis, legionellosis, etc., it has been noted that as one age, the microorganism that was latent in the cells and that was probably treated at the time of the first infection reactivates. an age-related decrease in the cytokine tnf-α and cd8+ t cell levels could explain the body's inability to keep these intracellular microorganisms under control and thus the frequency of these diseases in the elderly. in the case of extracellular pathogens, the increase in infections could be due to an age-related decrease in the phagocytic activity of macrophages and other granulocytes. (ginaldi et al., 2001; hakim and gress, 2007) the increase in morbidity due to the decline of the immune system is a direct consequence of the deregulation of adaptive immunity in the elderly. the low number of naive t cells compared to t cells is a consequence of the reduction in thymic production, as the thymus has regressed. as a result of this age-induced lymphopenia, t cells proliferate and increase the 'virtual memory' compartment, but at the same time, the ability to establish immunological memory in response to de novo antigens is reduced, compromising vaccinations. functions such as the production of cytokines by cd4 and cd8 t lymphocytes are impaired, the expression of surface key markers, and the cd4 + to cd8 + ratio is reversed. the development of t lymphocytes which control latent viruses such as ebv and cmv, reduce the space for cd8 + t lymphocytes specific for other potentially fatal viruses, all of this increased by the decrease in the production of naive t cells of thymic origin. (tarazona et al., 2002; globerson and effros, 2000). probably the most critical change as the aging innate immune system ages is the increase in the pro-inflammatory cytokines il-1β, il-6, il18, and tnfα. the resulting low-grade inflammation likely contributes to atherosclerosis, dementia, and cancer, inextricably linking inflammation and the aging of other tissues. (simon et al., 2015; müller and pawelec, 2014; di benedetto and müller, 2019). chronically ill and immunity people with certain hormonal abnormalities are increasingly at risk of infection. for instance, people with diabetes mellitus, hypothyroidism, and adrenal dysfunction are highly sensitive to staphylococcal infections, streptococcal infections, candidiasis, aspergillosis, zygomycosis, and many other microbial infections. (castle, 2000; castle et al., 2007). 190 global journal of public health medicine 2020, special issue gggggglo cardiovascular diseases the cardiovascular diseases are the affections that affect the heart more than those that affect the blood vessels. cardiovascular diseases include angina, myocardial infarction, or stroke, these diseases are either congenital or acquired which mostly caused by atherosclerosis. (ylä-herttuala et al., 1996; sherer and shoenfeld, 2006). the inflammatory response is a useful process for fighting disease. when this mechanism is strong, infection occurs very effectively. unfortunately, in other types of inflammatory processes, such as the response to the presence of cholesterol in blood vessels, the mechanism is amplified, causing lateral damage. (fernándezsánchez et al., 2011; vodovotz et al., 2009). inflammation and immune response are involved in the pathogenesis of atherosclerosis from the earliest stages and can influence the onset and outcome of acute coronary syndromes. the different components and phenotypes of the immuneinflammatory response can play both protective and deleterious roles. individual variation in immune reactivity, but also different environmental factors, may reflect the ability of some individuals to produce a protective and effective immune response while others have a deleterious immune response. (caligiuri, 2004) interferences and interactions between cholesterol metabolism and inflammatory pathways have a potential influence on the genes associated with these two processes. for example, in the network model, immune cells called macrophages turn into foamy cells when they absorb oxidized ldl cholesterol particles, the initial stage of plaque formation. in turn, the foam cells secrete substances called "cytokines" that stimulate the inflammatory response. (paquette et al., 2007; baldrighi et al., 2017) diabetes it is an autoimmune disease characterized by the destruction of insulin-producing beta cells by t cells in the immune system. (gillespie, 2006) t lymphocytes, b lymphocytes, macrophages, neutrophils, and dendritic cells are part of a set of cells making up our immune system. they perform specific functions and act in a cooperative and very organized manner to ensure the balance of our immunity. (sallusto et al., 2000) in the case of type 1 diabetes, studies have described the intervention of immune cells in triggering the disease. thus, in the absence of macrophages responsible for eliminating the remains of beta cells that die naturally or following an infection, debris from dead cells accumulates and attracts other types of immune cells and among them, the dendritic cells which present the antigens from this debris to the t lymphocytes. (roep, 2003). the dendritic cells also release molecules that trigger the inflammation process; those cells, therefore, come into contact with the t lymphocytes which recognize the antigen and thus target the beta cells of the pancreas and destroy them, since they are considered as a foreign body to be eliminated. 191 global journal of public health medicine 2020, special issue gggggglo b lymphocytes also participate in this offensive by producing antibodies directed against specific components of the pancreas or against insulin itself. (banchereau and steinman, 1998; rabinovitch and suarezpinzon, 1998) all these interactions between cells of the immune system, therefore, lead to the destruction of pancreatic beta cells. this autoimmune reaction takes place in a particular context linked to the genetic predisposition or a triggering environmental factor. it spans several years before the onset of diabetes. (van den driessche et al., 2009; katsarou et al., 2017). in type 2 diabetes, the immune system is involved in the chronic activation of the phenomenon of inflammation, which is harmful in the long term for the cells. (donath et al., 2009) the molecules responsible for the activation of inflammation are strongly present in the tissues of type 2 diabetic patients. they participate in the decrease in the sensitivity of the muscles and the liver to the action of insulin. this phenomenon called insulin resistance causes the accumulation of glucose in the blood. (osborn and olefsky, 2012) these so-called pro-inflammatory molecules also act on the pancreas. their presence disrupts the functioning of beta cells and therefore the production of insulin which will be greatly reduced (insulinogenic). (bailey, 2018). the presence of inflammatory molecules seems to be greatly increased in the event of obesity. indeed, under normal conditions, there is a balance between the production of molecules promoting inflammation and so-called antiinflammatory molecules (balistreri et al., 2010). adipose tissue cells upset this balance by promoting the production of proinflammatory molecules. (cersosimo et al., 2018; sun et al., 2012). chronically respiratory diseases the pulmonary affections also called pneumopathies are numerous and nonexhaustive, we have chosen three very common diseases. chronic bronchitis is the inflammation and exaggerated secretion in the mucous membranes of the bronchi (the layer of cells protecting the inside of the bronchi on contact with air). (sethi, 2000) asthma corresponds to a particular form of dyspnoea (difficulty breathing), and more particularly to exhaling (expelling air from the lungs). there is a decrease in the size of the bronchial tubes, among other things. ( cartier,1994). pulmonary emphysema is a chronic (progressive) disease of the lungs characterized by the destruction of the pulmonary alveoli, resulting in distension of the alveolar walls. (shapiro and ingenito, 2005; heppleston and leopold, 1961). the presence of a chronic respiratory disease such as chronic obstructive pulmonary disease or a disease that weakens the immune system increases the risk of covid 19 for the patient will develop it faster. (lai et al., 2020) 192 global journal of public health medicine 2020, special issue gggggglo cancer inflammation is activated every time tissue is attacked. one of its missions is to promote the reconstruction of damaged tissue. this aspect of the inflammation is diverted by the tumor to progress to a more advanced stage. (ran and volk-draper, 2020; johnson, 2020). however, inflammation can act against the tumor by recruiting immune system cells, some of which are responsible for eliminating cancer cells. to divert the inflammation to its advantage, the tumor may create a local environment, called the tumor microenvironment, which undermines the antitumor immune response. (annibaldi and walczak, 2020). at the tissue level, the tumor is not just a cluster of cancer cells but a collection of both cancerous and healthy cells associated with the tumor that contribute to its development, such as endothelial cells, macrophages, and fibroblasts, this association of different cells forms a complex environment that evolves according to the behavior of the cells that make it up: this is the tumor microenvironment (cassetta and pollard, 2020; blagih et al., 2020). healthy tumor-associated cells make an essential contribution to the development of a tumor by providing functions that cancer cells do not possess or by stimulating capacities that cancer cells have acquired (beltraminelli and palma, 2020; pang et al., 2020). conclusion inflammation is a complex process involving several types of immune cells, clotting proteins, and signaling molecules, all of which change over time. in a normal state, the inflammation will disappear on its own once irritation has subsided and the body is adequately protected. in some cases, the inflammation becomes a disease; this leads to problems with organ function and even complicity in infectious diseases or long-term inflammatory conditions "cytokine storm" is the pathological form of inflammation, and although the general concept of excessive or uncontrolled release of pro-inflammatory cytokines is well established, this concept and the biological implications of overproduction of cytokines are not well defined. but it is associated with a wide variety of infectious and noninfectious diseases. the "cytokine storm" is the pathological form of inflammation, and although the general concept of excessive or uncontrolled release of pro-inflammatory cytokines is well established, this concept and the biological implications of overproduction of cytokines are not well defined. but it is associated with a wide variety of infectious and non-infectious diseases. the term has been widely promoted in the context of infection with the h5n1 avian influenza virus, which has led to its inclusion in the popular media. 193 global journal of public health medicine 2020, special issue gggggglo cytokine storm syndromes (css) are a group of disorders representing a variety of inflammatory causes. the primary symptoms of a cytokine storm are high fever, swelling, and redness, extreme fatigue, and nausea. in some cases, the immune response can be fatal in the elderly where the immune profile has been compromised and its control will be difficult in infectious diseases, also in cases of chronic diseases associated with inflammatory conditions or which act directly on the immune system; at this level, the new coronavirus has proven that human immunity can induce death. it is recommended to treat the disease symptomatically with therapeutic interventions that target the mechanisms of inflammation such as anti-leukotriene and pro-inflammatory cytokine inhibitors. references • abbas, lightman and pober, cellular and molecular immunology, 1997. • annibaldi, a., & walczak, h. 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(1996). pathogenesis of atherosclerosis. maturitas, 23, s47-s49. microsoft word gjphm-2020cholera.docx 211 global journal of public health medicine 2020, vol 2, issue 2 gggggglo original article cholera outbreak in wasit governorate, iraq 2017 taqi mohammed jwad taher 1 , wejdan saeed assi 2 , mohammed a. jalal 2 & firas turki rashed sarray 2 1 department of community medicine, college of medicine, wasit university, iraq 2 wasit health directorate, ministry of health, iraq corresponding author: ttahir@uowasit.edu.iq abstract introduction: cholera is a major public health ongoing problem, causing significant morbidity and mortality particularly in developing countries. the main objective of the current study was to assess the distribution of cholera in wasit governorate during the 2017 epidemic. methods: this study was designed as a descriptive cross-sectional study. all patients were registered in health directorate records. the data collection lasted from 2nd of january 2018 till 28th february 2018 by formal registration for records of the directorate of wasit health\ section of communicable diseases\ epidemiological surveillance unit. all registered cholera confirmed cases were included and frequency tables were done using spss program version 23. results: the results showed that only (25) positive cases of cholera from (6175) total of stool samples taken from (20954) of acute diarrhoea recorded during 2017, and the highest percentage of cases (66.7%) were registered in september. the highest percentage of cases (32%) appear within the age category (>45) years while the lowest percentage was in under five years children(8%). women constituted about (68%) of all cases. all cases were in al-suwaira health care district and all cases were of the type inaba. all patients were recovered with no fatality. even, the highest attack rate of cholera nationally and in wasit was in 2015 outbreak. conclusion: cholera still one of the endemic diseases in iraq that caused an outbreak at different times. although, it still under control and need further work for special situations where the infection most likely distributed. keywords: cholera, outbreak, wasit. 212 global journal of public health medicine 2020, vol 2, issue 2 gggggglo introduction: cholera is an infection characterized by diarrhoea, the leading cause is a toxigenic serogroup of the bacterium vibrio cholerae, which is one of the main causes of death due to dehydration. many factors as poverty, lack of adequate water supply, and poor sanitation can play an important role in the transmission of cholera infection (who, 2017). as a disease, cholera considers as one of the highly virulent diseases because it may trigger acute, serious, watery diarrhoea. after consuming infected food or water, it takes 12 hours to 5 days for a person to start showing symptoms (azman as et al., 2013). with the presence of easy ways to treating diarrhoea initiated from cholera with the appropriate rehydration facilities including oral rehydration and intravenous fluid, the case fatality rate for cholera must be decease as possible as to less than 1%, but it is still exceeding 5% in most vulnerable settings (who, 2017). world-wide estimation of cholera cases was 1.3 million to 4.0 million cases of cholera and 21 000 to 143 000 deaths every year (ali m et al, 2015). over the past few years, the number of cholera cases confirmed to the world health organization (who) has remained high. in 2017, 1 227 391 cases, including 5654 deaths, were reported from 34 countries (who,2018). in several ways, the year 2017 was very significant in cholera history because of the passage of 200 years since the first documented cholera pandemic in 1817. the present pandemic is considered the seventh pandemic which continues to being reported as the longest one. thousands of people were killed in the last epidemic all over the world especially in yemen (2261), followed by the democratic republic of the congo (1190) and somalia (1007) (who, 2016). even people from all age groups can be affected by cholera, but nearly half of deaths occur in children less than five years of age. current predictions of the number of cholera cases range from 1.4 to 4 million with a range from 21,000 to 143,000 dead patients due to cholera (who, 2017). the presence of a large number of refugees and internally displaced people who live in camps and peri-urban slums where basic water and sanitation standards have not been met made these areas as typical places for initiation and spread of cholera infection (who, 2019). cholera infection can be avoidable and easily treated. the presence of vaccines can play a vital role in prevention, both two forms of oral cholera vaccines (killed whole-cell) are accessible and suggested in endemic areas, cholera outbreaks, and in high-risk humanitarian crises. vaccines alone are not helpful so it must be used in combination with other strategies for prevention and control (who, 2017). even with a high fatality rate of cholera, it still easily treatable disease. most cases can be successfully treated by the administration of oral rehydration solution (ors). while patients who reach a stage of severe dehydration are at risk of shock, so they need urgent treatment by intravenous fluids. such patients also need to receive proper antibiotics (who, 2019). 213 global journal of public health medicine 2020, vol 2, issue 2 gggggglo the first appearance of cholera in iraq was during the epidemic of 1999 (al-abbassi a m et al., 2005). then iraq suffered from the endemicity of this disease with the appearance of epidemic attacks and outbreaks in different periods. for a long period, the whole infrastructures in iraq were destroyed including electricity and safe drinking water, in addition to severely damaged or blocked sewage disposal networks particularly in the places where refugees and poor people live. the camps and poor regions consider as focus points for the spread of all water-borne diseases such as cholera (alabbassi a r, & amena sm, 2015). wasit was one of the iraqi governorates that suffer from the cholera outbreak in 2015, confirmed reported cases in wasit 67 (2.3% of the total cases in iraq) (al-abbassi a r, & amena sm, 2015), and the last epidemic was in 2017, in order to control further spread of the disease and prevent a future outbreak, this study was achieved. the main objective of the study was to know the distribution (person, time, and place) of cholera in wasit in 2017. in addition to comparing the results of the positive cases between wasit medical institution laboratories with the central public health laboratory to ensure the validity of the results done in wasit. other objectives were to describe the serotype of vibrio cholerae cases present in wasit and to illustrate the outcome of positive cases. methods: study design: a descriptive cross-sectional study. duration of study: carried out from the period 2nd january till 28th february 2018 in wasit province. study population and sample: study population include all cases with acute diarrhoea in wasit province during the surveillance period. those patients with a feature of probable cholera (watery diarrhoea with or without vomiting) were subjected to stool culture according to the passive surveillance program. positively diagnosed cases from the whole wasit population (around 1,500,000 people) during the epidemic in wasit ( from may through november 2017) were reported in the database of health directorate. cases were diagnosed by stool sample which transported by special media (cary blair media) and then incubated in the medium of alkaline phosphate water (apw) for one night then inoculated in thiosulfate citrate bile salt (tcbs) agar for culture. further confirmation to the results in the central public health laboratory was performed according to ministry of health instructions. data collection: data collected from the records of epidemiological surveillance unit for all confirmed cases reported according to the notification, database, and verification methods. this study was applied to describe the disease information about cholera patients during the last epidemic (that occurred during the year 2017) in wasit province. a person, place, and time epidemiological model was used to achieve this task in; age, sex, place of 214 global journal of public health medicine 2020, vol 2, issue 2 gggggglo residence, and the time trend of disease occurrence by (months). the outcome of all cases also registered. after obtaining the official approval from the ethical committee in wasit university and agreement from wasit health directorate, data were collected from the official wasit directorate registry of epidemiological surveillance that belongs to the communicable disease control section/ public health department. statistical analysis: data were computed and analysed by using spss version 23. frequency tables and descriptive statistics used for data presentations. results: out of (6175) total of stool samples taken from (20954) of acute diarrhoea recorded during 2017, only 25 cases of cholera were confirmed in wasit governorate. cholera cases by age in wasit 2017 the current study shows the distribution of cholera cases in wasit provinces as it was reported in health directorate from health institutions in wasit to the centre of the communicable disease which consists of 25 cholera patients. the highest percentage of cases (32%) appear within the age category (>45) years, while in (14) years age group it is 8% as (table 1) showed. table 1: frequency distribution of cholera cases by age in wasit in 2017. age class male female total percentage 1-4 1 1 2 8 5-14 4 0 4 16 15-24 2 2 4 16 25-34 3 0 3 12 35-44 3 1 4 16 >45 4 4 8 32 total 17 8 25 100 figure 1 below showed that females have the highest rate (68%) of disease among all cases. figure 1: frequency distribution of cholera cases according to sex in wasit 2017. 32% 68% male female 215 global journal of public health medicine 2020, vol 2, issue 2 gggggglo the figure 2 showed that the highest percentage of cholera cases (66.7%) reported in september, while may showed the least percentage of cases (8.3%) of all cases. figure 2: frequency distribution of cholera cases according to months in 2017 in wasit. cholera cases from 2012 to 2017 and attack rate in iraq and wasit governorate: the current study showed the highest attack rate per/100000 of the population was 8.2 in 2015 nationally, while the highest attack rate per/100000 of the population was 4.95 at 2015 regionally. the highest number of cholera cases in wasit was in 2015 (67 cases) followed by 2017(25) cases as shown on table 2 below. table 2: distribution of cholera cases from 2012 to 2017 and the attack rate in iraq and wasit governorate. years iraq wasit % no. of cholera attack rate per /100,000 no. of death no. of cholera attack rate per /100,000 no. of death 2012 653 1.92 0 1 0.072 0 0.153 2013 1 0.003 0 0 0 0 0 2014 0 0 0 0 0 0 0 2015 2868 8.2 2 67 4.85 0 2.33 2016` 3 0.008 0 0 0 0 0 2017 505 1.33 3 25 1.81 0 4.95 216 global journal of public health medicine 2020, vol 2, issue 2 gggggglo concerning geographical distribution according to all six primary health care districts ( kut1, kut 2, alhay, alsuwaira, alazyzia, and al-numania) in wasit governorate, all 25 cases of cholera in wasit were reported from alsuwaira primary health care district. in figure 3 below, all cholera cases were from inaba species. all cases diagnosed by the wasit institutional laboratories were corresponding to the confirming test done by the central health laboratory. figure 3: diagnosis of cholera cases according to wasit health institutions and central public health laboratories 2017. 100% of the cases mentioned using tap water for different home uses. the final progress of all cases in 2017 was complete recovery. 217 global journal of public health medicine 2020, vol 2, issue 2 gggggglo discussion: iraq has been experiencing repeated wars both externally and internally for a long time which leads to home destruction, immigration of people, lack of electrical power, insufficient of healthy water supply, as well as the degradation of its infra-structures (al-abbassi ar, & amena sm, 2015). all these factors caused iraq to suffer from cholera, and the last attack was in 2017 in which baghdad (alrisafa) and babylon took the first and second ranks in the number of cases reported respectively followed by wasit governorate as the third (hussein a a, 2018). the age distribution of cholera patients in this study showed the highest percentage in those older than 45 years old with the lowest percentage in children between (1-4) years old probably due to using a bottle or boiled water in feeding them. a study conducted in another province (alhilla) in 2015 found that people between (5-20) years old were most affected, with no significant difference between males and females (malik z, & baee h, 2017). nearly two-thirds of patients were females which may reflect bad hygiene and living situation for women in cholera affected places, likely because women are more engaged in domestic work in the home and responsibility of caring for sick persons in the family (who, 2007). out of the positive vibrio cholera cases recruited in a descriptive study to cholera cases in iraq 2017, there were (18.71%) age less than 15 years and (81.29%) in age over 15 years, with significant differences (p< 0.0001). among positive cases, of which 78 (45.60%) were in males and 93 (54.40 %) were females. on the other hand, statistical analysis did not show significant differences (hussein a a, 2018). cases were distributed in different months of the year, but the peak was on september, these results are similar to those of study done in hilla city in 2015 (malik z, & baee h, 2017), and that can be explained by the presence of inaba serotype which is a common type that occurs in iraq (mukhapadhyay ak et al., 2016). the serotyping of the isolates cholera cases in 2015 showed that the vibrio cholera cases in iraq were of serotype inaba with the presence of o few cases of ogawa (al-abbassi ar, & amena sm, 2015). previous cholera outbreaks in iraq showed the same seasonal distribution during september and october months of the year which is compatible with the classical trend of the disease (al-abbassi ar, & amena sm, 2015). annual distribution of the disease may show no or little control of the risk factors that lead to cholera, like inactive sewage disposal and using disinfectant water in daily life activities like cooking or drinking. all cases of cholera reported in one primary health care district (alsuwaira) which gave an idea about this place that complains from insufficient sewage disposal and water supply in addition to low social and economic class for most of the citizens as mentioned in the who report (hussein aa, 2018). in this study, all cholera patients mentioned the use of tap water which is in contrast to other studies that showed the disease is more prevalent in patients who drink unsafe water from wells or rivers (malik z, & baee h, 2017). this study revealed that the recovery rate was 100% percentage in wasit province which is of no different from the case fatality rate of the iraqi 218 global journal of public health medicine 2020, vol 2, issue 2 gggggglo epidemic in 2015 which reach only 0.075% (alabbassi ar, & amena sm, 2015). conclusion and recommendations: cholera is an endemic disease in iraq, but outbreaks can occur in different governorates. wasit is one of these affected places by the last epidemic in 2017, so the need for urgent work for prevention and control by surveillance, providing suitable investigation for diagnosis, and early treatment measures. in addition to improving health institutions' capacities at all levels especially those in the peripheral regions. enhance cooperative works between related agencies, in particular, sewage disposal of contaminated water and disposal of hazardous items. maintain strong and consistent contact between the health sector and other stakeholders to apply an intersectoral approach for the management of cholera and other diarrhoeal diseases. the main epidemiological features of the cholera outbreak in wasit in 2017 was it affected mainly adult females rather than other groups, especially in months of autumn due to a suitable environment for the present serotype. the attack was concentrated in one primary health care district although all of them mentioned using tap water for daily life activities and drinking. arising the need for increasing awareness in special areas and population about using treated or boiled water in different activities especially cooking food and washing, take care of personal hygiene, and washing hands. even so, this outbreak hit wasit province but it still under the control with no fatality rate. conflicts of interest: the author 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(2019). cholera. retrieved 30 july 2019, from https://www.who.int/newsroom/fact-sheets/detail/cholera 21 global journal of public health medicine 2019, vol 1, issue 1 gggggglo the prevalence of obesity stigmatization among private university students in shah alam, malaysia afiqah rajib, khin hla hla thein*, hasanain faisal ghazi & tiba nezar hasan international medical school, management & science university, selangor, malaysia. *corresponding author: khin_hla@msu.edu.my abstract introduction: stigma and discrimination toward obese person are pervasive and have created various consequences for their psychological and physical health. various studies in american society showed obese person are negatively stereotyped. the aim of the study is to identifying the perceptions of students towards the obesity stigmatisation. methods: this study used 300 students who will answer a self-administered questionnaire on obese stigmatization. a total of 150 male (50%) and 150 female (50%) are targeted in this research. the study used a convenience sampling method to collect the data using self-administered questionnaires result: the findings showed that a total of 51% of the students had negative attitude towards obesity. there was a significant correlation between attitude towards obesity stigmatization and eating disorder with (r = 0.201) and between attitude and body image with (r = 0.245) conclusion: a total of 51% of the students had negative attitude towards obesity. more health promotion and awareness on a balance diet and to understand the perspective view towards obesity stigmatization. keywords: obesity, stigmatization, attitudes, emotional eating, body image. 22 global journal of public health medicine 2019, vol 1, issue 1 gggggglo introduction the increase of overweight and obesity cases in malaysia concern the society because of the effect of this increase in weight on many of chronic illnesses such as diabetes, heart disease, arthritis and stroke. meanwhile, one study done in malaysia found that obese participant perceived themselves to have a normal weight and thus had no determination of reducing their weight (chang et al., 2009). furthermore, in addition to the obesity effect on physical health, it has psychological affect due to stigma and discrimination toward those suffering from it. many studies in american society showed obese person are negatively stereotyped. the overweight and obese individuals are said to be lazy, weak intention, unsuccessful, less intelligent, lack of selfdiscipline, not capable of following weight reduction treatment and many other negative stereotypes. this disease stigma arises when the society blamed those with obesity for their illnesses because they are considered as immoral unclean or lazy. furthermore, society regularly regards obese person not as innocent victims but as architects of their own ill health, personally responsible for their weight problems because of being inactive and eating too much. the stigma associated with obesity is a major psychological & socioeconomic burden for affected persons & their families (puhl & heuer, 2010). other than that, obesity stigma involves actions against people with obesity that can cause exclusion and marginalization and lead to inequities and individuals who are overweight or obese reported a significant history of being threatened by stereotypes related to weight (carels et al., 2013 & who, 2019). in the knowledge and information era we live in, we understand that the rate of obesity has been growing around the world and the obesity stigma is a result of devaluing the physical attributes which are related to being overweight. people tend to have negative & stigmatizing attitudes toward obesity including obese persons themselves (levit et al., 2018). in addition, a study in germany state that there is a large number of students have negative attitude towards those overweight people compared to those individual with normal weight in which it is consistent with the common stereotype that overweight individuals have less self-discipline and inactive physically (pantenburg et al., 2012). on the other hand, the bmi is an approximate measure of total body fat and the bmi for obesity are divided into 3 categories which include the obesity class i, obesity class ii and obesity class iii. the obesity class i are in range of 30 – 34.9. the obesity class ii are in range of 35 – 39.9. then, the obesity class iii are said to be 40 above (marengo, 2018). on the contrary, food and beverage television advertisements have been found to play a substantial role in marketing the nutrition less food among several sections of the population, contributing to the global obesity and pandemics (tempels et al., 2017). moreover, eating restraint is often related to weight loss in behavioural treatments and is suggested to be a risk factor for the development of eating disorders. besides that, the prevailing suggested definition of binge eating including consumption of large quantities of food without being in control of this behaviour (elfhag & rossner, 2005). at the same time, body disapproval and low satisfaction about body image has been identified as a psychological effect of obesity that is usually 23 global journal of public health medicine 2019, vol 1, issue 1 gggggglo associated and lead to disordered eating, poor self-esteem and depression (weinberger et al., 2016). therefore, the aim of the study is to identifying the perceptions of students towards the obesity stigmatisation. methods a cross-sectional study was conducted among 300 private university in shah alam. selfadministered questionnaires were used to collect data. students were age between 18 – 35 years old in which it is a range for a young adult and the study was conducted from february 2019 to april 2019. the questionnaire given are to access the prevalence attitude toward obesity stigma and demographic data of the young adults. also, to access the attitude with obesity stigmatization, attitude with eating disorder and attitude with body image disturbance. in addition, the questionnaire are given to 150 male students and 150 female students by using a non-probability quota sampling method. the questionnaires consist of 4 parts, part a about socio demographic background of the respondents. part b regarding attitude towards obesity that adopted from gipson et al., 2005. the responses of participants were numbered in order of preference from 1 to 6 (strongly disagree to strongly agree). part c about eating disorder adopted from fairburn & berlin, 1994, the participants’ responses were numbered in order of preference from 1 to 7 (no days to everyday). part d for body image disturbance adopted from (fairburn & berlin, 1994) the participants’ responses were numbered in order of preference from 1 to 7 (not at all to markedly) data was analysed using spss software version 23.0 . the significance value for the test will be p-value of <0.05. moreover, the prevalence of attitude of obesity stigmatization are expressed by using frequency (n) and percentages (%) and pearson correction test was used. all respondents signed the consent form before answering the questionnaires and ethical approval obtained from management and science university ethics committee. results three hundred participants were included in the analyses which showed 50% (150) male and 50% (150) female participated in this study. majority of the students involved were from degree program which is 62.7% (188) followed by 31.3% (94) from diploma program and 6% (18) from foundation program. in addition, 30% (90) were from ims, 8.3% (25) were from sess, 19% (57) were from fise, 25.7% (77) were from fbmp, 6.7% (20) were from fhls, 4.3% (13) were from sph, 1% (3) were from pgc and 5% (15) were from shca. meanwhile, the bmi for 300 students were founded to be 90.7% (272) were normal or underweight, 6.0% (18) were in obesity class i, 2.7% (8) were in obesity class ii & 0.7% (2) were in obesity class iii. based on descriptive statistic of attitudes towards obesity, the statement of ‘most obese people are more self-conscious than other people’ shows the highest mean of 4.16 refers to strongly agree and sd of 1.000. in addition, the eating disorder showed ‘have you had a strong desire to lose weight’ with the highest mean of 4.04 refers to 13 – 15 days and sd of 2.895. then, the body image disturbance showed ‘how dissatisfied have you been with your weight?’ with the highest mean of 3.52 refers to moderately agree and sd of 1.999. besides that, table 1 shows the prevalence of 24 global journal of public health medicine 2019, vol 1, issue 1 gggggglo attitude towards obesity among young adults in management & science university. in addition, the negative attitude towards obesity was 51.0% (153) which was slightly higher than positive attitude towards obesity that is 49% (147). table 1: prevalence of attitude towards obesity (n) (%) negative attitude towards obesity 153 51% positive attitude towards obesity 147 49% total 300 100% to test the hypotheses of the study, a pearson correlation test was used to identify relationship between attitude and eating disorder shown in table 2 and attitudes and body image shown in shows that r = 0.201 and p <0.05 which showed that there is a positive relationship between attitudes towards obesity and eating disorder. meanwhile, attitude & body image disturbance showed r = 0.245 and p <0.05 which showed that there is a positive relationship between attitudes towards obesity and body image. table 2: correlation between attitude with eating disorder & body image disturbance variables correlation p value attitude & eating disorder r = 0.201 0.03 attitude & body image disturbance r = 0.245 0.04 discussion the main findings of this study that 51% of respondents had negative attitude towards obesity. the result has revealed that the respondents were concerned about the manifestations of overweight or obesity which are considered as a moral failure. the result also showed the prevalence of attitudes towards obesity showed negative attitude are slightly higher compare to the positive attitude towards obesity. these conclude that the respondents are said to disagree on the statements of attitude towards obesity. however, majority of the respondent are strongly agree with one statement such as ‘most obese people are more self-conscious than other people’. furthermore, a study of attitudes towards obesity conducted in india showed peers have more negative than positive attitudes towards obesity (rashmi & jaswal, 2011). this study supported the result of the prevalence of attitude towards obesity of the past study by these two scholars. moreover, the negative attitudes as a blame were associated with the belief that individuals are responsible for obesity (luck-sikorski & riedel-heller, 2017). other than that, the age 18 – 25-year-old reported more negative attitudes towards obese people (flint et al., 2015). at the same time, many studies showed that obese individuals suffer from serious physical health consequences such as diabetes, cardiovascular problem, hypertension or dyslipidaemia in addition to suffering from social problems and restrictions due to negative attitudes and discrimination towards them (stein et al., 2014). moreover, this study also found that there is a relationship between attitudes towards obesity 25 global journal of public health medicine 2019, vol 1, issue 1 gggggglo and eating disorder. the eating disorders are diseases in which the people have severe imbalance in their eating behaviours and related emotions and thoughts. people having such eating disorders typically become preoccupied with food and their body weight. in the diagnostic and statistical manual of mental disorders 5, the eating disorders section was renamed ‘feeding and eating disorders’ and specified into three eating disorders which are anorexia nervosa, bulimia nervosa and binge eating disorder and three common feeding disorders such as pica, rumination disorder and avoidant or restrictive food disorder. common risk factors of obesity and eating disorders can be classified into three levels according to the social ecological model such as individual that includes sex, age and weight status. then, social like as media, weight teasing and ideal beauty pattern, in addition to psychological such as self-esteem and body satisfaction (leme et al., 2018). the consistent of this theory shows that the obese people who have been teased or victimized about their weight are more vulnerable to binge eating patterns and those who internalize weight-based stereotypes may be at heightened risk of engaging in binge eating behaviour (puhl et al., 2010). other than that, a previous study showed that a greater stigma is related with eating disorders (harrison & bertrand, 2016). apart from that, a study in australia between the years of 1995 to 2015 found that there were significant rises in the prevalence of obesity and eating disorder behaviours independently, however, the highest increases were in the prevalence of individuals with obesity and comorbid binge eating or very strict dieting. then, it is found that symptoms of depression & low self-esteem in dieters were important elements increasing the risk of binge eating. meanwhile, the dieting can be associated with these negative consequences (luz et. al., 2018). in addition, these related articles supported the result of eating disorder statement in the current study in which the most of the young adults strongly agree with a strong desire to lose weight. along similar argument, the study also showed there is a relationship between attitudes towards obesity and body image disturbance. the result revealed that participants were concerned about the body image appearance especially pertaining to ideal weight with a perfect physical body shape. besides that, the body dissatisfaction has been identified as a psychological correlate of obesity that is related to disordered eating, poor selfesteem and depression (weinberger et al., 2016). besides that, there are also concern for the four elements to a body image which include how you see your body, how you feel about your body, how you think about your body and what you do as a result of all of the clarification. moreover, the body image has implications on mental health such as selfesteem, anxiety, depression and selfconfidence and eating disorders. also, the physical illness such as obesity play a role in body image (pakki & sathiyaseelan, 2018). other than that, the weight bias and obesity stigma lead to low self-acceptance of body image and lower the self-esteem and selfconfidence, in addition to feelings of worthlessness and loneliness. also, it leads to general anxiety and depression in people who are overweight and obese. in addition, weight bias and obesity stigma have a negative influence on body mass, as they may provoke binge eating and reduce the motivation to lose weight. this negative effect results from a low 26 global journal of public health medicine 2019, vol 1, issue 1 gggggglo self-acceptance of body mass which leads to eat more in response to this negative emotion. thus, the emotional outcome associated with body mass image and acceptance may decline the general well-being and hinder weight loss in overweight or obese individuals (regwelski et al., 2019). conclusion a total of 51% of the students had negative attitude towards obesity. more health promotion and awareness on a balance diet and to understand the perspective view towards obesity stigmatization. the discriminated individuals may be emotionally and psychologically supported by various members of the society. furthermore, the understanding of attitudes towards obese people may motivate young adults to adopt healthier living and reducing negative attitudes as well as beliefs towards obesity stigmatization. this could be a proactive starting point in our battle against obesity stigmatization which has been a public health concern. the stigma is also a major barrier to psychological burden affecting overweight and obese persons. hence, stigmatization needs to be eliminated. references carels,ra. burmeister,j. oehlhof, mw et al. 2013. “internalized weight bias: ratings of the self, normal weight, and obese individuals and psychological maladjustment,” journal of behavioral medicine, 36(1): 86–94. chang c. t., chang k. h. & cheah w. l., 2009. adults’ perceptions of being overweight or obese: a focus group study. asia pacific journal of clinical nutrition. 18(2): 257 – 264 elfhag k. & rössner s., 2005. who succeeds in maintaining weight loss? a conceptual review of factors associated with weight loss maintenance and weight regain. obesity reviews. 6: 67–85 fairburn c. g. & beglin s. j., 1994. assessment of eating disorders: interview or self-report questionnaire?. international journal of eating 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obesity results from a survey experiment. bmc public health. 17(1): 373 levit t., lavack a. m. & watson l., 2018. obesity and stigmatization at work. stigmas, work and organizations. new york: palgrave macmillan. july: 11-34 luz f. q. d., hay p., touyz s. & sainsbury a., 2018. obesity with comorbid eating disorders: associated health risks and treatment approaches. nutrients. 10(829): 1 – 9 marengo k., 2018. bmi calculators and charts. retrieved on 22nd may 2019. https://www.medicalnewstoday.com/arti cles/323586.php pakki s. s. & sathiyaseelan a., 2018. issues related to body image in young adult women. saudi journal humanities social science. 3(2): 250 – 254 pantenburg b., sikorski c., luppa m., schomerus g., könig h-h., werner p. & riedel-heller s. g., 2012. medical students’ attitudes towards overweight and obesity. plos one. 7(11): 1 – 8 27 global journal of public health medicine 2019, vol 1, issue 1 gggggglo puhl r. m., masheb r. m., white m. a. & grilo c. m., 2010. attitudes toward obesity in obese persons: a matched comparison of obese women with and without binge eating. eat weight disorder. 15(1): e173–e179 puhl r. m. & heuer c. a., 2010. obisity stigma: important considerations for public health. american journal public health. 100(6): 1019 – 1028 rashmi & jaswal s., 2011. attitude of parents, peers and teachers towards obese teenagers. journal psychology. 2(1): 45 – 51 regwelski m, ewa lange , dominika gła˛bska and dominika guzek. 2019. analysis of the influence of age, bmi, and whtr on body mass acceptance, attitudes, and motivation towards body mass reduction in overweight and obese caucasian women, nutrients 2019, 11(3), 542; https://doi.org/10.3390/nu110305 42 stein j., luppa m., ruzanska u., sikorski c., könig h. h., riedel-heller s. g., 2014. measuring negative attitudes towards overweight and obesity in the german population – psychometric properties and reference values for the german short version of the fat phobia scale (fps). plos one. 9(12): 1 – 18 tempels, verweij t. & blok m. v., 2017. big food's ambivalence: seeking profit and responsibility for health. american journal of public health. 107(3): 402 – 406 weinberger n. a., kersting a., riedel-heller s. g. & luck-sikorski c., 2016. body dissatisfaction in individuals with obesity compared to normal-weight individuals: a systematic review and meta-analysis. obese facts. 9:424-441 world health organization, 2019. weight bias and obesity stigma: considerations for the who european region. retrieved on 22nd may 2019. http://www.euro.who.int/__data/assets/p df_file/0017/351026/weightbias.pdf microsoft word gjphm-2020plasmodium knowlesi in southeast asia.docx 220 global journal of public health medicine 2020, vol 2, issue 2 gggggglo review research risk factors for plasmodium knowlesi in southeast asia:a systematic review safirah jaan j, noor hazmi nh, noor amani mp m, mohd rohaizat h, norfazilah a & azmawati mn department of community health, university kebangsaan malaysia medical centre (ukmmc), faculty of medicine, universiti kebangsaan malaysia, cheras kuala lumpur, malaysia. corresponding author: azmawati@ppukm.ukm.edu.my abstract introduction: plasmodium knowlesi zoonotic malaria has been identified in borneo malaysia in 2004, and has led to an increase in the number of cases throughout southeast asia. many factors have contributed to increasing pattern. therefore, this systematic review aims to identify risk factors for plasmodium knowlesi infection that can aid in predicting and controlling the infection. methods: systematic search on articles related to risk factors of plasmodium knowlesi infection was conducted using three databases namely pubmed, scopus and science direct. all the articles from year 2015 till may 2019 were selected. results: a total of three articles were included in this review based on the study protocol. three common risk factors for plasmodium knowlesi infection was in identify mainly involved sociodemographic, work-related and behavioural factors. conclusion: risk factors for p. knowlesi ranges not only from individual and community socidemographic background but also by environmental and geographical determinants. the inconsistency of the result was due to the variability and limitations of the studies itself. the research on p. knowlesi, should be conducted with larger participants and longer length of follow up. keywords: plasmodium, p.knowlesi, risk factors, asia 221 global journal of public health medicine 2020, vol 2, issue 2 gggggglo introduction: plasmodium knowlesi (p.knowlesi) is a primate malaria parasite commonly found in southeast asia (perkin & schall, 2002). in malaysia, p. knowlesi is consider emerging infectious disease related to zoonotic human malaria. it causes zoonotic malaria in long-tailed macaques (macaca fascicularis). southeast asia(sea) reported most of the cases with macaque as a hosts. p. knowlesi zoonotic malaria has been identified in borneo malaysia in 2004, and has led to an increase in the number of cases of p. knowlesi throughout sea (singth et al, 2004) infections can cause severe illness and death although most people infected with p. knowlesi respond to treatment (ahmed et al, 2014). p.knowlesi malaria is potentially life-threatening due to the special features of the zoonotic malaria, that is, 1) having a much shorter incubation period of 24 hours as compared to other type of human malaria species, 2) having atypical presentation that has common symptoms shared by many other viral diseases such as dengue fever, 3) fast deteriorating once clinically symptomatic due to hyperparasitaemia found in macaque when infecting human as the macaque are their natural hosts who has developed natural immunity towards the parasite and have not suffer disease, 4) the zoonotic malaria is capable to cause acute multiple organs failure as the parasites invaded human body. people who are infested with p.knowlesi are usually died of hepatorenal syndrome and septicaemia (cox-singh et. al, 2010). the first cases of naturally acquired human infection described in peninsular malaysia in 1965. the spill-over infections from the traditional monkey-vector transmission cycle presumed to be infrequent (shearer et al, 2016). the majority of cases are from eastern malaysia, with increasing trend of the notifications (grigg et al. 2014). since year 2001, p. knowlesi has become an emerging vector-borne disease in malaysia, especially sabah, sarawak at east malaysia, and pahang, kelantan of west malaysia. in sabah, a marked, rapid increase in the number of p. knowlesi cases reported recently beginning in the southwest and progressing to northeasterly.7 (william, jelip et al. 2014). public health microscopy notifications for p. knowlesi in sabah (including those reported as p. malariae) have increased from around 2% (59/2741) of all malaria cases in 2004, to 35% (703/1936) in 2011 and, recently, to 62% in 2013 (996/1606) (sabah department of health). in sarawak, p. knowlesi or p. malariae microscopy notifications were 14.3% (1731/12 082) of all malaria cases between 2000 and 2006 (cox-singh & singh, 2008), increasing to 41% (897/2189) in 2009 (singh & daneshvar, 2010) and to 73% (737/1004) in 2013. p knowlesi cases have now been stated from all countries in sea except in laos (wesolowski et al, 2015). it is encompass the range of geographical area for the natural macaque hosts (macaca fascicularis and macaca nemestrina) and anopheles leucosphyrus group vectors (cox-singh & singh, 2008). since 2004, some sporadic cases of p. knowlesi human malaria have also been reported in several asian countries including 222 global journal of public health medicine 2020, vol 2, issue 2 gggggglo singapore, brunei, indonesia, thailand, cambodia, myanmar vietnam, india, china and the philippines (zhu et al, 2006) till date, there is no background data to gauge the actual prevalence unless country wide retrospective-cohort study is done. if this is true, a well-organized one-health team-based approach is urgently called for to face this challenge, as the epidemiology and risk factors for p.knowlesi are totally different from all the other plasmodium species. therefore, this study aim to systematically collect the evidence of possible risk factors that contributes to the transmission and infection of p.knowlesi in sea. methods systematic search related to relevant articles from four major search engines using boolean search strategy, search engines including pubmed (national library of medicine bethesda 1996), scopus, science direct (elsevier 1997), retrieving all articles published from year 2015 until may 2019. prisma checklist 2009 is used to describe the workflow of articles search for this study. the keywords used to search for the articles are risk factor or predictor or explantory and plasmodium knowlesi or p.knowlesia or simian malaria or zoonotic malaria and malaysia or southeast asia or sea or asean. inclusion criteria for the article search including: (1) full text, primary research articles on risk factor of plasmodium knowlesia infection; 2) reported at least one risk factor of plasmodium knowlesia infection and; (3) articles published from year 2015 – may 2019. exclusion criteria set were: (1) reviewed articles of no original research work empirical data; (2) entomology with no association to risk factors; (3) knowledge, attitude, practice studies; (4) clinical treatment; (5) pharmaceutical study and; (6) risk factors for other plamodium infection the articles obtained from the keyword search were first screened by titles to exclude totally irrelevant articles, then abstracts of the articles to look for pico criteria. when full texts are retrieved, it was assessed for relevance to include our inclusion and exclusion criteria. in total, there is a total of 114 articles retrieved based on boolean search strategy. 46 articles from pubmed, 53 articles from science direct and another 15 articles from scopus. after excluding 10 articles for duplication, 104 are screen by titles and abstract yielding 32 articles accepted for further screening. 29 of full-text articles were excluded due no risk factors (1), targeted specific population only (1), geographical study (5), diagnostic investigation (8) and mixed malarial infection (14). final full articles reviewed and proceed for qualitative syntheses are 3 articles (figure 1). 223 global journal of public health medicine 2020, vol 2, issue 2 gggggglo figure 1: studies selection related to p.knowles results: a summary table of all the included articles for analysis (table 1), there was a total of 3 articles, which consist of one cross sectional and two case control studies. the articles are mostly from sabah, malaysia and philippines. across the articles, the common risk factors for p. knowlesi infection are age, gender, occupation, contact with macaque, behavioural factor while protective factors are children, use of insecticide, house at ground level, presence of sparse forest & paddy field near the house. the quality of the studies which were assessed by using newcastle-ottawa scale ranged from 6 to 8 stars. total of 2 articles were given good quality and one with moderate quality of evidence as shown in table 2. sc re en in g in cl u d ed el ig ib il it y id en ti fi ca ti o 114 of records identified through database searching pubmed n = 46 science direct n =53 0 of additional records identified through other sources 104 of records after duplicates removed 32 of records screened 72 of records excluded by titles and abstract 3 of full-text articles assessed for eligibility 29 of full-text articles excluded, with reasons no risk factor n = 1 specific population n = 1 geographical study = 5 diagnostic investigation 3 of studies included in qualitative synthesis 224 global journal of public health medicine 2020, vol 2, issue 2 gggggglo author & year country population length of study effect measure risk factor or (95% ci) fornace,2019 sabah, malaysia kudat, kota marudu, pitas, & ranau, sabah 2849 household in 180 village n = 10,100 3 months (sept – dec 2015) or age male contact with macaque forest activities irrigated farming (300m radius) pulpwood plantation (3000m radius) oil palm (<3000m radius) use of insecticide house at ground level intact forest 1.33 (1.27, 1.39) 1.25 (1.04,1.48) 1.42 (1.17,1.71) 1.47 (1.65, 2.37) 1.17 (1.07, 1.28) 1.15 (1.07,1.24) 1.10 (1.01,1.20) 0.77 (0.63.0.91) 0.76 (0.63,0.91) 0.86 (0.75,0.96) fornace,2018 sabah, malaysia & bacungan, philiphine a) matunggong & limbuat, sabah n = 172 cases & 1957 control b)bacungan, philipinie n = 6 cases & 546 control 5 months (sept 14 – jan 15) or 15 – 45 years 45 – 60 years > 60 years farm or plantation work forest cover (1000m radius) proportion of cleared /open area (500m radius) 2.05 (1.30,3.22) 2.94 (1.70,5.11) 2.46 (1.32,4.58) 1.63 (1.07,2.48) 2.40 (1.29,4.46) 2.14 (1.35,3.40) grigg,2017 sabah, malaysia kudat & kota marudu, sabah n = 229 cases & 683 control 2 months (dec 2014 – jan 2015) or children < 15 years adult >15 years male contact with macaque farm or plantation work farming palm oil clearing vegetation sleeping outside travel 0.29 (0.18,0.47) 3.81 (2.31,6.28) 4.02 (2.83,5.72) 4.06 (2.71,6.08) 3.08 (2.20,4.29) 2.66 (1.82,3.88) 3.22 (1.72,5.61) 3.49 (2.44,5.00) 6.63 (3.47,12.69) table 1: summary of included studies 225 global journal of public health medicine 2020, vol 2, issue 2 gggggglo having long grass around house having open eaves or gap in walls g6pd deficiency lived in village past 6 months presence of young sparse forest residual insecticide presence of paddy field 2.66 (1.85,3.81) 2.13 (1.48,3.07) 2.17 (1.50, 3.14) 0.11 (0.02,0.46) 0.46 (0.26,0.88) 0.44 (0.30,0.64) 0.77 (0.54,1.09) 0.51 (0.19,1.36) 226 global journal of public health medicine 2020, vol 2, issue 2 gggggglo table 2: newcastle ottawa quality assessment scale no study selection comparability outcome quality score rep rese ntati ven ess of the sam ple sam ple size nonrespon dents ascertai nment of the exposur e (risk factor) the study controls for the most important factor the study control for any additional factor assess ment of the outcom e st ati sti cal te st 1. fornace 2019 * * * * * ** * 8 2. fornace 2018 * * * ** * 6 3. grigg 2017 * * * ** * ** * 8 discussion the main risk factors for p. knowlesi malaria infection for countries under sea region can be divided into three big groups which is the sociodemographic background, work related and behavioural factors. the finding of a higher risk of infection in adult males and age between 15 to 45 years old are consistent with other studies. according to fornace et al. (2016), risk of getting p.knowlesi in certain area like pulau banggi, kudat sabah is the highest with aor 10.83 (95%ci: 4.5-26.1) compared to other studied location such as palawan, filipina and other part of sabah. due to the job nature’s demand, risk factor like forest exposure are quite unavoidable. forest-based work such as: logging, clearing vegetation, palm oil plantation and rubber tapping is usually done by men. furthermore, the jobs mention requires workers to stay during the night in the forestry. therefore, the job natures are strongly associated with p. knowlesi infection and this leads to adult men are at high risk for infection. since forest workers are higher risk getting the p. knowlesi malaria therefore the efforts for mass screening needs to focus among them rather than targeting villagers. the screening radius may reduced to less than 100m even though the who recommended for 1-2km (herdiana et al. 2016). the collaboration with other agencies such as forestry, agriculture and local partner (logging site supervisor, farm owners) should be enhance in engaging the forest workers for malaria prevention and control activities. the activities may include health education in promoting health seeking behaviours. the distribution of itn should include among them as the distribution by local goverment mainly involve residence area and this product not available to purchase. itn used have a rapid treatment by providing personal protection to humans with maximal estimated reductions in human (natsuko et al. 2014). for 227 global journal of public health medicine 2020, vol 2, issue 2 gggggglo job require overnight stays at the forest far from village or subdistrict, a mobile surveilance system should be developed and enhanced for monitoring the forest workers. the data collected are useful for future planning in malaria elimination. behavioural risk factors are related to the individual or the local community’s culture and lifestyle. examples included in the study are sleeping outside, travel, long grass around houses, open eaves/gaps in walls and house at ground level. by providing adequate knowledge and awareness regarding mode of transmission and risk factors for p. knowlesi to the local community, it can helps with the transition of risk behaviour towards protective behaviour. in african countries, the prevalence of risk factors for malaria among households with clean water to be less. house with thatch and stick/mud roof and earth/local dung plaster floor found to be higher with malaria through rapid test. therefore, spraying anti-malaria to the house able to reduce the risk of malaria transmission. furthermore, the housing condition, source of water and its distance, gender, and ages in the households were identified in order to have two-way interaction effects (ayele et al 2012). such pattern of risk factors are quite different from the risk factors for specific zoonotic malaria like p. knowlesi where’s it highly linked to the patient’s nature of job and history of exposure to jungle or its natural reservoir. conclusion risk factors for p. knowlesi ranges not only from individual and community sociodemographic background but also by environmental and geographical determinants. the inconsistency of the result was due to the variability and limitations of the studies itself. however, there are still comparable prospect on the risk factors for p. knowlesi which can influence on health related behavioural modification. for future research on p. knowlesi, it should be conducted with larger participants and longer length of follow up with provided numbers for cases group and control group to produce quality results thus could generate significant result for meta-analysis. intevention study in future may provide a significant findings in reducing the burden of p. knowlesi malaria. the high burden of p. knowlesi in sea needs attention for further investigation related to its epidemiology and specific risk factors. p. knowlesi malaria transmission are the new challenge in endemic area in achieving malaria elimination. conflicts of interest: the author declare no conflicts of interest. 228 global journal of public health medicine 2020, vol 2, issue 2 gggggglo references: • ahmed, a. m., et al. (2014). "disease progression in plasmodium knowlesi malaria is linked to variation in invasion gene family members." plos negl trop dis 8(8): e3086. • ayele, d. g., et al. (2012). "prevalence and risk factors of malaria in ethiopia." malar j 11(1): 195. • cox singh j et al. 2010. severe malaria a case of fatal plasmodium knowlesi infection with postmortem findings: a case report. malar j.; 9: 10. • cox-singh, j. and singh, b. (2008). "knowlesi malaria: newly emergent and of public health importance?" trends parasitol 24(9): 406-410. • fornace, k. m., et al. (2016). "association between landscape factors and spatial patterns of plasmodium knowlesi infections in sabah, malaysia." emerg infect dis 22(2): 201. • grigg mj et al. 2014. factors that are associated with the risk of acquiring plasmodium knowlesi malaria in sabah, malaysia: a case-control study protocol. bmj open. 2014; 4(8): e006004. • herdiana, h., et al. (2016). "malaria risk factor assessment using active and passive surveillance data from aceh besar, indonesia, a low endemic, malaria elimination setting with plasmodium knowlesi, plasmodium vivax, and plasmodium falciparum." malar j 15(1): 468. • natsuko, i., et al. (2014). transmission and control of plasmodium knowlesi: a mathematical modelling study. plos negl trop dis 8(7):e2978 • perkins, s. l. and schall j. j. (2002). "a molecular phylogeny of malarial parasites recovered from cytochrome b gene sequences." the journal of parasitology: 972-978. • sabah department of health. (2019, march). retrieved from http://jknsabah.moh.gov.my/ • shearer, f. m., et al. (2016). "estimating geographical variation in the risk of zoonotic plasmodium knowlesi infection in countries eliminating malaria." plos negl trop dis 10(8): e0004915. • singh, b., et al. (2004). "a large focus of naturally acquired plasmodium knowlesi infections in human beings." the lancet 363(9414): 1017-1024. • • singh, b. and daneshvar c. (2010). "plasmodium knowlesi malaria in malaysia." med j malaysia 65(3): 166-172. • wesolowski, r., et al. (2015). "plasmodium knowlesi as a threat to global public health." the korean journal of parasitology 53(5): 575. • william, t., et al. (2014). "changing epidemiology of malaria in sabah, malaysia: increasing incidence of plasmodium knowlesi." malar j 13: 390 • zhu, h., et al. (2006). "human natural infection of plasmodium knowlesi." zhongguo ji sheng chong xue yu ji sheng chong bing za zhi= chinese journal of parasitology & parasitic diseases 24(1): 70-71. microsoft word new edited galley proof.docx 673 global journal of public health medicine 2022, vol 4, issue 2 gggggglo original research emotional intelligence and academic performance: a cross-sectional study among medical students deepana palaniappan , sudha valmurthy* , arunachalam, subash chandra bose, sevvanthi kumar department of community medicine , aarupadai veedu medical college and hospital, puducherry 607403 , india. *corresponding author : aswinsharwin@gmail.com abstract introduction: the evaluation of emotional intelligence is an important factor in determining medical students' academic performance. as a result, the study was carried out to compare the relationship between emotional intelligence score and academic performance in undergraduate medical students. methods: a cross-sectional study was conducted among 346 undergraduate medical students and schutte scale was used to assess their emotional intelligence through google form during the period between july 2021 to january 2022. academic achievement was assessed based on each student’s self-reported grade point average in the most recent examination. results : out of 346 study participants,3% had low emotional intelligence, 29% had moderate emotional intelligence, 68% had high emotional intelligence. a significant association was identified between emotional intelligence and academic performance, grade, gender, career choice. no statistically significant association was observed between emotional intelligence and year of study of participants. conclusion: the participants' academic performance was strongly associated with their emotional intelligence scores. emotional intelligence (ei) refers to the ability to comprehend and control emotions, to be empathetic, to be socially competent, and so on. these abilities increase overall communication skills, which improves achievement in medical school. keywords: medical undergraduates, academic performance, emotional intelligence 674 global journal of public health medicine 2022, vol 4, issue 2 gggggglo introduction: emotional intelligence is defined as "the ability to monitor one's own and other people's emotions, to discern between different emotions and label them appropriately, and to use emotional information to drive thought and behaviour"(romanelli 2006). self-awareness, self-regulation, empathy, motivation, and social skill are the five general components of emotional intelligence(goleman 1995). the first component of ei is self-awareness, which is defined as the ability to perceive and understand our own needs, emotions, and impulses, as well as their impact on others. the skills described within this ability are self-confidence, realistic self-evaluation, and a self-depreciating sense of humor. it entails being honest with ourselves and others, as well as an awareness of one's own emotions, strengths, shortcomings, and motivations. the ability to manage or redirect disruptive emotions and moods is known as self-regulation. it also encompasses the ability to hold one's judgement and reflect before acting. trustworthiness and integrity, as well as comfort with uncertainty and openness to change, are all hallmarks of self-regulation. motivation is a desire to labor for reasons other than financial gain. motivation is also the ability to view goals with vigor and perseverance. empathy is the ability to understand other people's emotional makeup and treat them as a result of their emotional reactions. in the case of leadership, empathy does not imply adopting other people's emotions and attempting to please everyone. social skills are managing relationships and forming networks. the capacity to discover common ground and establish rapport is also a social skill(goleman 1995). there are a variety of elements that influence students emotional intelligence and academic achievement, ranging from kindergarten to university level learning institutions. numerous studies conducted over a long period of time have revealed a range of elements including student personality, motivation, peer relationships, iq, teacher-student relationships, parental engagement, and socioeconomic status. intelligent quotient (iq) had been widely employed as a factor and connected with an individual's academic success(spear 2015). the famous book "emotional intelligence: why it can matter more than iq," daniel goldman (1995) contends that only 20% of a person's achievement can be linked to iq. iq alone is not a reliable predictor of students' academic performance, according to a growing number of recent and emerging studies (tripathy 2018). though salovey and mayer introduced the concept of ei, it should also aid in the development of stronger relationships, job satisfaction, and career achievement all of which are important components of ei goals(goleman 2003). based on salovey and mayer’s model, schutte’s emotional intelligence scale was formed which mainly includes three aspects of emotional intelligence such as appraisal and expression of emotion(self and other), regulation of emotion (self and other) and utilization of emotion (creative thinking, planning, motivation and redirected attention)(craggs 2021) .though the medical curriculum provides wonderful opportunities to try something new, undergraduate medical students will face a number of challenges when it comes to interpersonal and intrapersonal relationships(brackett 2011). building self-confidence in students can help them achieve and maintain a positive attitude in the face of emotional outbursts and stress in their curriculum(altwijri 2021). to develop a good social competency in students, one must establish good social relationships with others as teenagers are the 675 global journal of public health medicine 2022, vol 4, issue 2 gggggglo greatest treasure of the country's development. as a result, enormous psychological support must be provided to them. many studies were conducted to assess the effect of ei on work performance, but only very few studies were done on the effect of ei on academic performance. most of the studies showed a significant relationship between ei and academic performance. hence, the purpose of this study was to estimate the level of ei and to find out the association between ei and academic performance among undergraduate medical students and house surgeons. methods: after receiving approval from the institutional research and ethics committee, a cross-sectional study was done among second year, final year part i, final year part ii mbbs students and house surgeons of aarupadai veedu medical college and hospital in puducherry. house surgeons were included in the study because they had recently passed out their final year part ii examinations. universal sampling method was used, we included all the students from first year to internship students and sample size of 346 where were consented for the study included and those did not give consent were excluded from the study during july and aug 2021( 2 months) after obtaining aarupadai veedu medical college and hospital irc and iec clearance, data was collected via google form that was sent to each batch's whatsapp groups. consent for participation in the study and questionnaire are included in the google form. to promote active involvement by undergraduate students, all undergraduates were explicitly informed about the study's aim and objectives before beginning the questionnaire, and any questions concerning the study were answered in a succinct and satisfying manner. name, age, gender, parents' education, occupation, length of stay, year of study, and previous year's attendance are all included in this questionnaire. schutte's emotional intelligence scale, a highly validated scale with an internal consistency of cronbach's alpha of 0.90 and test retest reliability was (r=0.78)(schutte 1998). the schutte scale has 4 components according to derivation from the mayer and salovey model of emotional intelligence in which those 33 items were developed by schutte ns ; they are a) emotion perception ( 5,8,9,15,18,25,27,29,32) b) utilization of emotion (17, 20, 23), c) managing others' emotions (1,11,24,26) and d) managing one's own emotions (3,21,22,28,31) and remaining were uncategorized (2,4,6,7,10,12,13,14,16,19,30,33)(musonda 2013).the likert scale was used to grade the scale [1-strongly disagree, 2disagree, 3neither disagree nor agree, 4agree, 5-strongly agree]. the scoring for questions 5, 28 and 33 had been reversed. ei scores were classified as low (33-77), moderate (78-121), and high (122-165)(unnikrishnan 2015). to ensure the highest possible response rate, a friendly reminder was sent to the students three times after providing the link via google forms via whatsapp groups. questionnaires with missing or incomplete data were excluded from the analysis. finally, out of 400 students, 346 agreed to participate in the current study, which included 94 from the second year, i87 from the final year part i, 94 from the final year part ii, and 71 from the crri. the collected data were analysed using spss version 20.0. qualitative data were summarized as frequency and percentages. chi-square test or fisher’s exact 676 global journal of public health medicine 2022, vol 4, issue 2 gggggglo test was used to find the association between ei and different qualitative data. the p value less than 0.05 was considered as statistically significant. results: the mean age of the study participants was 21.93 +3.03. nearly 50% of the study participants were aged above 21 years (53.2%). out of 346 participants, with the females were out numbering the males (51.7%). the majority of students (80.6%) had chosen their career choice on their own. table 1: distribution of study participants based on their baseline characteristics (n=346) variable n (%) age of participants 18-21 162 (46.8) above 21 184 (53.2) gender male 167 (48.3) female 179 (51.7) year of study 2nd year 94 (27.2) 3rd year 87 (25.1) 4th year 94 (27.2) house surgeons 71 (20.5) career choice family members 67 (19.4) self 279 (80.6) grade distinction 31 (9) first class 219 (63.3) second class 76 (22) fail 20 (5.8) 677 global journal of public health medicine 2022, vol 4, issue 2 gggggglo in this figure, the majority (68 percent) had high emotional intelligence, 31 percent had moderate emotional intelligence, and 1 percent had low emotional intelligence. figure: 1 distribution of study participants based on emotional intelligence level table 2: the baseline characteristics such as gender (p=0.011), career choice (0.001) and grades (0.001) had significant association with emotional intelligence but year of study (p=0.817) had no significant association with emotional intelligence. more number of females had high emotional intelligent (75.4%) when compared to males. the students who had chosen the carrier choice by self (71%), had significantly higher emotional intelligence. fig 1: distribution of study participants based on the ei scores table 2: association between emotional intelligence and baseline characteristics of study participants (n=346) baseline characteristics emotional intelligence p value lown (%) moderaten (%) highn (%) gender male 6 (3.6) 60 (35.9) 101 (60.5) 0.011* female 5 (2.8) 39 (21.8) 135 (75.4) year of study 2 nd year 4 (4.3) 24 (25.5) 66 (70.2) 0.817 3rd year 3 (3.4) 27 (31) 57 (65.5) 4th year 3 (3.2) 24 (25.5) 67 (71.3) house surgeons 1 (1.4) 24 (33.8) 46 (64.8) career choice family members 7 (10.4) 22 (32.8) 38 (56.7) <0.001* self 4 (1.4) 77 (27.6) 198 (71) 3% 29% 68% low moderate high 678 global journal of public health medicine 2022, vol 4, issue 2 gggggglo grade distinction 1 (3.2) 4 (12.9) 26 (83.9) <0.001* first class 2 (0.9) 60 (27.4) 157 (71.7) second class 1 (1.3) 30 (39.5) 45 (59.2) fail 7 (35) 5 (25) 8 (40) discussion: “the capacity to recognize our own feelings & others feelings, to motivate ourselves and to manage emotions properly in ourselves and our relationships”, goleman(2003) says of emotional intelligence. our study mainly aimed at how mental ability affects the academic performance of undergraduate medical students using the standardized schutte’s scale we are primarily interested in how mental ability influences undergraduate medical students’ academic success. students confront a variety of numerous positive and negative challenges faced by the students during their medical curriculum and it is critical for them to understand how to control and manage their emotions in order to do well academically to perform better in academics and to maintain a pleasant doctor-patient relationship(altwijri 2021). females had greater ei than males in the current study. similar findings were shown in studies conducted by nahla khamis ibrahim(2017) in saudi arabia in 2017 among 540 medical students and a by parvathy rs (2009) in july 2019 among 368 medical students in kerala and also in baskaran unnikrishnan et al11 study in mangalore with 532 participants. the current study discovered that ei scores improved with age, which is consistent with various studies(unnikrishnan 2015; ibrahim 2017; parvathy 2009) however, ranasinghe (2017) in sri lanka among 471 medical undergraduates discovered that ei scores did not improve with age. carrier choice and ei scores were found to have a significant relationship (p=0.001) which was consistent in a study conducted by baskaran unnikrishnan (2015) and magna manjareeka (2020) in odisha among 522 medical students. there was a significant relationship between grades and ei (p=0.001), comparable to the findings of baskaran unnikrishnan (2015), ranasinghe (2017), and nahla khamis ibrahim(2017) in their studies. however, there was no relationship between emotional intelligence and grades, according to sulaiman altwijri (2021) among saudi arabian medical students in 2017 and similar findings were concluded by magna manjareeka (2020). however, no significant relationship found between year of study and ei was identified in our study, which was not reported in other studies. our research was based on self-reporting questionnaires. however, self-rated surveys may have a bias in reporting, performance-based exams may be a better indicator of ei. in our study population, higher ei was associated with satisfaction with one's professional course as well as one's career choice (manjareeka 2020). importantly, this cross-sectional study limits the inference of causality for the components linked to el (alwijri 2021). to strengthen the findings of the current study, a follow-up study could be conducted. 679 global journal of public health medicine 2022, vol 4, issue 2 gggggglo conclusion: the results of our research reveal that ei has a significant impact on medical students' academic performance. as a result, teaching medical students about ei, either as part of their regular curriculum or through workshops, should be considered. to have a better knowledge of the impact of ei on student performance, more study should be done in this area. conflicts of interest the author declares no conflicts of interest. references : • altwijri, s., alotaibi, a., alsaeed, m., alsalim, a., alatiq, a., al-sarheed, s., agha, s., & omair, a. (2021). emotional intelligence and its association with academic success and performance in medical students. saudi journal of medicine and medical sciences, 9(1), 31–37. https://doi.org/10.4103/sjmms.sjmms_375_19. • brackett, m. a., rivers, s. e., & salovey, p. (2011). emotional intelligence: implications for personal, social, academic, and workplace success: emotional intelligence. social and personality psychology compass, 5(1), 88–103. https://doi.org/10.1111/j.17519004.2010.00334. • craggs, j. g. (2021). developing a coherent model of intelligence: a mechanism for understanding neurolinguistic processing. • goleman, d. (1995). emotional intelligence -why it can matter more than iq. bantam books. • goleman, d. (2003). apples and applesauce. issues and recent development in emotional intelligence. 1, 425–448 • ibrahim, n. k., algethmi, w. a., binshihon, s. m., almahyawi, r. a., alahmadi, r. f., & baabdulla, m. y. (2017). predictors and correlations of emotional intelligence among medical students at king abdulaziz university, jeddah. pakistan journal of medical sciences quarterly, 33(5). https://doi.org/10.12669/pjms.335.13157 • manjareeka, m., & yadav, s. (2020). predictors of high achievers in indian medical undergraduates: association with emotional intelligence and perceived stress. journal of education and health promotion, 9(1), 202. https://doi.org/10.4103/jehp.jehp-263-20 • musonda, a., shumba, o., & tailoka, f. p. (2013). validation of the schutte selfreport emotional intelligence scale in a zambian context. european j psychol e, 2(2), 31–41. • parvathy, r. s., & smitha, c. a. (2009). emotional intelligence, perceived stress, and internet use behaviour among undergraduate medical students a cross sectional study. kerala journal of psychiatry, 33(2), 105–113. • ranasinghe, p., wathurapatha, m. s., mathangasinghe, y., & poonamperuma, g. (2017). emotional intelligence, perceived stress and academic performance of srilankan medical undergraduates. bmc med edu, 17(1), 84–85. • romanelli, f., cain, j., & smith, k. m. (2006). emotional intelligence as a predictor of academic and /or professional success. am j pharm educ, 70(3). • schutte n s, malouff j m, hall l e (1998) et al. development and validation of a measure of emotional intelligence. personality and individual differences; 25: 167-77. • spear, m. (2015). leadership and emotional intelligence: does it matter? plastic surgical nursing: official journal of the american society of plastic and reconstructive surgical nurses, 35(2), 55–57. https://doi.org/10.1097/psn.0000000000000088. • tripathy m. emotional intelligence: an overview. research gate. 2018 jan: 1-43. • unnikrishnan b et al. association of emotional intelligence with academic performance among medical students in south india. asian j pharm clin res. 2015 mar; 8(2): 300-02. microsoft word gjphm-2022 mycotic keratitis..final galley proof.docx 711 global journal of public health medicine 2022, vol 4, issue 2 gggggglo original research microbial profile and predisposing factors of mycotic keratitis in a teaching hospital, central india vaibhav misra1, chakresh jain2, ramesh agrawal3, abhishek kumar jain*4 1dept of microbiology, gajra raja medical college gwalior. m.p. india. 2department of community medicine, s s medical college, rewa. m.p. india. 3department of microbiology, n.s.c. govt. medical college, khandwa, m.p. india 4department of microbiology, rvrs govt. medical college, bhilwara, rajasthan. *corresponding author: drabhishekjain007@yahoo.com abstract introduction: mycotic keratitis is one of the commonest causes of eye infections especially in male which works mainly in outdoor. filamentous fungi (mould-like fungi) were the common cause of mycotic keratitis and common presentations seen in developing countries. the aim of present study assess predisposing factors and microbial profile of mycotic keratitis in central india. methods: the study was conducted in the collaboration of department of microbiology and ophthalmology in g. r. medical college, gwalior, india. samples were collected from corneal scraping by sterile cotton swab and inoculated on culture media sabouraud dextrose agar (sda) for fungal culture. material obtained from corneal scrapping also performed 10% koh mount preparation, gram’s staining and lactophenol cotton blue (lpcb) mount. identification of fungal isolates was done by colony morphology, growth characteristics and relevant standard tests. results: a total of 237 out of 740 (32%) fungal isolates was obtained from suspected patients of mycotic keratitis, out of which fusarium species (33.2%) was the most predominant followed by curvularia species (21.9%) and aspergillus species (16.7%), ocular trauma was the key predisposing factors. conclusion: trauma was the key predisposing factor of keratitis because of filamentous fungi. the commonest causative agent of fungal keratitis in current study was fusarium species followed by curvularia species. early proper diagnosis and management of fungal keratitis reduces the ophthalmic morbidity and mortality. keywords: culture, filamentous fungi, fungal keratitis. keratomycosis 712 global journal of public health medicine 2022, vol 4, issue 2 gggggglo introduction: microbial keratitis is a leading cause of ocular morbidity and mortality in developing countries, secondary to the cataract, (flaxman et al., 2017). etiology of the microbial keratitis includes bacterial agents, viruses, and fungal agents, amongst them mycotic keratitis cause more serious corneal infection may lead to blindness. it still remains the challenging issue of all ophthalmologists (khor et al., 2018 and acharya et al., 2017). incidence of mycotic keratitis was very according to geographical locations, population of patients, corneal health, mainly occurs in summer seasons, tropical climates and more among agricultural workers due to vegetative trauma (estopinal et al., 2016). hence, knowledge of risk factors, causative agents and epidemiological characteristics features in particular areas are critically useful in early recognition, prompt therapy, proper management and prevention of the microbial keratitis. proper laboratory investigation was necessary before the starting specific therapy. for the diagnosis of mycotic keratitis culture of corneal scrapings on sda media and microscopy were necessary for identification of the etiological agent (bashir et al., 2005). mycotic keratitis is leading cause of blindness, because it difficult to diagnosed, cause more serious infection, poor prognosis, less responding to treatment and worse visual outcome (prajna et al., 2013). etiological agents of mycotic keratitis were yeast like fungus and filamentous fungi, yeast like fungi are candida species was prevalent in temperate climates and filamentous fungi are aspergillus spp. & fusarium spp. were prevalent in tropical climates (shah et al., 2011 and galarreta et al., 2007). the objective of the study was to detect the predisposing factors and isolation of fungal agent from corneal scrapping for diagnosis of fungal keratitis prevalent in central indian populations. methods: a two-year prospective study of fungal keratitis was carried out from july 2016 to june 2018. only patients attending the ophthalmology clinic and were with microbiologically proven fungal keratitis were enrolled in our study. detailed history was obtained with socio-demographic and occupation data, ophthalmic medical and surgical history, contact lenses and immunosuppression history. the corneal scrapping material was collected by ophthalmologists by using strict sterile precaution under slit-lamp examination. 713 global journal of public health medicine 2022, vol 4, issue 2 gggggglo sample was collected from base and edges were subjected to microscopic examination using freshly prepared 10% koh and gram staining, (icmr 2nd edition., 2019) and, were inoculated on two plates/tubes of sabouraud’s dextrose agar media with antibiotics incubated at 25oc and 37oc separately for 4 weeks. the corneal scrapping was also cultured on blood agar media plates in the pattern of “s” or “c” shaped streaking, to ensure the growth in inoculum from rather than contaminant from the lab. all inoculated culture medias was incubated aerobically. in the first week time cultures plates were checked daily whereas on remaining next three weeks duration checked twice a week. identification of fungal agents was done by standard laboratory methods via microscopy, characteristics features of growth; colony morphology, according to icmr 2nd edition (2019), lactophenol cotton blue (lpcb) preparation and slide culture. statistical analysis: statistical analysis was performed by spss version 22 software. percentages and mean value were calculated and analysed. p< 0.05 considered statistically significant ethical consideration: the present study was ethically approved by institutional board of ethical committee; we have obtained informed consent from all the study participants results: during the study period, out of 740 patients, 237 (32%) patients were either smear or culture or both positive mycotic keratitis cases were enrolled in our study. out of 237 cases, 197 (83.12%) were both positive (koh and culture), 27 (11.40%) koh only positive, 13 (5.48 %) culture only positive and those were negative for both, were excluded from the study group. comparison of koh mount and culture isolates were shown in table 1. current study found the rate of fungal keratitis was reported higher among males 142 (59.92%) than female 95 (40.08%). most of the patients belong to the age group of 41-60 years. the common associated predisposing factors in descending order includes trauma from vegetative objects 53%, contact lens user 31%, on steroid therapy 29%, diabetic and hypertensive 27%, previous ocular surgery 23% and ocular surface disorder 21% as shown in figure:1. among the 237 mycological proven cases of mycotic keratitis the commonest fungal isolates obtained was fusarium species 33.2% (n=79) followed by curvularia species 21.9% (n=52). detail description of microbial isolates were shown in figure 2 it proves that koh is much more sensitive than culture in picking up fungal infections, and can save valuable time on diagnosis & treatment. 714 global journal of public health medicine 2022, vol 4, issue 2 gggggglo table 1: comparison of koh mount and culture of fungal isolates statistic koh mount culture sensitivity 93.81% 89.65% to 96.66% specificity 0.00% 0.00% to 12.77% positive likelihood ratio 0.94 0.91 to 0.97 disease prevalence 88.61% 83.86% to 92.36% positive predictive value 87.95% 87.57% to 88.31% negative predictive value 0 - accuracy 83.12% 77.73% to 87.66% figure1: distribution of associated predisposing factors trauma previous ocular surgery ocular surface disorder use of corticoste roid (oral or systemic) diabetic and hypertens ive contact lens users per cent 53.00% 23.00% 21.00% 29.00% 27.00% 31.00% 53.00% 23.00% 21.00% 29.00% 27.00% 31.00% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% pe rc en t of a ss oc ia ti on 715 global journal of public health medicine 2022, vol 4, issue 2 gggggglo figure 2: distribution of fungal isolates among mycotic keratitis patients image 1: lpcb mount shows fusarium solani image 2: lpcb mount shows aspergillus flavus 18.9% 14.3% 21.9%7.1% 5% 4.6% 8.9% 7.6% 11.4% distribution of fungal isolates (n=237) amonge mycotic keratitis patients. fusarium solani 18.9% fusarium oxysporum 14.3% curvularia spp. 21.9% aspergillus flavus 7.1% aspergillus fumigatus 5% aspergillus terreus 4.6% acremonium spp. 8.9% bipolaris spp. 7.6% koh positive 11.4% 716 global journal of public health medicine 2022, vol 4, issue 2 gggggglo discussion the mycotic keratitis is a leading cause of ocular morbidity and mortality. in india and other tropical countries fungal infection of eye is most frequently encountered condition. incidence of mycotic keratitis in current study was 32%, similar incidence was also reported by many other studies like, (kalshetti et al., 2015, rautaraya et al., 2011, jiragyal et al., 2016 and tewari et al., 2012), whereas (puig et al., 2020) reported only 7.1% incidence of fungal keratitis, lower than the present study. in contrast to current study (venkatesh et al., 2018 and javadi et al., 1996), reported 86% higher incidence of fungal corneal ulcer. these geographical variations may be due to predisposing and etiological agents of mycotic keratitis was differ in different regions, mainly mycotic keratitis seen in tropical and subtropical region. in the present study the male to female ratio was found to be 1.49, similar results were reported in a study by (satpathy et al., 2019). many studies observed that incidence of mycotic keratitis was high in farmers (kunimoto et al., 2000). farmers are prone to mycotic keratitis because of more chances of vegetative ocular trauma. in present study higher incidence of mycotic keratitis observed between ages of 35-60 years. (kalshetti et al., 2015) cited the higher incidence between ages of 21 to 50 years; this could be due to middle age group male were outside workers having more expose to infectious agents. in the present study, the mycotic keratitis was due to moulds; predominantly fusarium species followed by curvularia & aspergillus species, our finding was comparable with the (bharati et al., 2003 and chitamparam et al., 2020) whereas (chander et al., 2008), reported aspergillus species was the most common isolate in their study generally, most of the fungal agents do not invade the intact corneal epithelium, penetration of agents made after trauma (animal or plant agent). trauma can facilitate the implantation of fungal conidia in corneal stroma or indirect abrasion of corneal epithelium permit fungal invasion (thomas et al., 2013). in the present study, ocular trauma is the key predisposing factor, occurring in 53% of patients, comparable with the other studies like, (waghmare et al., 2019, singh et al., 2020 and hoffman et al., 2021) whereas (menard et al., 2022) reported contact lens was the most common risk factor of fungal keratitis. conclusion: incidence of mycotic keratitis was 32%, more in male than female in the present study. ocular trauma was the key predisposing factor of fungal keratitis. fusarium, curvularia and aspergillus were the most common fungal agents isolated from mycotic keratitis patients. the fundamental element in the diagnosis of mycotic keratitis is clinical suspicion by an ophthalmologist along with laboratory diagnosis by direct microscopic examination and culture. early definitive diagnosis of mycotic keratitis by culture may help in proper management. conflicts of interest the author declares no conflicts of interest. 717 global journal of public health medicine 2022, vol 4, issue 2 gggggglo references • acharya y, acharya b, karki p (2017). fungal keratitis: study of increasing trend and common determinants. nepal j epidemiol. 2017; 7:685-693. • 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abdalqader.docx 168 global journal of public health medicine 2020, special issue gggggglo review research the facts about corona virus disease (covid-19): the current scenario and important lessons mohammed a. abdalqader, hesham abdelaziz shebl, hasanain faisal ghazi, mohammed faez baobaid, hana chen wei jun, tiba nezar hasan, mustafa fadil mohammed, haitham assem abdalrazak & hassan omar ads. international medical school, management and science university, malaysia corresponding author: mohd_abdalqader@msu.edu.my abstract this paper discusses the important review about the corona virus disease (covid-19) and main facts about it. epidemiological and clinical characteristic of patients with covid-19:the wuhan city in china, faced an outbreak of coronavirus disease 2019 (covid-19) since december 2019, with extreme acute respiratory coronavirus syndrome 2 (sars-cov-2) being the causative agent. the clinical characteristics and the epidemiological criteria for covid-19 patients were described. still, the risk factors for mortality and a clear course of the disease clinically, including viral shedding, have not been identified. corona virus and its types: coronaviruses are a group of viruses belonging to the coronaviridae family which infect animals as well as humans. the name "coronavirus" was developed in 1968, which stemmed from the morphology similar to "corona" or crown-like. the coronaviridae family (order nidovirales) classifies into four genera of covs: alphacoronavirus (alphacov), betacoronavirus (betacov), deltacoronavirus (deltacov), and gammacoronavirus (gammacov). furthermore, the betacov genus divides into five sub-genera or lineages. covid-19 strategic prevention on different levels: in dealing with covid-19 challenge, most countries are practicing a mix of inclusion and stopping crowds hoping to delay an increased number of affected individuals and minimizing the need for hospital facilities, as well as securing those at higher risk from being infected, especially old age population and people with long-standing illness keywords : covid-19, corona virus types, epidemiological characteristic, prevention. 169 global journal of public health medicine 2020, special issue gggggglo epidemiological and clinical characteristic of patients with covid-19: the wuhan city in china, faced an outbreak of coronavirus disease 2019 (covid-19) since december 2019, with extreme acute respiratory coronavirus syndrome 2 (sars-cov-2) being the causative agent. the clinical characteristics and the epidemiological criteria for covid-19 patients were described. still, the risk factors for mortality and a clear course of the disease clinically, including viral shedding, have not been identified. in that retrospective cohort study, which was conducted in different centres (fei et al., 2020), all the adult hospitalised patients were included (≥18 years old) laboratory-confirmed covid-19 from jinyintan hospital and wuhan pulmonary hospital (wuhan, china) discharged or died before january 31 2020. the number of cases was 191 patients (out of the 191 there was 135 from the hospital of jinyintan and 56 from the pulmonary hospital of wuhan), and these cases were part of that cohort study, those who discharged were the majority of 137 patients, and only 54 passed away in that hospital. the statistical analysis expressed that chances of hospitalised death correlated with those older in the age group with p-value =0.0043, also significant with a higher level of the sequential organ failure assessment (sofa) score with p<0·0001), upon being admitted to hospital, the time of the median viral shedding was of 20.0 days in survivors. still, coronavirus was possible to be detected until subjects passed away in non-survivors. the longest time for the dropping of the virus was noticed in survivors until 37 days (fei et al., 2020). the median time to discharge from disease onset (i.e. before admission) was 22.0 days (iqr 18.0–25.0), while the median time to death was 18.5 days (15.0–22.0); 32 patients needed to be on invasive mechanical ventilation; of them, 31 patients (97%) passed away. the median duration from onset of disease to the need of the mechanical ventilation was of 14.5 days (12.0–19.0). one of the main complications was the sepsis attack, accompanied by a failure in the respiratory system, cardiac failure and septic shock. 50% of those who could not survive had a secondary infection, and ventilatorassociated pneumonia occurred in ten patients (31%). the prevalence of complications was more in those not survived as compared to those sustained (fei et al., 2020). it was also found that patients with diabetes mellitus or coronary cardiac disease had higher chances of in-hospital death (fei et al., 2020). heart-related complications, including new cases of heart failure, new cases or already existed of arrhythmia, or myocardial infarction, were high in those patients with pneumonia. heart arrest occurred in 3% of hospitalised patients with pneumonia (marrie et al., 2007). medina also found that there is a strong relationship between cardiac events after pneumonia and elder age, history of cardiovascular diseases (medina et al., 2013). coronary heart disease found to be connected with acute heart events and worse outcomes in influenza infections and other viral respiratory infections (medina et al., 2013, udell et al., 2013, blackburn et al., 2015). 170 global journal of public health medicine 2020, special issue gggggglo additionally, the sarsreceptor, angiotensinconverting enzyme 2, is found on the cardiac myocytes and endothelial vessels cells (gallagher et al., 2008, torres et al., 2015). this indicates that the probability of heart involvement directly by the virus is at least theoretical. note that interstitial mononuclear inflammatory infiltrations in the cardiac tissue were identified in fatal covid-19 cases, although no studies for viral detection have been reported (xu et al., 2020). while the 2019 coronavirus disease outbreak (covid-19) develops, epidemiological data are critical for guiding the strategies and methods of situational understanding and intervention. this analysis here illustrates the efforts to collect and disseminate clinical and epidemiological data from various scholars about covid-19. we checked in data on covid-19 from the china local health authorities in one population-level observational sample. they compiled a list of single covid-19 patients and updated daily for the province-level of case counting from january 13 and january 31, 2020, in china. they also assembled a list of covid-19 subjects, which were distributed internationally. they looked at patterns in covid-19 epidemiology and evaluated the progression of outbreaks across china, assessed delays between onset of symptoms, seek hospital or clinic treatment and reported before and after january 18 2020, as the level of awareness increased the sudden epidemics. information had been made accessible to the public in realtime. we find that data were collected between january 13 and january 31, 2020, for 507 patients with covid-19, out of the 364 living in the mainland china and the others 143 patients staying outside of mainland china. 281 patients (55%) are male gender and of median age of 46 years. less patients 13 of them (3%) were among younger age group who are younger than 15 years. the profile of chinese patients age confirmed a less of infections among children. delays between starting of symptoms and finding treatment in a health setting of clinic/ hospital were longer in the hubei province than in other regions in mainland china and globally over the timeframe studied. the duration was reduced from 5 days to 2 days as compared from the period before january 18, 2020 and the thereafter until january 31 with p value=0·000, that's showed the level of awareness and understanding was higher before and after january 18 2020 although our sample captures only 507 patients with covid19 reported by official sources (kaiyuan et al., 2020). human-to-human transmission has been found through the respiratory droplets of sneezing or coughing, as the number of cases that were not introduced to the animal market has risen and health workers have also encountered cases (huang et al., 2020). the transmissibility level of coronavirus disease was shown and estimated at 4.08 (cao 2020) indicating that any patient with covid-19 can produce up to four new cases on the average level. then this rate was considered to have risen 21-fold after january 17, 2020, compared to the early of january 2020 (zhao 2020). for the incubation period, it is estimated at 5.2 days, and show considerable variability among patients (li 2020), and the patient can spread infection asymptomatically (rothe 2020, ryu 2020). 171 global journal of public health medicine 2020, special issue gggggglo fever, chills, dry cough, coryza, sore throat, trouble in breathing, myalgia, nausea, vomiting and diarrhoea are main signs for the disease (chen 2020). elderly age group, people with medical illnesses and problems are at higher risk to become sick and with more severe symptoms (chen 2020). patients with advance symptoms can cause heart attacks, failure in the respiratory system and end life (holshue 2020). who stated that the death rate is around 2%, although other studies and centres sated the range from 0.3% to 0.6%. (nishiura 2020). corona virus and its types: coronaviruses are a group of viruses belonging to the coronaviridae family which infect animals as well as humans. the name "coronavirus" was developed in 1968, which stemmed from the morphology similar to "corona" or crown-like (tyrrel et al., 1968). the coronaviridae family (order nidovirales) classifies into four genera of covs: alphacoronavirus (alphacov), betacoronavirus (betacov), deltacoronavirus (deltacov), and gammacoronavirus (gammacov). furthermore, the betacov genus divides into five sub-genera or lineages (chan et al., 2013). alpha coronaviruses 229e and nl63, and beta coronaviruses oc43, hku1, sars-cov (sars), mers-cov (the coronavirus that causes middle east respiratory syndrome or mers) and sars-cov-2 (covid-19) are the seven types of coronaviruses that can infect human. coronaviruses can infect humans and animals and cause diseases of the respiratory, digestive, liver and central nervous systems (to et al., 2013). covid-19 is a beta coronavirus in the same genome sequencing and phylogenic study as, but in a separate clade, the extreme acute respiratory syndrome (sars). the receptor-binding gene region's structure is very similar to that of the sars coronavirus, and it has been shown that the virus uses the same receptor, the angiotensin-converting enzyme 2 (ace2), for cell entry (zhou et al.,2020 ). in wuhan, china, the first cases of covid-19 infected were identified in late december 2019 and then spread worldwide. the outbreak initially seems to have been triggered by zoonotic transmission at the setting of a food market in wuhan, where live animals were sold (guo et al., 2020). some of the patients had been operating or visiting and were then closed for disinfection (who 2020). however, as the epidemic progressed, the primary mode of transmission was spread from person to person. on january 12 2020, the world health organization named this coronavirus the 2019novel coronavirus (2019-ncov), after which the disease was officially known as the 2019 coronavirus disease. (covid-19) (guo et al., 2020). on march 11 (2020), covid-19 has been declared a global pandemic by the world health organisation. infection with the covid19 virus can spread to others by tiny droplets from the nose or mouth through coughs or exhales of covid-19. such droplets are focused on objects and surfaces so other people may receive covid-19 by touching such objects or surfaces and then rubbing their eyes, nose or mouth by breathing in coughs or droplets. (who, 2020). 172 global journal of public health medicine 2020, special issue gggggglo covid-19 strategic prevention on different levels: in dealing with covid-19 challenge, most countries are practising a mix of inclusion and stopping crowds hoping to delay an increased number of affected individuals and minimising the need for hospital facilities, as well as securing those at higher risk from being infected, especially old age population and people with long-standing illness (who, 2020). most plans utilise different manoeuvers of contact control and self-isolation or quarantining; upgrading the implementation of public health hygiene, including hand wash, respiration habits, and social distancing; readiness of health systems to face a sudden rise of advanced illness cases who need isolation, oxygen, and a ventilating machine, with a deferral or even cancelling significant mass occasions. the evolution of covid-19 in china in late 2019 as a pathogen than infects by the droplet infection leading to the covid-19 pandemic has alerted the world to local, global, and pandemic spread mainly due to mass gathering events. starting march 2020, there has been a sharp action taken in cancellation of religious, athletic, musical, and other mass gatherings as countries all over the globe made decisions to stop the spread of sars-cov-2. many famous mass gatherings have been deferred to a later time, including concerts and sports events such as the olympic games in japan and the pilgrims in saudi arabia (ebrahim & memish, 2020). the effect of non-symptomatic cases in the transmission of the virus is not yet apparent to a large extent. pre-symptomatic possibility of infecting is a challenge, and many nations are considering one to two days from symptoms appearance as the first day for identification of contact (zou et al., 2020, kim et al., 2020). covid-19 is a disease of special consideration, and immediate actions in critical care were taken to adapt to the severity of cases. emergency situations such as covid-19 pandemic can be a tough test for intensive care doctors, who require adequate comprehensive skills to deal with properly. from 2009 to 2019, more than 18000 doctors joined the critical care certified course program in china, out of which more than 13000 were emergency medicine practitioners. this program covered more than 30 provinces. courses in this program are provided by an inter-professional crew; multidisciplinary care is essential to reduce death rates for patients in critical care units (wu & mcgoogan, 2020). emergency and critical medicine have an obvious role in a public health emergency. such specialised training applied in this program benefits in the development of criticalcare medicine specialities and enhances the skills of physicians, resulting in teams that are efficiently prepared to face different emergency cases in the icu (ji et al., 2020, kim et al., 2010). sars-cov-2, same as any severe new pathogen, has affected health personnel in china and other countries. till now, in china specifically, where prevention and control of the infection have been considered earnestly, hospital-acquired transmission has not been a significant cause of the spread of the epidemic. 173 global journal of public health medicine 2020, special issue gggggglo reports from china show that maybe to 85% of human transmission has taken place within families and that more than 2000 health professionals were affected by the virus, in the absence of significant hospital-acquired significance and some reports showed that quite a number health personnel got infected at their homes (who, 2020, wu & mcgoogan, 2020) as nations are being affected by (covid-19), the older citizens will be requested to be isolated for "a long period". this attempt to consign the older, and thus protect exhausted health facilities, emerges as nations order for lockdowns, movement control orders, and social distancing to better control of spreading of the severe acute respiratory syndrome (sars-cov-2) (bbc, 2020). however, social isolation among the old population is a "serious public health issue" due to their high probability of cvs, immune, and psychological troubles. it is recently apparent that social isolation puts the elderly at a high risk of anxiety and depression. if health systems advice older individuals to stay put at home, have their grocery supplies and essential medical supplies delivered, and avoid contact with others, immediate action is required to control mental as well as physical complications (emerson & jayawardhana, 2015). online applications can be implemented to give social support and to care, although there might be discrepancies in the use of or knowledge of digital applications. interventions can be more frequent phone calls contact with the elders, volunteers, health personnel, and community services that can provide adequate help during these times. besides, behavioural therapy could be done online to reduce the feeling of being lonely and enhance or motivate psychological status. isolation of the elders may control the spread, which is most essential to bring down the number of infections and decrease the transmission to higher-risk individuals. however, the isolation strategy can taper in the long run. such isolation measures should be time sufficient to prevent spread, but minimise the morbidity of covid-19 associated with psychologic problems (newman & zainal, 2020, hesse et al., 2020). all nations must immediately trigger extreme levels of local critical management plans to make sure that the whole governmental and society approaches required to control covid-19 with non-pharmacological measures. this includes throughout education and raising the awareness of the community on the importance of their role and response. decision-makers must ensure that wellexperienced community personnel are ready, along with quarantine facilities, revised hospital plans, and lab schemes (selection of individuals to test, how, when and where). china implemented extraordinary public health measures at great socioeconomic cost, moving rapidly and firmly to ensure early identification of cases, prompt laboratory testing, isolation of cases, contact tracing, and quarantine. in the community, mobility was almost stopped, with social distancing applied at a large scale. china's massive transmission rates called for extreme measures, and the rules were successful (wilder & freedman, 2020). 174 global journal of public health medicine 2020, special issue gggggglo coronavirus disease 2019, commonly known as “covid-19”, is an infectious disease caused by a novel coronavirus named “sars-cov-2” introduced to humans for the first time (who,2020). this emerging respiratory disease was first detected in december 2019 in wuhan, china (the novel coronavirus pneumonia emergency response epidemiology team, 2020). the disease is highly contagious, and human-to-human transmission of covid-19 is mainly via respiratory droplets or direct contact. most people infected with covid-19 developed mild symptoms such as fever, cough or shortness of breath (moh, 2020). about 16% of reported cases – mostly elderly with chronic medical conditions, progressed into severe illnesses such as severe acute respiratory syndrome, kidney failure and even death (cdc, 2020). the covid-19 outbreak spanning the globe, and the world health organization (who) on january 20 2020, declared the outbreak a public health emergency of international concern (pheic). who then launched strategic preparedness and response plan to support all countries to prepare for and respond to covid-19 (who, 2020). soon enough, on march 11 2020, who director-general characterised the rapidly spreading covid-19 as a pandemic, acknowledging that the virus had reached 114 countries, with over 118000 cases and 4291 deaths worldwide (who,2020). in response to this critical situation, who together with the un foundation and partners, launched the covid19 solidarity response fund to help countries respond to the covid-19 pandemic (who, 2020). malaysian scenario as covid-19 surged across asia, malaysia was the most affected country that owned the highest number of covid-19 cases in southeast asia (who, 2020). as of june 16 2020, cumulatively there were 553 confirmed covid19 cases in malaysia – out of which selangor had the highest prevalence of covid-19 with 144 cases; and 12 cases being treated at the intensive care unit (icu) (moh, 2020). the ministry of health (moh) then declared malaysia had entered the third phase of outbreak – late containment phase and immediately, the prime minister of malaysia ordered the implementation of the movement control order, to be enforced under the prevention and control of infectious diseases act 1988 (act 342) and the police act 1967 (act 344) (pmo, 2020). the government of malaysia alongside the moh also implemented other public health measures to prevent further spread of the covid-19, such as free covid-19 screening, contact tracing, testing of samples, isolation care for infected patients, mobilisation of resources where needed, providing educational infographics and media contents, raising public awareness and providing financial supports (moh, 2020). never have we seen an infection that brought such intense fear to the whole full world. this is a long war, and to win the war, stay committed to strategies is crucial. in other words, citizens' compliance with preventive measures is vital to stop the spread of covid-19 in malaysia. consequently, the awareness, attitude, and behaviours of citizens (kap) towards covid19 have a significant impact on the implementation of preventive measures and bridging the gap in the dissemination of health information. previous kap research on sars 175 global journal of public health medicine 2020, special issue gggggglo outbreak in 2003 indicated that awareness and attitudes among the population are significantly correlated with age and education level. (hazreen et al., 2005). both knowledge and attitude much reflect the population's preventive practice behaviours, which can further impede the success of preventive efforts to control diseases (goni et al., 2019). due to the drastic increase in prevalence of covid-19 infections in malaysia. the collection of vital data is important for successful monitoring and preventive measures. to stop the massive covid-19 outbreak in malaysia; it is urgent to understand the level of public awareness on covid-19 among populations in malaysia. kap study allows us to identify the preference of population upon obtaining health information (hazreen et al., 2005). in general, kap is critical when it comes to providing the required strategies to implement. also, these will reinforce and review the steps currently available and identify practical approaches to enhance awareness, attitudes and practices on infectious diseases (goni et al., 2019). however, there is no study conducted in malaysia to assess the kap of covid-19 among the population in selangor, malaysia. hence, this kap study aims to assess knowledge, attitude and practices about prevention and control measures on covid-19 and to explore the relationship between sociodemographic and knowledge, attitude and practices among populations in selangor, malaysia. conflicts of interest the author declare no conflicts of interest. references: • british broadcast corporation bbc. coronavirus: isolation for over-70s ‘within weeks’. march 15, 2020. https://www.bbc.co.uk/news/uk-51895873 (accessed march 16, 2020). • cao,zhidong , qingpeng zhang, xin lu, di rk pfeiffer, zhongwei jia, hongbing song, daniel dajun zeng (2020). estimating the effective reproduction number of the 2019. medrxiv 2020.01.27.20018952; doi :https://doi.org/10.1101/2020.01.27.20018 952 • chan jf, to kk, tse h, jin dy, yuen ky.(2013). interspecies transmission and emergence of novel viruses: lessons from bats and birds. trends microbiol. oct;21(10):544-55. • chen, n. 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(2020) sars-cov-2 viral load in upper respiratory specimens of infected patients. new engl j med doi:10.1056/nejmc2001737. microsoft word gjphm-2019elisa.docx 85 global journal of public health medicine 2019, vol 1, issue 2 gggggglo evaluating the role of il-2 and il-6 in patients with burns using elisa technique sarah naji aziz1*, rana naji aziz2, karrar jasim al-sallami 1 , ali naji aziz3,4 walaa abdulsahib mikaeel 4, noor jameel mousa1, sundus qasim mohammed 1 1 college of science, mustansiryiah university, baghdad, iraq 2 college of tourism sciences, mustansiryiah university, baghdad, iraq 3 alrafidain educational dental clinics, baghdad, iraq 4 ministry of health, baghdad, iraq *corresponding author: sarahnaji2015@gmail.com abstract introduction: burns are common medical infections that examined in hospitals. cytokines are produced by innate immune response; cytokines determine the type of adaptive immune response. this study aims to screen and evaluate the role of il-2 and il-6 levels in the serum of patients who have suffered from burns by elisa technique. methods: seventy serum samples were collected from burned patients in baghdad city hospitals and tested by elisa technique to detect il-2 and il-6 levels. results: shows great differences in il-2 level of male patients (30.16 pg/ml) compared to males control group by an average of (29.66 pg/ml). while il-6 shows significant differences in female patients with range (63.39 pg/ml) and male (66.47 pg/ml) compared to females control group (2.48 pg/ml) and males (22.80 pg/ml). moreover cytokines shows significant differences between the three age groups of burned patients in comparison with the control group. in conclusion the result of present study showed significant difference in level of some cytokines il-2,il-6 for patients with burns. conclusion: the result of present study showed significant difference in level of some cytokines il-2, il-6 for patients with burns. keywords: cytokines, inflammatory response, il-2, il-6, elisa 86 global journal of public health medicine 2019, vol 1, issue 2 gggggglo introduction it is known that burns are one of the most common medical infections which are examined in hospitals and clinics. burns occur as a result of exposing the skin to higher temperatures whether by liquids, solid objects or by direct exposure to flames, chemicals and electrical touches (kaddoura et al., 2017). skin and mucous membranes are considered as the first line of defense in immune system against infection and the loss of these barriers leads to the suppression of general immunity in the body which paves the entry of pathogenic microorganisms at the site of the burn, the body's immune system initiates an inflammatory response in the area of infection (chen et al., 2018). interleukins function is stimulating and regulating the cellular and humoral immune response. interleukin 2 (il-2 )secreted from t-helper (th1), while interleukin 6 (il-6) secreted from (th2), monocytes, bone marrow and mast cells play an important role in differentiating b-cells into plasma cells that produce antibodies, (al-khafaji, al-mosawi, and al-saeedi, 2015), as well as stimulating acute phase proteins produced by liver cells (finnerty et al., 2007). the defense against microorganisms or intracellular microbes is called cell-mediated immunity, which is caused by t-cells, while b-cells are responsible for antibodies production. cytokines are produced by innate immune response, it determines the type of adaptive immune response (steven and vera 2000). this study aims to screen and evaluate the role of il-2 and il-6 levels in the serum of patients suffered from burns by elisa technique. methods total of seventy serum samples were collected from patients suffering from burns, between november 2017 and march 2018 from several hospitals in baghdad – iraq. the samples were from both male and females in a range of age between 1-55 years old. 5 mm of venous blood were collected in plane tubes and left for a while at room temperature for clotting. centrifugation had done at 3000 rpm for 10 min, to separate the serum. after that serum had been moved in plane tubes and serums were kept at 20 °c to the next tests. screening for interleukin-2 tests were done according to the principle of testing that is mentioned in (bodas et al., 2006). the immunoassay technique for adsorbed quantitative enzyme were done, il-2 antibodies were previously encapsulated with a microplate, standards and specimens were dispersed by a fine pipette in the wells. after removing unrelated substances, the biotin that conjugated with il-2 antibody was added to the wells. avidin reagent were added and bended with horseradish peroxidase (hrp) enzyme in wells. after washing to remove avidin reagent, substrate was added to the wells and the color density is measured (kiecolt-glaser & glaser 2002). each well was filled with 100 μl of substrate and the samples, procedure was done according to the leaflet of manufacture company. the optical density was measured by using elisa reader at 450 nm as showed in figure (1) (kiecolt-glaser & glaser 2002). screening for interleukin-6 as mentioned above, (bodas et al., 2006) is used as the main principle of testing. microtiter plate in this diagnostic kit was covered with il6 specific antibodies. standards samples were then added to the appropriate standard plate. the polyclonal biotin coupled with the specific il-6 antibodies and the avidin reagent that bended with horseradish peroxidase (hrp) enzyme for each well in the microscopic plate and incubated. tmb (3,3 ', 5,5' dimethylbenzidine) solution is then added to the wells. only wells that contained il-6, biotin were coupled with antibodies and avidin coupled with hrp will show a change in color. the enzyme reaction of the base enzyme is terminated by the addition of a sulfuric acid solution and color change spectrometry was measured by using elisa reader at 450 nm (kiecolt-glaser & glaser 2002). statistical analysis all statistical analyses were calculated using minitab software version 6 for data analyzing. p value was done also to compare means between groups in this study. p value equal or less than 0.05 was considered as the level of statistical significance. 87 global journal of public health medicine 2019, vol 1, issue 2 gggggglo ethical statement all samples which included human serum from baghdad hospitals were ethically approved according to the ethics committees in ministry of health, baghdad, iraq. tests which included elisa assay were done according to biosafety conditions in biology department college of science / mustansiryiah university iraq. results results show that the samples of patients that included a total of seventy samples of serum, 33 (47.14%) female and 37 (52.85%) male while control group were ten, 5 (50%) female and 5 (50%) male with different ages cleared in table(2). results show insignificant increase in the level of il-2 between male and female who were infected with burn in comparison with control group. highest levels in females and males with burns were 18.22 pg/ml and 29.64 pg/ml respectively, while control group for females and males were about 15.03 pg/ml and 18.48 pg/ml respectively. however, significant increase is revealed in the level of il-6 in females and male were about 63.39 pg/ml and 66.47 pg/ml respectively, while the control group for females and males in il-6 were about 2.48 pg/ml and 22.70 pg/ml respectively as showed in table.2. figure 1: elisa reader for measuring the samples optical density table 1: distribution of study groups by sex gender burned infected group control group n % n % female 33 47.14 5 50 male 37 52.85 5 50 total no. 70 100 10 100 table 2: distribution il-2 and il-6 levels in burned and control groups according to the gender pvalue between male in both groups pvalue between female in both groups p-value il-2 number average gender groups 0.014 0.242 0.242 33 18.22 female bourn infected group 37 29.64 male 0.354 5 15.03 female control group 5 18.48 male il-6 0.004 0.001 0.366 33 63.39 female bourn infected group 37 66.47 male 0.014 5 2.48 female control group 5 22.80 male 88 global journal of public health medicine 2019, vol 1, issue 2 gggggglo discussion the results of our present study are agreement with the previous study of (gauglitz et al., 2008) by conducting an evaluation of some interleukins in a group of males and females with different types and degrees of burns where they show a significant increase between the levels of interleukins in people with burns. the inflammatory response to the cells of the immune system and especially t lymphocytes and their production of these interleukins, which are key factors in determining the strength of the immune response. the high level of il-6 cellular motility is due to the stimulation of immune system cells such as helper tlymphocytes, monocytes, bone marrow and mast cells because of burned infections that stimulate these immunological cells. the previous study of (pileri et al., 2008), found that cytokines in patients with burned cases in both ganders were increased significantly with increasing in inflammatory processes. (gosain & gamelli. 2005), who studied the effect of levels of some cytokines, including il2, on different age stages of burn-affected people, showed that the increasing of these interleukins is the result of activation of t1 lymphocytes that play an important role in the inflammatory response of the immune system by forming a series of interleukins, including il2, which in turn affect other cells such as stimulating the toxicity of immune cells, from the above study, the results of our study converge or similar to the results of that study. while in another study (maass et al., 2002), it is found that the high levels of immune index in il6 within the first stages of age is due to the degree of burning of the infected person and the response of the immune system to the inflammatory process and stimulation of the t lymphocytes (th2) responsible for the rise of these interleukins and this is consistency with the results of our current study. as a final result, this study manifests significant changes in the levels of interleukins il-2 and il-6 in burn patients. conclusions: this study reveals that interleukins, in different age stages of burn-affected people, will be increased in levels and this increasing happens due to the activation of t1 lymphocytes that play a tremendous role in the inflammatory response of the immune system. as a final result. this study shows significant changes in the levels of motor cytokines il-2 and il-6 in burn patients. references al-khafaji, j. k.; al-mosawi, m.a. and alsaeedi, a. k. (2015). serum level of il-2, igg and igm in treated and untreated tb patents. advances in environmental biology. 9(27), 8589 bodas, m.; jain, n.; awasthi, a.; martin, s.; loka, r. k. p.; dandekar, d.; mitra, d. and saha, b. (2006) inhibition of il-2 induced il-10 production as a principle of phase-specific immunotherapy. j. immunol, 177 (7), 46364643 doi.org/10.4049/jimmunol.177.7.4636 chen, l. ; deng, h. ; cui, h. ; fang, j. ; zuo, z.; deng, j.; wang, x. and zhao, l. (2018) inflammatory responses and inflammationassociated diseases in organs. oncotarget 9(6), 7204-7218 doi: 10.18632/oncotarget.23208 gauglitz, g. g. ; song, j. ; herndon, d. n. ; finnerty, c. c.; darren, b.; jose, m. and marc, g. (2008). characterization of the inflammatory response during acute and post-acute phases after severe burn. shock, 30(5) 503-507 doi: 10.1097/shk.0b013e31816e3373 gosain, a. and gamelli, r. l. (2005) a primer in cytokines. j. burn care rehabil, 26: 7-12 doi: 10.1097/01.bcr.0000150214.72984.44 kaddoura, i. ; abu-sittah, g. ; ibrahim, a. ; karamanoukian r. and papazian , n. (2017) burn injury: review of pathophysiology and therapeutic modalities in major burns. annals of burns and fire disasters 30(2), 95–102. pmid: 29021720 kiecolt, j. k. and glaser, r. (2002) depression and immune function central pathway to morbidity and mortality. j. psychosom res., 53: 873-876 https://doi.org/10.1016/s00223999(02)00309-4 maass, d. l.; white, j. and horton, j. w. (2002). il-1 ß and il-6 act synergistically with tnfα to alter cardic contractile function after burn trauma. shock, 18 360-366 pmid: 12392281 89 global journal of public health medicine 2019, vol 1, issue 2 gggggglo pileri, d.; accardo, p.a.; d’amelio, l.; d’arpa, n.; amato, g.; masellis, a.; cataldo, v.; mogavero, r.; napoli, b.; lombardo, c. and conte, c. (2008) concentrations of cytokines il-6 and il-10 in plasma of burn patients: their relationship to sepsis and outcome. ann. of burns and fire disasters, 21(4) 182-185 pmid: 21991134 steven, m. opal. ; vera, a. d. (2000) antiinflammatory cytokines. chest. elsevier, 117 (4) 1162-1172 doi.org/10.1378/chest.117.4.1162 microsoft word gjphm-2020wound healing_edit.docx 260 global journal of public health medicine 2021, vol 3, issue 1 gggggglo review research a review on determining factors for wound healing in diabetic foot ulcers melvin ebin bondi1, syed sharizman syed abdul rahim2*, richard avoi2, firdaus hayati3, azizan omar2,4, sahipudin saupin2, zulkhairul naim sidek ahmad2, awang setia musleh2, mohammad saffree jeffree2 1 non communicable disease unit, penampang area health office,penampang sabah, malaysia 2 department of community and family medicine, universiti malaysia sabah, kota kinabalu, sabah, malaysia 3 department of surgery, universiti malaysia sabah, kota kinabalu, sabah, malaysia 4 rural medical education center, faculty of medicine and health sciences, universiti malaysia sabah, 89050 kudat, sabah, malaysia *corresponding author: syedsharizman@ums.edu.my abstract diabetic foot ulcers (dfu) are significant complications of diabetes mellitus. dfu will often heal in a shorter period if factors that inhibit wound healing are identified and managed. this review was to identify determining factors that are associated with wound healing in dfu patients. glycaemic control, adequate nutrition, presence of infection, the use of modern dressing approach, provide sufficient offloading and avoid unhealthy lifestyle like smoking are the highlighted determining factors discussed in this review and found to have an association towards a timely manner of wound healing in diabetic foot ulcers. keywords: determining factors, diabetic foot ulcer, wound healing, review. 261 global journal of public health medicine 2021, vol 3, issue 1 gggggglo introduction diabetic foot ulcers (dfus) are significant complications of diabetes mellitus, which are linked with increase mortality, and reduce the quality of life which potentially life-threatening amputations (sørensen, jansen, wilbek fabricius, jørgensen, & svendsen, 2019). for a lifetime prevalence of up to 25% in diabetes patients, foot ulcers are common and severe diabetes complications (walsh, hoffstad, sullivan, & margolis, 2016). because of the growing burden of diabetes ulcers, both to the patient and society, it is paramount to find relevant determining factors concerning diabetic foot ulcer wound healing. (jeffcoate, chipchase, ince, & game, 2006) about 2.7% of all hospitalized patients with diabetes mellitus have dfus (nussbaum et al., 2018; zimny, schatz, & pfohl, 2002). although a lot of these patients might still have inadequate arterial blood flow to their limbs, it is at least in part caused by a loss of cutaneous sensation (peripheral insensitive neuropathy) (walsh et al., 2016). diabetes patients are unable to perceive sensations because of peripheral neuropathy which makes them vulnerable to trauma. (grennan, 2019). for wound healing of diabetic foot ulcers with minimal to no complications, wound care management is essential (broughton, janis, & attinger, 2006). in four distinct and overlapping stages, wound healing is a complex sequence of interactions and reactions between cells and mediators, namely haemostasis, inflammation, fibroplasia, and maturation (awc, mr, helmy, & ramdhan, 2014). diabetic foot ulcer involves several modes and multidisciplinary teamwork (greenwell et al., 2018). wound infection and non-healing diabetic foot ulcers represent a hidden epidemic that affects a large fraction of the world’s population and poses a huge and increasing challenge to public health and the economy (ministry of health malaysia, 2018). roughly 200,000 patients in the united kingdom have infection-related non healing diabetic foot ulcers. treatment is estimated in the sum of 2.3 billion to 3.1 billion per year for patient with infected wound. (harries, bosanquet, & harding, 2016). this review aimed to highlight the determining factors of wound healing in diabetic foot ulcers and what impaired wound healing. methods this narrative review included articles searched through pubmed and google scholar as a search engine to look for articles related to keywords of "determining factors", "wound healing" and "diabetic foot ulcers". articles in these databases were from the year 2000 to 2019. a total of 50 eligible studies identified but only through the search. however, only 10 studies have met the inclusion criteria, whereas the other 35 studies were excluded in regard to duplicated and unrelated to the study criteria. 262 global journal of public health medicine 2021, vol 3, issue 1 gggggglo determining factors of wound healing in diabetic foot ulcers haemoglobin a1c level in wound healing haemoglobin a1c (hba1c) is a reliable marker to monitor blood glucose in diabetic patients. hba1c levels were associated with the process as well as the duration of wound healing in dfus (christman, selvin, margolis, lazarus, & garza, 2011). controlled hba1c level of less than 6.5mmol/l is linked to the acceleration of the duration of dfus wound healing within three months (li, chen, & kirsner, 2007). however, an elevated hba1c level (> 6.5 mmol/l)new cut off point for hba1c is 5.7mmol/l is associated with poor prognosis and significantly delayed in wound healing of more than six months(hasan et al., 2016). this is due to the inability of nutrients and oxygen to energize the cells. an uncontrolled level of sugar also prevents the immune system from functioning efficiently, which resulted in inflammation in the body cell, thus delayed in wound healing (christman et al., 2011). nutrition in wound healing the provision of nutritional care is proven to accelerate wound healing. malnutrition or nutrient deficiencies can impair the maturation phase such as collagen synthesis prolong inflammation, dysfunction of b and t cells due to decrease in phagocytosis, as well as reduce in mechanical strength of the skin (sajid, miyan, zaidi, jaffri, & abdeali, 2018; vas, edmonds, & papanas, 2017). optimal wound healing requires adequate nutrition as the process of healing demands increased consumption of energy to replace the injured tissue with new tissues (guo & dipietro, 2010). however, ongoing monitoring is necessary to evaluate the outcome of nutrition intervention. the recommended intake for wound healing is as shown in table 1 table 1: recommended nutrients intake for wound healing in diabetic foot ulcers patient nutrients recommended intake energy 30-45kcal/kg/day carbohydrate 50-60% of energy fat 0.8 – 1.5g/kg/day protein 1.25g – 1.5g /kg/ day pharma co-nutrients omega-3 fatty acid, linoleic acid, l-glutamine (0.20.5g/kg/day), arginine 30-60g/day vitamins vitamin a, vitamin b complex, vitamin c, vitamin e, vitamin k, zinc, selenium, manganese, copper source: ministry of health malaysia (2014) 263 global journal of public health medicine 2021, vol 3, issue 1 gggggglo modern dressing wound care management using a modern dressing approach showed a significant change in wound healing of dfus (bamohammed et al., 2012). selecting the appropriate wound care products on dfus based on times concept assessment (tissue, infection, moisture balance, epithelialisation, and skin surrounding) by providing a well-vascularized, stable wound bed that is conducive to normal and timely healing (dowsett, 2009; finlayson et al., 2017). modern dressing includes a selection of an appropriate solution, products, and technique of wound closure on the safety, preservation of function, and aesthetically pleasing outcome (ministry of health malaysia, 2018). diabetic foot infection wound infection is found to hinder the wound contraction for both acute and chronic wounds (gubara musa & ahmed, 2012). the mechanism of which this occurs is assumed to be the release of bacterial enzymes and degrading of metalloproteinase fibrin and wound growth factors (everett & mathioudakis, 2018). aerobic gram-positive cocci, mainly staphylococcus, are the most common pathogens that impair wound healing and increase the risk of gangrene, sepsis and bone infection like osteomyelitis. early identification of the local and systemic infection is essential to prevent the worsening of the wound (boulton, kirsner, & vileikyte, 2004). the infection could be treated either with oral antibiotics, topical microbial agents, and parenteral antibiotics or surgical considerations (raja, 2007). the selection of antibiotics is also paramount, especially patients with multidrug-resistant organisms, renal impairment, allergies, and immunosuppression (zimny et al., 2002). wound size and grading wound size and grade impaired wound healing (tsang et al., 2003). various wound classification systems are used to describe the wound size and grade (s. oyibo et al., 2001; wong et al., 2015). the wagner system is the one that commonly used to assess ulcer depth and the presence of osteomyelitis or gangrene by using the following grades; grade 0, grade 1 (partial/full-thickness ulcer), grade 2 (probing to tendon or capsule), grade 3 (deep with osteitis), grade 4 (partial foot gangrene), and grade 5 (whole foot gangrene) (s. oyibo et al., 2001). wound healing of dfu depends on the classifications, delayed wound healing is associated with the depth, size, and grade of the dfus (dinh, elder, & veves, 2011). smoking smoking has been related to slow wound healing (guo & dipietro, 2010) and insulin resistance (gubara musa & ahmed, 2012), especially in those smoking more than 10 packs/year (guo & dipietro, 2010). smoking is harmful and is associated with delaying the healing of diabetic foot ulcers (gubara musa & ahmed, 2012) and may help reduce the medical and economic burden on poor healing of diabetic foot (guest, fuller, & vowden, 2018). 264 global journal of public health medicine 2021, vol 3, issue 1 gggggglo off-loading off-loading is the most important healing factor in wound healing for diabetic foot ulcers (boulton et al., 2004). the central goal of any treatment program designed to heal these wounds is effective off-loading (guest et al., 2018). structural abnormalities in a diabetic foot such as claw toe deformity and charcot's neuroarthropathy are among the abnormalities that lead to significant disruption and elevate local foot pressures which resulted in the delay in wound healing (bharat kotru, 2015). common off-loading methods include bed rest, wheelchair, crutch-assisted gait, total contact casts, felted foam and removable cast walkers (cavanagh, lipsky, bradbury, & botek, 2005; margolis, kantor, santanna, strom, & berlin, 2000). therapeutic shoes are designed to reduce the risk of skin breakdown (walsh et al., 2016). selection of shoes depends on numerous factors; how long someone has had diabetes, the presence of normal sensation on the feet, and if there are any abnormalities or deformities on the feet (o’brien et al., 2003). discussion there are numerous determining factors in the literature reviews associated with wound healing in dfus. despite, there was no standard criterion yet established to predict the prognosis of diabetic foot ulcer healing; however, this review revealed several determining factors that help influence the healing rate of diabetic foot ulcer. this review found that glycaemic control, such as hba1c in the body shows the significant healing rate of dfus (gubara musa & e. ahmed, 2012). elevated glucose level due to compromised glycaemic control in the body results in impaired oxygen and nutrient supply (falanga et al., 2017; xiang et al., 2019) to the ulcer area and delayed the duration of healing (finlayson et al., 2017). hba1c is a reliable marker of glycaemic control to diagnosis diabetes as recommended by the american diabetes association and by the world health organisation (who) (manjunath & kumar, 2018). nutrition plays an essential role in the prevention and treatment of dfu, where an inadequate nutrient can result in altered immune function, malnutrition, and poor glycaemic control (sajid et al., 2018). nutrition is essential in healing which is also a substantial determining factor for accelerated healing rate (vas et al., 2017). all repeated (falanga et al., 2017; rohmayanti & handayani, 2017). patients with adequate nutrition and healthy body weight can help maximize wound healing due to obesity harms glycaemic control (falanga et al., 2017). modern dressing plays a pivotal role in the management of diabetic foot ulcers, which comprises cleaning techniques and selection of the proper wound care products to provide a moist healing environment (lindholm & searle, 2016). the modern dressing also comprises of topical treatment as well as bedside surgical management (debridement) and callous removal (rohmayanti & handayani, 2017). in the advanced wound care management uses of vacuum aided devices, hyperbaric oxygen, and maggots help in accelerating wound healing (margolis et al., 2000). 265 global journal of public health medicine 2021, vol 3, issue 1 gggggglo the local ulcer characteristic, that is, depth and presence of skin callous had a significant effect on delayed wound healing (oyibo et al., 2001). serial debridement may increase the healing rate (kavitha, 2014). a study by previously (chaby et al., 2007) found that grade 4 and above classifications may impair speedy healing and often lead to amputation if not treated effectively. the presence of infection as such staphylococcus aureus may also delay the healing rate as compared to those non-infected dfu (gubara musa & ahmed, 2012). similarly, smoking is related to slow wound healing (gubara musa & ahmed, 2012) and insulin resistance. an accelerated wound healing can also be seen in non-smoker patients compared to a smoker (guo & dipietro, 2010). meanwhile, offloading is commonly recognized as a tremendous offloading modality in healing dfu (cavanagh et al., 2005) and a substantial healing factor in dfu (gubara musa & ahmed, 2012). around 75% of dfu patients using off-loading had accelerated healing within six months to 1 year, while 25% did not heal for more than one year (dinh et al., 2011). despite all the highlighted determining factors discussed in this study, a few other factors could influence the delay in wound healing of dfu. these are the factors that suggested to be explored in future research; the role of growth factors in wound healing wound debridement, ischaemia and distal sensory neuropathy, delays in seeking treatment, systemic medication, antineoplastic chemotherapy, tumours and environmental factors. the failure of these wounds to heal is also multifactorial. therefore, treatment of dfu needs to be directed against main etiological factors responsible for the wound. conclusion diabetic foot ulcers remain a compelling burden despite the number of currently available treatment modalities. numerous determining factors could influence the healing rate of dfu in a timely manner such as haemoglobin, nutrition, modern, presence of infection, classifications of dfu, smoking, and offloading. this review revealed that these factors should be taken into considerations when managing dfu. as a result, future wound care management should be aimed at addressing these challenging deficiencies in the hope to accelerate the healing rate of dfu. however, this review did not further investigate the other confounding or determining factors that impair wound healing at every wound healing stage. conflicts of interest: the authors declare no conflicts of interest. 266 global journal of public health medicine 2021, vol 3, issue 1 gggggglo references • awc, l., mr, z., helmy, h., & ramdhan, i. 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(2002). determinants and estimation of healing times in diabetic foot ulcers. journal of diabetes and its complications, 16(5), 327–332. https://doi.org/https://doi.org/10.1016/s1056-8727(01)00217-3 404 not found microsoft word gjphm-2023 the lifestyle pattern -2.docx 762 global journal of public health medicine 2023, vol 5, issue 1 gggggglo original research the lifestyle pattern & prevalence of obesity and overweight among the adolescents of bhopal city, madhya pradesh, central india mahesh gupta1, anand kumar patidar1, vikash sharma1& manju toppo2 1department of community medicine, gmc ratlam 2department of community medicine, gmc bhopal *corresponding author:patidardranand@gmail.com abstract introduction: adolescence means “grow to maturity”. it is derived from the latin verb adolescere. this is a period of life between childhood and adulthood during which growth and development occur. the trend of consumption of fast food increases worldwide and in india fast food production and consumption are high. physical inactivity is associated with a high risk of non-communicable diseases. in india non-communicable diseases like metabolic syndrome are growing fast currently. methods: it was a cross-sectional study. sampling was done by using systematic multistage random sampling. by using the formula n= z2 pq/ d2, the sample size was calculated as 322. 536 adolescents of age (13-17 years) group were enrolled from the four schools in a different quadrant of bhopal city. results: in the present study 35.26% (189) adolescents were boys and 64.74% (347) were girls. in this study prevalence of overweight/pre-obese in boys was found at 8.06% & in girls, it was 12.17%. whereas the prevalence of obesity in boys was found 1.45% and in girls, it was 3.7%.conclusion: adolescents who spent leisure time on television or computer/internet were found overweight and obese relative to those who spend less time. the prevalence of overweight and obesity was found less in adolescents who were highly active as per the physical activity index as compared to those who were less active. keywords: life style, physical activity, overweight, obesity 763 global journal of public health medicine 2023, vol 5, issue 1 gggggglo introduction adolescence means “grow to maturity”. it is derived from the latin verb adolescere. this is a period of life between childhood and adulthood during which growth and development occur as physical and mental, behavioral patterns, emotional, and social changes and challenges (bhaveet et al.,2002). according to who, adolescence is a stage of life between 10 -19 years of age (harrington r.,2000). in india adolescent population is about one-fifth of the total population (approx 21.1%) (handbook s.,2014). the trend of consumption of fast food increases worldwide and in india, fast food production and consumption are high(ashikaran et al.,2012).in recent years it is observed that most of young people are having a poor diet(whitney et al.,1999).most of the individuals of this age group(adolescents) are influenced by their peers and advertisements on television(croll et al.,2001). globally, insufficient physical activity is one of the 10th risk factors for mortality. physical inactivity is associated with a high risk of non-communicable diseases. in india, non-communicable diseases like metabolic syndrome are growing fast currently. it is associated with diabetes, obesity, hypertension and insulin resistance (huang pl et al., 2009).overweight and obesity are defined by abnormal or excessive fat accumulation that causes a health risk. a body mass index (bmi) over 25 is marked as overweight, and over 30 is marked as obese. according to the global burden of the disease this issue has grown to epidemic proportions, with over 4 million people dying each year as a result of being overweight or obese in 2017(obesity.,who).in a study, researchers found the prevalence of overweight 12.64% and obesity 3.39%( midha t et al.,2012). due to epidemiological transition, patterns of health and diseases have been changed and trends of non-communicable diseases are increased now a day along with communicable diseases. as adolescent is a critical phase of development of various biological, psychological, social and environmental changes. overweight and obesity, which is a confirmed risk factors for the noncommunicable diseases are marginally increasing among them. so this study is conducted for the assessment of the association of the life styles pattern with the obesity and overweight in adolescents. the objective of the current study was to calculate the prevalence of overweight and obesity among adolescents and assess the life style pattern among adolescents. 764 global journal of public health medicine 2023, vol 5, issue 1 gggggglo methods: the present study was a cross-sectional study conducted for duration of 4months from october 2016 to january 2017. 536 adolescents of age (13-17 years) group were enrolled in the four schools in a different quadrant of bhopal city in madhya pradesh, india, with their consent. the approval was obtained from the ethics committee of the institute. sample size: by applying the formula of sample size calculation n= z2pq/ d2,with an estimated prevalence of 16% (overweight and obesity), 4% precision and 95% confidence interval, we found a sample size of 322 and considering 20% nonresponder, finally it comes to 388(536).sampling was done by using systematic multistage random sampling. first list of all schools was obtained from the bhopal school authorities and then four schools were randomly selected. inclusion criteria: all adolescents who were present at school during study periods and provided their consent was included. exclusion criteria: adolescents who were not present in the school during study periods and did not provide consent were excluded. data collection and procedure: a self-administered pre-tested semi-structured questionnaire was used. there were three parts to the questionnaire. in part one of the questionnaire, we collected information on socio-demographic variables (age, sex, height, weight), and in the second part by using the global based health survey (gshs) dietary module modified for india we collected information about food consumption patterns (gshs india., 2006).details of food (fruits, vegetables, junk food, and carbonated drink) items consumed in the last 7 days were collected by using the module. intake of food was categorized as follows,≤1 time per day, 2-3 times per day, and 4 or more times per day as low, moderate, and high respectively. the youth risk behavior survey (yrbs) questionnaire was used to assess tv watching and computer/internet usage and respondents were grouped as ‘’low’’, “moderate” and “high (cdc.,2017).a standardized procedure was followed for the measurements of weight and height. normal weight, overweight and obesity were categorized based on who classification (who.,2003). the third part of the questionnaire was designed to collect the intensity formation (low, moderate, high) duration (minutes), and physical activity performed by individuals in a week. the questionnaire covers activities by various modes such as transport, household, outdoor, fitness, sport etc. based on the metabolic equivalent (met) value assigned to every physical activity performed by participants calculation of total energy expenditure was done per week. the physical activity index (met minutes per week) was calculated by multiplying the intensity of various activities (in mets) and time spent on the activity (in minutes/week) (ainworth et al.,2011).based on the total mets-min/week, the physical activity index categorizes as highly active >1680 mets-min per week, moderately active: 840 to 1680 met-min per week, and low activity level: < 840 mets-min per week(who., 2010). statistical analysis: the analysis part was done by using excel and the software epiinfo 7.the test for significance applied was applied chisquare with a p-value < 0.05. 765 global journal of public health medicine 2023, vol 5, issue 1 gggggglo results: fig no.1: distribution of adolescents on the basis of their sex the above figure represents that the male and females contribute to the sample size of about 65% and 35% respectively. fig no.2: distribution of adolescent boys and girls on the basis of their bmi 64.74% (347) 35.26% (189) boys girls 0 10 20 30 40 50 60 70 80 90 100 boys girls 90.49% (314) 84.13% (159) 8.06% (28) 12.17% (23) 1.45% (5) 3.7% (7) f re qu en cy (n o. / % ) normal weight (bmi=> 18.50-24.99) overweight (bmi=> 25.00-29.99) obese (bmi=> ≥30.00) 766 global journal of public health medicine 2023, vol 5, issue 1 gggggglo the above figures represent that the problem of being overweight and obesity was high in girls as compared to boys. bmi of about 90.5% of boys and 84% of girls lies within the normal range. the prevalence of overweight in boys was 8% and in girls, it was about 12%.whereas the prevalence of obesity in boys was 1.5% and in girls, it was about 3.7%. fig. no.3: distribution of adolescents on the basis of bmi the above figures represent about the pattern of body mass index distributed among the sample-sized adolescents. about bmi of 88% of adolescents lies in the range of normal while the prevalence of overweight and obesity was found 9.51% and 2.24% respectively. 0 10 20 30 40 50 60 70 80 90 88.25% (473) 9.51% (51) 2.24% (12) f re qu en cy (n o. / % ) normal weight bmi=> 18.50-24.99 overweight bmi => 25.00 to 29.99 obese bmi => ≥30.00 767 global journal of public health medicine 2023, vol 5, issue 1 gggggglo table no. 1 showed that there was a significant association (p-value <0.05) found for the level of leisuretime activities performed between normal-weight adolescents and adolescents with overweight and obesity. it means that adolescents with normal bmi spent their time less on watching tv and on computers and the internet as compared to an adolescent with bmi in the range of overweight and obesity. similarly, adolescents with normal bmi spent more time in physical activity as compared to overweight and obese adolescents. table no. 1: leisure-time activities and their association with overweight /obesity level of leisuretime activities frequency of adolescents with normal weight no. (%) frequency of adolescents who were overweight /obese total p –value tv viewing low 102 (94.44%) 6 (5.56%) 108 (100.00%) 0.002977* (<0.05) moderate 154 (91.66%) 14 (8.34%) 168 (100.00%) high 217 (83.46%) 43 (16.54%) 260 (100.00%) computer/ internet use low 91 (94.79%) 5 (5.21%) 96 (100.00%) 0.013362* (<0.05) moderate 161 (90.49%) 17 (9.55%) 178 (100.00%) high 221 (84.35%) 41 (15.65%) 262 (100.00%) physical activity index low activity (<840 metsmin/week) 297 (85.84%) 49 (14.16%) 346 (100.00%) 0.042873*(< 0.05) moderate active (840-1680 metsmin/week) 142 (91.61%) 13 (8.39%) 155 (100.00%) highly active (>1680 metsmin/week) 34 (97.14%) 1 (2.85%) 35 (100.00%) total 473 (88.23%) 63 (11.75%) 536 (100.00%) 768 global journal of public health medicine 2023, vol 5, issue 1 gggggglo table no. 2 showed that there was a significant association (p-value < 0.05) found for the intake of carbonated drinks and junk food between normal-weight adolescents and adolescents with overweight and obesity. it means that overweight and obese adolescents had included carbonated drinks and junk foods in their diet plan more than the normal bmi adolescents. however, this study didn’t stabilise any significant association between the intake of fruits and vegetables in their diet between normal bmi and overweight /obese adolescents. table no. 2: association between dietary habits and overweight/obesity dietary variables value frequency of normal adolescents no. (%) frequency of overweight/obese adolescents no. (%) total pvalue fruits low 23 (85.18%) 4 (14.82%) 27 (100.00%) 0.576188 (> 0.05) moderate 98 (85.96%) 16 (14.04%) 114 (100.00%) high 352 (89.11%) 43 (10.89%) 395 (100.00%) vegetables low 29 (80.55%) 7 (19.45%) 36 (100.00%) 0.075133 (> 0.05) moderate 103 (84.43%) 19 (15.57%) 122 (100.00%) high 341 (90.21%) 37 (9.79%) 378 (100.00%) carbonated drinks low 298 (97.07%) 9 (2.93%) 307 (100.00%) 0.00001* (< 0.05) moderate 108 (83.72%) 21(16.28%) 129 (100.00%) high 67 (67.00%) 33 (33.00%) 100 (100.00%) junk food low 224 (98.68%) 3 (1.32%) 227 (100.00%) 0.00001* (< 0.05) moderate 153 (91.07%) 15 (8.93%) 16(100.00%) high 96 (68.08%) 45 (31.92%) 141 (100.00%) total 473 (88.25%) 63 (11.75%) 536 (100.00%) 769 global journal of public health medicine 2023, vol 5, issue 1 gggggglo discussion: this study was conducted for the assessment of various lifestyles patterns such as physical activity, dietary habits and leisure time activities and their effects on the prevalence of overweight and obesity in adolescents. in our study we found that 35.26% (189) adolescents were boys and 64.74% (347) were girls while in another study, 461 (51.2%) subjects were males and 439 (48.8%) were females (kotian ms et al.,2010). our study found the prevalence of overweight/pre-obese in boys was 8.06% & in girls, it was 12.17%. whereas the prevalence of obesity in boys was 1.45% and in girls, it was 3.7% (fig no.2) while in another study the prevalence of overweight among boys and girls was 9.3%, 10.5% and of obesity it was 5.2% and 4.3%, respectively(kotian ms et al.,2010). in the present study, overall prevalence of overweight/pre-obese and obesity was found 9.51% and 2.24% respectively (fig no. 3). the findings are similar to the study, where the prevalence of overweight and obesity was 9.9% and 4.8% respectively and11.4% and 2.7%respectively (kotian et al.,2010) (bhat et al.,2017). similar findings was also observed in the study, where the overall prevalence of overweight and obesity was found to be 22.5% and 9.7% respectively and the prevalence of overweight and obesity in boys was 20.4% and 10.3% respectively and in girls 24.9% and 9.7% respectively(saikia d et al.,2016). results of our study showed (table no.1) that low level of physical activity is significantly (p value<0.05) associated with overweight /obesity, and high tv viewing and high use of computer/internet use significantly (p value<0.05) associated with overweight/obesity among adolescents. while in other study, overweight and obese adolescent were significantly less involved in vigorous physical activity (saikia d et al.,2016). overweight and obesity were marginally higher among adolescents who were not involved in physical activities such as walking, cycling, and jogging (laxmaiah a et al.,2007). results of our study revealed that the consumption of high or more carbonated drinks and junk food is associated with overweight and obesity significantly (p value<0.05). the findings of our study are supported by various other studies, overweight and obesity were 5.6 times higher among those who ate chocolates daily in addition to a normal(kotian et al.,2010). researchers of the other study found significant association of daily intake of deep fried/fast food, bakery products, butter/ghee, carbonated soft drinks, chocolate, and sharbat /syrups with overweight and obesity(saikia d et al.,2016). researchers also states that junk food and chocolate eating habits have more prevalence of obesity and overweight than underweight (goyal r et al.,2010). conclusion: this study concluded that the problem of overweight and obesity is a major health problems among adolescents. prevalence of overweight and obesity was more common in adolescents who spend their leisure time activity more with television or computer/internet, as compared to those who spend less time with them. the problem of overweight and obesity was seen less in adolescents who were highly active as per the physical activity index as compared to those who were less active. this problem was also seen more in adolescents who were consuming more carbonated drinks and junk food. 770 global journal of public health medicine 2023, vol 5, issue 1 gggggglo recommendations :as many studies reveal that being overweight and obese is an emerging health problem among adolescents also, so governments should emphasize health promotion and provision of health education regarding physical activities and modifying lifestyles & dietary behaviors in the school curriculum in private schools as well. limitations:results of the study would be better generalized if we could include more numbers of schools. by including more numbers of schools in different areas of the bhopal city we would better understand the variability in the lifestyle patterns and might the prevalence we get would be more précised and selection bias would be controlled in better way. conflicts of interest the author declares no conflicts of interest. references • 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(2001). healthy eating: what does it mean to adolescents?. journal of nutrition education, 33(4):193-198. • centre for disease control and prevention. state and local youth risk behaviour survey.2017 available on http://www.cdc.gov/healthyouth/yrbs/pdf/questionnaire/2015.pdf. • gshs india, central board of secondary education(cbse) gshs questionnaire [internet]. 2006. available from: www.cdc.gov/gshs. • goyal, r. k., shah, v. n., saboo, b. d., phatak, s. r., shah, n. n., gohel, m. c., & patel, s. s. (2010). prevalence of overweight and obesity in indian adolescent school going children: its relationship with socioeconomic status and associated lifestyle factors. the journal of the association of physicians of india, 58: 151-158. • handbook, s. (2014). rashtriya kishor swasthya karyakram. adolescent health division ministry of health and family welfare government of india. • harrington, r. 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(2012). childhood obesity in india: a meta-analysis. the indian journal of pediatrics, 79(7) : 945-948. • obesitywho | world health organization, https://www.who.int • saikia, d., ahmed, s. j., saikia, h., & sarma, r. (2016). overweight and obesity in early adolescents and its relation to dietary habit and physical activity: a study in dibrugarh town. clinical epidemiology and global health, 4 :s22-s28. • whitney e. rolfes s. understanding nutrition.(1999) an international thomson publishing co. belmont.ca.pp.181-522 • who (2003, tech. rep. ser. no. 916). • world health organisation (2010).global recommendations on physical acivity for health; who press: geneva, switzerland,. microsoft word review research.docx 279 review research dexamethasone use in management of covid19: a review samer mohammed college of pharmacy, university of baghdad, iraq *corresponding author: samer.jameel@copharm.uobaghdad.edu.iq abstract the lack of active 2019 coronavirus disease (covid-19) pandemic treatment creates a challenge for researchers and scientists to find the most appropriate treatment for this disease. dexamethasone, according to the findings of the recovery clinical trial, declared mid-june 2020 in print media was one of those therapies. although the results from retrospective studies are not strongly supportive of corticosteroid routine use in covid-19 despite the signals for some benefits, the dedicated recovery trial found a significant reduction in death with dexamethasone only in severe cases on a ventilator or moderate cases on supplemental oxygen therapy nevertheless, no benefit observed in mild to moderate cases requiring no oxygen. more studies are still necessary to substantiate conclusive use with dexamethasone in covid-19. this narrative review attempts to summarize all available shreds of evidence from previously published research articles on the use of dexamethasone in covid-19 pandemic treatment. keywords: covid-19, dexamethasone, acute respiratory distress syndrome, randomized controlled trial, steroids, pandemic. 280 introduction the absence of efficient treatment for the 2019 pandemic of persistent coronavirus disease (covid19) creates a challenge for all specialists and scientists to find an efficient treatment for this disease (beigel et al., 2020). one of these potential treatment options was dexamethasone corresponding to a print media announcement in mid-june 2020 (along with consequent report2) from the recovery clinical trial(“dexamethasone in hospitalized patients with covid-19 — preliminary report,” 2020a). the u.k. guidelines released the use of glucocorticoids in hospitalized covid-19 patients was proposed by chief medical officers and by the national institutes of health in the united states (national institutes of health. 2020). as well known, dexamethasone is regarded as essential medicines according to the world health organization (who) and readily available worldwide at affordable low cost and long history of safety (national institutes of health, 2020). dexamethasone is a synthetic corticosteroid with a more significant activity of immunosuppression (30 times) and a longer duration of action (2–3days) than natural cortisone (beigel et al., 2020). the objective of this narrative review is to summarize all available data from previously published studies concerning the use of dexamethasone in the treatment of the covid-19 pandemic. methods a systematic and comprehensive search using specific keywords “dexamethasone,” “corticosteroids," "adult respiratory distress syndrome," "covid-19" from pubmed, google scholar, and cochrane library electronic database was conducted until september 31, 2020. all the papers were subsequently thoroughly investigated and presented in the text. the rationale of the use of dexamethasone in covid-19: according to who, the majority of hospitalized covid-19 patients developing acute respiratory distress syndrome (ards) (grasselli et al., 2020), and up to 12% of those patients required invasive mechanical ventilation (docherty et al., 2020; richardson et al., 2020)the pulmonary histological examination of patients with covid-19 showed diffuse alveolar damage with hyaline membranes (ackermann et al., 2020) additionally, a multiorgan failure may occur because of an uncontrolled inflammatory state (moore et al., 2020)(qin et al., 2020). consequently, corticosteroids can play a crucial role in managing these complications associated with hospitalized covid-19 patients(rhen & cidlowski, 2005). glucocorticoids have previously been used effectively in covid-19-related viral infections, such as “sars, middle east respiratory syndrome (mers), severe influenza, and community-acquired pneumonia”(arabi et al.,2018). nevertheless, due to the paucity of sufficient data from large randomized, controlled trials, the evidence to endorse or discourage the use of glucocorticoids for these 281 disorders has been weak(arabi et al.2018) (lansbury et al., 2020). the findings obtained from animal models or even small clinical trials of coronaviruses other than covid 19 were confusing(nelson lee et al., 2003). while some therapeutic benefits were observed from prior research measuring the efficacy of glucocorticoid therapy in the 2003 coronavirus severe acute respiratory syndrome spread (sars-cov) (nelson lee et al., 2003). on the other hand, recent glucocorticoid therapy meta-analysis for middle east respiratory syndrome coronavirus (mers-cov), sars-cov, and sars-cov-2 has elicited caution, referring to delays in viral clearance and lack of evidence for improved patient outcomes(li .h et al., 2020.). in line with these mixed findings, many recommendations for the treatment of hospitalized covid-19 patients have suggested that glucocorticoids have either been contraindicated or not prescribed due to the lack of credible evidence from large-scale randomized clinical trials (dagens et al., 2020.). however, dexamethasone and methylprednisolone have been suggested for severe cases(zhao et al., 2020.). one research evaluated the mortality effect of dexamethasone in hospitalized patients with severe respiratory complications of covid-19 and concluded that dexamethasone decreased mortality by onethird in ventilator patients and one-fifth in oxygen-only patients. however, this advantage was not seen in milder disease patients who did not require respiratory intervention (university of oxford, 2020). benefits of dexamethasone use in covid-19: we need to outline some main clinical characteristics of this disease to explain the potential benefits of dexamethasone in covid-19. the vital pathophysiological features of severe covid-19 cases are acute pneumonia with substantial radiological opacity and diffuse alveolar injury, inflammatory infiltrates, and microvascular thrombosis(carsana et al., 2020.). inflammation caused by the release of inflammatory chemokines, such as tumor necrosis factor-alpha(tnf-alpha), released by immune cells such as neutrophils, has led to pneumonia. (ware & matthay, 2000). acute respiratory distress syndrome (ards ) is caused by fluid accumulation and pneumonia(ware & matthay, 2000). severe condition of covid-19 represents about 15-30% of patients that may result in ards that is associated with a mortality rate of nearly 65% (x. li & ma, 2020). the main contributor to mortality in positive covid-19 patients is ards. (ware & matthay, 2000) by causing shock that leads to multiple organ failure followed by the death of the patients(c. huang et al., 2020). using dexamethasone in covid-19 infections is mainly because of its anti-inflammatory action comprising cytokine storm, which leads to disease aggravation(shang et al., 2020) and decreased mortality in acutely ill covid-19 illnesses(theoharides & conti, 2020). in hospitalized patients needing supplemental oxygen or mechanical ventilation due to the use of dexamethasone, reduced mortality was demonstrated by cumulative results from randomized clinical trials. (“dexamethasone in hospitalized patients with covid-19 — preliminary report,” 2020b) nevertheless, no proven improvements were noticed in covid_19 patients with mild or even moderate disease states or any 282 hospitalized covid-19 patients who did not require oxygen therapy or mechanical ventilation ( ledford et al.,2020.) in patients with comorbid conditions, including chronic respiratory disorders, cardiovascular and cerebrovascular diseases, diabetes, and hypertension, who have a greater risk of developing severe covid-19 with ard or multiorgan failure, the protective effect of dexamethasone from a cytokine storm is frequently observed(i. huang et al.,2020). besides cytokine storm suppression, dexamethasone is also indicated in covid-19 patients to treat severe immune thrombocytopenic purpura(bomhof et al., 2020). mechanism of action: it is proposed that dexamethasone's anti-inflammatory activity is likely to mitigate the cytokine storm caused by covid-19 infection, which protects the lungs and ultimately lives and needs thorough investigations(patel et al., 2020). on the other hand, dexamethasone suppresses lymphocytes' actions that play a crucial role in coronavirus suppression. therefore, it is necessary to avoid corticosteroids in patients with covid-19 infections in the initial stable or even in mild-to-moderate conditions (marinella, 2020). inhibition of dexamethasone's pro-inflammatory state occurs by inhibiting cytokines such as interleukin type 1 (il-1), tnf, and interleukin type 6( il-6), inhibiting chemokines, or other soluble mediators like leukotrienes, prostaglandin e2 (cain & cidlowski, 2020). covid-19 has recently been subdivided into two phases: in the early phase, virus pathology dominates; and in the later phase, immunopathology drives disease. (cain & cidlowski, 2020). perhaps it is not unexpected in this way of thinking about covid-19 that the offer of dexamethasone in the recovery study showed minimal benefit when used in patients whose disease had not progressed to a level requiring oxygen therapy or ventilation; the immunosuppressive effects of glucocorticoids at this phase of the illness may have been probable and may obstructing antiviral responses(cain & cidlowski, 2020). the predominant influential role of dexamethasone appeared clearly in the hyperinflammatory phase of covid-19 by interrupting the inflammatory cycle(cain & cidlowski, 2020). likewise, in one study's preliminary report specifically concludes, there was no obvious sign that dexamethasone offered any advantage to patients who did not receive respiratory care. (“dexamethasone in hospitalized patients with covid-19 — preliminary report,” 2020b). in viral severe respiratory infections, the beneficial role of glucocorticoids depends on selecting the correct dose. high doses can be associated with many complications, and the right time of administration as such care is provided when regulation of viral replication is crucial. inflammation is limited (nelson lee et al., 2003). the dexamethasone dose in covid-19 patients was chosen based on several clinical trials that used dexamethasone to treat non-covid-19 ards patients (theoharides & conti, 2020). all earlier 283 evidence concluded that large doses of corticosteroids equal to 30 mg / d of dexamethasone in viral pneumonia might be correlated with adverse effects (cao et al., 2016). accordingly, dexamethasone was used at a low dose rate (6 mg/day) in the several case series that evaluates the use of dexamethasone in covid-19(“dexamethasone in hospitalized patients with covid-19 — preliminary report,” 2020a). complications: dexamethasone has shown that it can reduce t cells' defensive function, inhibit the production of antibodies from b-cells, and prevent a macrophage clearance process, which potentially leads to higher viral plasma levels and a greater risk of secondary infection. (theoharides & conti, 2020). additionally, slower clearing of viral rna was also observed in sars, mers, and influenza patients treated with systemic glucocorticoids, but those findings' clinical significance is uncertain (lee et al., 2003). potentially severe, but preventable, less common adverse effects such as strongyloides hyper infection or dissemination syndrome (hyperinfection) could be difficult to recognize by many clinicians (krolewiecki et al., 2019). most of these fatal iatrogenic adverse effects are asymptomatic and independent of dose or duration of treatment and mainly appeared with the use of an immunosuppressive drug in patients with unrecognized chronic infection(requena-méndez et al., 2017). correspondingly, in cases with covid19 who are at risk for strongyloidiasis and are candidates for treatment with dexamethasone, physicians and health care systems should consider adopting a plan to avoid hyper infection syndrome(stauffer et al.,2020). as well-known, hyperglycemia can last more than 24 hours after a given dose of dexamethasone. but a short steroid course in most of the covid-19 studies is less likely to have triggered steroid-induced hyperglycemia or even worsened glycemic control of pre-existing diabetes patients. even so, every therapist must be attentive to the expected deterioration in hyperglycemia using corticosteroids in covid-19 patients and take some corrective action to deal with it (singh et al., 2020). in order to avoid some serious side effects of corticosteroids in patients with covid-19, immunoglobulins (iv-ig) and interferon-beta (ifn-β) have been administered simultaneously in some clinical trials to test the hypothesis that early administration of dexamethasone along with iv-ig and ifn-β could or may not minimize the consequences of cytokine storm in critically ill patients with covid19 (sibila et al., 2008). since dexamethasone is readily accessible and inexpensive and can be obtained without a prescription, some individuals can tend to self-medicate. dexamethasone is, in fact, not an antiviral, nor is it a definite cure for covid19, so it can weaken their immunity and lead to an increase in susceptibility to the viral and other infections in healthy individuals (lim & pranata, 2020). besides, dexamethasone costs may rise significantly and become difficult for those who need it or even 284 sell it at highly overestimated rates. in such unanticipated cases, healthcare professionals may turn to other corticosteroids, such as methylprednisolone, as an option for patients in need.(lim & pranata, 2020). for that, the who has also urged pharmaceutical companies to ramp up dexamethasone production, as demand is expected to increase (who director-general’s opening remarks at the media briefing on covid-19 22 june 2020). another issue associated with dexamethasone was the limitations in health systems in any context that could affect the intervention's effectiveness and change the risk-benefit balance. a reduced ability to monitor blood sugar levels or detect co-morbidities where, for example, steroids are contraindicated can have adverse effects. similarly, in the absence of critical care facilities and perfectly qualified staff, steroids can have an even more significant mortality impact than benefits that could turn covid-19's management (brotherton et al., 2020). clinical trial outlines although many previous trials assessed the role of corticosteroids for non-covid-19 ards with conflicting results however only a few trials evaluate the effect of corticosteroids or specifical dexamethasone in covid-19(steinberg et al., 2006; villar et al., 2020). most of these studies were cohort-limited and had a high degree of heterogeneity about steroid selection, dose, timing, and coprescribed broad-spectrum antibiotics and antivirals(guan et al., 2020; liu et al.,2020; wu et al.,2020; zhou et al., 2020). only one study clearly measured the steroid benefits related to their action(wu et al.,2020); others found little benefit in acute pulmonary injury or ards patients, regardless of steroid administration timing. indeed, corticosteroid therapy has also been shown to improve the body's time for viral excretion (ling et al., 2020). the most relevant study was the randomized assessment of the covid-19 treatment (recovery) trial (open-label, controlled study), which involved 6,425 patients randomized to 6 mg per day of dexamethasone or standard treatment. overall, dexamethasone resulted in a 2.8 % absolute reduction in mortality (22.9% vs 25.7% for standard care group; 0.83 [95 % ci, 0.750.93] age-adjusted rate ratio). the benefit was greatest for patients with invasive mechanical ventilation at randomization, with a mortality rate of 29.3% for dexamethasone vs. 41.4% for standard care (rate ratio, 0.64 [95% ci, 0.510.81]) (“dexamethasone in hospitalized patients with covid-19 — preliminary report,” 2020b). 285 conclusion still, there have been enduring debates regarding the role of corticosteroids in treating severe infections. the pandemic was a powerful stimulus that resolved this dispute in clinical science. dexamethasone may have a protective effect on serious covid-19 ards infections, as clearly appeared in the recovery trial. however, large-scale ongoing clinical trials may shed light on the clinical efficacy of corticosteroids in covid-19 conditions. the exploration of the dose-dependent reaction of dexamethasone in extreme covid-19 patients is warranted by further research. clinical studies have shown that treatment with low-dose dexamethasone supplements endogenous cortisol production to reduce immunopathology associated with covid-19 while preventing high-dose glucocorticoid's adverse effects therapy. conflicts of interest: the authors declare no conflicts of interest. references • arabi, y. m., mandourah, y., al-hameed, f., sindi, a. a., almekhlafi, g. a., hussein, m. a., ... & fowler, r. a. 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for diabetics as compared to gender-age matched control living in southern gaza, palestine. methods: this study was a case-control. about 100 dm patients and age-sex matched 100 controls were randomly selected from the department of internal medicine at the nasser medical complex in khanyunis governorate and the community. the world health organization quality of life questionnaire – short version (whoqol-bref) was used to evaluate the quality of life among the study population. results: those with diabetics, the hrqol was significantly lesser than for controls in all domains with the largest differences in the environmental domains (difference of 5 points) and tinier differences in physical health, psychological health & social relationships (2, 3 and 3 points difference) (<0.001 for all). low ratings in the field of social relations in both groups with tiny differences between them have been registered (3 points). furthermore, there were no differences in mean of scores for all domains according to gender. conclusion: the study population's total hrqol (diabetics and controls) was poor. health program must be developed to encourage improve dietary habits, healthier lifestyle, promote exercise, discourage smoking, avoid complications of diabetes and appropriately handle chronic diseases. keywords: diabetes mellitus; health-related quality of life; whoqol-bref; palestine. 64 global journal of public health medicine 2019, vol 1, issue 2 gggggglo introduction diabetes mellitus (dm) is a multifactorial disorder associated with hyperglycemia in addition to carbohydrate, fat and protein metabolism disorders arising from insulin secretion deficiency, insulin action, or both (altaher, et al., 2017). chronic elevated blood glucose in diabetics can lead to long-term dysfunction, and multiple organs failure, including eyes, kidneys, nerves, heart, and blood vessels (wendy and jean, 2007). over the past two decades, the prevalence of dm has increased significantly (pearson, 2003). according to recent estimates; there was nearly 135 million individuals with dm around the world in 1995, and this number estimated to rise to 300 million by the year 2030 (king, et al. 1998). in 2018, there were 538 deaths due to complications of dm and these complications came in the fifth leading cause of death among palestinian with a proportion of 7.5% (pmoh, 2018). in fact, long-term diabetes complications such as retinopathy, nephropathy, neuropathy, heart disease, and stroke, with their significant health impact, may also have an adverse effect on quality of life (redekop, et al., 2002). quality of life is a significant element for diabetes mellitus because poor quality of life contributes to decreased personal care, which in turn contributes to worsening glycemia control, enhanced risk of diabetic complications, and overwhelming aggravation of dm both in the brief and long term (jain, et al., 2014). it is therefore evident that quality of life topic is essential and predict how well a person can manage his illness and sustain long-term health and well-being (jain, et al., 2014). it is also essential to assess the perceived burden of diabetic patients about his chronic disease situation, in order to observe the trends in overtime health and quantify the therapy impact (vigneshwaran, et al., 2013). the uk prospective diabetes study has demonstrated that adequate glycemic control can significantly decrease complications of dm, open the way for early diagnosis and appropriate management advantages (davis, et al., 2001). dm is well-recognized to be associated with enhanced morbidity and mortality. but the impact of this disease on functional state of health and well-being is not yet well recognized (jain, et al., 2019). hrqol is the actual difference between one’s expectations and one’s actual physical, emotional, and social functioning (jain, et al., 2019). several studies have reported that health-related quality of life (hrqol) is affected negatively by diabetes, especially in the presence of complications (coffey et al., 2002; redekop, et al., 2002; smith, 2004; vileikyte, et al., 2005; goodridge, et al., 2005; eljedi, et al., 2006; jain, et al., 2014). however, most of these studies were carried out in developed countries (garratt, et al., 2002). unfortunately; there were few studies have been conducted about the hrqol in diabetic patients in developing (aghamollaei et al., 2003; ghanbari, et al., 2005; savli, & sevinc, 2005; aghamollaei et al., 2005). these studies ' results were diverse and distinct from one country to another owing to differences in dietary habits, lifestyle attitude, severity and disease duration among them. therefore, the main aim of this study was to determine the hrqol for patients with dm as compared to gender-age matched control in southern gaza strip, palestine. in addition, to find out the gender differences in diabetic group according to quality of life. methods the design of this study was a case-control carried out in between may and july 2019, the study population were 100 dm patients and age-sex matched 100 controls without diabetes living in in khanyunis and rafah governorates, southern gaza strip. the definition of dm was based on ada guidel ines. the range of the participants was in between 18 and 65 years. the cases group was randomly selected patients from the department of internal medicine at the nasser medical complex in khanyunis governorate (the study frame), palestine. the controls group were selected from the community. epi-info program version (vr) 7.2 was used to calculate the sample size at population size = 100000, 95.0 % confidence interval (ci), 4.0% acceptable margin of error and 9 % expected prevalence of diabetes mellitus based on previous study that carried out in palestine, the sample size was 196 diabetic patients (altaher, et al., 2017). inclusion criteria for patients were any diabetic patients with or without complications, his treatment began at 6 months or more before the research has been performed. dm patients with any other disease (any chronic disease not associated with dm) and pregnant patients at the time of the study carried out were excluded from the study. all formal letters of permission were obtained to perform the research from pmoh. before data gathering, consent forms were provided to define the purpose and importance of the research for all research respondents. 65 global journal of public health medicine 2019, vol 1, issue 2 gggggglo face to face questionnaires were used by research team to collect the social and demographic data (e.x. gender, level of education, type of housing, etc...) and dm associated data (e.x. dm type, its duration per years, medication for dm, etc..). the differences between co-morbidities and diabetes complications were based on the patient's medical records and were not reevaluated when the research was included. the short version of world health organization quality of life questionnaire (whoqol-bref) was used by research team to assess the quality of life among the study population (whoqol group, 1998). this questionnaire was created to acquire a crosscultural evaluation tool with 15 global field centers. the whoqol-bref is consisting of four domains which are physical health (e.x. physical pain feeling, medical treatment need), psychological (e.x. enjoy life, concentration ability), social relationships (e.x. personal relationships) and environment (e.x. opportunity for leisure activities). the participants rated all items on a 5-point likerttype scale. the questionnaire was translated into arabic language. the vr 22 of spss system was used for analysis of data. descriptive statistics, chi-square test and ttest were carried out at ci 95%. p-value of less than 0.05 for the test hypothesis was considered as statistically significant. results regarding the gender, this research found that 65.0% of patients were male and 35.0% were female vs. 59.0% of control were males and 41.0% were females (table 1). after using of chi-square the differences among the study population according to age, gender, education level, marital status, house type and monthly income were not reach the statistically significant levels (p=0.714, p=0.328, p=0.660, p=0.062, p=0.094 & 0.626 respectively) (table 1). approximately 32.0 % of patients with dm were smokers vs. 5.0 % for controls (p=0.000) (table 1). table 2 shows the situation of clinical characteristics of diabetics (cases) by gender. the mean ± sd of diabetes mellitus duration among the diabetic males was 8.36±5.66 years vs. 8.05 ± 5.33 for diabetic females (p=0.789). in addition, most of diabetic patients (92.0%) were t2dm (93.8% of males vs. 88.6% of females) (table 2). furthermore, about 49.0% of the total diabetic subjects were intake tablets as hypoglycemic drug. moreover, about 44.0% of the total diabetic subjects were not suffers from any diabetic complications (47.7% of males vs. 37.1% of females) (table 2). table 3 illustrates comparison of crude domain scores between the cases group and controls group. among diabetics, the hrqol was significantly lesser than for controls in all domains with the largest differences in the environmental domains (difference of 5 points) and tinier differences in physical health, psychological health & social relationships (2, 3 and 3 points difference) (p=0.000 for all) (table 3). this implies that in a comparable manner; poor physical health, poor psychological health, deteriorating social relationships, and poor environmental circumstances affect the hrqol of both groups. in the domain of social relationships, both groups had especially low ratings with tiny differences between them (3 points). table 4 displays comparison of crude domain scores between the diabetic's male group and diabetic's females group. however, the differences in crude domain scores in all domains between males and females were not reach the statistically significant level (p> 0.05 for all domains) (table 4). 66 global journal of public health medicine 2019, vol 1, issue 2 gggggglo table 1: distribution of the subjects by socio-demographic characteristics *level of significance at p<0.05 table 2: the clinical characteristics of diabetics by gender *level of significance at p <0.05. p-value subject variables control (n=100) dm (n = 100) 0.714 51.5±9.9 52.0±10.4 age (mean±sd) 0.382 gender (59.0%) (65.0%) male (41.0%) (35.0%) female 0.660 education level (21.0%) (18.0%) illiterate (46.0%) (43.0%) secondary (33.0%) (39.0%) undergraduate or more 0.062 marital status (5.0%) (7.0%) single (88.0%) (77.0%) married (5.0%) (13.0%) widowed (2.0%) (3.0%) divorced 0.094 house type (26.0%) (37.0%) rented (74.0%) (63.0%) owned 0.626 monthly income (nis) (29.0%) (35.0%) < 500 (51.0%) (45.0%) 500 to < 1500 (20.0%) (20.0%) > 1500 <0.001* smoking status (5.0%) (32.0%) yes (95.0%) (68.0%) no p-value gender variables female male 0.789 8.05±5.33 8.36±5.66 duration (mean±sd) 0.141 49.94±9.28 53.18±10.9 age (mean±sd) 0.047* diabetic type (2.9%) (6.2%) t1dm (88.6%) (93.8%) t2dm (8.5%) (0.0%) gestational 0.510 type of hypoglycemic drug (40.0%) (53.8%) tablet (31.4%) (26.2%) insulin (17.1%) (9.2%) both (11.4%) (10.8%) following diet 0.764 diabetic complication (major one) (37.1%) (47.7%) none (2.9%) (4.6%) nephropathy (31.4%) (29.2%) retinopathy (14.3%) (9.2%) neuropathy (14.3%) (9.2%) diabetic leg 67 global journal of public health medicine 2019, vol 1, issue 2 gggggglo table 3: crude domain scores of whoqol-bref for dm patients as compared to controls *level of significance at p<0.05 table 4: crude domain scores of whoqol-bref for dm males as compared to dm females *level of significance at p<0.05 discussion this study is a comprehensive study with the large sample size aimed to estimate the hrqol for patients with t2dm as compared to age-gender matched control in palestine. as we found in the current study, poor physical health, poor psychological health, declining social relationships and poor environmental circumstances influencing on the hrqol of diabetics and non-diabetic controls similarly. however, the overall hrqol of the participants of the current research (cases group and controls group) was poor. the findings of our study were in the line with most recent studies conducted to find out the status of health-related quality of life in dm patients as compared to controls (healthy individuals) (coffey et al., 2002; smith, 2004; vileikyte, et al., 2005; goodridge, et al., 2005; eljedi, et al., 2006; jain, et al., 2014). eljedi, et al. (2006) performed a survey to determine the impacts of diabetes on hrqol in gaza strip refugee camps under living circumstances. a sample of 197 dm patients and 197 age and gendermatched healthy individual (controls) selected from the same camps were researched. whoqol-bref which including four domains (physical health, psychological, social relations and environment) was used to assess the hrqol. cases and controls domain scores were compared and the effect of socioeconomic factors was assessed in both groups. the results of this research showed that all domains in dm patients were sharply decreased relative to controls, with weaker impacts in social relationships domain (52.4 vs. 71.4 at 0–100 score points) and environmental domains (23.4 vs. 36.2) and greater impacts in physical health domain (36.7 vs. 75.9) then psychological domains (34.8 vs. 70.0) (eljedi, et al., 2006). in addition, heath-related quality of life of diabetics women and older diabetics subjects (>50 years of old) were sharply affected by dm as compared to diabetics male and younger age group (<50 years). in the younger age group (< 50 years); the low socioeconomic status had a large negative influence on hrqol. (eljedi, et al., 2006). furthermore, another case-control study conducted in india, aimed to find out hrqol of diabetic patients attending the medical college, particularly in the department of medicine outpatient. the study population was 70 diabetics and 70 age-gender matched healthy individuals (controls) have participated in the study. whoqol-bref was used to assess the quality of life. after compared the crude domain scores between the diabetics and controls; the findings showed that the scores for both groups were poor in all areas such as physical, psychological, and environmental health. but in the field of social relationships; both diabetics and controls had incredibly low ratings. this implies that both groups are likewise affected by poor physical health, poor psychological health, bad social relationships, and poor environmental conditions (jain, et al., 2014). in contrast, two studies have reported mean scores greater in all the domains among diabetics and controls than our findings (bech, 2001; aghamollaei, et al., 2003). regarding the comparison of crude domain scores between both the diabetic male group and diabetic females group. the findings of the current study showed that there p-value controls (mean ±sd) dm (mean ±sd) domain <0.001* 25.76±1.92 23.45±2.72 physical health <0.001* 25.22±1.70 22.37±3.75 psychological <0.001* 13.05±1.88 10.83±2.01 social relationships <0.001* 35.12±4.29 30.30±6.43 environment p-value dm females (mean ±sd) dm males (mean ±sd) domain 0.119 24.02±2.52 23.13±2.78 physical health 0.404 22.80±4.51 22.13±3.29 psychological 0.060 10.31±2.02 11.10±1.96 social relationships 0.616 30.74±6.46 30.06±6.45 environment 68 global journal of public health medicine 2019, vol 1, issue 2 gggggglo was no difference between the two groups in domain scores in all domains (p> 0.05 for all domains), and this means that diabetics male hrqol is not better than diabetics female group. this finding is inconsistent with many recent studies (goodridge, et al., 2005; eljedi, et al., 2006; jain, et al., 2014). in contrast, few studies in the literature reported a high impact of interactions between condition of disease and sex among diabetics as compared to healthy individual (controls), and these studies clarified this relationship because of the worse disease condition of female patients (redekop, et al., 2002; aghamollaei, et al., 2003). conclusion & recommendation in summary, patients with diabetes residing in the southern gaza strip have bad hrqol in comparison to age-sex matched healthy individuals residing under the same circumstances, however, the overall hrqol of the population of the research (diabetics and controls) was poor. diabetes has not an impact on the hrqol of neither females nor males. in order to maintain a good hrqol among diabetics living in southern gaza strip; health program must be developed to encourage improve dietary habits, healthier lifestyle, promote exercise, discourage smoking, prevent complications of dm, and correctly handle concurrent chronic diseases. this will aid in arriving in the awaited objective of health care of diabetics particularly in gaza strip and generally in state of palestine. acknowledgements the authors gratefully acknowledge to the nasser medical complex administration and medical staff for the facilities they have provided to conduct this study. references altaher, a. m., ghafoor, e. s. a., amudi, w. i., & alderby, d. k. (2017). comparative identification of bacterial quality in liquid soap between nasser and european gaza hospitals, khanyounis governorate. journal of the arab american university, 3 (1), 54-66. al-taher, a. m., aljboor, h. s., alshaer, s. i., & soboh, m. m. (2017). a comparative study of coronary risk factors between urban and rural diabetics in gaza strip. journal of the arab american university. volume, 3(1). aghamollaei, t., eftekhar, h., shojaeizadeh, d., mohammad, k., nakhjavani, m., & pour, f. g. (2003). behavior, metabolic control and health-related quality of life in diabetic patients at bandar abbas diabetic clinic. iranian journal of public health, 54-59. aghamolaei, t., eftekhar, h., mohammad, k., nakhjavani, m., shojaeizadeh, d., ghofranipour, f., & safa, o. (2005). effects of a health education program on behavior, hba1c and health-related quality of life in diabetic patients. acta medica iranica, 89-94. bech, v. n. p. (2001). the who quality of life (whoqol) questionnaire: danish validation study. nordic journal of psychiatry, 55(4), 229235. coffey j. t., brandle, m., zhou, h., marriott, d., burke, r., tabaei, b. p., ... & herman, w. h. (2002). valuing health-related quality of life in diabetes. diabetes care, 25(12), 2238-2243. davis, t. m., cull, c. a., & holman, r. r. (2001). relationship between ethnicity and glycemic control, lipid profiles, and blood pressure during the first 9 years of type 2 diabetes: uk prospective diabetes study (ukpds 55). diabetes care, 24(7), 1167-1174. eljedi, a., mikolajczyk, r. t., kraemer, a., & laaser, u. (2006). health-related quality of life in diabetic patients and controls without diabetes in refugee camps in the gaza strip: a cross-sectional study. bmc public health, 6(1), 268. garratt, a. m., schmidt, l., & fitzpatrick, r. (2002). patient-assessed health outcome measures for diabetes: a structured review. diabetic medicine, 19(1), 1-11. ghanbari, a., yekta, z. p., roushan, z. a., & lakeh, n. m. (2005). assessment of factors affecting quality of life in diabetic patients in iran. public health nursing, 22(4), 311-322. goodridge d, trepman e, embil jm: healthrelated quality of life in diabetic patients with foot ulcers: literature review. j wound ostomy continence nurs 2005, 32(6):368-377. jain, v., shivkumar, s., & gupta, o. (2014). health-related quality of life (hr-qol) in patients with type 2 diabetes mellitus. north american journal of medical sciences, 6(2), 96. king, h., aubert, r. e., & herman, w. h. (1998). global burden of diabetes, 1995–2025: prevalence, numerical estimates, and projections. diabetes care, 21(9), 1414-1431. 69 global journal of public health medicine 2019, vol 1, issue 2 gggggglo palestinian ministry of health (pmoh) (2018). the health annual report, pp 93-95. retrieved from: https://www.site.moh.ps/index/books/booktyp e/2/language/ar pearson, t. a. (2003). education and income: double-edged swords in the epidemiologic transition of cardiovascular disease. ethnicity and disease, 13(2; supp/2), s2-158. redekop, w. k., koopmanschap, m. a., stolk, r. p., rutten, g. e., wolffenbuttel, b. h., & niessen, l. w. (2002). health-related quality of life and treatment satisfaction in dutch patients with type 2 diabetes. diabetes care, 25(3), 458-463. savli, h., & sevinc, a. (2005). the evaluation of the turkish version of the well-being questionnaire (wbq-22) in patients with type 2 diabetes: the effects of diabetic complications. journal of endocrinological investigation, 28(10), 683-691. smith, d. w. (2004). the population perspective on quality of life among americans with diabetes. quality of life research, 13(8), 1391-1400. vigneshwaran, e., padmanabhareddy, y., devanna, n., & alvarez-uria, g. (2013). gender differences in health related quality of life of people living with hiv/aids in the era of highly active antiretroviral therapy. north american journal of medical sciences, 5(2), 102. wendy, a., jean, b. (2007): clinical chemistry text book. a laboratory perspective, 1st ed. f. a. davis company. usa. pp 147-155. whoqol group. (1998). development of the world health organization whoqol-bref quality of life assessment. psychological medicine, 28(3), 551-558. microsoft word gjphm-2022 non vitamin k.docx 680 global journal of public health medicine 2022, vol 4, issue 2 gggggglo original research impact of non-vitamin k oral anti-coagulants on warfarin utilisation and nhs budget in uk mohammed ibrahim mohammed aladul1,2*, raymond fitzpatrick3, stephen chapman3 1pharmacy college, department of clinical pharmacy, university of mosul, mosul, iraq 2pharmacy college, ninevah university, mosul, iraq 3school of pharmacy, keele university, newcastle under lyme, uk *corresponding author: m.i.m.aladul@uomosul.edu.iq. abstract introduction: vitamin k anticoagulants were the mainstay prophylaxis of stroke in patients with atrial fibrillation and thromboembolic diseases. non-vitamin k oral anticoagulants were approved for use in uk. to evaluate the impact of the introduction and change in guidelines on the utilisation of newer agents on the prescribing oral anticoagulants in uk. methods: a segmented regression of interrupted time series analysis of the primary care data of oral anticoagulants from england, scotland, northern ireland, and wales between 2001 and 2021. results: the overall utilisation of oral anticoagulants increased from 85.8, 9, 2.8, and 7.3 million defined daily doses in 2001 to 430, 36, 14.1, and 26.5 million defined daily doses in 2021 in england, scotland, northern ireland, and wales respectively. in 2021, the market domination changed from warfarin to apixaban. segmented regression analysis showed that with the change in the national institute for health and care excellence clinical guidance in 2014, the utilisation of vitamin k anticoagulants decreased significantly by 2.39e+07, 1675341, 604863 and 2065009 defined daily doses annually in england, scotland, northern ireland, and wales, respectively. the overall expenditure on oral anticoagulants increased from £16, £1.6, £0.5, and £1.3 million in 2001 to £751, £60, £25, and £44.5 million in 2021 in england, scotland, northern ireland, and wales respectively. conclusion: prescribing oral anticoagulants changed in response to the change in clinical guidance. this suggests that the uk physicians followed evidence-based practice and changed to nonvitamin k oral anticoagulants primarily when recommended by the national institute for health and care excellence. keywords: apixaban, dabigatran, edoxaban, rivaroxaban, warfarin 681 global journal of public health medicine 2022, vol 4, issue 2 gggggglo introduction stroke is the fourth common cause of death in england and wales, the third in scotland and northern ireland, and the second worldwide. in 2020, two-thirds of stroke survivors were discharged with a disability (stroke association, 2018; brain research uk, 2021). atrial fibrillation (af) is a contributing factor in up to 1 in 5 cardioembolic strokes in the uk (bray et al., 2017). despite the national institute for health and care excellence (nice) and international guidance from the european society of cardiology recommendations to prescribe anticoagulants for af patients for secondary prevention of stroke, studies and reports showed that between 2009 and 2015, anticoagulants continue to be underprescribed and about 25% of eligible patients with af do not receive anticoagulant medicines (holt et al., 2012; nice, 2014a; barra & fynn, 2015; rose et al., 2019; ajabnoor et al., 2022). for decades, vitamin k antagonists (vkas), warfarin, phenindione, and acenocoumarol were the only available oral anticoagulants in use in uk (le heuzey et al., 2014). vkas were the mainstay prophylaxis of stroke in patients with atrial fibrillation (af) and thromboembolic diseases, including the treatment of venous thromboembolism (vte) (clayville et al., 2011). warfarin has been the most commonly used vka in the world due to its proven efficacy and low cost. the disadvantages of its use are that warfarin (and other vkas) requires close monitoring of the international normalised ratio (inr) measurements, have a narrow therapeutic index, food and drug interactions, and serious side effects such as bleeding (zirlik, & bode, 2017; morgan et al., 2018). nonvitamin k oral anticoagulants (apixaban, dabigatran, edoxaban, and rivaroxaban) (noacs) are noninferior if not superior alternatives to vkas as prophylaxis of stroke in patients with non-valvular af and have a better safety profile (connollyet al., 2009; granger et al., 2011; patel et al., 2011; giugliano et al., 2013). figure 1 shows the timeline of the market entry and approvals of direct oral anticoagulants. previous research has shown that the uptake of noacs is variable between different countries (le heuzey et al., 2014; loo et al., 2017; morgan et al., 2018). in the uk, new medicines’ marketing authorisation process is regulated by the medicines and healthcare products regulatory agency (mhra). then these licensed medicines are subjected to a further review by nice to ensure their safe and effective use through producing evidence-based guidance (the king’s fund, 2020). for a single medicine, the assessment process by nice would take a year on average. limited number of studies explored whether the market entry of noacs or nice guidance has an impact on the utilisation of these medicines and increases patients’ access to these life-saving medicines. this would provide an insight for initiatives and policymakers about period between medicines’ marketing authorisation and approval in which many strokes can be averted with noacs. the aim of this study is to explore the trends of the utilisation of noacs and the impact of the change in guidelines on the uptake of noacs in england, scotland, northern ireland, and wales. 682 global journal of public health medicine 2022, vol 4, issue 2 gggggglo figure 1: direct oral anticoagulants approval, change in guidelines and market entry in uk (nice, 2012a; 2012b; 2012c; 2013a; 2013b; 2014a; 2014b; 2015a; 2015b; 2015c; 2015d) methods data source the study was a retrospective analysis of primary care use of vkas and noacs (acenocoumarol, apixaban, dabigatran, edoxaban, phenindione, rivaroxaban, and warfarin) in england, scotland, northern ireland, and wales. primary care data on the annual volume and net ingredient cost of medicines for the period between 2001 and 2021 were derived from the national health service (nhs) digital (nhs digital, 2022), public health scotland (public health scotland, 2022), health and social care business services organisation (hsc business services organisation, 2022), nhs wales primary care services (nhs wales primary care services, 2022), for england, scotland, northern ireland, and wales, respectively. these databases provide annual information about medicines prescribed in primary care and dispensed by community pharmacies in these countries. to compare and contrast the volume of utilisation of different medications, the volume of utilisation was converted to defined daily dose (ddd) according to the world health organization (who) index for each medicine. the ddd index was for acenocoumarol 5mg, apixaban 10mg, dabigatran 300mg, edoxaban 60mg, phenindione 100mg, rivaroxaban 20mg and warfarin 7.5mg (who collaborating centre for drug statistics methodology, 2022). the expenditure on these medications was calculated from drug tariff prices, (set out by the department of health and social care). 683 global journal of public health medicine 2022, vol 4, issue 2 gggggglo statistical analysis to explore the impact of the market entry of the noacs and the change in nice guidance that included noacs on the utilisation of vkas in england, scotland, northern ireland and wales, a segmented regression of an interrupted time series analysis was performed using linden method (linden, 2015). the analysis involved two interventions; the first was the market entry of dabigatran and rivaroxaban first in 2009 and apixaban in 2012 on the utilisation of vkas. the second intervention, was the change in nice clinical guidance (cg 180) of af to include dabigatran, rivaroxaban, and apixaban in june 2014 (nice, 2014a) and technology appraisals (ta 327, 335, 341, 354, and 355) in 2015 on the utilisation of vkas and overall utilisation of all oral anticoagulants (oacs) (nice, 2015a; 2015b; 2015c; 2015d). all analyses were performed using stata 13mp software. holt-winters seasonal smoothing approach and prais-winsten ordinary least-squares regression approach were used to adjust for the present seasonality and autocorrelation. results volume of utilisation of oral anticoagulants between 2001 and 2008, the volume of utilisation of vkas (warfarin, phenindione, and acenocoumarol) increased gradually in uk from 85.8, 9, 2.8, and 7.3 million ddd to 126, 12.1, 3.9, and 10.2 million ddd in england, scotland, northern ireland, and wales respectively. warfarin was the most commonly utilised and dominant vka in these countries, and achieved about 99.5 % of the utilised oral anticoagulants during this period. following the market entry of non-vitamin k oral anticoagulants (dabigatran, rivaroxaban, apixaban and edoxaban (figure 1)) and the change in nice guidance to include the utilisation of newly approved oral anticoagulants (noacs) and approval of dabigatran, rivaroxaban, apixaban and edoxaban for stroke prevention in af patient and other indications (in 2014 and 2015), the overall volume of utilisation of oacs increased substantially. the volume of utilisation between 2009 and 2021 tripled to achieve 430, 36, 14.1, and 26.5 million ddd in 2021 in england, scotland, northern ireland, and wales respectively. during this period (2009 -2021) the market share of the oacs changed and warfarin lost market dominance to apixaban in all studied countries; apixaban achieved 40%, 37%, 58%, and 40% in england, scotland, northern ireland, and wales respectively in 2021 (figure 2). changes in oacs utilisation the interrupted time series analysis showed that the trend of utilisation of vkas, between 2001 and 2008, increased significantly by 5884176 ddds (ci 95% 4932809 6835543), 487343 ddds (ci 95% 381368 593319), 160100 ddds (ci 95% 131320 188880) and 444630 ddds (ci 95% 303145 586115) annually in england, scotland, northern ireland and wales, respectively. following the market entry of dabigatran and rivaroxaban in 2009, the level of utilisation of vkas did not change significantly whereas the trend of vkas utilisation did increase (figure 3). following the change in nice clinical guidance for af to include apixaban, dabigatran, edoxaban and rivaroxaban in june 2014, the trend of utilisation of vkas decreased significantly by 2.39e+07 ddds (ci 95% -2.55e+07 -2.23e+07), 1675341 ddds (ci 95% -1851742 -1498941), 604863 ddds (ci 95% -650792 -558933) and 2065009 ddds (ci 95% -2291243 -1838776) annually in england, scotland, northern ireland and wales, respectively. in contrast, the trend of overall utilisation of oral 684 global journal of public health medicine 2022, vol 4, issue 2 gggggglo anticoagulants (vkas plus noacs) increased significantly by 2.17e+07 ddds (ci 95% 1.82e+07 2.52e+07), 2235584 ddds (ci 95% 1990559 – 2480610), 580622 ddds (ci 95% 324270 – 836973) and 789,107 ddds (ci 95% 466,585 – 1,111,629) in england, scotland, northern ireland and wales, respectively (figure 3). expenditure on oral anticoagulants between 2001 and 2008, the expenditure on oacs decreased by 10% 20% in uk from £16, £1.6, £0.5, and £1.3 million sterling pounds to £12.5, £1.45, £0.4, and £1.15 million sterling pounds in england, scotland, northern ireland, and wales respectively, despite the increase in utilisation. in contrast, following the market entry of non-vitamin k oral anticoagulants (dabigatran, rivaroxaban, apixaban and edoxaban (figure 1)) and the change in nice guidance to include the newly approved oral anticoagulants (noacs) and approval of rivaroxaban, apixaban and edoxaban for stroke prevention in af and other indications (in 2014 and 2015), the expenditure on oral anticoagulants increased substantially. the expenditure in 2021 was £751, £60, £25, and £44.5 million sterling pounds in england, scotland, northern ireland, and wales respectively. figure 2: oral anticoagulants utilisation in england, scotland, northern ireland, and wales 685 global journal of public health medicine 2022, vol 4, issue 2 gggggglo figure 3: utilisation of vitamin k anticoagulants versus overall oral anticoagulants in england, scotland, northern ireland, and wales discussion this study showed that the change in nice guidance, rather than the market entry of newer agents (noacs) changed the market of oacs. before the market entry of noacs, three vkas were in the market, however, warfarin was the market dominant. this result was in line with the study by morgan et al., (2018) conducted in australia in which warfarin was the only prescribed anticoagulant before the entry of noacs. mcilmoyle and tran (2018) also found that warfarin dominated the american oacs market. despite the fact that acenocoumarol, phenindione, and warfarin have similar effects on prothrombin time (mccormick et al., 2014), warfarin was the most commonly prescribed vka due to its low price and longer duration of action compared with acenocoumarol and phenindione, therefore, warfarin associated with higher stability of anticoagulation and avoiding factor seven fluctuations (barcellona et al., 1998). clinical commissioning groups within the british national health services (nhs) issued guidelines to reserve acenocoumarol and phenindione for patients who were unable to tolerate warfarin (nhs, 2018). with the market entry of noacs, the uptake of the newer agents was slow and small and warfarin remained the market dominant until 2014-2015 in the studied countries. the uptake of noacs was more evident beyond 2014. this result was in line with a previous english study by loo et al., (2017) and the results of the eorp-af study conducted in nine european countries between 2012 and 2013 which showed that noacs were only prescribed in 8.4% of af patients (van brabandt et al., 2016). the first approved noacs was dabigatran in the mid of 2008 and started to be prescribed in 2009. however, dabigatran appeared to be a less attractive choice for prescribers possibly due to the perceived safety concerns about bleeding. these concerns were further augmented with reports that 686 global journal of public health medicine 2022, vol 4, issue 2 gggggglo indicated the lack of long-term safety, unavailability of antidote, short duration of action that requires twice-daily administration and other side effects like dyspepsia (riva & ageno, 2015). in contrast, rivaroxaban and apixaban gained more traction following the rocket-af and aristotle clinical trials. the longer duration of action of rivaroxaban permits its use in once-daily regimen (bielecki et al., 2018) and apixaban was associated with the least bleeding complications (bonde et al., 2020). this slow uptake of noacs might have been a result of nice guidance and technology appraisals recommended noacs for less common indications like the prevention of venous thromboembolism after total hip or total knee replacement in adults in comparison with the main indication of noacs, atrial fibrillation (af) management, that was licensed in uk in june 2014. subsequent the publication of the clinical guidance (cg 180) in june 2014, which recommended the use of either a noac or a vka for patients with nonvalvular af and an anticoagulant with aspirin (or other antiplatelet) for the prevention of non-valvular af-related stroke, increased the uptake of noacs (nice, 2014a). this was evident with the increased uptake of noacs and decreased utilisation of vkas in all uk nations. among noacs, apixaban and rivaroxaban were the most commonly utilised agents beyond the change in guidance. this result could be attributed to the clinical trials that suggested that apixaban had the most favourable efficacy and safety profile compared to other noacs and vkas (hernandez et al., 2017; vinogradova et al., 2018). these results were further augmented by the results of the segmented regression analysis that indicated that the market entry of noacs did not affect the prescribing pattern of oacs in the uk and suggested that the new agents (noacs) were reserved for selected indications for newly diagnosed patients. the change in nice guidance shifted warfarin from market domination and the use of apixaban and rivaroxaban sharply increased. this increase together with the gradual decrease in the utilisation of warfarin suggested patients switching from older agents to the newer agents. during the covid-19 pandemic, the nhs in uk published clinical guidance recommended switching patients on warfarin to noacs to avoid regular monitoring of the inr and reducing visits to the primary care units during lockdown (england nhs & improvement nhs, 2021; patel et al., 2021). the results of the segmented regression were in line with the study by morgan et al., (2018) which aimed to determine the change in the utilisation of oacs in a sample of the pharmaceutical benefits scheme in australia. they found that the change in the utilisation of oacs was evident following the expansion of the indications of the newer agents to include stroke prevention in af patients. regarding the expenditure on oacs in the uk, before the market entry of noacs, despite the gradual increase in the utilisation of vkas, expenditure decreased by 10-20%. this reduction in the expenditure was attributed to the shifting from prescribing branded agents like (marevan)® to the generic version of warfarin. between 2009 and 2014 the expenditure increased massively due to the increased prescribing of vkas and the also prescribing of the new branded agents which were expensive agents compared with generic warfarin. this study has several limitations. the utilised data were at a gross national level and limited to the primary care setting, therefore, we cannot determine the rate of switching from vkas to noacs and vice versa. the expenditure of oacs was based on the british national formulary (bnf) tariff prices and are not the real paid cost since these prices are subjected to discounts and these data are 687 global journal of public health medicine 2022, vol 4, issue 2 gggggglo considered confidential. on the other hand, the strength of this study includes the time frame of 20 years for four nations and the use of segmented regression of an interrupted time series analysis which is considered a robust quasi-experimental design for a study. conclusion the trend of prescribing ocas was not affected by the introduction of noacs. rather, the trend changed in response to the change in nice clinical guidance. this suggests that the uk physicians followed evidence-based practice and changed to noacs only when strong evidence 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(2017). vitamin k antagonists: relative strengths and weaknesses vs. direct oral anticoagulants for stroke prevention in patients with atrial fibrillation. journal of thrombosis and thrombolysis, 43(3), 365-379. doi: 10.1007/s11239-016-1446-0 microsoft word gjphm-2022systematic review lp.docx 732 global journal of public health medicine 2022, vol 4, issue 2 gggggglo review research community engagement in disaster preparedness during the covid-19 pandemic: a systematic review luca pigozzi james lind institute, rue de la cité 1, 1204 genève, switzerland *corresponding author: l.pigozzi@yahoo.it abstract introduction: preparedness in emergency and disaster management is crucial. in the last decades, community engagement and participation have been playing a key role in disaster preparedness, and during the ongoing covid-19 pandemic, this strategy has been encouraged. this systematic review aims at assessing the role of community engagement in disaster preparedness during the covid-19 pandemic. methods: a systematic review of english articles was performed on pubmed and embase, according to preferred reporting items for systematic reviews and meta-analyses (prisma) checklist and guidelines. studies were included if reporting on the community engagement and participation in disaster preparedness during the covid-19 pandemic. exclusion criteria included titles with not available full text, not in english, or not related to humans. results: eleven papers were examined. all studies were conducted in three continents (asia, africa, and north america). in 63.6% of studies, the objective of the emergency preparedness plans for fighting against covid-19 pandemic included implementing prevention measures against the spread of the pandemic. only in 36.3% of the studies, specific vulnerable groups were the final target of the preparedness plan. the implementation of the community engagement was reached through the use of social media (45.4%), face-to-face talks (36.3%), and electronic surveys and questionnaires (27.2%).conclusion: this systematic review wants to emphasize that the involvement of the communities and their leaders in the decision making processes and in the promotion of prevention of health could help the population in building its resilience and afford the humans and economic losses caused by the covid-19 pandemic. keywords: community engagement, covid-19, emergency preparedness, pandemic 733 global journal of public health medicine 2022, vol 4, issue 2 gggggglo introduction: preparedness and planning represent crucial milestones in disaster management. together with climate change, migration and massive urbanization, the planet has been facing a progressive increase of events related to public health emergencies and natural disasters (iyer et al., 2021). as consequence of that, the populations could be affected by a significant impact in terms of humans’ lives and economic loss, and the outcome aimed by public health is to prevent as much as possible such losses. in order to achieve this, a resilient and robust emergency response is always required. in order to be efficient, any emergency response needs to be delivered timely and to target the most urgent needs of the affected population. in the last two years, the global population has been facing the covid-19 pandemic caused by the sars-cov-2 virus (zhou et al., 2020). this exceptional event has been considered as a major challenge in all the aspects of humans lives. the scientific community had to face this new disease from different angles, including from the global public health perspective. the efficiency of an emergency response always depends on two major factors, which are represented by the quality of the job and efforts during the implementation phase, and the preparedness that should be provided before the emergency starts (qari et al., 2019). indeed, a good and comprehensive preparedness takes in consideration risk assessment, mitigation measures, and prevention strategies for the population at risk. it also considers historical and anecdotal events in the past, as example to outline the most likely scenarios for the development of the public health emergencies. finally, it addresses funds that need to be ready to be mobilized as soon as the emergency triggers, pools of crucial experienced staff, supply stock, and specific trainings. through the preparedness, the response could ensure efficacy and efficiency. a comprehensive and systematic emergency preparedness is crucial in order to mitigate the hazards, implement preventive measures, develop resilience in the population, and promptly activate and deploy an efficient emergency response (khan et al., 2018). over the last decade, community engagement has become a central tenet in public health emergency preparedness. nowadays, the involvement of the exposed population to specific hazards can contribute to disaster preparedness and strengthen community resilience. this strategy has been recognized as a crucial step in the emergency preparedness, and has been enhanced even more during the recent experience of the covid-19 pandemic. indeed, community engagement could explore deeper the specific needs of a population exposed to a risk, according to its specific composition in terms of demography and vulnerabilities. furthermore, community engagement allows also to understand the perception of a particular community about a specific hazard and the coping mechanisms. finally, it allows to explore the capacity of affording stressful times and the resilience of the population at risk (jewett et al., 2021). these findings when added and considered in the risk analysis and assessment could offer additional elements to use during the emergency preparedness phase. 734 global journal of public health medicine 2022, vol 4, issue 2 gggggglo finally, community engagement and the insights that it can offer are considered as milestones in order to obtain a robust and comprehensive emergency preparedness plan. nevertheless, despite community participation in the public health emergency planning has been well established as a crucial step to increase community resilience and raise the ownership of the preparedness and response (ramsbottom et al., 2018), nowadays there is not a recent and comprehensive systematic review on the impact of community engagement in disaster preparedness during the covid-19 pandemic within the scientific literature. the aim of the current study is to offer a systematic overview and the current state of the art about the impact of community engagement and participation within the public health emergency preparedness and planning during the covid-19 pandemic. methods: this study has been conducted according to the preferred reporting items for systematic reviews and meta-analyses (prisma) checklist and guidelines (liberati et al., 2009). the research have been conducted on two electronic databases, represented by pubmed, and embase. moreover, other sources of grey literature have been explored, such as google, the websites of the world health organization (who), the united states federal emergency management agency (fema), and the center for disease control and prevention (cdc). finally, websites and internal documents made available by international medical organizations such as médecins sans frontières (msf), and international committee of the red cross (icrc) have also been screened for inclusion. finally, to ensure a scientific literature saturation, additional references have been screened through a manual search among the cited references from the articles retrieved in the first round of search and in the included studies. this current systematic review includes only studies written in english since the beginning of the covid-19 pandemic up to the present. furthermore, the author included any qualitative and quantitative study related to humans, regardless of aim, and design that reports on the community engagement and participation in disaster preparedness during the covid-19 pandemic. articles for which the full text was not available, was not in english, or was not related to humans represent the exclusion criteria of this study. three groups of keywords have been identified, and all the possible combinations of the keywords from all the groups have been used for the search [table 1]. the author screened all the titles and the abstracts of the identified literature findings and removed the duplicates. literature not complying with the inclusion criteria has been excluded [figure 1]. the core data elements analyzed in this review included geographic location, main objectives of the preparedness plan, specific vulnerabilities and characteristics of the community, role of the community in the preparedness, and ways for implementing the community engagement strategies. 735 global journal of public health medicine 2022, vol 4, issue 2 gggggglo table 1 : keywords used for conduct the research group 1 and group 2 and group 3 public health emergency preparedness community engagement covid-19 or or or public health emergency planning community involvement coronavirus disease 2019 or or or disaster preparedness community participation sars-cov-2 figure 1: selection process for articles included in the study, according to prisma guidelines 736 global journal of public health medicine 2022, vol 4, issue 2 gggggglo results: the search strategy yielded a total of 22,956 references. after exclusion of duplicates, 47 titles were identified for further screening. after applying exclusion criteria, 36 articles were removed. finally, a total of 11 references underwent data extraction [figure 1, table 2]. the reviewed articles represented researches from institutions in 3 different continents. among them, 8 studies were conducted in asia and middle east (2 in china, 2 in singapore, 1 in vietnam, 1 in bangladesh, 1 in oman, and 1 in israel). furthermore, 4 studies were conducted in africa (1 in ethiopia, 1 in democratic republic of congo, 1 in south africa, and 1 in kenya), while 1 study occurred in north america, in particular in the united states [figure 2]. figure 2: global distribution of the studies included in the review 737 global journal of public health medicine 2022, vol 4, issue 2 gggggglo table 2: summary of data extraction for the selected articles article country main objectives of the preparedness specific characteristics of the community role of the community in the preparedness implementation of community engagement brewer et al., 2020 united states to implement covid-19 prevention african american groups linked to catholic churches religious leaders promote preventive measures and raise awareness communication through religious leaders, written manuals, and social media zikargae et al., 2020 ethiopia to implement covid-19 prevention specific vulnerable groups represented by pregnant women and people affected by mental health illness community volunteers and representatives mobilize the communities to increase level of prevention from covid-19 transmission knowledge attitude and practice (kap) survey hope corbin et al., 2021 singapore – kenya – south africa to implement covid-19 prevention, promote behavior change, and disseminate information about how to use face masks general population in kenya and south africa and specific vulnerable group represented by migrant workers in singapore community health workers and volunteers spread information within the target groups and provide trainings training and communication with specific smartphone app in singapore, and face to face communication in kenya ha wong et al., 2020 china to implement covid-19 prevention and to promote lockdown measures general population volunteers raise knowledge on covid-19 transmission, and raise awareness on prevention, specifically on lockdown measures volunteers implemented survey via telephone and on online platform ngoundoung anoko et al., 2020 democratic republic of congo to establish surveillance system for new cases and health promotion on covid-19 general population community leaders are involved in early case detection and contact tracing, following lessons learnt from recent ebola virus outbreak communication through social media, and face to face talks alam et al., 2022 bangladesh to support population with face masks distribution and other goods during lockdown general population share perceptions from the community for central government to provide distribution of masks and other goods for the population in lockdown volunteers implemented through electronic questionnaire and surveys cohen et al., 2020 israel to assess community resilience in ethnic minorities arab minorities within israel enhance the community resilience within vulnerable groups volunteers implemented through electronic questionnaire and surveys al siyabi et al., 2021 oman to implement covid-19 prevention, and to raise awareness on covid-19 general population community health workers raise knowledge on covid-19 transmission and prevention measures communication through social media, and face to face talks yip et al., 2021 singapore to implement covid-19 prevention, and to raise awareness on covid-19 general population enhance community resilience through decision making in planning promote wellness and community networking communication with public statements by moh and social media xuan tran et al., 2020 vietnam to implement covid-19 prevention, and to raise awareness on covid-20 general population develop adaptability for preventive measures, in particular lockdown communication with public statements by moh and social media guo et al., 2022 china to implement covid-19 prevention, and to raise awareness on covid-19 general population community volunteers are involved in enhancing risk perception and behavior change in the community communication through implementation of online survey in the studies included in the review, the most represented objective of the emergency preparedness plans for fighting against covid-19 pandemic included implementing the prevention measures against the spread of the pandemic (63.6% of the studies). in 36.3% of the studies, the objective was represented by raising general awareness about covid-19 disease, transmission, signs and symptoms, and behavior changes to prevent the infection. other specific objectives were represented by promoting lockdown measures and behavior changes, providing trainings on the correct use of face 738 global journal of public health medicine 2022, vol 4, issue 2 gggggglo masks, establishing surveillance and contact tracing systems within the community, and assessing the community resilience. in 72.7% of the studies, the preparedness plan and the involvement of the community were addressed to the general population, as no specific vulnerable groups were specified as target of the emergency plan. only in 4 studies (36.3%), the efforts in terms of community engagement and the implementation of the emergency preparedness plan were addressed to specific groups, represented by religious minorities, ethnic minorities, and vulnerable groups from either economic or health reasons. the role of the communities in implementing the preparedness plans was represented by health promotion and awareness rise about covid-19 in 72.7% of the included studies. in the other studies, the role of the community was related to setup a community-based surveillance system, to increase community resilience, and to provide trainings on the correct use of face masks. finally, the implementation of the community engagement was reached through the use of social media (45.4%), face-to-face talks (36.3%), and electronic surveys and questionnaires (27.2%). in one case, a “knowledge attitude – practice” (kap) survey was implemented. discussion: community involvement and its participation in public health emergency preparedness represent a fundamental step for reaching a comprehensive and efficient preparedness plan. several examples in the past showed the benefits of empowering the communities, through the direct involvement of their leaders and representatives in the decision process and in the dissemination of information within the population. such strategy could become crucial in particular in natural disasters and outbreaks, where the population needs clear guidance and leadership, and the effects of the emergency are detrimental. these could significantly help in promoting health and preventing additional casualties or infections in case of communicable diseases [ludin et al., 2019; hugelius et al., 2019]. the covid-19 pandemic also considered since the beginning communication, dissemination of information and community participation as crucial, in order to prevent the spread of the disease and to build community resilience. the who also defined community engagement as one of the pillars of the public health interventions to manage covid-19. it is important to remember that covid-19 has been happening when the speed and the quantity of the information are incredibly high, and few control could be made in terms of quality (moscadelli et al., 2020). therefore, in times when the people are confused and disoriented and the information can’t be always reliable, the support of a strong community through its leaders is the key to build trust and resilience among the population, and protect the most vulnerable groups within it. around the world, the perception of community and the setup of its hierarchies and unwritten rules are dependent on the historical and cultural background. therefore, it is not surprising that among all the studies included in the current review, only one have been developed in the western world. in the 739 global journal of public health medicine 2022, vol 4, issue 2 gggggglo current western world, the sense of community and public participation have been reducing significantly over time. the societies in these countries are more and more victims of huge urbanization, which leads inevitably to individualism and social isolation. in asia, middle east, and africa (nyirenda et al., 2020), the participation of the individuals within the community is still very active. also the healthcare system in these continents have a strong community component represented by the presence of social healthcare workers. most of the times these figures are represented by volunteers and they are able to promote health and implement prevention measures. this setup might represent a key of success in fighting against the covid-19 pandemic, and the studies included in this review are supporting this. since the beginning of the pandemic, some clear vulnerabilities related to previous conditions have been well established. furthermore, the strict preventive measures like the lockdown have reduced the economic growth, leading to a significant reduction of people’s movements and more direct or indirect poverty. the protection of specific health, social and economic vulnerabilities should be considered as one of the duties of a resilient community. nevertheless, only few studies included in the review could focus on health, social or economic minorities in the emergency preparedness planning, and in 63.7% of the cases, all the efforts were addressed for the whole population. this choice might be explained by the fact that covid-19 has been an event that encompasses all the individuals on the planet and makes the whole humanity so vulnerable, regardless the pre-existing health, social, and economic conditions. in the last decades, the humanity didn’t face such a global burden, that has been causing significant humans and economic losses, and finally all the human beings are vulnerable in front of covid-19. in this sense, a strong community participation in the emergency preparedness could definitely target the entire population, as covid-19 has been creating vulnerabilities and weaknesses among the entire global population. among the implementing models for community engagement, the most used one within the selected studies was represented by social media. indeed, in the last two decades, social media have been entering in the daily life all around the world. nowadays social media represent the fastest way to spread information around the world, including about health (o’reilly et al., 2019). nevertheless, social media could spread a significant quantity of information and not always reliable and true. therefore, the presence of community volunteers who could manage the flow of information through the social media and streamline them towards their community is an asset for building community trust among the population. conclusion: in conclusion, community engagement and its involvement in the emergency preparedness represent a cornerstone in disaster management discipline. in the last decades, this new approach has been representing an additional crucial element in public health strategies development. indeed, together with the concept of person-cantered care, community engagement represents the new revolutionary way to interpret medicine. 740 global journal of public health medicine 2022, vol 4, issue 2 gggggglo the modern social and economic world has been progressively getting the direction of the globalization. the old concept of regional public health has been challenged in the last decades, and progressively new concepts of “global public health” and “one health” have been raised. however, despite the diseases, including covid-19, have become globally relevant for the humans’ health, public health has been able to keep a significant regional and territorial footprint. the progressive importance get by community engagement around the world supports this. the recent covid-19 pandemic could be considered as one of the most important global public health emergencies in the history of the humanity. indeed, a gradual recent increase of natural disasters caused by the climate change, biodiversity loss and massive urbanization have been impacting the planet. several communities, in particular within the western world, were completely unprepared to afford such crisis that rapidly affected humans’ health and the economic and social life of the people. it is important to remember that within these populations, the communities don’t actively participate to emergency preparedness. in facts, no studies have been produced in the last two years in this topic during the covid-19 pandemic. this lack in the social and public health system could have get an additional impact in the effects of covid-19 on these populations. therefore, despite the who recommendations to engage at community level in order to implement preparedness and response to the covid-19 pandemic, few studies have been published around the world, and even fewer within the western world. this systematic review wants to call for a more efficient implementation of 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(2020) covid-19 in ethiopia: assessment of how the ethiopian government has executed administrative actions and managed risk communications and community engagement. risk manag healthc policy. 13: 2803-2810 microsoft word gjphm-2022smart phone copy.docx 690 global journal of public health medicine 2022, vol 4, issue 2 gggggglo original research does smartphone addiction affect social interaction among families in baghdad city? maryam aayd ismail , iman abbas fadhil , jaafar adnan hanoon , jinan kamil murhesh college of nursing, al-bayan university, baghdad ,iraq. *corresponding author: maryam.a@albayan.edu.iq abstract introduction: technology has completely transformed communication and the way people interact with each other. the development of smartphones may provide some insight into this. despite being user-friendly, smartphones can be harmful to a user's health if they are used compulsively. family members who have easy access to smartphones may develop smartphone addiction (sa), which could harm their social interactions. the objective is to identify the effects of using smartphones on social interaction among families. and find out the association between smartphone addiction and family interaction. methods: the study was ascertained the impact of smartphone addiction on social interaction between families in baghdad. using a quantitative approach, the study's pertinent data were collected, a non-probability (purposive) sample of 484 smartphone-using family members, whose ages vary from 11 to 55. a questionnaire met the objectives of the study. information about demographics is covered in part i. for part ii: adopted scale addresses smartphone addiction part iii serves as a gauge for mattick and clarke's family members' social interaction anxiety. results: show that 47.7% of the study sample have a moderate smartphone addiction, and 61% of them have anxiety about social interaction. then, there is a relationship between smartphone addiction and anxiety about social interaction in (0.00 p-value). conclusion: most of the family members experienced moderate smartphone addiction and anxiety about social interactions. to avoid potential problems, it is crucial to keep an eye on the social interaction of family members. keywords: smart phone addiction, social interaction, families interaction, family members 691 global journal of public health medicine 2022, vol 4, issue 2 gggggglo introduction: to address the demands of most mobile customers, mobile technology leaders, such as device makers and app/service developers, are competing for their attention. anyone can make calls and send emails (alijomaa et al., 2016) (taneja, 2014). according to the findings, cell phones, especially those used by adolescents, encourage behavioral problems and diseases (elsobeihi & abu naser, 2017). this fact has become increasingly clear in the communications media, giving rise to new pathologies like "nomophobia" (no-mobile-phobia), "fomo" (fear of missing out) — the fear of being without a cell phone, disconnected from the internet, "text aphrenia" and "ringxiety" — the false sense of having received a text message or call that causes constant checking of the device, and "textiety" — the anxiety (venkatesh, 2017), (chesley, 2005). harm, persistent disruptions to one's physical, mental, social, occupational, or familial life, and a preference for using a cell phone over face-to-face communication, brief consultations regularly for insomnia and sleep difficulties (sansone & sansone, 2013). excessive use, neediness, abstinence, tolerance, dependency, difficulties in control, yearning, and increased use to relieve stress or offset a depressive state are all signs of addiction (hooper & zhou, 2007), they want to stay connected, anger or a sense of being lost while away from a phone, or anxiety when sending and viewing messages when unable to use one (choliz, 2012), (procentese et al., 2019). it is evident that the technology used in the home influences how families interact. families frequently use technology; for instance, the average american family has five internet-connected devices (lin et al, 2014), (demirci et al., 2015). although using technology together to watch television or play video games could bring families closer (hooper & zhou, 2007). devices may potentially interfere with or interrupt parent-child interactions. studies have found that 73% of parents used their phones while spending time with their kids in a restaurant (padilla-walker et al., 2012), while taking their child to the park, 35% of caregivers spent one out of every five minutes (or more) on their phone (radesky et al., 2014). during playtime with their young child, 66% of mothers indicated that technology interfered with their parent-child connections. some people worry that the rise in child injuries may be related to parent smartphone use (hiniker et al, 2014), (elsobeihi & abu naser, 2017). overuse of smartphones can also cause social anxiety, which is the fear of being around other people in social circumstances. according to research by (elsobeihi & abu naser, 2017), (venkatesh, 2017), excessive smartphone use can hurt relationships, academic performance, and real-world social contact. university students constitute an excellent representative study sample because it is obvious that addictive behaviours and substance misuse typically begin during young adulthood and youth (jeong & lee, 2015). in a study of 189 dentistry students in saudi arabia, it was discovered that those with sa had higher body mass indices (bmi), lower levels of physical exercise, and higher levels of stress. in the practice of dentistry, effective doctor-patient communication is essential for developing a therapeutic doctor-patient relationship and for providing high-quality medical treatment (mattick & clarke, 1997), (long et al, 2016). 692 global journal of public health medicine 2022, vol 4, issue 2 gggggglo we conducted this study among iraqi society, specifically in baghdad. to get rid of the problems associated with smartphone addiction to the bodies, minds, feelings of society. in this study, we targeted families to learn about social media and its relation to social interaction. research objectives were to identify the effects of using smartphones on social interaction among families. to find the relationship between smartphone addiction and families interaction and to measure the effect of smartphone addiction among family members. methods: a cross sectional design was used the period from january (2021) to july (2021). a purposive (nonprobability) sample of (484) of family members in baghdad. the included participant family members (fathers, mothers, brothers or sisters), could read and write to fill the study instrument. the excluded participants were the people who could not read and write. the dependent variable is the family's social interaction, while the independent variables are (smartphone addiction, age, gender, academic achievement, and work). data are analyzed by using spss (statistical package for social sciences) version (20) application and excel. the researcher use: (frequency and percentage, mean and chisquare) to analyze the data. based on an anticipated effect size of 0.15, a designed statistical power of 0.95, predictors, and a probability level of 0.05, the minimum required sample size would be 227. by considering an attrition rate of 20%, it would be 45. so, the recommended sample size would be 272. the final sample size is 484. to achieve the research objectives, a questionnaire was composed of four parts, the first part includes demographic data (age, gender, academic achievement, work). the second part is the part related to the axis of using social networking sites, as it includes several points, including if he uses social media sites daily, usually, or at all. and the number of hours we use each day. and the feeling when not using social networking sites. the third part is deals with smartphone use, as it includes several paragraphs specialized in -smartphone addiction and from (kim et al., 2016) the total score of the scale is 72 and it divided to three categories (mild=0-24, moderate=25-48 and sever49-72). the fourth part is about social interaction anxiety conducted from (mattick, and clarke, 1998), this part specializes in social issues among members of society, the total score of the scale is 60 and it divided to three categories (mild=0-20, moderate=21-40 and sever41-60). the study approved by al-bayan university for completing the research by the number (con-he-004). 693 global journal of public health medicine 2022, vol 4, issue 2 gggggglo results: table 1. distribution of sample demographic variables characteristics n % study sample father 99 20.5 mother 55 11.4 son 200 41.3 daughter 130 26.9 age 16-30 years old 378 78.1 31-46 years old 75 15.5 47-60 years old 31 6.4 educational level primary 19 3.9 secondary 247 51.0 bachelors degree 195 40.3 higher education 23 4.8 work not work 42 8.7 student 190 39.3 employer 133 27.5 earner 93 19.2 retired 5 1.0 housewife 21 4.3 total 484 100.0 this table shows that most of the sample was between the ages of (16-30) and, also showed the educational level was a secondary school (51%) and bachelor (40%). the highest age category (16-30 year) 78.1% and most of study samples either students 39.3% or employer 27.5%. table 2: distribution of sample according to mobile phone use variables characteristics n % daily use always 297 61.4 sometimes 153 31.6 never 34 7.0 total 484 100.0 hours of use less than 1 hour 51 10.5 1-3 hours 157 32.4 4-6 hours 117 24.5 more than 6 hours 159 32.9 total 484 100.0 no feelings 167 34.5 694 global journal of public health medicine 2022, vol 4, issue 2 gggggglo feelings without using mobile phone stress 20 4.1 sad 10 2.1 calm 54 11.2 boring 233 48.1 total 484 100.0 table (2) shows that most of people use their smartphones every day 61.4% for more than 6 hours 32.4% because they are bored 48.1%. table 3: distribution of smart phone addiction among study sample characteristics n % smartphone addiction mild 134 27.7 moderate 231 47.7 sever 119 24.6 total 484 100.0 this table shows that most of sample have smartphone addiction symptoms to a moderate degree. table 4: distribution of social interaction anxiety among families characteristics n % social interaction low 139 28.7 moderate 295 61.0 high 50 10.3 total 484 100.0 this table shows that most of sample have social interaction anxiety to a moderate degree. table 5: relationship between smartphone addiction and social interaction anxiety scale: smartphone addiction social interaction anxiety mild moderate sever value df significance (p≥0.05) low moderate high 56 62 21 68 152 75 10 17 23 28.967 4 <0.001* *significant level at p value <0.05 table (5) mention the relationship between social communication and addiction in (p value≥ 0.001) in ch-square test. 695 global journal of public health medicine 2022, vol 4, issue 2 gggggglo discussion: the process of reciprocal influence people exercise over one another during social encounters is known as social interaction. it usually refers to face-to-face concurrence, where participants are in close proximity to one another for a certain amount of time. the introduction of smartphones, however, has fundamentally altered how we acquire information, manage our time, and interact with others, which may have important behavioral and social ramifications (kim et al, 2016) (jones, 2014). the main findings of this study are as follows: first, the majority of the study sample were between age (16-30) years old. this ratio is similar to the researcher (elsobeihi & abu naser, 2017) also showed the educational level for the majority of study samples was between secondary school and bachelor level, and the highest number of family members in the study sample were sons and then daughters and fathers. also, the work of most of the study samples were either employers or students. the second section showed that most people use their smartphones every day for more than 6 hours because they feel bored. after that, we notice that the majority of the sample have smartphone addiction signs and symptoms in a moderate degree, and this result similar to the researcher (mcdaniel & coyne, 2016), (jones, 2014). in the same part, there are table four is showing a moderate degree of social interaction anxiety among study sample families. the last part shows the relationship between social interaction and smartphone addiction for family members, this similar to (krishna et al, 2019) that mention smartphone addiction proneness scale had significantly higher odds with social interaction anxiety. family members overuse of smartphone causes a lack of social interaction between them. the world and society have become dependent on the smartphone in managing many businesses, some people run their work from home, and students, especially in the time of coronavirus pandemic. in addition, some mothers and children use the smartphone for games and entertainment. conclusion according to the study, social anxiety was highly prevalent among family members who used smartphones for social media. the current study thus provided evidence in favor of the claim that sa influences family members' social interaction anxiety. finding the detrimental psychological impacts of compulsive smartphone use is quite helpful, especially in the world of today. ask someone to set an alarm with instructions on how often to check their smartphone is the first and most fundamental action that can be advised to minimiz smartphone usage. when the alarm goes off, they should spend one minute reviewing all notifications before restarting the timer. however, the findings of this study also offer practical advice to those who have little social interaction in their daily lives, i.e.. they should refrain from using their phones during serious interactions and should use them when they are alone. 696 global journal of public health medicine 2022, vol 4, issue 2 gggggglo conflicts of interest the author declares no conflicts of interest. references • alijomaa s.s., qudah m.f.f.and albursan i.s., (2016). smartphone addiction among university students in the light of some variables. computers in human behavior, 61: 155-164. • chesley n., (2005), blurring boundaries linking technology use, spillover, individual distress and family satisfaction. j. marriage fam.,67: 1237-48. • choi j, rho mj, kim y, yook ih, yu h, kim dj, et al., (2017) smartphone dependence classification using tensor factorization. plos one.;12(6):e0177629. • choi j, rho mj, kim y, yook ih, yu h, kim dj, et al., (2017), smartphone dependence classification using tensor factorization. plos one.;12(6):e0177629 • choliz m., (2012), mobile-phone addiction in adolescence: the test of mobile phone dependence (tmd). prog. health. sci. ,, 2: 33-44. • demirci k, akgonul 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health.;2:2–8. microsoft word gjphm-2020kap medicine_latest24082020.docx 235 global journal of public health medicine 2020, vol 2, issue 2 gggggglo original article knowledge, attitude and practice of unregistered medicines among patients with chronic disease at urban health clinic, kelantan, malaysia haniff mohd nawi1,4, mohd afiq arifin1,5, mohd rohaizat hassan1, azmawati mohammed nawi1, izamin idris2 & hasanain faisal ghazi 3 1department of community health, faculty of medicine, universiti kebangsaan malaysia, cheras kuala lumpur, malaysia. 2kota bharu district health office, kelantan state health department, kota bharu, kelantan, malaysia 3international medical school, management and science university, malaysia 4pharmaceutical care section, pharmacy practice & development division, pharmaceutical services programme, ministry of health malaysia 5pharmaceutical services division, kelantan state health department, kota bharu, kelantan, malaysia corresponding author: rohaizat@ppukm.ukm.edu.my abstract introduction: products registered with the national pharmaceutical regulatory agency (npra) have two main features: mal registration number and meditag™ hologram sticker. both of these features need to be displayed on each pack of drug sales. missing either one or both above features consider as unregistered medicines. this study aims to determine the prevalence and factors associated with knowledge, attitude and practice of unregistered medicines usage among patients with chronic disease attending klinik kesihatan bandar kota bharu, kelantan. methods: a cross-sectional study involving 108 respondents using convenient sampling was conducted at the outpatient unit of klinik kesihatan bandar kota bharu, kelantan, malaysia, from june 2019 to july 2019. results: the prevalence of unregistered medicines usage was 15.7%. although the respondents had good knowledge about unregistered medicines. more than half (64.8%) of respondents have good knowledge of unregistered knowledge and 91.7% of respondents have negative attitude towards unregistered medicines. factors associated with practice of unregistered medicines use is found to be level of education and perceived of health believe. lower education and perceived benefit of unregistered medicines 4 times and 12 times more likely to take unregistered medicines respectively compare to higher education level and perceived no health benefit. conclusion: in conclusion, prevalence of unregistered medicines usage was 15.7%. more than half (64.8%) of the respondents were categorized as having good knowledge. we need to strengthen our education program to modify patient's belief on the non-benefit using unregistered medicines. keywords: unregistered medicines, chronic diseases, kap, malaysia 236 global journal of public health medicine 2020, vol 2, issue 2 gggggglo introduction: according to know your medicine booklet (ministry of health 2016a) chemical substances that are used to prevent, control and treat diseases are medicines. at best, a fake medicine will do nothing to relieve a patient’s condition: at worst, a fake medicine contain toxins such as arsenic or anti-freeze can kill (liu & lundin 2016). yet fake medicines are a booming global trade. the growth in counterfeit medications is a significant public health issue. these products were produced and marketed as equivalents to the regulated versions of the medications they represent. however, it can cause an inadequate therapeutic response or contribute to mortality and morbidity among those who use these medications. in protecting and preserving the people’s health, all medications either pharmaceuticals or traditional medicines can be imported, manufactured or sold in malaysia, provided it must first be registered with the drug control authority (dca), ministry of health malaysia. the objective of product registration is to ensure safety, efficacy and quality, while the traditional products have been evaluated and tested for safety and quality (ismail 2017). a definition of registered and unregistered medicines is quite confusing and interchangeable at the beginning. world health organization (who) provided 60 countries (including malaysia) to give feedback regarding their use of the term “counterfeit drugs” and majority of these countries use “counterfeit” (34) in their national legislation. others used “falsified”, “illicit “illegal”, “unregistered”, “unauthorized” and “adulterated” (sabine 2009). in malaysia, there is no precise definition of counterfeit drugs in malaysian law, but in the sale of drug act (soda) 1952 there are specific provision under regulation 7(1) (a), 7(1a) (a-g) control of drugs and cosmetics regulations (cdcr) 1984 which requires all medicinal products to be registered with national pharmaceutical control bureau (npcb) of the ministry of health (moh) before entering the market and follow a process which requires stringent evaluation and final approval by the drug control authorities (dca). after the medicinal products have gone through all the requirements it is known as registered medicines or registered products. according to ismail (2017) a registered medicine is a medicine which has been evaluated, tested and proven to be of quality, effective and safe and approved by the dca and can be sold or used by consumers in malaysia. in this study the term unregistered medicines were used. in malaysia, unregistered medicines are illegal to be in the market. according to annual report 2012 by enforcement pharmacy, there is an increasing trend in the number of raids since 2010 till 2012. raid amount of seized unregistered medicine has achieved up to rm27 million per year was reported (ministry of health 2012). zulkifli et al. (2015) stated that there is a high possibility of increasing trend in the seized value year by year and the pharmacy programme annual report 2016 proved it (ministry of health 2016b). unregistered medicines are dangerous and considered threat to public health and 237 global journal of public health medicine 2020, vol 2, issue 2 gggggglo safety around the world (furman-assaf et al. 2010). with the growing unregistered medicines in the market and the lack of stringent enforcement (zulkifli et al. 2016b), more patients with chronic diseases are susceptible to unregistered medicines. this study is designed to determine the prevalence and factors associated with knowledge, attitude and practice of unregistered medicines use among patients with chronic disease attending klinik kesihatan bandar kota bharu, kelantan and provide the suggestions for the current policy and what needs to be done in combating unregistered medicines in malaysia. methods: study design and population a cross-sectional study using validated questionnaire involving patients with chronic disease receiving treatment in the outpatient clinic klinik kesihatan bandar kota bharu was conducted for 60 days from june 2019 to july 2019. the study was approved ministry of health nmmr (nmrr-19-1570-48485 iir) and review board and ethics committee of ukm (ff-2019-328). kish l (1965) formula was used to calculate the sample size. the prevalence used in the calculation was set at 0.052, obtained from the report by steven and mydin (2013) where fake medicine use is prevalent in 5.2% of the study population. using this formula, the sample size is calculated to be 73. an additional 20% was added as buffer for rejection and/or incomplete data. the final sample size needed to conduct this study was determined as 100. the sampling population was all registered patients who have an appointment at the date of the study and the sampling frame was generated from the patient’s appointment list the day before. convenient sampling was employed in this study. the inclusion criteria was any malaysian aged 18 years old and above and diagnosed of chronic diseases attending outpatient clinic klinik kesihatan bandar kota. patients who could not understand malay or english were excluded from the study as well as patients who did not consent to be interviewed. also excluded were patients who were diagnosed with active psychiatric conditions and unable to give informed consent. those who did not meet any of those criteria were excluded from the study. development of questionnaire the questionnaire was adapted from previous studies. patients were interviewed face-to-face using this questionnaire by the investigator. other than that, details regarding patient’s medical conditions and treatments were obtained from their medical records. the questionnaire comprised of four parts. part a obtained the demographic characteristics of the respondents. patient’s medical conditions were also collected, and patients were asked to rate their health status based on these categories (very poor, poor, fair, good, very good). part b was designed to evaluate knowledge of unregistered medicines by answering seven questions relating to medicines and unregistered medicines in malaysia. three options are provided for 238 global journal of public health medicine 2020, vol 2, issue 2 gggggglo answer based on 'yes', 'no' and 'not sure'. part c of the questionnaire consisted of 10 statements to evaluate their attitude towards unregistered medicines. based on a 5-point likert scale, with 1 denoting extremely disagree and 5 denoting extremely agree, patients were required to select the option that most represent their thoughts on the statements in the section. the maximum score a patient can get was 50 whereas the minimum score was 10. part d was designed to evaluate the practice of unregistered medicines by answering 11 questions. patient’s use of unregistered medicine was measured in the first two questions and the remaining 9 questions were designed to explore how unregistered medicines were used and the environmental factors that influence patients’ unregistered use. the questionnaire was solely designed in malay (the national language of malaysia). face and content validation of the questionnaire was done by is senior principal assistant director and principal assistant director in enforcement division, kelantan state health department. a pre-test was conducted to ensure construct validity of the questionnaire after experts have ensured its content validity. the questionnaire was pretested among 53 patients with chronic diseases attending the outpatient unit at klinik kesihatan wakaf che yeh which was still within kota bharu district approximately 7km from the actual study site. eligible respondents were approached and face-to-face interviews using the questionnaire were conducted after consent were obtained. apart from answering the questions, respondents were also asked regarding their opinion on the questionnaire. consequently, the same interviewer conducted the interview of main study in klinik kesihatan bandar kota bharu. the respondents who participated in the pre-test were excluded in the main study. cronbach's alpha for section c that measure attitude was 0.825. reliability testing was conducted for the attitude’s responses from the pilot test. the results showed internal consistency of the items tested with the cronbach’s α value of 0.76. data analysis upon return of the completed questionnaires, raw data were processed and uploaded into statistical package for social sciences (spss) software version 23.0 for data analysis until the end of the study period or the number of samples required was achieved. at the end of the study, computer assisted analysis was carried out. descriptive analysis is used to summarize the data accordingly (frequency and percentage, mean and standard deviation). bivariate analysis was conducted (chi-square) to determine the association between the independent variables and the use of unregistered medicines. multivariate analysis was also conducted to detect and control any confounders. results: a total of 108 respondents from the outpatient unit of klinik kesihatan bandar kota bharu, kelantan completed the questionnaire given throughout the study. a summary of the demography of respondents is seen in table 1. all respondents recruited were almost equal balance between male and female. there is wide range of age among the respondents, with the youngest being 24 years old and the oldest 239 global journal of public health medicine 2020, vol 2, issue 2 gggggglo being 80 years old. according to dosm, our study includes 79.6% of respondents that is within the age of working group (£ 64 years old). a total of 86.1% (n= 93) respondents were malay, making up majority of the respondents in the study. non-malay races includes 9.3% (n= 10) chinese respondents, 4.6% (n= 5) indian. more than half of the respondents were married (80.6%), 4.6% single, 3.7% divorced and 11.1% widowed. table 1 respondent profile variable n (%) gender male 52(48.1) female 56(51.9) age (in years) (mean ±sd) 55.99 ±9.996 age £64 86(79.6) 65 and above 22(20.4) race malay 93(86.1) chinese 10(9.3) indian 5(4.6) others 0(0) marital status married 87(80.6) single 5(4.6) divorced 4(3.7) widow 12(11.1) education no formal education 1(0.9) primary 5(4.6) secondary 58(53.7) diploma/certificate 27(25.0) degree 15(13.9) postgraduate degree 2(1.9) work sector government 36(33.3) private 11(10.2) self-employed 21(19.4) pensioner 26(24.1) not working 2(1.9) housewife 12(11.1) student 0(0) household income per month (rm) (mean ±sd) 3774.07±4165.17 household income per month £rm3079 69(63.9) rm3080 and above 39(36.1) diseases diabetes mellitus 64(59.3) hypertension 87(80.6) 240 global journal of public health medicine 2020, vol 2, issue 2 gggggglo dyslipidemia 25(23.1) renal disease 3(2.8) ischaemic heart disease 0(0) osteoarthritis/osteoporosis 4(3.7) stroke 1(0.9) copd 0(0) heart failure 1(0.9) gout 2(1.9) cancer 0(0) others 5(4.6) morbidity single morbidity 46(42.6) multiple morbidity 62(57.4) duration of disease (years) (mean ±sd) 7.08±5.898 duration of disease (years) <15 99(91.7) ≥15 9(8.3) self-perceived health status good 97(89.8) poor 11(10.2) table 2 association between sociodemographic / socioeconomic and practice of unregistered medicines use among chronic patients variable unregistered medicines user, n (%) unregistered medicines non-user, n (%) x2 pvalue gender male 10(19.2) 42(80.8) 0.921 0.337 female 7(12.5) 49(87.5) age £ 64 13(15.1) 73(84.9) 0.001a 0.981a 64 and above 4(18.2) 18(81.8) race malay 16(17.2) 77(82.8) 0.433a 0.511a non-malay 1(6.7) 14(93.3) marital status married 12(13.8) 75(86.2) 0.636a 0.425a unmarried 5(23.8) 16(76.2) education higher education 4(9.1) 40(90.9) 2.476 0.116 lower education 13(20.3) 51(79.7) work sector employed 10(14.7) 58(85.3) 0.148 0.700 unemployed 7(17.5) 33(82.5) household income per month group b40 13(18.8) 56(81.2) 1.384 0.239 non group b40 4(10.3) 35(89.7) 241 global journal of public health medicine 2020, vol 2, issue 2 gggggglo morbidity single morbidity 5(10.9) 41(89.1) 1.434 0.231 multiple morbidity 12(19.4 50(80.6) duration of disease (years) <15 3(27.3) 8(72.7) 0.451a 0.502a ≥15 14(14.4) 83(85.6) self-perceived health status good 16(16.5) 81(83.5) 0.041a 0.840a poor 1(9.1) 10(90.9) knowledge toward unregistered medicine good ≥4 8(11.4) 62(88.6) 2.789 0.095 poor <3 9(23.7) 29(76.3) attitude toward unregistered medicine good attitude ≥30 15(15.2) 84(84.8) 0.006a 0.937a poor attitude <30 2(22.7) 7(77.8) perceived benefit of unregistered medicine no benefit 11(11.5) 85(88.5) 9.217a 0.002a* benefit 6(50.0) 6(50.0) perceived safety of unregistered medicine safe 3(50.0) 3(50.0) 3.220a 0.073a not safe 14(13.7) 88(86.3) in terms of education, majority of the respondents in this study completed (53.7%) their mandatory education and only 5.5% (n= 6) did not. among those who pursued their tertiary education, certificate/diploma holders comprised the most numbers (25.0%). in accordance with high participation of respondents among the younger age group, most of them were employed (62.9%), with 33.3% (n= 36) working in the public sector and 10.2% working in the private sector. respondent’s monthly household income median were rm 3774.07±4165.17. there is notable wide range of monthly household income. the lowest income is rm300.00 while the highest is rm26,000.00. more than half (57.4%) of respondents suffer from at least two chronic diseases whereas 42.6% (n= 46) of respondents are diagnosed with only single morbidity. the most diagnosed diseases obtained were hypertension (80.6%) and diabetes mellitus type-2 (59.3%). the duration of disease is calculated from the date of diagnosis, giving a median of 7.08 years ±5.898. almost all (89.8%) of respondents perceive their health to be good and their diseases were well-managed. table 2 shows summary of bivariate analysis regarding association between sociodemographic / socioeconomic and practice of unregistered medicines among chronic patients. among the many sociodemographic / socioeconomic factors measured, only perceived benefit of unregistered medicine is significant. 242 global journal of public health medicine 2020, vol 2, issue 2 gggggglo bivariate analysis is conducted to identify factors associated with practice of unregistered medicines use. bivariate analysis reveals only perceived benefit of unregistered medicine and perceived safety of unregistered medicine be statistically significant between user and nonuser. prior to conducting multiple logistic regression, all variables are run through simple logistic regression with ‘enter’ method. multiple logistic regression is then conducted using ‘forward lr’ and ‘backward lr’ method. factors associated with unregistered medicines use simple logistic regression reveals only perceived benefit of unregistered medicine (p=0.003), and perceived safety of unregistered medicine (p= 0.042) to be statistically significant. table 3 show summary of factors associated with unregistered medicine use using multiple logistic regression. table 3 factors influencing unregistered medicines use among chronic patients based on multivariate analysis variable crude or (95% ci) adjusted or (95% ci) x 2(df) pvalue education level (1) 0.392 (0.119,1.296) 0.226 (0.054,0.948) 4.131(1) 0.042 perceived benefit of unregistered medicine (1) 0.129 (0.035,0.472) 0.079 (0.018,0.360) 10.798(1) 0.001 lower education [wald: x2(df=1,n=1080=4.131,p<0.05;or=0.226] and perceived health benefit of unregistered medicines [wald: x2 (df=1,n=108)=10.798, p<0.05;or=0.079] increased the risk of using unregistered medicines by 77.4% and 92.1%, respectively. gender, age, race, marital status, employment status, income, morbidities, duration of disease, self-perceived health status, knowledge on unregistered medicines and perceived safety of unregistered medicine all result in pvalue of more than 0.05, thus no association can be proven between these variables and unregistered medicine use. discussion: the prevalence of unregistered medicines use among patients with chronic disease attending outpatient clinic at klinik kesihatan bandar kota bharu was found to be 15.7%. compared to the prevalence of unregistered medicines in malaysia, our finding was considerably larger. steven and mydin (2013) found that the prevalence of unregistered medicine in malaysia is 5.2%. the state prevalence is higher that than the national because kelantan is more prone to medicine trafficking due to the nearby border of malaysia and thailand. carolyn nordstrom (2007) in her book discusses various forms of border crossings between legal and illegal space, including smuggling of medicines. this article may suggest that, the easy availability of 243 global journal of public health medicine 2020, vol 2, issue 2 gggggglo unregistered medicines may increase the prevalence. however, more specific study should be done to dig in more accurate reason for this prevalence. the declaration of the regulation of drugs and cosmetics in june 1984 marked the beginning of a regulatory era in malaysia. this sets the necessary benchmarks for the development of a more systematic system of pharmaceutical regimes in malaysia. in january 1985, the drug control authority (npra) was established chaired by the director general of health malaysia with the aim of ensuring the quality, safety and effectiveness of pharmaceutical products before being marketed in malaysia. to achieve this goal, the drug control authority (un) through a national pharmaceutical control agency (npra) secretariat carries out regulatory functions such as product registration, sample analysis, inspection and licensing, post-marketing monitoring and monitoring of drug side effects. control over the sales of pharmaceutical products was started in 1985 with the first phase of registration for product containing poison listed in the poisons act 1952. the enforcement of registrations was then continued with non-poison products (otc) in 1988, traditional medicinal products in 1992 and followed by veterinary products which was enforced in 2014. after almost 35 years of the regulation, unregistered medicines still exist. according to a study by narsai et al. (2012), some of the reason of the availability of unregistered medicines were registration costs; commercial; retention costs, gmp inspection fees and gmp inspection requirements. without registration, manufacturers just have bear minimal cost for production and will generate wider profit without needing to pay other costs. this is the reason why unregistered medicines still are available in market with cheaper price. in this study, almost all the respondents who used unregistered medicines (94.1%, n=16) did not inform their healthcare providers about their usage of unregistered medicines. this finding is common among patients in malaysia and thailand (hasan et al. 2009; putthapiban et al. 2017). they did not see the need to disclose the information on their use of unregistered medicines. the statements ‘‘doctor never asked’’ and ‘‘afraid of doctors disagree and get scolded ’’ were the main reasons provided by the respondents for their non-disclosure of unregistered medicine use. thus, this information is important for healthcare professionals in order to assess patient needs, and more importantly to know whether there are any potential drug interactions and adverse drug reactions due to the use of unregistered medicines. similarly, conventional health practitioners should acquire and develop essential skills in the area of unregistered medicines practice and its education should be incorporated into medical and health sciences curriculum. most of the patients (80%) knew that they need to take prescribed medications and unregistered medicines at different times to avoid any possible interactions. this study was comparable to a study by fadzil et al. (2018) in which patients take supplement and prescribed medicines at different times to avoid interactions. 244 global journal of public health medicine 2020, vol 2, issue 2 gggggglo section b of the questionnaire aims to measure respondents’ knowledge of registered medicines. it consists of seven questions that gave 1 mark for each correct answer, the questions were based on the basic information on registered medicines. twenty-two of the respondents managed to achieve full mark, and 64.8% (n=70) of respondents were found to have good knowledge of registered medicines. compared to the national survey use of medicines (nsum) 2015 (division 2016), which found that 53.2% of patients have a good knowledge of medicines, this finding was a bit higher, probably because of the nsum 2015 was done throughout malaysia, and the locality effect was a significantly associated factor in that study. in term of attitude towards unregistered medicines use, the theory of reasoned action that was developed by martin fishbein and icek ajzen, explicitly note that respondent’s attitude influences behavior on the use of unregistered medicines. however, this theory also recognized that there were situations (or factors) that limit the influence of attitude on behavior. for example, if our attitude leads us to want to go to buy something but at the same time, we have no money, it will prevent our attitude from causing us to buy it. the same goes to the usage of unregistered medicine, associated with a few factors. the perceived benefit of unregistered medicines influences the patient to take medicines. this is also supported by health belief model (janz & becker 1984). various sociodemographic parameters were examined in this study, but not all parameters were statistically significant in the bivariate and multivariate analysis. for example, the race of respondents was not significantly associated with unregistered medicines use, even though in the study on cosmetics showed that attitudes toward cosmetic products among the participants were influenced by race and religion (ayob et al. 2016). another study by albarrán and zapata (2008) about selfmedication showed that women were selfmedicated compared to men. however, the usage of unregistered medicine in this study does not show similar finding with the above studies. kotler and keller (2012) stated that monthly income was one of the economic circumstances that fall into the personal factors category which influences consumers’ buying behavior. however, this study found that the monthly household income did not influence them to buy unregistered medicines. this finding was different compared other study where household income was a factor affecting this behavior which give a significant impact on their attitudes related to cosmetic products (ayob et al. 2016). among the most obvious explanations for the association between education and health is that education itself produces benefits that later predispose the recipient to better health outcomes (zimmerman et al. 2015). the human capital theory of learned effectiveness states that educated, instrumental people merge otherwise unrelated habits and ways into a healthy lifestyle that consequently behaves as a coherent trait. in theory, education makes individuals more effective users of information. education encourages individuals to acquire information with the intent to use it. thus, 245 global journal of public health medicine 2020, vol 2, issue 2 gggggglo person with higher education may assemble a set of habits and ways that are not necessarily related except as effective means toward health (mirowsky 2017). the health belief model (hbm) is a social psychological health behavior change model developed to explain and predict health-related behaviors, particularly regarding the uptake of health services. the hbm was developed in the 1950s by social psychologists at the u.s. public health service (janz & becker 1984). the hbm suggests that people's beliefs about health problems, perceived benefits of action and barriers to action, and self-efficacy explain engagement (or lack of engagement) in healthpromoting behavior. a stimulus, or cue to action, must also be present in order to trigger the health-promoting behavior. the theory also supported by other theory of reasoned action. this theory was developed by martin fishbein and icek ajzen, in which it is explicitly concerned with behavior. however, this theory also recognizes that there are situations (or factors) that limit the influence of attitude on behavior. this will lead the chronic disease patients to practice unregistered medicines because of their perceived benefit towards unregistered medicines. this study found that perceived benefit of unregistered medicines was a factor associated with the practice. it was also demonstrated in another study by killelea et al. (2019) in which multivariate analyses demonstrated that participants who reported a large perceived benefit were significantly more likely to undergo radiotherapy treatment (odds ratio 10.34; 95% confidence interval: 1.66-66.35). furthermore, advertisements nowadays may influence the perception towards use of unregistered medicines. patients will use unregistered medicines for the sake of benefit, and its use was not affected by income in this study. the high perception of benefit led them to buy the unregistered medicines. ismail et al. (2016) found that the attitude and the actual purchase is more compelling for buyers who have a high perception of benefit compared to buyers with low perceived benefits. in addition to our study, patients probably use unregistered medicines due to cheaper price. this statement is supported by a study by rao (2017) which found that smuggled medicine is cheaper. the results of this study were impeded by several limitations. firstly, the sampling method employed was convenience sampling, thus the results obtained cannot be inferenced to the whole population. another limitation of the study was although we try to include patients of differing demography, voluntary participation indicates a certain pattern of respondents. younger patients for instance, were less likely to be included in the study. the prevalence of unregistered medicines use in this study might also not represent the whole population of malaysia as the composition of respondents of in this study is focused on patients attending klinik kesihatan bandar kota bharu which was located in a semi-urban area. extending this study to several other areas in urban and rural areas might result in a different result. moreover, the location of kelantan has a neighboring border of thailand, whereas the medication may be easily accessed from the neighbor country by smuggling. 246 global journal of public health medicine 2020, vol 2, issue 2 gggggglo the prevalence of unregistered medicines use in this study was larger than the prevalence of unregistered medicines in malaysia, it is undeniable that unregistered medicines still hold a place among these patients. some findings from this study further consolidates the finding of previous studies, and many others were unable to be ascertained as no statistically significant difference was detected. conclusion: the prevalence of unregistered medicines usage was 15.7%. more than half (64.8%) of the respondents were categorised as having good knowledge of unregistered medicines. in term of attitude towards unregistered medicines, the proportion of respondents with a negative (91.7%) views of unregistered medicines was comparable to those with positive (8.3%) attitude towards unregistered medicines. various parameters were investigated in the study to determine the factors associated with the practice of unregistered medicines use. after adjusting for confounders, respondents with lower education and perceived benefit of unregistered medicines were more likely to take unregistered medicines. it is therefore suggested that we should strengthen our education programme to modify patient's belief on benefit unregistered medicines. heavier fine or penalty should be administered to manufacturers who did not register their medicines acknowledgement: we would like to thank the director general of health, ministry of health malaysia and dean of faculty of medicine, universiti kebangsaan malaysia for the approval of this study and publication of this article. this study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. conflicts of interest: the author declare no conflicts of interest. references: albarrán, k. f. & l. v. zapata 2008. analysis and quantification of self-medication patterns of customers in community pharmacies in southern chile. pharmacy world & science 30(6): 863-868. alghanim, s. 2011. self-medication practice among patients in a public health care system. eastern mediterranean health journal 17(5). aris, n. a. 2019. ministry tracks thousands of online ads for illicit medicines. free malaysia today, ayob, a., a. i. awadh, h. hadi, j. jaffri, s. jamshed & h. m. a. ahmad 2016. malaysian consumers’ awareness, perception, and attitude toward cosmetic products: questionnaire development and pilot testing. journal of pharmacy & bioallied sciences 8(3): 203. balbuena, f. r., a. b. aranda & a. figueras 2009. self-medication in older urban mexicans. drugs & aging 26(1): 51-60. carolyn nordstrom. 2007. crime, money, and power in the contemporary world. r. borofsky. ed. berkeley: university of california press, 2007. division, p. s. 2016. a national survey on the use of medicines (nsum) by malaysian consumers 2015. eisend, m. & p. schuchert-güler 2006. explaining counterfeit purchases: a review and preview. academy of marketing science review 2006: 1. el nimr, n., i. wahdan, a. wahdan & r. kotb 2015. self-medication with drugs and complementary and alternative medicines in alexandria, egypt: prevalence, patterns and determinants. emhj-eastern mediterranean health journal 21(4): 256-265. 247 global journal of public health medicine 2020, vol 2, issue 2 gggggglo fadzil, s. k., m. omar & n. m. j. i. j. o. p. h. r. tohit 2018. practice of dietary supplements and its influence towards treatment adherence among chronic disease patients. 8(2): 9981005. furman-assaf, s., o. tamir, e. marom, m. arieli & j. shemer 2010. 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(15-0002): 347-84. zulkifli, n. w., n. a. aziz, y. hassan, m. a. hassali & n. l. z. bahrin 2015. development of validated questionnaire to access public knowledge on registered drugs. procedia social and behavioral sciences 172: 749-753. microsoft word gjphm-2023 e learning .docx 742 global journal of public health medicine 2023, vol 5, issue 1 gggggglo original research psychological effect of e-learning in light of covid-19 pandemic on children in baghdad city maryam aayd ismail1, sarah abdullatef kadhim 2 , musaab majid abdulwahhab 3 & iman abbas fadhil2 1psychiatric and mental health nursing department, college of nursing, al-bayan university 2 adult nursing department, college of nursing, al-bayan university 3 adult nursing department, college of nursing, university of baghdad *corresponding author: maryam.a@albayan.edu.iq abstract introduction: the coronavirus 2019 (covid-19) pandemic may be viewed as a traumatic stressor with severe detrimental effects on health. e-learning is transitioning from traditional education or training to more individualized and flexible electronic-based education and may also be referred to as distance learning, virtual education, digital education, or web-based training (wbt). electronic learning in iraq is a new experience, especially in primary schools. for that, we expect psychological and behavioural effects on students. this study is designed to determine the effects of e-learning in light of the coronavirus 2019 (covid-19) pandemic on children's psychological functioning from the parent's point of view. methods: a descriptive (cross-sectional) approach was adopted, and a non-probability (purposive) sample was used to collect the relevant data for the study from 646 parents (fathers and mothers) who have children in baghdad’s primary schools. a google form has been used to collect data through the social media programs of the intended schools. result: study results show that 50.4% of primary school students have a moderate degree while 48% have a mild degree of psychological and behavioural problems; these problems are associated with the class time of electronic learning during the time of coronavirus 2019 (covid-19) pandemic in p-value 0.000 and 0.04. however, there is a significant relationship between psychological and behavioural problems and variables related to electronic learning, like using electronic devices and activity after coronavirus 2019 (covid-19). conclusion: most parents experienced moderate psychological and behavioural issues with children during the epidemic. to avoid potential problems, it is crucial to keep an eye on school students' mental health. keywords:coronavirus 2019 (covid-19) pandemic, e-learning, psychological functioning, primary school age children 743 global journal of public health medicine 2023, vol 5, issue 1 gggggglo introduction the world health organization (who) has deemed the coronavirus diseases 2019 (covid-19) an international public health emergency and has urged all nations to take precautions to contain the disease (world health organization, 2020). several nations created healthcare procedures to prevent the spread of the virus because there are currently no available treatments. these protocols included measures that limited free circulation and, in some cases, required quarantine and social isolation (world health organization, 2020). due to the separation of essential relatives and the heightened impression of loneliness and isolation, these preventive actions may have elevated the levels of sadness and anxiety (banerjee & rai, 2020). people may experience various mental health issues following a stressful event (gerbe et al., 2018), and some pre-existing psychiatric illnesses, like the risk of suicidality, neurological abnormalities, and substance use disorders, could get worse (adhanom, 2020). the coronavirus disease 2019 (covid-19) pandemic may be viewed as a traumatic stressor with severe detrimental effects on health (lee, kim & kim, 2020). in 2021, evidence rapidly evolved, and therapeutic indications changed quickly to prevent or cure covid-19 in the best ways. if an asymptomatic infection in children did not require specific treatment, therapeutic options were different based on the presentation. vaccination is considered the best advisable strategy to prevent covid-19 infection. until now, immunization has been available for people aged five years and older, demonstrating good efficacy or an acceptable security profile (elena & et al., 2022). schools in iraq must be updated since technology is advancing so quickly. they had to be able to learn anywhere, at any time (wolfinger, 2016). over the past 20 years, some international institutions have adopted online education. on the other hand, most schools, colleges, and universities in iraq do not employ this kind of instruction, and their staff is not familiar with what e-learning includes (ja'ashan, 2020), (lynch, 2004). learners need additional social support during a dire situation like the coronavirus disease 2019 (covid-19) pandemic to increase their focus and enthusiasm for online learning (harter, whitesell, & kowalski, 1994), (lynch, 2004), (villani & et al., 2020). to preserve social distance and stop the sickness from spreading, governments around the world should switch to electronic learning. some nations immediately turned to internet education since they were already prepared for it. all universities and schools in iraq offered elective and core courses via distance learning using a specific technology. coronavirus disease 2019 (covid-19) pandemic has significantly altered people's daily life worldwide in a relatively short period. many countries have adopted social solid restrictions, such as lockdowns, to prevent the virus from spreading (eccles, 1993). only a few instances of quarantine-like practices include home confinement, banning public gatherings and commuting to work unless necessary, closing schools, universities, and any non-essential businesses, and avoiding contact with people outside the family. a growing body of research shows that the lockdown is associated with poor social and emotional wellness in both adults and children, even though the long-term repercussions on mental health are not entirely understood (villani & et al., 2020), (midgley, anderman, & hicks, 1995) who are 744 global journal of public health medicine 2023, vol 5, issue 1 gggggglo being locked up. more consideration must be given to children living in institutions or low-income households to meet their requirements (jiao & et al., 2020). online education has several advantages and disadvantages, including accessibility to all students, cost, time, and effort savings. the faculty's capacity to record lectures at the request of students is one advantage of online education. teachers' thorough evaluations and planning for recording have a positive impact on teaching methods and procedures. to better understand the material, students can watch the lectures whenever they want. reading, speaking, and writing impediments are difficulties in english language skills and other english courses. the teacher in linguistics classes must provide instruction on phonemes, allophones, morphemes, and other concepts to meet the needs of the pupils. some pupils only sometimes have reliable access to the internet. the network affected certain children (cao & et al., 2020). the study aims to assess primary school-age children's psychological and behavioural problems during the coronavirus disease 2019 (covid-19) and to find out the relationship between the psychological and behavioural problems with the types of school, class of children, and use of electronic devices before and after the pandemic) among participants methods study design: a descriptive (cross-sectional) design was used for the period from december (2020) to october (2021). sample and sampling of the study: non-probability (purposive) sample was used. a sample of 646 parents (fathers and mothers) who have children in baghdad primary school was collected by an electronic form questionnaire sent to the parents via social media programs (facebook, instagram, telegram and whatsapp). the included participants were all parents of children in primary school who could read and write to fill out the study instrument. the excluded participants were the parents who refused to participate, could not read and write, and parents who did not have children in primary schools. data analysis : data are analyzed using the spss (statistical package for social sciences) version (20) application statistical analysis system and the excel application. the researcher used multiple tests to analyze the data: frequency and percentage, mean, and chi-square. power analysis (study size): based on an anticipated effect size of 0.15, a designed statistical power of 0.95, predictors, and a probability level of 0.05, the minimum required sample size would be 227. by considering an attrition rate of 20%, it would be 45. so, the recommended sample size would be 272. the final sample size is 646. 745 global journal of public health medicine 2023, vol 5, issue 1 gggggglo study instrument a questionnaire was composed of three sections; part i: deals with the parent's and children's demographic information (age, educational level, work, number of family members, caregiver's situation concerning coronavirus disease (covid-19), education type, school year group, use of electronic devices before and after coronavirus disease (covid-19), and child's activity before and after coronavirus disease (covid-19). part ii: represents the measure of psychological and behavioural problems for children from the point of view of children followed by the researcher (evren & et al., 2020) in their research prepared (wolfinger, 2016). then the researcher converts the instrument to a google form to collect the data easily. the measure consists of 24 phases, each representing psychological or behavioural problems different from the other. the scale is designed according to the likert method, and the five-way answer alternatives include (much less, somewhat less, same, somewhat more, much more), and scores (4, 3, 2, 1,0) are given according to the direction of the phrase. thus, the highest score on the scale is (94), and the lowest grade is (0). the scale has demonstrated excellent internal consistency and reliability (cronbach's alpha=.89) ethical considerations: this research is funded by the researcher and is considered a single independent research project. the parents themselves must consent to the data collection. the children's or parent's names were left off the questionnaire out of respect for their privacy. al-bayan university approved the study's completion with the number (con-he-002). results: the presentation of the findings of parents and children during the time of corona virus pandemic 2019 and the psychological and behavioural problems of these children from the parent's point of view. table 1. distribution of parents' demographic variables characteristics n % parents father 202 31.3 mother 444 68.7 age 18-28 91 14.1 29-38 359 55.6 39-48 172 26.6 49-61 24 3.7 educational level primary and secondary 91 14.1 preparatory 164 25.4 college 322 49.8 higher education 69 10.7 parents' situation concerning covid-19 belong to a risk group 186 28.8 people belonging to a risk group live with the participants 172 26.6 do not know anyone from risk groups 288 44.6 family members 3-5 384 59.4 6-8 214 33.1 9-11 48 7.5 n= frequency, %= percentage, risk groups= any person working out of the home in contact with people infected or at risk of being infected. table (1) shows that the higher average age (29-38) is 55.6% of total parents, while the more significant number of samples educational level is 49.8% in college. 746 global journal of public health medicine 2023, vol 5, issue 1 gggggglo table (2): distribution of child demographic variables characteristics n % child sleep 4-6 hour 47 7.3 7-10 hour 484 74.9 11-13 hour 115 17.8 class first 118 18.3 second 116 18.0 third 136 21.1 fourth 95 14.7 fifth 88 13.6 sixth 93 14.4 age 6-9 403 62.4 10-13 243 37.6 learning place governmental 434 67.2 privet 142 22.0 at home 70 10.9 could the child spend some time out of the door? yes 380 58.8 no 266 41.2 table 2. shows the more significant number of children between 7-10 years in percentage 74.9%. the more significant number of children, 62.4%, their school is a governmental school, and 58.8% could spend time out of the door. table (3): compare child data of using electronic devices and activity before and after covid19 child uses of electronic devices hours\ day before covid-19 after covid-19 n % n % less than 30 minutes 172 26.6 57 8.8 one hour 186 28.8 147 22.8 two hours 136 21.1 134 20.7 three hours 76 11.8 134 20.7 more than 4 hours 76 11.8 174 26.9 child activity (any activity without electronic devices) hours\ day before covid-19 after covid-19 n % n % less than 30 minutes 75 11.6 172 26.6 one hour 161 24.9 181 28.0 two hours 184 28.5 111 17.2 three hours 124 19.2 89 13.8 more than 4 hours 102 15.9 93 14.4 table 3. shows that the use of electronic devices hours increase after covid-19, like in 4 hours increase in percentage to 26.9%. at the same time, child activity decreases to become the highest percentage of one hour\ day in 28.0 after covid-19. 747 global journal of public health medicine 2023, vol 5, issue 1 gggggglo table (4). distribution of childs psychological and behavioral problems: these results in table 4 show that some phrases have a high percentage in parents' responses compared with other phrases, for example, my child is sad (44% for somewhat less), my child is very dependent on us (39.2% for much more). my child complains about homework greatly (31.7% for much more). child symptoms much less n(%) somewhat less n(%) same n(%) somewhat more n(%) much more n(%) my child is worried 88 (13.6) 271 (42.0) 138 (21.4) 98 (15.2) 51 (7.9) my child is restless 77 (11.9) 225 (34.8) 162(25.1) 112 (17.3) 70(10.8) my child is anxious 101 (15.6) 252 (39.0) 131 (20.3) 114(17.6) 48(7.4) my child is sad 105(16.3) 284 (44.0) 113 (17.5) 91 (14.1) 53 (8.2) my child has nightmares 174 (26.9) 204 (31.6) 92 (14.2) 87 (13.5) 89 (13.8) my child feels lonely 112 (17.3) 246 (38.1) 137 (21.2) 91 (14.1) 60 (9.3) my child is uneasy 143 (22.1) 205 (31.7) 104 (16.1) 119 (18.4) 75 (11.6) my child is nervous 53 (8.2) 192 (29.7) 129 (20.0) 126 (19.5) 146 (12.6) my child argues with the rest of the family 44 (6.8) 190 (29.4) 134 (20.7) 104 (16.1) 164 (26.0) my child is very quiet 90 (13.9) 191 (29.6) 143 (22.1) 131 (20.3) 91 (13.0) my child cries easily 67 (10.4) 148 (22.9) 143 (22.1) 112 (17.3) 176 (27.3) my child is angry 89 (9.4) 218 (33.7) 146 (22.6) 119 (18.4) 84 (13.0) my child feels frustrated 119 (18.4) 232 (35.9) 119 (18.4) 92 (14.2) 84 (12.3) my child is bored 49 (7.6) 186 (28.8) 25 (19.3) 114 (17.6) 172 (26.6) my child is irritable 42 (6.5) 171 (26.5) 148 (22.9) 120 (18.6) 172 (25.6) my child has no appetite 122 (18.9) 185 (28.6) 141 (21.8) 106 (16.4) 92 (14.3) my child has difficulty concentrating 105 (16.3) 212 (32.8) 115 (17.8) 116 (18.0) 98 (15.1) my child is afraid of covid-19 infection 106 (16.4) 186 (28.8) 102 (15.8) 98 (15.2) 154 (23.8) my child is very dependent on us 31 (4.8) 126 (19.5) 115 (17.8) 121 (18.7) 253 (39.2) my child has behavioural problems 183 (28.3) 190 (29.4) 105 (16.3) 96 (14.9) 69 (11.1) my child eats a lot 145 (22.4) 162 (25.1) 115 (17.8) 110 (17.0) 114 (17.6) my child worries when one of us leaves the house 112 (17.3) 165 (25.5) 115 (17.8) 94 (14.6) 160 (24.7) my child complains about homework a lot 34 (5.3) 159 (24.6) 121 (18.7) 127 (19.7) 205 (31.7) my child is afraid to go to school 185 (28.6) 151 (23.4) 104 (16.1) 100 (15.5) 106 (16.4) 748 global journal of public health medicine 2023, vol 5, issue 1 gggggglo table (5). distribution of the sample according to their psychological and behavioral problems: psychological and behavioural problems scale n % mild (0-32) 151 23.4 moderate (33-64) 346 53.6 sever (65-96) 149 23.1 total 646 100.0 table 5. shows that 53.6% of the study sample have moderate psychological and behavioural problems. table (6). relationship between psychological and behavioral problems and other demographic characteristics: psychological and behavioural problems variables mild moderate sever value df significance (p≥0.05) age of child 6-9 year 10-13 year 96 55 209 137 98 51 1.398 2 0.497 learning place governmental private at home 97 44 10 243 64 39 94 34 21 11.373 6 0.08 the child uses of electronic devices after covid-19 less than 30 m. one hour two hours three hours more than four h. 17 27 15 39 53 26 74 76 74 96 14 46 43 21 25 36.058 8 ≥0.001* childes activity after covid-19 less than 30 m. one hour two hours three hours more than four h. 34 38 21 23 35 100 98 65 42 41 38 45 25 24 17 15.945 8 0.04* *significant level at p value ≥0.05. chi-square test use. table 6 indicates a significant relationship between psychological and behavioural problems and child use of electronic devices and activity after covid-19 (p=0.08 & ≥0.001). discussion: the main findings of this study are as follows, first, the children in this study were distributed like the general population but had a poorer psychological status. they found that, statistically, the use of electronic devices increased in comparison to the time before the pandemic. at the same time, the activities decreased, indicating that in terms of psychological health, they were affected. these differences were higher for externalizing problems than for internalizing problems from the impact of the coronavirus disease 2019 (covid-19). according to the parents' socio-demographic information, most of them were mothers and belonged to the young parent age group of 29 to 38. the majority of parents have completed their college education. 44.6 per cent of respondents to the question about how to deal with people who have the 2019 coronavirus disease (covid-19) report not knowing anyone who has it, and other responses vary when it comes to knowing and handling sick individuals. the findings of (mohammad, 2020), (orgül & et al., 2017) support this. the study sample's variable on the parents' status concerning coronavirus disease 749 global journal of public health medicine 2023, vol 5, issue 1 gggggglo 2019 (covid-19) shows the parents' approaches to those at risk for coronavirus disease 2019 (covid19). since the study sample came from a primary school, children in all age groups between 6 and 12 could be seen in all primary school classrooms. children's activity dropped while their usage of electronic gadgets grew both before and after the (covid-19) epidemic. these findings, which are corroborated by (orgül & et al., 2017), confirm the negative association between lockdown-related restrictions and children’s lifestyle in the (uk) united kingdom. further investigation is required to determine whether the reported alterations enhanced the likelihood of long-term mental health issues and whether the degree of change in children's daily activities was related to the caregiver and child characteristics. according to study findings, most children experience moderate behavioural and psychological issues. also, children were more bored (44.2%), low (39.8%), frustrated (44.9%), irritable (67.1%), restless (53.2%), worried (52.4%), angry (54%), anxious (45.3%), and were more likely to argue with the rest of the family (26.8%) during the lockdown compared to the pre-covid-19) period. this is supported by (orgül, kallitsoglou & essau, 2020) , (ghanamah & eghbaria-ghanamah, 2021) results and reflects the effect of e-learning during the coronavirus disease 2019 (covid-19) pandemic. the study results show a significant relationship between psychological and behavioural problems and children's use of electronic devices and activities after the coronavirus disease 2019 (covid-19) pandemic, and the learning environment of children. this reflects the effect of e-learning during the pandemic. conclusion children used screens much more and engaged in physical activity, and napped significantly less during the lockdown. more than half of the caregivers claimed that the pandemic and e-learning were strongly related to their moderate to severe distress during the epidemic. most parents experienced mild to severe psychological and behavioural issues with children during the epidemic. to avoid potential issues, it is crucial to keep an eye on youngsters' mental health. such monitoring may be required to find at-risk children and treat them for children in protection or prevention systems. additionally, the kid or adolescent must provide the information because the diverse perspectives of the caregivers could lead to misinterpretation. acknowledgements we acknowledge all the volunteers who participated in the online survey to make this study possible. conflicts of interest the author declares no conflicts of interest. 750 global journal of public health medicine 2023, vol 5, issue 1 gggggglo references • adhanom ghebreyesus, (2020). addressing mental health needs: an integral part of covid19 response. world psychiatry, pp. 19, 129–130. 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(2016). an exploratory case study of middle school student academic achievement in a fully online virtual school (doctoral dissertation, drexel university). drexel university. • world health organization, (2020). critical preparedness, readiness and response actions for covid-19—interim guidance; who: geneva, switzerland. • world health organization, (2020). novel coronavirus (2019-ncov): situation report-10; who: geneva, switzerland. microsoft word gjphm-2023 cathetrization .docx 752 global journal of public health medicine 2023, vol 5, issue 1 original research determination of the benefits and complications of clean intermittent catheterization to spinal cord injured patients raheem atyia badir adult nursing department, college of nursing, al-bayan university *corresponding author: raheem.atyia@albayan.edu.iq abstract introduction: intermittent catheterization (ic) is the best method for bladder emptying in patients with spinal cord lesions who are suffering from neurogenic bladder dysfunction. the aim of the study was to determine the benefits of using clean intermittent catheters for patients with spinal cord injury at regular intervals daily to empty the bladder and identify the complications from its use. methods: a quantitative descriptive design study was done at ibn al-kuff hospital for spinal cord injuries in baghdad city, including (60) male spinal cord injured patients from the 14th of february 2021 to the 20th of april 2022. a non-probability (purposive) sample of (60) male spinal cord-injured (sci) patients with paraplegia and tetraplegia were selected. a questionnaire format was used, which consisted of three major parts with a total (of 26) items. results: the present study included (60) male paraplegic and tetraplegic patients, half of them in the age group between (18-27) years old, and 33 (55%) of them were single. the majority24 (40%) of the study sample were primary school graduates. furthermore, 24 (40%) were employees before they were injured. concerning the clinical characteristics of patients, the study indicates that (48 (80%) of the sample were paraplegic patients, 41(68.3%) were complete paralysis and 55(91.7%) of them the cause of injury was traumatic sci. furthermore, 51(85%) of them use selfclean intermittent catheterization; concerning the number of daily catheterizations, 33(55%) of them used it from 7and more daily, while 34(56.7%) of them, the time between the catheter and the next was each two hours. concerning the urinary complication occurs during the last 3 months associated with intermittent catheterization, 22(36.7%) of the sample had (utis). conclusion: the current study has demonstrated that the practices of spinal cord injury patients about clean intermittent catheters were acceptable and regular, and it was beneficial to them, as it reduced complications, especially urinary tract infections, noting the need to increase the time between each interval of catheterization to (4-6) hours for each period. keywords: determination, benefit, complications, intermittent catheterization, clean intermittent catheterization, spinal cord injured patients. 753 global journal of public health medicine 2023, vol 5, issue 1 introduction a neurogenic bladder (nb) is any bladder dysfunction related to abnormal or absent bladder innervation and causes urine incontinence (myers et al., 2019), (priscilla, l., karen, b., & gerene, 2017), (lewis et al., 2000). to maintain the vital capacity of the neurogenic bladder, clamping is started regularly, gradually over time, until it reaches two hours of clamping (grundy & swain, 2002). previously, specialists used to treat (nb) using an intermittent catheter and supra pubic, but a sudden change to using clean intermittent catheterization with great benefits was observed in reducing many urinary tract complications related to (nb), such as utis, nephritis, pyelonephritis, urethritis, bladder and urethral erosion(dinh et al, 2019) (kessler, ryu & burkhard, 2009). measuring fluid intake, output, residual urine volume, urine examination and assessing sensory awareness of bladder fullness and motor control are all part of nb evaluation (bader, 2021) (hinkle & cheever, 2017). intermittent catheterization (ic) is the preferred method of bladder emptying for many persons with voiding difficulties as a result of spinal cord injury (sci) (wyndaele, 2007). in recent years, there has been a technological development in the manufacture of intermittent catheters( hydrophilic catheter) making them easier to insert and more resistant to preventing urinary tract infections (beiko et al, 2004). using intermittent catheterization is a safe and effective method to treat neurogenic bladder dysfunction due to a spinal cord lesion. the use of hydrophilic-coated intermittent catheters may reduce the urethral complication rate. the most important factors for the success of ic include good education for sci patients, good adherence and the application of a good catheterization technique (wyndaele, 2002). despite such benefits of (ic), repeated catheterization by using uncoated catheters can lead to a group of complications; such as urinary tract infections (utis), which can be recurrent and constant, urethral mucosa irritation over urethral lesions, strictures and false passages may occur (wyndaele & maes, 1990) (perrouin-verbe et al., 1995). a survey study done in canada in 2008 included (912) sci patients and found a significant relationship between the number of catheterizations per day and uti rate, with the infection rate reducing as the number of catheterizations per day increased (woodbury et al., 2008). this is consistent with previous suggestions that the frequency of catheterization influences the occurrence of symptomatic bacteriuria by increasing the time that colonized urine resides in the bladder (in case of infrequent catheterization) or by increasing the risk of urethral damage when too frequent catheterization occurs (de ridder et al., 2005). the data also confirm with previous reports, which mentioned that when caregivers perform, ic increases the risk of infection (bakke & vollset, 1993). the involvement of others is usually borne out of necessity in the case of patients with tetraplegia and compromised upper limb function. neurological level of injury and severity of injury (complete or incomplete), and hence the degree of independence, have individually been identified as risk factors for uti (esclarin, garcia & herruzo, 2000). 754 global journal of public health medicine 2023, vol 5, issue 1 urinary tract infection in sci patients most commonly results from ascending transurethral invasion of the bladder by pathogenic organisms normally present in the intestines (kennelly et al., 2019) (moloney et al., 1981). neurological lower urinary tract dysfunction (nlutd) always results in high post-voided residual (pvr) volume, so it needs catheterization for complete bladder emptying regularly. clean intermittent catheterization (cic) is the first technique of option. it needs sterile gloves and antiseptics and can be used by patients themselves or caregivers in the home environment (mckibben et al., 2015) (vahr et al., 2013). furthermore, the cic procedure was first reported by lapides et al. in 1972, who mentioned that urinary tract infection (uti) in nlutd is caused by pvr and bladder distention, not as a necessary result by asepsis of the technique, thus proving to be more important to keep a regularity of emptying than an aseptic technique (lapides et al,. 1972). the steps to be followed include; hygiene of the genital area, hand washing and lubrication, and administering the cic. the independence in performing the procedure may not be accomplished by patients with high injuries (santos et al., 2015). methods a quantitative descriptive design study was done at ibn al-kuff hospital for spinal cord injuries in baghdad city, which has five spinal units with a total of (120) beds; the study included (60) male spinal cord injured patients because it is difficult to observe female patients with them. the study started from the period (the 14th of february 2021 to the 20th of april 2022). a non-probability (purposive) sample of (60) male spinal cord injured (sci) patients with paraplegia and tetraplegia were selected from different ages and educational levels and admitted to the hospital for rehabilitation. for this study, a questionnaire format was used for data collection, which consisted of three major parts with a total (of 26) items; the first part is concerned with patients' socio-demographic characteristics, which include (4) items; (age and level of education, marital status, and occupation before injury), the second part is dealing with the clinical characteristics of sci patients and the complication that occurs as a result of patients using clean intermittent catheters, which consist of (7) items, and the third part consist observational checklists to evaluate patients' practices concerning intermittent clean catheterization (cic) include (15) items. the items of patients' practices were rated on three level likert scale; always, sometimes, and never, and scored as 3, 2, and 1, respectively. patients were observed performing clean intermittent catheters concerning the neurogenic bladder. for cic practices, data were collected through concealed observation techniques. a total of (3) events were observed for each respondent's practices as a means of data collection. ( 3 ) correct practices out of (3 ) episodes were rated as always, ( 2 ) correct practices out of ( 3 ) episodes were rated as sometimes, and ( 1 ) or less correct practices of ( 3 ) episodes were rated as never (25). the mean score was done to assess patients' practices concerning cic. the mean score, which was equal to (1.5-2.5), was considered significant, while greater than (2.5) was considered highly significant and less than (1.5) was considered non-significant. 755 global journal of public health medicine 2023, vol 5, issue 1 on the other hand, the content validity is estimated through a panel of experts. at the same time, the reliability of the questionnaire was estimated using alpha cronbach for the test-retest approach. data analysis was performed by applying descriptive statistics (frequency, percentage, cumulative percent, and mean of the score (ms). ethical considerations: this research is funded by the researcher and is considered a single independent research project. the patients themselves must consent to the data collection. patient's names were left off the questionnaire out of respect for their privacy. al-bayan university approved the study's completion to complete the data collection from hospitals. results: table (1): distribution of spinal cord injured patients by socio-demographic characteristics (n= 60) sdcvs. group n % cum. % 1. age groups (year) 18 27 30 50 50 2837 21 35 85 38 and more 9 15 100 total 60 100 2. level of education read and write 9 15 15 primary school graduate 24 40 55 intermediate school graduate 15 25 80 secondary school graduate 9 15 95 institute or college graduate 3 5 100 total 60 100 3. marital status single 33 55 55 married 27 45 100 total 60 100 4. occupation before the injury student 9 15 15 employee 24 40 55 free business 15 25 80 unemployed 12 20 100 total 100 100 sdcvs = socio-demographic variables table (1) indicated that the present study included (60) male paraplegic and tetraplegic patients, half of them in the age group between (18-27) years old, and 33 (55%) of them were single. regarding the level of education, the majority24 (40%) of the study sample were primary school graduates. furthermore, 24 (40%) of them were employees before they were injured. 756 global journal of public health medicine 2023, vol 5, issue 1 table (2): clinical characteristics of (60) sci patients cum. % (%) n variables 1. type of paralysis 10 10 6 tetraplegia 100 90 54 paraplegia 100 60 total 2. complete or incomplete lesion 68.3 68.3 41 complete 100 31.7 19 incomplete 100 60 total 3. cause of sci 91.7 91.7 55 traumatic sci 100 8.3 5 non-traumatic sci 100 60 total 4. intermittent catheterization 90 90 54 self 100 10 6 others 100 60 total 5. number of daily catheterizations 10 10 6 2-3 45 35 21 4-6 100 55 33 7-and more 100 60 total 6. time between the catheter and the next(hour) 56.7 56.7 34 each two hours 90 33.3 20 3-4 hours 100 10 6 5-6 hours 100 60 total 7. urinary complication occurs during the last 3 months 36.7 36.7 22 urinary tract infection 41.7 5 3 bladder stone formation 46.7 5 3 urethral structure 50 3.3 2 upper tract stone 100 50 30 free from uti 100 60 total f=frequency; %= percentage table (2) shows the clinical characteristics of sci patients in the present study, indicating that 54 (90%) of the sample were paraplegic patients, 41(68.3%) were complete paralysis, and 55(91.7%) of them the cause of injury was traumatic sci. furthermore, 54(90%) of them use self-clean intermittent catheterization; concerning the number of daily catheterizations, 33(55%) of them used it from 7and more daily, while 34(56.7%) of them, the time between the catheter and the next was each two hours. concerning the urinary complication occurs during the last 3 months associated with intermittent catheterization, 30(50%) of the sample were free from utis during the last 3 months, while 22(36.7%) of the sample had urinary tract infections (utis). 757 global journal of public health medicine 2023, vol 5, issue 1 table (3): assessment of patients' practices regarding clean intermittent catheterization no standard items n =60 a lw ays s om etim e s never m. s assessm en t n n n 1 preparing equipment (prepare cic, sterile gloves, lidocaine ointment, and urine bag). 44 8 8 2.60 h 2 good hand washing is standard. 33 15 12 2.35 m 3 good genital washing (penis, perineum and urine opening). 25 17 18 2.12 m 4 wearing sterile gloves as standard. 22 13 25 1.95 m 5 choose the right catheter size. 48 8 4 2.70 h 6 choose the appropriate position for the insertion of the catheter. 51 4 5 2.77 h 7 use lidocaine gel to lubricate the catheter 52 4 4 2.80 h 8 the penis is held in an upright position and extended slightly upward. 41 10 9 2.53 h 9 insert the catheter into the urethra until the urine begins to exit, and then push the catheter for another 2cm. 43 11 6 2.61 h 10 the catheter is slowly drawn to allow the urine to drain from the bottom of the bladder after the urine flow has stopped. 39 13 8 2.52 h 11 pull the catheter out gently after finishing, and clean your hands after the gloves are removed. 32 12 16 2.27 m 12 clean the catheter well with soap and water immediately after use. 12 4 44 1.47 l 13 rinse the catheter well and let it dry. 23 13 24 1.98 m 14 store the catheter dry and clean inside the clean towel. 19 16 25 1.90 m 15 he discards a catheter that has become cracked or brittle, accumulated sediment, or lost its shape. 28 17 15 2.22 m total items 512 165 223 2.32 m ms= mean of the score, l=low = less than (1.5), m= moderate= (1.5-2.5), and h=high = (greater than 2.5). table (3) shows the assessment of patients' practices regarding clean intermittent catheterization, which depicted that there is a moderate practice for sci patients regarding clean intermittent catheterization, where (7) items had highly significant and (7) items get moderate significance, concerning the total mean of scores (ms) which was moderate (2.32). 758 global journal of public health medicine 2023, vol 5, issue 1 discussion: discussion of socio-demographic characteristics and clinical characteristics of the study sample. the present study, as it has been shown in table (1) that the present study included (60) male paraplegia and tetraplegia patients admitted to ibn al-kuff spinal cord injuries hospital for rehabilitation, half of them the age group between (18-27) years old, and 33 (55%) of them were single. from the researcher's point of you, this result shows that most of the patients are young people in the prime of life; most of them have been exposed to a traumatic injury, either by gunshot, road traffic accident, falling from a high place, or driving a motorcycle without wearing safety equipment, and the accident of heavy work. we can say that this result is consistent with a study conducted in canada that included 912 sci patients to elicit information on clinical and demographic data, techniques and use of ic, genital care, the occurrence of uti, and consequences of uti. fifty-five percent (55%) of all respondents use ic regularly. those who used ic were significantly younger than those who did not use it (woodbury, 2008). concerning the level of education, the majority, 24 (40%) of the study sample, were primary school graduates, while 15(25%) were intermediate school graduates. furthermore, 24 (40%) of the study sample were employees before they were injured. concerning the clinical characteristics of the study sample, table(2) shows the clinical characteristics of sci patients in the present study, indicating that 54 (90%) of the sample were paraplegic patients, 41(68.3%) were complete paralysis, and 55(91.7%) of them the cause of injury was traumatic sci. also, this result is consistent with a survey study done in canada, which included 912 sci patients; they found that (86%) of respondents were traumatic sci, while this study did not agree with the type of paralysis and the lesion of injury (complete or incomplete), where (62%) ;( 55%) of them were paraplegic patients and complete lesion respectively (woodbury, 2008). furthermore, the present study indicated that 54(90%) of them use self-clean intermittent catheterization; concerning the number of daily catheterizations, 33(55%) of them used it from 7and more daily, while 34(56.7%) of them, the time between the catheter and the next was each two hours, and only 20(33.3%) of them the time between the catheter and the next was each (3-4) hours. this result is inconsistent with the study conducted in canada, whereby (in 69.8%) of respondents, the number of daily catheterizations was (4-6) per day (woodbury, 2008). to find an explanation for this result, the sci patients need more bladder rehabilitation to increase the time of each bladder interval voiding by using cic from (4-6) times per day. concerning the urinary complication occurs during the last 3 months associated with intermittent catheterization, 30(50%) of the sample were free from urinary tract infections (utis), while 22(36.7%) of the sample had utis. these infections may be attributed to poor technique or catheter misuse. 759 global journal of public health medicine 2023, vol 5, issue 1 gggggglo this result agrees with a survey study done in canada (2008) that included 912 sci patients find that (23%) of respondents reported no infections in the past 12 months. the most frequent infection rate was one to two infections per year (35%); 20% of respondents reported the occurrence of more than four utis in the past year (woodbury, 2008). this result is consistent with a study that found that the frequency of catheterization influences the occurrence of symptomatic bacteriuria by increasing the time that colonized urine resides in the bladder or by increasing the risk of urethral damage when too frequent catheterization occurs per day (de ridder et al., 2005). also, this result is consistent with the study found that most of the (75) patients had neuropathic bladder dysfunction, and 92% were continent. bilateral hydronephrosis was relieved in 14/19 patients following cic. chronic or recurrent utis were present in 42% of patients using cic. patients with positive urine cultures were not necessarily symptomatic. in general, symptomatic infections were found to be related to poor technique or catheter misuse. complications occurred in 15/75 (20%) of patients, with a urethral pathological condition (urethral stricture, false passage, mastitis, meatal stricture) being the most frequent complication in male patients during follow-up (wyndaele & maes, 1990). the result of the present study is consistent with another study included (159) patients. the analysis showed a rate of symptomatic lower urinary tract infection (uti) of 28%. asymptomatic cytobacteriological infection was seen in 60% of patients, while men had significantly more symptomatic and asymptomatic infections than happened to women (perrouin-verbe et al., 1995). this result of the present study agrees with another study which found that sci patients who are using intermittent catheterization are less likely to experience urological complications compared to the other bladder management methods investigated (weld et al., 2000). conclusion: the current study has demonstrated that the practices of spinal cord injury patients about clean intermittent catheters were acceptable and regular, and it was beneficial to them, as it reduced complications, especially urinary tract infections, noting the need to increase the time between each interval of catheterization to (4-6) hours for each period. conflicts of interest the author declares no conflicts of interest. 760 global journal of public health medicine 2023, vol 5, issue 1 gggggglo references • bader. mk, (2021). aann core curriculum for neuroscience nursing, 6th edition. american association of neuroscience nurses. • bakke a, vollset se., (1993). risk factors for bacteriuria and clinical urinary tract infection in patients treated with clean intermittent catheterization. j urol. 149(3):527-531. • beiko dt, knudsen be, watterson jd, cadieux pa, reid g, denstedt jd., (2004). urinary tract biomaterials. j urol.; 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(2022). complications of intermittent catheterization: their prevention and treatment. spinal cord. 40:536–541. • wyndaele jj., (2007), intermittent catheterization and intermittent self-catheterization have become properly introduced. eur urol;52(1):220 microsoft word gjphm-2023 modelling.edited.docx 772 global journal of public health medicine 2023, vol 5, issue 1 gggggglo original research modelling the factors associated with difficulty in seeing (vision loss) among the ageing population of ghana using ordinal logistic regression to who’s global ageing and adult health (sage) ghana datawave 1 michael arthur ofori*, amos kipkorir langat , daniel biftu bekalo , youssouf bouzir pan african university institute for basic sciences, technology, and innovation, jkuat-kenya *corresponding author: mkyofori1920@gmail.com abstract introduction: the study modeled the factors associated with difficulty in seeing (vision loss) among the aged population of ghana using the who study on global ageing and adult health (sage) ghana wave-1 data. methods: the sampled data consisted of 4223 participants aged 50 years and above. the respondents were asked to indicate their difficulty seeing things in the last 30 days. the study grouped the responses into three (none, moderate and severe) and analyzed them using the proportional odds model of the ordinal logistic regression. results: we found that more than half (66%) of the aged population of ghana have some difficulty seeing. the females were more susceptible to experiencing difficulty in seeing (51.8% against 48.2%), with odds exceeding that of males by more than 43%. we also found a significant association between difficulty in seeing and the variables (age, sex, problem with remembering, depression, cataracts, and tobacco intake) using the pearson chisquare again, we discovered that those with some memory problems tend to have difficulty seeing. also, the log odds of severe difficulty in seeing was 1.044 higher on average for those 70 years and above than those below 60 years. conclusion: the ordinal logistic regression model found age, sex, a problem with remembering, depression, tobacco intake, cataracts, sbp, and heart rate as significantly linked with difficulty in seeing among the aged population of ghana at keywords: seeing, difficulty, ordinal, logistic, vision loss ( .001).p< ( .001).p< 773 global journal of public health medicine 2023, vol 5, issue 1 gggggglo introduction the aging population keeps rising worldwide, specifically in most developing countries. the occurrence of challenges associated with the health of the aged keeps increasing due to the increasing population. the commonest among these is the difficulty in seeing. one of the crucial human senses necessary for life and autonomous functioning is sight. good vision is necessary for us to carry out our daily duties, but unfortunately, aging often results in eyesight loss for many people (lauwen, 2021). difficulty in seeing associated with the aged is a significant global healthcare issue. according to ganley and roberts (1983), by age 65, one in three people has an eye condition that impairs vision. around a billion individuals worldwide have some degree of difficulty in seeing, primarily with close or distant vision, according to the world health organization (who) (vision impairment and blindness, 2022). more specifically, 217 million individuals have moderate to severe difficulty seeing, and over 36 million are blind (bechange et al., 2020). the deficiency associated with difficulty in seeing is mainly referred to as age-related macular degeneration (amd). amd is a common disorder that affects the central portion of your eyesight. amd affects 196 million people globally and is the main factor in visual loss in the west (ratnapriya, 2019). it can lead to blurred vision or loss of central vision. seeing is mainly caused by refractive error, cataracts, glaucoma, corneal opacities, diabetic retinopathy, trachoma, and presbyopia, among other conditions (vision impairment and blindness, 2022). according to who (2013), the majority (90%) of visually impaired people reside in lowand middle-income countries, where a lack of infrastructure, a lack of human resources, and expensive user fees make it difficult to provide ophthalmic services (bechange et al., 2020). however, 80% of all vision loss may be largely avoided or treated with few measures (stevens et al., 2013). seeing impacts on employment and educational chances lower quality of life and raises mortality risk (bourne et al., 2017; eckert et al., 2015). also, due to the inability to read or identify faces, individuals with amd lose their independence, impacting their quality of life (lonsdale et al.,2013). seeing is linked with smoking, high blood pressure, being overweight, and having a family history of amd (nhs website, 2021). reduction in the capacity to carry out everyday tasks, as well as a higher risk of depression, are both linked to vision loss (shmuely-dulitzki & rovner, 1997). who (2013) has also asserted that smoking, diabetes, preterm delivery, rubella, and a lack of vitamin a are all risk factors associated with difficulty in seeing (who, 2013). age, gender, and dietary variables are among the significant risk factors for vision loss (nuertey et al., 2019). low and middle-income nations, particularly those in sub-saharan africa, such as ghana, have the highest prevalence of sight-related issues. despite the burden, there need to be more reports of analyses to understand the frequency and causes of eyesight problems. therefore, our study filled this information gap by modeling the variables associated with vision loss. 774 global journal of public health medicine 2023, vol 5, issue 1 gggggglo methods: data this study used the wave 1 ghana data from who study on global ageing and adult health (sage). in all, 4223 participants aged 50 years and above were considered. the sage data comprised 5573 participants, but this study considered only those aged 50 years and above. the data were analyzed using the r statistical software. statistical model specification this study used the proportional odds model similar to that of singh et al. (2020) in the "ordinal logistic regression model describing factors associated with the extent of nodal involvement in oral cancer patients and its prospective validation. "most health, biomedical and epidemiological studies use either the continuation ratio model or the proportional odds model of the ordinal logistic regression class of models. in situations where the parallel regression assumption associated with the proportional odds model fails, many opt for the partial proportional odds model as the best alternative (long & freese, 2014b). the proportional odds model is preferred in this study because of its reasonable and significant interpretation in application. when the dependent variable takes on values in a set of ordered categories, the proportional odds model for ordinal logistic regression is a helpful extension of the binary logistic model (brant, 1990). the proportional odds model was appropriate as participants were requested to indicate their difficulty in seeing in the last 30 days, of which the outcome was ordinal. the response variable (difficulty in seeing) was put into three categories: none, moderate and severe. as a result, the dependence of the response variable on the predictor variables is given by where is the cumulative probability of the event are the respective intercept parameters; is a vector of regression coefficients corresponding to the predictor variables. the goodness of fit test we assessed the general significance of the model using the likelihood ratio statistic given by where is the log-likelihood computed using the full estimator, the complement computed using the restricted estimator, and the associated degrees of freedom representing the number of restrictions? also, the model's goodness of fit was measured using the pearson chi-square test and the deviance test. again, the brant test was employed to test the validity of the proportional odds assumption. ( ) ( ) pr log , 1, 2, 3 1 pr j j i j y y x x j y y x a b é ù³ ê ú ¢= + = ê ú³ê úë û ( )pr jy y³ ( );jy y³ ja b ( )1p´ ( ).ix [ ] ( )2 02 log logai l lc = log al 0logl i 775 global journal of public health medicine 2023, vol 5, issue 1 gggggglo results: the ordinal logistic regression model was fitted to the data extracted. according to table 1, 56.1% of the population had moderate difficulty in seeing, and 10.5% had severe difficulty in seeing. that is, about 6 out of every ten people in ghana's aging population have difficulty seeing. again, 65.3% of participants with a moderate problem with remembering have moderate difficulty seeing. likewise, 12.5% of them with a moderate problem with remembering have severe difficulty in seeing. in all, 77.8% of people with a moderate problem with remembering also have difficulty seeing. furthermore, 42.2% of participants with a severe problem with remembering have moderate difficulty in seeing, while 28.4% of them with a severe problem with remembering also have severe difficulty in seeing. that is, 70.6% of people with a severe problem with remembering also have difficulty seeing. also, difficulty in seeing is predominant in females compared to males (60.0% against 52.4% for moderate and 12.4% against 8.8% for severe). most participants (81.5%) who were 70 years and above had some difficulty seeing. also, 68.0% of those with difficulty seeing are 60 years and above. furthermore, 61.4% of those with difficulty seeing (moderate or severe) are also depressed (moderate or severe). most of the aged people (65.4%) who take tobacco products (cigarettes, cigars, pipes, and other tobacco products) have difficulty seeing. lastly, 68.0% of the participants with cataracts have difficulty seeing. table 1: cross tabulation of difficulty in seeing against some selected variables difficulty in seeing none moderate severe total total 1411 (33.4) 2367 (56.1) 445 (10.5) 4223 (100.0) problem with remembering none 799 (51.0) 702 (44.9) 64 (4.1) 1565 (100.0) moderate 523 (22.2) 1537 (65.3) 295 (12.5) 2355 (100.0) severe 89 (29.4) 128 (42.2) 86 (28.4) 303 (100.0) age 50 – 59 years 761 (45.8) 816 (49.1) 85 (5.1) 1662 (100.0) 60 – 69 years 396 (33.5) 697 (58.8) 93 (7.8) 1186 (100.0) 70 years and above 254 (18.5) 854 (62.1) 267 (19.4) 1375 (100.0) sex male 856 (38.7) 1159 (52.4) 195 (8.8) 2210 (100.0) female 555 (27.6) 1208 (60.0) 250 (12.4) 2013 (100.0) depression status none 918 (46.0) 945 (47.4) 132 (6.6) 1995 (100.0) moderate 449 (21.7) 1355 (65.5) 256 (12.8) 2069 (100.0) severe 44 (27.7) 67 (42.1) 48 (30.2) 159 (100.0) tobacco intake yes 422 (34.6) 664 (54.4) 135 (11.1) 1221 (100.0) no 1510 (39.8) 1948 (51.4) 332 (8.8) 3790 (100.0) 776 global journal of public health medicine 2023, vol 5, issue 1 gggggglo cataracts yes 350 (32.0) 614 (56.1) 131 (12.0) 1095 (100.0) no 1061 (33.9) 1753 (56.0) 314(10.0) 3128 (100.0) the pearson chi-square test from table 2 shows a significant association between difficulty in seeing and age, sex, problem with remembering, depression, cataracts, and tobacco intake at table 2: pearson chi-square value for selected variables variables chi-square value df p-value age 350.42 4 <0.001 sex 62.97 2 <0.001 problem with remembering 478.87 4 <0.001 depression 344.04 4 <0.001 cataracts 134.44 2 <0.001 tobacco intake 134.44 2 <0.001 the ordinal logistic regression model presented in table 3 shows that a problem with remembering is a statistically positive significant factor that predicts difficulty in seeing . the odds of a person with a moderate problem with remembering experiencing severe difficulty in seeing is 2.32 times that of someone with no difficulty remembering. also, the odds of a person with a severe problem with remembering experiencing severe difficulty in seeing is 2.53 times someone with no problem with remembering. age is also a statistically significant predictor of difficulty in seeing . the log odds of someone between 60 and 69 experiencing severe difficulty in seeing is 0.30 higher than someone younger than 60. likewise, the log odds of someone who is 70 years and above experiencing severe difficulty in seeing is 1.04 higher than someone who is less than 60. it implies that aging comes with some difficulty in seeing. table 3: parameter estimates for ordinal logistic regression model variables estimates p-value odds ratio (or) 95% ci for or problem with remembering moderate .8420 <0.001 2.321 2.014 – 2.674 severe .9296 <0.001 2.534 1.917 – 3.348 age 60 – 69 years .3009 .0001 1.351 1.159 – 1.575 70 years and above 1.0443 <0.001 2.841 2.429 – 3.323 sex female .3577 <0.001 1.430 1.246 – 1.640 depression moderate .7107 <0.001 2.035 1.779 – 2.329 severe .9464 <0.001 2.576 1.810 – 3.667 tobacco intake yes .3067 <0.001 1.359 1.165 – 1.585 cataract yes 1.0630 <0.001 2.895 2.172 – 3.859 ( .001).p< ( .001).p< ( .001).p< 777 global journal of public health medicine 2023, vol 5, issue 1 gggggglo heat rate -.0010 .0000 .991 .998 – .995 sbp .0082 .0000 1.008 1.006 – 1.011 threshold none 1.2098 .0000 3.353 2.073 – 5.422 moderate 4.5453 .0000 94.187 56.901 – 155.898 sex is a statistically significant positive predictor of difficulty in seeing . the odds of experiencing severe difficulty in seeing were 43% higher for females than males. that is, females stand a higher risk of experiencing severe difficulty in seeing than men as they grow. depression is also a positive predictor that is statistically significant in predicting difficulty in seeing . the odds of a depressed person experiencing difficulty seeing are twice higher than someone who is not depressed. also, cataract is a significant contributor to difficulty in seeing, as the odds of those with cataract experiencing difficulty in seeing is found to be 2.90 higher than those without cataract. tobacco intake, heart rate, and systolic blood pressure were also found to be statistically significant predictors of difficulty in seeing at table 4: model fitting information and goodness of fit test model/test -2 log likelihood chi-square df p-value null 7785.17 final 6890.65 894.51 11 <0.001 deviance 6841.19 8119 1.000 pearson 8188.62 8119 .291 the model fitting information shown in table 4 indicates that, comparatively, there is a substantial improvement in fit in our final model to that of the null model . also, the pearson and deviance test s indicate that the model fits the data well. a non-significance of the parallel test indicates that the assumption of proportional odds is satisfied. from table 5, it is evident that the parallel regression assumption holds. table 5: parallel test test chi-sq df p value omnibus 26.2 11 .436 depression (moderate) 2.78 1 .139 depression (severe) 1.12 1 .223 problem with remembering (moderate) 1.46 1 .212 problem with remembering (severe) 2.24 1 .181 sex 2.71 1 .142 age 1.37 1 .241 sbp 0.38 1 .543 pulse 0.1 1 .751 tobacco intake 0.58 1 .454 cataracts 1.89 1 .176 h0: parallel regression assumption holds ( .001).p< ( .001).p< ( .001)p< ( .001).p< ( )2 11 894.51, .001 .pcé ù= <ë û ( )2 8119 8188.62, .291pcé ù= =ë û ( ) 2 8119 6841.19, 1.000pcé ù= =ë û 778 global journal of public health medicine 2023, vol 5, issue 1 gggggglo discussion: one of the crucial human senses necessary for life and autonomous functioning is sight. we modeled the factors associated with difficulty in seeing among the aged population of ghana. the prevalence of difficulty in seeing among the aged population of ghana was 66.6%. the prevalence of difficulty in seeing among females was higher than among males (51.8% against 48.2%). this finding confirms the result of seidu et al. (2021), who also found more women (23.45%) with vision difficulties than men (14.67%). they also found that the prevalence of difficulty in seeing was higher among females in ghana and togo. nuertey et al. (2019) also found gender to be associated with difficulty in seeing among the aged population. women stand a high risk of experiencing difficulty in seeing and, as such, must do well to avoid other contributing factors like tobacco intake and depression, among others, that can be prevented. another result that aligns with this finding is that of rius ulldemolins et al. (2019). they credited the higher female prevalence to gender disparities in health care access. the age factor also contributes to difficulty in seeing. we found the age groups 60 to 69 years and 70 years and above significant, yet the odds of experiencing severe difficulty in seeing among the 70 years and above group was very high. the result is consistent with steinmetz et al. (2021), who asserted that more than 80% of the people who have some difficulty seeing are 50 years and over. also, seidu et al. (2021) found across ghana, togo, and gambia that there was a higher possibility of vision loss among people 40 years and above. we also found that difficulty in seeing is associated with depression. previous studies (virgili et al. (2022); zhang et al. (2013); osaba et al. (2019); parravano et al. (2021) had established a strong relationship between depression and vision loss, and our result was not different from that. another factor we found to be associated with difficulty in seeing was cataracts. a cataract is a highly significant contributor to vision loss among the aging population in some studies (lópez-sánchez et al. (2019); tang et al. (2015); nakamura et al. (2010)). the impact of cataracts on the difficulty in seeing cannot be overshadowed. cataracts sometimes lead to total blindness (foster & johnson, 1990). alcohol intake and usage of tobacco products were also found to be significant. lópez-sánchez et al. (2019), in their study "the association between difficulty seeing and physical activity among 17,777 adults residing in spain," found alcohol consumption and smoking as significant predictors of difficulty in seeing. the aged should be educated to desist from tobacco products such as cigarettes, cigars, and pipes, as well as excessive alcohol intake, to reduce their risk of experiencing vision loss. lastly, the problem with remembering or memory loss was a factor associated with difficulty in seeing. this result corroborates the assertion by the alzheimer's society that sight and hearing loss are associated with dementia (sight and hearing loss with dementia, n.d.). 779 global journal of public health medicine 2023, vol 5, issue 1 gggggglo conclusion: more than half (66%) of the aged population of ghana have some difficulty seeing. the gender difference was detected for difficulty as the number of women reported with some difficulties in seeing exceeds that of the men. again, there is an association between difficulty in seeing and the variables; age, sex, difficulty in remembering, depression, cataracts, and tobacco intake. the aged who have some problem with remembering to tend to have difficulty seeing, like those who are depressed. difficulty in seeing is more severe in those who take tobacco products and those with cataracts. we can infer that women who have difficulty remembering, are depressed, and take tobacco products will have a higher probability of experiencing difficulty seeing as they grow older (60 years and above). lastly, age, sex, problems with remembering, depression, tobacco intake, cataracts, sbp, and heart rate are significantly linked with difficulty in seeing among the aged population of ghana. conflicts of interest the author declares no conflicts of interest. references • bechange, s., jolley, e., virendrakumar, b., pente, v., milgate, j., & schmidt, e. 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(1990). magnitude and causes of blindness in the developing world. international ophthalmology, 14(3), 135–140. https://doi.org/10.1007/bf00158310 • ganley, j. p., & roberts, j. (1983). eye conditions and related need for medical care among persons 1-74 years of age, united states, 1971-72. • lauren, s. (2021). age-related macular degeneration: from gwas to functional effects (doctoral dissertation, [sl]:[sn]). • long, j. s., & freese, j. (2014). regression models for categorical dependent variables using stata, third edition. amsterdam university press. • lonsdale, j., thomas, j., salvatore, m., phillips, r., lo, e., shad, s., hasz, r., walters, g., garcia, f., young, n., foster, b., moser, m., karasik, e., gillard, b., ramsey, k., sullivan, s., bridge, j., magazine, h., syron, j., . . . moore, h. f. 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(2019). prevalence, causes, and factors associated with visual impairment and blindness among registered pensioners in ghana. journal of ophthalmology, 2019, 1–10. https://doi.org/10.1155/2019/1717464 780 global journal of public health medicine 2023, vol 5, issue 1 gggggglo • osaba, m., doro, j., liberal, m., lagunas, j., kuo, i., & reviglio, v. e. (2019). relationship between legal blindness and depression. medical hypothesis discovery and innovation in ophthalmology, 8(4), 306–311. • parravano, m., petri, d., maurutto, e., lucenteforte, e., menchini, f., lanzetta, p., varano, m., van nispen, r. m. a., & virgili, g. (2021). association between visual impairment and depression in patients attending eye clinics. jama ophthalmology. https://doi.org/10.1001/jamaophthalmol.2021.1557 • quillen, d. a. (1999, july 1). common causes of vision loss in elderly patients. aafp. https://www.aafp.org/pubs/afp/issues/1999/0701/p99.html • ratnapriya, r., sosina, o. a., starostik, m. r., kwicklis, m., kapphahn, r. j., fritsche, l. g., ... & swaroop, a. (2019). retinal transcriptome and eqtl analyses identify genes associated with age-related macular degeneration. nature genetics, 51(4), 606-610. https://doi.org/10.1038/s41588-019-0351-9 • rius ulldemolins, a., benach, j., guisasola, l., & artazcoz, l. (2018). why are there gender inequalities in visual impairment? european journal of public health, 29(4), 661–666. https://doi.org/10.1093/eurpub/cky245 • seidu, a. a., agbadi, p., duodu, p. a., dey, n. e. y., duah, h. o., & ahinkorah, b. o. 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(2022). the association between vision impairment and depression: a systematic review of population-based studies. journal of clinical medicine, 11(9), 2412. https://doi.org/10.3390/jcm11092412 • vision impairment and blindness. (2022, october 13). https://www.who.int/news-room/factsheets/detail/blindness-and-visual-impairment • world health organization (2013). who universal eye health: a global action plan 2014–2019. who. geneva: world health organization; 2013. available from: https://www.who.int/blindness/actionplan/en/. • zhang, x., bullard, k. m., cotch, m. f., wilson, m. r., rovner, b. w., mcgwin, g., owsley, c., barker, l., crews, j. e., & saaddine, j. b. (2013). association between depression and functional vision loss in persons 20 years of age or older in the united states, nhanes 2005-2008. jama ophthalmology, 131(5), 573. https://doi.org/10.1001/jamaophthalmol.2013.2597 microsoft word gjphm-2023 thrombosis 1.docx 792 global journal of public health medicine 2023, vol 5, issue 1 gggggglo originalresearch evaluating the incidence of thromboembolic disorders during pregnancy and puerperium with their presentation, complications, and risk factors: a prospective observational study monica. r*, chamrutha r department of obstetrics and gynaecology,rajah mirasudhar hospital, thanjavur medical *corresponding author: priya.dharshini13048@gmail.com abstract introduction: due to the pro-thrombotic state during pregnancy, cortical venous thrombosis, dural venous sinuses, and thrombosis of the cerebral veins afflict people more frequently throughout the puerperal phase. this study aims to assess the incidence, types of sinuses involved, symptoms and risk factors of thromboembolic disorder throughout pregnancy and the puerperal phase.methods: this prospective observational study was conducted during the study period of 18 months (january 2020-june, 2021). this included 100confirmed cases (both clinical and radiological) of thromboembolic disorders in pregnancy and puerperal period who were admitted at thanjavur medical college hospital, tamil nadu. data was collected in the schedule, and responses were entered in microsoft excel. the descriptive statistics such as frequency and percentages were calculated using epi info free software available online. results: in the current investigation, 100 cases of thrombosis were analysed. most thromboembolic patients (56 cases) were between the ages of 26 and 35. nearly more than one-third (29%) were in the post-natal period of gestation, almost half (51%) of them had a caesarean section as a mode of delivery, 63% were multiparous, 42% were in the bmi range of 25.130 and majority (96%) had venous thromboembolism. out of 70 cases of cortical venous thrombosis, the superior sagittal sinus was the most frequently affected (55.7%). we found hypertensive disorders (54%) and diabetes (12%) are the most important predisposing factor for thrombosis. the most common symptom is headache, contributing to 41.4%, and convulsions, contributing to 27%. conclusion: thromboembolism is most common in post-natal women who have undergone caesarean section and multiparous. obese people are more likely to develop thromboembolism than non-obese people. keywords: thromboembolism,deep vein thrombosis, cortical venous thrombosis 793 global journal of public health medicine 2023, vol 5, issue 1 gggggglo introduction thromboembolic disorders account for 0.5to 2.0 per 1000 pregnancies, which leads to 1.1 deaths per1,00,000 pregnancies. the risk of thromboembolism in pregnancy is four to five times higher than that of non-pregnant women(parunov et al., 2015). early recognition of signs and symptoms and prompt treatment reduce the morbidity and mortality due to thromboembolic disorders(tarbox & swaroop, 2013). in 1856, rudolf virchow postulated the virchow triad–venous stasis, hypercoagulability and endothelial changes(kumar et al., 2010). pregnancy itself predisposes the risk of thromboembolism due to a hypercoagulable state; the uterus compresses the leg vein – causing venous stasis and endothelial injury in case of preeclampsia(dado et al., 2018). around 70% of deep vein thrombosis in antenatal patients occurs within less than 15 weeks of gestation during the antenatal period.most deep vein thrombosis occurs in the iliofemoral vein, which is more prone to embolism and challenging to diagnose(devis & knuttinen, 2017). cortical venous thrombosis, dural venous sinuses and thrombosis of cerebral veins affect more commonly during the puerperal period due to the pro thrombotic state.the patient typically exhibits localised neurological impairments, papilledema, altered sensorium, headaches, and seizures(alvismiranda et al., 2013). cantu from mexico reported that 59% of cortical venous thromboses are puerperal. international study on cerebral and dural sinus thrombosis reported that 20% are obstetric cerebral venous thrombosis; compared to mexico, india showed the highest frequency of cases(alvis-miranda et al., 2013). (cross et al., 1968) stated that "if the patient survives acute episode, recovery is rapid and complete". the clinical spectrum of cerebral sinus venous thrombosis is vast, where its mode of onset is highly variable, and it is regarded as a medical emergency(nagaraja et al., 1999). pulmonary embolism is rare and affects 1 in 7000 pregnancies. pulmonary embolism is fatal if not treated promptly(bonnin et al., 2005).this study aims to assess the prevalence, demography, risk factors, clinical characteristics, diagnosis, and treatment of thromboembolic disorder throughout pregnancy and the puerperal phase, as well as to examine the results for both the mother and the perinatal outcomes. the current study aimed to assess the prevalence, types of sinuses involved, symptoms and risk factors of thromboembolic disorder throughout pregnancy and the puerperal phase. methods this is a prospective observational study including 100confirmed cases (both clinical and radiological) of thromboembolic disorders in pregnancy and puerperal period who were admitted at thanjavur medical college hospital, tamil nadu, during the study period of 18 months (january 2020-june, 2021) and followed up till their completion of treatment. exclusion criteria:all patients without a definitive diagnosis of thromboembolic disorders or without radiological evidence of cortical vein thrombosis (cvt) or women who presented with complaints after six weeks' puerperium were excluded. 794 global journal of public health medicine 2023, vol 5, issue 1 gggggglo study procedure: all patients admitted during the study were analysed based on a performed proforma. primary demographic data were recorded regarding the name, age, parity, number of live children, type of antenatal care, mode of delivery, and presence of predisposing factors. results of the procedure concerning incidence, risk factors and complications associated with thromboembolic disorders were inferred. among the radiologically confirmed cases, the following investigations were performed. cortical venous thrombosisall patients underwent neuroimaging, including brain computed tomography (ct) and magnetic resonance imaging (mri) with magnetic resonance angiography (mra) and magnetic resonance venography (mrv) with clinically confirmed cases of cortical venous thrombosis deep vein thrombosis-doppler ultrasound is done in a patient with deep vein thrombosis. a pulmonary embolism-ct pulmonary angiogram was performed. mitral valve thrombosis-echocardiography done. brachial artery thrombosis-doppler sonography cephalic vein thrombosis doppler sonography ethical considerations: the prepared protocol was submitted to the institutional ethics committee (iec), and permission to carry out the study was obtained before the study was started. the pregnant mothers were interviewed in person, and various radiologic investigations and blood for coagulation profiles were drawn after obtaining informed written consent. the privacy and confidentiality of the mother were conserved statistical analysis: data was collected in the schedule, and responses were entered in microsoft excel. the descriptive statistics such as frequency and percentages were calculated using epi info free software available online. a value less than or equal to 0.05 was inferred as statistical significance. results: in the current investigation, 100 cases of thrombosis were analysed. fifty-six individuals, or most thromboembolic patients, were between 26 and 35. the oldest is 45 years old, and the youngest is 16. the mean age was found to be 30.5. among which majority of the thrombosis contributes to the puerperal group, post caesarean section 51%, post-natal 29% and post-abort-al 10%. thromboembolism risk increases during multi para contributing to 63% (out of 100 cases). most patients are overweight, contributing to 42%, and obese patients contribute 16%. , majority of the thrombosis is venous thrombosis 96 cases (table: 1) 795 global journal of public health medicine 2023, vol 5, issue 1 gggggglo table: 1 distribution of study participants according to several variables (n=100) patients(n=100) percentage (%) based on age (in years) 16-25 34 34 26-35 56 56 >35 10 10 based on the period of gestation antenatal 10 10 postabortal 10 10 postnatal 29 29 postcaesarean section 51 51 based on the mode of delivery normal vaginal delivery 26 32.5 assisted vaginal delivery 3 3.75 caesarean section 51 63.5 based on parity primi 37 37 multi 63 63 <18.5 2 2 based on bmi 18.6 25 40 40 25.1 30 42 42 > 30.1 16 16 type of thrombosis arterial thrombosis 1 venous thrombosis 96 cortical venous thrombosis-70 deep vein thrombosis-21 mesenteric vein thrombosis-1 cephalic vein thrombosis-4 pulmonary embolism 1 mitral valve thrombosis 2 796 global journal of public health medicine 2023, vol 5, issue 1 gggggglo table: 2. types of sinus involved in cortical vein thrombosis (cvt) (n=70) s.no types of sinusinvolvedincvt (n=70) patients % 1 superiorsagittalsinus 39 55.7 2 superiorsagittalsinusandtransversesinus 10 14.2 3 sigmoidsinus 6 8.6 4 transversesinus 7 10 5 straightsinus 2 2.6 6 cerebralveinthrombus 6 8.6 among 70 patients, the most common sinus involved was found to be superior sagittal sinus (55.7%) followed by the combination of superior sagittal sinus and transverse sinus, (14.2%).(table:2) the most frequent symptom in the current study, accounting for 41.4% of cases, is headache, convulsions contributing to 27%, blurring of vision contributing to 15%.(figure:1) figure: 1 symptoms of thrombus in cortical vein thrombosis (n=70) 0 5 10 15 20 25 30 35 40 45 headache alone headache with convulsion s acute confusion blurring of vision/ papilledem a psychosis convulsion s with loss of consiousn ess fever patients 29 19 2 11 4 4 1 % 41.4 27.1 2.8 15 5.7 5.7 1.4 symptoms of thrombosis in cvt 797 global journal of public health medicine 2023, vol 5, issue 1 gggggglo table: 3. the available risk factors in the study,(n= 100) risk factors no. % hypertension(ght/chronic ht) 54 54 hypothyroid 8 8 diabetes(gdm/dm) 12 12 prolonged immobilisation 8 8 dehydration 5 5 heart disease 3 3 antiphospholipid antibody syndrome (apla) 3 3 covid cases 2 2 sepsis 3 3 ventilator 2 2 in our study, we found hypertensive disorders (54%), diabetes (12%), dehydration (5%), sepsis (3%), and ventilator (2%) are the most important predisposing factor for thrombosis. (table:3) discussion in pregnant individuals compared to those who are not, thromboembolism is more prevalent and harder to diagnose. the main factor contributing to maternal deaths in developed countries is pulmonary embolism(marik & plante, 2008; simpson et al., 2001). many of these deaths result from delayed diagnosis, delayed or ineffective treatment, and insufficient thromboprophylaxis. focusing on venous thrombosis during pregnancy, this study will provide an overview of its prevalence, types of sinuses involved, symptoms and risk factors of thromboembolic disorder throughout pregnancy and the puerperal phase. in this study, 100 cases were studied, with the highest thromboembolic disorder being within the age group of 26 to 35 years. this is consistent with various studies. pregnancy-related (antepartum and postpartum) thromboembolism occurred 59 times per 10,000 pregnancies. in contrast, the incidence rate of thromboembolism in women of reproductive age (20-49 years old) was 28 instances per 10,000 people per year(coon ww.,1973). vte incidence rates in the modern era (1987–2004) are thought to be significantly lower. the absolute risk of vte outside of pregnancy (before the date of conception or after three months following delivery) was estimated by (sultan a., 2015) in significant population-based cohort research to be 2 per 10,000 people per year (for the population of reproductive-aged females). most of the patients are overweight, contributing to 42%, with obese patients contributing to 16%. likewise,(finkelstein et al., 2012) proposed a positive association between increasing bmi and escalating risk of thromboembolism. (borch et al., 2009) found that increasing bmi was related to an 798 global journal of public health medicine 2023, vol 5, issue 1 gggggglo increased incidence of recurrent thromboembolism. this showed that increased bmi increases the risk of thromboembolism. in the present study, most of the thromboembolic disorder is mainly confined to the puerperal group consisting of post-c-section. the annual incidence of thromboembolism was five times higher among postpartum women who underwent lower caesarean section than pregnant women, and the incidence of deep venous thrombosis was three times higher than that of pulmonary embolism in postpartum women, according to (heit et al., 2005). according to (berg et al., 2003), 42% of women with lower limb extremity deep vein thrombosis went on to develop pulmonary thromboembolism. in the present study, out of 70 patients with cortical vein thrombosis, most of the cortical vein thrombosis occurs in the post-natal period contributing to 21.4%, followed by post-cesarean section contributing to 61.4%. in a study by (kumar s., 2004), 65 out of 85 cases (about 76%) of puerperal cortical vein thrombosis were discovered. the present study of the cortical venous thrombosis (cvt) group is comparable (kumar s., 2004). in the current study, headache was the most prevalent symptom, affecting 41.4% of patients, comparable to the(kumar s.,2004) study with 66%. only 20% of cortical venous thrombosis (cvt) patients with pre-eclamptic toxaemia show prolonged diastolic pressure of >105mmhg before stroke occurs, according to a study by (james et al., 2005). other trials, such as those by (daif a., 1995),(nagaraja et al., 1999), and (plum, 1987), reported a very high (>50%) frequency of headaches. a link between gestational diabetes and thrombosis was also discovered by (james et al., 2005)and (jacobsen et al., 2008) in two trials. in the current study, seizures occurred in 27% of individuals, which is equivalent to (schell & rathe, 1988)'s study. the study's findings were found to be incongruent with those of (kumar et al., 2004)(67%)(schell & rathe, 1988)(39.2%). the superior sagittal sinus is most frequently affected in the current study of the cvt group, accounting for 55.7% of cases, followed by the transverse sinus with 10%, and the cerebral vein with 8.6%, which is comparable to (ameri & bousser, 1992) (72%) and (schell & rathe, 1988)(72.2%). similar to our study group, (bansal et al., 1980)observed that postpartum cvt occurred 7–10 days after birth. the percentages of the superior sagittal sinus, transverse/sigmoid sinus, straight sinus, and internal cerebral vein were reported by (daif a., 1995). according to (brown et al., 2006), women with pre-eclampsia had a 60% higher risk of having an ischemic stroke than women without it. this current study is more comparable with (brown et al., 2006), in which women with hypertensive disorders were 54%. all cases of dvt presented with the same symptoms of leg pain and swelling. in the present study, thromboembolism risk increases during multipara, contributing to 63% (out of 100 cases). the study had a few limitations. firstly, there needed to be more sample size obtained for the appropriate study design. the causal relationship is difficult to assess. secondly, this was a single 799 global journal of public health medicine 2023, vol 5, issue 1 gggggglo centred study; most participants were from rural areas.it will be easier to establish a link between the aetiology and disease prognosis through longitudinal studies that take the form of follow-up studies. conclusion the postpartum period and pregnancy put women at higher risk for venous thromboembolism. even though venous thromboembolism is the main factor in maternal mortality in developing countries, it is still a relatively uncommon occurrence. the majority of these incidents are deep vein thromboses that happen after childbirth. multiple pregnancies are a significant risk factor. women who underwent a caesarean section postpartum, obese, multiparous or have a history of hypertension disease should have their risk for venous thromboembolism thoroughly evaluated. conflicts of interest the author declares no conflicts of interest. references • alvis-miranda, h. r., milena castellar-leones, s., alcala-cerra, g., & rafael moscotesalazar, l. 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(2013). pulmonary embolism. international journal of critical illness and injury science, 3(1), 69–72. https://doi.org/10.4103/2229-5151.109427 microsoft word gjphm-2022 role of public health copy.docx 698 global journal of public health medicine 2022, vol 4, issue 2 gggggglo review research role of public health professionals in tackling pandemic situations sabiha sultana 1, ahmad muddasser 2, md mahmudul hasan 3, maimuna khatun 4, sajidur rahman akash 5, prodip kumar baral 6, imtiaj hossain chowdhury 5. 1 department of pharmacy, university of asia pacific, dhaka-1205, bangladesh. 2 department of social work, tejgaon college, dhaka 1215, bangladesh. 3 al basar international foundation, dhaka-1207, bangladesh. 4 department of microbiology, jahangirnagar university, dhaka-1342, bangladesh. 5 department of pharmacy, bangladesh university, dhaka-1207, bangladesh. 6 department of pharmacy, noakhali science and technology university, noakhali 3814, bangladesh. *corresponding author: imtiaj.eham@gmail.com abstract a pandemic of a disease occurs in many countries and so on continents at a time and affects its huge population physically, mentally, socially and economically. in order to minimize or eliminate the burden of pandemic, it is required to plan and implement effective strategies promptly. the rapid emergence and spread of these pandemic diseases raise severe public health, economic, and development implications. additionally, it underlines how crucial it is to build comprehensive disease diagnosis and response skills, especially in "hot spot" zones where a wide range of factors may combine to bring about the manifestation of disease. as the entire planet attempts to slow the spread of pandemics from the time of occurrence, public health is now more significant than ever before. public health professionals are individuals who fight epidemics for the population through disease identification and prevention, conducting research and promoting healthy lifestyles. recognizing symptoms, such as unusual disease, that indicate a developing outbreak requires public health initiatives, particularly those incorporated in conventional health service provision. once an unusual disease has been recognized and an outbreak has been established, core health care facilities work to identify individuals and their ties, as well as dismantle transmission chains in communities. this paper will try to present the responsibilities of public health professionals in tackling pandemic situations briefly. in the first section, a short overview of pandemic will be mentioned, then it will structurally discuss what public health experts particularly do during a pandemic. keywords: pandemic, public health professionals, outbreak. 699 global journal of public health medicine 2022, vol 4, issue 2 gggggglo introduction: a pandemic, according to the centres for disease control and prevention (cdc), is a disease outbreak that has expanded several geographic and cultural boundaries and has impacted a substantial amount of people (“principles of epidemiology | lesson 1 section 11,” 2012). in the occurrence of a global pandemic, the world health organization (who), in partnership with national and international stakeholders and public health professionals, has a crucial impact in controlling and suppressing its propagation. pandemics with higher prevalence may affect a substantial proportion of the world's population and lasts over a period of months (wolfe et al., 2007). majority of the disease with pandemic severity are frequently caused by fast-spreading infectious organisms (bacteria or viruses). research shows that over the past century, pandemics have become more likely as a result of increased global tourism and inclusion, urbanization, drug resistance, impoverished healthcare systems, strenuous forms of agriculture, changing land uses, and greater destruction of natural eco system (madhav et al., 2017; o’dowd 2007). the massive outbreaks of pandemic infectious diseases that are appearing and cropping up in any region occur without prior planning and development of disease control techniques. the lack of preparedness for the outbreak, as well as a lack of understanding of the potential cause, make the problem more difficult and complicated to address (tekalign,2020). finally, pandemics inflict enormous economic, social, and political disruption in addition to increasing morbidity and mortality across a broad range of geographic arena (madhav et al., 2017). there have been a number of notable pandemics that have affected the world, including the spanish flu, the e. coli o157:h7 (e. coli) pandemic, the zika virus pandemic, and the hiv/aids pandemic [table-1] (madhav et al., 2017). table 1: remarkable pandemic events since middle ages and impact on the economy and society (madhav et al., 2017). event starting year impact on the economy, society bubonic plague (black death) pandemic 1947 likely hastened end of the feudal system in europe introduction of smallpox early 1500s demolished native communities, allowing europe to assume dominance fifth cholera pandemic 1881 prompted strikes on the russian tsarist administration and hospital professionals spanish flu influenza pandemic 1918 australia's gdp decreased by 3%, canada's by 15%, the united kingdom's by 17%, and the united states' by 11%. asian flu influenza pandemic 1957 canada, japan, the uk, and the us all had a 3% gdp decline. hong kong flu influenza pandemic 1968 direct and indirect costs in the us range from us$23 to us$26 billion. hiv/aids pandemic 1981 gdp growth in africa is lost by 2-4 percent annually. 700 global journal of public health medicine 2022, vol 4, issue 2 gggggglo sars pandemic 2003 hong kong sar, china experienced a us$4 billion gdp loss, us$3 billion to us$6 billion in canada while singapore suffered a us$5 billion gdp loss. swine flu influenza pandemic 2009 republic of korea's gdp decreased by $1 billion. mers epidemic 2012 republic of korea suffered a us$2 billion loss, which led to us$14 billion in government stimulus spending. west africa ebola virus disease epidemic 2013 oss in guinea, liberia, and sierra leone of us$2 billion zika virus pandemic 2015 loss in latin america and the caribbean of us$7–us$18 billion emergence and spread of infectious diseases with pandemic potential: throughout history, infectious disease with pandemic potential have frequently emerged and spread. as a result of increased interaction with animals due to breeding, hunting, and international commerce activities, zoonotic microorganisms, which are infectious diseases that can spread to people, are to blame for many infectious diseases that trigger pandemics (boyce & katz, 2019). five sequential steps make up the process of cross-species transmission by which an animal pathogen becomes a competent pathogen in humans (boyce & katz, 2019; piret & boivin 2020; pike et al., 2010). (1) under natural conditions, the pathogens are exclusively infecting animals such as most malarial plasmodia.; (2) the pathogen transforms once it has been transferred to people but without enduring human-tohuman transmission.; such pathogens include tularemia bacilli, nipah, rabies, and west nile viruses.; (3) like the viruses that cause ebola, marburg, and human monkey pox, the pathogen only passes through a few rounds of secondary human transmission.; (4) although the disease affects animals, protracted sequences of secondary human-to-human transmission, like that of influenza a, vibrio cholerae, and the dengue virus, happen without the involvement of animal hosts.; and (5) the disease affects humans exclusively, such as human immunodeficiency virus (hiv) infection, smallpox, and tuberculosis. 701 global journal of public health medicine 2022, vol 4, issue 2 gggggglo the likelihood of zoonotic transmission is probably modulated by the pathogen-carrying animal species, the type of human connection with that animal, and the frequency of these encounters. figure 1: cross-species transmission of pandemic diseases to human (gan et al., 2020). every pandemic starts off as a small-scale disease episode that spreads fast over the world. in the case of the covid-19 pandemic, in late 2019, healthcare professionals in wuhan, china, began reporting a cluster of uncommon double lung infections with no known explanation to the who headquarters in china. the huanan seafood market in wuhan was the source of all covid-19 cases in the beginning. these marketplaces sell live fish, meat, and wild animals, which brings a wide variety of animal species together in close proximity. as a result, viruses might easily switch between species. the genetic code of the viruses alters as a result of this, and a new animal viral strain emerges. when the infected animal was butchered, the virus infected a human by coming into contact with the mouths, eyes, nose, or blood. and because it was a new virus, humans had very little immunity to it. globally, as of 16 june 2022, there have been 542,529,476 confirmed cases of covid-19, including 6,336,651 deaths, reported to who (“who coronavirus (covid-19) dashboard,” n.d.). to evaluate the effects of a pandemic, it is important to consider two key variables. the first is clinical severity, or the severity of the infectionrelated disease. the second factor is the pandemic virus's transmissibility, or how quickly it spreads from individual to individual. these two characteristics are used to help the cdc decide which activities to propose at any particular point during the pandemic (branswell, 2009). 702 global journal of public health medicine 2022, vol 4, issue 2 gggggglo classification and phases of pandemic the classification of “pandemic” comes when a disease affects the global population. the stages of an outbreak that result in the proclamation of a pandemic have been established by the world health organization (who) (“the who pandemic phases”,2009). in 1999, the who created its pandemic phases, which were updated in 2005. the phases offer a universal framework to assist nations in pandemic preparedness and response planning and are relevant to the entire world. for ease of integration of new recommendations and methodologies into already-existing national preparedness and response plans, the who has retained the use of a six-phased strategy in this iteration. phases 13 relate to preparedness, including activities for building capacity and reaction planning, whereas phases 4-6 indisputably indicate the need for response and mitigation measures (branswell,2009). figure 2: phases for the declaration of pandemic (riley, 2021) this following staggered strategy is designed by the who to assist countries and other stakeholders in anticipating when certain conditions would necessitate decisions and determining when major actions should be implemented (table-2) (branswell,2009). this approach allows nations to establish additional global inequalities based on their unique circumstances in addition to the pandemic phase that has been declared globally. it is advised that governments investigate whether the potential pandemic virus is spreading disease within their borders, in neighbouring countries, or in countries that are in close proximity to them in this situation (fraser, 2020). it is critical to emphasize that the phases were developed to provide guidance to countries on the implementation of activities, not as an epidemiological prediction. although global influenza surveillance and monitoring systems have 703 global journal of public health medicine 2022, vol 4, issue 2 gggggglo significantly enhanced, it is still possible that the first outbreaks of a pandemic will go completely unnoticed. for example, if symptoms are mild and non-specific, an influenza virus with pandemic potential may achieve relatively widespread circulation before being detected, causing the global phase to shift from phase 3 to phases 5 or 6. if the rapid containment operations are successful, phase 4 may be reverted to phase 3 (“world health organization” 2009). table 2: who pandemic influenza phase descriptions and main actions by phase (branswell,2009) estimated probability of pandemic summary main actions in affected countries main actions in nations that have not yet been impacted phase 1 uncertain no animal influenza virus circulating among animals has been reported to cause infection in humans. designing, executing out, practicing, and coordinating national pandemic influenza preparedness and response plans with national emergency preparedness and response plans. phase 2 since it is known that an animal influenza virus that is present in farmed or wild animals may infect people, it is recognized as a specific potential pandemic danger. phase 3 there have been isolated cases or small clusters of disease in humans brought on by an animal or human-animal influenza reassortant virus, but there hasn't been enough human-to-human transmission to support widespread epidemics. phase 4 medium to high it has been proven that an animal or human-animal influenza reassortant virus capable of sustaining community-level outbreaks can rapid containment. readiness for pandemic response. 704 global journal of public health medicine 2022, vol 4, issue 2 gggggglo be transmitted from person to person. phase 5 high to certain the same identified virus has caused sustained communitylevel outbreaks in at least two countries in one who region. pandemic response: each country to implement actions as called for in their national plans. readiness for imminent response. phase 6 pandemic in progress the same virus has produced persistent community-level outbreaks in at least one additional nation in a different who region, in addition to the requirements specified in phase 5 of the assessment process. post-peak period most countries with effective surveillance have seen a decline in pandemic influenza levels from their peaks. evaluation of response; recovery; preparation for possible second wave. possible new wave in most countries with effective surveillance, the level of pandemic influenza activity is once more on the rise. response post-pandemic period throughout most countries that have effective surveillance, influenza levels have restored to those seen during the seasonal influenza season. evaluation of response; revision of plans; recovery. role of public health professionals at the time of pandemic: public health workers are those who are in charge of delivering vital public health services, such as monitoring health status to identify community health problems, diagnosing and investigating community health problems and hazards, informing, educating, and empowering people about public health issues, mobilizing community partnerships to identify and solve health issues, and developing policies and plans that support individual and community health efforts; ensure a competitive environment for all (rogers,2022). like other health professionals, public health professionals endeavor to advance the general public's health and wellbeing by offering pertinent information on healthy behaviors and self-care (“pandemic severity assessment framework (psaf) | pandemic influenza (flu) | cdc,” 2016). as a result, public health workers at all levels must be involved in all stages of the planning and implementation process for public health crisis management. 705 global journal of public health medicine 2022, vol 4, issue 2 gggggglo in the case of pandemic situation, public health measures play a significant role since public health works for protecting and improving the health of people and their communities in a scientific and artistic way (mcgavran, 1953). public health efforts include encouraging healthy lifestyles, researching disease and its prevention, and identifying, preventing, and combating infectious diseases. protecting the health of large populations, ranging in size from a single neighborhood to an entire nation or part of the world, is the overarching purpose of public health. public health experts include people who conduct study on topics relating to community health, educate and promote healthy lifestyles in communities, set health standards and initiatives, etc. dedicate their knowledge, proficiency and experiences for protecting the health of populations (kemppainen, 2017). the health of the poor during pandemic is totally dependent on government measures. in the pandemic, public health professionals aid in protecting the health of populations by taking several actions. at the first place, public health professionals work to identify the sources of pandemic, developing models predicting the number of cases, then stop it to spread through planning and implementing control measure and keep communities as healthy as possible. public health professionals do field investigations, door to door survey, interviews, observations, situation and lab analysis for coming into a scientific and evidence based point to ascertain the causation of disease transmission. on the basis of these evidences, action plans are prepared to find out the current number of cases and to predict potential population who are at risk of pandemic. in addition, public health specialists play important role to prepare strategic framework and guidelines to prevent disease for spreading and refraining to get from further complications of diseases, to promote healthy lifestyles and to prolong wellbeing (mcgavran, 1953; kemppainen, 2017). public health professionals who execute such policies and programs safeguard the public. the majority of the time, ignorance is to blame for the spread of several deadly diseases. raising public awareness is the main duty of public health professionals. they inform people on the gravity of illnesses and the best ways to stop the spread of disease or defend themselves from it in a pandemic. increasing awareness is a crucial component of the public health strategy to enhance the standard of care for families and communities ((“10 essential functions of public health professionals | texila,” 2021) social marketing or “mass media” campaigns and ehealth interventions are effective techniques for promoting engagement in general health issues and raising public awareness (gebbie et al,. 2002). public health practitioners also encourage those with whom they work to be healthy and happy. they advocate for healthy behaviors and instruct individuals or groups on how to engage in self-care and healthy behaviors. examples of this include educating people about the importance of having excellent mental health or working with them to develop nourishing and healthy eating habits. 706 global journal of public health medicine 2022, vol 4, issue 2 gggggglo identify the source of pandemic: identification of the source of diseases is the first and foremost responsibilities of a public health professional. public health professional such as epidemiologists begin to search for the causation of diseases as soon as a public health concern occurred in a place. the field investigation is a widely practiced method using by the public health professionals for identifying the sources of diseases on urgent basis (goodman et al,. 1990). they conducted surveys in the surrounding and at medical facilities, and they collected nose and throat samples for laboratory investigation. these studies identified the afflicted individuals as well as the times and locations of their illnesses (“coronavirus disease 2019 (covid-19),” 2020). to help hubei province and wuhan city health officials with their epidemiological and etiological investigations in response to the covid 19 incident, the chinese center for disease control and prevention (china cdc) established a rapid reaction team. although no specific animal linkage was discovered, the who attributed the coronavirus epidemic spread to the huanan south china seafood marketplace. the novel coronavirus, covid-19, was discovered to be its source by a research team led by prof. yong-zhen zhang, and its first genome was made public on january 10 of 2020. the virus rapidly spread throughout china in less than a month during the chinese new year, a time of significant human mobility among chinese people (adhikari et al,. 2020). although it is still too early to determine who will be infected, early patterns resemble the coronaviruses that caused the middle east respiratory syndrome and the severe acute respiratory syndrome (sars) (mers). susceptibility appears to be correlated with aging, biological sex, and other health parameters (fehr et al,. 2017). covid-19 has been formally designated as a public health emergency of international concern by the who (“statement on the second meeting of the international health regulations (2005) emergency committee regarding the outbreak of novel coronavirus (2019-ncov),” 2020). developing models predicting the number of cases the most convenient way to model pandemic diseases is to use deterministic compartmental models. epidemiologists and other public health professionals strive to anticipate the number of cases involved in disease pandemics around the world. adjusting the equations' parameters allows for better simulation of environmental variables like social constraints. these models are named seir, sit, sirs, etc., since they are based on flow patterns between compartments such as susceptible (s), exposed (e), infected (i), and recovered (r). the most popular paradigm for modelling the global pandemic effects of diseases like covid-19 is the conventional susceptible, expose, infectious, and recovered (seir) model. the seir model, which looks to be a difficult problem for general statistical approaches, can be used to evaluate the effectiveness of various activities taken after the epidemic. a common model for describing how humans move through three mutually exclusive stages of infection—prone, contaminated, and recovered—is the sir (susceptible, infected, recovered) model for human-to-human transmission (šušteršič et al,. 2021). 707 global journal of public health medicine 2022, vol 4, issue 2 gggggglo planning and implementing control measure public health experts and decision-makers take appropriate planning and control measures into account in order to prevent the rapid spread of pandemic diseases and protect everyone, especially those who are more likely to suffer severe illnesses, disproportionately impacted groups, and essential workers. the objective of using control measure strategies in nations where community transmission is common is to decrease overall transmission while minimizing the unfavourable social and economic effects of tactics like isolation, quarantine, or the closure of establishments like businesses, schools, and other public gathering places (šušteršič et al,. 2021). covid-19 and public health professional: health professionals are exposed to dangers that could result in infection with an outbreak pathogen like covid-19 since they are on the front lines of any outbreak response. potential risks include pathogen exposure, long work hours, psychological discomfort, weariness, occupational burnout, stigma, and physical and mental violence (“coronavirus disease (covid-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health”, n.d.) public health professionals are starting to think about the future and how society may be better prepared for future pandemics based on what has been learnt from this coronavirus and global health care responses while the covid-19 pandemic continues to affect the global population (hussain et al,. 2021). public health workers (phws) are critical in combating the pandemic, particularly in low-income nations with weak health systems. immediate investment in health systems, as well as the involvement of health experts, may aid in the achievement of the following objectives: a. protect healthcare workers, b. interrupte the virus, c. maintain current healthcare services while expanding capacity, and d. protect the most vulnerable from socioeconomic shocks. examples of pandemic public health measures include monitoring disease progression, creating models to estimate the number of cases, creating and testing novel vaccines, screening and testing for covid-19, public health messaging, public health prevention guidelines, contact tracing, and establishing standards for work, school, and other social activities ((“what do public health professionals do? | goodwin college,” 2019). phws play an important role in providing health services, and because they often volunteer, their personal happiness and motivation are important factors in their participation in health treatments. for instance, public health worker’s programs in the central african republic demonstrated that they could provide some level of care at all times, reach the most vulnerable populations, and maintain disease surveillance activities even in conflict zones (boyce & katz,2019). given the covid-19's zoonotic roots, the emergence of new infectious illnesses, and phws' aptitude for sensitively and culturally appropriate communication of key health themes, phws could be utilized to construct and promote one health messaging initiatives. inherent resilience could be strengthened by environmental incursion, bush meat consumption, and other factors that cause infectious disease spill over occurrences by encouraging more effective behavioral change initiatives and raising knowledge of the dangers posed by these 708 global journal of public health medicine 2022, vol 4, issue 2 gggggglo factors. phws may be used as a reserve health corp during a public health emergency to develop adaptive resilience. phws are frequently involved in developing national risk communication strategies, as well as communication networks that increase the perception of the information's credibility. during an outbreak response, this helps to limit the possibility of disinformation and rumours, which can lead to fear, social unrest, and violence (seymour, 2018). conclusion: in conclusion, it can be stated that public health experts play an important role during pandemic which is ranged from identifying, tracking, and preventing disease to research conducting for saving the future pandemic. in addition, they provide evidence-based suggestions and recommendation to the policy makers to plan and implement provisions for ensuring population health. conflicts of interest the author declares no conflicts of interest. references. • 10 essential functions of public health professionals | texila. 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(2009). pandemic influenza preparedness and response. retrieved august 18, 2022, from jstor.org website: https://www.jstor.org/stable/pdf/resrep27905.9.pdf microsoft word gjphm-2021covid islamic new.docx 315 global journal of public health medicine 2021, vol 3, issue 1 gggggglo review research covid-19 pandemic and religion: islamic law perspective: a mini review sameer mohammed al-gorany department of medical laboratory technology, baqubah technical institute, middle technical university, iraq. *corresponding author: sameermohammed@mtu.edu.iq abstract at the moment, humanity lives in chaos and panic as a result of what is being spread about covid-19 pandemic through media, including tv's and social networks. this mini review displayed the procedures and the measures to deal with the diseases and pandemics according to the islamic shari'a concept. it also addressed the responsibility of the patient and the doctor in such situations as well as against other diseases. in addition, this review addressed the causes and the symptoms of covid-19 pandemic and how it could spread, avoided and treated by following and committing to the recommendations of the islamic religion and through the application of holy quran verses as well as the prophet's speech. this is due to the fact that the islam is a comprehensive religion that can effectively well handle all the humanity issues and solve all of its scientific and practical implications. keywords: pandemic , covid-19 , islamic law, religion , quarantine. 316 global journal of public health medicine 2021, vol 3, issue 1 gggggglo introduction we live these days throughout a difficult stage due to the spread of this pandemic "corona". as the quarantine forced each of us to zoom in inside our dwells, and the people started to feel bored and started expressing bitterness, also each one of us patience is being tested in the first place, which is proving to be exhausting . in the past several days and until now, the spread of this virus has been observed in many countries, which in turn has led to an increase in fear and panic among people. severe acute respiratory syndrome coronavirus 2 has now spread rapidly across china and around the world, causing acute infectious pneumonia to break out. in islam, the quran and the prophetic traditions or the sunnah are the basic sources of referencing for the laws and principles that direct the way of muslims lives and from which policies and recommendations of the responses can be extracted, including those of contemporary social and health problems. when viewed through the islamic principles of faith, life, intellect, progeny and wealth preservation and protection harm reduction measures are acceptable and, in addition, offer a realistic solution to a problem that could result in much greater harm to society at large if left unaddressed. muslims consider that adherence to islamic teachings and what the prophet mohammed (peace be upon him), recommended 1400 years ago (quarantine) is the only survivor of the spread of the epidemic. prophet mohammed's following declaration (peace be upon him) inspired the author to write this study paper on corona's latest pandemic and its connection to the teachings of islamic law and what the prophet of islam made clear more than 1400 years ago. accordingly a broad writing search has been made to discover the distributed data on the logical explores and artistic articles published internationally. hence, the purpose of this review is to prove the truth and validity of the prophet's pandemic statement. osama bin zaid (radiyallahu anhu) narrates that prophet mohammed (peace be upon him), said: "if you hear of an outbreak of plague in a land, do not enter it; but if the plague outbreaks out in a place while you are in it, do not leave that place." (al-bukhari, 1995). the prophet (peace be upon him), in his lifetime of 63 years, never spoke a single lie. that's why, regardless of their religious beliefs and nations, he received the nickname "alamin" meaning trustworthy from all. his claims on healing are still valid, and modern medical science is now showing this through 14 centuries of study. one considers how an unschooled desert man without a pen and paper could offer such an awesome expression about clinical science? about mohammed (peace be upon him), the almighty god (allah) says in the holy qur'an, “he does not speak anything of his own desire…” (surah an-najm 53:3) (hussain et al., 2016). in different words, all in all, whatever he talks is only supernaturally roused words. since islam is a finished and awesome method of human life, it must contain certain parts of wellbeing and prosperity, sickness and fix, and malady and therapy. that is the reason god (allah) motivated the prophet (peace arrive) to make in excess of 1,000 explanations of recuperating to support man for his brief remain on earth; since man needs to remain well, liberated from disorder, to satisfy his short mission on earth. it is astonishing, not withstanding, that not a solitary 317 global journal of public health medicine 2021, vol 3, issue 1 gggggglo proclamation by mohammed (peace be upon him) on recuperating is found to negate the fundamental standards of present day clinical science and drug store (mousavi, 2006). islamic concepts of health and disease lately intrigue has expanded in understanding the wellbeing impacts of religion in clinical and mainstream researchers. it is difficult enough to handle disease without tossing in the additional complexities of social and cultural differences. yet in every culture, religion exerts significant impact on personal expectations, behaviors and values about health care and forms models of treatment provided to patients (galanti, 2001)(atiyeh et al., 2008). it's no big surprise that medical services laborers in numerous nations are confronted with the issue of treating patients whose wellbeing and sickness esteems and practices that fluctuate totally from their own. muslims are only one of numerous gatherings introducing such a test. islam is definitely in excess of a profound custom, since it has a social aspect, too. shari'a, or sacred law, has five primary objectives: to protect life, to safeguard freedom of thought, to preserve the intellect, to preserve human honor and integrity and to protect property (al-hayani , 2007)(aksoy, 2002). in islam, all forms of conduct are governed by the qur'an precepts and the sunnah sacred law is an authority that accepts all aspects of human life. man is the crown of creation. they have direction, decision and commitments, including the executives of different creatures, the climate and their own prosperity (al khayat, 1995). ideas about the starting points, nature, cause, results, and wellbeing and sickness mediations give off an impression of being intensely impacted by solid linkages to islam and its customary culture. these likewise impact the transaction between the specialist and his accomplice and profoundly strict traditionalist patient. verifiably, islam instructs that god has proclaimed from paradise all great and terrible, all that occurs, regardless of whether dutifulness or noncompliance, confidence or disloyalty, ailment or wellbeing, riches or neediness, decisive. all things considered, there are two contending thoughts in islam: the fate idea and the testing idea, which incorporates a thought of a type of choice that fundamentally invalidates the previous rule. muslims recognize that disorder, enduring and biting the dust structure part of life and god's test. god's will is viewed as a significant illness, and birth absconds are viewed as a proportion of one's perseverance and trust in him. it is a cleansing encounter, not a revile or reprisal or a statement of the rage of god (atiyeh et al., 2008) (hammoud et al., 2005)(daar and al khitamy, 2001). while the believer's "reading" is reduced to a measure of adherence to the creed instead of a measure of the desire to discover what is right and real for oneself. this clarifies why the muslim says so rapidly, "in shaa allah," signifying "if god wishes." it is additionally the motivation behind why it is said that the disease, injury, passing or favorable luck is from god. the holy qur'an accomplishes its corrective and wellbeing advancing reason by laws forbidding unfortunate way of life and conduct, focusing on wellbeing advancing propensities (moderate eating; restraint from liquor, tobacco, and other psychoactive substances; day by day work out; supplications; fasting; bathing and washing; breastfeeding; and a few different orders) (atiyeh et al., 2008)(rebecca, 2006). 318 global journal of public health medicine 2021, vol 3, issue 1 gggggglo background and history of the pandemic it may be thought that adherence to islamic principles could theoretically provide protection against the risk of severe acute respiratory coronavirus syndrome (sarscov). over 1 billion people live in the islamic world that covers three continents. around %40 or more of the population is practicing some sort of islam on the backdrop of different histories and cultures (mahjoob et al., 2016). in islam, the quran and the prophetic traditions or the sunnah are the focal wellsprings of references to the laws and rules that control the method of muslims lives (rispler-chaim, 1989). while the quran and the sunnah don't have explicit answers for a large number of the social, wellbeing and different issues that have emerged since the heavenly disclosure of the quran and the lessons and conventions of the prophet mohammed (peace be upon him), such two sources have general guidance which could be examined from an islamic viewpoint on current problems and topics like harm reduction (kamarulzaman and saifuddeen 2010). the fundamental purpose of islamic divine laws is to protect and maintain the religion, culture, intelligence, offspring and wealth. consequently, the shari'a 's injunctions are stipulated to preserve and protect the integrity of man, to guide mankind from harm and destruction and to show the way to success in this world and in the future (ellison and levin, 1998). the covid-19 pandemic is compelling governments and news sources to give the most exact and supportive exhortation to the total populace, as the sickness is undoubtedly worldwide in reach. medical care experts are popular, thus also are researchers who study the transmission and impact of pandemics (craig, 2020). middle east respiratory coronavirus syndrome (merscov) was identified as a causative agent of acute respiratory distress (and renal failure) in 2012 on the arabian peninsula with an unusually high fatality rate of ~35%. extensive study has shown that the corona virus, which is the source of respiratory syndrome in the middle east, is the only camel hump for humans (farag et al., 2019). recently a serious respiratory disease was reported in wuhan, china's hubei province. on 9th january 2019, the first confirmed death from (ncov) infection occurred. the first outbreak of the virus outside china occurred in vietnam from a father to his son. on the other hand, the first outbreak outside china did not involve members of the same family, which occurred in germany on 22 january of the same year, when a german businessman fell ill from a visiting chinese businessman at a meeting in the state of bavaria, germany. epidemiological studies have suggested that the outbreak was related to a wuhan seafood market (tao et al., 2020). epidemiological studies corona viruses are a wide group of viruses that cause diseases ranging from common cold to more extreme illnesses including middle east respiratory syndrome (mers-cov) and severe acute respiratory syndrome (sars-cov). the emerging corona virus (ncov) is a new strain previously unidentified in humans. corona viruses are animal vectors, meaning they are transmitted between humans and animals (letko et al., 2003). the two known modes of infection are zoonotic mers-cov 319 global journal of public health medicine 2021, vol 3, issue 1 gggggglo transmission from dromedical camels (the host reservoir for this virus) along with human-to-human transmission (zaki et al., 2012)(haagmans et al., 2014)(hu et al., 2017). severe acute respiratory coronavirus-related syndrome (sarscov) first developed in quite a while in 2003 after transmission from creatures in outside business sectors in china. simultaneously, propels in cutting edge sequencing innovations prompted an infection revelation blast that revealed huge number of infection arrangements in natural life populaces around the world. while the majority of these infections were never distinguished in people, a considerable lot of them are hereditarily like perceived human infections inside the class beta coronavirus (letko et al., 2003). the passage of cells is a fundamental segment of cross-species transmission, particularly for beta coronaviruses. all covs encode a spike of glycoprotein that ties to the receptor of the host cell and intervenes viral data (li, 2016). for beta coronaviruses, the collaboration with the host-cell receptor is intervened by a solitary locale of the spike protein called the receptor binding domain(rbd). subsequent to restricting the receptor, the close by have protease divides a spike that delivers the spike combination peptide, encouraging the section of the infection. (simmons et al., 2013). scientists were able to isolate and determine the virus 'genetic sequence, and quickly made it available to these others to develop pcr tests independently to detect the disease. it was confirmed that the genome sequence of ncov-2019 corresponds to 75-80% of the sars sequence and more than 85% of the corona bat viruses (kirchdoerfer et al., 2019). sialic acids (neuraminic acid derivatives) are ubiquitous carbohydrates found as end-buildups on glycoproteins and glycolipids that adorn the outside of eukaryotic cells. changes in neuraminic acids, alongside the advancement of novel glycosidic linkages, bring about a wide scope of sialoglycoconjugates across cell types, tissues and creature species (stencel-baerenwald et al., 2014). differential identification of sialoside may therefore have a significant influence on the zoonotic propagation, tropism and virulence of many viruses. for example, a few amino acid substitutions in influenza virus hemagglutinins account for the preferential shift from avian enteric tract to sialylated receptors in human respiratory tract (park et al., 2019). causes and symptoms emerging infectious diseases including extreme acute respiratory syndrome (sars) and zika virus disease pose a significant threat to public health. given extensive research, how, when, and where new diseases often emerge is a source of considerable uncertainty (ventura et al., 2016). signs and symptoms of the virus appear two to 14 days after exposure to the virus, the most widely recognized manifestations of covid-19 infection are fever, weakness, and dry hack. a few patients may encounter agony and hurts, nasal clog, cool, sore throat or looseness of the bowels. these indications are normally mellow and start steadily. a few people become tainted without indicating any manifestations and without feeling sick. a great many people (about 80%) recuperate from the illness without the requirement for unique treatment. also, the seriousness of the ailment heightens in around one individual out of each 6 individuals who create covid-19 disease, who experience the ill effects of trouble relaxing. the danger of the old and individuals with essential clinical issues, for example, hypertension, coronary illness or diabetes is serious. about 2% of individuals who have gotten the malady have died (world health organization 2020b)(wolfe et al., 2007). tao et al., have been studied in patients with 320 global journal of public health medicine 2021, vol 3, issue 1 gggggglo 41 years of age who have no history of hepatitis, tuberculosis or diabetes. he was admitted to and hospitalized at wuhan central hospital on 26 december 2019, 6 days after the onset of disease. the patient reported fever, tightness of the chest, unproductive cough, pain and weakness for 1 week on presentation (tao et al., 2020). physical assessment of cardiovascular, stomach and neurological attributes was that they were typical. gentle lymphopoenia was watched, yet white platelets and blood platelet includes were typical in a total blood check test. raised degrees of c-receptive protein have been observed blood routine, crp, pct, organ function (liver enzyme, bilirubin, myocardial enzyme, creatinine, urea nitrogen, urine volume, etc.), coagulation function, arterial blood gas analysis and chest imaging (strong recommendation) levels have been slightly increased in blood chemistry tests (jin et al., 2020). cases of confirmed and deaths according to the world health organization recent stats, the united states of america leads the world countries in regard to the confirmed cases of deaths and infections due to covid-19 pandemic. then india comes second, followed by brazil and russian federation respectively, and so forth comes the rest of the world countries. a close look at the arabic counties reveals that the republic of iraq (which ranks 17th globally) tops the list of infections and confirmed deaths. then saudi arabia (that is ranked 27th globally) comes 2nd in the arab world countries. in particular, at 9:54am cet, 26 november 2020, there have been 59,816,510 confirmed cases of covid-19, including 1,410,378 deaths, reported to who (world health organization 2020c). emphasis on pandemic in hadith although a person is commanded with caution, exaggeration in caution may cause some kind of confusion, and reveal the mysteries of those who have rumors in terrorizing safe societies. a new pandemic bearing the name of corona, or (covid-19) has been borne by societies in the east and west of the earth, according to what has been recently called. the prophet mohammed (peace be upon him), did not underestimate dealing with the pandemics, nor did he panic, but rather ordered the muslim to be cautious, and he advised him to deal practically with the pandemic to prevent it is better than to mourn and cry over the spilled milk, so the pandemic is an enemy of man. all human beings to put an end to it and confront it by all available scientific means, so that it does not spread and move from one place to another as the prophet of islam commanded (craig, 2020). in the noble hadith, the prophet mohammed (peace be upon him) said, “god did not bring down a disease, or did not create a disease, but he sent down, or created a medicine for him: the death" (al-bukhari, 1995). this prophet of islam warns muslims and all of the mankind that the treatment proceeds from preserving the soul, body and mind, and shows that every disease is a medicine, and every disease cures its knowledge from its knowledge and its ignorance from its ignorance. this differs according to several aspects, such as; the ages and times, the development of medications, treatment and medical means, so the prophet gives hope to every patient, as he decides that every disease has a medicine and every disease has a cure, and thus does not lose hope, no matter how serious his illness is. unlike what is the case today where some diseases are classified as having no cure (al-kassimi, 2003). the prophet mohammed (peace be upon him), observed its moderation as usual in setting the scientific method for dealing with the disease, by intermarriage between spiritual and psychological medicine and physical medicine, and not 321 global journal of public health medicine 2021, vol 3, issue 1 gggggglo only on the physical side, and thus islam in everything where it combines religion and the world and between matter and spirit (monroe et al., 2003). prevention and treatment according to who, the centers for disease control and prevention (cdc), and the u.s. food and drug administration (fda), currently no medications or vaccines have been shown to be successful for the treatment or prevention of the 2019 extreme acute respiratory coronavirus syndrome 2 (sars-cov2) (smith and prosser, 2020). (except for those mentioned in table 1). be that as it may, those with it ought to get care to mitigate manifestations. individuals with serious ailment ought to be hospitalized. most patients recoup with strong consideration. some possible immunizations and medications explicitly expected to treat this ailment are being explored. it is being tried by clinical preliminaries. who organizes endeavors to create immunizations and meds to forestall and treat coronavirus illness. the best approaches to shield yourself as well as other people from coronavirus illness are to continue cleaning hands, spread the mouth when hacking by twisting the elbow or a tissue, and remain at any rate 1 meter (3 feet) from individuals who cough or sneeze (world health organization 2020a). table 1. conventional treatment for patients with covid-19 virus type of treatment therapeutic agent or device oxygen therapy nasal cannula non-invasive mechanical ventilation invasive mechanical ventilation extracorporeal membrane oxygenation antibiotics combination amoxicillin azithromycin fluoroquinolones antivirals lopinavir ribavirin favipiravir chloroquine oseltamivir remdesivir interferon corticosteroids methylprednisolone the prophet mohammed (peace be upon him), after he had been warned that every disease has a medicine, warned about how to deal with the epidemic, that if it falls on the land where you are, do not get out of it to escape from it, and if it falls on land and you are not in it, do not go down on it. as he said in the noble hadith: “if you hear of an outbreak of plague in a land, do not enter it; but if the plague outbreaks out in a place while you are in it, do not leave that place” (craig, 2020). it is the approach that humans have known after more than a thousand years, where if a person doubts that he has any contagious disease, he must avoid councils, mosques and public meetings, so that infection does not spread between people, and he must refrain from taking public buses and going to restaurants, markets, schools and public places (world health organization, 2020a).the prophet mohammed (peace be upon him), commanded the preservation of the human soul and not subjecting it to decimation and taking all the available causes to pay the disease, with caution, caution and prevention before falling and injury, and then taking all the available reasons for treatment and recovery. he also 322 global journal of public health medicine 2021, vol 3, issue 1 gggggglo ordered the patient to strive for treatment, but to consider him guilty if he left it and treated it with carelessness, and he must also make every effort to prevent the spread of his illness and his aggression to others by not mixing and not going out except for necessity. to prevent disease and the epidemic, one of the methods of treatment that the prophet (peace be upon him) indicated was maintaining cleanliness and preserve it is a manifestation of faith and adherence to morality and humanity. moreover, to make ablution from the conditions of prayer and the imposition of washing from impurity, and this purity extended to include the mouth. the prophet mohammad said: “if i did not make hard for my nation, i would command them with miswaak at every ablution.” miswaak (it is a wooden stick from the arak tree used to clean the mouth) (nur et al., 2012). the noble prophet urged to take the reasons for preventing infection, including his hadith, may god’s prayers and peace be upon him, “cover the bowl and put on the watering water. that epidemic" is inferred from this hadith that caution should be exercised when the epidemic is carried out with various reasons designated for it: such as covering utensils, open foods (salah, 2008). medication, wearing protective masks, caring for personal hygiene, washing vegetables and fruits, good cooking of food, boiling drinking water and quarantine on the injured .. etc. corona and double standards the consistency between islam and life is deep and not recent, and it surely what muslims are proud of and the world are proud of. we live at this time an exceptional stage in which the precautionary measures are applied which are undoubtedly important and necessary where the actual spoilage and damage (infected with the virus) or the suspicion (to be infected or not infected), and despite that, the principle in such cases is that nothing deserves venture with your health and life even if it is a handshake! the introduction of the causes is at the heart of the trust that has been commanded by the true shari'a , and it is definitely against dependence, rules and leaving the causes, and prevention is always better than cure. where is the consistency between islam and life? the answer to this question: is that these precautionary measures are the worldly aspect of what imam malik, al-shatby, and other islamic scholars have created in an instrument and editing a rule: “closing the excuses”, which we work in our religion and our world, and defining them in a briefly: “leaving those who are permissible”. in fact, the important and necessary measures published by the world health organizations and ministries of health in countries throughout the world, and talk about not waiting for injury or spread of movement, and that everyone should contribute to stopping the spread of infection by leaving a lot of good practice and meeting outside the nearby circle, and people accept the idea in a streamlined manner, and even contribute to spreading community awareness about it. the numbers are alarming, and the numbers of the injured are increasing, which makes the subject uncompromising all of this makes us marvel at how the world measures a double standard, as it believes in this rule “closing the excuses”, in the corruption of its life and its world, and it does not follow it in relation to the corruption of its religion and its aftermath, which is more important and greater!. 323 global journal of public health medicine 2021, vol 3, issue 1 gggggglo how has our profound vision of the vast universe witnessed and metaphysical turned into a narrow vision that is aware only of the material, physical, and immediate nearness?! always busy with events that have recently become consecutive and fast at an unprecedented pace, we wonder about the next and the numbers, as if we are watching a movie that is not one of its champions! ( al-qahtani, 2020) ٍةَنَس َفَْلأ ُرَّمَُعی ْوَل ُْمُھدََحأ ُّدَوَی اوُكَرَْشأ َنیِذَّلا َنِمَوٍ ةاَیَح ىَلَع ِساَّنلا َصَرَْحأ ْمُھََّندَِجتَلَو اَمِب ٌریِصَبُ َّ�اَو َرَّمَُعی َْنأ ِبَاذَعْلا َنِم ِھِحِزْحَزُمِب َُوھ اَمَو [96 ٩٦ :ةرقبلا[ َنُولَمْعَی the world is shivering, airports are suspending flights, and countries are closing their borders. for fear of facing a virus, it cannot be seen with the naked eye! how can you you weak one confront your master and your creator in a meeting that only you and his (allah) will be present in front of you? you are nothing other than god! [15 ١٥ :رطاف[ ُدیِمَحْلا ُّيِنَغْلا َُوھُ َّ�اَو َِّ�ا ىَلِإ ُءاَرَُقفْلا ُُمتَْنأ ُساَّنلا اَھَُّیأ اَی how do i behave at a time of a pandemic? in the islamic religion, there is a set of health directives and instructions in the time of the epidemic and the spread of diseases, including: 1) belief in god almighty, in the amount of good and bad, and the taking of causes, lack, dismay and alarm, god almighty said in his holy book: [11 ١١ :دعرلا[ ٍلاَو ْنِم ِھِنُود ْنِم ْمُھَل اَمَو ُ ھَل َّدَرَم َالَف اًءوُس ٍمْوَقِبُ َّ�اَ داََرأ َاذِإَو ْمِھُِسفَْنأِب اَم اوُرِّیَُغی ىَّتَح ٍمْوَقِب اَم ُرِّیَُغی َال ََّ�ا َّنِإ ا ُفِّرَُصن َفْیَك ْرُظْنا ٍضْعَب َْسأَب ْمُكَضْعَب َقیُِذیَو ًاعَیِش ْمُكَسِبْلَی َْوأ ْمُكِلُجَْرأ ِتَْحت ْنِم َْوأ ْمُكِق ْمُھَّلَعَل ِتاَیْآل ْوَف ْنِم ًابَاذَع ْمُكْیَلَع َثَعْبَی َْنأ ىَلَع ُرِداَقْلا َُوھ ُْلق [65 ٦٥ :ماعنألا[ َنوُھَقْفَی 2) preserving prayer, supplication, and pleading with a lack and refraction of god almighty. in a tweet to us president (donald trump), he said: it is a great honor for me to announce on sunday, march 15, 2020, the national day of prayer in america! and the pope of the vatican says: we pray that god will remove this epidemic from the people of the earth. then he says, i unite with the bishops and the believers in these difficult times to live by faith, love and trust in the power of god, that we pray for those who suffer from the corona epidemic and for those who support them. 3) commitment to quarantine and avoid crowded places, as the prophet mohammed (peace be upon him), said “if you hear of an outbreak of plague in a land, do not enter it; but if the plague outbreaks out in a place while you are in it, do not leave that place”. 4) great care for hygiene by washing hands with water and detergent, and caring for body hygiene, clothes, and others. on the authority of abu hurairah (radiyallahu anhu) that he said: (the messenger of god, if he sneezed, put his hand or his garment on his mouth). and on the authority of aisha, (radiyallahu anha), he said: the messenger of god was if he wanted to eat or drink, wash his hands, then eat or drink)(islamweb.net 2020). 5) avoid contact with patients or suspects and in this the prophet mohammed (peace be upon him), clarified this principle by saying: "flee the leper as you flee from the lion." 324 global journal of public health medicine 2021, vol 3, issue 1 gggggglo 6) honey and black seed, god almighty said in honey: [69 ٌفَِلتْخُم ٌباَرَش اَھِنوُُطب ْنِم ُجُرْخَی ًُالُلذ ِكِّبَر َُلبُس يُِكلْساَف ِتاَرَمَّثلا ِّلُك ْنِم يِلُك َُّمث :لحنلا[ َنوُرَّكََفتَی ٍمْوَقِلً ةَیَآل َكَِلذ يِف َّنِإ ِساَّنلِل ٌءاَفِش ِھیِفُ ُھناَوَْلأ the prophet mohammed (peace be upon him), said in the black seed “black seed is a remedy (cure) for all diseases (ailments) except death” [al-bukhari and muslim] (ahmad et al., 2013). where scientific research has proven that honey and black seed raise the efficiency and ability of the human immune system (hussain et al., 2016) (saleh and schleicher, 2000)(seward, 2015)(swamy and tan, 2000). finally, we must verify the news and not spread rumors, how many have been destroyed by societies, and raise the slogan “they found out” and let us take the advice and instructions of scholars and specialists from theologians and from specialized doctors so that people do not fear and panic, and in this he said the prophet mohammed (peace be upon him), an uqba bin amer (radiyallahu anhu) he said: i said, o messenger of god, what is deliverance? he said: (i hold your tongue on you and your home can help you) narrated by (tirmidhi 2406). (hold your tongue on you) means healing rumors, (for your house can help) means quarantine. conclusion according to what has been reviewed in the literature and what was mentioned in islamic shari'a , it was found that there is a close link between the spread of this virus (covid-19) and the teachings and recommendations of islamic shari'a in terms of adherence to quarantine, prevention and personal hygiene for the individual to avoid infection and reduce the spread of epidemics .the above results of modern scientific research affirm the fact of the statements of the prophet which were stated 14 centuries ago, which says that "epidemic" “if you hear of an outbreak of plague in a land, do not enter it; but if the plague outbreaks out in a place while you are in it, do not leave that place” however, the prophet (peace be upon him) made the declaration at a time when medical science or pharmacy had not been discovered. this further confirms that no one can claim the credit of knowing all these hidden medical facts fourteen centuries ago except a prophet (peace be upon him) and a man of god (allah) chosen, because allah reveals that in the qur'an : [4-3 ٤ :مجنلا[ ىَحُوی ٌيْحَو َّالِإ َُوھ ْنِإ ٣ ىَوَھْلا ِنَع ُقِطْنَی اَمَو acknowledgments: great appreciation goes to dr. ziad q.a alabbasi from the department of electrical technologies, baquba technical institute, middle technical university. to provide his assistance in revising this manuscript linguistically and to provide some advice on the subject. conflicts of interest: the authors declare no conflicts of interest. 325 global journal of public health medicine 2021, vol 3, issue 1 gggggglo references • al-hayani, a. f. 2007. “biomedical ethics: muslim perspectives on genetic modification.” zygon 42(153). • ahmad a, husain a, mujeeb m, khan sa, najmi ak, siddique na, damanhouri za, anwar f. 2013. “review on therapeutic potential of nigella sativa: a miracle herb.” asian pac j trop biomed 3(5): 337–352. • aksoy s, 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a. d. &, and r. a. fouchier. 2012. “isolation of a novel coronavirus from a man with pneumonia in saudi arabia.” n. engl. j. med. 367: 1814–20. 1 global journal of public health medicine 2019, vol 1, issue 1 gggggglo food choices and knowledge about diseases associated among private university students in shah alam, malaysia. yogesraj selvamoney, mohammed a. abdalqader international medical school, management and science university, selangor, malaysia corresponding author: yogesraj6994@gmail.com abstract introduction: diet related diseases are diseases in human body for a long period of time that is not dangerous and it can be preventable. this diet related diseases occur due to poor eating habits. diet related diseases includes obesity, cardiovascular diseases, cancer, diabetes, osteoporosis, and dental diseases. methods: a survey was carried out to discover the food choices and knowledge about diseases associated among management and science university students. for this research study, survey method was used to collect the data. the method used to collect data which is by questionnaire which is very effective and cost effective. the questionnaire was designed in simple manner, easy to read and easy to understand for the respondents and avoid any misunderstanding. results: most of the students which is 277 had poor knowledge in choosing food (69.3%). not only that, 123 students have good knowledge in choosing food (30.8%). by this, we found out that most of the students have poor knowledge in choosing food. moreover, 161 students have poor knowledge about diet related diseases (40.3%). moreover, 239 students have good knowledge about diet related diseases (59.8%). students who have poor knowledge in choosing food which is 156 students have poor knowledge about diet related diseases as well (96.9%). only 5 students who are good in choosing food are having poor knowledge about diet related diseases (3.1%). moreover, 121 students who are poor in choosing food have a very good knowledge about diet related diseases (50.6%). whereas, 118 students who are good in choosing food have a very good knowledge about diet related diseases (49.4%). conclusion: by this, we found out that majority student have poor knowledge in choosing food and poor knowledge about diet related diseases. keywords: msu students, food choice, knowledge about diet related diseases mailto:yogesraj6994@gmail.com 2 global journal of public health medicine 2019, vol 1, issue 1 gggggglo introduction diet related diseases are diseases in human body for a long period of time that is not dangerous and it can be preventable. this diet related diseases occur due to poor eating habits. diet related diseases includes obesity, cardiovascular diseases, cancer, diabetes, osteoporosis, and dental diseases.(who, 2002). more than that, diet related diseases are major cause of death and disability. cardiovascular diseases, diabetes, cancer, obesity, respiratory diseases, are amount for 59% of 57 million mortality annually and 46% of diseases that burden the global. not only that, there is a relationship between dietary habits and diet related diseases. moreover, if there is a modification in dietary habits and physical activity, there is a major impact in reduction of the rates of these diet related diseases.(who, 2005). a total of 63.6% of the people who responded had a very low knowledge of diabetes, 27.2 % had a fair knowledge about diabetes and only 9.3% had a very good knowledge about diabetes. more than that, 50.5% had a very poor knowledge about hypertension, 19.8% had a very fair knowledge about hypertension, and 29.7% had a very good knowledge about hypertension. moreover, 63.6% had a very poor knowledge about obesity, 27.2% had a fair knowledge about obesity and 9.3% had a very good knowledge about obesity. (nti et al., 2012). nutritional needs are very high for both genders and dietary inadequacies in adolescence is high. more than that, development and rates of growth combined with appropriate psychosocial changes. (who, 2002). moreover, eating patterns exist during the period of adolescence which may follow throughout the whole life cycle. (stewart et al., 1995). nti, 2012 mentioned that 87.9% of people who responded ate three times in a day, 10.5% ate twice a day and 1.6% ate once in a day. more than that, 41.8% of respondents skipped breakfast, 16% of respondents skipped lunch, 1.9% of respondents skipped supper, 12% of respondents skipped snacks and 28.3% of respondents didn’t skip any meals. there were many reasons respondents skipped the meal. most of the respondents which is 94% skipped their breakfast due to lack of time to eat. there is a lack of time due to they woke up late or late to school. more than that, 4% of the respondents felt uncomfortable after eating breakfast and that was one of the reason they stop eating breakfast. not only that, breakfast was the most common mistake due to desire to sleep longer, lack of time and appetite. by skipping breakfast, the total daily energy, vitamins and minerals intakes are low compared to respondents who did not skip meals. (nti et al., 2012). even though, university students have grown up, they still face some nutritional problems during this stage. some students may eat a lot but they remain their body size. but, some students they eat less, but they put a lot of weight. this can be due to body metabolism and the way the body reacts to food. this can be a reason some students eat a lot and some students eat very less. overeating or not eating at all can result in obesity and diabetes as well. the overall prevalence for obesity and overweight is high and the prevalence of obesity and overweight is higher in boys compared to girls. some of them may don’t have the knowledge about nutrition value in food which can lead to certain diet related diseases. to sort this problem out, parents should bring their children to a regular medical check-up to see their health status. parents or guardian should ask the physician about their children’s health. another way to solve this problem is by checking body mass index used by medical personnel and can be done by ourselves as well. this is one of the solutions to prevent obesity. last but not least, students are suggested to look or review on calorie requirements that is needed for their body and some nutritional guidelines which may benefit them and leave a healthy lifestyle. the objectives of the study is to discover the food choices and the knowledge of diseases associated among management and science university students. 3 global journal of public health medicine 2019, vol 1, issue 1 gggggglo methods the target population used for this research is management and science university students age between 18 to 45 years old. this research finds the food choice and knowledge about diseases associated among students in the following age range who study in management and science university. the objective of the study was to discover the food choices and the knowledge of diseases associated among management and science university students. this research involves convenience sampling method where the population is obtained in management and science university. convenience sampling is a type of sample which has nonprobability sampling where the target population has certain criteria such as accessibility, geographical, availability and willingness for the purpose of study. (dornyei, 2007). the target respondents are foundation, diploma, undergraduate and post graduate student. the total sample size was 400 respondents. few previous articles were used to obtained the sample size. the sample size was obtained by using two population proportion formula. moreover, the calculation was done using each specific objective. out of all the calculation for each objective, the highest sample size which is 345 was obtained from a objective which is “to study the relationship between knowledge about diet related diseases and socio demographic factors”. another 55 was added to the sample size to get a round number. data collection procedure the data collection process involves collecting respondent’s opinions and getting useful information from participants for the research questions stated. (cooper et al., 2003). from the literature review, the most important method used to collect data was done using questionnaires. the use of questionnaire gives an advantage which is cost effective, easy to analyse, familiar, bias and less intrusive. a complete questionnaire which was taken from ucl which is a website where we can get questionnaires for nutrition knowledge which is titled “general nutrition knowledge questionnaire or gnkq” is printed for 400 respondents. the questionnaire took almost 10 minutes to complete which has total of 3 sections which is sociodemographic survey, food choice and knowledge about diet related diseases. the data was collected between september and october 2018. the survey was approved by the ethics committee of msu research and development. moreover, informed consent was collected from all the students which was attached in front of the questionnaire. a total of 400 msu students participated to complete the 8 pages of questionnaire. survey instrument the method used to collect data which is by questionnaire which is very effective and cost effective. the questionnaire shows a very organized and method that is effective to collecting data, asking questions, factor of interest and accuracy. (sekaran et al., 2009). the questionnaire is designed in simple manner, easy to read and easy to understand for the respondents and avoid any misunderstanding. moreover, participants are informed that the research is done to study the food choice and knowledge about disease associated. approximately 43 questions are developed by modifying the questionnaires based on the objectives of the study. more than that, the questionnaire has total of 3 sections. in the first section, participants have to fill up their sociodemographic profile such as age, race, weight, height, race and health perception. secondly, part 2 consist of questions about food choice knowledge which is healthy and unhealthy. lastly, part 3 consist of questions about knowledge about diet related diseases. ethical consideration permission was obtained from concerned authorities of management and science university, shah alam. an informed verbal consent will be taken from each participant prior to data collection. participation will be completely voluntary and participants will be allowed to withdraw at any time without any repercussions. other than that, confidentiality will be maintained throughout the entire course of this research. 4 global journal of public health medicine 2019, vol 1, issue 1 gggggglo results first of all, study about food choice of msu students was done. according to the data analysis, most of the students which is 277 had poor knowledge in choosing food (69.3%). not only that, 123 students have good knowledge in choosing food (30.8%). moreover, we also discovered the level of knowledge about diet related diseases among msu students. it shows that, 161 students have poor knowledge about diet related diseases (40.3%). moreover, 239 students have good knowledge about diet related diseases (59.8%). secondly, the relationship between food choices and knowledge about diet related diseases among msu students. according to the data analysis, students who have poor knowledge in choosing food which is 156 students have poor knowledge about diet related diseases as well (96.9%). only 5 students who are good in choosing food are having poor knowledge about diet related diseases (3.1%). moreover, 121 students who are poor in choosing food have a very good knowledge about diet related diseases (50.6%). whereas, 118 students who are good in choosing food have a very good knowledge about diet related diseases (49.4%). by this, we found out that majority student have poor knowledge in choosing food and poor knowledge about diet related diseases. not only that, food choice was compared with student’s social demographic profile such as gender, race, faculty and health perception. first of all, the relationship between food choice and gender of msu students was tested. it shows that 96 of male students have poor knowledge in choosing food (71.6%). not only that, 38 male students have good knowledge in choosing food (28.4%). moreover, female students also participated in this survey. the data analysis found out that 181 female students were having poor knowledge in choosing food (68.0%). then, 85 female students were having good knowledge in choosing food. (32.0%). moreover, the relationship between food choice and races of msu students was tested. we found out that 93 malay students have poor knowledge in choosing food (60.0%). not only that, 62 malay students are good in choosing food that is healthy for them (40.0%). moreover, 57 chinese students were having poor knowledge in choosing food (66.3%). then, 29 chinese students have poor knowledge in choosing food that is healthy for him (33.7%). if we look at indian students, 106 indian students have poor knowledge in choosing food (79.1%). where else, 28 indian students are good in choosing food that is healthy for them (20.9%). lastly, 21 of other races students were having poor knowledge in choosing food (84.0%). 4 of other races students were having good knowledge in choosing food (16.0%). by this we found out that, majority students of different races have poor knowledge in choosing food that is healthy for them which includes malay, chinese, indian and others. after that, the relationship between food choice and faculty of msu students was tested. the analysis shows that 25 fbmp students are poor in choosing food that is healthy for them (75.8%). moreover, 8 students from fbmp are having good knowledge in choosing food (24.2%). not only that, fhls student also participated in this research. the analysis shows that 5 fhls students are poor in knowledge of choosing food that is healthy (62.5%). where else, 3 fhls students are good in choosing food that is healthy for them (37.5%). fise students also joined this study. it showed that, 57 fise students are having poor knowledge in choosing food that is healthy for them (85.1%). moreover, 10 fise students only have good knowledge in choosing food that is healthy for them (14.9%). now, we take a look at ims students’ statistics. it shows that 103 ims students have poor knowledge in choosing food (66.5%). 52 ims students are good in choosing food that is healthy for them (33.5%). sess faculty students also joined this research. the data analysis showed that 40 sess students have poor knowledge in choosing food (75.5%), where else, 13 sess students are good in choosing food that is healthy for them (24.5%). moreover, now we take a look at shca faculty students’ statistics. 21 shca students are having poor knowledge in choosing food (95.5%). only 1 shca students have a good knowledge in choosing food that is healthy for them (4.5%). lastly, sph students were also involved in this research study. it shows that 26 sph students are having poor knowledge in choosing food that is healthy 5 global journal of public health medicine 2019, vol 1, issue 1 gggggglo for them (41.9%), 36 sph students are having good knowledge in choosing food with health concern (58.1%). by this we got to know that most of the faculty students have poor knowledge in choosing food except for sph students where (58.1%) of the students have good knowledge in choosing food and (41.9%) of the students have poor knowledge about healthy food choice. lastly, the relationship between food choice and health perception was tested. 16 students who have poor health perception are also poor in choosing food that is healthy for them as well (88.9%). moreover, 2 students with poor health perception only are good in choosing food that is healthy (11.1%). now, we move on to students who have fair health perception. the analysis shows that 59 students with fair health perception are poor in choosing food that is healthy (60.2%). on the other side, 39 students with fair health perception are good in choosing food that is healthy for them. 148 students with good health perception are poor in choosing food that is healthy for them (70.8%). 61 students with good health perception are good in choosing food that is healthy for them (29.2%). moreover, 39 students who have very good health perception are having poor knowledge in choosing food that is healthy for them (70.9%). 16 students with a very good health perception are very good in choosing food that is healthy for them (29.1%). lastly, 15 students with excellent health perception are very poor in choosing food that is healthy for them (75.0%). 5 students with excellent health perception are having good knowledge in choosing food (25.0%). by this we can found out that most of the students with different health perception which includes poor, fair, good, very good and excellent health perception are having poor knowledge in choosing food (69.3%). the others are having good knowledge in choosing food (30.8%). next, the relationship between knowledge about diet related diseases and social demographic factors. level of knowledge about diet related diseases of students was compared with student’s social demographic profile such as gender, race, faculty and health perception. first of all, the relationship between knowledge about diet related diseases and gender of msu students. the analysis found out that 59 of male students have poor knowledge about diet related diseases (44.0%). not only that, 75 male students have good knowledge about diet related diseases (56.0%). moreover, female students also participated in this survey. the data analysis found out that 102 female students were having poor knowledge about diet related diseases (38.3%). then, 164 female students were having good knowledge about diet related diseases (61.7%). moreover, the relationship between knowledge about diet related diseases and races of msu students was tested. the data analysis found out that 45 malay students have poor knowledge about diet related diseases (29.0%). not only that, 110 malay students have good knowledge about diet related diseases that (71.0%). moreover, 37 chinese students were having poor knowledge about diet related diseases (43.0%). then, 49 chinese students have poor knowledge about diet related diseases (57.0%). if we look at indian students, 68 indian students have poor knowledge about diet related diseases (50.7%). where else, 66 indian students have good knowledge about diet related diseases (49.3%). lastly, 11 of other races students were having poor knowledge about diet related diseases (44.0%). 14 of other races students were having good knowledge about diet related diseases (56.0%). by this we found out that, majority students of different races have poor knowledge about diet related diseases which includes malay, chinese, indian and others. next, the relationship between knowledge about diet related diseases and faculty of msu students. it shows that that 10 fbmp students have poor knowledge about diet related diseases (30.3%). moreover, 23 students from fbmp are having good knowledge about diet related diseases (69.7%). not only that, fhls student also participated in this research. the analysis shows that 5 fhls students are poor in knowledge about diet related diseases (62.5%). where else, 3 fhls students are having good knowledge about diet related diseases (37.5%). fise students also joined this study. it showed that, 42 fise students are having poor knowledge about diet related diseases (62.7%). moreover, 25 fise students only have good knowledge about diet related diseases (37.3%). now, we take a look at ims students’ statistics. it shows that 42 ims 6 global journal of public health medicine 2019, vol 1, issue 1 gggggglo students have poor knowledge about diet related diseases (27.1%). 113 ims students are having good knowledge about diet related diseases (72.9%). sess faculty students also joined this research. the data analysis showed that 35 sess students have poor knowledge about diet related diseases (66.0%), where else, 18 sess students are having good knowledge about diet related diseases (34.0%). moreover, now we take a look at shca faculty students’ statistics. 15 shca students are having poor knowledge about diet related diseases (68.2%). only 7 shca students have a good knowledge about diet related diseases (31.8%). lastly, sph students were also involved in this research study. it shows that 12 sph students are having poor knowledge about diet related diseases (19.4%), 50 sph students are having good knowledge about diet related diseases (80.6%). lastly, the relationship between knowledge about diet related diseases and health perception of msu students was observed. 13 students who have poor health perception are also have poor knowledge about diet related diseases (72.2%). moreover, 5 students with poor health perception only have good knowledge about diet related diseases (27.8%). now, we move on to students who have fair health perception. the analysis shows that 38 students with fair health perception have poor knowledge about diet related diseases (38.8%). on the other side, 60 students with fair health perception have good knowledge about diet related diseases (61.2%). 80 students with good health perception have poor knowledge about diet related diseases (38.3%). 129 students with good health perception have good knowledge about diet related diseases (61.7%). moreover, 24 students who have very good health perception are having poor knowledge about diet related diseases (43.6%). 31 students with a very good health perception have very good knowledge about diet related diseases (56.4%). lastly, 6 students with excellent health perception have very poor knowledge about diet related diseases (30.0%). 14 students with excellent health perception are having good knowledge about diet related diseases (70.0%). when we compared the knowledge about diet related diseases with age among msu students. the p-value obtained was (p=0.751). moreover, the p-value is (> 0.005). so, we can say that the association between knowledge about diet related diseases and age is not significant. when we compared the knowledge about diet related diseases with bmi among msu students. the p-value obtained was (p = 0.142). moreover, the p-value is (> 0.005). so, we can say that the association between knowledge about diet related diseases and age is not significant. table1 association between knowledge about diet related diseases and food choices knowledge about diet related diseases food choice poor choosing food good choosing food x2 p value poor knowledge about diet related diseases 156 (96.9%) 5 (3.1%) 96.70 <0.001 good knowledge about diet related diseases 121 (50.6%) 118 (49.4%) total 277 123 discussion in a previous research, there was a significant relationship between vegetable intakes in a high level and high knowledge about diet related diseases among children and their guardians as well (keiko et al., 2017). according to previous research, only 12 percent of consumers know that there is relationship between sodium intake and hypertension (nih, 1981). 7 global journal of public health medicine 2019, vol 1, issue 1 gggggglo according to previous research, it shows that both male and female are at risk of poor dietary habits, poor nutrition knowledge and awareness which affects their food choice and food preference (suneetha et al., 2014). moreover, previous research shows that males choose select taste, quality and cost as reason of food dislikes. not only that, females consider health when buying food compared to male (stacey et al., 2012). previous research shows that students of different races other than white choose taste, convenience and cost as reason to dislike the food (stacey et al., 2012). in contrast, another research says that race was not an important factor in food choices among college students (rozin et al., 2003). according to previous research, 73.6% of students have an episode of gastroenteritis due to food choice (bagordo et al., 2013). in contrast, it shows that fast food restaurant has an association with prevalence of diabetes which is significant relationship which is p= 0.001 (tarun et al., 2017). another research showed that fast food intake which is high was significant among obese or overweight students. moreover, it says that 72.5% of students choose fast food more than 4 times a week and some take daily as morning snack (monira et al., 2014). conclusion the alternative hypothesis is accepted. there is significant relationship between food choice and knowledge about diet related disease among management and science university students. moreover, there is significant relationship between food choices and social demographic factors among management and science university students. lastly, there is significant relationship between knowledge about diet related diseases and social demographic factors among management and science university students. references aldallal, s. 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(2005). anemia of inflammation and chronic disease. new england journal of medicine, 325(10), 1011–1023. who. (2003). diet, nutrition and the prevention of chronic diseases. world health organization technical report series, 916, i–viii-1-149-backcover. https://doi.org/isbn 92 4 120916 x issn 0512-3054 (nlm classification: qu 145) willett, w. c., koplan, j. p., nugent, r., puska, p., & gaziano, t. a. (2006). chapter 44 prevention of chronic disease by means of diet and lifestyle changes. disease control priorities in developing countries (2nd edition), (chapter 45), 833–850. microsoft word gjphm-2022 qol final draft.docx 719 global journal of public health medicine 2022, vol 4, issue 2 gggggglo original research quality of life of patients with diabetes mellitus at specialized center for endocrinology and diabetes in baghdad city wissam i. wardia , sajad z. tariq , sajjad k. adai , samah a. salman , samah r. jabaar & samira m. hassan college of nursing, al-bayan university, baghdad, iraq *corresponding author: wissamwardia@gmail.com abstract introduction: diabetes mellitus is considered one of the crucial chronic diseases with several complications; people with type 2 diabetes have a lower quality of life than normal ones. around the world, health related quality of life is widely used as a health outcome measurement. this study was conducted to assess the quality of life of patients with type diabetes mellitus (dm) and to determine some selected clinical and sociodemographic factors that affect the quality of life of these patients. methods: a descriptive cross-sectional study design was used to assess the health-related quality of life of patients with diabetes mellitus. the study was achieved from 12th january 2021 to 2nd of august 2021. a purposive sample selection was used to collect data from (150) patients. the study tool was constructed by the researchers to meet the study's objectives including an adopted scale to measure health-related quality of life in diabetic patients, participants were asked to complete three parts of the questionnaire: part i socio-demographic data, part ii includes clinical data and part iii which measure health-related quality of life by using (sf-12 short-form health survey) which measure health related quality of life for the diabetic patients. results: the result shows the general health level of patients are fair (mean= 27.00±20.382), while physical role (mean= 25.33±43.631) and emotional role (mean= 23.33±42.437) are poor, on the other hand the physical function (mean= 48.50±37.161), bodily pain (mean=53.83±27.742), mental health (mean= 51.20±28.391), vitality (mean= 42.13±28.393) and social function (mean= 49.00±33.887) are at a moderate levels. the results show a significant association between the age, level of education, and monthly income of the patients in relation to physical and mental domains at a p-value ≤0.001. conclusion: the overall health of the patients was fair despite their physical and emotional well-being levels being poor. while physical function, vitality, and bodily pain, levels were demonstrated as moderate. keywords: quality of life, diabetes mellitus, baghdad. 720 global journal of public health medicine 2022, vol 4, issue 2 gggggglo introduction: diabetes mellitus (dm) is a metabolic condition that causes hyperglycemia because of impaired insulin response, total insulin deficiency, or both. it is a non-communicable disease with high prevalence all over the world (ajeena et al., 2019). according to the atlas of diabetic international federation in 2019, there were about 463 million adults (20–79 years old) with diabetes, and by 2045, this number is expected to increase to 700 million. a total of 55 million people suffer from diabetes in the middle east and north africa (international diabetes federation, 2019). approximately 80% of the estimated 463 million adults with diabetes worldwide live in lowand middle-income countries (flood et al., 2021). according to the world health organization (who), in iraq, the currency of diabetes among adults was 13.2% in 2016 and women were more likely to be affected (who, 2016). diabetes kills 4.2 million people, and more than 20 million live births (1 in 6 live births) are affected by diabetes during pregnancy (international diabetes federation, 2019). diabetes being a chronic disease with number of complications deteriorates the quality of life among the people with dm type ii. quality of life is widely used as an important health outcome measure worldwide (thapa et al., 2019). diabetes is a highly disabling disease, which can cause blindness, amputations, kidney disease, anemia, cardiovascular, brain complications and impairing the functional capacity and autonomy and individual quality of life (ajeena et al., 2019). several studies have demonstrated that the quality of life (qol) of patients with diabetes especially those who had complications is remarkably lower than the qol of the general population (ahmed et al., 2019). the previous studies found that long-term dm complications had negative effects on an individual's physical, emotional, and social well-being, as well as health-related quality of life (hrqol) (wong et al., 2020). this study was conducted to assess the quality of life of patients with type diabetes mellitus (dm) and to determine some selected clinical and sociodemographic factors that affect the quality of life of these patients. methods: a descriptive cross-sectional study design was carried out to assess the health-related quality of life of diabetic patients. the study started on the 12th of january 2021 till 2nd of august 2021. a nonprobability purposive sample of (150) patients with diabetes were randomly selected when attending the specialized center for endocrinology and diabetic to seek medical care. the study was conducted at the specialized center for endocrinology and diabetes, which located in baghdad city / alrusafa sector. this center was established in year 2000 in response to the increased numbers of the patients who need medical care and follow up by the specialists in baghdad. the center received about (4701) patients in september 2017, (2274) of them were diabetic patients. the study sample was chosen by using the following criteria: patients who accept to participate in the study and patients with type i and type ii diabetes mellitus in baghdad with different age groups. patients how refused to participate in the study and patient who did not complete the form completely were excluded from the study. 721 global journal of public health medicine 2022, vol 4, issue 2 gggggglo a final total of (160) patients with diabetes, who were attending the center during the time of the study period, met the study criteria and agreed to participate. (150) patients of them were assigned to take a part in the study. a close ended questionnaire format was used to collect data with an adopted scale (sf12) to measure the health-related quality of life for diabetic patients. the questionnaire included three parts and were distributed as the followings: part i: socio-demographic: this part is about the socio-demographic characteristics of the participants, which were collected from the patients, and it includes: (age, gender, level of education, marital status, monthly income, occupational status, residency, body mass index (bmi), height, weight, and smoking) part ii: clinical data of the patients: this part is about the clinical data of diabetic patients and consists of five items, including (type of diabetes mellitus, duration of disease, type of medication, presence of chronic disease [hypertension, cardiovascular disease, rheumatic arthritis, renal failure, retinopathy, and diabetic foot). part iii sf12 short form health survey to measure patients' quality of life: the sf-12 is a valid alternative to the sf36 for use in large surveys of general and specific populations which adopted from medical outcomes trust and quality metric incorporated, (2002) and used to measure the level of health-related quality of life for the purpose of the study. the sf-12 contains 12 items all sf-12 items came from the sf-36 consist of eight dimensions: general health consists of (1) items, physical functioning consists of (2) items, limitation in role due to physical health problems consist of (2) items, role limitations due to emotional problems consist of (2) items. limitation in role due to mental health consist of (2) items, bodily pain consists of (1) item, vitality consist of (1) item and social functioning consists of (1) item. sf-12 is a registered trademark of medical outcomes trust. sf-12 arabic version it was translated by the academic translator in king fahd university hospital medical education center. for content validity, three consultants from the department of family and community medicine reviewed the arabic version. they translated it to english again and their translation was compared with the original english version of the questionnaire (al-shehri et al., 2008). the physical component summary (pcs) and mental component summary (mcs) scores were examined for reliability (internal consistency, test-retest), construct validity (convergent and discriminant, structural), and criterion validity (concurrent and predictive). pcs and mcs demonstrated high internal consistency (cronbach’s alpha—pcs: 0.87, mcs: 0.86) (shah & brown, 2020). the purpose of the study was explained to the participants verbally, and they were asked to take part voluntarily. they also stated that they have the right to refuse or withdraw from the study at any time. the use of good communication skills with participants was emphasized as a means of creating a relaxed atmosphere during the interview. statistical analysis was performed by using descriptive statistical procedures (frequency, percentage, mean and standard deviation) so as inferential statistical procedures (pearson correlation coefficient, spearman's corelation). statistical package for the social sciences (spss) version 23 was used in this study. 722 global journal of public health medicine 2022, vol 4, issue 2 gggggglo results: according to the study findings, the majority of the sample's age group (26.0%) is between 51 and 60 years old. in terms of gender, the results show that (61.3 %) are female and (38.7%) are male. at educational level, the study found that (29.3 %) of the participants have completed elementary school, while (17.3 %) have completed intermediate school. as shown in (table 1) most of the participants, (66.7%) are married. in respect of occupation, half of the participants were housewives (49.3%), with the remainder working )26.0%( regarding monthly income, the study findings found that (46.6%) of the sample have insufficient monthly incomes. the table demonstrates most of the samples are living in the urban area (71.3%) and the minority of the sample live in suburban (24.7%). regarding bmi results show that a higher percentage of participants (35.3%) are overweight. the great majority of the persons in the sample are nonsmokers (90.0 %). table 1. distribution of participants by their socio-demographic data: list variable frequency percentage 1. age group less than 10 1 0.7 11 – 20 8 5.3 21 – 30 11 7.3 31 – 40 15 10.0 41 – 50 33 22.0 51 – 60 39 26.0 61 – 70 35 23.3 71 – 80 7 4.7 81 and more 1 0.7 2. gender male 58 38.7 female 92 61.3 3. level of education illiterate 25 16.7 read and write 13 8.7 elementary school 44 29.3 intermediate school 26 17.3 high school 12 8.0 diploma 14 9.3 bachelor 13 8.7 higher education 3 2.0 4. marital status married 100 66.7 single 18 12 widowed 25 16.7 divorced 5 3.3 separated 2 1.3 5. occupational status working 39 26.0 not working 28 18.7 student 9 6.0 housewife 74 49.3 6. monthly income sufficient 28 18.7 somewhat sufficient 52 34.7 insufficient 70 46.7 7. residency urban 107 71.3 suburban 37 24.7 rural 6 4.0 8. bmi less than 18.5 (underweight) 7 4.7 18.5 24.9 (normal weight) 32 21.3 25 29.9 (overweight) 53 35.3 30 34.9 (obese class i ) 36 24.0 723 global journal of public health medicine 2022, vol 4, issue 2 gggggglo 35 39.9 (obese class ii) 12 8.0 40 and more (obese class iii) 10 6.7 9. do you smoke? no 136 90.7 yes 14 9.3 table 2. distribution of clinical characteristics of the study sample: list variable frequency (f) percentage (%) 1. type of diabetes mellitus type i 38 25.3 type ii 112 74.7 2. duration of disease less than 1 year 8 5.3 1-5 years 44 29.3 610 years 34 22.7 10 years and more 64 42.7 3. type of treatment yes no f % f % oral tablets 83 55.3 67 44.7 insulin 76 50.7 74 49.3 diet regimen only 11 7.3 139 92.7 4. do you experience any chronic disease? 108 72.0 42 28.0 5. type of chronic disease yes no f % f % hypertension 63 42.0 87 58.0 cardiovascular diseases 28 18.7 122 81.3 rheumatic arthritis 61 40.7 89 59.3 renal failure 5 3.3 145 96.7 retinopathy 44 29.3 106 70.7 diabetic foot 10 6.7 140 93.3 table 2 illustrates the clinical data of individuals, the majority of whom (74.7 %) have type 2 diabetes. table 2 displays that less than half of the participants (42.7%) have had diabetes for more than 10 years. in concerns of treatment, slightly more than half of the patients (55.3%) take oral tablet medications, while (50.7 %) are using insulin. according to the statistics, most of the people in the sample (72.0%) had chronic illnesses, the most common of which were hypertension (42.0%) and rheumatoid arthritis (40.7%). 724 global journal of public health medicine 2022, vol 4, issue 2 gggggglo figure 1: assessment of quality-of-life domains for the study participants\ assessment of quality-of-life domains as shown in figure 1, the result shows the general health level of patients are fair (mean= 27.00, sd=.20.382), while physical role (mean= 25.33, sd= 43.631) and emotional role (mean= 23.33, sd= 42.437) are poor, on the other hand the physical function (mean= 48.50, sd= 37.161), bodily pain (mean=53.83, sd=27.742), mental health (mean= 51.20, sd= 28.391), vitality (mean= 42.13, sd= 28.393) and social function (mean= 49.00, sd= 33.887) are at a moderate levels. table 3. the relationship between sociodemographic data and quality of life domains (physical and mental domains): 27 48.5 25.33 23.33 53.83 51.2 42.13 49 0 10 20 30 40 50 60 general health physical function physical role emotional role bodily pain mental health vitality social function to ta l m ea n assessment of quality-of-life domains variables correlation coefficient physical mental age pearson c. -.244-.187 p value .003 .022 gender pearson c. -.016-.123 p value .842 .133 level of education pearson c. .288 .217 p value 0.001 .008 marital status pearson c. -.142-.008 p value .083 .924 occupational status pearson c. -.133-.211 p value .106 .010 monthly income pearson c. -.324-.299 p value 0.001 0.001 residency pearson c. .022 .049 p value .794 .549 bmi pearson c. -.273-.102 p value .001 .216 do you smoke? pearson c. -.016.032 p value .847 .697 number of cigarettes / days pearson c. -.042-.016 p value .886 .958 duration of smoking pearson c. .039 .186 p value .895 .525 725 global journal of public health medicine 2022, vol 4, issue 2 gggggglo table 3 shows that there is a highly significant relationship between the patients' age (.003) (.022), level of education (0.001) (.008) and monthly income (0.001) with both physical and mental domains respectively, while there is highly significant relationship between bmi and physical domain (.001). in relation to mental domain there is a highly significant relation with regards to participants' occupational status (.010) with a significant relation with their age (.022), at p-value level (0.05) for significance and (0.01) for the highly significant relationships. table 4. the relationship between clinical data and quality of life domains (physical and mental domains variables correlation coefficient physical mental type of diabetes mellitus pearson c. -.117-.062 p value .154 .454 duration of disease pearson c. -.110-.200 p value .179 .014 oral tablets pearson c. .072 -.059 p value .383 .470 insulin pearson c. -.012.071 p value .880 .387 diet regimen only pearson c. -.087.022 p value .290 .788 do you experience any chronic disease? pearson c. .275 .143 p value 0.001 .080 hypertension pearson c. .117 .014 p value .152 .864 cardiovascular diseases pearson c. .239 .216 p value .003 .008 rheumatic arthritis pearson c. .333 .171 p value 0.001 .036 renal failure pearson c. .173 .040 p value .034 .627 retinopathy pearson c. .172 .213 p value .036 .009 diabetic foot pearson c. .081 .030 p value .323 .714 726 global journal of public health medicine 2022, vol 4, issue 2 gggggglo concerning the correlation between health domains and clinical data, the results found that there is a significant relationship between physical aspect and some variables, including: chronic disease (.001), cardiovascular diseases (.003), rheumatic arthritis (0.001), renal failure (.034), and retinopathy (.036). while there is a relationship between mental aspect with some variables, including: duration of disease (.014), cardiovascular diseases (.008), rheumatic arthritis (.036), and retinopathy (.009), at p-value level (0.05) for significance and (0.01) for the highly significant relationships. table 5: correlation between physical and mental domains table 5 findings demonstrate there is a highly significant relation between physical and mental domains of the quality of life concerning each other. discussion: according to the study findings, the highest percentage of the sample's age group (26.0%) is between 51 and 60 years old. this differs with a study by (wong, et al., 2020) which stated most sample age was aged≥65 years (60%) and agrees with a study by (al ayed et al., 2020) which stated most age samples were between 51-60 years old. the risk of diabetes rises with age, contributing to an increase in the prevalence of diabetes in persons as they get older. in terms of gender, the result shows that (61.3%) are females and (38.7%) are males. this finding was supported by studies done by (ababio et al., 2017) in nigeria and (mehta, et al., 2015) in nepal. they also found most diabetic patients are females and, according to the international diabetic federation, most diabetic patients are females (international diabetes federation, 2019). but a study conducted by (tiwari et al., 2016) showed a higher percentage of subjects are males (58.1%). domains physical mental physical spearman's correlation coefficient 1.000 .511 p value . 0.001 mental spearman's correlation coefficient .511 1.000 p value 0.001 . 727 global journal of public health medicine 2022, vol 4, issue 2 gggggglo regarding the educational level, the study found that (29.3 %) of the participants had completed elementary school. these findings are supported by the study done by (ghailan & al-akaily, 2018) in al-mosul, iraq. they also found that the educational level of diabetic patients, the highest percentage was (40.0%) who graduated from elementary schools. on the other hand, (dhillon et al., 2019) in malaysia, found the highest percentage was (48.0%) who graduated from secondary school. among the respondents, (66.7%) are married. this finding is similar to the findings of other research such as (tietjen et al., 2021) and (george and premkumar, 2017), which found that most of the samples were married. in respect of occupation, half of the participants are housewives (49.3%). this percentage coincides with (asa`ad et al., 2019) that found half of the respondents are housewives (50.6) and contradicts the findings of (tonetto et al., 2019).in brazil (5.3%) of patients are housewives. regarding economic status, 86% of the study sample is without enough monthly income. this is consistent with another study (stojanović et al., 2018) which revealed in their study that most of the study sample had insufficient monthly income. these results disagree with (imad et al., 2021) who illustrated that 60.8% of the sample were of moderate income. chronic diseases including diabetes consider as a burden physically, psychologically, and financially so as the economic status of iraqi people especially in covid 19 era were decreased in obvious way. the results demonstrate that most of the people in the sample live in an urban area (71.3 %) this result corresponds to the findings of a study conducted by (abedini et al., 2020) which highlighted that the majority of respondents lived in a city (93.0%). this finding might be related to the fact that the incidence of diabetes is higher in urban areas than in rural areas, and that rural residents are more likely to engage in daily physical activity than urban patients, making them less likely to get diabetes (mohammed-ali & hamza, 2016). the bmi results show that a higher percentage of participants (35.3%) are overweight. (al ayed et al., 2020) found a higher proportion of participants were overweight (46.9%) as opposed to the findings of (hsieh et al., 2020) (36.31%) had a normal bmi. non-smokers make up most of the participants in the sample (90.0 %) was consistent with that of (ananchaisarp et al., 2019), who found that the vast majority of the participants were nonsmokers (93.0%). this contradicted the findings of (khunkaew et al., 2019), who found that most of the sample (30.0%) were smokers. according to the findings, people with type ii diabetes have a greater percentage (74.7%) than those with type i diabetes. which was corroborated with rwegerera et al., 2018, that showed that most of the samples had type 2 diabetes. the results show that the duration of the disease, the higher percentage (42.7%) is for those who have been suffering from the disease for a period of 10 years or more. the findings are in line with those of (ahmed et al., 2019), who observed a higher proportion of patients with an illness duration of 10 years or more. 728 global journal of public health medicine 2022, vol 4, issue 2 gggggglo in regard to medication, slightly more than half of the patients (55.5%) use oral tablet medications. this conclusion was supported by (alshayban & joseph, 2020). they observed that the majority of patients were taking oral tablets. while disagreeing with a study done in brazil (tonetto et al., 2019) that showed the most common drug used was insulin (41,92). moreover, the majority of the study's participants had a chronic condition (72.0 %). the most frequent conditions were hypertension (42.0 %) and rheumatoid arthritis (40.0%). these results were similar to the findings of prior research done in palestine (khdour et al., 2020). they discovered that more than half of the patients had chronic illnesses, with hypertension (51.6 %) and rheumatoid arthritis being the most frequent. these results do not fit with a study conducted in kufa, iraq which found most patients suffered from heart disease (40.0%). (mohammed-ali & hamza, 2016) in the context of general health, the statistics demonstrate the patient's general health is fair (27.00). this outcome consists with a study done by (feyisa et al., 2020) that shows the general health of participants is fair (30.20). according to the findings of the study, physical function (48.50), bodily pain (53.83), mental health (51.20), vitality (42.13) and social function (49.00) are at moderate levels. these results were supported by (jiao et al., 2017) study that stated physical, mental health, vitality, and social function were moderate scores. the results show that both the physical and emotional roles have poor ratings. this is consistent with the findings of (feyisa et al., 2020), who claimed that the physical and emotional roles had poor results. there is a highly significant relationship between the patients' age (.003), level of education (0.001) (.008) and monthly income (0.001) with both physical and mental domains respectively. this result was reinforced by (stojanović et al., 2018) that showed there is a highly significant relationship between age (.001), level of education (.001) and monthly income (.008) (.003) with both physical and mental domains respectively. these results are inconsistence with (degu et al., 2019) that stated no significant relationship between monthly income with physical and mental domains . the statistical shows there is a highly significant relationship between bmi and the physical domain (.001). these results are constant with (ananchaisarp et al., 2019) that showed there is a highly significant relationship between bmi and physical health (.003). in relation to mental domain there is a highly significant relation with regards to participants' occupational status (.010) with a significant relation with their age (.022). these findings are in fit with (degu et al., 2019) that show there is a highly significant relation between mental domain and occupational status with significant with their age. concerning the correlation between health domains and clinical data, the results found that there is a significant relationship between physical aspect and some variables, including cardiovascular diseases (.003), rheumatic arthritis (0.001), renal failure (.034), and retinopathy (.036). these results are contrary to (pham et al., 2020) study that show there is no significant relationship between the physical aspect and some clinical data, including cardiovascular disease, retinopathy, and renal failure. in terms of relationships between the mental aspect and clinical data, the findings show that there is a significant association with disease duration (.014), cardiovascular diseases (.008), rheumatoid arthritis (.036), 729 global journal of public health medicine 2022, vol 4, issue 2 gggggglo and retinopathy (.036). these findings are like (jiao et al., 2017) that clarified there is a significant mental aspect and some clinical data, including cardiovascular disease and retinopathy. several challenges were encountered throughout the completion of this study, including data collection duration is synchronized with the pandemic of corona virus. the center's policy regarding patient attendance. time of data collection is simultaneously with ramadan which was a burden during data collection conclusion: the study revealed that diabetic patient's quality of life was poor in terms of physical and emotional role, while fair in terms of general health. in addition, the quality of life was moderate in terms of mental health, physical function, vitality, bodily pain, and social status. there is a strong relationship between several sociodemographic data (age, level of education, monthly income, and occupational status) with physical and mental domains. there is a significant relationship between the physical domain and the clinical data (chronic disease, cardiovascular diseases, rheumatic arthritis, renal failure, and retinopathy). whilst there is a relationship between mental domain and clinical data (duration of disease, cardiovascular diseases, rheumatic arthritis, and retinopathy). moreover, there is a highly significant relationship between the physical domain and the mental domain. acknowledgements we would like to express our sincere appreciation for all of those who have support and help us through our journey in this life. finally, the last but not the least, our deep thanks and respect to the patients who participated in the present study despite of their suffering. conflicts of interest the author declares no conflicts of interest. references • ababio, g., bosomprah, s., olumide, a., aperkor, n., aimakhu, c., oteng-yeboah, a., agama, j., chaplin, w., okuyemi, k., amoah, a., & ogedegbe, g. 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(2020). measurement of health-related quality of life in patients with diabetes mellitus using eq-5d-5l in hong kong, china. quality of life research, 29(7), 1913–1921. https://doi.org/10.1007/s11136-020-02462-0 microsoft word gjphm-2023 post drug.edited.docx 812 global journal of public health medicine 2023, vol 5, issue 1 gggggglo original research post mass drug administration assessment of coverage, compliance, and obstacles in a lymphatic filariasis endemic district of central india. neelam anupama toppo, aditya thakur, deepali soni, tej pratap singh* department of community medicine, netaji subhash chandra bose medical college, jabalpur, india *corresponding author: drtej2009@gmail.com abstract introduction: lymphatic filariasis is still a huge problem in the endemic districts as it can cause deprivation in the economic condition of the sufferer, it is linked with stigma, and shame which leads to psychological problems in the individual. the aim was to assess the coverage, compliance, and obstacles post-mass drug administration (mda) of filariasis in the katni district. methods: this community-based study was conducted in selected areas of the katni district of madhya pradesh. three rural primary health centers (phcs) and one urban phc were selected for the study. afterward, 30 households were randomly selected from these 4 phcs. the mda drive was held in late dec 2020 in the whole katni district. as an external evaluation, this study commenced 30 days after the drive and the data were collected. results: a total of 128 households were surveyed, and 621 people were covered. 607 were eligible for drug administration. the overall coverage rate of mda in the study was found to be 95.88 %. the overall effective coverage rate was 88.63 %. it was 93.93 % in urban and 86.65 % in rural areas. the overall coverage compliance gap was 7.37 %. the most common reason for the non-consumption of tablets was people busy doing work i.e., 47 %. conclusion: it would be a challenge for the district to sustain this performance in the coming rounds of mda. equal sensitization of the urban and rural populations through iec activities and proper training for drug distributors is required. keywords: lymphatic filariasis, coverage, compliance, mda, obstacles. 813 global journal of public health medicine 2023, vol 5, issue 1 gggggglo introduction lymphatic filariasis (lf) is a disfiguring and debilitating disease and was ranked as the second leading cause of disability globally (ramaiah & ottesen, 2014). it can cause deprivation in the economic condition of the sufferer, it is linked with stigma, and shame which leads to psychological problems in the individual. its chronic condition in families will lead to loss of work and opportunities in employment which ultimately increases the treatment cost. economic loss annually due to lymphatic filariasis in india came out to be huge about us $ 1.0 billion (ramaiah & ottesen, 2014). lf is still prevailing in 256 districts of 21 states and union territories (uts) and, as of 2017,630 million population live in the endemic districts (mohfw, 2018). the national vector borne diseases control programme (nvbdcp) is an umbrella program in india for the prevention and control of vector-borne diseases namely malaria, japanese encephalitis, dengue, chikungunya, kala-azar, and lymphatic filariasis. out of the three diseases namely, malaria, lymphatic filariasis, and kala-azar are targeted for elimination. the single dose of dec (diethylcarbamazine) annually as a mass drug administration in all endemic areas of filariasis in the country is the recommended strategy adopted by all the countries facing the problem. several changes have been done in india’s program for filarial control in nvbdcp in the last few years like the addition of the tablet albendazole for treating the countrymen who are residing in endemic areas. the drugs used in the mda program are a combination of dec (6 mg/kg body weight) + alb (albendazole) (400 mg) in endemic areas (mohfw, 2018). to interrupt the transmission of lf in india, essentially there should be five to six rounds of mda annually. for each round to be effective, there should be an accomplishment of at least 65 % of coverage of the treatment of lf (who, 2011). after the completion of mass drug administration rounds, the first transmission assessment survey i.e., tas1 is implemented among the children of 6-7 years of age in that particular district to validate the effectiveness of mda. if the infection rate is less than 2% ag(antigen) or ab(antibody) in children, then mass drug administration is stopped. tas 2 (transmission assessment survey) and tas 3 rounds are conducted after mda. the country is considered lymphatic filariasis free only if tas 3 has been successfully cleared by the districts (mohfw, 2018; who, 2011; ichimori et.al., 2014). much of the success of the filarial elimination in the district depends on the successful completion of mda. but often it was evident in previous studies and reports based on post-mda surveillance that consumption of one dose of dec was below the recommended levels. many reasons were identified in the post-mda surveillance based on which many implementations were improvised. when the countrymen fail to comply with mda, there arises a situation in which the causative agent is left untreated which results in the resurrection of the filarial cases and ultimately results in poor program success (esterre et.al., 2001). therefore, the midterm assessment must be done by a neutral body who are associated with the district hospital or administration. the assessment should be completed within one month of mda so that there should not be any recall bias reported. keeping this in view the current study was undertaken to assess 814 global journal of public health medicine 2023, vol 5, issue 1 gggggglo the coverage, compliance, and obstacles with mass drug administration of filariasis in the katni district india. methods this community-based study was conducted in selected areas of the katni district of madhya pradesh. primary health centres of katni district were stratified into 3 categories according to their mda 2013 coverage. sample size calculation was based on the pre-laid guidelines of the national vector-borne disease control program (directorate general of health services, mohfw, government of india, 2009). primary health centers with below 50 % coverage form 1st category whereas 2nd and 3rd category was formed by phcs having coverage between 50-80 % and above 80 % respectively. in rural area, one phc from each category were selected randomly. from each of the selected phcs, one village was selected randomly for the household survey. in urban areas, one ward was randomly selected from the medium coverage i.e., 2nd category as per the nvbdcp guidelines (directorate general of health services, mohfw, government of india, 2009). in each village and ward, 30 households were covered. mda drive was held in late dec 2020 in the whole katni district. as an external evaluation, this study commenced 30 days after the drive and the data were collected. we started the survey from the center of the village and ward, one direction was randomly selected, and all the consecutive households in that direction were included. if any household was found locked or the participant refused to take part or was not available at the time of the survey were excluded and next the household was approached. from every household, the interview was taken from the responsible adult member. children less than 2 years, pregnant women, and severely ill persons were excluded from the study. the household members were asked to bring the wrappers of consumed medicine to make spot observations. a pre-designed structured questionnaire in google form was used for data collection. informed consent was obtained from each participant. confidentiality was maintained. this study was conducted after getting approval from the institution’s ethics committee. for calculating various rates, the following working definitions were used as per nvbdcp guidelines (ministry of health and family welfare): coverage rate the percentage of the eligible population who have received the tablet. compliance rate the percentage of the eligible population who have consumed the tablet after receiving it. effective coverage rate the percentage of the actual target population who have consumed the tablet among the eligible population, and coverage compliance gapthe percentage of the covered eligible population who have not consumed the tablets. data were entered into microsoft excel 2016. epi info version 7.2.5 was used to calculate descriptive statistics including the number and percentages of coverage and compliance of mda. 815 global journal of public health medicine 2023, vol 5, issue 1 gggggglo results a total of 128 households were surveyed during the surveillance, covering a population of 621. out of them, 607 were eligible for drug administration as shown in table 1. table no. 1: distribution of the study population concerning eligibility, tablets received and consumed village/ward name population covered eligible population tablet received tablet consumed clp ward 167 165 162 155 bistara 164 160 156 139 gairtalai 134 129 118 109 majhgawan 156 153 146 135 total 621 607 582 538 the overall coverage rate of the study population was found to be 95.88 % as shown in table 2. the coverage was highest in the clp ward (urban area) and lowest in gairtalai (rural area). the overall effective coverage rate was 88.63 %. it was 93.93 % in urban and 86.65 % in rural areas. the overall coverage compliance gap was 7.37 %. effective coverage rate was higher among females and families with 4 or fewer members as shown in table 3. table no. 2: area-wise coverage, compliance, effective coverage, and coverage compliance gap rates clp ward % bistara % gairtalai % majhgawan % total % coverage rate 98.18 % 97.5 % 91.47 % 95.42 % 95.88 % compliance rate 95.67 % 89.10 % 92.37 % 92.46 % 92.43 % effective coverage rate 93.94% 86.87 % 84.49 % 86.53 % 88.63 % coverage compliance gap 4.33 % 10.90 % 7.63% 7.54 % 7.37 % 816 global journal of public health medicine 2023, vol 5, issue 1 gggggglo table no. 3: distribution of the study population according to their eligibility, consumption of tablets, and effective coverage variables eligible population actually consumed effective coverage rate percentage village/ward clp ward 165 155 93.93% bistara 160 139 86.87% gairtalai 129 109 84.49 % majhgawan 156 135 86.53 % age group 2-5 27 21 77.77% >5-14 97 79 81.44% ≥15 483 438 90.68% gender male 295 258 87.46% female 312 280 89.74% family size ≤4 155 147 94.83 % >4 452 391 86.50 % area urban 165 155 93.93% rural 442 383 86.65% only 42.97% of families had prior information aboutmass dec administration due to earlier rounds of mda but about the recommended dosage, contraindications, or side effects people were unaware of or didn't receive any information from any source. most of the families had not read or seen any banner, poster, newspaper advertisement, handbill, mike announcement, drama, street play, television /radio sports, etc., on mda. only 21.88% of families gave positive replies mostly from urban settings and few saw in health facilities. the most common reason for the non-consumption of tablets was people busy doing work i.e., 47 %. while 20 % of the people were not present at home when the drug distribution came to their houses. (figure 1) the most common side effect of drug consumption was abdominal pain and diarrhea i.e.,20.93 % while 16.28 % of the people develop a fever after consuming the drug. (figure 2). 817 global journal of public health medicine 2023, vol 5, issue 1 gggggglo figure no. 1: various reasons for non-consumption of the drugs. figure no. 2: distribution of the most common side effects after drug consumption. busy in doing work 47% not present at home 20% empty stomach 19% no elder family member present 7% not informed 7% 16.28 % 9.3 % 13.95 % 20.93 % 16.28 % 9.3 % 6.98 % 6.98 % 0 5 10 15 20 25 nausea/vomiting dizziness drowsy abdominal pain + diarrhea fever n/v + diarrhea pain in legs itching 818 global journal of public health medicine 2023, vol 5, issue 1 gggggglo discussion in katni district 97.74% of the total population was eligible population as per programme criteria for receiving mda tablets i.e. 607 people were eligible out of a total of 621 surveyed populations. it was found that more females (89.74%) swallowed tablets compared to males (87.46%) reason for more compliance among women due to availability at home during mda. but gunasekran et al.,2015 and hussain et al., 2014 found overall coverage of drug distribution is lower in females than males. the reason they quoted was the better literacy rate in males as compared to females. overall 88.63% of the eligible population swallowed tablets. the percentage of people who swallowed tablets was observed in increasing order with age as highest in the age group more than 15 years and lowest in 2 to 5 years. similarly, gunasekran et al.,2015 also reported lower coverage among children in the age group 2-5 years. the reason may be due to parents' concerns regarding their children and the lack of iec and interpersonal communication between drug distributors and beneficiaries. a high coverage (>85%) in endemic areas, which is sustained for 5 years, is required to achieve the interruption of transmission and elimination of filariasis in india (mohfw, 2018; ministry of health and family welfare,” n.d"). in the present study, the coverage rate was found to be 95.88 % which was above the recommended level for the endemic area. in previous studies were done by bhue et al.,2021 in western odisha and panika et al.,2019 in madhya pradesh, the coverage rates were 87.2% and 86.54 %. while hussain et al., 2014 found 99 % of the surveyed population had received the drug but only one-third of them had consumed it. there was a huge drop in compliance. similarly, in our study, there was a drop observed in the effective coverage rate which was ranging from 84.49% to 93.93%. the effective coverage rate was higher in urban than in rural areas. singh et al., 2013 reported 89% to 99% effective coverage, which was higher in proportion than our findings. the compliance rate was 92.43 % in the current study which is also above the recommended level, it was higher in an urban area. similar studies were done by bhue et al.,2021 and bhavani et al., 2022 where the compliance rate was higher, they stated that the higher compliance rate was because the people were compelled to take drugs in front of the drug distributors. their finding was at a satisfactory level for effective coverage. 819 global journal of public health medicine 2023, vol 5, issue 1 gggggglo in the present study, the tablets were recovered from 19 (14.84%) families. it could be due to a lack of information about its benefits given to families and the unavailability of members during drug distribution. they had fear of side effects as well. the absence of elderly people at home, being busy at work, and empty stomach were the reasons given by the family members for noncompliance. singh et al.,2013 reported the reasons behind noncompliance were forgetfulness regarding where they did keep the drugs or to eat, fear of side effects, and even without reason too. in the population of 621, 8.73% of individuals did not swallow the dec tablets. in 79.69% of families, at least one member swallowed drugs in the presence of drug distributors. in only 26 families, none of the family members swallowed the drug in front of the drug distributor. it was found that there was a lack of interpersonal communication by drug distributors. though drug distributors visited most of the families i.e. 96.1% and explained to more than 75% of families the purpose of dec administration, about lymphatic filariasis and its transmission even then not all consumed tablets in the presence of drug distributors. it was also observed that no one favors the collection of dec tablets from the booth. 100% of people in katni preferred house to house approach for mda. major obstacles in lymphatic filariasis elimination 1. dearth of entomological data indices like mosquito density, infection rate, infectivity rate, and the mean number of l3/ infective mosquitoes were unavailable in the district as there was no entomological survey carried out in recent times. there was no entomologist appointed at the endemic district level. also, we observed that the district which is endemic to filariasis for so long should be a good opportunity for research in the field like vector-parasite compatibility, vector control, monitoring and implementation, techniques, etc. one thing that must be ongoing in practice is xenosurveillance, “it is the direct assessment of worms in vector mosquitoes with polymerase chain reaction (pcr) techniques used to detect recurrence of new infections during post-mda surveillance" (mohfw, 2018). 820 global journal of public health medicine 2023, vol 5, issue 1 gggggglo 2.no impact assessment post-mda by the district as per the district nodal officer, there was no assessment by the district health team regarding the effectiveness of the mass drug administration. at the district level, there was no data on how many remaining tablets of albendazole and dec are left are the peripheral health facilities. although a balance of about 54000 dec tablets is left at the district hospital, that had been unused in the urban areas. 3.no iec activity at the village level. there was a huge difference in iec activity done in rural and urban areas. we found a lack of iec activities in villages. interpersonal communication has not been done adequately, no mike announcement or drum beating at the village level was done, and no group meeting regarding the mda was done in the village as it was validated by the villagers during our survey. so, there should be intensive iec activity mainly in the form of large group meetings, public announcements, and personal communication. but specifically in the low coverage area reported in the last mda and should be completed at least 23 days before mda. there should also be an increase in the number of the poster and wall paintings. we appreciate the efforts in the urban area where many innovations like filaria rath (chariot), voice messages for filariasis, and bags with messages for drug distributors were executed. 4. lack of proper training for drug distributors it was found at most of the places that drug distributors had not persuaded the family members to swallow the drug in front of them. which resulted in an increased compliance gap in the villages. during the training of the drug distributors, more emphasis should be given to age-wise doses of tablets given to patients. drug distributors should be well-trained to encourage all the family members to swallow tablets in his/her presence. must not exclude elderly people as we found that elderly people with diabetes and hypertension were not given the drugs. only people with very sick conditions should be excluded from mda. the drug distributor should stress the importance of drug swallowing, and the purpose & dose schedule of the drug mandatory. to overcome the hindrances, the filariasis elimination program must need a proper address from the district and state authorities on how to overcome these obstacles in the program with an appropriate roadmap guiding towards filariasis elimination in the district. 821 global journal of public health medicine 2023, vol 5, issue 1 gggggglo limitation of the studythe study might have recall bias occurred in the study participant as the time duration between the mass drug administration round and the assessment of mda implementation round was one month. ideally, it should be 2-3 weeks so that the community can recall the events without memory lapse. conclusion although the effective coverage rate in our study was above the recommended level, it would be a challenge for the district to sustain this performance in the coming rounds of mda. equal sensitization of the urban and rural populations through iec activities and proper training for drug distributors is required. supportive supervision and monitoring of activities need to be strengthened in the program. an all-around approach should be needed by the district to break all the obstacles reported in the study to achieve a filairiasis-free status. conflicts of interest the author declares no conflicts of interest. references • bhavani r, kumari sm, divyasri r, jha pk. (2022) coverage and compliance assessment survey following lymphatic filariasis mass drug administration in warangal, telangana. mrims j health sci;10:87-92. doi: 10.4103/mjhs.mjhs_22_22 • bhue pk, majhi p, panda m. (2021) coverage and compliance of mass drug administration for elimination of lymphatic filariasis in a district of western odisha, india. j evid based med healthc;8:2058-63. doi:10.18410/jebmh/2021/386 • esterre p, plichart c, sechan y, nguyen nl. (2001) the impact of 34 years of massive dec chemotherapy on wuchereria bancrofti infection and transmission: the maupiti cohort. trop med int health; 6:190–195. doi: 10.1046/j.1365-3156.2001.00682.x. • gunasekaran s, kalimuthu t, rajalakshmi s, jaipratha jr. (2015) processes evaluation of coverage and compliance to a round of mass drug administration with dec and albendazole for the control of lymphatic filariasis in puducherry, india. trop biomed.dec 1;32(4):659-668. pmid: 33557456. • hussain et al.:( 2014) mass drug administration for lymphatic filariasis elimination in a coastal state of india: a study on barriers to coverage and compliance. infectious diseases of poverty.3:31. doi:10.1186/2049-9957-3-31 • ichimori k, king jd, engels d, yajima a, mikhailov a, lammie p, ottesen ea. (2014) global programme to eliminate lymphatic filariasis: the processes underlying programme success. plos negl trop dis. dec 11;8(12):e3328. doi: 10.1371/journal.pntd.0003328. pmid: 25502758; pmcid: pmc4263400. doi: 10.1371/journal.pntd.0003328 822 global journal of public health medicine 2023, vol 5, issue 1 gggggglo • directorate general of health services, mohfw, government of india. 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(2011) monitoring and epidemiological assessment of mass drug administration in the global programme to eliminate lymphatic filariasis: a manual for national elimination programmes. geneva: who. microsoft word gjphm-2023 sublingual -2.docx 781 global journal of public health medicine 2023, vol 5, issue 1 gggggglo originalresearch safety and efficacy of sublingual misoprostol and intracervical dinoprostone gel as cervical ripening agent in term prelabour rupture of membranes: a comparative study monica. r & dharini.m department of obstetrics and gynaecology,rajahmirasudhar hospital, thanjavur medical college, thanjavur *corresponding author: priya.dharshini13048@gmail.com abstract introduction: "premature rupture of membranes" (prom) refers to the chorioamnionitis membranes spontaneously rupturing before the start of labour. this study compares the safety and effectiveness of intracervical dinoprostone gel and sublingual misoprostol for cervical ripening in term prom.methods: this is an analytical cross-sectional study including 100 term mothers with spontaneous prom attending obstetric casualty at the department of obstetrics and gynaecology, government raja mirasudhar hospital, thanjavur, india, selected using a multistage sampling technique from the study period of february 2021 – november 2021 (10 months). one hundred samples were assigned randomly into two groups which were 50 in each group as group a (misoprostol group) and group b (dinoprostone gel group). results: in group a, the study participants' median ages were 25 years (8.48) and 26.2 years (6.42), respectively. the difference in age averages between groups a and b was found to be 6.03, with a statistically significant p-value of 0.016. in both groups, the induction delivery interval was nearly equal. the link between the indication for lower segmental caesarean section and both groups was statistically significant. when the two groups' delivery modes were compared, natural labour was shown to be statistically significant (p = 0.048). normal and abnormal heart rates were statistically significant for the association between fetal heart rate and the groups, respectively, with chi-square values of 6.854 and 9.281 (p = 0.022 and 0.013, respectively). the remaining groups were not statistically significant. conclusion: it was concluded that though sublingual misoprostol is more efficacious than intracervical dinoprostone, its safety margin is significantly less; hence, misoprostol induction should be done only in a double setup under medical supervision. keywords:misoprostol, dinoprostone, premature rupture of membranes, efficacy 782 global journal of public health medicine 2023, vol 5, issue 1 gggggglo introduction the term "premature rupture of membranes" (prom) refers to the chorioamnionitis membranes spontaneously rupturing before the start of labour. about 10% of all pregnancies are complicated by it(middleton et al., 2017). prom occurs in 7–12% of labourers, according to indian studies (bhalerao& desai, 2000; bhide, 2001). at 24, 48, and 96 hours after term prom, spontaneous labour occurs in 70%, 85%, and 95% of women, respectively(gaikwad h & maskar p, 2016). the available management options in prom are expectant management, which is waiting for the labour process to occur and induction of labour. according to this, induction of labour within 6-12 hours of membrane rupture in term prom is advised if a woman is not in labour. this reduces the duration between the rupture of membranes and delivery, which is called a latent period, and it is essential in those with an unfavourable cervix (middleton p et al.). even the view of women is more favourable towards induction of labour in term prom than expectant management(hannah et al., 1996). also, who strongly recommends labour induction in women with prelabour rupture of membranes at term as the quality of available evidence is very high(world health organization, 2018). although oxytocin is the most commonly preferred agent for induction of labour in term prom, in a subset of women with unfavourable cervix determined by bishops score <6, prostaglandins play a more significant role. bishops score is a tool health care providers use to determine if the cervix is ready for labour. a score of 6 or less is considered unfavourable for induction; if induction is indicated, cervical ripening agents may be utilised. when labour begins in a previously unfavourable cervix, cervical ripening is done to facilitate softening, thinning and dilation of the cervix. this should be done to reduce failed induction as an unfavourable cervix (according to the bishops score) at induction increases the cesarean rates and also decreases the induction-delivery interval. mechanical methods of cervical ripening are relatively contraindicated in ruptured membranes as it further increases the chances of chorioamnionitis. hence pharmacological methods of cervical ripening are advised in term prom. pharmacological agents for cervical ripening include various formulations of prostaglandin, such as prostaglandin e1 and e2. a synthetic analogue of prostaglandin e1 called misoprostol, has been used widely as an agent for cervical ripening. routes of administration include oral, sublingual and intravaginal routes. misoprostol is available as a 100mcg(in scored) or a 200mcg tablet, and for cervical ripening, 25mcg or 50mcg is used by breaking the tablet(‘acog practice bulletin no. 107’, 2009). a study (yadav & chandwaskar, 2017)compares the efficacy and safety profile of sublingual misoprostol (pge2) and intracervical dinoprostone (pge1) for cervical ripening and induction of labour. the most significant advantage of misoprostol usage lies in its storage at room temperature. there are two commercially available preparations of pge2 for cervical ripening. 0.5mg of dinoprostone gel in a 2.5ml syringe, and the other is a vaginal insert containing 10mg of dinoprostone. 0.5mg dinoprostone gel is used either intravaginally or intracervical. this study compares the safety and 783 global journal of public health medicine 2023, vol 5, issue 1 gggggglo effectiveness of intracervical dinoprostone gel and sublingual misoprostol for cervical ripening in term prom. methods this is an analytical cross-sectional study including term mothers with spontaneous prelabor rupture of membranes (prom) attending obstetric casualty at the department of obstetrics and gynaecology, government raja mirasudhar hospital, thanjavur from the study period of february 2021 – november 2021 (10 months). one hundred pregnant women were selected using a multistage sampling technique, including women with singleton fetuses of cephalic presentation, gestational age >37weeks, spontaneous rupture of membranes < 6 hours, lack of uterine contractions for atleast1hour from prom and bishops score <6. the exclusion criteria include women with scarred uterus/with any associated medical or obstetrical complications/ with suspected cephalopelvic disproportion/with contraindications to vaginal delivery/non-reassuring foetal heart rate/meconium staining of amniotic fluid/cases being referred from phc/gh/women with contraindications to prostaglandins. the previous study by nivedita et al. (jha et al., 2015) compared the effectiveness and safety of sublingual misoprostol and intracervical dinoprostone gel for cervical ripening in prelabour rupture of membranes after 34 weeks of gestation, used to determine the sample size. prevalence of misoprostol usage was found to be 60%; the formula calculates sample size for the cross-sectional study, n=4pq/d2 where p=prevalence = 60%, q= 100 p = 40%, d= allowable error = 10%; therefore, n = 4×60×40/ 10x10 = 96; on rounding off, the final sample size (n) = 100. the 100 samples were assigned randomly into two groups which were 50 in each group as group a (misoprostol group) and group b (dinoprostone gel group). a semi-structured validated schedule consisting of questions on basic demographic details viz., name, age, occupation, address, personal histories such as alcoholism and smoking and history of past and present medical, previous and present obstetric history, and surgical history was used. natal history was also noted, including apgar score and neonatal intensive care unit (nicu) admission. apgar: this is a quick test performed on a baby at 1 and 5 minutes after birth; the provider examines the baby's: breathing effort, heart rate, muscle tone, reflexes, and skin colour. each category is scored with 0, 1, or depending on the experimental condition. a score of 7, 8, or is typical. per abdominal examination, basic anthropometric measurements such as height, weight, pulse, and blood pressure were done. they were also assessed for amniotic fluid index (afi), and fetal presentation was confirmed sonographically. temperature assessment at four hourly and pulse rate at every half-hour interval was measured. the biochemical investigations, such as total leucocyte count and c-reactive proteins, were also measured. a swab was taken from the posterior vaginal fornix of the cervix of all women in the group. women were allocated randomly into one of each group andinduced accordingly. labour progress monitored with partograph. the induction delivery interval and the mode of delivery were noted and included in the study's findings. all prom mothers were started on inj. cefotaxime 1g iv bd immediately after admission to our institute. all these were 784 global journal of public health medicine 2023, vol 5, issue 1 gggggglo measured for every mother who participated in the study, irrespective of the group they were assigned. group a (misoprostol group) the mothers who were in term and with prelabour rupture of the membrane were given two doses of misoprostol (25 micrograms) four hours apart and observed for uterine contractions, fetal heart rate, cervical dilatation, mode of delivery, duration of delivery after induction and outcome and complications. group b (dinoprostone gel group), the second group, the mothers were given a single dose of intra cervicalcdinoprostone gel with 0.5-milligram strength. they were also observed for uterine contractions, fetal heart rate, cervical dilatation, mode of delivery, duration after induction, outcome and complications. ethical considerations: permission was received from the institutional ethical committee. before beginning treatment, each patient has informed written consent obtained. the mother's confidentiality and privacy were protected. statistical analysis: data was collected in the schedule, and responses were entered in microsoft excel. the descriptive statistics such as frequency and percentages were calculated using epi info free software available online. the association between descriptive variables was found using the chi-square test. the difference and similarities between the groups were analysed using repeated measures of anova and inferential statistics. student t-tests and paired t-tests were done to determine the significant difference between the means of the two groups. a value less than or equal to 0.05 was inferred as statistical significance. results: in group a, the study participants' median age was 25 years (8.48), while in group b, it was 26.2 years (6.42). each of the 20 people belonged to group a or group b, depending on their age range of 26 to 30. the difference in age averages between groups a and b was found to be 6.03, with a statistically significant p-value of 0.016. the participants' average height in the intervention group was 160 centimetres, compared to 159.7 centimetres in the control group, which was considered negligible. the t value was insignificant, with a value of 0.187, because the weight between the two groups was 60.41 in the case group and 61.9 in the control group. bishop's score was similar in both groups and statistically significant at "0" and "6" hours. the induction delivery interval was nearly the same in both groups, 8.54 hours for group a receiving misoprostol and 8.60 hours for group b receiving dinoprostone gel for induction. it was determined by the anova test that there was a statistically significant difference between the two groups' means (p 0.001). (table:1) 785 global journal of public health medicine 2023, vol 5, issue 1 gggggglo table 1: comparison of various factors between dinoprostone gel and sublingual misoprostol. t able 2: associ ation betwee n indicati on for lscs and mode of induction indication for lscs group a (with misoprostol) n=50 group b (with dinoprostone gel) n=50 𝑿2 p-value failed induction 2 1 5.621 0.045* failure to progress 3 1 7.789 0.651 fetal distress 9 8 9.265 0.011* others 1 1 4.652 0.084 failure to induce was a statistically significant indicator of lscs with a chi-square value of 5.621 (p = 0.045), and fetal distress was found to be a statistically significant indicator of lscs with a chi-square value of 9.265 (p = 0.011). the remaining associations were not statistically significant. (table: 2). the correlation between prom and delivery interval is found to be statistically significant only at less than 6 hours with a p-value of 0.053, and all the other intervals are insignificant. (table: 3) group a (sublingual misoprostol) mean±sd group b (intracervical dinoprostone gel) mean±sd p value age 25.0±8.48 26.2±6.42 0. 016* height 160±4.10 159.70±4.67 0.51 weight 60.41±4.68 61.96±4.01 0.81 bishops score (time interval in hours) at 0 hour 2.52 ±0.53 2.61±0.56 0.000* at 4 hours 3.61±0.61 3.54±0.58 0.01* at 6 hours 3.82±0.68 3.65±0.61 0.12 inductiondelivery interval 8.54± 1.21 8.60± 1.34 0.001* 786 global journal of public health medicine 2023, vol 5, issue 1 gggggglo table 3: correlation between prom and delivery interval prom to delivery interval (in hours) mode of induction n mean std. deviation (±) anova p value < 6 hours group a(with misoprostol) 10 4.54 2.11 2.672 0.053* group b (with dinoprostone gel) 8 6-12 hours group a(with misoprostol) 30 8.12 3.14 1.567 0.132 group b (with dinoprostone gel) 20 >12 hours group a(with misoprostol) 10 11.52 3.42 1.823 0.141 group b (with dinoprostone gel) 22 table 4: correlation between the groups and the stages of labour, mode of delivery, and fetal heart rate. mode of induction mean p-value group a (with misoprostol) group b (with dinoprostone gel) first stage of labour (interval in hours) < 6 hours 14 8 4.86 0.052* 6-10 hours 20 12 8.54 0.731 10-20 hours 10 18 12.42 0.062 >20 hours 6 12 21.25 0.091 second stage of labour (interval in hours) < 1 hour 10 12 4.21 0.021* >1 hour 18 20 8.65 1.221 mode of normal 35 39 5.82 0.048* 787 global journal of public health medicine 2023, vol 5, issue 1 gggggglo delivery caesarean 15 11 fetal heart rate normal 35 45 6.854 0.022* indeterminate 10 3 8.576 0.782 abnormal 5 2 9.281 0.013* only a time interval of fewer than 6 hours is shown to be statistically significant in the initial stage of labour, with a p-value of 0.052 with the induction medications, i.e., between the groups. (table: 4) with a p-value of 0.021, the only time interval in the second stage of labour determined to be statistically significant was when the induction medications were taken or among the groups. when the two groups' delivery modes were compared, natural labour was shown to be statistically significant (p = 0.048). (table: 4). normal heart rate was found to be statistically significant with a chisquare value of 6.854 (p = 0.022). with a chi-square value of 9.281 (p = 0.013), abnormal heart rate was found to be statistically significant. the other results were not statistically significant. table 5: association between mode of induction and complications complications observed mode of induction 𝑿2 p-value group a (with misoprostol) n=50 group b (with dinoprostone gel) n=50 meconium stained amniotic fluid 3 2 6.635 0.001* apgar<7 3 2 2.705 0.065 nicu admission 12 8 5.023 0.031* postpartum haemorrhage 1 2 0.151 1.312 pyrexia 10 7 7.362 0.042* tachycardia in baby 2 1 7.328 0.041* git effects 5 6 0.125 1.452 oxytocin usage 1 2 0.326 0.621 only 8 of the 12 newborns in group b's birth cohort needed nicu admission, compared to 12 of the 12 newborns in group a. 10 participants in group a and 7 in group b both complained of pyrexia. meconium-stained amniotic fluid had a statistically significant χ2value of 6.635 and a p-value of 0.001 when χ2was used to determine the connection. the same was observed in nicu admission (p = 788 global journal of public health medicine 2023, vol 5, issue 1 gggggglo 0.031), pyrexia and induction (p = 0.042) and also tachycardia in the baby (p =0.041) was also statically significant. (table: 5) discussion: in this study, patients with term rupture of membranes who came to the hospital were given either sublingual misoprostol or intracervical dinoprostone gel to groups assigned randomly. according to this study, the indication for induction was for those presenting to obstetric casualty within 6 hours of rupture of membrane and not having uterine contractions for almost 1 hour after rupturing of membranes and with the unfavourable cervix of bishops score <6 at the time of admission. according to this study, induction with sublingual misoprostol results in a quicker delivery than induction with intracervical dinoprostone gel, which is the same as in the study by (jha et al., 2015). studies like (denguezli et al., 2007), (veena et al., 2016), (chitrakar, 2012), (wankhede et al., 2017) had inconsistent findings with induction to the delivery interval. in the present study, those who delivered within 6 hours are 8% in grou6 hours0% in group b., 28% in group a and 30% on group b delivered within 6-12 hours of rupture of membranes, and 14% in group a and 10% in group b delivered more than 12 hours of membrane rupture. as all the women included in the study were induced, the prom-delivery interval was less than in other studies. (p et al., 2021) did a retrospective, non-comparative, observational study and mothers were not induced in which prom to the delivery interval was 10% in less than 12 hours, 59% in 12-24 hours and 31% in more than 24 hours. in a prospective trial by (wankhede et al., 2017), mothers were placed into two groups and given either expectant management or intracervical pge2 induction; the prom to the delivery time for the expectant group was 22.36 hours, and for the intracervical pge2 induction group was 15.5 hours. about 35 (70%) participants in group a and 39 (78%) in group b experienced a normal delivery. additionally, 11 (22%) of group b and 15 (30%) of group a participants underwent caesarean deliveries. chi-square analysis revealed a statistically significant value of 5.911 with a p-value of 0.05. moreover, from all the available studies comparing expectant management versus any method of induction in prom, the rate of vaginal delivery is high. this shows that only a tiny proportion of prom mothers will go for lscs. in this present study also, the majority delivered vaginally. in the study by (p et al., 2021), 50.81% were delivered vaginally, and 49.19% were delivered via lscs. it was found not to be statistically significant as there is a higher incidence of lscs related to high induction rates and maternal co-morbidities. 789 global journal of public health medicine 2023, vol 5, issue 1 gggggglo in this study, at 4 hours after induction means bishop's score in group a is 3.61, whereas in group b is 3.54, which is statistically significant. this indirectly shows that more women induced with misoprostol have progressed well into the active phase of labour. in the present study, 28% in group a had a duration of 1st stage <6 hours, whereas in group b it is 16%, which is only statistically significant and it implies that among people induced with misoprostol, more people had a duration of 1st stage < 6 hours than those induced with intracervical dinoprostone gel. moreover, 12% in group b and 10% in group a had a duration of 2nd stage < 1 hour which is statistically significant, implying that dinoprostone gel had a shorter 2nd stage of labour. regarding failed induction, in this study, 2 in group a and 1 in group b failed, which is statistically significant, implying that failed induction with misoprostol was more. the most common indication for lscs in this study is fetal distress. 9 in group a,8 in group b had been taken for lscs because of fetal distress. this shows that sublingual misoprostol has got more rate of fetal distress. similar findings like non-reassuring fetal status (29.6%), fetal distress (25.6%) and failure to progress (45.45%) were found as the most common indication for lscs with the studies by (geethanjali et al., 2020), (p et al., 2021) and (surayapalem et al., 2017). respectively. in the current study, most cases occurred in women between the ages of 26 and 30. the median age of the participants was 25 years, with a standard deviation of 8.48 years in group a (sublingual misoprostol), but 26.2 years with a standard deviation of 6.42 in group b (intracervical dinoprostone gel). our investigation determined the mean difference between the two groups was 6.03, with a statistically significant p-value of 0.016. in a study conducted by (gupta et al., 2018) and another study by (surayapalem et al., 2017), the most common age group was 20-24 years. (gaikwad h & maskar p, 2016) study had a majority (64%) of the study participants within the age group of 21-25 years. these are the postpartum haemorrhage, pyrexia, and git consequences documented in the current study. 10 (20%) of the individuals who were given misoprostol sublingually (group a) and 7 (14%) of the participants who were given dinoprostone gel (group b) experienced pyrexia, which had a statistically significant chi-square value of 7.362 and a p-value of 0.042. hence maternal pyrexia is more familiar with misoprostol in this study. git effects like diarrhoea are more common with dinoprostone gel. at the same time, misoprostol has lower rates of postpartum haemorrhage than dinoprostone. all cases of postpartum haemorrhage were managed medically. no other significant maternal morbidity was observed in the study group. likewise, fetal complications like meconium-stained amniotic fluid and cases of nicu admission were reported. it was concluded that misoprostol induction is associated more with meconium-stained amniotic fluid. with a chi-square value of 5.023 and a statistically significant p-value of 0.031, only 12 (24%) of the babies delivered to mothers who were induced by misoprostol sublingually (group a) and 8 (16%) of the babies born to mothers who were induced by dinoprostone gel (group b) had to 790 global journal of public health medicine 2023, vol 5, issue 1 gggggglo be admitted in nicu. (surayapalem et al., 2017) reported 17.5% of febrile morbidity being the most common maternal complication and 26% of birth asphyxia as the most common fetal complication. (gupta et al., 2018) reported 26% of nicu admission as fetal complications. (jaiswal et al., 2017) documented 26% of chorioamnionitis as a maternal complication and 30% of early-onset neonatal sepsis as a fetal complication. (endale et al., 2016) found that 22% of puerperal sepsis was a maternal complication, and 33.5% had fetal complications. the study has a few limitations. firstly, the sample size is not large enough to favour generalizability. secondly, not all studies used the same drugs to compare. additionally, as only one referral hospital was used for the study, the findings might need to be more generalisable to other organisations and the community. further, the study findings can be elaborated in a better study design. conclusion: it has been observed that though there is no significant difference between the group induced with misoprostol by sublingual route or in the group induced with intracervical application of dinoprostone gel, the induction delivery time is less in the group administered with sublingual misoprostol than dinoprostone and misoprostol given sublingually is having higher maternal febrile morbidity and fetal distress. thus, it was concluded that though sublingual misoprostol is more efficacious than intracervical dinoprostone, its safety margin is significantly less; hence, misoprostol induction should be done only in a double setup under medical supervision. conflicts of interest the author declares no conflicts of interest. references • acog practice bulletin no. 107: induction of labor. (2009). obstetrics and gynecology, 114(2 pt 1), 386–397. https://doi.org/10.1097/aog.0b013e3181b48ef5 • chitrakar, n. s. (2012). comparison of misoprostol versus dinoprostone for pre-induction cervical ripening at-term. journal of nepal health research council, 10(1), 10–15. • denguezli, w., trimech, a., haddad, a., hajjaji, a., saidani, z., faleh, r., & sakouhi, m. (2007). efficacy and safety of six hourly vaginal misoprostol versus intracervical dinoprostone: a randomized controlled trial. archives of gynecology and obstetrics, 276(2), 119–124. https://doi.org/10.1007/s00404-006-0313-1 • endale, t., fentahun, n., gemada, d., & hussen, m. a. (2016). maternal and fetal outcomes in term premature rupture of membrane. world journal of emergency medicine, 7(2), 147– 152. https://doi.org/10.5847/wjem.j.1920-8642.2016.02.011 • gaikwad h, b., & maskar p, r. (2016). study of maternal and perinatal outcome in premature rupture of membrane at term pregnancy. journal of evolution of medical and dental sciences, 5(37), 2226–2228. https://doi.org/10.14260/jemds/2016/517 • geethanjali, s., palli, s., & dasari, m. (2020). maternal and fetal outcome of pre labour rupture of membranes, a prospective study. https://www.semanticscholar.org/paper/maternal-and-fetal-outcome-of-pre-labour-ruptureof-geethanjali-palli/b2736688dec1da6204bc6d6c598e174cb772e307 • gupta, a., gautam, s., prakash, o., & chauhan, m. (2018). early induction versus expectant management in prelabour rupture of membranes. international journal of reproduction, 791 global journal of public health medicine 2023, vol 5, issue 1 gggggglo contraception, obstetrics and gynecology, 7(11), 4634. https://doi.org/10.18203/23201770.ijrcog20184521 • hannah, m. e., ohlsson, a., farine, d., hewson, s. a., hodnett, e. d., myhr, t. l., wang, e. e., weston, j. a., & willan, a. r. (1996). induction of labor compared with expectant management for prelabor rupture of the membranes at term. termprom study group. the new england journal of medicine, 334(16), 1005–1010. https://doi.org/10.1056/nejm199604183341601 • jaiswal, a. a., hariharan, c., & dewani, d. k. c. (2017). study of maternal and fetal outcomes in premature rupture of membrane in central rural india. international journal of reproduction, contraception, obstetrics and gynecology, 6(4), 1409–1412. https://doi.org/10.18203/2320-1770.ijrcog20171400 • jha, n., sagili, h., jayalakshmi, d., & lakshminarayanan, s. (2015). comparison of efficacy and safety of sublingual misoprostol with intracervical dinoprostone gel for cervical ripening in prelabour rupture of membranes after 34 weeks of gestation. archives of gynecology and obstetrics, 291(1), 39–44. https://doi.org/10.1007/s00404-014-3383-5 • middleton, p., shepherd, e., flenady, v., mcbain, r. d., & crowther, c. a. (2017). planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). the cochrane database of systematic reviews, 1, cd005302. https://doi.org/10.1002/14651858.cd005302.pub3 • p, d. a., s, d. v., k, d. v., & m, d. t. (2021). study on maternal and fetal outcomes in term prelabour rupture of membranes in a tertiary care teaching institute. international journal of clinical obstetrics and gynaecology, 5(1), 26–29. https://doi.org/10.33545/gynae.2021.v5.i1a.789 • surayapalem, s., cooly, v., & salicheemala, b. (2017). a study on maternal and perinatal outcome in premature rupture of membranes at term. international journal of reproduction, contraception, obstetrics and gynecology, 6(12), 5368–5372. https://doi.org/10.18203/23201770.ijrcog20175244 • veena, b., samal, r., inbaraj, l. r., & george, c. e. (2016). sublingual misoprostol (pge1) versus intracervical dinoprostone (pge2) gel for induction of labour: a randomized control trail. journal of obstetrics and gynaecology of india, 66(suppl 1), 122–128. https://doi.org/10.1007/s13224-015-0820-8 • wankhede, s., goverdhan, n., thakare, s., & daware, d. (2017). early induction versus expectant management in term prom. journal of evolution of medical and dental sciences, 6(15), 1226–1230. https://doi.org/10.14260/jemds/2017/266 • world health organization. (2018). who recommendations: induction of labour at or beyond term. world health organization. https://apps.who.int/iris/handle/10665/277233 • yadav, s., & chandwaskar, n. (2017). comparative study of misoprostol sublingually and dinoprostone gel intracervically for cervical ripening and induction of labor. international journal of reproduction, contraception, obstetrics and gynecology, 6(8), 3624–3627. https://doi.org/10.18203/2320-1770.ijrcog20173497 microsoft word gjphm-2023 the practice of universal health precautions .edited.docx 823 global journal of public health medicine 2023, vol 5, issue 1 gggggglo original research the practice of universal health precautions among nurses in a tertiary care hospital in south india – a cross-sectional study manoj prabhakar e1, k madhan mohan2, rock britto d3*, aswin a3, bala pavithra s3, jeevan t c3, girish kumar s3, jagan s3 1 department of general surgery, dhanalakshmi srinivasan medical college and hospital, perambalur, tamilnadu india 2 department of respiratory medicine, dhanalakshmi srinivasan medical college and hospital, perambalur, tamilnadu india 3 department of community medicine, dhanalakshmi srinivasan medical college, and hospital, perambalur, tamilnadu india *corresponding author: rockbritto@gmai.com abstract introduction: the level of preventive measures against hospital-acquired infections depends on the practice of universal precautions by the nurses. this study aimed to assess the awareness of universal health precautions among nurses. methods: it’s a cross-sectional study done among nursing staff in various specialties in a tertiary care hospital. systematic random sampling was done and 200 nurses were tested with a study tool of a semi-structured questionnaire consisting of 20 questions. results: out of 200 respondents 44.5% were aged 26-30 years, 88.5% were females, 66.5% were from urban and 86% had bachelor of science in nursing degrees. the practice was assessed and the mean score was 16.71 range (12-24). the maximum score was for ages 31-35 years, male, married, urban, master of science in nursing, inpatients nursing staff, surgical departments, the experience of more than 5 years. conclusion: this study concludes with clues that there are gaps in formal teaching for nursing 824 global journal of public health medicine 2023, vol 5, issue 1 gggggglo students and practice. for the reduction of infection, we require repeated implementation and oversight of universal precaution measures along with formal teaching, and further research and intervention are needed. keywords: nurses, tertiary care, universal precautions, hospital introduction healthcare workers [hcws] are more prone to the risk of various blood borne infections, like hepatitis c and b, and human immunodeficiency viruses (hiv) viruses. various kinds of universal health precautions are used to reduce the risk of exposure to such infections with blood and body fluids. (sadoh et al., 2006) in the medical industry, precautions are taken to lessen the risk of spreading pathogens from both known and unidentified sources, including blood-borne illnesses. they are the fundamental infection prevention measures that must be applied at the very least when providing care for all patients. because the risk of hepatitis b or hiv transmission through sputum, feces, vomit, tears, urine, or nasal secretions is extremely low or non-existent, universal precautions (ups) should not apply to these substances unless they are contaminated with blood. (broussard & kahwaji, 2022) one of the best ways to prevent the spread of infections linked to the medical profession is by washing one's hands frequently, which is an essential component of healthcare measures. according to the findings of various research, hcw compliance with ips and hand hygiene is frequently insufficient.(eveillard et al., 2007; kermode et al., 2005) a risk assessment and the anticipated level of contact with blood, bodily fluids, or infections should be used to determine the best personal protection equipment in addition to practicing excellent hand hygiene. (cdc, 2020; chan et al., 2002) increased usage of healthcare precautions on a global scale would eliminate unneeded hazards related to healthcare. when giving treatment to all patients, healthcare precautions should be the minimal standard of care. healthcare providers often work to prevent and control diseases, especially contagious ones. (uddin et al., 2014) healthcare workers are at risk of contracting bloodborne pathogens due to occupational exposure to blood, which has led to the widespread promotion of universal precautions (ups) and more recently healthcare precautions. (singh et al., 2021a) in lowincome nations, things are substantially different: ups are sometimes only partially or never practiced, putting hcws at unnecessary risk for infection. (kermode et al., 2005) to prevent healthcare workers from coming into contact with blood and other bodily fluids, the universal health care precautions (uhp) program employs several infection control strategies, including handwashing, the wearing of gloves and masks, the disposal of infectious waste safely, and the safe cleaning of used equipment. (singh et al., 2021a) to stop the transmission of infection, nurses must take precautions including constantly washing their hands, donning gloves when in touch with human fluids, and properly discarding needles and other 825 global journal of public health medicine 2023, vol 5, issue 1 gggggglo sharp objects. it is also important for nurses to be up-to-date on their vaccinations, as this can help to prevent the transmission of infectious diseases. (infection control yearly, n.d.) in addition to following these guidelines, nurses should also educate their patients about the importance of universal precautions and how to protect themselves from infections.(akagbo et al., 2017) this may involve teaching patients how to properly wash their hands, use personal protective equipment, and follow other infection control measures.(bouchoucha & moore, 2018) overall, universal precautions are a crucial component of the nursing profession since they serve to prevent the spread of infectious diseases to both patients and healthcare staff. it is observed that knowledge influences the practice and compliance with these precautions, therefore there were many studies on knowledge assessment but limited studies about the practice. the objective was to assess the practice of universal health precautions among nurses in tertiary care hospitals in the perambalur district. methods in the month of june 2022, a cross-sectional study was carried out at a tertiary care facility close to perambalur. the study's participants comprised nursing professionals with a range of specialties. participants were selected by a simple random method like the name list of the nurses was taken and arranged in attendance order and then the 5th name was taken as the first participant and every 10th name was selected irrespective of the department. if the participant is not available the 2nd time then the next participant on the list was taken. as a research tool, a self-administered questionnaire was employed. to validate it, the questionnaire underwent a pilot test with 20 different specialists and was subsequently adjusted. the pilot testing experts were not included in the study. written informed consent from selected nursing professionals was taken individually to collect participants' sociodemographic and personal information, including gender, age in years, marital status, residence, education, their designation, the department, and work year of experience, as well as to evaluate the disposal of used needles, use of barrier equipment, handwashing, and gloving practices. each question received a score. a score of one was assigned to each appropriate response. zero points were awarded for incorrect responses and unanswered questions. zero is the lowest possible score, and 20 is the highest. the collected data were entered into microsoft excel and analyzed using spss v 26 software. the overall mean score, standard deviation, and 95% confidence interval of mean were calculated for all participants. the descriptive data were analyzed using frequency and percentage. t-test and anova were used to determine how the groups differed. statistics were deemed significant when the p-value was less than 0.05. 826 global journal of public health medicine 2023, vol 5, issue 1 gggggglo results there were 200 participants. results showed that 89 (44.5 %) of participants were between the ages of 26 and 30. they were followed by 89 (34.5 %) participants who were under 25. the majority of participants—177 (88.5%) were women, 101 (50.5%) were married people and 133 (66.5%) people from metropolitan areas. of the participants, 86 % had bsc degrees in nursing, followed by 7.5 % who held nursing diplomas, and 83.5 % who worked as ward staff nurses.[table 1]. table 1: analysis of variance for the association of practice score with age group, sex group, marital status, place of residence, designation, and educational qualification parameter frequency percent practice score p-value mean sd age group (years) <25 69 34.5 16.6812 1.45008 0.366* 26-30 89 44.5 16.5730 1.60176 31-35 31 15.5 17.1290 1.31001 >35 11 5.5 16.7273 1.42063 gender female 177 88.5 16.6723 1.51694 0.394** male 23 11.5 16.9565 1.36443 marital status married 101 50.5 16.8911 1.47581 0.076** unmarried 99 49.5 16.5152 1.50756 place of residence rural 67 33.5 16.5075 1.55089 0.187** urban 133 66.5 16.8045 1.46917 education 827 global journal of public health medicine 2023, vol 5, issue 1 gggggglo bsc 172 86 16.6570 1.50392 0.471* dgnm 15 7.5 16.8667 1.68466 msc 13 6.5 17.1538 1.21423 designation nursing sisterip 167 83.5 16.7246 1.52752 0.679** nursing sister-op 33 16.5 16.6061 1.36792 department general medicine 37 18.5 16.5405 1.48314 0.084* icu 39 19.5 16.7179 1.50348 orthopaedics 23 11.5 16.3478 1.66812 general surgery 16 8 17.1875 1.32759 paediatrics 10 5 15.7000 1.82878 radiology 3 1.5 16.3333 1.15470 general ot 4 2 18.2500 1.50000 og 13 6.5 16.5385 1.19829 ophthalmology 2 1 17.5000 2.12132 ent 8 4 17.6250 .91613 casualty 20 10 16.5000 1.14708 super specialty 25 12.5 17.0400 1.61967 year of experience less than 5 years 153 76.5 16.5490 1.56416 0.008** more than 5 years 47 23.5 17.2128 1.14086 *one way anova, **independent t-test, p-value <0.05 is statistically significant 828 global journal of public health medicine 2023, vol 5, issue 1 gggggglo out of 200 participants, 177 are saying hand washing is done in contacting different patients, 199 practices isolation of communicable diseases patients, but only 94 out of 200 have needle stick injury dangerous. but recapping of the needle is practiced by 190 out of 200 and 167 wear masks whenever there is a possibility of splash/splatter. all the participants use gloves for protection when working with or around blood and body fluids. [figure 1] figure no. 1: practice regarding universal health precautions in nurses 200 190 94 190 167 130 181 60 188 188 182 170 94 194 178 164 197 199 198 177 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% gloves used for protection when working with or around blood and body fluids washing hands if contaminated and after removing gloves recaping the used needle before disposal recaping the used needle before disposal wearing face mask whenever there is a possibility of splash/splatter should not eat/drinking while working in contaminated area with blood/body fluids promptly wiping up all contaminated spills with a disinfectant. decontaminating a device (with only in contact with skin) by washing with usual detergent is enough apron, shoes, goggles be used wounds/lesions are coverd with waterproof dressing gloves be changed between patients contact surgical mask or disposable ppe not been re used needle stick injury dangerous isolation ward entry restricted for staff or patients from outside proper handling of soiled linen(bedspreads) universal precautions are not only done for hiv,hbv infected patients proper labeling, transportation, handling samples for testing must communicable diseases patients isolated sterilized articles not come in contact with contaminated articles hand washing done while contacting different patients 829 global journal of public health medicine 2023, vol 5, issue 1 gggggglo the mean practice score of the respondents was 16.71 ± 1.50 with a range of a minimum of 12 to a maximum of 24 [table 2]. table 2: descriptive statistics showing overall mean practice score n minimum-maximum mean sd 95% ci of mean practice score 200 12-20 16.71 1.50 16.50-16.90 anova was applied to evaluate the practice differential among different groups. the mean practice score varies from 17.13 ± 1.31 (31-35 years) followed by 16.73 ± 1.42 (>35 years) then follow by ages less than 30 years. it was not statistically significant that this difference existed ( p=0.366). the mean practice score of males was 16.95 ± 1.36 higher than females (16.67 ± 1.51) which is statistically insignificant (p=0.394). the practice score is higher for married (16.89 ± 1.48) than for unmarried which is statistically insignificant (p=0.076) and comparatively urban (16.80 ± 1.47) has a higher practice score than rural (16.50 ± 1.55) which is statistically insignificant (p=0.187). the participants holding a degree of m.sc., have a higher practice score of 17.15 ± 1.21 compared to that of b.sc., and dgnm., which is statistically insignificant (p-value = 0.471). the ward nurse's mean score was 16.72 ± 1.53 which is slightly higher than outpatient sisters (16.60 ± 1.37) which is statistically insignificant (p=0.679). the majority of the surgical departments have a higher practice score in order of general ot (18.25 ± 1.5), ent(17.63 ± 0.92), ophthalmology (17.50 ± 2.12), general surgery (17.19 ± 1.33), super specialty (17.04 ± 1.62), icu (16.71 ± 1.50), general medicine (16.54 ± 1.48), obg (16.53 ± 1.20), casualty (16.50 ± 1.15), orthopaedics (16.34 ± 1.67) radiology (16.33 ± 1.15) and paediatrics (15.70 ± 1.83) which is statistically not significant (p=0.084). [table 1] 830 global journal of public health medicine 2023, vol 5, issue 1 gggggglo discussion in a tertiary care hospital, this study examines how nurses practice universal precautions. the study's conclusions showed that nurses generally followed the universal precaution principles to a good degree. (gershon et al., 1995a) the term "universal precautions" refers to a set of rules that medical personnel, including nurses, adhere to stop the spread of infections, especially blood-borne illnesses like hiv, hepatitis b, and hepatitis c. to prevent healthcare professionals from coming into contact with potentially infectious materials, these measures apply to all patients, regardless of how contagious they may appear to be.(moriceau et al., 2016; nugmanova et al., 2015) ups must be known and followed properly by all healthcare workers. in tertiary care, this survey was undertaken among nursing professionals. in our investigation, we discovered that the average practice score represented 16.71% of the possible score overall. compared to fayaz et al., this score was higher. (fayaz et al., 2014) in research by afemikhe et al., nursing practitioners in edo state, nigeria, received a higher score than our study.(afemikhe et al., 2020) some significant differences in the practice score have been produced by our investigation. respondents who were between the ages of 31 and 35, married, male, urban inhabitants, m.sc., and ward sisters performed better than respondents who were under 30 years old, single, female, rural residents, b.sc., and op sisters. the surgical ward nurses also scored better than the medicine ward sisters. among the departments, the operation theater nurses have better practice than the outpatient sisters and other medical ward sisters. this might be due to the supervision or monitoring by the doctors and continuous practice. the nurses with experience over 5 years have a better mean score than those less than 5 years. this might be due to the experience and training that one could have undergone in the institution or elsewhere during these past years. healthcare practitioners must adhere to a set of rules known as universal precautions to stop the spread of illnesses. (singh et al., 2021b; standard precautions, 2022) these guidelines are based on the assumption that all bodily fluids are potentially infectious, and as such, healthcare professionals should take the necessary precautions to protect themselves and their patients from coming into contact with 831 global journal of public health medicine 2023, vol 5, issue 1 gggggglo these fluids. (gershon et al., 1995b; summary of infection prevention practices in dental settings, 2022) for numerous elements of the infection chain, the significance of all-encompassing measures for nursing staff, nosocomial infections, hand hygiene, etc., the practice score in the current study was extremely good. nursing educators must regularly reinforce and monitor students' understanding of the universal precautions issue that is covered in the first year of their training. limitation: the study was done by subjective assessment considering a few variables in a tertiary care hospital and the results were not generalizable to all teaching medical institutes in tamil nādu. conclusion the current study reports that the overall practice of universal precautions and their importance thereby reduces many infections. our study shows a major difference between surgical and non-surgical wards and year of experience plays a major role in their practice. continuous training should be made compulsory for providing a better environment for healthcare workers and patients. formal teaching is not just enough for this precaution. acknowledgment we would like to thank all our study participants for their full participation conflicts of interest the author declares no conflicts of interest. references • afemikhe, j., esewe, r., enuku, c., & timothy, e. 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(2014). knowledge on hospital waste management among senior staff nurses working in a selected medical college hospital of bangladesh. journal of waste management, 2014, e573069. https://doi.org/10.1155/2014/573069 microsoft word gjphm-2020indoor microbiome and human health.docx 249 global journal of public health medicine 2020, vol 2, issue 2 gggggglo review research the phyllosphere, indoor microbiome and human health favour o. omeiza & funmilola a. ayeni* department of pharmaceutical microbiology, faculty of pharmacy, university of ibadan, ibadan, nigeria *corresponding author: funmiyeni@yahoo.co.uk abstract a healthy indoor environment is very vital as humans spend a greater percentage of their life within built environments. a healthy and quality environment is determined by the biodiversity of and features of the natural environment. the indoor environment just like every other environment possesses a unique community of microorganism which depends on the level of contact between the environment and natural sources. plants are significant sources of microbial diversity in an environment. there is an interplay between the phyllosphere and the troposphere where the microorganisms released from the phyllosphere perform several beneficial effects consequently, improving human health. the indoor environment must however be enriched with natural sources of microbial release to enhance its biodiversity. this paper therefore focuses on the phyllosphere as a natural source for enhancing indoor biodiversity, the interplay between the phyllosphere and its surrounding environment and its implication on human health. keywords: phyllosphere, indoor, environment, microbiome, health. 250 global journal of public health medicine 2020, vol 2, issue 2 gggggglo microbial communities of plants plants relates with a broad and varied group of microorganisms including bacteria, viruses, fungi, and oomycetes that colonizes their tissues, with bacteria being the most abundant. plants derive the bulk of their microbiota from the environment and the soil which harbours highly varying microorganisms dominated by verrucomicrobia, bacteroidetes, acidobacteria, actinobacteria, proteobacteria, and planctomycete (fierer, 2017). seeds can house several microbial communities, and these seed-borne microorganisms perform a vital duty in the plant's early development and growth (truyens, 2015). the seed also provides an effective way to spread and transfer the microorganism from one plant to the next. most pathogens of plants are transmitted by seeds like the aspergillus flavus ascomycete and the rhizoctonia solani basidiomycete. nonetheless, beneficial microorganisms and commensal are also found in plant seeds, e.g. beneficial fungal species epichloë and alternaria and bacteria such as curtobacterium and paenibacillus (harrison et al., 2018). another very important source of microbes is the substratum on which plant growth takes place. it is usually the soil (bulgarelli et al., 2015). specific microbial sources such as air, precipitation and soil are the target of the above-ground plant tissues (muller, 2016). microbiota study of a. thaliana and crops such as maize, barley, rice and citrus have shown that actinobacteria and proteobacteria dominate the plant microbiota, and also bacteroidetes and firmicutes at lower dominance (xu et al., 2018). the rhizosphere most root microbiota are distributed horizontally, i.e. they are collected from the soil ecosystem which harbors a wide variety of microorganisms (fierer, 2017). the rhizosphere is described as a microbial activity hot spot (compant et al., 2019). kawasaki et al. (2016) indicated that sphingobacteriales, burkholderiales, and xanthomonadales dominated the rhizosphere of brachypodium distachyon (a model for wheat), while bacillales dominated the soil. root exudates like those of amino acids, organic acids, plant growth regulators, fatty acids, phenolics, nucleotides, putrescine, carbohydrates, vitamins and sterols influence microbial composition around the roots (olanrewaju et al. 2019). bacterial endophytes enter the root tissues through passive processes, root cracks, lateral root points and active mechanisms as well (hardoim et al., 2012). many factors affect the rate of colonization and transmission of endophytes within plants, including the ability of the endophyte to colonize the plant and the distribution of plant resources. for example, acidobacteria, proteobacteria, bacteroidetes, planctomycetes, actinobacteria, firmicutes, verrucomicrobia, gemmatimonatedes and chloroflexi were the most abundant phylate found in grape vine roots (burns et al., 2015). maize roots is found to be dominated by firmicutes, bacteroidetes and proteobacteria (correa-galeote et al. 2018). the phyllosphere certain phyllosphere areas include the anthosphere: which is the flowers ' external environment, the spermosphere: the seed's external environment, the caullosphere: the stem's external environment and the 251 global journal of public health medicine 2020, vol 2, issue 2 gggggglo carposphere: the internal fruit ecosystem (compant et al., 2019). the microbial population of the plant, usually found in numbers ranging from 106 to 107 cells / cm2 / g) of soil, is dominated by bacteria (andrews and harris, 2000). the bacterial population of the planetary phyllosphere may be as large as 1026 cells (lindow and brandl, 2003). apparently, these bacteria are numerous enough in aggregate to influence global activities and the actions of their host plants. the indoor microbiome and the human health the indoor microbiome indoor environments are usually greatly affected by bacteria associated with human as a result of the activities of human and the high emission levels of up to 10 bacteria per personhour from aerosols (qian et al., 2012). the human microbiome is formed by the bacteria, fungi, and viruses that colonize indoor environments and can fundamentally alter human health trajectory. the indoor microbiome can affect the development of children's immunology, physiology, and neurology. children will spend 98% of their first year of living indoors with an extremely impoverished exposure to a complex microbiota that would usually train a healthy immune system and promote good physiology and neurology (gilbert and stephens, 2019). microorganisms harboured in built environments can be seen in air, in water systems and on surfaces. these microbes arise from and are transported by living creatures residing within that environment, such as human occupants, plants, pets, and pests which possess individual distinct microbial communities. the microbial community of an indoor environment is therefore affected by several factors which can be broadly classified into two viz: design choices and behavioural choices. the design choices that impact microbial communities include: flooring content, ventilation system, humidity / relative moisture, occupant density and location of buildings while some behavioural considerations include: cleaning procedures and duration, presence of animals, presence of plants and overcrowding. relationship between indoor microbiome and human health built environments are the predominant ecosystems colonized by man in industrialized areas of the world and human microbiome may be influenced by the environments in which people live, which may consequently affect human health. environmental microbes, for example, can proliferate in the human host's niche-specific ecosystems such as in gut, skin and airways. in developed parts of the world, human spend a major part of their lives indoors (gilbert and stephens, 2019), which can limit the microorganism diversity to which they get in contact with. the exterior of a building (the foundation, windows, walls and roofs) divides the indoor and outdoor worlds, thus minimizing contact with outdoor thriving microbes and inherently modulating contact to indoor thriving organisms. nevertheless, it is not well known to what degree the indoor microbiome leads to this diversity or lack of it. people who spend more time outdoors in economically disadvantaged and less developed communities may have higher risk of infectious disease and greater risk of infant mortality (hanski et al., 2012, clemente et al., 2015). 252 global journal of public health medicine 2020, vol 2, issue 2 gggggglo this may, however, be as a result of their health status when contact with infectious agents is made than the exposed microbial nature. some studies implicated the beneficial effects of exposure to different microbes on the immune system (sordillo et al., 2010; behbod et al., 2015). under certain conditions, indoor microorganism, their metabolites and components could trigger both positive and negative health effects (quansah et al., 2012; lai et al., 2015). the features of an indoor environment, community of microorganism present and human activities in that environment may affect the amount of exposed microorganism which may invariably decide the adverse, beneficial or neutral effects on health. several factors such as the features of a building, life stage exposed individuals, exposure dose, route of exposure and genetic sensitivity determine the beneficial or detrimental effects of a microbial community at a given time. microorganisms that improves the human immune system are primarily potential beneficial microorganism (kelly et al., 2005), they release little molecules that transforms human health (neish, 2009) or initiates other helpful functions of the human health (rook and lowry, 2008; reber et al., 2016). sick building syndrome (sbs) is a situation where time spent indoor in a particular building, room or zone affects human health or comfort and is characterized by headache, nausea, fatigue, personality changes e.t.c. without any specific course except time spent in the building (brilli et al, 2018, amoatey et al, 2020) the outdoor environment harbours diverse microorganisms which possess richer microbial diversity than the indoor environment. the difference in this microbial diversity is connected to the fact that outdoor environment has more vegetation and more varying source of microbes that contributes to its diversity. several factors such as cleaning procedures, building materials and design choices affects the microbial diversity of the indoor environment. less contact with natural sources is the key factor militating against the microbial diversity of the indoor air in accordance to the highly recognized “hygiene hypothesis” and “biodiversity hypothesis (haahtela et al., 2015). degradation of harmful compounds by indoor microbes within the built environment, viable indoor microbes are likely to metabolize chemicals. variety of chemicals seen in furniture or household products, such as perfluorooctanoate (pfoa), perfluorooctane sulfonate (pfos) and bisphenol have an effect in the endocrine function (e.g. risk of diabetes or glucose metabolism) and growth in children, as well as the chance of obesity (heindel et al., 2017). several investigations has shown that microbes in the environment can degrade these chemicals and other chemicals with destructive endocrine potentials, which may produce more bioactive chemicals and may also decrease toxicity (janicki et al., 2016; vejdovszky et al., 2017). the skin’s community of microorganism promote the state of health of the body via immune responses that preserve health or, in some situations, may modulate disease conditions (barnard and li, 2017). 253 global journal of public health medicine 2020, vol 2, issue 2 gggggglo effect of indoor microbes on respiratory conditions dust from areas where dogs reside and the microbial communities within it reduce symptoms of atopy in mice (fujimura et al., 2014). the mode of action is suggested to be characterized with the microbial communities related with animals. gut microbiota differences such as accelerated concentration of lachnospira spp., faecalibacterium spp and veillonella spp from the firmicutes phylum (arrieta et al., 2015), seem to have a function in asthma protection within the first three months of life (lynch et al., 2014). in addition, there is a proposed relationship between high bacterial exposure and fungal diversity at tender age and protection from wheeze and asthma (ege et al., 2011; dannemiller et al., 2014; tischer et al., 2016). there are reports on the antagonistic effects of microorganisms, their metabolites and their constituents on the onset and progression of allergies and asthma, (quansah et al., 2012; lai et al., 2015). also, there are reports of protection from the onset of allergy and asthma conditions as a result of exposure to microbes (sordillo et al., 2010; behbod et al., 2015). increased atopy rate has been associated with decreased exposure to some species of bacteroidetes and firmicutes associated with house dust (lynch et al., 2014). the absence of these bacterial phyla which is usually found in the mammalian gut indicates a decrease in stool present in the environment. indoor pathogens and infections fomites are seen in the transmission of infectious disease, and transfer of pathogens by aerosol in various built environments can occur ((julian, 2010, wong et al., 2010). fungi are a source of various constituents beneficial to health, however, some allergens and other antigens found on indoor fungi can aggravate respiratory symptoms increased exposure to certain non-microbial allergens in early life, can help in increasing protection and tolerance from allergic responses (du toit et al., 2015). it is however not known if tolerance can take place when there is exposure to fungi allergens in the early stage of life. summarily, fungal exposure in the early years of life may worsen the children’s health jaakkola et al. (2013) reported that rhinitis, other allergic rhinitis and rhinoconjunctivitis can arise and or be exacerbated by dampness and exposure to mold at home. the phyllosphere and indoor microbiome interplay humans contribute immensely to the availability of microorganisms in the indoor environment (mahnert et al., 2015). the phyllosphere should be of key concern in examining indoor microbiomes because the surface area of the phyllosphere is broad and possesses a remarkable microbial diversity (meyer and leveau, 2012; vorholt, 2012; rastogi et al., 2013). all plants microbiome has several neutral and beneficial inhabitants, they also possess pathogens of plants and humans as well (berg et al., 2014). a vast range of plant pathogens is well recognized to cause outbreaks of diseases in them. the interaction between the soil and the microbial diversity of the rhizosphere which have a selective subset in common has been reported (smalla et al., 2001). plant defense signaling performs a vital task in this process (doornbos et al., 2012). an essential part of phyllosphere bacteria is in constant contact with the air microbiome while 254 global journal of public health medicine 2020, vol 2, issue 2 gggggglo some fewer fraction reside within the phyllosphere (lindow and brandl, 2003). as a result of this fact, there is an obvious huge association and exchange between the phyllosphere, rhizosphere microbiome and neighbouring microbiome. a study conducted by mahnert et al. (2015), promotes the hypothesis that indoor plants contributes significantly to the abundance and diversity of microorganisms in an indoor environment. fungi and bacteria are reputable colonizers of plants, but plant-associated archaea (euryarchaeota, methanobrevibacter and thaumarchaeota) have been found on the leaves of olive plant (müller et al., 2015). as a result of the fact that numerous indoor pathogens are recognized as source of some health issues, (nunes da rocha et al., 2009), a greater diversity could actually hinder the colonization of these pathogens. all environmental microbes interplay with the microbiomes of house plants which also act as a bio-resource. beneficial effects of the phyllosphere on the indoor environment some studies reveal that plant-associated microbes play both beneficial and detrimental roles in the environment with the former possessing higher impacts than the latter (berg et al., 2005; mendes et al., 2013). the effect of the phyllosphere on stabilizing the indoor ecosystem constructed environments, such as hospitals, are more easily colonized by pathogens associated with patients (oberauner et al., 2013). consequently, a lot of patients in hospitals and particularly in intensive care units (icus) get hospital-acquired “nosocomial infections” that worsen their initial critical disease (plowman, 2000). bacteria associated with plants could serve as opposing agents against pathogens found in the microbial ecosystems (bamidele et al. 2013, ayeni and afolayan, 2017). they provide stability to the ecosystem and prevent pathogen outbreak by enhancing biodiversity. genera such as pseudomonas, bacillus streptomyces, enterobacter, paenibacillus, pantoea, paraburkholderia and burkholderia have played vital role in the suppression of pathogens (gomez et al., 2017). acidobacteria, actinobacteria, and firmicutes were reported to control the invasion of fusarium wilt at a continental scale (trivedi et al, 2017). the activity of endosphere microbial community in suppressing take-all disease (gaeumannomyces graminis) was reported by durán et al. (2018), some plant-associated microorganism which includes: pseudomonas aeruginosa, stenotrophomonas maltophilia or burkholderia cepacia may be pathogenic to humans with predispositions, they however play a significant role in maintaining a balance to the indoor ecosystem when this environment harbour abundant diversified microorganisms. the effect of the phyllosphere on enhancing indoor biodiversity microbial diversity is implicated as vital for human and plant health and can be enriched by various sources of microbial release. plants, asides animals and humans are usually a portion of indoor environments and providing sustainable source for microbial communities, thus enhancing indoor microbial diversity (berg et al., 2014; mahnert et al., 2015; brilli et al., 2018). plants individually have distinct 255 global journal of public health medicine 2020, vol 2, issue 2 gggggglo microbiomes; the productivity and health of the plant and its surrounding environment is dependent on their functional interplay. many more evidences are rising that points that a degree of microbial abundance and diversity critically influences human health, for example, fujimura et al. (2014) showed that there was a unique gut microbiome composition in mice that were exposed to dust in homes where dogs resides, these mice had protection against the challenge of airborne allegies as a result of lactobacillus johnsonii enriched microbiome. a study carried out by hanski et al. (2012) confirmed the biodiversity hypothesis which states that decreased contact of people with features of the natural environmental and biodiversity may negatively influence the community of commensals in the human microbiota and likewise its immunomodulatory capacity. the effect of the phyllosphere in degrading indoor pollutants viable indoor microbes released from plants have the ability to metabolize chemicals present in the built environment. experiments carried out in laboratories proved that microorganisms in the environment microbes can degrade varieties of chemicals found in regular products in homes or furnitures, such as perfluorooctanoate (pfoa) and several other chemicals which can disrupt the endocrine, resulting in more bioavailable or bioactive chemicals and sometimes decreasing their toxicity (kim et al., 2008; blavier et al., 2016; janicki et al., 2016; vejdovszky et al., 2017). eradication of potency of volatile formaldehyde by indoor plants has been reported (kim et al. 2008) improving the indoor microbiome the use of indoor plants a relevant source of useful microorganisms is the indoor plants which can bring a rise in microbial diversity, these useful microbes have the ability to influence a room’s microbiome (mahnert et al., 2015). contact with natural vegetation particularly in an outdoor environment is key in microbial diversity and health, however, humans cannot continuously stay outdoor, therefore microbial researches have suggested the contingency of increasing the microbiome of a room by the use of indoor plants (mahnert et al., 2015), to enhance the population of beneficial microorganism and invariably microbial diversity (berg et al., 2014). plants microbes have the ability to degrade human, plant and environmental toxic compounds (bringel and couee ´ 2015), they can also assist in the maintenance of healthy indoor air quality in an environment. indoor plants (orwell et al. 2004; pegas et al. 2012) together with the microbes associated with them function synergistically to ameliorate the quality of the air (weyens et al. 2015). the bringing of plants into built environments is capable of suppressing the growth of pathogenic fungi and molds which are the etiology of ‘sick building’ syndrome (strauss 2009). the use of natural ventilation window ventilation is known to bring an increase in the abundance of chloroplast dna than in rooms exclusively ventilated mechanically. it has been reported that patient rooms ventilated by windows had lesser population of potentially pathogenic bacteria than in rooms ventilated mechanically 256 global journal of public health medicine 2020, vol 2, issue 2 gggggglo confirming that natural ventilation (opening of windows) is a better design for microbial diversity (kembel et al. 2012, oberauner et al., 2013),). meadow et al. 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(2012). microbial life in the phyllosphere. nature review. microbiology. 10:828-840. weyens, n., thijs, s., popek, r. 2015. the role of plant-microbe interactions and their exploitation for phytoremediation of air pollutants. the international journal of molecular sciences. 16:25576– 604. wong, b. c., lee, y., li, p. k., chan, h., qiu, z. l. 2010. possible role of aerosol transmission in a hospital outbreak of influenza. clinical infectious diseases 51.10:1176-1183. xu, j., zhang, y., zhang, p., trivedi, p., riera, n. 2018. the structure and function of the global citrus rhizosphere microbiome. nature communications. 9:4894. microsoft word gjphm-2023 psycosocial docx.edited.docx 801 global journal of public health medicine 2023, vol 5, issue 1 gggggglo original research occupational stress among nursing staff and perception regarding the work environment: a cross-sectional study shambhavi, rajesh kunwar & sandeep rai* department of community medicine, t s misra medical college lucknow. *corresponding author: drsrai68@gmail.com abstract introduction: occupational stress has been closely linked with healthcare professionals, including nurses. the strenuous workload in the profession not only impacts the care of the patients but also hampers their own physical and mental health. thus, this study aimed to study the stressors of the work environment and their impact on their overall health. methods: an institutional based cross-sectional study was conducted among all the nursing staff working in a tertiary hospital in gurugram. a predesigned and pre-tested questionnaire covering their details, socio-demographic details, perception towards the work environment and impact of the job on their psycho-social health was made. the stress level was measured by the professional life stress scale given by david fontana, the british psychological society and routledge. ltd, leicester, england,1989. data analysis was done in microsoft excel sheet and epi-info. results: in this study, on the stress scale, 47.14% reported moderate stress, 38.57% mentioned that stress was a problem, and 10% reported stress as a major problem in their lives. stress was not a problem among 4.28% of the nursing staff only. among the socio-demographic variables, married nursing staff and the increasing stress score were found to be significant.(p<0.05) conclusion: stress was a crucial issue among 47.14 % of the nursing staff. 54.29% of people wanted more from their work environment. thus, the stress induced due to work culture should be taken care of so that they can be physically and mentally efficient at work. keywords: nursing staff, occupational stress, coping strategy, psycho-social health, work environment 802 global journal of public health medicine 2023, vol 5, issue 1 gggggglo introduction occupational stress, also known as workor job-related stress, refers to the process by which stressors in the work environment lead to the development of psychological, behavioural or physiological strains that result in long-term health effects.[salih s z, 2014] occupational stress significantly impacts workers' health and well-being, quality of life, family life, job satisfaction, turnover, and absence from work. nursing has always been identified as a profession with a high-stress level. they have to face and undergo a high number of potent stressors, lowering any individual's work efficiency. [okuhara m, 2021] to meet their profession's physical and emotional demands, nurses need to be free of occupational stress and maintain good health. occupational stress has been reported to affect job satisfaction and performance among nurses, thus compromising nursing care and placing patients' lives at risk. [dighe sv, 2020] the nurse-population ratio in the country at present is 1:670 population with the who recommendation of 1:300. [ indian nursing council. nurses registration and tracking system] it is quite significantly challenging to ignore the factors that impact work-related stress, i.e., including long working hours, the quality of the relationships between hospital workers, quality of supervision, work environment, and high workload. in a study conducted in delhi by bhatia n et al., 87.4% of nurses reported occupational stress [bhatia n, 2001], while in another study conducted in saudi arabia, the prevalence of occupational stress in nurses was reported 45.5%.[almakhaita, 2014] stress-related hazards at work can be divided into work content and work context. work content includes job content; workload and work pace; working hours; and participation and control. work context includes career development, status and pay; the worker's role in the organization (unclear role, conflicting roles); interpersonal relationships (inadequate, inconsiderate or unsupportive supervision, poor relationships with colleagues, bullying/harassment and violence, isolated or solitary work, etc.); organizational culture (poor communication, poor leadership, lack of behavioural rule, lack of clarity about organizational objectives, structures and strategies); and work-life balance.[who.occupational health stress at the workplace] there is a need that we develop some norms of desirable or acceptable levels for the nursing staff. all the stressors should be worked upon, and a positive environment should be created for the nursing staff. the nurses constitute the main pillar of support in the treatment and recovery of patients. efforts should be made to rebuild the work environment in a positive way. thus, this study was done to assess the psycho-social impact of occupational stress on the nursing staff of a tertiary care hospital in gurugram, india and also to determine their perception regarding the work environment. methods: an institutional based cross-sectional study was conducted among all the nursing staff working in a tertiary hospital in gurugram was conducted between october 2019november 2019. all the nursing staff working in the hospital where the study population includes 140 nursing staff. 803 global journal of public health medicine 2023, vol 5, issue 1 gggggglo inclusion criteria: all the nursing staff working in the hospital set-up who have given consent were included in the hospital. repeated attempts were made to contact all those who were on leave or were not available at the time of data collection. exclusion criteria: those who did not give their consent or were not available after repeated visits were excluded from the study data collection: data collection was done using a pre-designed and pre-tested questionnaire covering their personal details, socio-demographic details, perception towards the work environment and impact of the job on their psycho-social health. data collection tool: the stress level was measured by the professional life stress scale given by david fontana, the british psychological society and routledge. ltd, leicester, england,1989. [fontanad,1989] it had 22 questions which covered different variables like personality perception by others, optimism for life, satisfaction with self and work, adjustment to the professional environment and so on. a total score of 60 was classified as follows: a) 0–15: stress is not a problem in life; b) 16–30: moderate stress, which can reasonably be reduced; c) 31–45: stress is clearly a problem and needs remedial action; d) 46–60: stress is a major problem, and something must be done. informed consent was obtained from all the participants. statistical analysis: statistical analysis was done in microsoft excel sheet and epi-info. univariate analysis was done, and pthe value was calculated <0.05. ethical approval was obtained from the institutional ethical committee. results: among the 140 nursing staff, they were in the age group of 25-36 years, and the majority were in the young age group of 18-25 years (77.14%). most of the nursing staff recruited were females (74.29%). the working experience of the maximum nursing staff interviewed was less than 1 year (47.14%), and mostly married nursing staff were recruited in the hospital at that time span with income between rs. 30,000 – rs. 60000. (57.14%). table 1: socio-demographic details of the nursing staff(n =140) variables n (%) 1. age 18-25 years 108 (77.14%) 2635 years 32 (22.85%) 2. gender females 104(74.29%) males 36 (25.71%) 3. working experience 804 global journal of public health medicine 2023, vol 5, issue 1 gggggglo <1 year 66 (47.14%) 1-3 years 36 (25.71%) 3-5 years 28 (20%) >5 years 10(7.14%) 4. marital status married 80(57.14%) unmarried 60(42.85%) 5. income <30,000 22(15.71%) 30,000 – 60,000 82(58.57%) > 60,000 38( 27.14%) table 1 shows that among the 140 nursing staff, they were in the age group of 25-36 years, and the majority were in the young age group of 18-25 years (77.14%). most of the nursing staff recruited were females (74.29%). the working experience of the maximum nursing staff interviewed was less than 1 year (47.14%), and mostly married nursing staff were recruited in the hospital at that time span with income between rs. 30,000 – rs. 60000. (57.14%). 805 global journal of public health medicine 2023, vol 5, issue 1 gggggglo table 2: bivariate analysis showing an association between socio-demographic variables and stress scale variables stress score total ( n=140) p-value; (<0.05) chisquare(x2) 0-15 16-30 31-45 age n (%) n (%) n (%) p=0.2360; x2= 2.89 18-25 14 (12.96%) 44 (40.75%) 50 (46.29%) 108(100%) 26-35 8(25 %) 10(31.25%) 14(43.75%) 32(100%) gender p=0.001 x2= 17.5307 female 14(14.86%) 22(31.20%) 68(57.94%) 104(100%) male 6(5.14%) 20(10.80%) 10(20.06%) 36(100)%) working experience p=0.566809 x2 = 4.822 <1 year 26( 26.40%) 30(27.34%) 10(12.26%) 66(100%0) 1-3 years 14(14.40%) 16(14.91%) 6(6.69%) 36(100%) 3-5 years 12( 11.20%) 10( 11.60%) 6(5.20%) 8(100%) >5 years 4( 4.00%) 2(4.14%) 4(1.86%) 10(100%) marital status p=o.002053 x2= 12.3773 married 18(11.43%) 20(18.29%) 42(50.29%) 80(100%) unmarried 2 (5.04%) 12(13.71%) 46(37.71%) 60(100%) income p= 0.55511 x2 = 3.0162 <30,000 4(5.97%) 6(7.23%) 12(8.80%) 22(10%) 30,000-60,000 24(22.26%) 26(26.94%) 32(32.80%) 82(100%) >60,000 10(9.77%) 14(11.83%) 12 (14.40%) 36(100%) 806 global journal of public health medicine 2023, vol 5, issue 1 gggggglo table 2 depicts that among all the socio-demographic factors, the association between stress levels among females was more in comparison to males in this study. hence, it came out to be statistically significant. (p<o.oo1). another factor which was statistically significant with the increased stress was the marital status of the participants. (<0.05) the stress was found more in married nursing staff compared to unmarried nursing staff. table 3: prevalence of stress score among the nursing staff stress levels (as per david fontana scale) frequency percentage stress is a major problem (46-60) 14 10% stress is clearly a problem (31-45) 54 38.57%% moderate stress (16-30) 66 47.14% stress, is not a problem (0-15) 6 4.29% table 3 shows the stress levels among the participants; 10% reported stress to be a major problem in their lives, 38.57% mentioned that stress was clearly a problem for them, while moderate stress was reported by 47.14%. only 4.29% of the nursing staff reported that stress was not an issue for them. 807 global journal of public health medicine 2023, vol 5, issue 1 gggggglo figure 1: reasons for a stressful environment figure 1 depicts the factors which contributed to the stressful work environment. 54.29% were not satisfied with the working hours of the hospital. the prolonged and strenuous working hours made things worse for the nursing staff of the hospital. the extended working hours in the hospital were actually a troublesome matter to deal with for the nursing staff. 17.14% of nurses felt that they were underpaid. the need for a better salary was also a crucial issue for the nursing staff. the workload they had and the salary received were definitely unsatisfactory. 12.14% of participants felt that there was a shortage of nursing staff which was responsible for the deteriorated work culture. 10% of nursing staff felt that the leaves sanctioned to them are quite a few as they hardly get time to spend with their family. 6.42% felt that the working staff behaviour made the condition worse 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% no t s at isf ied w ith th e… ne ed fo r b et te r sa la ry sh or ta ge o f s ta ff un sa tis fie d w ith th e l ea ve s un sa tis fa ct or y b eh av io ur … 76(54.29… 24(17.14… 17(12.14… 14(10… 9(6.42… 808 global journal of public health medicine 2023, vol 5, issue 1 gggggglo figure 2: impact on mental health figure 2 shows that mental occupational work stress impacted their mental health also. 50% of them reported that they had severe mood swings due to work stress. 19.28% felt anxiety, 15.71% always felt depressed due to severe stress, and 15% felt constantly fatigued and tired throughout the day. not only mental health, due to occupation burnout, but their sleep cycle was also impacted. talking about the sleep disorders impacted due to the severe stress at the working place. 68 (48.57)% complained that it also impacted their sound sleep, and they used to wake up at odd hours due to the stress of reaching the hospital at the time. 48(34.29%) couldn't take a proper 7-8 hours of sleep, and they faced disturbed sleep at night. 24(17.14%) of the nursing staff took a long time to fall asleep, although they were highly tired and felt fatigued. 50%(70) 27(19.28%) 22(15.71%) 21(15%) mood swings anxiety depression tiredness always 809 global journal of public health medicine 2023, vol 5, issue 1 gggggglo figure 3: adverse work effects on life occupational stress at work also impacted their personal lie. figure 3 depicts that 51.42% complained of having an imbalanced social life, and they suffered hard in maintaining a work-life balance in life. 17.86% have felt that the uneven working hours and the associated stress impacted their married life. they experienced a stressful situation in their marriage due to their work. 14.28% felt that their children were being ignored due to the strenuous working hours, and they couldn't spend quality time with their kids. 16.43% complained about self-irritation, which was enhanced due to the consistent work stress. the factors decreasing the stressors in the work environment included well-coordinated staff duties (36.42%) followed by proper staffing (21.43%), and the well-equipped ward (38.75%) made things easier. discussion: in this study, 47.14% of participants reported moderate stress, 38.57% mentioned that stress was clearly a problem, and 10% reported stress to be a major problem. among the socio-demographic factors, married females and the stress factor came statistically significant, while a study done in a tertiary hospital in delhi shows that there was no significance found in the study among the increasing work-related stress among married females. the increased responsibility post-marriage could be the reason behind this.[bhatia n,2001] however, reported that single nurses had marginally higher stress scores than married nurses. this was again not statistically significant. hence, to ascertain the association between marital status and stress, further studies are required. [callaghan et al., 2011] age and increased experience were not statistically significant found in this study, whereas a study reveals that increasing work experience and increasing age are significant factors for increasing work25(17.86%) 51.42%(72) 20(14.28%) 23(16.43%) fig.3 adverse work effects on life problems in married life imbalanced social life ignored children irritating self personality 810 global journal of public health medicine 2023, vol 5, issue 1 gggggglo related stress. different work cultures and staffing patterns could be the reason for the difference. [piko b.,1999] in a study done by kakeman e et al., 78.4% of respondents reported that their job was stressful. nurses reported issues with shiftwork, staffing, pay, workplace discrimination, management, policy and excessive workloads as sources of occupational stress.[kakeman e, 2019] in another study of iran by eslami r et al., nurses reported issues with shiftwork, staffing, pay, workplace discrimination, management, policy and excessive workloads as sources of occupational stress. [eslami r,2015] in a study done by chaudhary et al., stress existed among 87.6% of nursing staff, which was similar to the current study. the reasons were conflicts with supervisors, unreasonable demands from patients and their families, workload and limited experience with death and dying were the leading causes, while problems relating to peers and discrimination were the least common. it is quite proven that similar reasons are the triggers for the nursing staff in the hospital.[chaudhary ap, 2018] in this study, 34.29% of participants opted for yoga/meditation to cope with the stressful workload, whereas, in a study done in delhi, 44.8% of the nurses handled it by being optimistic and positive. .[bhatia n,2001] as we all know, yoga and meditation are the best modes to relieve daily stress, so the maximum of them took help by inculcating this in their routine. coming to the main stressor of the nurses in this study was the prolonged working hours in the hospital. 56.7% of people were not satisfied with the stressful working hours, which could not let them have a work-life balance. 17.4% complained of curtailed salary, which became a gross issue in contributing to the unsatisfaction in the work environment again. in another study done by sharma p, inadequate salary was also one of the key factors causing stress, as perceived by 75% of nurses.[sharma p, 2014] in another study done by latif r. et al., the six domains of stressors included taking care of patients, clinical educators/instructors and ward staff, clinical assignments and workload.[latif r, 2019] another study by zyga s. also depicts that, in particular, it was found that women nurses systematically manifest the ways focused on emotion, i.e. search for divine intervention" and "prayer/daydreaming.[zyga s, 2016] conclusion: stress was majorly a crucial issue among 47.14 % of the nursing staff. 50% of the nursing staff were impacted by mood swings. a major concern among nurses comprises a major part in the proper functioning of hospitals. their role is not only professional but also to provide emotional care to the patients. thus, the stress induced due to work culture should be taken care of so that they can be both physically and mental peace while at work. conflicts of interest the author declares no conflicts of interest. 811 global journal of public health medicine 2023, vol 5, issue 1 gggggglo references • a b latif, r., & mat nor, m. z. (2019). stressors and coping strategies during clinical practice among diploma nursing students. the malaysian journal of medical sciences : mjms, 26(2), 88–98. https://doi.org/10.21315/mjms2019.26.2.10 • al-makhaita hm, sabra aa, hafez as. predictors of work-related stress among nurses working in primary and secondary health care levels in dammam, eastern saudi arabia. j family community med. 2014 may;21(2):79-84. doi: 10.4103/2230-8229.134762. • bhatia n, kishore j, anand t, jiloha r.(2001) occupational stress amongst nurses from two tertiary care hospitals in delhi. amj; 3 (11): 731-38. doi 10.4066/amj.2010.289 • callaghan a. (2011) student nurses’ perceptions of learning in a perioperative placement. journal of advanced nursing. 67(4), 854–864. https://doi.org/10.1111/j.13652648.2010.05518.x • chaudhari ap, mazumdar k, motwani ym, ramadas d.(2018) a profile of occupational stress in nurses. ann indian psychiatry.2;109-14. doi: 10.4103/aip.aip_11_18. • dighe sv.(2020) occupational stress among nurses. international journal of science and healthcare research. 26(5);25-29 • eslami akbar r, elahi n, mohammadi e, fallahi khoshknab m.(2015) what strategies do the nurses apply to cope with job stress? a qualitative study. glob j health sci.sep 28;8(6):5564. doi: 10.5539/gjhs.v8n6p55 • fontana, d. (1989). managing stress. british psychological society; taylor & frances/routledge • indian nursing council. nurses registration and tracking system. available at: inc (indiannursingcouncil.gov.in) • kakemam e, raeissi p, raoofi s, soltani a, sokhanvar m, visentin d, cleary m.(2019) occupational stress and associated risk factors among nurses: a cross-sectional study. contemp nurse. apr-jun;55(2-3):237-249. doi: 10.1080/10376178.2019.1647791 • okuhara m, sato k, kodama y.(2021). the nurses’ occupational stress components and outcomes, findings from an integrative review. nurs open:2153– 2174. https://doi.org/10.1002/nop2.78 • pikó b.(1999) work-related stress among nurses: a challenge for health care institutions. j r soc promot health. sep;119(3):156-62. doi: 10.1177/146642409911900304. • salilih, s. z., & abajobir, a. a. (2014). work-related stress and associated factors among nurses working in public hospitals of addis ababa, ethiopia: a cross-sectional study. workplace health &amp; safety, 62(8), 326–332. https://doi.org/10.3928/2165079920140708-02 • sharma, p., davey, a., davey, s., shukla, a., shrivastava, k., & bansal, r. (2014). occupational stress among staff nurses: controlling the risk to health. indian journal of occupational and environmental medicine, 18(2), 52–56. https://doi.org/10.4103/00195278.146890 • who. occupational health: stress at the workplace. https://www.who.int/newsroom/questions-and-answers/item/ccupational-health-stress-at-the-workplace. • zyga s, mitrousi s, alikari v, et al. (2016) assessing factors that affect coping strategies among nursing personnel. materia socio-medica. apr;28(2):146-150. doi: 10.5455/msm.2016.28. microsoft word gjphm-2019-metabolic syndrome modi.docx 44 global journal of public health medicine 2019, vol 1, issue 2 metabolic syndrome status defined by the international diabetes federation among a sample of college students from palestine akram m. h. altaher*, yasmeen s. abu-mustafa, abeer r. elujeili, enas a. almasry and eman o. almasry *corresponding author: a.taher@cst.ps department of medical sciences, university collage of science and technology-khanyounis, gaza strip, palestine abstract introduction: metabolic syndrome (mets) is a cluster of risk factors including central obesity, insulin resistance, dyslipidemia, and high blood pressure (bp). it viewed as the main risk factor for cardiovascular disease (cvd) and diabetes mellitus (dm). we aim to determine the prevalence of mets among palestinian college students using the definition proposed by the international diabetes federation (idf). methods: this study was a cross-sectional. a total of 100 male students and 100 agematched female students were randomly selected. personal, clinical, and lifestyle data of the students were gathered by questionnaire. anthropometric and biochemical indices were measured. spss version 20 was used for data analysis. results: male students were more active in their lifestyle, more obese, hypertensive, hyperglycemia and hypertriglyceridemia than female students (p≤0.05). the most common mets criteria among the students were low high density lipoprotein cholesterol (hdl-c) 31.0%, large waist circumference (wc) 14.0%, high glucose 12.5%, high triglycerides (tg) 8.5%, and high blood pressure (bp) 6.0%. mets occurrence in the current study was 7.0% with 8% of women and 6% of men having mets. obese students had the greatest occurrence of high wc and elevated bp compared to those in other students (p≤0.05). furthermore, obese students had a higher prevalence of mets than found among other students. conclusion: mets is found among college students in palestine. it also appears that obesity contributes to the high incidence of mets. early diagnosis and treatment of mets risk factors and healthier lifestyle promotion lead to decrease the risk of mets occurrence. keywords: metabolic syndrome; idf; college students; palestine. 45 global journal of public health medicine 2019, vol 1, issue 2 introduction mets is known as a set of interrelated risk factors including fail to respond normally to the insulin by the cells, dyslipidemia, and high bp (grundy et al., 2005). mets is a major risk factor for many non-communicable diseases especially; cardiovascular diseases (cvd) and type 2 diabetes mellitus (t2dm) (isomaa et al., 2017). cvd remains the first leading cause of death among palestinians, accounting for 30.3% of deaths recorded in 2017 and is the 2nd major cause of young adults’ death whose age in between 20 & 29. dm complications came in the fifth rank with a proportion of 9.0% (pmoh, 2017). seven percentage of death around the word is due to mets, the risk of cvd is increased by 34% and 16% for men and women, respectively due to mets (reaven, 2011). little information is known about the frequency of mets among the arab population in the middle east region. this is because few studies were concerned with this topic, but the available data suggest that it is an increasingly common problem. mets originates from the diverse interaction of genetic predisposition and risk factors for lifestyle (oh et al., 2012). many studies suggested that the prevalence of mets is directly correlated with aging (ford et al., 2004; mattsson et al., 2007). in addition, other reports found gender differences according to mets criteria (huang et al., 2007; fernandes, & lofgren, 2011). one of the most frequently working definitions of mets is that proposed by the international diabetes federation (idf) (altaher et al., 2018). according to the idf, mets is described as high wc presence plus two of the four risk causes for cardiac disease: high fbg, low hdl-c, high tg and high bp (de marco et al., 2012). a previous study observed that the bp and low hdl cholesterol were the most morbid element of mets with the percentages of 33% and 25% respectively (reaven, 2011). university students undergrow of changes their habits on entering university, where they following a sedentary lifestyle and unhealthy dietary practices which leads to the arising of chronic disease risk factors (smith, & essop, 2009). early identification of mets components in young adulthood can lead to targeted interventions, thus lowering the risk of future development of diabetes and cvd among them. palestine like many other countries around the world pays high attention concerning chronic diseases because of its role in the high rates of mortality and morbidity in addition to its adverse health effects on the individuals with the young age group. for that, it is very important to detect this silent syndrome early. thus, the over the aim of this study was to identify the frequency of mets criteria among palestinian college students using the definition proposed by the idf. methods this study was conducted in between may and september 2016 and designed as crosssectional style, the study samples were two hundred students (50.0% males and 50.0% females) selected by simple random sampling method from the sampling frame (student's lists at admission and registration department in the university college of science and technology khan yunis governorate). the calculated sample size was 138 students, and the epi-info program vr 7.2 was used to calculate the sample size at population number= 80000, 95.0 % confidence interval, 5.0% acceptable margin of error and 10 % expected prevalence of mets based on previous study that carried out in palestine (altaher, et al., 2018). both genders were aged at least 18 years old 18 and agematched. all official approval letters to conduct the study were obtained. consent forms which describe the study aim and significance were given for all study participants before data collection. face to face questionnaires were used research team to collect the personal data, clinical data and lifestyle status of the study population. the body height of the participants was measured in centimetre using stadiometer, and the weight in kilogram using weighing scale. the bmi was calculated by dividing the weight (in kg) by the height square (in m). the bmi was classified according to who instructions (who, 2012). the wc was measured according the who instructions at minimal inhalation narrow to 0.1 cm, in between the lowest rib and the superior edge of the iliac crest (who, 2012). according to american heart association; bp of the study participants is measured using mercury sphygmomanometer (pickering et al., 2005). about 4 ml venous blood sample was withdrawn from the students in fasting status 46 global journal of public health medicine 2019, vol 1, issue 2 (14-16 hours) in a tube without anticoagulation and the sera of students were isolated by centrifuge (fuhua type) at 3000-4000 round/minute for ten minutes then stored at 18°c until analysed. by spectrophotomer (stat fax-1904 plus, usa) and according to the beer's law; the levels of serum fbg, tc and tgs were measured using elitech clinical kit, france (trinder, 1969; allain et al., 1974; fossati, & prencipe, 1982). the elitech clinical kit, france was used to determine the hdl-c concentration based on precipitating method (burstein, et al., 1970), while ldl-c was calculated using the formula of friedewald: [ldl-c = tc – (hdl-c) – tg/5 (mg/dl)] (friedewald et al., 1972). all lab tests were performed at the university college of science and technology-khanyounis clinical chemistry laboratory, calculation of colorimetric tests for fbg, tc and tgs were performed by spectrophotomer (stat fax-1904 plus, usa) according to beer's law. version 20.0 of the spss system was used to analysis of data. descriptive statistics, chi-square test and ttest were carried out at confidence intervals (ci) 95%. the p-value < 0.05 was considered as statistically significant. results a total of 200 students (100 males vs. 100 females) were included in this research. there was no statistically significant difference between the male group and females group according to the age in years (p=0.104) (table 1). most of the female group (52.0%) vs. 5.0% of males group, their lifestyle was moderately. however, there was a statistical difference among the study subjects within related to the type of life style (p=0.000) (table 1). table 2 demonstrates the mets components and the differences in anthropometric, clinical and biochemical indices between males and females involved in the research. males were more obese, hypertensive, hyperglycaemia and hypertriglyceridemia than females and these differences reach a statistical significance (p≤0.05) (table 2). in the original sample, the most common mets components were low hdl-c (31.0%), large wc (14.0%), high glucose (12.5%), high tg (8.5%) and high bp (6.0%) (table 3). it is also observed that the females group had higher wc as compared to males group (p=0.011) (table 2). according to idf definition, the prevalence of mets in the total sample was 7.0% with 8% females and 6% of males having mets (figure 1). in addition, the prevalence of mets was higher in women than in men (figure 1). as show on the figure below, about 2.5 % of the total sample had at least one metabolic criteria, while 4.5% of them had at least two metabolic criteria (figure 1). the present findings indicated that only 12.5% (n=25) of the total sample were obese and 17.0% (n=35) of them were overweight, while 70.0% (n=140) of them were underweight and normal weight (figure 2). table 4 illustrates the most common criteria of mets in the original sample per bmi category. the obese group had the highest prevalence of elevated wc (15%) and elevated blood pressure (3.0%) as compared to those in other bmi categories (p=0.000 & 0.003 respectively) (table 4). the findings also show that 32.0% of obese subjects had at least three or more mets requirements, much greater than those observed in the overweight or normal classifications (20.0 % and 3.6 % respectively) (figure 3). figure 1: number of idf mets components according to gender 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% 0 1 2 3+ female male 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% underw eight & normal w eight ov erw eight obesity figure 2: percentage distribution of study participants by bmi category 47 global journal of public health medicine 2019, vol 1, issue 2 table 1: distribution of study participants by general characteristics variables males females p value n (%) n (%) age groups 18 – 20 years 69 (69.0%) 57 (57.0%) 0.087 21 23 years 22 (22.0%) 29 (29.0%) ≥ 24 years 9 (9.0%) 14 (14.0%) address rafah 18 (18.0%) 25 (25.0%) 0.115 khanyounis 85 (82.0%) 71 (71.0%) medial camps 0 (0.0%) 4 (4.0%) smoking status smoker 0.0% 25.0% <0.001* non-smoker 100.0% 75.0% lifestyle sedentary 20 (20.0%) 26 (26.0%) <0.001* moderately 5 (5.0%) 52 (52.0%) vigorously 8 (8.0%) 13 (13.0%) extremely 67 (67.0%) 9 (9.0%) *significant level at p value <0.05 table 2: participants anthropometrical, clinical and biochemical description *significant level at p value <0.05 variable male group no.=100 female group no.=100 total no.=200 pvalue mean ±sd mean ±sd mean ±sd bmi (kg/m2) 23.94 ± 4.30 23.27 ± 4.30 23.15 ± 4.30 0.702 wc (cm) 80.67 ± 10.06 78.49 ± 11.33 79.58 ± 10.69 0.152 sbp (mm hg) 122.70 ± 6.00 117.25 ± 4.68 119.98 ± 5.34 <0.001* dbp (mm hg) 76.45 ± 7.01 74.90 ± 6.07 75.68 ± 6.54 0.096 tc (mg/dl) 131.04 ± 27.84 136.27 ± 39.12 133.65 ± 33.48 0.277 ldl-c (mg/dl) 67.31 ± 30.02 84.19 ± 40.47 75.75 ± 35.24 0.001* hdl-c (mg/dl) 44.44 ± 19.67 37.89 ± 22.23 41.16 ± 20.95 0.028* tgs (mg/dl) 99.58 ± 52.39 84.21 ± 39.08 91.89 ± 45.73 0.020* glucose (mg/dl) 87.39 ± 11.84 83.12 ± 13.41 85.25 ± 12.62 0.018* 48 global journal of public health medicine 2019, vol 1, issue 2 table 3: percentage of idf mets criteria of the participants by gender *significant level at p value <0.05 table 4: prevalence of idf mets criteria of the participants per bmi category *significant level at p value <0.05 figure 3: number of idf components according to bmi category variable male group no.=100 female group no.=100 total no.=200 pvalue n (%) n (%) % of total low hdl-c 30 (30.0%) 33 (33.0%) 63 (31.0%) 0.648 high tgs 9 (9.0%) 8 (8.0%) 17 (8.5%) 0.800 high glucose 14 (14.0%) 11 (11.0%) 25 (12.5%) 0.521 large wc 9 (9.0%) 19 (19.0%) 28 (14.0%) 0.011* high bp 7 (7.0%) 5 (5.0%) 12 (6.0%) 0.552 variable underweight & normal weight overweight obesity pvalue % of total % of total % of total low hdl-c 20.0% 4.0% 5.5% 0.415 high tgs 4.5% 2.0% 2.0% 0.055 high glucose 7.0% 2.0% 2.5% 0.336 large wc 0.0% 10.0% 15.0% <0.001* high bp 1.0% 2.0% 3.0% 0.003* 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 0 1 2 3+ undew eight/norm al w eight overw eight obese 49 global journal of public health medicine 2019, vol 1, issue 2 discussion as stated in the present findings, the most prevalent mets criteria in the total sample were low hdl-c (31.0%), large wc (14.0%), high glucose (12.5%), high tg (8.5%) and high bp (6.0%). in their research sample, a prevalence rate of 47.3% was recorded for low hdl-c (dalleck, & kjelland, 2012). although, ervin recorded that high wc and elevated bp as the most common mets risk factors among adults with 20 years of age (ervin, 2009). furthermore, most studies in young adults have reported the greater occurrence of low hdl-c and elevated tg (huang et al., 2007; burke et al., 2009; fernandes, & lofgren, 2011; dalleck, & kjelland, 2012). it should be noted that the many past previous studies have also shown that racial variations in the wc cut points correspond to enhanced danger for mets (topè, & rogers, 2013). in the line to the majority of previously reported studies, the current study also reports high occurrence rate (12.5%) for pre-diabetes (elevated blood glucose) among college students (huang et al., 2007; burke et al., 2009; fernandes, & lofgren, 2011; dalleck, & kjelland, 2012). in addition, as reported in the current study the prevalence of mets components was (7.0%). however, the occurrence rate of mets criteria in the total sample is considerably lower than the majority previously reported studies around the word (topè, & rogers, 2013; al-azzawi, 2018). this finding may be attributed to a good lifestyle and healthy dietary habits which were followed by the students in this study during their daily life which in turn lead to lowering the prevalence of mets criteria among them. on the other hand, the finding of this study was in agreement with many published works that found a low prevalence of mets components (less than 10.0%) among university students (abolfotouh et al., 2012; silva et al., 2014). the differences in the prevalence of mets results among previously published report may be attributed to the diversity in the criteria that studied and in the cut-off points identified by the researchers. in addition, the prevalence of mets was higher in females than in males and this finding was in the line with many previously published studies (topè, & rogers, 2013; al-azzawi, 2018). the higher prevalence of mets among females group may be due to the high tendency of females towered sedentary lifestyle, in addition to widen their wc as compared to males group. furthermore, as mentioned, a total of 2.5% of the sample had at least one metabolic dysfunction, 4.5% of the sample had at least two metabolic criteria and this finding is less than thus reported by two studies reported previously (f de freitas et al., 2013; silva et al., 2014). moreover, as we expected, the obese group had the highest occurrence of high wc and high bp as compared to those in the categories of underweight, normal and overweight, these findings were consistent with the study that conducted in 2013 which recorded that obese students had the greatest incidence high wc, low hdl-c, increased bp and increased fasting blood glucose compared to those in the categories of underweight, normal and overweight (topè, & rogers, 2013). in addition, our results indicate that the bmi status of students plays an significant part in anticipating the likelihood of mets since 32.0% of obese subjects had three or more mets components, a much greater rate than that discovered among participants in the overweight or normal categories (20.0% and 3.6% respectively). similar results nearly were reported by the work that conducted in 2013 where they observe that about 40% of obese students had three or more factors for mets (topè, & rogers, 2013). conclusion in summary, this is the first report on the prevalence of mets defined by idf definition in gaza strip, palestine. the prevalence of mets in the total sample was (7.0%) with (8%) females and (6%) males having mets. male students were more likely to be more obese, hypertensive, hyperglycaemia and hypertriglyceridemia than females (p≤0.05). obese students had the greatest occurrence of high wc and high bp as compared to those in students who were underweight, normal and overweight. however, prevention, early detection and early intervention programs need to be designed at universities to address mets risk factors such as low hdl, high tgs and high wc, as well as focus on better management for pre-diabetic, diabetic and hypertensive students. in addition, students should be regularly checked to detect mets factors in advance, which in turn reduces the danger of chd, htn, and diabetes. furthermore, health program must be developed to encourage improve dietary habits, healthier lifestyle, promote exercise and discourage smoking among university and college students to reduce the likelihood of mets development. 50 global journal of public health medicine 2019, vol 1, issue 2 references abolfotouh, m. a., al-alwan, i. a., & al-rowaily, m. a. 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(accessed 22-82019). microsoft word gjphm-2021retinopathy.docx 457 global journal of public health medicine 2021, vol 3, issue 2 gggggglo review research retinopathy of prematurity, an important public health problem in pakistan: a review tabish ali shalwani1 , bakhtawar khowaja*2 & ghulam kubra rind2 1 al-ibrahim eye hospitalkarachi 2the aga khan university – department of obstetrics and gynecology, stadium road, po box 350, karachi 74800 *corresponding author: bakhtawar.hanif@aku.edu abstract introduction: retinopathy of prematurity (rop) is the significant cause of blindness in children globally. although the incidence of rop is greater in premature infants worldwide, statistics show that it is more common in low-middle-income countries. multiple causes and complications of rop in low middle-income countries have been reported therefore the purpose of this literature review was to review the findings from literature about the burden, causes, outcomes, and important preventive measures of rop for low middle-income countries, especially in pakistan. methods: a comprehensive review of the literature was conducted from published articles. research studies were selected that included risk factors of rop, screening, and diagnosis of rop, treatment of rop, and prevention of rop. results the cause of the high rate of rop in low-middle income countries (lmics) includes a high rate of preterm babies, lack of awareness regarding rop, financial instability, and insufficient treatment and screening programs at the newborn units. rop is found to be the significant cause of preventable blindness in south asia. there are three different levels of prevention aimed at reducing the burden of rop in lmics. primary prevention aims at reduction in preterm births, secondary prevention aims at early diagnosis of the disease and tertiary prevention aims at reducing deterioration of conditions due to disease. conclusion: the emphasis on preventive measures especially primary and secondary level prevention can help in decreasing the burden of rop. this requires a multidisciplinary approach at all levels including at the level of policymaking, program implementation, health care providers, and community level. keywords: rop, lmics, pakistan, prevention, literature review 458 global journal of public health medicine 2021, vol 3, issue 2 gggggglo introduction retinopathy of prematurity (rop) is a proliferative vitreoretinopathy affecting neonates. it is a significant cause of blindness in children globally (blencowe, lawn, vazquez, fielder, & gilbert, 2013). according to the who report of 2012, around 1 in 10 preterm babies are born globally (organization, 2012). research shows that rop affects around 300,000 infants globally (wheatley, dickinson, mackey, craig, & sale, 2002). in the us the incidence of having any stage of rop was 68% among infants with weight <1,251 gms, and 36.9% among them were those who developed clinically significant rop (group, 2005). according to the global estimate of 2010, around 184,700 out of 14.9 million preterm babies developed any stage of rop, among them 20,000 were blind having visual acuity (va) <20/400, some of them had severely impaired va and among them, 12,300 had a mild or moderate visual disability (blencowe et al., 2013). among the developed countries, the estimates of 2010 showed that 6,300 babies out of 32,700 had rop requiring treatment and data shows around 1,700 of them had severely impaired vision resulting from rop (blencowe et al., 2013). in 2010 around 170,000 premature babies developed rop globally, and 54,000 among them were those who required immediate treatment for the disease and only 40% among them received the treatment (blencowe et al., 2012) in comparison to high-income countries, where the incidence of rop was found 13.2-46% (brown et al., 1998), (rodríguez-hurtado & cañizares, 2006), (holmström, broberger, & thomassen, 1998). the incidence of rop in lmics is greater than 40% with more survival rate of premature babies and with limited diagnostic services (gilbert et al., 2005) (austeng, källen, ewald, jakobsson, & holmström, 2009); (blencowe et al., 2013; blencowe, lawn, vazquez, fielder, & gilbert, 2013);(gilbert et al., 2005). research evidence from schools demonstrates that 50,000 children aged 15 years were blind because of rop worldwide, with the highest ratio from latin america (gilbert, 2008). as per the 2005 international classification of rop, the disease has been described based on zones (location of disease) and stages (severity of abnormal vascularization) (jefferies, society, fetus, & committee, 2016) that are mentioned below: stages (1 to 5) and description of retinopathy of prematurity: stage 1: a line segregating avascular retina from vascularized one stage 2: rising elevations in the section of segregating line stage 3: additional retina fibrovascular proliferation outspreading into the vitreous stage 4: partial retinal detachment stage 5: complete retinal detachment plus disease: increased vascular dilatation and tortuosity of posterior retinal vessels in at least two quadrants of the retina 459 global journal of public health medicine 2021, vol 3, issue 2 gggggglo pre-plus disease: more vascular dilatation and tortuosity than normal but insufficient to make the diagnosis of plus disease (jefferies et al, 2016) furthermore, retinopathy of prematurity has been classified into five stages depending on the severity of the disease (reynolds, 2014) • stage i is the condition with mildly abnormal blood vessel growth. stage i mostly improve without treatment and develop normal vision without further progression. • stage ii is the condition with moderate abnormal blood vessel growth. this condition also mostly improves without treatment, to normal vision. • stage iii has severely abnormal blood vessel growth. the blood vessels grow towards the center of the eye instead of along the surface of the retina. infants who develop stage iii rop develop normal vision without treatment, however, an infant with stage iii rop and the plus disease requires treatment. plus disease is the disorder when blood vessels of the retina enlarge and become twisted. • stage iv is the condition in which the retina is partially detached that results in bleeding and abnormal vessels pull the retina away from the wall of the eye. • stage v is the complete detachment of the retina and the end-stage of the disease. the preterm infant with grade v rop suffers from visual impairment and permanent blindness. rop is a significant cause of blindness (reynolds, 2014). the development in neonatal care around the world has improved the survival rate of premature infants (organization, 2000). these infants are at high risk of the development of rop. the infants with mild rop improve without any treatment (holmström et al., 1998).however, infants with severe disease may require treatment and can develop permanent blindness (blencowe, 2016). although the incidence of rop is greater in premature infants worldwide, statistics show that it is more common in low-middle-income countries (blencowe et al., 2012). multiple causes and complications of rop have been reported in the literature which is not established in one place. hence, the purpose of this literature review was to review and demonstrate the findings from literature about the burden, causes, outcomes, and important preventive measures of rop for low middle income countries, especially in pakistan. methods search strategies and data sources a comprehensive review of the literature was conducted from articles using pubmed, google scholar, science direct, international council of ophthalmology, and who databases using terms such as retinopathy of prematurity, lmics, south asia, pakistan, pre-term births, visual impairment, ophthalmology, and etcetera. moreover, links to “related articles” were accessed in electronic databases. 460 global journal of public health medicine 2021, vol 3, issue 2 gggggglo eligibility criteria the studies included were descriptive, observational studies, comparative studies, and correlational studies. inclusion criteria included only full-text papers in the english language. all relevant articles were preferred and there was no restriction on publication date as few older articles contained important content relevant to the subject. research studies were selected that included risk factors of rop, screening, and diagnosis of rop, treatment of rop, and prevention of rop. results a total of 40 peer-reviewed papers were selected for literature review. 28 papers were eligible for the review that included risk factors of rop, screening, and diagnosis of rop, treatment of rop, and prevention of rop. 12 papers were excluded from the selected papers based on the criteria that: 1) they were not generalizable and were context-specific; 2) included interventional studies and 3) qualitative studies to explore experiences of rop. the eligible papers were reviewed to understand the background, context, causes, treatment, and complications of rop. the epidemics of rop have been comprehended in three different periods (gilbert, 2008). the first epidemic was during the 1940s and early 1950s when the association of rop with oxygen administration was acknowledged. due to the association of high oxygen to the development of rop, oxygen use was restricted (quinn, gilbert, darlow, & zin, 2010). during that time, there was a significant decrease in rop blindness but an increase in high infant mortality due to restricted oxygen administration. in the late 1960s and 1970s, the second epidemic of rop was seen when the development of neonatal units in most high-income countries increased the survival of low birth weight and very premature infants (hellström, smith, & dammann, 2013). this increased the survival of premature infants while resulted in an increased rate of cases of rop. the third epidemic of rop was recorded in 1990s (hellström et al., 2013).the countries including china, russia, european countries, and southeast asian countries developed well-established neonatal care units (hellström et al., 2013). it is estimated from the records of 2010, that around 2.6 million premature infants were born with a gestational age of less than 32 weeks. around 20,000 infants had blindness and many infants had mild to moderate rop (hellström et al., 2013). global situation analysis according to who, 1.4 million children are visually disabled globally, among them 2/3rd are from lowmiddle-income countries (organization, 2012). because of improved neonatal care, the survival rate of preterm babies has been enhanced, and the risk of preterm-related rop has been increased globally, particularly among the middle-income countries including pakistan, china, and india (blencowe et al., 2013). the cause of high rate of rop among these countries is the high rate of preterm babies born in these countries, lack of awareness regarding rop, financial instability, and insufficient treatment and screening programs at the new-born units (blencowe et al., 2012). 461 global journal of public health medicine 2021, vol 3, issue 2 gggggglo among many countries around the globe, the incidence of premature infants is higher which is 13.3% in south asia and poses a significant public health concern for the development of rop (murthy, 2017). rop is found to be the significant cause of preventable blindness in south asia. alongside, there is limited literature available on rop from low-income countries (adams, bunce, dahlmannnoor, & xing, 2016). pakistan is suffering from poor health resources and facilities related to screening, diagnostics, and treatment procedures (taqui, syed, chaudhry, ahmad, & salat, 2008). also, the actual incidence of rop is still not known because of limited studies (chaudhry et al., 2014). few of the studies have represented the incidence of rop within their clinical settings. a cross-sectional study conducted at a private hospital in karachi reported 32.4% of rop incidence (taqui, 2008). another study was conducted in the same setting to measure the frequency of rop in preterm babies. study results showed that the incidence of rop in premature neonates is 10.5% (sohaila et al., 2014). a study conducted at an ophthalmology department of a tertiary care hospital in lahore found the incidence of retinopathy of prematurity around 24.6% (jamil, tahir, ayub, & mirza, 2015) risk factors for rop the major risk factors for rop were recognized during three epidemics of rop (gilbert, 2008). the causes of rop have been demonstrated by the causal model. this model in epidemiology was introduced in 1976 by rothman (rothman & greenland, 2005) (figure 1). this model is used to reflect the variety of causes among the components of the disease. considering the risk factors for rop, each pie in the causal model is a sufficient cause to develop the disease. the major causes of rop include low gestational age, low birth weight, and prolonged exposure to supplementary oxygen following birth (rodriguez-hurtado & canizares, 2006). figure 1. causal model” representing sufficient causes of rop prematurity supplementary oxygen following birth birth weight 462 global journal of public health medicine 2021, vol 3, issue 2 gggggglo screening and diagnostic procedures for rop the first-line management for rop is screening. the management demands good training and skilled individuals along with suitable and proper screening equipment (chan-ling, gole, quinn, adamson, & darlow, 2018). nearly all of the guidelines use birth weight and gestational age as an indicator for the screening of rop as both of these are the major risk factors of rop(gilbert et al., 2005). the latest guidelines by the american academy of pediatrics, american academy of ophthalmology, and american association for pediatric ophthalmology and strabismus recommends screening of rop to all newborns who are born at 32 weeks or less than 32 weeks gestational age; and born with a birth weight of 1,500 grams or less (gilbert et al., 2005) treatment of rop retinopathy of prematurity is classified by its zone, severity, and presence of plus disease. based on the classification and severity of rop, the royal college of ophthalmology provides the guidelines for the treatment of retinopathy of prematurity demonstrated in table 1(chan-ling, 2018). table 1: guidelines for treatment of rop treatment indicated zone i, any rop with plus zone i, stage 3 without plus disease zone ii, stage 3 with plus disease treatment should be considered zone ii, stage 2 with plus disease time from diagnosis to treatment 48 hours treatment modality trans pupillary diode laser therapy first line (argon laser second line) treating surgeon babies with rop should be treated by ophthalmologists who have appropriate competency options to address the problem of rop preventive services are an essential part of the health care system and include a diverse range of activities aimed at decreasing risks and health problems (offord, 2000). there are three different levels of prevention aimed at reducing the burden of rop in lmics (figure 2). primary prevention primary prevention prevents the disease before its occurrence (offord, 2000). this is done by preventing exposures to the cause of disease. the major cause of rop is preterm births. the major risk factors for preterm births include maternal weight, short birth intervals, maternal infections during pregnancy, and maternal chronic conditions. antenatal care is preventive healthcare and it helps women in the prevention of potential health problems through prenatal screening (gullotta & bloom, 2003). evidence suggests that there is a lack of anc services utilized by women in lmics. a study examining coverage of anc services demonstrated that around 29.9% of women in nigeria, 34.4.% in 463 global journal of public health medicine 2021, vol 3, issue 2 gggggglo rwanda, 30.4% in zambia, and 30.3% women in nepal utilized anc services (benova, tunçalp, moran, & campbell, 2018). the data from pakistan demographics and health survey shows improvement in the trend of antenatal care services utilized by women in pakistan, however, there is still a need for improvement for utilization of anc services. anc services are important to prevent the risk factors of rop including low birth weight and premature infants. secondary prevention secondary prevention reduces the consequences of an occurred disease. this is done by detection of disease at an earlier stage to prevent complications of the disease. blindness is the major complication of rop. to prevent the complication of blindness due to rop, regular examinations and screening tests are important for a preterm infant (gilbert et al., 2005). regular ophthalmic examinations of a premature infant can help in early detection and the prevention of long-term complications. screening of rop requires proper infrastructure, coordination, planning, and skilled ophthalmologists to perform specialized procedures (woolf, 2008). most of the lmics lack health care infrastructure, proper planning, and coordination, and skilled health care providers. this is the reason for the high incidences of rop in lmics (peters et al., 2008). tertiary prevention tertiary prevention aims to reduce the long-term complications of the disease (offord, 2000). this is achieved by preserving the quality of life and permanent impairments. timely interventions within 48 hours to 72 hours are essential to save infants from visual impairments (peters et al., 2008). laser therapy is the gold standard treatment for retinopathy. in the absence of laser therapy, cryotherapy may be considered (azad & chandra, 2003). evidence suggests the positive role of antivascular endothelial growth factor injection in the treatment of rop (azad & chandra, 2003). surgical intervention like scleral buckle and vitrectomy is performed for retinal detachment due to rop (azad & chandra, 2003). these interventions require financial considerations. the countries like pakistan where people pay out-of-pocket payments for health care services utilization, treatment of rop remains a challenge. figure 2. levels of prevention for rop tertiary prevention: medical and surgical treatment of rop secondary prevention: early screening and investigation for rop in premature infants primary prevention: anc care and prevention of premature births 464 global journal of public health medicine 2021, vol 3, issue 2 gggggglo discussion the cases of rop are increasing in lmics leading to blindness among children (brown et al., 1998). neonatal care has been improved in recent years and have improved the survival rate of neonates which has correspondingly increased the risk of preterm-related rop globally and extensively among lmics. the major risk factors for rop include prematurity, low birth weight, and oxygen administration to neonates. therefore, birth weight and gestational age are important indicators for the screening of rop as both of these are the major risk factors of rop. to decrease the burden of this important disease, it is important to integrate rop screening services in every neonatal unit to timely diagnose and treat the problem. there are three different levels of prevention aimed at reducing the burden of rop in lmics. primary prevention can be done by utilizing anc services to prevent premature births. secondary prevention can be done by detection of disease at an earlier stage to prevent complications of the disease through regular examinations and screening tests. and tertiary prevention can be achieved by preserving the quality of life and permanent impairments through procedures like laser therapy and cryotherapy. therefore the policymakers in these countries should establish newborn health policies for rop prevention, the level of staffing of health care providers should be ensured by hospital administrators, the referral mechanisms for premature infants should be channelized and the guidelines for anc care should be strengthened. the program implementers in these countries need to build the capacity of health care providers for screening and treatment of rop and there should be proper procurement of types of equipment required for rop screening and they should develop region-specific rop guidelines according to incidence and causes of rop. the health care providers should educate mothers and parents about complications of preterm births before delivery and should emphasize the need for screening and diagnostic investigations required for preterm infants. conclusion the incidences of rop in premature children especially in lmics are continuously increasing (organization, 2012). the emphasis on preventive measures especially primary and secondary level prevention can help in decreasing the burden of rop. this requires a multidisciplinary approach at all levels 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(2008). the power of prevention and what it requires. jama, 299(20), 2437-2439. microsoft word gjphm-2022-life expectancy edited.docx 537 global journal of public health medicine 2022, vol 4, issue 1 gggggglo original research factors affecting life expectancy in vietnam, laos, cambodia anh ngoc nguyen faculty of pharmacy, thai binh university of medicine and pharmacy, thai binh, vietnam *corresponding author: hyyhlywa@gmail.com abstract introduction: according to the general statistics office and world bank, the average life expectancy of vietnam, laos, cambodia is increasing gradually. the aim of the research is to determine the relationship between three factors affecting life expectancy (demographics, socioeconomics and health care determinants) among many other factors methods: data were taken from the general statistics office and the world bank. the data are taken continuously from 1985 to 2019. this is an appropriate timeline because it is the period after the independence of laos, vietnam, and cambodia and before the outbreak of the covid-19 pandemic. thus, this study has excluded the factor of death due to war and the covid-19. a multiple regression analysis was conducted with stata to research factors. results: three factors chosen were as follows: demographics, socioeconomics, and health care resources determinants. average life expectancy increased about 1.6 times. the above data also showed that population age 65 and older increased about 59 times, gdp growth changed from negative growth to positive growth and industry increased approximately 1000 times. conclusion: the result shows that life expectancy has a positive relationship with demographics, and health care resources. it also shows that socioeconomics affects life expectancy so weakly. keywords: life expectancy, demographic aging, socioeconomic factors, community health care 538 global journal of public health medicine 2022, vol 4, issue 1 gggggglo introduction life expectancy is one of the problems of life. it is a measure of the quality of life. a happy and healthy life will lead to high longevity. however, at present and to the best of writer’s knowledge, there are not many studies on this issue in the world especially in developing countries. according to data from the general statistics office and world bank , the average life expectancy of vietnam, laos, cambodia is increasing gradually. hence, the author proceeded to get data from the general statistics office and the world bank to study the factors leading to this increase. due to the research conditions, in this researcher, the author conducted a research in three countries vietnam, laos, cambodia. life expectancy is the concept about the number of years that is expected to live based on the statistical average (mandal, 2016). according to data from the general statistics office and the world bank, the average life expectancy of people tends to increase. research studies in developed countries have indicated four factors as financial income, high literacy rate, standard health facilities, and daily circumstances. affecting life expectancy (alamgir khan, 2016). following beckman, in america, one of the most developed countries, nine factors affecting longevity are gender, genetics, prenatal, and childhood status, as well as education, marital status, ethnicity/migration status, lifestyle and health technology (beckman, 2016). in detail, according to who, many factors such as socioeconomic conditions, including income, education, employment, and economic welfare; the quality of the health system and the state of the population; health behaviors such as drinking or eating harmful things, poor nutrition and inactivity; social factors; genetic factors; and environmental factors, including pollution, lack of clean drinking water, climate are all factors affecting human life expectancy. cheng-wen (2017) introduced new factors such as infant mortality rate, internet consumption, education, and electric power. moon fai chan et al (2015) conducted a study in singapore, malaysia, and thailand; three south east asian nations, concluding that demographics, socioeconomics and health care resources have impact on life expectancy. to sum up, there are three general factors that have impact on life expectancy: demographics, socioeconomics and health care determinants. the rest of the factors are included in these factors. demographics is the study of a population based on factors such as age, race, and sex. demographic data is relevant to socioeconomic information expressed statistically, including employment, education, income, marriage rate, birth rate and death rate, etc. education is a key factor in improving people's health and life expectancy (alamgir, 2016). currently, in the world, spain, japan, switzerland and hong kong are among the highest in life expectancy.the common feature of these four countries is the strong development of education (amir, 2016). hendi (2021) also pointed out that positive educational innovation has displayed a good sign on life expectancy. socioeconomic determinants include urbanization, industrial development, environmental pollution, gdp, etc.. urbanization is an essential factor in determining life expectancy. urban residents of developing countries often enjoy advanced health care and modern means of living, better education 539 global journal of public health medicine 2022, vol 4, issue 1 gggggglo and enhanced socioeconomic factors. this has a positive impact on human health as stated (hendi, 2016). industrial development will lead to environmental pollution, which adversely affects human life. the increase in gdp per capita is the proof of income growth and improvement in quality of life. raj chetty (2016) has also conducted a research study proving that income has an effect on life expectancy. research by venkataramani (2021) indicates that social and economic forces are likely to be the main drivers of america's decline in life expectancy. kabir (2008) argued that total health care spending has a significant impact on life expectancy because it directly reduces mortality and disease rates. according to statistics from the worldbank, who shows that advances in health have led to an increase in longevity, a reduction in the risk of diseases and an increased ability to cure diseases. it can be seen that one of the advances in medicine is the vaccination of infants. vaccinating for children reduces the risk of infectious diseases and has good resistance from childhood. therefore, health care is an important factor in increasing life expectancy. in sum, in this study, i used this three-factor model and the data from the general statistics office and the world bank. this study aimed to find out the relationship between these factors and consider the increase in life expectancy of people. in addition, from the review of research results, it has been shown that there are differences between these factors in two groups of developing and developed countries. methods this original research is a quantitative study. indirect sampling was used. the data were extracted from the annual statistical report of the general statistics office. this data is formal, reliable, readily available, easily accessible, and produced by a government entity. data was taken from the general statistics office and the world bank of three countries vietnam, laos and cambodia from 1985 to 2019. this is an appropriate timeline because it is the period after the independence of laos, vietnam, and cambodia and before the outbreak of the covid-19 pandemic. thus, this study has excluded the factor of death due to war and the covid-19. it is used to find out the factors affecting life expectancy in three countries vietnam, laos, and cambodia during this period. research subjects are the citizens living in vietnam, laos, cambodia, excluding those who have the nationality of these three countries but live in other countries. to ensure representativeness, a random sampling technique was utilized. a sample of the national population is taken up by the general statistics office of each country and averaged. the author recorded this survey data and made statistics with stata software. thus, the sample size is large enough to be reliable to extrapolate the characteristics of the population. this study is in accordance with the scientific ethical standards according to internal documents issued in these three countries. the mathematical formula was established based on previous studies mentioned in the introduction of the present study. in summary, demographics, economics, and health care determinants have an effect on life expectancy. moreover, the author added coefficients α and error ε to increase the reliability of the model. 540 global journal of public health medicine 2022, vol 4, issue 1 gggggglo to research the effects of different independent variables on life expectancy, earlier studies usually followed the method of quantitative research with assistance from the software. hence, in this research, stata version 14.0 was employed. health issues are increasingly concerned and there are more and more studies related to this issue. only when people are healthy can they build and live a better life. human life expectancy assesses the quality of life. although there are many studies on longevity, there are very few studies on longevity in vietnam, laos, cambodia. realizing the urgency of this problem, the author used a data set that was accurately derived from statistics to study factors affecting life expectancy. this study also helps to compare factors between developing countries and developed countries; in addition, it is a premise to study the changes of factors through covid 19 pandemic. the formula which represents the dependent variable is built like the following: model; le = α + β1 * dg + β2 * se + β3 * hl + ε α, β1, β2, β3 are coefficients ε is error the important variables are dg, se, hl with corresponding coefficients to express their influence on le as β1, β2, β3. the meaning and role of different variables are as follows: table 1. list of dependent and independent variables of the regression models variable meaning determined by role le life expectancy life expectancy dependent variable dg demographic determinants =mean (dg1, dg2) independent variable dg1 demographic determinants population ages 65 and older, female independent variable dg2 school enrollment, primary (% gross) independent variable se socioeconomic determinants =mean (se1,se2,se3,se4) independent variable se1 socioeconomic determinants gdp growth (annual %) independent variable se2 urban population growth (annual %) independent variable se3 industry (including construction), value added (constant lcu) independent variable se4 co2 emissions (metric tons per capita) independent variable hm health care determinants =mean (hm1,hm2) independent variable hm1 health care determinants immunization, dpt (% of children ages 12-23 months) independent variable hm2 mortality rate, infant (per 1,000 live births) independent variable 541 global journal of public health medicine 2022, vol 4, issue 1 gggggglo result after collecting data through the world bank and the general statistics office, the author entered them into microsoft excel. next, the author recalculated the answers based on the likert scale with a scale of 1-5 corresponding to the levels from weak to strong. through excel, the data is calculated the maximum and the minimum value, using scaling, with the maximum value of 5, the smallest value is 1, the results are decimal numbers from 1 to 5. the descriptive statistics in table 2 indicate dependent variable le and three different independent variables (dg, se, hm) with their mean, minimum, and maximum values. table 2. variables summary variable obs mean std. dev min max le 105 64.25856 7.941212 47.864 75.37 dg1 105 1168544 1447309 74703 4423377 dg2 105 109.6907 10.71641 85.02592 131.937 se1 96 6.333176 4.862933 -34.80864 14.19064 se2 105 3.932691 1.195572 2.109575 6.945852 se3 81 2.37e+14 3.47e+14 1.26e+12 1.35e+15 se4 105 .6617799 .8659623 .0518955 4.568923 hm1 105 67.25714 25.98003 4 99 hm2 105 53.25333 29.54952 15.9 120.9 looking at table 2, it is clear that the maximum value of le is 75.37 and the minimum is 47.864. so the difference between them is quite large. this shows that the socio-economic situation and people's lifestyle have changed markedly. figure 1: tendency in vietnam 542 global journal of public health medicine 2022, vol 4, issue 1 gggggglo figure 2: tendency in cambodia figure 3: tendency in laos according to figure 1,2,3, it is possible to see the changing trend of factors. factors such as le, dg1, se1, se3 tend to increase in all three countries. furthermore, through the results, it is shown that the remaining factors do not change significantly. their changing tendency is not obvious. in the regression model, if the independent variables are closely related, or have a linear relationship, it indicates that the independent variables are strongly and strongly correlated with each other, and the phenomenon of multicollinearity will occur illustrating that independent variables in the model depend 543 global journal of public health medicine 2022, vol 4, issue 1 gggggglo on each other and can be expressed as a function. therefore, the author performs the vif coefficient test. the result vif=2.01 indicates that the model does not suffer from multicollinearity. moreover, in the regression model the phenomenon of autocorrelation and variance can also occur. therefore, to consider these cases, the author used white and wooldrige tests and both obtained p value < 0.05 which indicates that there is autocorrelation between variables and the variance varies in a fixed direction. table 3. general regression model regression coef. std. err. z p value dg .2428934 .0369247 6.58 <0.001 se .0083835 .0152808 0.55 0.583 hm .2081466 .0202195 10.29 <0.001 _cons 3.485768 .0978025 35.64 <0.001 there are four regression models commonly used in stata: pool, fixed effects model (fe), random effects model (re) and general regression model (fgls). the author has performed all four regression models to compare the level of reliability and choose the appropriate model. initially, the author used a linear regression model pool. however, after running it, the results had autocorrelation and variable variance (p-value < 0.05 of white test and wooldridge test). therefore, the more suitable models are fe (fixed effects model) and re (random effects model). after using "test of variance" a prob result of 0.0098 proved the variance in a fixed direction. thus, the more suitable model is fe (fixed effects model) because it helps to overcome the occurrence of fixed variance in the model. but after using the fe (fixed effects model), we still get the results showed the variable variance and the autocorrelation phenomenon. thus, although the fe model has overcome the disadvantages of the pool model, it still exists the phenomenon of variable variance and autocorrelation. according to the linear regression theory, the fgls (general regression model) can overcome this phenomenons and give the most accurate results. therefore, the fgls (general regression model) was selected. according to the above table, the variables dg and hm have a p-value of less than 0.05 except se with a p-value of 0.583. therefore, the reliability of le's dependence on se is not high. in addition, based on coef. column (coefficient) and the values of dg, hm, _cons rounded to the third decimal, then the model representing the dependence of le is: le= 0.243*dg + 0.208*hm + 3.486+ ε discussion from the research results mentioned above, it can be said that no socioeconomic determinants is related to the life expectancy. nevertheless, vietnam, laos, and cambodia should improve people's quality of life and their income and socio-economic development associated with environmental protection. the reason that this variable does not affect human life expectancy is that the economies of these three countries are in the developing stage. besides, health care and demographics have positive changes and good effects on life expectancy. 544 global journal of public health medicine 2022, vol 4, issue 1 gggggglo thus, with the correct use of data from data world bank, the general statistics office and the analysis through stata software, the author has come to the conclusion that the factors socioeconomic determinants, health care determinants, and demographic determinants have influences on life expectancy. this is consistent with previous studies by major authors mentioned in introduction such as (alamgir khan, 2016), (mandal, 2016), (moon fai chan, 2015). in the study of lubitz (2003), he clarified that health care has a positive effect on the increase of life expectancy in the elderly. the results of this study show similarities and confirm that healthcare is an essential factor. research by eggleston et al (2012) found the share of increases in life expectancy realized after age 65 was close to 80 percent by the dawn of the 21st century. thus, it can be seen that the elderly are tending to increase, and that also leads to an increase in life expectancy. in addition, compared with the study done in the uk by welsh (2021), the results all show the similarity in the influence life expectancy. life expectancy is closely related to demographics, socioeconomics, and healthcare resources. however, this study also showed a difference in the degree of correlation. because the three studied countries have their own specific characteristics in terms of culture, politics, especially the economy, thus health has the strongest impact, while economic development such as polluting the environment, increasing discontent social equality, urbanization, gdp... have negligible influence. according to statistics on worldometers in 2017 (the world had not yet been impacted by covid), it has been shown that gdp: $19,485,394,000,000 (usa), $12,237,700,479,375 (china), $4,872,415,104,315 (japan)… and $223,779,865,815 (vietnam), $22,158,209,503 (cambodia) $16,853,087,485 (laos). thus, there is a significant difference in gdp between the two groups of countries. following teichler (2005) and baum et al (2013), the countries of north america and europe are considered to provide the best education for people. differences in the quality of education lead to people's perception of life and health care. this is also a vital factor in life expectancy. conclusion from the research results mentioned above, it can be said that no socioeconomic determinants is related to human life expectancy. nevertheless, governments could improve quality of life leading to positivity in increasing life expectancy. demographic determinants, health care determinants, on the other hand, impacts positive on life expectancy. these two factors play almost equal roles in influencing aspects of life expectancy. thus, this study has conducted research on the factors affecting health typical in three countries vietnam, laos, cambodia. each factor has a different degree of influence and is specific between groups of developed and developing countries. the scope of this study is not wide and only shows the influence of factors on human life expectancy from developing countries and in the time before the covid-19 epidemic. however, it is a premise for policy makers to find solutions to improve life expectancy. in the future, i will expand this study during covid to see how the factors influence mortality. 545 global journal of public health medicine 2022, vol 4, issue 1 gggggglo acknowledgements the author would like to thank organizations and units that have conducted the survey: general statistics office of vietnam, laos, cambodia and databases of world bank and who. conflicts of interest the author declares no 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pujalte and chua,2013; chmela et al.,2016). classification of tick ticks are compulsory ectoparasites that feed on blood from their hosts. ticks belong to the arthropoda phylum, arachnida class,acari subclass, parasitiform order and ixodida suborder (estrada-pena et al., 2010). three tick families are classified as ixodidae (hard ticks), argasidae (soft ticks), and nuttalliellidae (restricted tanzania and south africa) (shi et al.,2018). more than 900 tick species have been classified by the world. ticks not only lead to physical damage through blood sucking and skin wound to their hosts, but some of these tick species always have the ability to transmit pathogens to their host. the tick prevalence in any region depends on various variables such as climate, predators and competitor species. (bartikova et al.,2017). species the ixodidae family consists of 14 genera and 704 species and is generally divided into prostriata (the ixodes genus alone) and metastriata (all other family genera). this classification is based on morphological (i.e. anal groove collocation compared to anus) and biological characteristics (walker et al., 2003). there are 5 genera and 195 species in the argasidae (guglielmone et al., 2010). they include comprise the most genera and species of greatest medical and veterinary concern (jongejan and uilenberg, 2004). life cycle of tick there are four distinct phases in the tick life cycle: egg, larva, nymph and adult. the adult phase with male and female sexes is characterized by sexual dimorphism (walker et al., 2003). a single gravid female can produce several hundred to thousands of globular eggs, generally brown, before dying in the environment oviposition lasts for several days (sonenshine, 1991). depending on the tick species and the climatic conditions, eggs can hatch between two weeks to several months after laying. each viable egg gives origin to a six-legged (i.e. hexapod) larva. when hatched from their respective eggs, larvae begin to seek a host to feed on for a long time depending on the biological characteristics of each species (sonenshine, 1991). larvae consume their blood meal after feeding and moult into an eight-legged (i.e., octopod) nymph, in addition to larvae, stigmata and tracheal structures have been developed in tick nymphs and adults, making them more vulnerable to desiccation than the developmental stage of hexapod (needham and teel, 1986). nymphs will also feed on a vertebrate host for several days after moulting (i.e. 4–8) before moulting into the next adult developmental stage (sonenshine, 1991). adults ticks are sexually competent. mating can happen off the host in the setting for prostriate ticks (genus ixodes), while it happens only on the host for metastriates, generally at the same time as blood feeding (sonenshine, 1991). the engorged, fertilized woman falls off the host after mating and moves through the surroundings in search of an appropriate oviposition site. according to the number of individual hosts on which they feed on throughout their life cycle (figure.1), ticks can be classified as: *one-host ticks: food and moulting of the same animal, parasitized by the larval stage of the tick. the species of the boophilus subgenus of the genus rhipicephalus provide an example of one-host ticks ; their life cycle can be completed within a few weeks (walker et al., 2003). *two-host ticks: during their cycle, parasitize two animals: one as larvae and the other as adults. therefore, larva and nymph happen in the same host. after feeding to moult in the environment, the engorged nymph drops off the host. then it would parasitize the resulting adult and feed on another host. rhipicephalus evertsi is a typical instance of a two-host tick in africa that parasites cattle (walker et al., 2003). 41 global journal of public health medicine 2019, vol 1, issue 1 gggggglo *three-host ticks: three distinct animals, one for each growth stage, are parasitized. all three-host tick moults in the virtual environment can be detected. the life cycle of a three-host tick is considerably longer than that of one-host ticks (walker et al., 2003). (fig.1) life cycle of tick source: http://medent.usyd.edu.au/fact/ticks.htm isolation of tick the selected ticks put in a mixture of 70% ethanol with few drops of glycerin while the remaining ticks were combed on a white rug soaked with cypermethrin, then all dropped ticks were counted and burned. . the specimens were identified steromicroscopically according to (soulsby, 1982). adult arthropods and larvae were cleaned in cooked 10% naoh(aq) ; or lactophenol at room temperature for distinct times , installed by canada balsam between the slide and cover slip, which was put in 40c. hard mounting medium oven for a few days (apanaskevich et al.,2008). pathogenicity of tick ticks can vertically transfer several pathogens to their descendants of the larval stage, which can then be transferred to the nymph and then to the adult. thus contagious state can be maintained over several generations without contact with a vertebrate reservoir. the vector capacity of ticks changes between species and particular pathogens is sometimes transferred by a limited range of ticks only (diaz, 2010 ). tick bites can cause a range of adverse reactions in regards to infectious diseases, ranging from localized pain and inflammation to severe allergic reactions such as anaphylaxis or tick paralysis. tick paralysis caused by a toxin found in saliva. holocyclus is a common cause of animal paralysis and death, and although it is uncommon today, it was deadly to the developers in humans (chris et al.,2011) review in the previous studies distribution of hard tick species in different area of iraq. distribution of ticks on hosts affected by multiple variables such as tick morphology (hypostome length), host morphology (fur coat length) (pfaffle et al., 2013). vatsya et al.(2007) related to host immune sponses, self-grooming, inter-specific relationships, heat-dissipating behaviour and feeding phase duration . so far as seasonal abundance is concerned, the results showed a significant distinction among the months in the number of tick collections. tick abundance and distribution rely on many indicators, including environment (temperature, moisture, sunlight, wind acceleration and dust) (patel et al 2012). host nature (susceptibility, gender, age, and sex) and management procedures including acaricide use. tick species ' seasonal dynamics are the result of suitable environmental circumstances, temperature, moisture, light intensity, and rainfall (gray, 1991; das, 1994). the occurrence of ticks with restricted movements can be significantly impacted by the chances of encountering a prospective host and their densities of population. the variation in the distribution of ticks in various seasons of the year is based on a multitude of factors such as climatic circumstances, host lifestyle and habitat characterization. (dantas-torres, 2010 ; kwak, 2014; gonzalez et al.,2017). temperature is the main extrinsic factor of incidence of ectoparasites because it controls the metabolic rate and affects both the effectiveness of the use of blood-meal, the length of periods of oviposition and the rate of development, relative humidity is the controlling factor of water balance mechanisms of ticks. low humidity is a major stress on tick water balance and appears to have an adverse effect on the effectiveness of converting the blood meal into egg biomass. (chabra et al., 1983;labruna et al.,2002). 42 global journal of public health medicine 2019, vol 1, issue 1 gggggglo al-fatlawi et al ., (2008) ) recognizing the 50 tick species obtained from infested cattle skin in al-najaf provence. while in aldoura region south baghdad recorded infested with tick was 27.8% (hasson ,2012 ). alrammhi,(2013) recorded two tick species ; rhipicephalus turanicus and rhipicephalus leporis with burden average 61.14% in alqasim district –babylon province. hasson and al-zubaidi, (2014) recorded prevalence of cattle ticks infestation 91.3% in wasit province districts. while al-dulimy and alamery, (2015) recorded the chicken were infested with one tick species (argas persicus), in a whole rate of 17.22% in baghdad province . conclusion the spread and identification of different types of hard ticks in different regions of iraq. authors were able to review most of the local and international studies related to tick's diagnosis (classification), especially tick species distribution in iraq. references apanaskevich ,d.a. schuster, a. l. and horak, i. g. (2008). the genus hyalomma: vii. redescription of all parasitic stages of h. (euhyalomma) dromedarii and h. (e.) schulzei (acari: ixodidae) . j. med. entoml. vol.45(5):pp817-831. al-fatlawi, m.a.a. ali m.j. and albayati, h.h.(2018). morphological and phylogenetic study of hyalomma anatolicum in al-najaf, iraq, iraqi journal of veterinary sciences, vol. 32, no. 2, 2018 (261-266). al-dulimy e. j f and alamery, a. m. a (2015) . isolation and diagnosis of the ectoparasites of house chickens in the province of baghdad and study their effects on the blood, qadisiyah journal of veterinary medicine vol. 14 issue (1);1-6. al-rammhi , h. m , mohammad mohammad, km and mohammad, h( 2013). tick infestation of hares (lepus capensis) in alqasim district babylon, iraq. euphrates journal of agriculture science-5 (1): 8-14. bartíková p, holíková v, kazimírová m, štibrániová i (2017). tick-borne viruses. acta virologica.;61(04):413-427. bente da, forrester nl, watts dm, mcauley aj, whitehouse ca, bray m. crimean-congo. (2013). hemorrhagic fever: history, epidemiology, pathogenesis, clinical syndrome and genetic diversity. antiviral research.;100:159-189. chmela˘r j, kotál j, kopecký j, pedra jh, kotsyfakis m (2016). all for one and one for all on the tick-host battlefield. trends in parasitology.;32:368-377. chabra mb, ruprah and s.k. gupta.(1983) .ixodid ticks on bovines in haryana: a preliminary report.cherion.; 12:298-303. chris p. lowbridgea, stephen l. doggettb and stephen gravesc (2011) . tickborne diseases ,nsw public health bulletin vol. 22(11–12) . das ss(1994). prevalence of ixodid ticks infestation on farm animals in pantnagar, tarai of uttar pradesh. jparasit. appl.anim. biol.; 3:71-73. dantas-torres f (2010). biology and ecology of the brown dog tick, rhipicephalus sanguineus. parasites and vectors.;3:26-35. diaz jh (2010). ticks, including tick paralysis. in: mandell, douglas and bennett’s principles and practice of infectious diseases. mandell gl, bennett je and dolin r, editors. philadelphia: elsevier;. p. 3649–62. estrada-peña a, mangold aj, nava s, venzal jm, labruna mb, guglielmone aa (2010). a review of the systematics of the tick family argasidae (ixodida). acarologia.;50(3):317333. gray js (1991). the development and seasonal activity of the tick ixodes ricinus: a vector of lyme borreliosis. med. vet. entomol. 79:323-333. gonzalez i, labruna m, chagas cr, salgado p, monticelli c, morais lh et al (2017). ticks infesting captive and freeroaming wild animal species at the são paulo zoo, são paulo, brazil. braz. jvet. parasitol., jaboticabal; 26(4):496-499. guglielmone aa, robbing rg, apanaskevich da, petney tn, estrada-peña a, horak ig, shao r, barker sc (2010) the argasidae, ixodidae and nuttalliellidae (acari: ixodida) of the world: a list of valid species name. zootaxa. 2528: 1–28. 43 global journal of public health medicine 2019, vol 1, issue 1 gggggglo hasson r.h (2012). tick distribution and infestation among sheep and cattle in baghdad’s south suburb, kufa journal for veterinary medical sciences vol. (3) no. (1). hasson, r.h and al-zubaidi, h.h (2014). cattle and buffaloes tick's infestation in wasit province districts , iraqkufa journal for veterinary medical sciences vol. (5) no. (1); 31-40. jongejan f, uilenberg g (2004) the global importance of ticks. parasitology.129: 3s–14s. karim s, budachetri k, mukherjee n, williams j, kausar a, hassan mj, et al. a study of ticks and tick-borne livestock pathogens in pakistan. plos neglected tropical diseases. 2017;11(6). kwak ys, kim ty, nam sh, lee y, kim hp, mduma s, et al (2014). ixodid tick infestation in cattle and wild animals in maswa and iringa, tanzania. korean j parasitol;52(5):565568. labruna m, de paula c, lima t, sana d (2002). ticks (acari: ixodidae) on wild animals from the porto-primavera hydroelectric power station area, brazil. mem. inst. oswaldo cruz, rio de janeiro.; 97(8):1133-1136. needham gr, teel pd (1986) water balance by ticks bloodmeals. in: morphology, physiology and behavioral biology of tick. edited by sauer jr, hair ja. ellis horwood ltd, chichester, uk, pp. 100–104. pujalte gga and chua jv (2013). tick-borne infections in the united states. primary care; clinics in office practice.;40:619-635. pfaffle m, littwin n, muders sv, petney tn (2013). the ecology of tick-borne diseases. international journal of parasitology.; 43:1059-1077. patel g, shanker d, jaiswal ak, sudan d, verma sk. prevalence and seasonal variation in ixodid ticks on cattle of mathura district, uttar pradesh. j parasit. dis., doi buffalo bulletin. 2012; 34(1). sonenshine de (1991) biology of ticks. vol. 1. oxford university press, new york, u.s.a. shi j, hu z, deng f, shen s (2018). tickborne viruses. virologica sinica.;33(1):21-43. soulsby, e. j. l. (1982). helminths, arthropods and protozoa of domesticated animals. 7th edition, london. vatsya s, yadav rr, kumar r, garg s (2007). seasonal activity of boophilus micropluson large ruminants at an organized livestock farm. j vet. parasitol.; 21(2):125-128. walker ar, bouattour a, camicas jl, estradapeña a, horak ig, latif a, pegram rg, preston pm (2003) ticks of domestic animals in africa, a guide to identification of species. bioscience reports, edinburgh, u.k. walker ar, bouattour a, camicas jl, estradapeña a, horak ig, latif a, pegram rg, preston pm (2003) ticks of domestic animals in africa, a guide to identification of species. bioscience reports, edinburgh, u.k. elmer gray (may 16, 2012). the university of georgia .circular 937 retrieved from http://medent.usyd.edu.au/fact/ticks.htm microsoft word gjphm-2022rota virus.docx 547 global journal of public health medicine 2022, vol 4, issue 1 gggggglo original research investigation of awareness of rotavirus infection and vaccination in parents of infants less than one year-a questionnaire study from turkey önder kılıçaslan, muhammet mesut nezir engin, merve aslantaş, furkan timur, kenan kocabay düzce university, school of medicine, department of pediatrics, düzce, turkey. *corresponding author: dronderklcsln@gmail.com abstract introduction: rotavirus infection is one of the most common causes of infantile diarrhea, with significance in developing countries where it accounts for 15–30% of the mortality rate. vaccination is an effective way to prevent disease and mortality. therefore, parents' knowledge about rotavirus infection and vaccination is critical in increasing vaccination rates. we aimed to investigate parental awareness about rotavirus infection and vaccine, evaluate attitudes towards rotavirus vaccination, and determine factors affecting acceptance and hesitations about immunization. methods: this survey included 1856 participants: parents who had a child aged under one year of age. a self-explanatory questionnaire consisting of 13 questions was composed to determine parental awareness and behavior regarding rotavirus infection and the vaccine. results: more than half (n=541, 58.30%) of the parents knew that diarrhea could be a fatal disease, less than half (n=354, 38.15%) knew that rv could cause diarrhea. the parental knowledge rates about the rotavirus infection and the vaccine were positively correlated with parents' education level and monthly family income. less than half (41.59%) of the parents were found to have vaccinated their children for rotavirus infection. vaccination rates increased in parallel with the increase in income and education level of parents. the primary reasons for nonvaccination were lack of knowledge (44.83%) and the fear of possible side effects (14.94%). conclusion: the present survey demonstrates that parents' knowledge of rotavirus vaccination is not adequate, and the rate of rotavirus vaccination is even low. the present study underlines that health providers are critical insufficient society awareness and acceptance of rotavirus immunization. keywords: awareness, parents, rotavirus vaccination 548 global journal of public health medicine 2022, vol 4, issue 1 gggggglo introduction rotavirus (rv) is the most common cause of severe gastroenteritis (ge) worldwide in children <5 years of age in countries that have not adopted the universal use of rv vaccines. however, the infection rate has been decreased in the countries that have successfully vaccinated a large proportion of infants against rv (o’ryan et al.,2015). although recurrent infection is usually asymptomatic or mild to moderate among older children and adults, it can be severe in a subdivision and may lead to death in infants (rana et al.,2021). the viral rvge is transmitted via the fecal-oral route and has an incubation period of fewer than 48 hours. there is no specific treatment protocol for viral ge in children; the general approach is supportive and supplementary treatment. the rv vaccine is the most effective way to prevent rvge in children (burnett et al.,2020). since 2013 the world health organization (who) has recommended including rv vaccines into national vaccination programs and lists them in the essential medicines list (who,2013). interestingly, the rv vaccination rate is around 25% in some countries; despite that, the rv vaccination has been introduced into the routine vaccination program (giaquinto et al.,2011). rotarix and rotateq vaccines are safe and effective vaccines approved for clinical use in turkey. these vaccines are equivalent in terms of safety, effectiveness, and cost. these vaccines have strict age recommendations for administration: the first dose should be given before 15 weeks of age, and all doses must be provided by eight months. when this study was conducted, turkish health ministry has not raised the rv vaccination in the standard vaccination program, and the routine national childhood immunization program does not cover it. therefore, turkey statistic reports project that rv vaccination rates are relatively minimal in turkey. the present study aimed to evaluate parents who have an infant child from the awareness and behaviors aspect for rv infection. the main aim of this study was to consider what determinants affect vaccination decision or hesitation. the outcomes of this study may guide strategies to increase population immunity gains rv infection. methods recruitment and data collection the present study is a six-month study conducted between january 01, 2018, and july 01, 2018, in the pediatric outpatient clinic of the department of pediatric health and diseases, university faculty of medicine, düzce, turkey. a total of 1856 parents who have a child under one year of age were involved. the parents of the children who had been admitted to the emergency department for an acute illness, those previously informed of the rv vaccines at our department, and who had a child older than one year were excluded from the study. 549 global journal of public health medicine 2022, vol 4, issue 1 gggggglo study design it is a descriptive cross-sectional study. a self-explanatory questionnaire was designed with the help of the medical statistics department. we enclosed all the patients aged under one year, admitting to the outpatient policlinic sequentially; no maximum sample size was required. all the parents signed informed consent before participating in the study. development of survey instruments to quaternate the study groups, a self-explanatory questionnaire was designed; it was comprised of 13 questions it assessed parents' awareness, knowledge, and behaviors regarding rvge and rv vaccines. the questionnaire was completed under observation without any intervention. it included questions that queried parents on the following: • demographics: age, gender, education, socioeconomic status, • knowledge of ge-related mortality, rv-related ge, rv vaccines, • attitude and behavior regarding rv vaccination and also reasons for hesitation regarding the use of rv vaccines, • the source of their knowledge regarding the topics questioned. ethical issues the regional scientific ethics committee approved the study following the world medical association declaration of helsinki: ethical principles for medical research involving human subjects. statistical analysis all analyses were performed on spss v21. data are given median (minimum-maximum) for continuous variables and frequency (percentage) for categorical variables. the utilization of chi-square tests performed categorical comparisons. p<0.05 values were defined as the significance level for all statistical analyses. results study population our study included 1856 parents (926 males and 926 females). mothers' median age was 28 (17-45) years, 308 (33.2%) of the mothers had graduated from high school, and 695 (74.9%) were housewives. the fathers' median age was 32 (19-56) years, 334 (36%) of the fathers had graduated from high school, and 561 (60.45%) had working-class jobs. among the 926 families, 442 (47.7%) had 250-500 usd income per month. the median age of the children was 79.5 (1-350) days, and 428 of the children 550 global journal of public health medicine 2022, vol 4, issue 1 gggggglo (46.1%) were girls, 500 (53.9%) were boys. the summary of parent and child-related characteristics is presented in table 1. table 1. summary of parent and child characteristics child age (day) [median, min-max] 79.5 (1-350) gender girl (n) 428 (46.12%) boy (n) 500 (53.88%) mother age (median, min-max) 28 (17-45) mother education status illiterate 28 (3.02%) primary school 187 (20.15%) secondary school 212 (22.84%) high school 308 (33.19%) university 193 (20.80%) mother occupation housewife 695 (74.89%) worker 103 (11.10%) officer 111 (11.96%) others 19 (2.05%) father age (median, min-max) 32 (19-56) father education status illiterate 4 (0.43%) primary school 119 (12.82%) secondary school 200 (21.55%) high school 334 (35.99%) university 271 (29.20%) father occupation unemployed 35 (3.77%) working-class job 561 (60.45%) civil servant 257 (27.69%) others 75 (8.08%) income (monthly, usd) < 250 204 (21.98%) 250-500 442 (47.63%) > 500 282 (30.39%) data given as median (minimum-maximum) for continuous variables and frequency (percentage) for categorical variables parental awareness data when information about rvge was questioned, although more than half (n=541, 58.30%) of the parents knew that diarrhea could be a fatal disease, less than half (n=354, 38.15%) knew that rv could cause diarrhea. when knowledge about the rv vaccine was questioned, it was found that more than half (n=528, 56.90%) of the parents declared that they knew diarrhea was a vaccine-preventable disease. however, less than one-third (n=265, 28.56%) had any knowledge about the rv vaccine. the results regarding parents' knowledge about rv infection are presented in figure 1. 551 global journal of public health medicine 2022, vol 4, issue 1 gggggglo figure 1: the results regarding the knowledge of parents about rv infection univariate analysis showed that, when both parents possessed a university degree, they were significantly more likely to have correct knowledge regarding the following statements: 'diarrhea can be a fatal disease' (mothers n=140 72.54%, p<0.001, fathers n=182 67.16%, p=0.002), 'rv infection is associated with diarrhea' (mothers n=135 69.95%, p<0.001, fathers n=167 61.62%, p<0.001), 'diarrhea can be prevented with vaccination' (mothers n=150 77.72%, p<0.001, fathers n=194 71.59%, p<0.001). also, these parents had significantly higher knowledge levels about rv vaccines (mothers n=104 53.89%, p<0.001, fathers n=140 51.66%, p<0.001) (table 2 and 3). when the knowledge level of the parents was evaluated according to the monthly income, it was seen that those with a monthly income of 500 usd or higher had more information about rvge and rv vaccines (diarrhea can be a fatal disease; n=179 63.48%, p=0.016, rv infection is associated with diarrhea; n=174 61.70%, p<0.001, diarrhea can be prevented with vaccination; n=199 70.57%, p<0.001, and better knowledge about rv vaccines; n=142 50.35%, p<0.001) (table 2 and 3). 552 global journal of public health medicine 2022, vol 4, issue 1 gggggglo table 2. summary of answers regarding mother's education status and comparison results primary or less secondary high school university p n 215 212 308 193 n.a can diarrhea be a fatal disease? yes 109 (50.70%) a 117 (55.19%) a 175 (56.82%) a 140 (72.54%) b <0.001 no 106 (49.30%) 95 (44.81%) 133 (43.18%) 53 (27.46%) do you know about rotavirus-related diarrhea? yes 46 (21.40%) a 45 (21.23%) a 128 (41.56%) b 135 (69.95%) c <0.001 no 169 (78.60%) 167 (78.77%) 180 (58.44%) 58 (30.05%) can diarrhea be prevented with vaccination? yes 99 (46.05%) a 95 (44.81%) a 184 (59.74%) b 150 (77.72%) c <0.001 no 116 (53.95%) 117 (55.19%) 124 (40.26%) 43 (22.28%) do you know about rotavirus vaccines? yes 31 (14.42%) a 30 (14.15%) a 100 (32.47%) b 104 (53.89%) c <0.001 no 184 (85.58%) 182 (85.85%) 208 (67.53%) 89 (46.11%) chi-square test. the same letter denotes a lack of significant difference between groups. data are given as frequency (percentage) table 3. summary of answers regarding father's education status and comparison results primary or less secondar y high school university p n 123 200 334 271 n.a can diarrhea be a fatal disease? yes 68 (55.28%) a 101 (50.50%) a 190 (56.89%) a 182 (67.16%) b 0.00 2 no 55 (44.72%) 99 (49.50%) 144 (43.11%) 89 (32.84%) do you know about rotavirusrelated diarrhea? yes 28 (22.76%) a 59 (29.50%) a 100 (29.94%) a 167 (61.62%) b <0.0 01 no 95 (77.24%) 141 (70.50%) 234 (70.06%) 104 (38.38%) can diarrhea be prevented with vaccination? yes 60 (48.78%) a 103 (51.50%) a 171 (51.20%) a 194 (71.59%) b <0.0 01 no 63 (51.22%) 97 (48.50%) 163 (48.80%) 77 (28.41%) do you know about rotavirus vaccines? yes 20 (16.26%) a 43 (21.50%) a 62 (18.56%) a 140 (51.66%) b <0.0 01 no 103 (83.74%) 157 (78.50%) 272 (81.44%) 131 (48.34%) chi-square test. the same letter denotes a lack of significant difference between groups. data are given as frequency (percentage) 553 global journal of public health medicine 2022, vol 4, issue 1 gggggglo parental attitudes for vaccination data when rv vaccination behaviors were questioned, less than half (n=386, 41.6%) of the parents reported that they had vaccinated their child. however, as the income level and education level increased, it was found that vaccination rates increased (income >500 usd; n=167, 59.22%, p<0.001). the primary cause of hesitancy among parents regarding rv vaccinations was: lack of knowledge (n=243, 44.8%), concerns about side effects (n=81, 14.9%), no specific reason (n=62, 11.4%), being unable to decide without asking the opinion of their spouse (n=58, 10.7%), believing there would be no benefit (n=52, 9.6%), and being unable to obtain the vaccine due to cost (n=46, 8.5%) (figure 2). figure 2: the primary cause of hesitancy among parents regarding rv vaccinations sources of information data the most common sources of information about rvge and rv vaccines among mothers and fathers were: health professionals (n=169, 47.7% and n=150, 56.6%, respectively) and television/internet (n = 169, 47.7% and n=67 25.3%), followed by friend/family sources (n=77, 21.8% and n=48, 18.1%). discussion this is not the only but one of the most comprehensive studies that had assessed the awareness, and knowledge levels of parents of children under one year of age, about rv infection, attitudes towards vaccination, and the determinants that affect immunization preference in turkey. we can summarize our results as follows: the knowledge level of ge mortality, rv infection, and rv vaccination was insufficient among parents of infants. lack of knowledge on rv vaccination and fear of its probable side effects were the main reasons for vaccination hesitation established in our study. 554 global journal of public health medicine 2022, vol 4, issue 1 gggggglo parental awareness about gastroenteritis, association of rotavirus infection and immunization more than half of the study participants claimed that they knew about the mortality risk of gastroenteritis (58.3%). interestingly, mothers were meaningfully more aware of gastroenteritis mortality than fathers. again, the majority have stated that they were aware of the prevention of the disease via vaccination (56.9%). besides, few participants were aware of rv infection as diarrhea pathogenesis (38.2%), and even less knew it is preventable by vaccination (28.56%). on these topics of knowledge, there was no difference between mothers and fathers. when we examined the articles on rv infection published in turkey, we determined that, in recent years, the parental awareness rates of vaccination and the rv infection itself are higher than the studies conducted in previous years. for example, in their study presented in 2010 and 2011, the awareness rates of rv infection and medical prevention köksal et al. (2013, 2016) reported 19.2% and 24.8%, respectively. and, the later studies, published in 2020, ayyıldız et al. (2020) reported the rate as 51.1%, and cıklar & güner (2020) reported the rate of the parent who has and adequate information of rv infection and vaccination as 4.5%. again, cıklar & güner (2020) claimed that the rv vaccine is among turkish mothers' most known self-paid vaccines. we suppose that this may be due to the increased recommendation of the rv vaccine in recent years and its prevalence. this data should encourage increasing population awareness on rv and medical prevention. considering that rv infection is a successfully preventable disease that may cause a significant mortality rate, it is essential to take necessary precautions for the government. parental intention and hesitations to immunize their child against rotavirus in their study, bulbul et al. (2013) found the rate of rv vaccination to be .007%. cıklar & güner (2020) reported that 27.7% of parents vaccinated their children against rv infection. in our study, the vaccination rate was found to be 41.6%. chronological studies have shown that the rate of rv vaccination is low. although the application rate of the rv vaccine is low in this study compared to those reported from some european and developed countries, it was observed that vaccination rates against rv remarkably increase compared to previous years (van damme et al.,2006; dubé et al.,2012). as proved above, we suppose this satisfactory progress is due to the increased awareness of vaccination against rv in turkey. similar to the data above about awareness of rv infection and vaccination, the most critical parental characteristics affecting the willingness for vaccination rate were education level and family income. vaccination rates were positively correlated with higher education and monthly income. both the international and the turkish literature reports support our findings that education and family income levels affect the rates of immunization willingness (cıklar & güner,2020; odabaş & ayyildiz, 2020). 555 global journal of public health medicine 2022, vol 4, issue 1 gggggglo our study has introduced some points determining parental intention and hesitation about vaccination. the most common cause was lack of knowledge (44.8%). the next following causes were concerns about side effects (14.9%), no specific reason (11.4%), being unable to decide without asking the opinion of their spouse (n=58, 10.7%), expecting no benefit (9.6%), and cost (8.5%) respectively. what is the data on this concern in the medical literature? the turkish studies claim that lack of information, or even not have been heard of the presence of the rv vaccine, is above 80%; these are the studies conducted in 2016 and 2020 (cıklar & güner,2020; kaçmaz et al.,2016). similar rates of causes for non-vaccination were reported from european studies; in the low non-vaccinated rates, the most common reason was the lack of knowledge (van damme et al.,2006; della polla et al.,2020). what is the outcome we benefit from this finding? first, wide-spreading and increasing the knowledge levels of rv and the vaccine are obliged to be a public health destination. literature directs us that the rv vaccine provides herd immunity, indicating that increasing rv vaccination rates may provide significant advantages in child health, disease burden, and healthcare expense (mast et al.,2015; seybolt & bégué.,2012). parental sources of information about rotavirus infection and immunization in the present study, we determined that the most common parental source, the rv infection, and the vaccine were health providers with the highest rate, followed by internet and television sources, and in minor rate followed by environmental and friend authorities. in previous studies, similar to this, it was determined that information about vaccines was obtained from health personnel at a high rate (cıklar & güner,2020; dubé et al.,2012). relying upon this consequence, health providers must make broader and further plans to raise public acknowledgment of rv and the vaccine. again, public announcements via various media and television broadcasts are essential in increasing public vaccination acceptance. as a result, parents' knowledge of rv vaccination was low, and the rate of rv vaccination was even lower. the leading causes for not vaccinating were unaware of the vaccine, lack of knowledge, financial inability, and the fear of possible side effects of the vaccine. the study observed that as the parents' education level increased, the knowledge rate of the rv and rv vaccine and immunization rates increased. it was determined that the most important information source about the rv vaccine was the health providers. study limitations this is a self-declared survey; therefore, the data is subjective and may not provide the accurate status of vaccination of the children. the other limitation of this study is that it was conducted in a singlecenter, one concrete tertiary healthcare center, which may not represent the whole population. nevertheless, the high number of survey participants increases the value of the study and the importance of our research. 556 global journal of public health medicine 2022, vol 4, issue 1 gggggglo conclusion vaccination plays a significant role in preventing rv infections and reducing disease-related mortality and morbidity in our country. therefore, we suggest having an information policy for parents about rv infection and immunization during routine vaccination admission; it may be provided by trained health care providers or with introductory brochures. besides, the most critical factor in increasing the rate of rv vaccination is that the ministry of health includes the rv vaccine in the childhood routine vaccination program in turkey. conflicts of interest the author declares no conflicts of interest. references • ayyildiz t, altintaş hk, aydin c, minaz e, yörük t. (2020). 0-5 yaş çocuklarda rotavirüs sıklığı ve anne-babaların rotavirüse yönelik bilgi düzeyleri ve uygulamaları. dokuz eylül üniversitesi hemşirelik fakültesi elektronik dergisi, 13(3), 124-130. • bulbul m, ergüven m, yasa o, tombalak na. (2013). sağlam çocuk polikliniğimize başvuran çocukların rutin aşı ve diğer aşıların uygulama oran ve düzeninin değerlendirilmesi. göztepe tıp dergisi, 28(4), 171-178. doi: 10.5222/j.goztepetrh.2013.171 • burnett e, parashar ud, tate je. (2020). real-world effectiveness of rotavirus vaccines, 2006– 19: a literature review and meta-analysis. lancet glob health, 8(9), e1195-e202. doi: 10.1016/s2214-109x(20)30262-x • cıklar s & güner pd. (2020). annelerin çocukluk çağı aşıları hakkındaki bilgi, davranış ve tutumları ve aşı reddi nedenleri: nitel ve nicel bir araştırma. ankara medical journal, 20(1), 180195. doi: 10.5505/amj.2020.80148 • della polla g, napolitano f, pelullo cp, de simone c, lambiase c, angelillo if. (2020). investigating knowledge, attitudes, and practices regarding vaccinations of community pharmacists in italy. hum vaccin immunother, 16(10), 2422-2428. doi: 10.1080/21645515.2020.1720441 • dubé e, bettinger j, halperin b, bradet r, lavoie f, sauvageau c, gilca v, boulianne n. (2012). determinants of parents’ decision to vaccinate their children against rotavirus: results of a longitudinal study. health educ res, 27(6), 1069-1080. doi: 10.1093/her/cys088 • giaquinto c, dominiak-felden g, van damme p, myint tt, maldonado ya, spoulou v, mast tc, staat ma. (2011). summary of effectiveness and impact of rotavirus vaccination with the oral pentavalent rotavirus vaccine: a systematic review of the experience in industrialized countries. human vaccin, 7(7), 734-748. doi: 10.4161/hv.7.7.15511 • kaçmaz ersü n, ersü a, öztürk yk, helvacı m, öngel k. 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(2015). evidence of herd immunity and sustained impact of rotavirus vaccination on the reduction of rotavirus-related medical encounters among infants from 2006 through 2011 in the united states. pediatr infect dis j, 34(6), 615-620. doi: 10.1097/inf.0000000000000702 • parez n, giaquinto c, du roure c, martinon-torres f, spoulou v, van damme p, vesikari t. (2014). rotavirus vaccination in europe: drivers and barriers. lancet infect dis, 14(5), 416-425. doi: 10.1016/s1473-3099(14)70035-0 • odabaş n & ayyildiz t. (2020). anne babaların çocukluk dönemi aşılarına yönelik bilgi ve uygulamalarının değerlendirilmesi. med j west black sea, 4(1), 7-11. doi: 10.29058/mjwbs.2020.1.2 • o’ryan m, giaquinto c, benninghoff b. (2015). human rotavirus vaccine (rotarix): focus on effectiveness and impact 6 years after first introduction in africa. expert review of vaccines, 14(8), 1099-1112. doi: 10.1586/14760584.2015.1059282 • rana r, dahiphale r, kalrao v. (2021). epidemiological and clinical profile of rotavirus gastroenteritis among children younger than 5 years of age. indian j child health, 8(1), 4650. doi: 10.32677/ijch.2021.v08.i01.009 • seybolt lm & bégué re. (2012). rotavirus vaccination and herd immunity: an evidence-based review. pediatric health, medicine and therapeutics, 3, 25-37. doi: 10.2147/phmt.s25705 • simpson e, wittet s, bonilla j, gamazina k, cooley l, winkler jl. (2007). use of formative research in developing a knowledge translation approach to rotavirus vaccine introduction in developing countries. bmc public health, 7, 281. doi: 10.1186/1471-2458-7-281 • who position paper. (2013). rotavirus vaccines. wkly epidemiol rec, 88(5), 49-64. retrieved 1 june 2021, from https://apps.who.int/iris/handle/10665/242024 • van damme p, van der wielen m, ansaldi f, desgrandchamps d, domingo jd, sanchez fg, gray j, haditsch m, johansen k, lorgelly p, lorrot m, parez n, reschke v, rose m. (2006). rotavirus vaccines: considerations for successful implementation in europe. lancet infect dis, 6(12), 805-812. doi: 10.1016/s1473-3099(06)70657-0 microsoft word gjphm-2019klebsiella pneumoniae.docx 70 global journal of public health medicine 2019, vol 1, issue 2 gggggglo purification of inulinase from klebsiella pneumoniae and study the antibacterial effect of combination of inulinase and ceftazidime sarah naji aziz 1 *, rana naji aziz 2, marwa sabbar falih 1, karrar jasim al-sallami 1, haydar hassan ghadi 3, ali muhsin ali1 , ali naji aziz 4, walaa abdulsahib mikaeel 3, murtadha adnan mohammed1, rusul abbood alwan 1, al-maamoon hussein abed 1, ahmed ghalib ibraheem 1 1 college of science, mustansiryiah university, baghdad, iraq 2 college of tourism sciences, mustansiryiah university, baghdad, iraq 3 ministry of health, baghdad, iraq 4 alrafidain educational dental clinics, baghdad, iraq *corresponding author: sarahnaji2015@gmail.com abstract introduction: klebsiella pneumoniae are gram-negative which cause many diseases such as urinary tract infections, respiratory tract infections and septicemia. inulinase is an enzyme used in food manufacture and pharmaceuticals. inulinase is used in decreasing lipid ratio and, cholesterol in blood and considered as a prebiotic factor inside intestine. many microorganisms can produce inulinase, such as yeast, fungi and bacteria; among such bacteria: bacillus spp., arthrobacter spp., and pseudomonas spp. but there are no studies about inulinase production by k. pneumoniae have been reported. so the current study aims at investing the ability of producing and purification inulinase by k. pneumoniae. method: k. pneumoniae were isolated from many hospitals and screened for the production of inulinase. isolation percentage was 32%. a combination between the enzyme and the ceftazidime were assayed for detecting the antibacterial activity agonist gram positive and gram negative bacteria were done. results: it is found that k. pneumoniae k4 isolate is the best producer of this enzyme. inulinase, purified with ammonium sulfate at 70% saturation with specific activity 7.01 u/mg protein. as well, it's found that inulinase had increased the activity of ceftazidime against bacteria when combination between this enzyme and the antibiotic had done. conclusion: this study proves for the first time that k. pneumoniae can produce inulinase which can be used in tremendous applications and also proves the broad spectrum bioactivity of inulinase against microbial pathogens. ceftazidime antimicrobial activity against bacteria, is increased when a combination between inulinase and ceftazidime had done. keywords: inulinase, inulin, klebsiella pneumoniae, urinary tract infection, ceftazidime. 71 global journal of public health medicine 2019, vol 1, issue 2 gggggglo introduction klebsiella pneumoniae are gram-negative, motile rod-shaped bacteria. typical k. pneumoniae are opportunistic bacteria that cause nosocomial infections, urinary tract infections, respiratory tract infections and septicemia (vasaikar et al., 2017). these bacteria can be found in the skin, mouth and intestines, as well as in hospital settings and medical devices. inulinase (2, 1 b d fructano hydrolases ec 3.2.1.7) is a microbial enzyme hydrolyzes inulin to fructose and inulooligosaccharides, which are used in food manufacture and pharmaceuticals. beside its important role in decreasing the ratio of lipid and total cholesterol in blood (nascimento et al., 2012). inulin stored in the tubers and roots of plants like jerusalem artichoke jicama, dahlia, garlic and chicory (fawzi, 2011). inulin and fructooligosaccharides (fos) are indigestible food that widely beneficial to human body health (angel et al., 2012, bradford., 1976) and considered as prebiotic factors inside intestine (bharathi et al., 2011). fructose, very important food and drink manufacture (gao et al., 2007) (dilipkumar et al., 2011). microorganisms are important producers sources of inulinases, many studies among which (wang et al., 2003) (sahin et al. 2004) (singh et al.,2017) showed the successful production of inulinase from various filamentous fungi, yeast and bacteria strains like bacillus spp., arthrobacter spp., and pseudomonas spp. have been studied as high productivity producers of inulinase. the bacteria k. pneumoniae have been rarely used as producers to this microbial enzyme. to our knowledge there is no previous study about inulinase production by these bacteria have been reported. there is a need for developing substrate in cheaper and more effective process, thus this study aims to detect the ability of producing inulinase from k. pneumoniae in addition to partial purification of this microbial enzyme and study its antibacterial activity with antibiotic ceftazidime. methods samples collection during a period of two months from september to november, 2017. twenty-five diverse clinical samples, which included: blood, urine and burns, were collected from several hospitals in baghdad – iraq. bacteriological analysis the bacterial diagnosis, including morphological characters and biochemical tests, were done (holt, 1994) the klebsiella spp. isolates were identified by characteristic colonies (mucoid, fermentation of lactose, hemolysis), indole test (-) methyl red test (+) voges – proskauer test (+) citrate utilization test (+) urease (+), followed by the complementary api 20e test that carried out according to directives of the company (biomeriux/france). primary screening for inulinase activity for detecting inulinase production by klebsiella pneumoniae, all k. pneumoniae were cultured in to the inulin agar media, which contained (per liter) the following: inulin 20g as (carbon source), yeast extract agar 20g, mgcl2 0.5g, nh4no3 2g, pepton 2 g, kh2po4 5g and of agar 20g. all components were dissolved in 1 liter of distilled water and ph was adjusted at 7. the mixture was autoclaved at 121ᴏc for 15 min. this medium was used for the screening the capability of bacteria to produce inulinase. after 24 hrs. of incubation periods at 37 ̊c, bacteria showed growth with clear inhibitions zones round bacterial colonies that had measured (jenny et al., 2012). secondary screening for inulinase activity k. pneumoniae isolate was transferred into inulin 20g, yeast extract 20g , mgcl2 0.5g, nh4no3 2g, pepton 2 g, kh2po4 5g, ph fixed at 7. k. pneumoniae isolate put on rotary shaker incubator at 100rpm at 30̊c for 24 hrs. centrifugation had done at 10000 xg for 20 min, cells removed, specific activity and the protein content were checked (angel et al., 2012). assay of inulinase enzyme solution (2 with ml) was incubated 2% of inulin, with citrate phosphate buffer 10 mm and ph 7 at 35 ̊ c for 50 min and then the reaction was terminated by putting reaction 72 global journal of public health medicine 2019, vol 1, issue 2 gggggglo tubes in water bath at 100 ̊c for 10min so that inactivate the reaction of enzyme. after that enzyme was cooled at room temp. then in order to reduce fructose sugar, mixture tested by using method of dns that described by (jenny et al., 2012). by spectrophotometer, reaction was measured at (575 nm) and standardized against the fructose standard. one unit of the enzyme activity was defined as the amount of inulinase needed to produce 1µ mole of fructose from inulin per minute under the standard condition of the assay. estimation of protein content the estimation of total protein content was carried out according to bradford dye method with bovine serum albumin as a standard (bradford., 1976). inulinase purification the selected isolate that secreted inulinase was purified by the method explained by (fawzi, 2011). after incubation, centrifugation had done so cells detached in centrifuge at 10000 rpm for 20 min under cooling conditions. the supernatant which is the crude extract, was precipitated by ammonium sulfate with gradient concentrations saturations (40-80%). the precipitate was dissolved in 5ml of buffer at ph 6.5, the protein concentration was distributed for the measurement of volume and specific activity. determining the minimum inhibitory concentration (mic) ceftazidime was used as antimicrobial against s. aureus and e. coli by using macro dilution method (bharathi et al., 2011). for determining mic, ceftazidime was solved in distilled water for giving 10000 μg/ml of stock concentration, stock concentration of ceftazidime was filtered by millipore filter with 0.22 μm. two fold serial dilutions of ceftazidime were made inside the nutrient broth in order to give the rang of concentrations (1 5000) μg/ml. one hundred microliter of 104 cfu/ml bacterial suspension that consists of s. aureus and e. coli was added to test tubes, separately. 50µl of each dilution entered through the wells of mueller-hinton agar media. the plane tubes and plates put in incubation for 24 hrs at 37°c. lowest antibiotic concentration can inhibit the growth of 50% or more of microorganisms that showing inhibition zone in plates, no growth in tubes, was determined and recorded as minimum inhibitory concentration (mic). determination the interaction between inulinase and ceftazidime a combination between the enzyme and the antibiotic were assayed in the same way mentioned above with s. aureus and e. coli, as 100 microliter of inulinase and the bacterial suspension were added in secluded to two fold serial dilutions of ceftazidime. 50µl of each dilution entered through the wells of muellerhinton agar media. the plane tubes and plates put in incubation for 24 hrs at 37°c. lowest antibiotic concentration can inhibit the growth of 50% or more of microorganisms that showing inhibition zone in plates, no growth in tubes, was determined and recorded as the minimum inhibitory concentration (mic). ethical statement all experiments that included human blood, urine and burns samples, bacterial collection and isolation were ethically approved according to biosafety conditions in biology department college of science -mustansiryiah university iraq and according to the ethics committees in ministry of health, baghdad, iraq results isolation of klebsiella pneumoniae to determine the distribution of k. pneumoniae, twenty-five diverse clinical samples of k. pneumoniae were collected from several hospitals in baghdad – iraq. eight isolates of k. pneumoniae (32%) were gained of 13 k. spp. isolates. k. pneumoniae was assayed and diagnosed through biochemical tests and api 20e test as shown in figure (1). screening the production of nulinase from klebsiella pneumoniae eight isolates of k. pneumoniae were tested and screened for producing the inulinase in agar plates. 5 isolates of k. pneumoniae grew in inulin production medium and showed the inulinase activity. all five isolates of k. pneumoniae were submitted to the next step of screening for producing the inulinase in broth media. results detected that klebsiella pneumoniae k3 was the best inulinase producer as shown in figures (2). inulinase purification klebsiella pneumoniae k3 was selected for inulinase purification by culturing in broth media that contains inulin. table (1) show results of purification. precipitate of the enzyme done by 73 global journal of public health medicine 2019, vol 1, issue 2 gggggglo ammonium sulfate at saturation of 70% from the supernatant with higher specific activity. antibacterial activity of ceftazidime table (2) detected a little antibacterial activity of ceftazidime with the tested isolates. the minimum inhibitory concentration value for. s. aureus was (256 μg/ml) and for e. coli was (1024 μg/ml). furthermore, a mixture of inulinase and ceftazidime detected high activity to the antibacterial to these bacteria. the (mic) of ceftazidime decreased to the (64 μg/ml) for s. aureus and (16 μg/ml) for e. coli. the same results were obtained when agar diffusion method used, since in this method at (16 μg/ml) concentration the diameter of inhibition zone for s. aureus was (19 mm) and at a (64 μg/ml) concentration the diameter of inhibition zone was (22 mm) for e. coli (figure 3 and figure 4). through these result we can prove that g+ve bacteria have more sensitivity than g-ve bacteria in combination of inulinase enzyme and ceftazidime antibiotic by comparison with the control. these results proved that β-lactam antibiotics had increased in the inulinase presence, this will be useful agent for treatment many infections of s. aureus with the β-lactam antibiotics. figure 1: api 20e system for characterization of k. pneumoniae figure 2: diameter of inhibition zone and inulinase activities for k. pneumoniae isolates shows that isolate. k3 was the best inulinase producer. k.pneum oniae k1 k. pneum oniae k2 k. pneum onia k3 k. pneum oniae k4 k. pneum onia k5 74 global journal of public health medicine 2019, vol 1, issue 2 gggggglo table 1: treatments used for inulinase partial purification from k. pneumoniae k3 purification step size (ml) protein concentration (mg/ml) inulinase activity (u/ml) specific activity (u/mg) crud extract 150 112.6 165.8 1.47 (nh4) so4 at 70% 70 34.3 240.7 7.01 table 2: mics (μg/ml) of ceftazidime antibiotic for s. aureus and e. coli strains in tubes and plates with or without inulinase antibiotic bacteria mic for antibiotic alone (μg/ml) diameter of inhibition zone(mm) mic for antibiotic and inulinase (μg/ml) diameter of inhibition zone(mm) ceftazidime e. coli 1024 28 64 22 s. aureus 256 26 16 19 figure 3: (a) diameter of inhibition zones of ceftazidime against e. coli (b) diameter of inhibition zones of ceftazidime and inulinase combination against e. coli figure 4: (a) diameter of inhibition zones of ceftazidime against s. aureus (b) diameter of inhibition zones of ceftazidime and inulinase combination against s. aureus 75 global journal of public health medicine 2019, vol 1, issue 2 gggggglo discussion in this research work, the inuilnase extraction and purification from the bacterium k. pneumoniae is discussed. for the first time klebsiella sp. shows excellent results in the production of inuilnase. inuilnase enzymes must be manufactured either when the substrate is existent with the surrounding medium or in the presence of structurally related compounds to this enzyme (peter & robinson, 2015). the activity of inulinase are various depending on the fermentation conditions (neagu et al.,2012). the results show that the highest inulinase activity is 240.7(u/ml) by precipitate inulinase with ammonium sulfate at saturation of 70% this suggests that the difference in inulinase production may be related to the microbial strain, composition of fermentative media and parameters of the fermentation process. purification of inuilnase from this specious of bacteria are so simple by using the crude extract or precipitation method with using ammonium sulfate. many generations of bacteria were developed a virulence resisting against antibiotics include ceftazidime. so, purified microbial inulinase from k. pneumoniae can be a new biotic medicine (andrea du toit 2018) especially when it is combined with classical antibiotic. conclusion: inulinase is considered as a very important industrial enzyme. therefore the need to produce and purify inulinase from new microbial isolates is required. in this study, we have successfully purified inulinase from klebsiella pneumoniae. the purified enzyme shows a broad spectrum bioactivity against microbial pathogens. ceftazidime antimicrobial activity against bacteria, is increased when a combination between inulinase and ceftazidime had done. references: andrea du toit (2018) bacterial enzymes 'straighten out' antibiotics nature reviews microbiology 16(3):122. doi: 10.1038/nrmicro.2018.19. angel s. j., kavitha c., vidyadharani g., roy p. and dhandapani r. . (2012). isolation of inulinase producing bacteria from sugarcane soil. international journal of applied biology and pharmaceutical technology. 3(4):320326 bharathi, s.; saravanan, d.; radhakrishnan, m.; balagurunathan, r. (2011). bioprospecting of marine yeast with special reference to inulinase production. international j. chem.tech. research. 3 (3):1514-1519. bradford, m. (1976). a rapid and sensitive method for the quantitation of microgram quantitities of protein utilizing the principle of protein dye binding, annal . biochem.72:248254. dilipkumar, d.; rajasimman, d.; and rajamohan, n. (2011).response surface methodology for the optimization of inulinase production by k. marxianus var. marixianus. j. appl. scien. environ. sanit. 6 (1): 85-95. fawzi, e.m. (2011). comparative study of two purified inulinases from thermophile thielavia terrestris nrrl 8126 and mesophile aspergillus foetidus nrrl 337 grown on cichorium intybus l. brazilian j. microbiol. 42: 633-649. gao, l.; chi, z.; sheng, j.; wang, l.; li ,j. and gong, f.(2007). inulinase producing marine yeasts: evaluation of their diversity and inulin hydrolysis by their crude enzymes. microbial ecology. 54:722–729. holt, j.g.(1994). bergey's manual of determinative bacteriology. 2nd ed. vol.2, williams and wilkins. baltimore. jenny, s.; kavitha, c.; vidyadharani, g. ; priya, r. and dhandapanil, r.(2012). isolation of inulinase producing bacteria from sugarcane soil. internat. j. appli. biol. pharmaceut. technol.3 (4):320-326. nascimento, d.; jiunio,v.; fernades,p.; ribero, g.; danyo, m.; and sandra, a. (2012). production, characterization and application of inulinase from fungal endophyte ccmb 328. ann. brazilian acade. scien. 84 (2):443-453. neagu b. c., constantin o. and bahrim g. (2012) increase in extracellular inulinase production for a new rhizoctonia ssp. strain by using buckwheat (fagopyrum esculentum) flour as a single carbon source letters in applied microbiology. doi:10.1111/j.1472765x.2012.03279.x (55) 195–201). peter k. robinson (2015) enzymes: principles and biotechnological applications essays biochem. 59, 1–41: doi: 10.1042/bse0590001 76 global journal of public health medicine 2019, vol 1, issue 2 gggggglo sahin, f.; cakmakci, r. and kantar, f. (2004). sugar beet and barley yields in relation to inoculation with n2-fixing and phosphate solubilizing bacteria. plant and soil.265: 123129. singh, r. s.; chauhan, k.; kennedy, j. f. (2017) a panorama of bacterial inulinases: production, purification, characterization and industrial applications. international journal of biological macromolecules. 96: 312-322 vasaikar, s.; obi, l.; morobe, i. and bisijohnson, m. (2017). molecular characteristics and antibiotic resistance profiles of klebsiella isolates in mthatha, eastern cape province, south africa. int. j. microbiol. 42: 1-7. wang, j.; zhengyu, j; bo, j. and xueming, x. (2003) separation and identification of exo and endoinulinases from aspergillus ficuum. current microbiology 47:109e12. microsoft word gjphm-2022dust.docx 570 global journal of public health medicine 2022, vol 4, issue 1 gggggglo original research the impact of exposure to cement dust on the parameters of oxidative stress among cement plant workers sadeel a. shanshal*, harith kh. al-qazaz department of clinical pharmacy, college of pharmacy, university of mosul *corresponding author: sadeelshanshal@uomosul.edu.iq abstract introduction: working in cement industry exposes the workers to various hazards that could be in some cases life threatening. one such threat is cement dust which can predispose to oxidative stress. this study is a part of larger project to investigate the negative impacts of cement dust and it specifically aims at determining the parameters of oxidative stress in people working in cement plants in comparison to apparently healthy controls. methods: a cross-sectional comparative study design was adopted in this work. four cement factories in nineveh governorate in iraq were included in the study for the period from december 2019 to march 2020. ninety-seven non-smoking healthy workers were compared with 97 apparently healthy controls. oxidative stress was assessed by measuring malondialdehyde (mda) and total antioxidant capacity (tac) in the two groups. results: significantly higher mda mean (6.49 ± 1.75 nmol/ml) was found in the workers group as compared to the controls (4.85 ± 1.36 nmol/ml) with a p-value of less than 0.001. conversely, tac was significantly higher in the control group (16.63 ± 2.99 u/ml) than in the workers (13.12 ± 2.85 u/ml) and the p-value was also less than 0.001. conclusion: cement dust exposure can predispose to oxidative stress by raising mda and decreasing tac exposing the workers to the damaging effects of free radicals. keywords: cement industry, dust, oxidative stress, occupational health 571 global journal of public health medicine 2022, vol 4, issue 1 gggggglo introduction cement is a fundamental ingredient required for the progress and development of nations (rampuri, 2017). the global production of cement is around four billion tons each year; and this cement is used in various construction sites as well as for the production of concrete. the demand for cement and concrete is expected to double in the near future to meet the progress and development requirements of the world (naqi & jang, 2019). in iraq, the industry of cement is a major national industry that contributes significantly to the country’s infrastructure. eighteen cement plants are currently present in iraq, with a production capacity of about 18 million tons per year. only in nineveh governorate, there are 5 cement factories; 3 factories in badosh and 2 in hammam al-alil (icsc, 2019). many people are employed in cement industry which exposes them to various hazards as a result of long-term contact with the dust. all the workers in cement plants are vulnerable to these hazards because cement dust is emitted at different steps of the manufacturing process. probably the most important health hazard is the effect of the dust on the respiratory system (aljeesh et al., 2015). another threat to human health is the potential of cement dust to induce oxidative stress from the prooxidants present in the dust or due to the increased production of free radicals (al salhen, 2014; aydin et al., 2004; malekirad et al., 2019; pournourmohammadi et al., 2008). chromium and aluminum in the dust are known pro-oxidants that may induce lipid peroxidation of different membranes (al salhen, 2014; malekirad et al., 2019; marrocco et al., 2017). the free radicals produced from lipid peroxidation are normally neutralized by antioxidants. when there is an imbalance between the two, oxidative stress occurs which can be a risk factor for many serious and chronic medical conditions such as arthritis, diabetes and cancer (marrocco et al., 2017). in these disease states, there would be either increase in oxidants and/or decrease in antioxidants (moylan & reid, 2007). in osteoarthritis there is a disruption in the hemostasis of cartilage due to increased levels of free radicals which induce oxidative damage and lead to death of chondrocyte (bolduc et al., 2019). diabetic patients suffer from different complications which are mediated by oxidative stress, beside its role in insulin resistance which occur due to glucose oxidation and lipid peroxidation (asmat et al., 2016). moreover, oxidative stress is involved in many aspects of cancer development (liou & storz, 2010). beside the negative impacts of cement on respiratory system and oxidative status, many cancer types may be induced like lung, stomach and colorectal (fatima et al., 2001; pournourmohammadi et al., 2008). the different constituents present in cement have high alkalinity which would be strong irritants for the skin and can lead to varying skin injuries (chung et al., 2007; nunes et al., 2019). eye problems might also occur due to direct contact of cement with the eyes (jayakrishnan et al., 2013). 572 global journal of public health medicine 2022, vol 4, issue 1 gggggglo an indirect method to assess the occurrence of oxidative damage is to measure the lipid peroxidation biomarkers because lipid, and especially polyunsaturated fatty acids, are highly prone to oxidation (cipak gasparovic et al., 2017; rajendran et al., 2014). and because oxidative stress occurs due to an imbalance between the free radicals and antioxidant molecules, assessment of antioxidants is also required (katerji et al., 2019). the peroxidation of polyunsaturated fatty acids leads to the production of malondialdehyde (mda) which is the commonest aldehyde used to assess oxidative damage (ito et al., 2019; rajendran et al., 2014). mda measurement depends on the production of thiobarbituric acid reactive substance which can be easily detected by spectrophotometer (ito et al., 2019; rajendran et al., 2014). total antioxidant capacity (tac) is measured by different analytical methods which depend on the production of a colored substance that can also be detected by spectrophotometer at a specific wave length (pisoschi & negulescu, 2011). jasim et al. (jasim et al., 2012) conducted a study in iraq which measured oxidative stress parameters (mda and an enzymatic antioxidant) among cement workers in kufa. they reported a significant increase in mda among workers with no significant variation in antioxidant levels. al-hayali (al-hayali, 2009) conducted another study in iraq, which aimed to assess oxidative stress parameters. the author found a statistically significant reduction in the antioxidant glutathione among cement workers in contrast to mda which was significantly higher. however, the total antioxidant capacity was not measured in those two studies (al-hayali, 2009; jasim et al., 2012). although there are no accurate statistics about the numbers of people working in cement factories in iraq, they are estimated by thousands. because such workers constitute an important fraction of the society, and due to the numerous health hazards associated with cement dust exposure, a project was initiated to investigate the specific effects of the dust on spirometric and oxidative stress parameters in cement plant workers in nineveh, iraq. this particular part of the project focuses on oxidative stress parameters in the workers and how they compare to healthy people. the effects of the dust on the lungs and the correlation between the spirometric parameters and those of oxidative stress in the workers have already been published (shanshal & al-qazaz, 2020a, 2020b; shanshal & al-qazaz, 2021). methods: details of the methods employed in this project are available in our previously published papers (shanshal & al-qazaz, 2020b; shanshal & al-qazaz, 2021). briefly, a cross-sectional comparative study design was applied on workers from four cement factories in nineveh from december 2019 to march 2020. appropriate approvals were obtained from the central ethical committee at nineveh health directorate (reference number 34777 in 16/12/2019) and from directorate of the northern cement cooperation (reference number 6936 in 17/11/2019). consents from participants were also obtained. all workers from the four factories who are in direct contact with cement dust were asked to participate in the study. ninety-seven non-smoking males constituted the final workers group and were matched with 97 apparently healthy non-smoking male volunteers. subjects of the control group were employees in the directorate of agriculture, college of dentistry and college of pharmacy in mosul. 573 global journal of public health medicine 2022, vol 4, issue 1 gggggglo being older than eighteen years, having service duration of more than one year and working in the milling or packaging sections of the factories were the inclusion criteria for the workers group. chronic conditions such as hypertension, diabetes or gout and using antioxidant supplements were considered exclusion factors. five millilitres of blood were taken from each participant using disposable syringes. a gel tube was used to allow clotting of the blood for half an hour at room temperature. after centrifugation at 3,000 rpm for 10 minutes, serum was collected to be used for the assessment of oxidative stress parameters (mda and tac) and kits from elabscience® (texas, usa) were used. the mda in the serum reacts with thiobarbituric acid in the kit to produce a red compound which can be detected by spectrophotometer at 532 nm. on the other hand, tac is detected by the formation of stable-colored complexes resulting from the reduction of fe3+ to fe2+ in the kit by the antioxidants in the serum. these colored complexes can be measured spectrophotometrically at 520 nm. statistical analysis: statistical package for social science from ibm (spss, version 25) (ibm corp., armonk, ny, usa) was used for processing and analyzing the data. a p-value smaller than 0.05 was taken to be significant. differences in continuous variables between workers and controls were assessed by independent samples t-test. the relationships between oxidative stress parameters were determined by calculating the pearson’s correlation coefficient. 574 global journal of public health medicine 2022, vol 4, issue 1 gggggglo results: at the start, 105 workers attended an interview to participate in the study. of these, 8 workers were eliminated due to their refusal of blood donation leaving 97 workers to constitute the final group for the workers. the control group consisted of 97 apparently healthy subjects who agreed to take part in the study. as a result, the workers' response rate was 92 percent, whereas the controls' response rate was 100 percent. socio-demographic characteristics of the participants are detailed in our previous paper. in short, the differences in the socio-demographics between the two study groups were non-significant as shown by independent sample t-test (p-value > 0.05) indicating that the two groups were matched (shanshal & al-qazaz, 2020b; shanshal & al-qazaz, 2021). table1 summarize these socio-demographic characteristics. table 1: socio-demographic characteristics of the workers and controls, adapted from (shanshal & al-qazaz, 2021). variable workers (n=97) controls (n=97) t-test* p-value age mean ± sd 39.46 ± 9.51 38.24 ± 8.54 0.945 0.346 height mean ± sd 172.11 ± 8.05 174.14 ± 6.07 1.983 0.06 weight mean ± sd 83.21 ± 15.4 85.22 ± 12.95 -0.984 0.326 bmi mean ± sd 28.07 ± 4.85 28.14 ± 4.31 -0.105 0.916 *independent samples t-test with regard to the measured oxidative stress parameters in the two study groups, significant difference was found between the means of mda with a higher value in the workers group (6.49 ± 1.75 nmol/ml in the group of workers versus 4.85 ± 1.36 nmol/ml in the healthy controls). conversely, the level of tac was significantly higher in the controls than in the workers (16.63 ± 2.99 u/ml in the controls versus 13.12 ± 2.85 u/ml in the workers). these statistical differences are presented in table 2. significant positive statistical correlation was found between mda and the age of the workers. no other significant correlation was obtained (table 3). table 2: differences in oxidative stress parameters between the study groups variable workers (n=97) controls (n=97) t-test* p-value mda (nmol/ml) mean ± sd median (iqr: 25-75) 6.49 ± 1.75 6.20 (4.96-7.89) 4.85 ± 1.36 4.58 (4.05-5.3) 7.273 ˂0.001§ tac (u/ml) mean ± sd median (iqr: 25-75) 13.12 ± 2.85 12.95 (11.16-14.98) 16.63 ± 2.99 16.28 (14.43-18.38) -8.336 ˂0.001§ *independent samples t-test 575 global journal of public health medicine 2022, vol 4, issue 1 gggggglo table 3: correlations between age and oxidative stress parameters in the study groups variable age (workers) age (controls) r* p-value r* p-value mda 0.263 0.009§ -0.044 0.668 tac 0.154 0.132 -0.089 0.385 *pearson correlation discussion: an increase in the generation of reactive oxygen species brought about by exposure to cement dust can result in oxidative stress (malekirad et al., 2019) and this was confirmed in this study. an appropriate matching between the workers and the controls was achieved in this study in terms of numbers included and the socio-demographics. this was evident from the lack of significant differences between the two groups in the matching criteria. this matching was lacking from other similar studies carried out in iraq (al-hayali, 2009; jasim et al., 2012) and libya (al salhen, 2014) where groups which were not matched or had different numbers of participants were employed. working in the milling or packaging departments and being directly subjected to the dust were important inclusion criteria in our study for the workers group, while working away from cement plants and being healthy constituted the criteria for the control group. similar criteria were applied in egypt (hakim et al., 2018) and palestine (aljeesh et al., 2015). however, studies carried out in iran (malekirad et al., 2019; omidianidost et al., 2019; rafeemanesh et al., 2015) used office employees from the same factory as the control group whereas those directly exposed to the dust comprised the worker group. the average of the workers’ age in this study (39.46 ± 9.51) was lower than that in studies conducted in congo (46.5 ± 9.6) and greece (47 ± 19) (mbelambela et al., 2018; rachiotis et al., 2018), but higher than the mean age in an iranian study (35.73 ± 7.3) (omidianidost et al., 2019). the average of the duration of employment was 15.4 years for the workers in the current study compared to 24.34 years recorded in a study by hakim et al. (2018) in egypt. primary education was prevalent among the workers in the present study (55.7%) while secondary and university education had lower percentages (28.9% and 15.4% respectively). in contrast, the workers in a nigerian study were mainly tertiary educated (musa et al., 2012). significant differences between the workers and the controls in the measured oxidative stress parameters were observed in the current study, with higher mda in the workers and higher tac in the controls. similarly, higher mda levels in the workers was reported in iran (afaghi et al., 2015), iraq (alhayali, 2009; jasim et al., 2012), in libya (al salhen, 2014), in egypt (elhosary et al., 2014) and in turkey (orman et al., 2005). for tac, pournourmohammadi et al. (2008) reported comparable result with higher mean in the control group. some studies, (al salhen, 2014; elhosary et al., 2014; jasim et al., 2012), assessed individual antioxidant components of the serum rather than measuring the total antioxidant capacity, and they still reported results which are comparable to ours. there were, however, some studies that failed to report any difference in antioxidant activity such as those conducted by malekirad et al. (2019) and afaghi et al. (2015). since the workers and the controls in the current study 576 global journal of public health medicine 2022, vol 4, issue 1 gggggglo were matched for socio-demographic characteristics, these significant differences in mda and tac that favors oxidative stress can only be attributed to cement dust exposure. the positive correlation between the age and mda in the workers was in agreement with a study conducted in egypt (elhosary et al., 2014). the lack of significant correlation between age and mda in the controls probably indicates that the positive correlation seen in the workers was due to longer contact with cement dust rather than just the older age. oxidative status can be affected by a variety of factors such as lifestyle and living conditions. taking these factors into account should be considered in future works. limitation of the study diet can have an important effect on oxidative status, and this was not evaluated in the study. nonetheless, this study aimed at assessing the parameters of oxidative stress and test how they compare between cement workers and healthy subjects. conclusion exposure to cement dust exposure can negatively affect health, one mechanism could be increasing mda and decreasing tac in the exposed workers. acknowledgment the authors are thankful for the participating cement plants and the directorate of the northern cement corporation for the facilities presented in conducting this study. the authors would also like to thank the university of mosul, represented by the college of pharmacy for their support. conflicts of interest the author declares no conflicts of interest. references • afaghi, a., oryan, s., rahzani, k., & abdollahi, m. 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(2021). consequences of cement dust exposure on pulmonary function in cement factory workers. american journal of industrial medicine, 64(3), 192–197. microsoft word gjphm-2022 renal stones.docx 631 631 global journal of public health medicine 2022, vol 4, issue 2 gggggglo original research epidemiological study of risk factors of renal stones formation among patients attending in block phc-thanjavur district d. ramprakash1* d. arunachalam2 shanmugha priya1 g. subash chandrabose1 1department of community medicine, thanjavur government medical college, thanjavur, tamil nadu, india. 2 department of community medicine, aarupadai veedu medical college and hospital, puducherry, india. *corresponding author:subashstat@gmail.com abstract introduction: urolithiasis is the third most common and painful disease in the globe, afflicting both men and women. the accumulation of a few minerals and crystalline elements in the renal calculi and urinary bladder are during the process of metabolism. the study's goals were to determine the frequency of risk variables for urinary stone patients. methods: across-sectional study had on urinary stone disease in thanjavur and the surrounding areas. the study included 102 cases, 79 urinary stone patients, and 23 normal patients that all lived in the same area. results: a total of 102 participants between the ages of 20 70 were studied. thirty-eight percentages of urinary stone patients were over 60 years old. in this study, men accounted for 63 %. it was discovered that kidney stone patients were more prevalent in the age groups 41-70 (77%) and <40 (23%), which was statistically significant (15.5±20.51; p=0.01). patients with lower education levels (56%) and patients from lower-income areas were found. the non-veg food intake status showed a higher proportion of kidney stone patients with control (68% vs. 13%), which was statistically significant (36.06±28.5; p = 0.005). conclusion: this study confirms that the urinary stone formation may be due to the various environmental factors. the significant associated with the risk factors between control and urinary stone patients were found. the high burdens of urinary stone formation were observed and their associations of socio-demographic behavioral risk factor and the results have been discussed. keywords: urinary stone; epidemiology, rural population, risk factors. 632 631 global journal of public health medicine 2022, vol 4, issue 2 gggggglo introduction: urolithiasis is the third most prevalent and widespread disease, affecting a vast number of people of all ages and genders (ghosh et al., 2009; knoll, 2007). urinary stone disease is a serious disabling issue that affects about 12% of the world's population. disease frequency is increasing as a result of changing lifestyles, food choices, and global warming (diana & george, 2013). stone formation is influenced by both hereditary and environmental factors. urolithiasis affects around 20% of the population in most industrialized countries (marickar et al., 2009; taylor et al., 2004). urolithiasis affects roughly 2 million persons in india each year, with a lower incidence in southern india (girija et al., 2007).urinary stone composition in india differs from that in western countries, with calcium oxalate being the most common component. urinary stones can contain a variety of mineral combinations. the most painful and common urological problem of the urinary system is the formation of urinary stones (davidson et al., 2005). the most prevalent urinary disease ailment, urinary calculi, is caused by a variety of reasons including metabolic disorders, dietary variables, bacterial infections, and environmental conditions (kumar et al., 2006). male patients are usually more vulnerable than female patients. in a 5:2 ratio, men and women are impacted with urinary calculi illness at some point in their lives. men between the ages of 40 to 70 are more likely to get kidney stones (sharma & filler, 2010). silberstein et al., (2010) have reported that obesity and weight gain have been linked to a higher risk of stone development. there may be a relationship between fat tissue, insulin resistance, and urine composition. larger bodies produce more calcium and uric acid, increasing the risk of kidney stones. men with kidney stones were more than three times as likely as non-stone-formers to have a family history of stones.kidney stone incidence appears to be rising in the general population, as does the medical expenditure associated with this disease (stamatelou et al., 2003). risk factors connected with kidney stones are different among various populace gatherings and natural elements play a vital part in their pathogenesis (parvin et al., 2021). research on urological patients has shown that the rate of kidney stones can be related with sex, race, geo-realistic area, occupation, sweltering environment, positive family ancestry, unfortunate eating routine (over the top admission of caffeine, salt, dairy items, creature proteins and fat), smoking, liquor utilization, actual work, weight, low liquid admission, lack of hydration financial status (sofia et al., 2016), training, water quality, high admission of nutrients d and c, hereditary foundation and comorbid metabolic problems (diabetes mellitus, hypertension, chronic kidney infection, and cardiovascular infection) (safarinejad, 2007; salmeh et al., 2012). urolithiasis epidemiology varies depending on geographical location and historical time. the incidence and kind of lithiasis, as well as the location and composition of urinary stones, have changed as socioeconomic conditions have improved. around 80% of stones in most developed countries are calcium salts, which are most typically calcium oxalate and less commonly calcium phosphate (apatite or brushite). uric acid, struvite or carbonate apatite, cystine, and unusual stones make up the remaining 20% of stones (daudon et al., 1995).the study's goals were to assess the prevalence of risk factors for urinary stone patients in rural areas of tamilnadu, india. 633 631 global journal of public health medicine 2022, vol 4, issue 2 gggggglo methods a total of 102 patients of were studied in the thanjavur area looked at the prevalence of risk variables for urinary stone patients. the research was carried out in the rural field practice area of block phc thanjavur, tamilnadu, india. this research took place for six months, from november 2021 to april 2022. a cross-sectional quantitative design was used by the researcher. this study included 23 seemingly healthy participants (15 men and 8 females) who were clinically examined by expert doctors as controls. those individuals were chosen at random from the general population. the following was the epidemiological distribution of those subjects: all subjects enrolled in this study, including their residence (15 urban and 8 rural areas), marital status (12 married and 11 single), economic status (4 good, 9 medium, and 10 low levels), and educational level (4 high educations, 19 low educations). details of the survey included age, sex, marital status, family financial status, educational status, residence region (urban/rural), smoking habit, food habit, and past history of kidney stone and heredity of kidney stone infection. these subtleties were gotten by clinical officials working the separate emergency clinics and preceding review assent was acquired from all study subjects. the controls were volunteers, comparable financial and segment attributes. the workers were from a similar segment locale without any set of experiences of kidney stone disease. the strategy for talking was painstakingly normalized with the goal that the expected data could be gotten and deciphered in a uniform manner. to some extent filled in poll from the members were rejected from this review. a similar survey was utilized for the two cases and controls. statistical analysis the statistical analysis was carried out using the spss 20.0 software program. the average and standard deviations were calculated. analysis of variance was used to examine the data (anova). statistical significance was defined as a probability level (p-value) of less than 0.05. all values were reported as means±sd. to examine the differences between one group (urinary stone patients) and another, the anova test was used (healthy people). results the study comprised 102 patients with urinary stones (aged 45±18.7 years), with ages ranging from 20 to 70 years. thirty eight percentages of urinary stone patients were over 60 years old. males accounted for 63% of the sample, while females accounted for 37%. in terms of where they lived, 20 (28%) were urban patients and 52 (72%) were rural patients. males outnumbered females by 78% to 22% among 23 healthy persons. patients with kidney stones were seen in 72% of urban areas and 28% of rural areas. table 1 shows the prevalence of kidney stone patients and a control study in response to various parameters. in rural areas account for 15 of the 23 healthy persons, while urban areas account for eight. the distribution of urinary stone patients is based on education, with 35 patients having a high level of education and 44 having a low level of education. four of the 23 634 631 global journal of public health medicine 2022, vol 4, issue 2 gggggglo healthy people have a high education level, whereas the other 19 have a low education level. it reveals the marital status-based distribution of urinary stone patients. there are 55 married patients and 24 unmarried patients. twelve of the 23 healthy persons are married, while 11 are single. it depicts the socioeconomic distribution of urinary stone patients. the 30 patients have good stones, 22 have medium stones, and 27 have low stones. 4 persons are good, 9 are medium, and 10 are low out of 23 healthy people. the bulk of patients (78%) used tap water, whereas only 22% used bore well water. there are 50 smokers and 29 non-smokers among the patients. they show the distribution of urinary stone patients dependent on whether or not they use alcohol. there are 25 daily drinkers among the 79 patients, 38 weekly drinkers among the 38, and 16 monthly drinkers among the patients. table 1: factors associated with the prevalence of urinary stone patients and control study. parameters urinary stone patients (n=79) normal patients (n=23) mean ± sd ‘p’ value number % number % gender male 50 63 18 78 15.5±20.51 0.001s female 29 37 5 22 8±7.07 age in years 0.001s 20-30 8 10 8 35 - 31-40 10 13 6 26 8±2.83 41-50 18 23 5 22 11.5±9.19 51-60 13 16 3 13 8±7.07 61-70 30 38 1 4 15.5±20.51 residence 0.025s rural 52 72 15 65 32.5±24.75 urban 20 28 8 35 18.5±14.85 education 0.000s high education levels 35 44 4 17 19.5±21.92 low education levels 44 56 19 83 31.5±17.68 marital status 0.027s married 55 70 12 52 33.5±30.41 unmarried 24 30 11 48 17.5±9.19 economic status 0.009s good 27 34 4 17 17±18.38 medium 22 28 9 39 15.5±9.19 low 30 38 10 44 18.5±12.02 genetics of stone disease yes 12 15 nil nil --- 635 631 global journal of public health medicine 2022, vol 4, issue 2 gggggglo no 67 85 nil nil - 0.005s drinking water tap water 62 78 06 26 39.59±34 bore well 17 22 17 74 - food habit vegetarian 25 32 20 87 22.5±3.53 non-veg 54 68 03 13 36.06±28.5 smoking habit smoker 50 63 nil nil - non smoker 29 37 nil nil alcohol intake - daily drinkers 25 32 nil nil weekly drinkers 38 48 nil nil - monthly drinkers 16 20 nil nil ssignificant; ns-not significant. p<0.05 level of significant. discussion it observed that the urinary stone infection were higher in the age group of >60 (38%) and lower <20 (10%) which was statistically significant (15.5±20.51; p=0.001) (huang et al., 2013; parvin et al., 2021). the majority of male 63% than female were representing 37% of the sample which was statistically significant (15.5±20.51; p=0.001) (stamatiou et al., 2006). the rural urinary stones patients were (32.5±24.75; p=0.025) in higher than urban area (18.5±14.85; p=0.025) as compared with the healthy people, which is further compared with the control values (yanagawa et al., 2007). the education status showed a higher proportion of stone patients with control (44% vs. 17%; 19.5±21.92; p = 0.000) and a lower proportion (56% vs. 83%; 31.5±17.68) were observed (wang et al., 2017). the married patients (33.5±30.41; p=0.027) were infected with urinary stone diseases than unmarried (17.5±9.19; p=0.027) as compared with the control study (sas et al., 2010). the good economic status of stone patients with control (38% vs. 17%; 17±18.38; p = 0.009) and a lower status of (34% vs. 44%; 18.5±12.02) were presented (daudom et al., 2004). the non-veg food intake status showed a higher proportion of kidney stone patients with control (68% vs. 13%; 36.06±28.5; p = 0.005) and veg food intake status showed a lower proportion of kidney stone patients with control (32% vs. 87%; 22.5±3.53; p=0.005) were observed. the non-veg food intake is associated with a higher risk of stone formation. the value of 63% (50/79) smokers and 37% (29/79) non-smokers had urinary stone infection (prakash et al., 2019; merlin et al., 2019). daily drinkers (32%) were two times more likely than monthly drinkers (20%) to have urinary stone infection. high fluid intake is associated with a lower risk of developing kidney stones in men and women (prakash et al., 2019). between urinary stone patients and controls, a probability level (p-value) of larger than 0.05 is considered statistically insignificant. when compared to healthy people, investigations of risk factors for urinary stone patients have dominated. 636 631 global journal of public health medicine 2022, vol 4, issue 2 gggggglo conclusion in conclusion, the prevalence of urinary stone disease increases among various risk factors due to gender, age, diet, environmental factors, geographical location, climate and lifestyle. the prevention of growth of risk factors for urinary stone diseases can be achieved by rising health awareness programs focusing essentially on reducing alcohol consumption, restrict sodium, reduce protein intake and metabolic risk factors. the most important dietary recommendations for calcium stone risk are to increase fluid intake. the high burden of urinary stone formation were observed and their association of socio-demographic behavioral risk factors. conflicts of interest the author declares no conflicts of interest. references • daudom, m., dore, j.c., jungers, p., & lacour, p. (2004). changes in stone composition according to age and gender of patients: a multivariate epidemiological approachurol. res., 32(3): 241-7. • davidson, m.t.m., batchelar, d.l., & velupillai, s. (2005). laboratory coherent-scatter analysis of intact urinary stones with crystalline composition: a tomographic approach. phy. med. bio., 50: 3907-3925. • diana, k.j., & george, k.v. j. (2013). urinary stone formation: efficacy of seed extract of ensetesuperbum (roxb.) cheesman on growth inhibition of calcium hydrogen phosphatedihydrate crystals. crys. growth, 363: 164-170. • ghosh, s., basu, s., chakraborty, s.j., & mukherjee, a.k. (2009). structural and microstructural characterization of human kidney stones from eastern india using ir spectroscopy, scanning electron microscopy, thermal study and x-ray rietveld analysis. appl. crystall., 42: 629-635. • girija, e.k., kalkura, s.n., & sivaraman, p.b. (2007). investigations on the crystalline components of urinary stones. j. sci. indu. res., 66: 632-639. • huang, w.y., chen, y.f., carter, s., chang, h.c., lan, c.f., & huang, k.h. (2013). epidemiology of upper urinary tract stone disease in a taiwanese population: a nationwide, population based study. the journal of urology, 189(6): 2158-2163. • knoll, t. (2007). stone disease. european urology supplements., 6: 717-722. • kumar, n., singh, p., & kumar, s. (2006). physical, x-ray diffraction and scanning electron microscopic studies of urolithsind. j. biochem. biophy., 43 (4): 226-232. • marickar, y.m., lekshmi, p.r., varma, l., & koshy, p. (2009). optical microscopy versus scanning electron microscopy in urolithiasis. urol. res., 37: 293-297. • merlin, k.k., shalini, g.n., & janet, p.d. (2019). int. j. of caring sciences. 12: 1193-1202. • parvin k , zahra j, tabandeh s , ali e , maryam m, amir m , fatemeh a, alireza n. bmc urol., 2021; 21:141-149. • prakash, r. (2019). prevalence and sociodemographic status on kidney stone patients in thanjavur district, tamil nadu, india. int. j. commu. med. pub. health, 6(5): 1943-1947. • safarinejad, m.r. (2007). adult urolithiasis in a population-based study in iran: prevalence, incidence, and associated risk factors. urol res., 35(2):73–82. • salmeh, f., yaghoubi, t., zakizadeh, m., yaghoubian, m., & shahmohammadi, s. (2012). evaluation of health behaviours in patients with kidney stones in sari/iran. int j urol nurs., 6(1):17–21. • sas, d.j., hulsey, t.c., shatat, i.f., & orak, j.k. (2010). increasing incidence of kidney stones in children evaluated in the emergency department. journal of pediatrics, 157: 132– 137. 637 631 global journal of public health medicine 2022, vol 4, issue 2 gggggglo • sharma, a.p., & filler, g. (2010).epidemiology of pediatric urolithiasis. indian j urol., 26(4): 516-522. • silberstein, j.l, millard, f., mehrazin, r., kopp, r., bazzi, w., diblasio, c.j., patterson, a.l., downs, t.m., yunus, f., & kane, c.j. (2010). feasibility and efficacy of neoadjuvant sunitinib before nephron-sparing surgery. bju int., 106(9): 1270-1276. • sofia, n.h., walter, t.m., & sanatorium, t. (2016). prevalence and risk factors of kidney stone. glob j res anal. 5(3): 183–7. • stamatelou, k.k., francis, m.e., & jones c.a. (2003). time trends in reported prevalence of kidney stones in the united states: 1976–1994. kidney int., 63: 1817-1823. • stamatiou, k.n., karanasiou, v.i., lacroix, r.e., & kovouras, n.g. (2006). j. rural and remote health res., 21: 1-9. • taylor, e.n., stampfer, m.j., & curhan, g.c.j. (2004). dietary factors and the risk of incident kidney stones in men: new insights after 14 years of follow-up. ame. soc. nephrol., 15: 32253232. • wang, w., fan, j., huang, g., li, j., zhu, x., tian, y., & su, l. (2017). prevalence of kidney stones in mainland china: a systematic review. scientific reports, 7(1): 1-9. • yanagawa, m., kawamura, j., onishi, t., soga, n., kameda, k., & sriboonlue, p. (2007). int. j. urol. 2007; 4(16): 537-40. microsoft word gjphm-2022 otitis media.docx 656 global journal of public health medicine 2022, vol 4, issue 2 gggggglo original research chronic suppurative otitis media complications scenario during covid 19 pandemic raghvendra singh gaur ¹ , swati chandel 2 , chhavi gupta 3 1 department of ent & head-neck surgery, brlsabvm mc, rajnandgaon, cg,.india 2 ent centre, rajnandgaon, cg,india 3 department of ent gautam buddha medical college, jhajhra, dehradun. india. *corresponding author: dr.raghu007@gmail.com abstract introduction: in december 2019, world health organisation (who) declared corona virus disease (covid 19) led to disruption in routine and non-emergency medical facilities. this increased the morbidity risk associated with some of the preventable conditions, one of them being chronic suppurative otitis media (csom). methods: retrospective data was collected between march’s 20192021 in the department of ent and head neck surgery, brlsabvm medical college, rajnandgaon, cg,.india.. all chronic otitis media patients with or without complications were included results: in our study the number of complicated cases which were 30 patients out of the 402 patients, the rate comes out to be 7.4%. in this study, before the pandemic that is form march 2019 to march 2020 the percentage of complicated cases were found to be 7 (23.6%) and during the pandemic that is from april 2020march 2021 it was 23(76.3 %) that shows increase in number of complications during pandemic. most common age group involved was 21 to 40 years. the most common extra cranial complication was mastoid abscess (36.6%), followed by facial nerve palsy (fnp) 20% the most common intracranial complication was meningitis (16.6%) followed by brain abscess (6.6%) and extradural abscess (3.3%). conclusion: in our study we could find that there was a change in csom behaviour in terms of complications in prepandemic and pandemic period. study shows rise in complication rate from 7 cases during the prepandemic times to 23 cases during pandemic times. this shows the importance of timely intervention which should be available to treat common diseases like csom to avoid the possible complications and their sequelae. keywords: chronic supportive otitis media, covid-19 pandemic, complications. 657 global journal of public health medicine 2022, vol 4, issue 2 gggggglo introduction in december 2019, world health organisation (who) declared corona virus disease (covid-19) pandemic (later on india government did so in march 2020) which led to disruption in routine and nonemergency medical facilities. this increased the morbidity risk associated with some of the preventable conditions; one of them being chronic suppurative otitis media (csom). it is characterised by recurrent discharge over 2 to 6 weeks due to inflammation of middle ear cleft and permanent perforation syndrome. .csom can lead to extra cranial and intracranial complications, and these complications are more common in unsafe type of csom compared to the safe type csom because of the associated cholesteatoma which has bone eroding capacity. the most common organisms associated with csom are pseudomonas aeruginosa and staphylococcus aureus. pseudomonas aeruginosa is more commonly associated with bony necrosis which causes complications in csom (verhoeff m et al 2006).extra cranial complications are acute mastoiditis, labyrinthitis, facial nerve paralysis and different types of abscess in relation to middle ear cleft. intracranial complications are meningitis, brain abscess, lateral sinus thrombophlebitis and otitic hydrocephalus etc (harker la et al 2003). the routes of spread of extra cranial and intracranial complications include thrombophlebitis of venules of adjoining cranial bones, bone erosion by pressure, bone necrosis by enzymatic actions, preformed pathways and hematogenous spread (yorgancılar e et al 2013). the prevalence of csom in india is 7.8% (who 2012). if not treated timely, accurately and properly, it can lead to several complications. these complications are more common in developing countries because of low socioeconomic status, poor hygiene, scarcity of health infrastructure etc. though the frequency has reduced from 20% in 1938 to 2.5% in 1948 to current 0.7 to 3.2% worldwide (abada rl et al 2009). this study is based on the change in rate of complications of csom before and during pandemic for which data was analysed. methods retrospective data was collected between april 2019 to march 2021 in the department of ent and head neck surgery, brlsabvm medical college, rajnandgaon, cg,.india. patients were selected based on the clinical features and otoscopy on outpatient basis. the demographics, chronological distribution, symptoms, complications were assessed and analysed. in this study all csom patients with or without complications were included, and patients with other conditions like acute otitis media, other infective conditions and not willing to take part were excluded. patients were evaluated clinically and routine investigations were done along with pure tone audiometry, and radiological studies. complications of csom were studied as extracranial (ec) and intracranial (ic) complications. data was evaluated using percentages and was compiled on ms excel spreadsheet. 658 global journal of public health medicine 2022, vol 4, issue 2 gggggglo result during the period from april 2019 to march 2021, 402 patients presented to otorhinolaryngology department were diagnosed with csom out of which 30 (7.5%) patients were diagnosed with one or other complications. male to female ratio was 1.15. table i depicts the patients with complications of chronic otitis media ranged from 6 to 52 years of age. the complications were more in age group between 31 to 40 years. figure 1 showing age distribution of the cases figure 2: total number of csom complications no. of complicated cases from march 2019-2021 april 2019march 2020 april 2020march 2021 659 global journal of public health medicine 2022, vol 4, issue 2 gggggglo in this figure ii out of the 30 cases diagnosed with complicated csom, 23 (76.6%) happened during pandemic, rest 7 (23.3%) happened before pandemic, this trends is of increasing type compared to the non-pandemic duration. table 1 extra and intracranial complications complications no. of patients percentage (%) extracranial mastoid abscess 11 36.6 labyrinthitis/labyrinthine fistula 5 16.6 fnp 6 20 petrositis 0 0 intracranial lateral thrombophlebitis 0 0 meningitis 5 16.6 brain abscess 2 6.6 extra dural abscess 1 3.3 otitic hydrocephalus 0 0 total 30 figure 3 : showing intracranial complication of csom 660 global journal of public health medicine 2022, vol 4, issue 2 gggggglo figure 4: showing extra cranial complication of csom in figure iii and iv, the most common extracranial complication was mastoid abscess (36.6%), followed by fnp (20%) and the most common intracranial complication was meningitis (16.6%) followed by brain abscess (6.6%) and extradural abscess (3.3%). figure 5: extra cranial and intracranial complications trends in time line. 0 2 4 6 8 10 12 14 2019 2020 2021 ecc icc 661 global journal of public health medicine 2022, vol 4, issue 2 gggggglo from the figure v it is clear that there is increase in number of both extra and intracranial complications of csom during covid pandemic. either extra cranial or intracranial or both complications occurred in 30 patients and majority of complication happened during pandemic duration. table 2: symptomatology of complicated csom. symptoms no. of patients percentage (%) otorrhea 30 100 headache 6 20.0 decreased hearing 13 43.3 meningeal sign 6 20.0 fever 17 56.6 vertigo 8 26.6 postauricular swelling 12 40.0 facial nerve paralysis 6 20.0 patients presented with main complaint of otorrhoea (100%)which was foul smelling, scanty, occasionally blood stained and aggravated at the time of upper respiratory tract infections, fever (56.6%) second most common symptom which was mild to moderate degree and in few cases it was high, some patients also had chills and rigor associated with it, decreased hearing was present in 43.3% patients, may be because the patient was not aware or was habitual to the decreased hearing and was more worried about complications associated with it, followed by other complications. following is the table (table iv) showing the complications in safe as well as unsafe type. table 3 extra and intra cranial complication of csom complications mucosal disease squamous disease extracranial mastoid abscess/mastoiditis 2 9 labyrinthine fistula/labyrinthitis 0 5 facial nerve paralysis 2 4 intracranial lateral thrombophlebitis 0 0 sigmoid sinus abscess 0 0 meningitis 1 4 brain abscess 0 2 extradural abscess 0 1 otitic hydrocephalus 0 0 total 5(16.6%) 25(83.3%) 662 global journal of public health medicine 2022, vol 4, issue 2 gggggglo discussion in csom, pathology occurs in middle ear cleft which may be safe that is mucosal typeor unsafe which is squamous type. though the incidence of the safe type csom in general public is more compared to the unsafe type, but the percentage of the complications is less in mucosal type that is 16.6% to that of squamous type that is 83.3%.the reason behind more complications in unsafe ear is presence of cholesteatoma with granulations which has the potential to erode the bones by proteolytic enzymes before the covid pandemic started in december 2019, all the medical facilities were available and all the conservative treatment facilities were given timely but as the pandemic started in 2020, there was lockdown leading to the disruption in transportation and medical facilities and the medical attention was shifted to treat the increasing burden of the covid patients leading to the delay in medical care for other conditions. in our study, the following findings were made out ,more commonly involved group with complications was young and middle aged that to males more than females.the other studies also suggested the same findings like (abada rl et al 2009) and (sharma n et al 2015). symptomatically, the most frequent symptoms of patients were otorrhea, fever and hearing loss.before the pandemic that is form april 2019 to march 2020 the percentage of complicated cases were found to be 23.6% and during the pandemic 76.3 %, shows increase in number of complications.in our study if we talk about the number of complicated cases which were 30 patients out of the 402 patients, the rate comes out to be 7.4% which is comparatively higher with respect to other study like (mustafa a et al 2008). may be because complications have increased in pandemic duration approximately three times compare to prepandemic making it 7.4 %. according to the pathology, 83.3% complications occurred in cholesteatoma patients and 16.6% in mucosal ear diseases (abada rl et al 2009) and (kangsanarak j et al 1993). the mastoid abscess was most common extracranial complication (36.6%) which may be due to the blockage of the aditus, leads to empyema in mastoid process. this empyema may erode the outer cortical bone of mastoid process leading to formation of post auricular mastoid abscess or fistula. in one study, (dubey et al 2010) found a correlation of the intracranial complication with the mastoid abscess. it stated that since the pus is getting accumulated or drained in subperiosteal abscess or fistula which leads to the reduction of pressure in middle ear cleft, so chances of intracranial spread is less.according to data next most common complication was facial nerve paralysis in this study which was present in 20 % cases. this facial nerve paralysis incidence varies from study to study (osma et al 2000) found 12.8% facial nerve paralysis (kangsanarak et al 1993) found 58% facial nerve paralysis cases. most common intracranial complication was meningitis which was 16.6% but meningitis incidence varied from study to study like (osma et al 2000) and (yorgancilar e et al 2013).as per the literature there are many more complications associated with csom like different types of abscesses like sigmoid sinus thrombosis, subdural abscesses, space occupying cp angle abscess. but in our study, none was reported as super speciality facility was yet to be started. 663 global journal of public health medicine 2022, vol 4, issue 2 gggggglo conclusion in this we could find that there was a change in csom behaviour in terms of complications in prepandemic and pandemic period. study shows rise in complication rate from 7 cases during the prepandemic times to 23 cases during pandemic times. this shows the importance of timely intervention which should be available to treat common diseases like csom to avoid the possible complications and their sequelae. all sorts of complications which were reported in our study increased, that is extracranial as well as intracranial complications. the probable reasons being, during the pandemic, multiple lockdowns hampered the transport facilities, economically jobs were less to make up for the expenditure for the investigations and treatment. also, because of the novel disease the priority has been shifted to this pandemic management, also health resources were overburdened. since our study was done at a new setup and sample size was low, further studies warranted to assess the real relationship with bigger sample size at larger scale and at different centres. conflicts of interest the author declares no conflicts of interest. references • abada rl, mansouri i, maamri m, kadiri f (2009); complications of chronic otitis media; ann otolaryngol; 2009;1-5. • dubey sp, larawin v, molumi cp (2010); intracranial spread of chronic middle ear suppuration; am j otolaryngol; 2010;31(2):73-7. • harker la (2003); cranial and intracranial complications of acute and chronic otitis media; in: snow jb, ballenger jj, editors. ballenger’s otorhinolaryngology head and neck surgery. 16th ed. hamilton, ontario; decker. 2003;294-316. • kangsanarak j, fooanant s, ruckphaopunt k, navacharoen n, teotrakul s (1993); extracranial and intracranial complications of suppurative otitis media: report of 102 cases; j laryngol otol. 1993;107:999-1004 • mustafa a, heta a, kastrati b, dreshaj sh (2008); complications of chronic otitis media with cholesteatoma during a 10-year period in kosovo; eur arch otorhinolaryngol.2008;265 (12):1477-82 • osma u, cureoglu s, hosoglu s (2000); the complications of chronic otitis media: report of 93 cases; j laryngolotol; 2000;114:97-100. • sharma n, jaiswal aa, banerjee pk (2015); complications of chronic suppurative otitis media and their management: a single institution 12 years experience; indian j otolaryngol head neck surg; 2015;67:353-60 • verhoeff m, van der veen el, rovers mm, sanders ea, schilder ag (2006); chronic suppurative otitis media: a review; int j pediatr otorrhinolaringol; 2006; 70:1-12. • yorgancılar e, yıldırım m, gun r, bakir s, tekin r, gocmez c et al (2013); complications of chronic suppurative otitis media: a retrospective review; eur arch otorrhinolaringol. 2013;270:69-76. • world health organization (2012); chronic suppurative otitis media; burden of illness and management options; 2004.http://www.who.int/entity/pbd/deafness/activity. es/ hearing, care/otitis media.pdf; accessed on 3 may 2012. microsoft word gjphm-2022 edited.docx 638 global journal of public health medicine 2022, vol 4, issue 1 gggggglo original research contraceptive use and women empowerment: a cross sectional study among married females in a rural area of gurugram, india. shambhavi 1 , b s deswal , 2, shalini ray 3, rajesh kunwar 1 1department of community medicine, faculty of medicine, t s mishra medical college & hospital, lucknow,india 2world college, gurugram,india 3department of community medicine, sgt medical college & hospital, gurugram,india *corresponding author: doc.shambhavi@gmail.com abstract introduction: its appropriately said that empowering women is fostering the nation’s empowerment. in the last two decades much focus has been given on women’s empowerment and promoting their rights. the cruciality linking the use of contraceptives and women empowerment has been well established with a direct and positive impact on maternal health and child health. although there has been limited literature in this reference especially in rural area of gurugram. the aim to assess the prevalence of women empowerment and assess the association between use of contraceptives and unmet needs with women empowerment among the married females constituting the study area. methods: the study was conducted among married females (18 to 45 years)after getting informed consent from each subject. two stage sampling technique was done through pps (probability proportional to size), in which a pre-tested, semi structured questionnaire was used with information about age, education, type of family, socio-economic status, age at first child, number of children, use of contraceptive methods, factors associated with unmet needs. a self-validated scale was used to assess the status of women empowerment among the study participants. results: in this study mean age of study population was 25.96 ± 30.021. in this study, 40.83% were not empowered still in the current study while 24.72% were partially empowered and 34.44% were fully empowered in the current study. conclusion: the use of contraception was more in higher empowered women as compared to partially empowered or not empowered females. keywords: women empowerment, family planning, contraceptives, unmet needs. 639 global journal of public health medicine 2022, vol 4, issue 1 gggggglo introduction: women empowerment is the biggest pillar to attain the path of sustainable development goals: one (to end poverty in all of its forms everywhere), four (to ensure inclusive and high-quality education for everyone and encourage lifelong learning), and five (to eliminate inequity in all of its forms everywhere) (to achieve gender equality and empower all the females including). women's empowerment has become a keystone for the development of society because it contributes to the development of efficient, more educated, peaceful, and affluent societies. when women are empowered in society, poverty is reduced, the economy thrives, and both maternal and child health improves.(united nations,2019) according to unfpa state of world population 2021 report, the prevalence of the contraceptive usage among indian women aged 15 – 49 years was found 43% and 39% for ‘any method’ and for ‘modern methods’ respectively. (unpf,2021) however there was limited data available in india for ‘decision making on sexual and reproductive health and reproductive rights’ in india the unfpa executive director, dr. natalia remarked at the opening of the 54th session of the commission on population and development that “the data of the countries show that globally, nearly half of women lack the power to make their own decisions about whether to have intimate relations with their partner, to use contraception or to seek health care”. (unpf,2021) women's empowerment, published in an article by lee rife et al(2010), is the process of increasing women's ability and freedom to make essential life decisions, such as forming opportunities, gaining control over resources, and making decisions that have a significant impact on their life outcomes.(lee rife et al., 2019) it is quite obvious that the females who are empowered, can more efficiently make fertility decisions, use contraceptives and have increased communication with their partners. (prata et al.,2017) two essential components required for empowerment are, (i) the essential preconditions such as education, income etc.; and (ii) the actual act of choosing and making decisions. (cornwall et al.,2016) women's empowerment is connected with reduced fertility, longer birth intervals, and lower rates of unwanted pregnancy, according to a more recent assessment of women's empowerment and fertility.(upadhyay et al.,2012) limited data in india is available on women empowerment and use of contraceptives. as no such study was done in the rural area of gurugram to assess the contraceptive use and its association with empowerment of women. thus, the present study was undertaken to study and assess the status of empowerment of rural women in gurugram in association with use of contraceptives. methods: the study was a cross sectional study which was conducted among married women residing in the rural area under phc garhi harsaru of gurugram district, haryana from june 2019 to december 2019. the study included all married women in reproductive age group 18-45 years who were willing to participate in the study and gave consent for the same. women who were not co-operative and were not willing to give consent for the study; unmarried/ widowed/ separated/ divorced women were also excluded from the study. 640 global journal of public health medicine 2022, vol 4, issue 1 gggggglo considering the prevalence of contraceptive use as 54% (according to nfhs-4), with confidence interval at 95% and precision value of 10%, the calculated sample size was 327 which was rounded off to 360. the sampling process was divided in two stage random sampling technique using pps (probability proportional to size); a) simple random sampling: to identify the villages to be taken from the total 14 villages under phc garhi harsaru.7 villages were taken for the study using simple random sampling. i.e. about 50% from all the 14 villages under phc which was expected to give adequate sample size planned. b) pps (probability proportional to size): to identify the households to be taken from each village expecting at least one eligible couple from each household, to obtain the minimum sample size of 360. sampling interval was found to be 13 considering the total no. of households 4975. a random number i.e. 10 was selected which was less than or equal to the sampling interval. this number gave the location of the first household to be included in the study. if any household was found to be locked/unhabituated after two subsequent visits, then the next available household was taken for the study. households in which more than one eligible couple were found, in such case all couples were recruited for the study. the status of women empowerment in decision making was assessed by scoring system which was self-validated during the pilot study. the empowerment assessment questions were developed based on an empowerment scale, which was taken from maholtra and schuler. (malhotra et al.,2002) measuring women’s empowerment was categorized into five dimensions: economic, social and cultural, legal, political and psychological. the assessment was done in relation to their ability to freely decide individually and discuss with their partners about family planning needs and choices, social/political activity, economic decision, health seeking using set of 11 questions. on the basis of this, females were divided into fully empowered, partially empowered and not empowered. a score of 1 was given if the decision was made independently by the lady or with the consent of spouse or together. zero (0) was scored for those who don’t decide independently. table 1: scoring of status of women empowerment score status of empowerment 0 – 3 not empowered 4 – 8 partially empowered >9 fully empowered written informed consent was taken from the study participants assuring the confidentiality. after taking informed consent, the pre-designed and pre-tested questionnaire-based performa was used for the data collection by house to house visit in study area. 641 global journal of public health medicine 2022, vol 4, issue 1 gggggglo all the study participants were explained about the importance and purpose of the study. written informed consent along with detailed information sheet was translated into local language i.e. hindi. in case of illiterate subjects, the information sheet was explained to them and their consent was witnessed by another literate person. strict confidentiality was ensured to them. statistical analysis: data was compiled in microsoft excel 2010 spreadsheet and analysed further by using the statistical software spss version 21.0. suitable statistical tests were applied. after filtering the data adequately, an in-depth data analysis was undertaken keeping in view the specific objective of the study. ethical considerations: the institutional ethical committee approval of faculty of medical sciences, sir guru tegh bahadur university was taken before conducting the study. results: the current study was a community based cross-sectional study undertaken in phc garhi harsaru among married females among the age group of 18-45 years. a total of 360 subjects fulfilling the inclusion criteria were recruited for the study. the factors determining contraceptive use and unmet needs were assessed and the association of women empowerment with contraception was also analysed. in the present study, 112 females (31.11%) were in the age group of 18-20 years. 92 (25.56%) were in the age group of 21-25 years while 68 (18.89%) were in the age group of 26-30 years. 43 (11.94%) were in the age group of 3135 years and 31 (8.61%) females were in the age group of 36-40 years and only 14 (3.89%) in the study were in the age group of 4145 years mean age of study population was 25.96 ± 30.021. figure 1 depicts the prevalence of empowered women on the basis of scoring them on their decision taking capacity regarding contraception, occupation, social issues and financial independence. in this study population, 124 (34.44%) females were fully empowered, 89(24.72%) were partially empowered and 147 (40.83%) were not empowered. thus, in this era of women empowerment, still a lot of females have to get the rights they deserve. figure1: status of women empowerment 34.44% 24.72% 40.83% fully empowered partially empowered 642 global journal of public health medicine 2022, vol 4, issue 1 gggggglo table 2 shows the association between women empowerment and use of contraception. it is depicted that among 124 fully empowered females, 91 (73.39%) were users and 33 (26.61%) were non-users. 89 participants were partially empowered, in which 57 (64.04%) were contraceptive users and 32 (35.96%) were noncontraceptive users. the rest 147 were not empowered which includes 84(57.14%) participants who were using some mode of contraception and 63 (42.86%) were nonusers. the study indicates that use of contraceptive was more in the empowered females as compared to nonempowered females. the association of empowerment of women and the use of contraception was statistically significant in this study. table 2: bivariate analysis showing association between women empowerment and contraceptive use scores contraceptive user(n=232) nonuser(n=128) total(n=360) tests of significance fully empowered 91(73.39%) 33(26.61%) 124(100%) x2 = 7.75, d.f.=2, p-value < 0.05 partial empowered 57(64.04%) 32(35.96%) 89 (100%) not empowered 84(57.14%) 63 (42.86%) 147(100%) table 3: bivariate analysis showing association between women empowerment and unmet needs unmet needs unmet needs present(n=58) unmet needs absent(n=302) total(n=360) tests of significance fully empowered 12(9.68%) 112(90.32%) 124(100%) x2=8.32, d.f.=2, p-value = 0.015 partially empowered 13(14.60%) 76 (85.39%) 89( 100%) not empowered 33(22.45%) 114(77.55%) 147(100%) 643 global journal of public health medicine 2022, vol 4, issue 1 gggggglo table 2 is depicting the association between unmet needs of contraception and status of women empowerment. in this study, among total 124 fully empowered women, only 12(9.68%) had unmet needs while unmet needs was absent in majority of 112(90.32%) females (90.32%). gradually the prevalence of unmet needs increased in partially empowered (14.60%) and not empowered females (22.45%). thus, the empowerment of females plays a major role in planning their family size by deciding for use of contraception and preventing the unmet needs. thus, the association between unmet needs and empowerment status of women have come out to be significant. (p value = <0.001). discussion: present study on women empowerment and use of contraceptives has shown an association between empowerment and contraceptive uses. the use of contraceptives was found to increase with increased level of empowerment. similar findings were reported by prata et al(2017) in their study examining the relationship between contraceptives use and women empowerment. their study suggested that empowerment was consistently and positively associated with ever use of contraception and intention to use contraception in the future.(lee rife et al.,2019) in another study done in peri urban area of ghana, among 761 currently married women aged 15-49 years, to understand how women’s empowerment influences contraceptive uptake, only 29% of respondents were found empowered in all the three categories. the study also showed that the odds of empowered women using contraceptives was 1.76 times more as compared to those not empowered. (ansong et al.,2019) in our study 34.4% were fully empowered and association between empowerment and use of contraceptives was found statistically significant. the scales used for measuring empowerment was different in the two studies but effect of empowerment on use of contraceptives was found similar. dasgupta et al, in their study to find the current contraceptive use and its relationship with women empowerment among adult married women of reproductive age showed that women empowerment and education of women were significantly associated with contraceptive use. ( dasgupta et al.,2016) the findings were quite similar to the current study in which fully empowered women were using contraceptives more often than the non-empowered females. in a study done by s patriker among married females attending opd in a tertiary care hospital of pune, women empowerment and contraceptive use was analysed. (patriker et al.,2014) in the study, women empowerment was based on considering two indices viz women’s decision-making power index and women’s autonomy index. the study found an association between women empowerment in terms of women autonomy and use of contraception. the study included mainly urban population. even then, the findings were similar to our findings in rural population. a study done in indonesia by utami, using data from 2017 indonesia demographic and health survey (idhs) to assess unmet needs and women empowerment, indicated that the components of women’s 644 global journal of public health medicine 2022, vol 4, issue 1 gggggglo empowerment have a statistically significant effect on unmet needs namely women’s work participation, knowledge level, and household participation decision-making, and asset ownership.( utami et al.,2021) our study also showed that the unmet needs of women decreased with increasing empowerment level. limitation of this study that it was carried out among rural population of north india. india is a vast country with diverse culture and population. findings of the study, therefore, may suffer from loss of external validity. a multicentric study covering a much larger population may be useful in substantiating the findings of the study. conclusion: in india, we have come a long way in imparting equal rights to the women and making them empowered but still there are miles to go. empowering women makes them efficient in handling their fertility issues and improving maternal health. the current study significantly indicates that empowering women will permit them to have a say in their contraceptive choices and will reduce their unmet needs. reduction of unmet needs and better family planning will not only improve the contraceptive prevalence but control the increasing population and thus improves overall development and well-being of the nation. acknowledgements: the authors are grateful to all our study subjects who helped us to conduct this study. conflicts of interest the author declares no conflicts of interest. references: • ansong jk, otupiri e, apenkwa j and kuma aboagye p. (2019). women’s empowerment and contraceptive use: a community-based survey in peri-urban kumasi, ghana. gate openres 2( 3),1512. https://doi.org/10.12688/gatesopenres.13025.1 • cornwall, a. (2016). women’s empowerment: what works? journal of international development, 28(3), 342–359. https://doi.org/10.1002/jid.3210 • dasgupta a, bandyopadhyay k, bandyopadhyay l, paul b, banerjee s( 2016). does women empowerment predict contraceptive use? a study in a rural area of hooghly district, west bengal. indian j comm health, 28(3), 228-235. • diah a utami and omas b samosir (2021). women’s empowerment and unmet needs for family planning in indonesia. iop conf. ser.: earth environ. sci. 716 012057. https://doi.org/10.1088/17551315/716/1/01205. • lee-rife, s. m. (2010). women’s empowerment and reproductive experiences over the lifecourse. social science & medicine, 71(3), 634–642. https://doi.org/10.1016/j.socscimed.2010.04.019 . • malhotra, a., schuler, s.r. and boender, c. (2002) measuring women’s empowerment as a variable in international development. the world bank, washington • patrikar, s., basannar, d., & seema sharma, m. (2014). women empowerment and use of contraception. medical journal armed forces india, 70(3), 253–256. https://doi.org/10.1016/j.mjafi.2013.12.014. 645 global journal of public health medicine 2022, vol 4, issue 1 gggggglo • prata, n., fraser, a., huchko, m. j., gipson, j. d., withers, m., lewis, s., ciaraldi, e. j., & upadhyay, u. d. (2017). women’s empowerment and family planning: a review of the literature. journal of biosocial science, 49(6), 713–743. https://doi.org/10.1017/s0021932016000663. • united nations. the sustainable development goals report. new york; 2019 • united nations population fund , 54th session of the commission on population and development. (2021, april 19).. retrieved june 25, 2022. https://www.unfpa.org/press/54thsession-commission-population-and-. • upadhyay, u. d., & karasek, d. (2012). women’s empowerment and ideal family size: an examination of dhs empowerment measures in sub-saharan africa. international perspectives on sexual and reproductive health, 38(02), 078–089. https://doi.org/10.1363/3807812 microsoft word gjphm-2022dm babylondocx.docx 608 global journal of public health medicine 2022, vol 4, issue 1 gggggglo original research association between socio-demographic, health characteristics and type 1, type 2 diabetic cases in governorate of babylon, iraq wael sulaiman sabea1, suhair mohammed hassoun2, ahmed ali hussein1 1 community health technician, master of community health technology, ministry of environment and health. 2assistant professor, community health department, college of health and medical technology/baghdad, middle technical university, iraq *corresponding author: wael2791992@gmail.com abstract introduction: health characteristics and socio-demographic of diabetic patients are important in the determination of livening patterns and factors that contributed in development of diabetes. we aim to identify on socio-demographic and health characteristics of diabetics, and find out association between them and with type of diabetes. methods: the study of cross-sectional was carried out in governorate of babel /iraq in endocrinology and diabetics centre for period that starting on 3rd november /2018 and to 10th march /2019.samples of study were collected through systematic random technique using a questionnaire form had been constructed and developed by a researcher after a comprehensive review of available literature and related books about subject. spss had used for data statistical analysis in the current study. results:. (420 diabetics ) of both type 1 and type 2 had been participated in the study with response rate (96. 9%). their ages ranged from (15-75 ) old years with a mean and standard deviation of (51.8 ± 13.5) years, (46.7%) were male and 53.4% were female. most of diabetic patients were married and (63.3%) were livening in urban areas. low percentage (26.9%) of diabetics were with illiterate level and type 2 diabetes was calculated for (81.2%). hypertension was accounted for (36.4%) while obesity for (35.7%) of them. the study has been showed significant association between type of diabetes and relating their age (type 2 was more in adult group > 44 years while type 1 more in 1544 years old ), gender (type 2 was more in women compared to type 1), family history (diabetics with type 1 were more with history of family), body mass index (obesity was more in type 2 compared to type1), comorbidity diseases (chronic hypertension and kidney diseases were more in type 2). conclusion: the current study had concluded that prevalence of type 2 diabetes was more compared to type 1 dibetes and with high percentage in women group and more in age group > 44 years. high percentage of diabetics with type 2 were with chronic hypertension and obesity and especially in women compared to type 1 diabetes. keywords: association, diabetic patients, socio-demographic, health, babylon. 609 global journal of public health medicine 2022, vol 4, issue 1 gggggglo introduction diabetes mellitus is a chronic disorder characterized by the presence of hyperglycemia due to insulin secretion, defective insulin work or both. many of disease-causing processes are involved in the development of diabetes (american diabetes association, 2014) . type 1 diabetes (insulin dependent) accounts for 5%-10% of all cases of diabetes and refers to a condition of autoimmune diseases that represents a very complex metabolic disorder characterized by massive destruction of the pancreas, specifically beta cells which in turn leads to an absolute lack of insulin (turton et al., 2018). while the second type of diabetes (non-dependent insulin) accounts for around 90% of all cases of diabetes and refers to a group of disorders that are characterized by high blood sugar that results from a combination of resistance to insulin work, insufficient secretion of insulin and excessive or inappropriate glucagon secretion (goyal r., 2019). diabetes is one of the main causes of morbidity, mortality and high costs to the community (seuring et al., 2015). international diabetes federation has suggested that the number of adults living with diabetes around the world increases from time to another (alemu, 2015). prevalence of type 2 diabetes mellitus for 45 countries representing nearly 90% of the world's population; in 2018, there were more than 500 million type 2 diabetes cases around the world, and type 2 diabetes prevalence is compared between high and low-income countries (kaiser et al., 2018). in iraq, the prevalence of diabetes in basrah city, southern iraq, had increased from 5% in 1978 to 19.7% in 2012, with a prevalence of hypoglycemia of 48.8%. this shows the outbreak of diabetes in iraq, which is facing a diabetic epidemic like the middle east (mansour & al douri, 2015). in another study about incidence of type 1 diabetes mellitus in basra, results of study have showed that the mean annual incidence rate of t1dm was 7.4 per 100,000 among people 0–40-year-old. incidence rate has been increasing over the past three years (from 2012 to 2016), this is explained by the changes in t1dm epidemiology in iraq (almahfoodh et al., 2017). demographic and health factors like age, family history, genetic factors, bad meals, stress, others had been considered as contributing factors in development of type 1 diabetes mellitus (antonela et al., 2017).the increase in the prevalence of metabolic diseases (such as type 2 diabetes mellitus ) in old age may be directly related to age or the process of ageing itself or indirectly through other risk factors associated with age of t2dm (suastika et al,. 2012) . individuals at the middle socio-economic level that are living in urban areas with low sport activity and do not consume large amounts of fruit are the most susceptible to the incidence of type 2 diabetes (gudjinu & sarfo, 2017). hence , the researcher in this study had aimed to identify the sociodemographic and health characteristics of diabetics and find out association between them and types of diabetes in governorate of babylon, iraq 610 global journal of public health medicine 2022, vol 4, issue 1 gggggglo methods a descriptive study design (cross-sectional) had been carried out for a period from 3rd november 2018 to 10th march 2019. this study had taken place in endocrinology and diabetics center in (medical marjan city), babel governorate/iraq. it isi located 100 km south of baghdad city. the researcher collected diabetic responses through direct interviews and informed diabetics about the purposes of research and aims. period of interview for the patient from 20-30 minutes. the sample size was collected (420) diabetics through systematic random sampling method from both genders and different ages. sample size had calculated according to specific daniel sample size formula for the continuous (infinite) community; which was explained as the following formula: n = 𝒛 𝟐 𝒑(𝟏&𝒑) 𝒅𝟐 ,n = expected sample units number;z: statistic value for a level of confidence (for the level of confidence of 95%;which is conventional, z .value = 1.96), p: expected proportion or prevalence; d:is level of the desired of absolute precision. (d is considered as 0.05 to produce precision of good and smaller error of estimate). (thompson, 2012).this is meaning that z = 1.96 , diabetes prevalence in iraq according to study in iraq was 20% (mansour & al douri, 2015) ,d = 0.05. n = [(1.96)2 *(0.20 * 0.80) / (0.05)2 = 3.8416 * 0.16 / .0025] = 245 (minimum sample size). so that the number = 420 diabetics were specific suitable for the study. the questionnaire form had constructed and revised by a researcher after an adequate review of a previous literature review and articles related to the subject of the study. it consists of 2 parts 15 items. six items for socio-demographic characteristics which include age, sex, residency, job, marital status, and education level. nine items for health characteristics of diabetics include diabetes type, period for the onset of diabetes, age of onset of diabetes, history family with diabetes mellitus, medications used for diabetes mellitus, body mass index (bmi), associated diseases or medical history according to a specialized doctor, history of smoking, drinking alcoholic beverages. the validity of the questionnaire was determined through a panel of 13 experts that have experience of more than 3 years in their specialties. the expert's responses were assessed based on their agreement or disagreement on the relevancy of items. expert's suggestions were taken into consideration; modifications are utilized and the final copy of the constructed instrument is completed to be an appropriate tool for conducting the study. evaluation results by experts indicated that the questionnaires were clear, adequate, relevant, and valid. statistical analysis of data by using statistical package of social sciences (spss) version 25, examples: frequency, mean, percentage, pearson chi-square test. where at least one cell of table had an expected count less than 5 for 2x2 tables; yate's corrected chi-square instead of pearson chi-square test had used to get adequate results. ethical consideration administrative approval from college of health and medical technology/middle technical university/bagdad; furthermore, endocrinology and diabetes diseases center /babylon health directorate had approved and gave final permission for author to conduct the study and collect data from diabetics after verbal consent. 611 global journal of public health medicine 2022, vol 4, issue 1 gggggglo results: the results of this study had been based on the analysis of 420 diabetics; 224 (53.4%) were female but 196 (46.7%) were male (female: male ratio was 1.14:1). diabetic ages ranged from (15-75) years with a mean of 51.8 years old and a standard deviation of (±) 13.5 years old. more than half (50.5%) were in the age group of 55-75 years and the lowest percentage (11%) were in the age group < 35 years. regarding the residence; most of the cases (63.6%) were from urban areas. respecting an occupation; high percentage (39.3%) were housewife. regarding the marital status and educational level; majority (83.1 %) were married and (26.9%) were illiterate as noted in table no. (1). table (1):socio-demographic characteristics of diabetics sociodemographic & health characteristics no. % total no. of diabetics 420 100.0 age (years) < 35 years 46 11 35--44 64 15.2 45--54 98 23.3 55--75 212 50.5 mean±sd (range) 51.8±13.5 (15-75) gender female 224 53.3 male 196 46.7 residence urban 267 63.6 rural 153 36.4 occupation employee 46 11.0 student 20 4.8 earner 52 12.4 housewife 165 39.3 retired 76 18.1 free work 61 14.5 marital status single 25 6.0 married 349 83.1 separated 1 0.2 divorced 23 5.5 widow 22 5.2 educational level illiterate 113 26.9 read & write 47 11.2 primary 79 18.8 intermediate 66 15.7 secondary 49 11.7 institute 37 8.8 college and higher 29 6.9 612 global journal of public health medicine 2022, vol 4, issue 1 gggggglo table (2) had showed that high percentage (81.2%) were in type 2 diabetics group. regarding the age of onset of diabetes mellitus was ranged from (8-65) years with mean of (39.6) years and a standard deviation of (±) 13.4 years. high percentage (53.3%) were with history of family for dm and (46.7 %) without family history, most of them (80.5%) with using oral hypoglycemic drugs. regarding the comorbidity diseases were ordered as following percentages; chronic hypertension (36.4%), rheumatoid arthritis (19.5%), respiratory diseases (9.5%), kidney diseases (5.7%), thyroid gland diseases (4.3%) respectively. regarding the body mass index; the higher percentage (35.7%) was with obesity. while regarding the smoking; the higher percentage (74.8%) were non-smokers and duration of smoking was ranged from (2-50) years old with mean of (17.0) years and standard deviation (±) 10.8 years. the high percentage (96.4%) of patients were not drinking alcoholic beverages and duration of alcoholic was ranged from (1-15) years old with mean of (6.3) years and standard deviation (±) 10.8 years. while the higher percentage (63.3%) of patients were not drinking soft drinks. table (2):. health -characteristics of diabetics : health characteristics no. % total no. of diabetics 420 100 type of diabetes type 1 diabetes mellitus (dmt1) 341 81.2 type 2 diabetes mellitus (dmt2) 79 18.8 age for onset of dmt1 mean±sd (range) 20.5±8.4 (8-55) age for onset of dmt2 mean±sd (range) 44±8.2 (15-65) family member with dm yes 224 53.3 no 196 46.7 medications used for dm oral hypoglycemic drugs 338 80.5 insulin 82 19.5 suffered from any of the diseases according to specialized doctor or medical history no. % chronic hypertension 153 36.4 rheumatoid arthritis 82 19.5 respiratory diseases 40 9.5 kidney diseases 24 5.7 thyroid gland diseases 18 4.3 bmi (kg/m2) thin (<18.5) 29 6.9 normal (18.5-24.9) 123 29.3 overweight (25-29.9) 118 28.1 obese (=>30) 150 35.7 smoking (years period) yes 107 25.5 no 313 74.5 duration of smoking (years) mean±sd (range) 17.0±10.8 (2-50) drinking alcoholic beverages yes 15 3.6 no 405 96.4 613 global journal of public health medicine 2022, vol 4, issue 1 gggggglo table (3) showed that there was a significant association (p.value ≤ 0.05) between types of diabetes and their age {type 2 was more in adult group > 44 years while type 1 more in (1544 years) }, gender {type 2 was more in women compared to type 1}, family history {diabetics with type 1 were more with history of family },bmi {obesity was more in type 2 compared to type1}, comorbidity diseases {chronic hypertension and kidney diseases were more in type 2} . and in another side, although thyroid gland diseases were more in type 1, and arthritis, respiratory diseases were more in type 2 but there wasn't significant. table (3): the association between type of diabetes and some selected demographic & health characteristics. socio-demographic and health variables type of diabetes mellitus type 1 % type 2 % total % total no. 79 100 341 100 420 100 age < 35 y. 43 54.4 3 0.9 46 11 35---44 27 34.2 37 10.9 64 15.2 45--54 4 5.1 94 27.6 98 23.3 55--75 y. 5 6.3 207 60.7 212 50.5 chi-square test χ2 = 242.333 df=3 p. value = 0.0001 * gender male 51 64.6 154 42.5 196 42.5 female 28 35.4 196 57.5 224 53.3 chi-square test χ2 = 12.513 df=1 p. value = 0.0001 * family history yes 54 68.4 170 49.9 224 53.3 no 25 31.6 171 50.1 196 46.7 chi-square test χ2 = 8.821 df=1 p. value = 0.003 * bmi < 18.5 (thin) 25 31.6 4 1.2 29 6.9 18.5 – 24.9 31 39.2 93 27.3 124 29.5 25-29.5 13 16.5 104 30.5 117 27.9 >=30 10 12.7 140 41.1 150 35.7 chi-square test χ2 = 108.393 df=3 p. value = 0.0001* chronic hypertension yes 6 7.6 147 43.1 153 36.4 no 73 92.4 194 56.9 267 63.6 chi-square test χ2 = 34.931 df=1 p. value = 0.0001 * kidney diseases yes 0 0 24 7 24 5.7 no 79 100 317 93 396 94.3 yate's corrected chisquare y = 4.663 df=1 p. value = 0.031 * thyroid gland diseases yes 4 5.1 14 4.1 18 4.3 no 75 94.9 327 95.9 402 95.7 yate's corrected chisquare y= 0.005 df=1 p. value = 0.944 arthritis yes 12 15.2 70 20.5 82 19.5 no 67 84.8 271 79.5 338 80.5 614 global journal of public health medicine 2022, vol 4, issue 1 gggggglo discussion the current study had illustrated that 50.5% of diabetics were in the age group of 55-75 years with a mean age of 52 years. this finding was agreement by the study in lebanon that showed the role of ageing in the development of diabetes type 2 (karaoui et al., 2018), and also similar according to report of american diabetes association, which had found that diabetes is an increasing burden on public health and the ageing of the world's population is a major contributor to the epidemic of diabetes (kalyani et al., 2017). more than half of diabetics were female, this showed that the prevalence of dm among females more than males, may because nature of life style for women this study is similar to studies in iraqi that had been explained that the majority of diabetes were female (al-tukmagi & moussa, 2014; ebrahim et al., 2014), but compared to another study in lebanon by had been illustrated that ratio the male/ female was 1.38, (karaoui et al., 2018).this disagreement may be because of the nature of the study place or different lifestyles between the two countries. regarding the residence; most of the cases are from the urban area; the findings are similar to the study in baghdad, iraq (abbas et al,. 2016) and also another study in palestine that showed that most of the diabetics were from the urban population (ishtaya et al., 2018). regarding an occupation; a high percentage of diabetics were housewives, the possible reason may be related to educational level or may the opportunity to get a job for a woman is few in iraqi society. this outcome was also supported by other studies in iraqi (alrubaye, 2011; mansour et al., 2018). regarding marital status; most the diabetics were married, this was interpreted as the effect of the early marriage; similarly reported by other studies (ebrahim et al., 2014; al-tukmagi & moussa, 2014). relating the educational level; the high percentage of diabetics were illiterate, this might reflect the educational background of iraqi population especially with poor economic level and impact of many wars that happened in the past periods; where many students left school in first stage of the study to work. this result is similar to what had been reported by study in basra, iraqi that had noted that high percentage of diabetics were with poor level of education ( mansour et al., 2018), but this the result was disagreement by the study of in basra , iraqi ; where had found that the high percentage of diabetics were in secondary & high education (ebrahim et al., 2014). this difference might be because of nature of the study place and method of sample selection. in relation to smoking, most of diabetics (74.5%) were non-smokers and duration of smoking ranged from 2-50 years. the possible explanation of the result is that the majority of diabetics were female and more compliance to social habits in iraq about avoiding the smoking; the finding was the nearest to the chi-square test χ2 = 1.163 df=1 p. value = 0.281 respiratory system diseases yes 6 7.6 34 10 40 9.5 no 73 92.4 306 90 379 90.5 chi-square test χ2 = 0.517 df=1 p. value = 0.420 *significant association between proportions using pearson yates correction and chi-square tests ≤ 0.05 level. 615 global journal of public health medicine 2022, vol 4, issue 1 gggggglo study in babylon, iraq (alsaadawi, 2016) and in southeastern nigeria (nwaokoro et al., 2014). the present study showed that the majority of diabetics (96.4%) were not drinking alcoholic beverages; this might be related to religious attitude and reject these alcoholic beverages by iraqi society. to the best of our knowledge; there is no previous similar study, but in comparison to survey results in iraq, it had been illustrated that 96.8% of people do not drink alcoholic beverages (al-hemiery et al., 2017), unlike the study done in america that had indicated that the majority of diabetics in america were drinking different alcoholic beverages (vaeth et al., 2014) . most of diabetics were not drinking soft drinks on daily basis; this explains the good behavior and awareness towards avoiding the soft drinks; similarly the finding was supported by the study in al-khobar, saudi arabia kingdom (mokabel et al., 2017). regarding the type of dm, study had been illustrated that most of diabetics were female with type 2 dm and the mean age of onset of dm was equal or more than 44 years; this had shown that bad lifestyles like lack of physical activity and obesity play a main role in the development of diabetes type 2. this outcome was similar with another study in basra, iraqi ( mansour et al., 2018) and the study in palestine which had been shown that diabetes type 2 was accounted for a high ratio compared to diabetes type 1 that was calculated for low percentage (el sharif, 2017).concerning with family history of diabetes; a high percentage of diabetics (53.3%) had shown that they have a family history and higher in type 1 diabetes, this illustrates family role in the development of diabetes; similarly this the finding was similar by the study in basra ,iraqi (ebrahim et al., 2014) and in lebanon (karaoui et al., 2018). regarding the type of therapy; majority of diabetics (80.5%) took oral hypoglycemic drugs, the reason that most of diabetics were with type 2 diabetes and most of diabetics had taken oral tablets to keep on normal glucose in the blood; this result of the study is similar to other studies in lebanon (karaoui et al., 2018), and also with acceptable level by the study in tehran, iran (darvishpoor & abed, 2013).the present study explained that most of adult female diabetics with type 2 have {chronic hypertension (36.4%), obesity (35.7%)}; this had interpreted that diabetes with bad life styles like unhealthy diet, bad sleeping, stress, lack of physical activity have significant main impact with long period of time in development of chronic hypertension and obesity among diabetics; this result had agreed by the study in baghdad, iraq (al-rubaye, 2011), (colosia et al,. 2013). conclusion: the present study had concluded that the prevalence of type 2 diabetes was more compared to type 1 and with a high percentage in the women group and more in age group morr than 44 years. a high percentage of diabetics with type 2 were with chronic hypertension and obesity and especially in women. the study has been suggested the establishment of modern well-organized educational programs supported with modern developed educational technologies for diabetics in diabetic centers and other institutions show role of socio-demographic and health factors in development of diabetes. continuing many studies on large samples of diabetics in other countries to identify more on socio-demographic and health characteristics of diabetics, and show effect of them on diabetes in other countries. 616 global journal of public health medicine 2022, vol 4, issue 1 gggggglo abbreviations ada: american diabetes association; bmi: body mass index; dm: diabetes mellitus; f: frequency sd: standard deviation; spss: statistical package of social sciences; ts: total scoring; x2: chi-square. acknowledgement the author would like to thank staff in endocrinology and diabetes diseases center in babylon governorate for approving to collect data, as well as special thankful for diabetics for participation in the study. conflicts of interest the author declares no conflicts of interest. references • abbas, s.-q. k., al-tukmagi, h. f., & al-auqbi, t. f. 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(2014). ethnicity and alcohol consumption among us adults with diabetes. annals of epidemiology, 24(10), 720–726. microsoft word gjphm-2022 methotrexatedocx.docx 618 global journal of public health medicine 2022, vol 4, issue 1 gggggglo original research adherence to methotrexate in iraqi patients with rheumatoid arthritis : a cross-sectional study ali m. kadhim al-tuma¹ & nizar abdulateef jassim 2 1 department of internal medicine ,college of medicine, karbala university , karbala, iraq 2 department of internal medicine,college of medicine , university of baghdad , baghdad, iraq *corresponding author: doctor88ali@gmail.com abstract introduction: methotrexate (mtx) is the most widely used disease modifying antirheumatic drugs (dmards) in the treatment of rheumatoid arthritis (ra). in ra, medication adherence is variable and sub-optimal. poor adherence affects 20-70% of patients. adherence to mtx is the key to attaining the goal of low disease activity or disease remission. the aim of the study is to determine adherence of ra patients to mtx when used as a monotherapy and when combined with anti-tumor necrosis factor (tnf) and to look for the factors that may positively and negatively affect adherence. methods: an observational cross sectional study was conducted at rheumatology clinic/baghdad teaching hospital over a period from january-june 2020. a total of 100 patients diagnosed with ra according to american college of rheumatology (acr) and european league against rheumatism (eular), 2010 criteria are included. all were on mtx for more than 3 months. a questionnaire was used to collect information from them. results: young age, middle-high educational level and good socio-economic state increase the regular mtx intake and thus improve the adherence. long duration of the disease and treatment, oral and combination therapy decrease the patients’ adherence. conclusion: non-adherence to mtx is noted frequently in ra patients and variable factors tend to affect adherence. multiple factors encourage or discourage the continuity of mtx intake, some are related to patients themselves while others are related to the course of the disease or mtx itself. keywords: adherence, non-adherence, methotrexate , rheumatoid arthritis. 619 global journal of public health medicine 2022, vol 4, issue 1 gggggglo introduction: rheumatoid arthritis (ra) is a chronic, systemic, inflammatory disorder of joints and connective tissues (jeffery, 2014). the primary site of involvement is the synovium of the joints which become inflamed and proliferate (firestein, 2017). extra-articular manifestations might accompany the joint disease such as eye involvement, rheumatoid nodules, cardiovascular and hematological changes (angelotti et al., 2017). the exact cause of ra is still unknown, but it tends to be multi-factorial. genetic and environmental factors (smoking, pollutants, and others) play important roles (lin et al., 2016). the incidence of ra is estimated to be 1%, females are more affected than males with a predisposition for more severe disease manifestations. the peak age of presentation is around 30-45 years old and its incidence increases with age (silman, 2001 ; feist and burmester, 2013). the characteristic, typical presentations of ra are pain and swelling in the small joints of hands, wrists and feet and prolonged morning stiffness, often more than 1 hour (odells, 2014). patients are classified as having ra according to the 2010 american college of rheumatology (acr)/ european league against rheumatism (eular) classification criteria as shown in figure 1. they are scored from 0 to 10, a patient with a score equal to 6 is classified under the name ''definite ra'' (neogi et al., 2010). figure 1: acr/ eular classification criteria of ra,2010 (neogi et al., 2010). *rf: rheumatoid factor, acpa: anti-citrullinated protein antibody, crp: c reactive protein, esr : erythrocyte sedimentation rate. 620 global journal of public health medicine 2022, vol 4, issue 1 gggggglo methotrexate is one of the most frequently used dmards for ra either as a monotherapy or combination therapy. methotrexate when used as monotherapy, it may induce low disease activity in about 30% of patients. (singh et al., 2015). the precise mechanisms of action are not understood completely, it seems to have both anti-inflammatory and immunemodulatory actions (ranganathan and mcleod, 2006). insight to the molecular pathogenesis of ra, the need of using targeted diseases modifying anti-rheumatoid drugs (dmards) has increased significantly to get a state of low disease activity or disease remission(mcinnes and schett, 2007). early intervention with these dmards prevents joint damage and improves long term functional outcomes (escalas et al., 2012). according to acr and eular treatment guidelines for ra, mtx is an anchor drug whether alone or in combination with conventional or biologic dmards (curtis et al., 2016). as in all chronic diseases, compliance to therapy plays a vital role in treatment success. adherence to mtx is the key to attaining the goal of disease remission or low disease activity. non adherence (na) is defined as poor implementation of a generally continued therapy for one reason or another. it has been reported that na to mtx is considered a major challenge in the real-world treatment of ra patients (salt et al., 2010). various social and economic issues predispose to na and adherence could be promoted by physician counselling. however, due to the lack of follow up studies among mtx nonadherent ra patients, it is difficult to precisely assume the possible factors which might affect patients’ adherence (müller et al., 2017). na to treatment may impair the patient’s health by a progressively severe joint damage, functional disability, poor health-related quality of life and higher disease morbidity and mortality (rapoff and pediatr, 2002). in addition, na increases the unnecessary clinic appointments and diagnostic tests with increased usage of additional treatments' modalities with an ultimate result of increased treatment cost (de achaval and suarez-almazor, 2010). so, the study aimed to explore the patient and drug-related aspects of methotrexate adherence and it was one of few studies that deal with the mtx adherence. it tried to investigate or evaluate the mtx adherence and the barrier to the adherence to be considered and discussed clearly with the patients before the start of therapy methods: this study is an observational cross sectional study was conducted at rheumatology clinic in baghdad teaching hospital over a period from january 2020 to june 2020. a total of 100 patients (male =30, female=70) diagnosed with ra according to acr and eular, 2010 criteria were included. the sample size was calculated according to the prevalence of ra in the population. all had been on mtx for more than 3 months. informed consent was taken from the patients and the study was done under the supervision of scientific council of the iraqi board for medical specializations in partial fulfilment of the requirement for the 621 global journal of public health medicine 2022, vol 4, issue 1 gggggglo degree of the fellowship of the iraqi board for medical specialization in rheumatology and medical rehabilitation. inclusion criteria: 1. patients with ra diagnosed according to acr /eular 2010 criteria for more than 1year duration. 2. taking mtx for more than 3 months. exclusion criteria: 1.patients with chronic diseases which necessitate chronic drug intake: ht, dm, asthma and epilepsy. 2.patients with multi-drug usage (combination therapy with dmards other than anti-tnf e.g. hydroxychloroquine, prednisolone and sulfasalazine). 3. patients with mental illness: dementia and memory loss. a questionnaire was used to collect information from the patients and verbal consent was taken from them to be included in the study. adherence questionnaires, the medication adherence report scale (mars-5) and the compliance-questionnaire-rheumatology (cqr) as well as a visual analogue scale (vas) measuring mtx adherence, were administered to these patients as the following (de cuyper et al., 2016). demographic data; age in years, sex, address, educational level (primary, secondary and tertiary), socioeconomic state (according to the monthly income of the family). duration of ra (years), duration of mtx intake (years), the current dose of mtx mg/week), mode of intake: oral or s.c/ i.m. combined with anti-tnf or not (type, dose and duration). disease activity at the time of visit according to clinical disease activity index (cdai) score as shown in figure 2 and table 1 (mild when cdai of 2.8-10, moderate from 10-22 and severe 22 and above) (jeka et al., 2018). 622 global journal of public health medicine 2022, vol 4, issue 1 gggggglo . figure 2: clinical disease activity index (cdai) score (jeka et al., 2018) table 1: calculation scores of cdai (jeka et al., 2018). variable range value tender joint score (0-28) swollen joint score (0-28) patient global score (0-10) provider global score (0-10) add the above values to calculate the cdai score (0-76) to calculate both the patient global assessment disease activity and provider global assessment disease activity, the doctor must consider all the ways that arthritis affects the patient, and ask the patient to rate how well he/she is doing on the following scale ranging from very well 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 very poor. joint left right tender swollen tender swollen shoulder elbow wrist mcp 1 mcp 2 mcp 3 mcp 4 mcp 5 pip 1 pip 2 pip 3 pip 4 pip 5 knee total tender: swollen: 623 global journal of public health medicine 2022, vol 4, issue 1 gggggglo adherence to mtx: when 2 or less of prescribed mtx doses are omitted in the previous 8 weeks. nonadherence to mtx: when 3 or more doses are omitted in the previous 8 weeks. possible reasons which encourage or discourage the patients to take the drug were discussed. data were analyzed statistically by ibm spss statistics for windows version 24.0 (ibm corp., armonk. n. y,. usa). in each group, either mean ± sd for continuous data or number and percentage for categorical data was calculated. an independent sample student t-test was used for comparing parameters between both groups. for categorical values, chisquare was used. only at a p-value ≤ 0.05 the differences between the values were considered as significant statistically. results: below are demographic characteristics of both groups. there was a significant statistical difference between both groups regarding age (the adherent group is younger with a mean of 48.4± 10.4 vs 54.3±10.7 years old), educational level, socio-economic state (in which the non-adherent patient exhibited both low educational and socio-economic levels respectively) at a significant p-value of less than 0.05. table 2: demographic data of the studied groups. parameter adherent=58 non-adherent=42 p-value age m±sd 48.4± 10.4 54.3 ±10.7 0.008* sex male 16 14 0.53 female 42 28 educational level high 6 (10.3%) 2 (4.76%) 0.009* medium 34 (58.6%) 14 (33.3%) low 18 (31%) 26 (61.9%) socio-economic state high 4 (6.89%) 2 (4.76%) 0.001* middle 44 (75.8%) 18 (42.85%) low 10 (17.2%) 22 (52.3%) table 3 illustrates the medical history of the patients in both groups represented by the duration of ra, disease activity (depending upon cdai score), duration of mtx treatment, the dose of mtx, mode of mtx intake (oral vs parenteral) and type, duration of treatment (mono vs combined). there was a significant difference between both groups regarding duration of ra ( the duration of ra is less in the adherent group with a mean 7.6±3.8 vs 12.0±6.3 years non-adherent one), duration of mtx treatment (being less in the adherent group 4.5±3.0 vs 7.3±5.8 years), mode of intake (37.9% of the adherent group were on oral 624 global journal of public health medicine 2022, vol 4, issue 1 gggggglo treatment and 62% on parenteral, while 76.19% of non-adherent group on oral and only 23.8% on parenteral treatment) and type of treatment ( 58.6% of adherent patients used mtx monotherapy and 41.37% used mtx in combination with anti-tnf in contrast to 28.5% and 71.42 respectively in the non-adherent group). while, the activity of the disease, dose of mtx and duration of combined therapy showed no significant difference between both groups with a p-value> 0.05. table 3: medical history of patients in both studied groups. parameter adherent, 58 non-adherent, 42 p-value duration of ra(years) 7.6 ±3.8 12.0± 6.3 0.0001* disease activity mild (2.8-10) 0 (0%) 0 (0%) 0.58 moderate (10-22) 48 (82.75%) 33 (78.57%) sever >22 10 (17.2%) 9 (15.5%) duration of mtx (years) 4.5 ±3.0 7.3 ±5.8 0.02* dose of mtx 15.9± 4.2 15.2± 4.7 0.44 mode of mtx intake oral 22 (37.9%) 32 (76.19%) 0.001* parenteral 36 (62.06%) 10 (23.80%) type of treatment mono 34 (58.62%) 12 (28.57%) 0.003* combined with anttnf 24 (41.37%) 30 (71.42%) duration of combined (years) 3.7± 2.3 3.8± 2.4 0.90 table 4 shows the likely reasons which encourage the patient to take the drug regularly and in turn improve adherence to mtx. improvement of joint pain is at the top of the list 86.2%, followed by ra control 79.3%, improvement of quality of life 65.5%, fear from ra complications 44.8%, fear from ra morbidity & mortality 31% and the lowest reason is fear from disability 24%. 625 global journal of public health medicine 2022, vol 4, issue 1 gggggglo table 4: possible reasons for increased adherence to mtx while table 5 explains the major reasons which decrease the ra patient adherence to mtx. starting from forgetfulness 61.9%, lack of awareness of its importance in disease control 57.1%, lack of availability and lack of awareness regarding its’ long term intake 42.5%, lack of affordability and fear from se 38.0%, peoples’ negative advice 33.33%, lack of family support and intractable se 23.8% and only 14.2% due to difficulty regarding the mode of intake. no one of the patients had a concept of mtx dependence in long term use. table 5: possible reasons for decreased adherence to mtx. parameter total number percentage forgetfulness 26/42 61.9% lack of affordability 16/42 38.09% lack of availability 18/42 42.58% fear from dependence 0/42 0% fear from side effects 16/42 38.09% peoples’ negative advice 14/42 33.33% lack of awareness of its importance in disease control 24/42 57.14% lack of awareness regarding its long term intake 18/42 42.85% lack of family support 10/42 23.80% difficulty regarding the mode of intake: oral or parenteral 6/42 14.28% intractable side effects: nausea, vomiting, stomatitis, oral ulcers, epigastric pain…etc. 10/42 23.80% parameter total number percentage pain improvement 50/58 86.20% improve quality of life 38/58 65.51% disease control 46/58 79.31% fear from ra complications 26/58 44.82% fear from handicap & disability 14/58 24.13% fear from ra morbidity & mortality 18/58 31.03% 626 global journal of public health medicine 2022, vol 4, issue 1 gggggglo discussion the current study showed that about 58% of patients with ra exhibited adherence to mtx which is consistent with the results of many studies; one large american cohort study that included more than 14,000 ra patients and a prevalence study of 2662 ra patients who reported an adherence rate up to 65% (mcinnes and schett, 2007 ; escalas et al., 2012 ). however, a higher adherence rate of 80% was registered by a longitudinal study conducted in denmark which followed 941 patients with ra for 10 years (curtis et al., 2016). the adherent patients in this study were significantly younger, with middle educational and socio-economic levels in comparison to non-adherent who exhibited an older age and low both educational and socio-economic levels. similar results were obtained by arshad et al. in 2016 despite no significant differences among these parameters (arshad et al., 2016). for disease activity, disease duration, dose and duration of the mtx therapy, the study showed a significant difference between both groups. the duration of ra and mtx intake was longer in the non-adherent group while both disease activity and dose of mtx showed no significant difference. this means that with increasing the duration of both disease and treatment, drug adherence is decreased. with the exception of disease activity, this result is in some agreement with what was recognized by some studies in which the adherent patients had the more active disease (müller et al., 2017 ; rapoff and pediatr, 2002). for the route of administration, the study concluded that the adherent group were used the parenteral rout more than the oral route in contrast to the non-adherent group. although, little data is available regarding the adherence and route of intake as most studies compared between oral and parenteral including drug safety, efficacy, disease response and tolerability but not adherence. it had been reported by some studies that parenteral intake is associated with higher bioavailability, bypassing the 1st pass hepatic metabolism, a reduced frequency and intensity of some gi side effects than oral mtx which may improve treatment compliance and reduce mtx discontinuation rates (de achaval and suarezalmazor, 2010 ; de cuyper et al., 2016 ; grijalva et al., 2007). other studies suggested that there was no difference in adherence between oral and parenteral mtx intake and increased adherence to oral intake was reported in certain ra patients; those who had phobia from the injection, elderly patients who didn’t have caregivers, those with severe involvement and deformity of hand joints in which they could not use their hand to inject themselves (harley et al., 2003). 627 global journal of public health medicine 2022, vol 4, issue 1 gggggglo studying the type of therapy, mono or in combination with anti-tumor necrosis factor, the results showed that patients who used mtx alone showed more adherence than those who used mtx in combination with anti-tumor necrosis factor. little data is available regarding the difference in patients’ adherence to mtx alone or in combination with other biological agents. however, few studies were directly assessed the patients’ adherence as most of them tried to assess treatment efficacy, toxicity, disease control, symptoms improvement, drugs' interaction and side effects (pascual-ramos et al., 2009 ; hovstadius and petersson, 2011 ; kromann et al., 2015 ; rutkowska-sak et al., 2009). some studies had been suggested that despite improvement in ra symptomatology, combination therapy might potentiate mtx side effects especially gi upset, liver toxicity, anemia and increasing the risk of recurrent infections (chest infection) which indirectly lead to treatment discontinuation and ultimately lead to non-adherence to combination therapy (curtis et al., 2016 ; boers et al., 1997). for the factors which tend to affect patients' adherence, the study showed that the most important factors that encourage the patients to take the drug are; 86.2% due to improvement of joint pain and 79.3% and 65.5% due to disease control and improvement of quality of life respectively. psychological factors are also seemed to be another candidate, 44.8% of adherent patients take the drug due to fear from ra complications, 31% fear from morbidity & mortality and 24% fear from disability. these results were in proximity with what was reported by a study which illustrated that more than 60% of adherent ra patients took the drug regularly due to improvement of pain, up to 30% due to improvement in quality of life and approximately 5% due to fear from disability and long term ra complications with a statistically significant difference (salt et al., 2010). for non-adherence group, there were many factors that affect adherence; some are related to the patients and others are related to the drug itself. the most common patients related causes of decreased patients’ adherence were forgetting the drug in 61.9%, lack of awareness of its importance in disease control in 57.1%, lack of awareness regarding its long term intake in 42.5%, and fear from its side effects in 38.09% which could be related to age and patients’ education. while the main drug-related factors were lack of availability in 42.58%, lack of affordability in 38.09% (which might be attributed to the low socio-economic state, expensiveness and the drug is not available in local pharmacies), intractable side effects in 23.8%, and 14.2% due to difficulty in the mode of intake, especially parenteral intake. 628 global journal of public health medicine 2022, vol 4, issue 1 gggggglo peoples’ negative advice and lack of family support are not uncommon, it constituted about 33.33% and 23.08% of causes of non-adherent respectively. fortunately, no one of the patients had a concept of mtx dependence in long term use. these were highly in agreement with the results of most of the studies had been done on mtx adherence in ra patients with some differences in the percentages (salt et al., 2010 ; calguneri et al., 1999 ; mottonen et al., 1999 ; keystone et al., 2010 ; keystone et al., 2014 ; breedveld et al., 2006 ). limitations: patients’ lost from follow up, mtx intake for less than 3 months, selfdiscontinuation of the drug and multi-drug usage. conclusion: non-adherence to mtx is noted frequently in ra patients, multiple factors encourage or discourage the continuity of mtx intake, some are related to patients themselves while others are related to the course of the disease or mtx itself. recommendations: future researches are highly recommended to study the effect of nonadherence on patient health outcomes, to provide a good patient education and counseling by doctor which might promote patients’ adherence. conflicts of interest the author declares no conflicts of interest. references • angelotti, f., parma, a., & cafaro, g. 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(2016). 2015. american college of rheumatology guideline for the treatment of rheumatoid arthritis. arthritis rheumatol.,68(1):1–26. microsoft word gjphm-2022kap covid19 (1).docx 523 global journal of public health medicine 2022, vol 4, issue 1 gggggglo original research knowledge, perceptions, and preventive practices towards covid-19 during the early stages of the outbreak among saudi people: a cross-sectional study mohammad a. albanghali1*, abdulmajeed a.a. sindi2, yasser m. kofiah3, mohammad s. iqbal4, aisha tabassum4, hussain a. almasmoum4, raed a. alharbi5, doaa a. koufeya6, and mohammed a. shanawaz 1 1department of public health, faculty of applied medical sciences, albaha university, albaha, saudi arabia. 2department of basic medical science, faculty of applied medical sciences, albaha university, albaha, saudi arabia. 3department of general surgery, faculty of medicine, albaha university, albaha, saudi arabia. 4department of laboratory medicine, faculty of applied medical sciences, umm al qura university, al abdeyah, makkah, saudi arabia 5department of laboratory medicine, faculty of applied medical sciences, albaha university, albaha, saudi arabia. 6department of e-learning, deanship of e-learning and information technology, albaha university, albaha, saudi arabia. *corresponding author: mohammad.aref@bu.edu.sa abstract introduction: knowledge of and adherence to preventive measures concerning the transmission of coronavirus disease (2019) (covid-19) remain the frontline strategies to control its spread. this cross-sectional study aims to determine the knowledge, perceptions, and preventive practices towards covid-19 among the general saudi population. methods: a 40-item self-administered online questionnaire concerning knowledge and preventive practices towards covid-19 was developed and validated. the questionnaire was highly reliable (standardized cronbach’s alpha = 0.89). results: a total of 2024 participants were included (60% men; age range: 18 to 73 years). estimated median knowledge and preventive practices score were 63 (iqr = 59–67) and 63 (iqr = 54–68) respectively. the results reflected high levels of knowledge and preventive practices among the participants. the knowledge score and preventive practices score were significantly differed by educational level, work status, region, and purpose of leaving one’s house. correlation analyses demonstrated a significant weak correlation between knowledge and preventive practices (r=0.056, p=0.012). conclusion: this study indicates that majority of saudi people having above average level of knowledge and preventive practices towards the covid-19. health education programs must be designed to target less 524 global journal of public health medicine 2022, vol 4, issue 1 gggggglo educated residents and expatriates. the findings provide a baseline for the knowledge, perceptions, and preventive practices towards the covid-19 pandemic among saudi arabian residents at the early stages of the outbreak. keywords: covid-19, knowledge, preventive practices, saudi arabia introduction coronavirus disease (covid-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (sars-cov2), was first reported in wuhan, china (jin et al., 2020; zhu et al., 2020) and rapidly became a public health crisis (ahn et al., 2020). covid-19 was first declared a public health emergency of international concern on 30th january and subsequently a pandemic on 11th march by the world health organization (who) (who_director-general's, march 2020). since then, cases have increased at an alarming rate, and there is no sign of an end to the pandemic (lee et al., 2020). the virus can be transmitted through droplet inhalation, with increased disease severity and mortality reported in older adults and patients with pre-existing illnesses (chan et al., 2020; leung, 2020; liu et al., 2020). the most common symptom reported among covid-19 patients are fever and cough. other symptoms like shortness of breath, muscle ache, confusion, headache, diarrhea, vomiting have been reported as well.(chen et al., 2020; eastin & eastin, 2020; pan et al., 2020) conjunctivitis and transmission of the virus by aerosol contact with the conjunctiva have also been reported (fu et al., 2020; grant et al., 2020).the who’s recommended general preventive practices include regular handwashing or the use of alcohol-based hand sanitizers; social distancing; and respiratory hygiene, such as covering one’s mouth and nose while coughing or sneezing (who, 2020). presently, the vaccines are available which have shown efficacy in phase three clinical trials were done on a large scale, although novel lineages of sars-cov-2 have been identified globally and these variants can evade human immune responses and vaccination alone might not be sufficient for containing outbreaks.(eastin & eastin, 2020; emary et al., 2021; moore et al., 2021) many countries have experienced a dramatic increase in cases, which has overwhelmed their healthcare systems. currently, in the absence of a cure, supportive therapeutic management is the sole approach for covid-19 (tobaiqy et al., 2020). the covid-19 pandemic is not the first infectious disease outbreak, in recent years—in 2012, middle east respiratory syndrome coronavirus (mers) was discovered in saudi arabia and was responsible for middle eastern respiratory syndrome with the majority of cases reported in the kingdom of saudi arabia. the previous experience with mers has helped in the present times of covid-19 and the saudi health authorities were quick in action in implementing measures to contain covid-19 spread. in the same vein, educating the public on various aspects of covid-19, such as its mode of transmission, infection control measures, and preventive strategies, must be implemented as a routine exercise. (algaissi et al., 2020). 525 global journal of public health medicine 2022, vol 4, issue 1 gggggglo the first confirmed case of covid-19 in saudi arabia was reported on 2nd march, 2020 (moh_saudi_arabia, march 2, 2020). displaying vigilance, the country implemented various measures in compliance with the who’s guidelines (algaissi et al., 2020). these included the suspension of all domestic and international flights; closure of all commercial establishments except pharmacies and grocery shops; and closure of schools, colleges, and universities. analogously, the suspension measures included pray in mosques and pilgrimage tourism. a national curfew was also imposed to contain people’s movement within the kingdom. along with these measures, the general public’s adherence to preventive practices will help combat this pandemic. (west et al., 2020). adherence to infection control practices is greatly influenced by people’s knowledge and perception of disease. behavioural decisions such as effective hygienic practices and social distancing can drive prevention strategies and lessen the societal impact of covid-19 (bavel et al., 2020). public perception and subsequent behavioral changes are greatly influenced by the government’s healthcare approach and governments can intervene through various measures to change health related behaviours among the population (diepeveen et al., 2013; jose et al., 2020). hence understanding the people’s perception is very essential in this regard in order to frame guidelines and their implementation. globally, several studies have examined general public behaviour and individuals’ preventive practices regarding covid-19 (al-hanawi et al., 2020; hezima et al., 2020; meier et al., 2020; narayana et al., 2020; reuben et al., 2020; zhong et al., 2020). this study was designed to determine the knowledge, perceptions, and preventive practices towards covid-19 among the general population of saudi arabia utilising a large sample in the early stages of the pandemic. methods this online survey study, which employed a cross-sectional design, was conducted over 30 days, from 27th march to 28th april 2020. residents of saudi arabia (aged ≥ 18 years) and were willing to participate were eligible for the study. people who had already been diagnosed with covid-19 and were in a hospital/quarantine facility or had been discharged after recovery were excluded. the sample size required to achieve objective of this study (n = 1514) was calculated using epi infotm software (version 7.2.4, 2020; cdc, atlanta, ga, usa). for this step, the total number of people living in saudi arabia (n = 34,218,169) was retrieved from the general authority for statistics, saudi. the confidence interval was 99%, with a marginal error of 5%. ethical approval for this study was obtained from the deanship of scientific research at al baha university, al baha, saudi arabia (1441-28-41206495-2). consent for participation was provided by completion and submission of the questionnaire. a 40-item self-administered online questionnaire to measure knowledge and preventive practices towards covid-19 (covid-19-kpq) was developed and validated by authors based on information available from cdc (cdc, 2020), and its reliability was tested using data collected from 2042 526 global journal of public health medicine 2022, vol 4, issue 1 gggggglo participants. the estimated standardised cronbach’s alpha was 0.89, which demonstrates good internal consistency. to ensure that the covid-19-kpq was comprehensible to the majority of saudi residents, three versions were developed: english, arabic, and urdu. the covid-19-kpq comprised three parts: socio-demographic variables, knowledge and perceptions, and preventive practices. the demographic variables included age, gender, geographical region, nationality, educational level, employment status, place of work, presence of any chronic diseases, history of infection with other coronaviruses, and frequency of venturing outside the home. the second part of the covid-19-kpq consisted of 16 items to assess participants’ knowledge and perceptions of the symptoms and transmission methods of covid-19. the third section contained 24 items that investigated preventive practices to avoid being infected with covid-19. for each participant the covid-19 knowledge score (covid-19-ks) and preventive practices score (covid-19-ps) were calculated by summing the scores from each item as follows; covid-19-ks, for an item making a true statement, the response options were ‘strongly agree’ (score=5), ‘agree’ (score=4), ‘don’t know’ (score=3), ‘disagree’ (score=2), ‘strongly disagree’ (score=1), for an item making a false statement, the responses were recorded reversely. for the covid-19-ps for statements related to a lack of preventive practices, the response options were ‘always’ (score=3), ‘sometimes’ (score=2), ‘never’ (score=1), for statements concerning negative preventive practices the responses were recorded reversely.the ranges for the sum scores of covid-19-ks and covid-19-ps were 16–80 and 24–120, respectively. owing to complete country lockdown, data were collected through non-probability snowball sampling; the authors sent an invitation to participate in this study within their personal networks (colleagues, relatives, friends, etc.) over e-mail and whatsapp. statistical analyses data were analysed using statistical package for the social sciences version 20.0 (ibm corp., armonk, ny, usa). frequencies, percentages, medians, and interquartile ranges (iqrs) were calculated using descriptive statistics. kruskal-wallis h and associated p-value were estimated and reported for the comparison of median scores among different groups. spearman correlation coefficient were conducted to determine the association between the covid-19-ks and covid-19-ps. standardised cronbach’s alpha was calculated to determine the psychometric properties of the covid-19-kpq. statistical significance was set at 0.05. results a total of 2042 (40% women) participants completed the covid-19-kpq. most respondents were saudi citizens (88%), had at least an undergraduate education (60%), and were employed ( %65 ). the participants belonged to all regions of saudi arabia (table 1). 527 global journal of public health medicine 2022, vol 4, issue 1 gggggglo table 1. participants’ demographics and covid-19 knowledge and preventive practices scores. frequency covid-19-ks median (iqr) p covid-19-ps median (iqr) p n % all 2042 100 63 (59–67) 63 (54–68) age (years) 18–30 674 33 63 (59–67) 0.190 62 (52–67) 0.004 31–49 1006 49 64 (59–68) 63 (54–68) ≥ 50 362 18 62 (59–66) 64 (55–68) gender women 818 40 63 (60–68) 0.210 63 (53–68) 0.974 men 1224 60 63 (59–67) 63 (53–68) nationality saudi 1788 88 63 (59–68) 0.044 63 (53–68) 0.347 non-saudi 254 12 62 (58–67) 64 (54–67) educational level general education ‡ 368 18 60 (56–65) <0.001 64 (54–68) 0.010 undergraduate education 1226 60 63 (59–67) 63 (54–68) graduate education 448 22 66 (62–70) 62 (53–66) work status employed 1332 65 64 (59–68) 0.017 64 (55–68) 0.002 unemployed 342 17 62 (59–67) 62 (49–67) student 368 18 62 (58–67) 63 (51–67) working site home-based‡ 782 62 64 (59–68) .127 63 (54–68) .333 outside the home 482 38 64 (59–68) 64 (56–68) region al baha 435 21 64 (60–67) <0.001 63 (54–67) 0.009 eastern province 191 9 62 (58–66) 64 (53–68) makkah 458 22 64 (60–68) 62 (54–67) aseer 82 4 60 (58–65) 64 (52–70) najran 106 5 60 (57–65) 63 (53–68) jazan 67 3 64 (60–68) 60 (49–63) riyadh 218 11 64 (59–70) 61 (51–67) qassim 94 5 65 (60–67) 63 (56–67) medina 104 5 63 (60–69) 64 (54–68) hail 92 5 61 (58–67) 64 (51–68) tabuk 60 3 64 (61–66) 65 (60–68) northern border province 135 7 63 (57–67) 63 (56–69) chronic disease presence 442 22 63 (59–67) 0.530 64 (55–68) 0.142 absence 1600 78 63 (59–68) 63 (32–44) previous infection with any coronavirus (non-covid-19) yes 30 1.5 60 (52–69) 0.360 55 (36–68) 0.084 no 2012 98.5 63 (59–67) 63 (54–68) frequency of leaving one’s house never 184 9 63 (60–65) 0.467 64 (50–68) 0.225 once a week 574 28 63 (59–68) 63 (53–63) twice a week 408 20 63 (59–68) 63 (55–67) four times a week 732 36 64 (60–67) 63 (54–68) more than once per day 144 7 64 (59–68) 60 (53–66) purpose of leaving one’s house necessary⸙ 1844 98 63 (59–68) 0.004 63 (54–68) 0.003 unnecessary 38 2 60 (57–63) 53 (48–63) *p-value calculated using the kruskal-wallis h test; iqr: interquartile range; covid-19-ks: covid-19 knowledge score; covid19-ps: covid-19 preventive practices score, ‡ general education includes participants of which their highest education is primary, secondary or high school; home-based employment indicates participants had to work at home due to role applied by government during the lockdown,⸙ necessary leaving of one’s house (e.g. going out for groceries or medication, work, receiving healthcare services, etc.). 528 global journal of public health medicine 2022, vol 4, issue 1 gggggglo the median covid-19-ks score was 63 (iqr = 59–67), while 100% of the participants obtained a score > 50%. most participants (96%) knew that touching the nose, mouth, or eyes after contacting a contaminated surface was one way of spreading sars-cov2 along with exposure to aerosols from an infected person’s sneezing or coughing. there was uncertainty among respondents regarding the risk of infection from asymptomatic individuals with covid-19 (53%). in addition, 43% of the participants were unaware that fever and sore throat are common symptoms of covid-19. only 46% of the respondents answered correctly regarding either the use of sanitiser (ethyl alcohol) or washing hands as beneficial for hand hygiene. only one-third answered correctly when asked if contact with animals increased the risk of infection with covid-19 (table 2). table 2. a comparison of the frequencies of favourable and other responses. question favourable response n (%) knowledge and perceptions of the symptoms and transmission methods of covid-19 1 the symptoms of covid-19 are similar to those of the common flu; they include nasal congestion, cold, or sore throat. 1490 (73%) 2 some people may be infected by covid-19 without showing any symptoms. 1716 (84%) 3 one of the signs of infection of covid-19 is that the body temperature is above average (i.e. > 37 degrees celsius). 1668 (82%) 4 one of the signs of infection of covid-19 is the discolouration of the skin and the appearance of skin ulcers. 776 (38%) 5 the severity of symptoms of covid-19 increases in the event of a chronic disease such as diabetes, high blood pressure, heart disease, etc. 1756 (86%) 6 shortness of breath and dry cough are the main symptoms of covid-19. 1886 (92%) 7 a simple sore throat accompanied by a slight rise in body temperature is not classified as one of the symptoms of covid-19. 1172 (57%) 8 smoking plays a role in increasing the aggressiveness of the symptoms of covid-19. 1494 (73%) 9 touching your eyes, nose, or mouth after contacting contaminated surfaces is one of the ways of spreading covid-19. 1986 (97%) 10 getting within one metre of people with covid-19 may lead to infection via air-borne transmission of the virus. 1778 (87%) 11 contact with animals increases the chance of getting infected by covid-19. 668 (33%) 12 one way to spread covid-19 is through exposure to flying mist from an infected person’s sneezing or coughing. 1968 (96%) 13 there is no risk of being infected with covid-19 through contact with asymptomatic people. 1090 (53%) 14 there is a possibility of disease transmission from one person to another during the incubation period of covid-19 (time gap between entry of the virus and appearance of signs and symptoms). 1758 (86%) 15 using ethyl alcohol-sanitising products to sanitise hands is the only way to get rid of hand-held viruses. 934 (46%) 16 sharing personal belongings and other equipment (toothbrush, hookah, etc.) with infected people may lead to being infected with covid-19. 1858 (91%) 529 global journal of public health medicine 2022, vol 4, issue 1 gggggglo preventive practices to avoid getting infected by covid-19 1 i immediately contact 937 when experiencing any covid-19 symptoms. 1884 (92%) 2 i wear a mask, gloves, and/or other protective products when dealing directly with individuals who may have covid-19 living. 1862 (91%) 3 when leaving the house to buy food and other supplies, i prefer to visit large commercial places and store chains. 1582 (77%) 4 when leaving the house to buy food and other supplies, i avoid buying vegetables and fruits from street vendors or those standing by the side of the road. 1770 (87%) 5 when leaving the house to buy food and other supplies, i wear gloves. 1816 (89%) 6 when leaving the house to buy food and other supplies, i make sure to wash and sanitise my hands. 1990 (97%) 7 after purchasing food and supplies, i sterilise all the purchases and dispose of all carry bags before bringing everything inside the house. 1814 (89%) 8 i make sure to avoid using banknotes or coins; i use electronic payment methods instead. 1928 (94%) 9 when leaving the house to buy food and other supplies, i only purchase necessities. 1894 (93%) 10 i make sure to reduce the number of times i leave the house by buying the weekly/monthly needs in one trip. 1932 (95%) 11 i avoid buying ready-made foods from restaurants and always rely on preparing food at home. 1912 (94%) 12 i rely on delivery services when purchasing my supplies. 1490 (73%) 13 i make sure to wash my hands with soap and water regularly for at least 30 seconds each time. 1912 (94%) 14 i cover my mouth while coughing and sneezing. 1990 (97%) 15 i appropriately and immediately dispose of any waste that may carry the virus (such as wipes used for sneezing or wiping surfaces). 1984 (97%) 16 while i am in my workplace, i avoid indoor gatherings with several people. 1808 (88%) 17 while i am in my workplace, i avoid eating meals with my colleagues. 1666 (82%) 18 while i am in my workplace, i wear a mask and/or gloves. 1676 (82%) 19 while i am in my workplace, i make sure to wash and sterilise my hands regularly. 1786 (87%) 20 while wearing gloves, i use my mobile and some other personal belonging. 1228 (60%) 21 while i am in the workplace, i keep a minimum distance of one metre from other people 1774 (87%) 22 i make sure to dispose of used gloves properly. 1974 (97%) 23 i wear gloves or sterilise my hands after using an atm to withdraw cash. 1932 (95%) 24 when leaving the house to buy food and other supplies, i wear a mask. 1856 (91%) the analysis indicated that the knowledge score was significantly different based on nationality (p=0.044), educational level (p<0.001), work status (p=0.044), region (p<0.001) and purpose of leaving one’s house (p=0.004) (table 1). there was a significant difference in knowledge between saudi nationals and non-saudi respondents, with the former obtaining higher scores. more (vs. less) educated participants scored higher. those who resided in qassim had higher knowledge scores in contrast to people from other regions, whereas the lowest score was reported from the aseer and najran regions. those who left their homes for groceries or medication, work, receiving healthcare services knew significantly more about the disease in contrast to people leaving house for unnecessary purpose. the students and unemployed who participated in this study were less knowledgeable in comparison to the participants who were employed. 530 global journal of public health medicine 2022, vol 4, issue 1 gggggglo preventive practices towards covid-19 a total of 97% of the participants were aware of basic preventive practices such as covering their mouth and nose while coughing and sneezing, handwashing, using sanitiser often, and properly disposing of used wipes and gloves. more than 90% of the participants preferred electronic modes of payment instead of using banknotes or coins, preferred to eat at home instead of buying food from a restaurant, followed preventive practices when dealing with individuals suspected of having covid-19, and preferred staying at home and not going out unnecessarily or frequently. a significant incorrect practice reported by 60% of respondents was the usage of individual belongings, such as a mobile phone, after wearing gloves. other practices are described in table 2. the median covid-19-ps score was 63 (iqr = 54–68), while analyses indicated that 88% of participants scored > 50% on the covid-19-kp. participants aged > 50 years were more likely to engage in preventive practices than their younger counterparts (p=0.004). there was a significant regional variation among followers of preventive practices (p=0.046): the highest scores were seen in participants from tabuk regions, whereas those from jizan did not follow all practices promptly, and their scores were low compared to other regions. employed (p=0.002) or participants with general education level (p=0.01) were showed higher scores for following preventive practices. association between knowledge and preventive practices towards covid-19 scores on the covid-19-ks and covid-19-ps were significantly correlated; however, this association was weak (spearman correlation coefficient; r=0.056, p=0.012). although participants from qassim, jizan had a high knowledge score, their implementation of preventive practices was low; however, the opposite was true for participants from the aseer and hail region. knowledge scores were positively correlated with practice scores for a few characteristics. however, evidence suggests that there are various factors other than knowledge that influence the implementation of preventive measures towards covid-19 (figure 1). 531 global journal of public health medicine 2022, vol 4, issue 1 gggggglo figure 1. correlation between the covid-19 knowledge score (covid-19-ks) and the preventive practices score (covid-19-ps). discussion this study was conducted at the end of march 2020, when the pandemic was in the early stages and the level of people’s general understanding of covid-19 was not clear . our study included a large cross-section of the adult population representing various regions of saudi arabia. to the best of our knowledge, this is the second study examining knowledge of and adherence to preventive measures towards covid-19 utilising a large sample size from various regions of saudi arabia. al-hanawi et al. (2020) conducted a similar study during the same period. our study indicated that most respondents were fairly knowledgeable about covid-19, which was consistent with al-hanawi et al.’s results (alhanawi et al., 2020). various other reports worldwide have also shown a similar level of knowledge regarding covid-19 among the general population (azlan et al., 2020; gao et al., 2020; hezima et al., 2020; honarvar et al., 2020; hussain et al., 2020; kebede et al., 2020; mehrotra et al., 2020; papagiannis et al., 2020; reuben et al., 2020; saqlain et al., 2020; zhong et al., 2020). saudi arabia has successfully dealt with past infectious outbreaks such as sars and middle east respiratory syndrome (al-tawfiq et al., 2014). in saudi arabia, an early curfew helped curb the spread of covid-19, and most people were at home and had access to covid-19-related information from sources such as television, social media, and ministry of health (moh) notifications (alshammari et al., 2020). however, there is also a possibility of the spread of false information about covid-19 through social media, as reported in other similar studies (barua et al., 2020; yusof et al., 2020). most respondents knew about how the disease spreads; however, nearly half were unaware that fever and sore throat are common symptoms, and 53% were unaware that asymptomatic patients can transmit 532 global journal of public health medicine 2022, vol 4, issue 1 gggggglo the infection. these issues need to be addressed by the authorities by assuring that authentic information is disseminated to all along with keeping a check on spread of false information related to signs and symptoms of covid-19. a high knowledge score was noted in saudi respondents, whereas a low score was reported in the expatriate group. this might be owing to differences in educational levels among expatriate participants. non-saudis may not be well versed in arabic, and they might have difficulties in understanding and following the health advisories delivered through social media, moh alerts via sms services, and guidelines displayed on hoardings. however, this issue was subsequently addressed, with the moh releasing guidelines in 10 languages (moh_saudi_arabia, 2020). in our study, most participants were well-versed with preventive practices and were following them, especially older adults. similar findings were reported in studies conducted in the netherlands, germany, italy, iran, australia, and pakistan (afzal et al., 2020; meier et al., 2020; seale et al., 2020). our study also showed that there was less of a likelihood of wrong practices and negative attitudes in participants with high knowledge scores. most respondents were aware of basic hygienic practices and the need for disposal of contaminated waste. however, 53% were not aware that asymptomatic patients can also transmit the infection. a similar finding was previously reported—that 69% of participants did not know that covid-19 can be transmitted by asymptomatic patients (kebede et al., 2020). 60% participants were also unaware that the handling of mobile phones or any other personal belongings with gloves is not an advisable practice. the reason could be due to non-clarity of messages given to public regarding conduct while wearing hand gloves as well as due to a casual attitude towards the disease, or an incorrect perception about disease transmission. during the covid-19 pandemic, the rules and regulations enacted by the saudi government could have promoted preventive practices before the related knowledge was obtained. this was clear from the low (although significant) correlation between knowledge and preventive practices scores. further investigation is required to reveal the influencing association between practising preventive measures and confounding factors such as laws and policies. this study has a few limitations. owing to recruitment through online snowball sampling, there is insufficient evidence to estimate or report a response rate. in addition, as the recruiting strategies directly influenced the number of participants from each region of the country, gender and nationality, the sample’s representativeness might have been affected. however, most participants were from three geographical regions—makkah, albaha, and riyadh—which account for approximately 50% of the total population of saudi arabia. this may, to some extent, support the generalisability of the findings (general authority for statistics, 2019). furthermore, the resident participants were more in number than their expatriate counterparts. this might have been owing to expatriates’ limited access to the online questionnaire. moreover, circumstances surrounding the lockdown like unavailability of internet connection at home and closure of public transport facilities to reach out, which might have limited 533 global journal of public health medicine 2022, vol 4, issue 1 gggggglo chance to participate in this study. at early phase of the pandemic, associations such as that between smoking or animal contact with chances of getting affected by covid-19 or severity of the disease might were not clear, however, analysis of data and responses from participants were carried taking into account available evidence on current literature. conclusion this study found significant differences in participants’ knowledge of covid-19 based on age, gender, educational level, and place of residence. health education programs should target less-educated residents, and expatriate populations. health education programmes directed at disseminating accurate covid-19 knowledge may foster optimistic attitudes and appropriate practices. in sum, the current findings highlight the knowledge, perceptions, and preventive practices towards covid-19 among saudi residents in the early stages of the pandemic. furthermore, evidence from this study emphasis the need for further exploring factors influencing association between knowledge and practices toward covid-19. conflicts of interest the author declares no conflicts of interest. references • afzal, m. s., khan, a., qureshi, u. u. r., saleem, s., saqib, m. a. n., shabbir, r. m. k., . . . ahmed, h. 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(2020). a novel coronavirus from patients with pneumonia in china, 2019. n engl j med, 382(8), 727-733. https://doi.org/10.1056/nejmoa2001017 microsoft word gjphm-2021traditional birth revised.docx 479 global journal of public health medicine 2021, vol 3, issue 2 gggggglo original research health care providers’ views concerning knowledge and practices of traditional birth attendants in tajikistan: a qualitative study dilofarid miskinzod women’s and gender studies program, college of social and behavioral sciences, northern arizona university, flagstaff, arizona, usa *corresponding author: dilofarid.miskinzod@nau.edu abstract introduction: this study seeks to explore health care providers’ perspectives of the traditional birth attendants’ knowledge and practices. methods: this qualitative study was conducted in 2018 with 16 health care professionals working at various levels of maternal health care system in two purposefully selected research settings, khorog town and dushanbe, which have different social, economic and ethnic backgrounds. semi-structured face-to-face interviews were conducted to gather the data. duration of interviews ranged from 30-60 min. nvivo software for qualitative research was used to analyse the results. results: this study has shown that health care workers have extremely negative views of the knowledge and practices of traditional birth attendants. they highlight the lack of adequate knowledge of traditional birth attendants on biomedical aspects of birth, poor skills in infections control and lack of use of clean delivery practices. they also claim that the traditional birth attendants’ practices also lead to different complications while they are woefully unprepared to recognize obstetric complications during birth. conclusion: the study recommends providing a skilled birth attendant in every area. it also recommends avoiding a homogeneous approach to address maternal health issues in diverse countries of the global south and reviewing maternal health care policies and programs to provide the most marginalized groups of women with skilled birth services to improve their maternal health and further decrease maternal mortality in tajikistan. keywords: traditional birth attendant, unsafe practices, home birth, tajikistan 480 global journal of public health medicine 2021, vol 3, issue 2 gggggglo introduction before the emergence of modern obstetric services, traditional birth attendants (tbas) had been providing obstetric services to women during pregnancy, childbirth and after the birth for a long period of time (aziato & omenyo, 2018). they have historically been the main caregivers for women during delivery. the world health organization [who] (1992) defines a tba as “a person who assists a mother during childbirth and who initially acquired her skills by delivering babies herself or through apprenticeship to other traditional birth attendants” (p. 18). thus, tbas comprise of individuals who help women during childbirth, but unlike skilled birth attendants (sbas) (nurses, doctors, midwives) who have training in the obstetric skills and services vital to assisting normal deliveries, tbas learn to deliver babies through apprenticeships, attain their skills by delivering babies themselves (patzer, 2008; pyone et al., 2014) or observations made during deliveries (pfeiffer & mwaipopo, 2013). in a study in ghana, most tbas received apprenticeship from close relatives including mothers (aziato & omenyo, 2018; pfeiffer & mwaipopo, 2013). the tbas learn on the job and therefore may not take advantage of scientific and standard practices of delivery (aziato & omenyo, 2018). strictly speaking, “the term tba only refers to traditional, independent (of the health system), informally trained and community-based providers of care during pregnancy, childbirth, and postnatal period” (pfeiffer & mwaipopo, 2013, p. 55). one of the key benefits of tbas for women in the local community is their proximity (gurara et al., 2019). this is especially important in remote and rural areas where access to primary and secondary health care facilities is difficult because of lack of transportation and its high cost, and other financial, social, and economic reasons (aziato & omenyo, 2018; pyone et al., 2014). they are not paid in cash for the obstetric skills and services they provide to women in the rural areas (pyone et al., 2014), but are paid in kind (pfeiffer & mwaipopo, 2013; pyone et al., 2014). these aspects of the nature of the work of the tbas are considered as strengths that the official health care system has tried to leverage (pyone et al., 2014). unfortunately, tbas are also often accountable for implementing possibly unsafe cultural practices or for delaying and not seeking specialized medical assistance in case of emergency obstetric complications (chi & urdal, 2018; gurara et al., 2019, lane & garrod, 2016). they have been also criticized for unsafe practices including lack of hygiene during delivery practices and mismanagement of complications (aziato & omenyo, 2018; chi & urdal, 2018; pfeiffer & mwaipopo, 2013). there have been concerns regarding transmission of hiv between the tbas and the women they help due to lack of use of infection control measures (aziato & omenyo, 2018; chi & urdal, 2018; pfeiffer & mwaipopo, 2013). the opinion regarding tbas throughout the globe has been changing over last years (gurara et al., 2019). the who and partners such as other agencies of the united nations initially promoted the use of tbas during home births if they had received adequate training (choguya, 2014; gurara et al., 2019). these organizations promoted it as a global public health strategy to decrease maternal mortality (choguya, 2014). therefore, from 1970s until the early 1990s, training of tbas was considered as an important intervention to decrease the high maternal and infant mortality and morbidity rates (gurara et al., 2019). this strategy was accepted and implemented in more than seventy countries of the global 481 global journal of public health medicine 2021, vol 3, issue 2 gggggglo south which suffered from the lack of sbas (gurara et al., 2019). nevertheless, the program was reformed and revised in the late 1990s due to evidence demonstrating little impact of tbas’ training on the decrease of maternal mortality without the help of sbas from healthcare institutions (gurara et al., 2019). as a result, tbas were essentially disregarded throughout the 1990s. instead, based on numerous studies, the global health community recommended that tba training was cost ineffective and had little influence (hobday et al., 2018). these studies concluded that the training of tbas seems to have had minimum impact on maternal mortality in the countries of the global south. thus, it was suggested to replace this strategy by a new strategy under which more professional midwives were to be trained (choguya, 2014; hernandez et al., 2017; walraven & weeks, 1999). after the global evidence showed the ineffectiveness of tbas training, the new who guidelines on tbas’ practices recommend rendering companionship and assistance during pregnancy and delivery, in addition to health promotion as the most appropriate way in which the tba skills are to be employed (pyone et al., 2014; thatte et al., 2009). this is a complete shift from the previous scope of tba training which sought to prepare them to identify mothers and newborns at high risk, to deliver low-risk women safely at home, and to refer women with risk or with diagnosed obstetric complications to a medical institution (pyone et al., 2014). under this new strategy, tbas receive training and orientation to be able to practice as health promoters and birth companions, instead of their traditional role of delivering women at home and referring women to a medical institution only when they develop complications (pyone et al., 2014). therefore, tbas were educated as “health promoters” and “birth companions” and were connected with certain health care facilities (pyone et al., 2014, p. 41). their training comprised of a focus on the importance of antenatal care, recognizing the dangers of a home birth, and the advantages of a birth at a medical institution (pyone et al., 2014). the main research question guiding the current research is: how do health care professionals perceive the knowledge and practices of tbas in tajikistan? the existing literature on tbas provides some valuable information on the knowledge and practices of tbas from various research settings around the world. however, there is a paucity of information regarding the perspectives of health care providers about the knowledge and practices of tbas. therefore, this study provides additional insight on the subject of tba from this important angle, because most previous studies have inadequately explored the viewpoints of health professionals by mainly focusing on the standpoints of tbas regarding their own practices. changes in a birthplace and care in tajikistan and their impacts during the soviet period, tajikistan similar to other soviet republics benefited from the soviet system of free and universal health care system (falkingham, 2003; habibov & fan, 2008; wiegers et al., 2010). the rate of the utilization of health care was high and there was a negligible difference in its usage among different groups of population. during the soviet period, pregnant women received comprehensive antenatal care in a health facility, and most births took place in maternity wards 482 global journal of public health medicine 2021, vol 3, issue 2 gggggglo (falkingham, 2003). as a result, most women had their deliveries attended by midwives and obstetricians (falkingham, 2003). the utilization of maternal health care services, including health care institutions for birth, has decreased dramatically since independence resulting in an increasing home birth rate and, a significant rise in the number of women giving delivery at home without a sba (falkingham, 2003; wiegers et al., 2010). with the dissolution of the union of soviet socialist republics [ussr] the universal free-of-charge health care system has fragmented. in addition, civil war resulted in a long and deep economic recession that has negatively impacted the healthcare system in tajikistan (balabanova et al., 2004; wiegers et al., 2010). after the independence, poor families could not afford even a trip to the hospital due to the increasing costs (falkingham, 2003). changes in the setting of delivery and the individual providing assistance, where a clear shift was observed from giving birth in a medical setting with sba towards giving birth at home without skilled attendance. the maternal health survey undertaken in karategin valley by medecins sans frontieres indicated that 83% of women delivered at home and 63% of all women delivered with tbas being present (skinnider, 2000). these changes also resulted in an increase in maternal mortality rate [mmr] in tajikistan. however, with the improvement of socio-economic situation and life and the reduction of poverty rate in the country, a reverse shift happened again. the demographic and health survey [dhs] conducted in tajikistan in 2012 showed that 77% of women delivered their babies at a medical institution and 23% at home (statistical agency under the president of the republic of tajikistan [saprt], the ministry of health of the republic of tajikistan [mhrt] & icf international, 2013). a recent study shows that health care providers argue that most urban and many rural women give births in health care facilities again (miskinzod, 2020). as a result, mmr decreased in the country. maternal health outcomes’ trend shows that the type of obstetric services which tajik women receive impacts their maternal health. the mmr for ussr (tajikistan was a part of ussr until 1991and there is no data on mmr for tajikistan alone) was 43 per 100,000 live births in 1988 (baranov, 1991). mmr was at 68 deaths per 100,000 live births in 1990. it then significantly increased to 120 in 1995 and then dramatically decreased to 85 in 2000 and further to 59 in 2005 and approached 44 deaths per 100,000 live births in 2013 (who, 2014) (figure 1). the mmr was at 17 per 100,000 live births in 2017 (republican medical statistical center under the ministry of health and social protection of the republic of tajikistan [rmsc], 2018). the data show that mmr worsened dramatically following the collapse of the ussr and the civil war. it was also time that more women did not receive antenatal care and gave birth to their babies at home without skilled attendance. it then stabilized by 2005 when the government with donor support implemented several interventions in the health care sector. with more women giving birth at a health care facility and with the improvement of antenatal care, mmr decreased (miskinzod, 2020). 483 global journal of public health medicine 2021, vol 3, issue 2 gggggglo figure 1: trends in maternal mortality rate from 1990 to 2013 in tajikistan methods sample selection to understand health care workers’ perspectives regarding the knowledge and practices of tbas and their impact on maternal health in tajikistan, i used qualitative research method with social constructivist and critical interpretive approaches. the only eligibility criterium was work experience with women during pregnancy, delivery, and postnatal period. health care professionals were from different layers of maternal health care system, such as maternity hospitals, reproductive health centers and a private clinic. study respondents were doctors of obstetricians and gynecologists. the respondents were quite homogeneous in terms of their education background. the mean work experience of study participants was 31 years. in-depth semi-structured interviews were conducted with sixteen purposefully selected health care professionals. the study was conducted in two purposefully selected research settings, khorog town and dushanbe city, which represent people with different social, economic, and ethnic backgrounds. 0 30 60 90 120 150 1990 1995 2000 2005 2010 2013 484 global journal of public health medicine 2021, vol 3, issue 2 gggggglo data collection an in-depth, semi-structured, problem-centered individual interviews were conducted with health care providers to collect data. an interview guide based on prior literature included questions about the knowledge and practices of tbas. the interviews were conducted in shugni, tajik, and russian depending on respondent’s preferences. the author of the study conducted all interviews and speaks fluently all three languages. the institutional review board of the northern arizona university and the ethical committee of the ministry of health and social protection of the republic of tajikistan approved the study. each participant was provided with details of the study prior to the interview and the consent form. oral consent was obtained and recorded on digital recorders with the permission of the respondents. the interviews were conducted face-to-face in the respondents’ office (private setting) and lasted from 30 to 60 minutes. three participants of the study refused to be recorded and the author took detailed notes during these interviews. all interviews and notes were fully transcribed verbatim in the language they were originally conducted, and then translated into english for coding and analysis purposes by the author. data analysis the transcripts were analyzed using nvivo software for qualitative data analysis, version 12 plus, 2019 (qsr international pty ltd, 2019). transcripts were read numerous times before coding them for initial codes. codes were extracted across all transcripts. the research question directed initial coding and when new concepts emerged, they also guided the coding process. single codes or those irrelevant to the research question were removed. the remaining codes were tested against the data to guarantee reliability of coding and face validity (i.e., that they mirror the meaning given to them by the respondents). all initial codes were examined to identify overarching themes. the emerging themes were carefully and deliberately examined. similar factors in both research settings were used to merge them into common and atypical themes. relevant documents were also reviewed. careful reading of documents led to the creation of a coding template with themes and subthemes of interest in nvivo. the coding template guided extraction of excerpts from analyzed documents and they were added to the appropriate sections of the template. there are limitations which should be taken into consideration when considering the study findings. they include the retrospective nature of the study. the reflective nature of the interview methodology itself invites the interviewees to recall information from the past; there is, therefore, a high chance of a recall bias. the power dynamic between the interviewer and interviewee could be another limitation. although the researcher tried to use the self-reflexivity method to avoid reproduction of inequality in the research (naples & sachs, 2000). 485 global journal of public health medicine 2021, vol 3, issue 2 gggggglo results poor and inadequate knowledge of tbas qualitative research findings in the research settings suggest that most health care providers in the present study expressed complete dislike for tbas criticizing them of having poor, insufficient and inadequate knowledge of pregnancy and birthing practices. study respondents argue that the tbas’ poor knowledge is a result of not receiving any special training or education on obstetric skills, practices, and services. these claims/statements were captured in the following quotes: i am very sceptical about tbas. i do not think that they have sufficient knowledge about birth. they do not have a medical knowledge (r12). i have a very negative opinion about them. i asked [them] “how do you (i.e. a tba) know that it is time for a woman to have a baby?” she [i.e. tba] said: “when i see”, showing on her finger, “that this much is left, then i know that she is about to give birth.” they basically do not know anything. they did not study (i.e. study in a medical college or university) and are not aware of these aspects. she (i.e. tba) says that it all depends on her finger. they only know by finger. they basically do not have any other anatomical or physiological knowledge about birth (r2). according to some health professionals, the poor knowledge is the reason that tbas are not aware of anatomical and physiological aspects of birth, stages of birth, how to properly manage the third stage of the birth, how to deliver a baby, how to manage each stage in particular, and childbirth in general as well as not being able to demonstrate an active management of the third stage of the birth. they also cannot give injections such as an oxytocin if there was a need according to study respondents. the health care workers also suggest that the poor and inadequate knowledge of tbas about obstetric practices may potentially harm the health of new-borns. i think they are uneducated. they do not have a special training, neither this nor that. they do not even know how to deliver a baby; how to manage the placenta (posled); and how to manage the third stage of the birth. many new-borns can become disabled (invalid) as a result (r1). for example, they do not know about the active management of the delivery. a midwife would prepare an injection of oxytocin for herself. she would perform a massage of uterus and this and that, but tba will not know what a massage of uterus is, and what a management of the birth is (r2). 486 global journal of public health medicine 2021, vol 3, issue 2 gggggglo thus, one of the main findings of the present study is a significant gap in knowledge of tbas. however, health care providers, who were all doctors of obstetrician gynaecologists, held a very positive view about midwives or nurses assisting during birth due to them having medical education/training. i am not for this. i have never supported this. i do not support when deliveries are assisted by tbas. midwives, yes. births should be assisted by midwives, those who have medical education. i do not support tbas. it is ok for women to choose to have home delivery, but it should be attended by medical personnel (meaning sbas) (r9). failing to follow clean birth practices health care providers also argue that tbas had poor skills in infection control and were not aware of the importance of clean and hygienic birth practices during delivery and postnatal period. the health care workers state that they do not use clean and sterile delivery materials such as new or sterilized/disinfected scissors or cord cutting materials, clean sheets, and towels. they [i.e. tbas] do no use sterile material, because they simply can use any cloth that is available. i am confident that even her [tba’s] scissors are not sterile. so, there will be microbe and then infection (r3). i do not think that they even know how to sterilize their scissors or use clean sheets or cloth during delivery, and it is a very big concern for me (r13). many respondents of the study also state that tbas do not use gloves to prevent transmission of infections and fail even to protect themselves from different infections such as hiv/aids and hepatitis. health care workers also argue that without adequate infection control skills, tbas cannot prevent and manage infections, which might lead to complications in the postnatal period. failing to follow clean birth standards/practices might also predispose the tbas themselves to infections and could even turn them into becoming vectors for transmission. the following quotes will show this way of thinking: they do not even wear gloves when they assist women during birth… above all, they do not wear gloves to protect even themselves from all the infections including hepatitis, hiv, and particularly hiv (r2). they do not follow hygienic norms even for their own safety. they often do not sterilize their material that they use during deliveries (r12). 487 global journal of public health medicine 2021, vol 3, issue 2 gggggglo i am very distrustful about tbas. i do not think that they have sufficient knowledge about birth. they do not have medical knowledge and they do not follow hygiene norms even for their own safety. they often do not sterilize the material they use during deliveries (r16). management of complications and poor maternal health outcomes health care providers interviewed for this study state that tbas have lower professional competence due to issues such as inability to recognize early and manage obstetric complications that might be fatal for women. tbas are not aware of standard practices to identify obstetric complications including determining whether it is a postnatal haemorrhage or a normal loss of blood after a birth. they use visual observation to identify excessive bleeding instead of using standard measurement of postnatal haemorrhage which is, as well known, dangerous. only one health care provider despite her negative view of tbas highlights that tbas are only useful for emergency cases when sbas are not available. we see these sentiments from the below quotes: if a woman losses blood after birth, it will also lead to anaemia. i doubt whether she [i.e. a tba] knows what the normal loss of blood is, and what is not. she would think that it is a normal blood loss after the delivery (r1). i do not support them [i.e. tbas]. they do not provide good quality care. i do not believe they can learn a lot from a short training that they receive if they receive any at all. however, i think in the emergency situation, it is better to have them [present during delivery] than no one. at least they know how to deliver the baby and cut cord. so, they are good only for the extreme and emergency situations when there are no other health care workers available (r16). some health care providers argue that tbas are not able to provide medical assistance when complications arise during deliveries. for instance, tbas cannot stitch tears of vagina and vulva after childbirth which leads to cystocele (when the wall between the bladder and the vagina weakens and the bladder drops from its normal position in the pelvis and pushes on the wall of the vagina) and poor maternal health outcomes. some women who receive assistance from tbas during their delivery would later need genital surgery. many health care providers highlight that the use of tbas has a negative impact on the maternal health of women in tajikistan. they do not know how to manage the third stage of delivery – the placenta management. for example, when a piece of placenta retains in the uterus, they do not know how to manually remove it. they also cannot inject oxytocin. they are also not able to stitch the tears during deliveries. women come and their vaginas are ripped and were not stitched properly. their vaginas look so bad, and these women then need to have genital surgeries. this also results in poor maternal health (r3). 488 global journal of public health medicine 2021, vol 3, issue 2 gggggglo i do not support when nonmedical personnel deliver births. it already impacts maternal health. if a woman has vaginal tears, she will then develop cystocele, and later other complications. then when a woman comes [to us], her anus and vagina are interconnected. she will lose all her health (r9). rare positive perspectives only few health care providers expressed positive view about the use of tbas during childbirth. one of them states that if she encounters delays in reaching a woman to assist a childbirth at home and by the time, she arrives a tba has already assisted the woman, it leads to good results. i think they do well. sometimes, people ask me to come to assist with the birth. by the time i arrive, i see tbas already delivered the baby, cleaned her spot, and the woman does not have any tear after birth. i think it is normal. those who are traditional birth attendants (pirzecha) are quite good (r4). despite very negative views about tbas, two other respondents appreciate that they avoid using unnecessary medical interventions during delivery. they even compare their management of a childbirth with the one that who recommends at present. in particular, health workers highlight who advocacy for a minimum use of medical interventions during delivery. on the one hand, they do not touch the woman unnecessarily – this is the only advantage of giving birth with tbas. the most ancient traditional birth attendants did not intervene so much in the physiological process of birth. they do not touch unnecessary women without any need…… birth therefore unfolds as a physiological process without a medical intervention. but she [i.e. a tbas] also does not do anything about the placenta (r2). yes, there are some old women who assist women during deliveries in some places. do you know that their methods (metodika) are quite ancient? it is very similar to the one used during the standard management of delivery protocols. it is almost the basis of the standard management of delivery. the only aspects missing are the use of oxytocin and placenta management. they manage complications that is called [locally] ar poth thod [i.e. when baby is in oblique position] very well (r3). 489 global journal of public health medicine 2021, vol 3, issue 2 gggggglo discussion most of the existing literature devoted to the study of tbas focus on their perspectives regarding their knowledge and practices although they are set in very diverse research settings. however, insights of the health care professionals about the knowledge and practices of the tbas have not been adequately explored. this paper explores the view of health care workers on tbas’ knowledge and practices and therefore not only opens new avenues in the study of this subject, but also can potentially improve our understanding of this very important topic. a strong critique of tbas and negative viewpoint about their knowledge and training among the health care workers interviewed for this study are among the main findings of the current study. a thorough analysis of responses of health care workers shows that such a viewpoint is mainly based on the poor and inadequate knowledge of tbas in terms of different anatomical and physiological aspects of birth. the tajik health care workers consider tbas’ knowledge as insufficient to safely manage births. this finding is in line with kruske and barklay (2004) who also state that the tbas’ knowledge, including those who were instructed by health care workers, was considered as inferior and did not have professional eminence. a study in tanzania also shows that most tbas did not possess comprehensive bio-medical proficiencies, skills, and resources (pfeiffer & mwaipopo, 2013). health care providers in the present study connect the poor knowledge of tbas with the fact that the latter do not receive any special training or education on obstetric skills and services. similar to the findings of the current research, several studies have also reported that tbas receive negligible training and education and, even those who receive, training, require the assistance of skilled health care services (adatara et al., 2018). the study in ghana emphasizes that while tbas have not been officially educated to assist births, they have been helping women deliver their babies at home for years (adatara et al., 2018). the finding in ghana resonates with the situation in tajikistan, where tbas without any or some training on obstetrics also assist women yet they lack knowledge of different aspects of childbirth. lack of knowledge of tbas is an important finding that needs to be explored further in future research studies in the tajik context. however, a future study should be conducted not only among health care providers but also among the tbas. the inclusion of tbas in the future studies in the context of tajikistan will help show the real knowledge of tbas and also might address the possible biases of health professionals against tbas. the present study also found that the study respondents have a negative point of view about the tbas because of their use of unsafe practices. the health care providers in the current study argue that tbas had poor skills in infection control and did not follow clean delivery practices during childbirth. tajik health workers claim that tbas do not use clean cord-cutting instruments, clean sheets, and towels to prevent infection in women and newborns. moreover, tbas were also blamed for not using gloves to prevent transmission of infections to women or to protect themselves. this was also reported by pfeiffer 490 global journal of public health medicine 2021, vol 3, issue 2 gggggglo and mwaipopo (2013) who found that safety principles and hygiene measures are seldom upheld by tbas in tanzania. tbas were accused of unsafe practices in a study in uganda as well (chi & urdal, 2018). aziato and omenyo (2018) highlight that tbas rarely use gloves during their assessments (for example, to assess cervical dilatation and the amniotic membranes) or delivery thus increasing the risk of transmitting infections significantly and might lead to the introduction of bacteria from the vagina to the fetus (chorioamnionitis). the tbas might also assist more than one pregnant woman at a time, they could therefore consequently transmit infections from woman to woman (aziato & omenyo, 2018). this is a significant concern in the era of hiv and aids (aziato & omenyo, 2018; pfeiffer & mwaipopo, 2013). the concern about transmission of hiv between pregnant women and tbas who assist their birth and poor infection control measures were among the main reasons behind the prohibition of the use of tbas in other research settings (chi & urdal, 2018). these unsafe, unhealthy and risky practices can harm the health of tajik women and need to be addressed to improve maternal and newborn health in tajikistan. the tajik government needs to provide an sba in each remote rural area in the near future. this can be done by addressing disparities in the availability of health care workers across the different regions and geographical locations in tajikistan. tajikistan has a large number of doctors and other health care workers, but their geographic distribution varies considerably, and they are mainly concentrated in the cities, while there is a deficit of doctors and nurses in remote rural areas (mirzoev et al., 2007; parfitt & cornish, 2007). for instance, the number of doctors is much higher; in dushanbe, at 71 per 10,000, than in the whole country (fan & habibov, 2009; mirzoev et al., 2007). unlike other countries of the global south, it is not a lack of health professionals but misdistribution of health care workers that tajikistan is suffering from. the government should tackle disparities of health care workers by using different strategies such as providing incentives to health care professionals to work in places which lack ones. it is within this context that one of the main arguments of this paper also emerges. it is important to draw a clear distinction between the various countries of the global south or the so-called third world regardless of the term we use – without brushing the condition and health indicators of these countries with one paint. the historical circumstances of tajikistan and other central asian countries of the postsoviet sphere means that their health care system cannot be even likened or compared to that of the many countries of africa, latin america, south and southeast asia. these are countries which, at one point in the late 1980s, had access to a comparatively well-functioning primary and secondary health care systems and benefited from highly trained and large numbers of nurses and doctors. moreover, the health care system was universal and free. the mistake that many studies make when talking about the health care system in the post-soviet countries of central asia therefore is that they use the same language and images that they would use to describe the health care systems and provisions in the countries that never saw a health care system that was universal, free and of good quality. 491 global journal of public health medicine 2021, vol 3, issue 2 gggggglo there are of course similarities between the various systems of the global south countries, such as in the case of the use of tbas, but that similarity mainly ensues from the geographical terrain of these countries and the issues of accessibility rather than the lack of doctors and nurses, and the notion of how a health care system is meant to function. therefore, one would find, for example, that similar to the midwives in the study of gurara et al. (2019) in ethiopia, the tajik health care providers also argue that tbas do not contribute to the improvement of maternal health. chi and urdal (2018) discuss the critique of tbas’ involvement in delivery by health care workers of the official health care system in burundi and uganda. health care workers state that tbas practices result in various complications such as injuries to vagina and vulva requiring further genital cosmetic surgeries. their practices also lead to different kinds of newborn disabilities. tajik health care providers also believe that tbas are woefully unprepared to determine complications (e.g. determining blood loss) during delivery. the criticism regarding tbas’ practices by health care professionals are not limited to tajikistan. a study in nepal also found that the tbas were required to use an official methodology to measure postnatal blood loss after it was revealed that 83% of tbas mentioned that they recognized excessive bleeding “by seeing it” (falle et al., 2009, p. 58). however, early detection and correct assessment of blood loss are essential factors for managing postpartum bleeding and saving the life of a woman (walraven & weeks, 1999). thatte et al. (2009) also highlight that improving the recognition of signs of danger, including excessive hemorrhage, and defining the optimum response, can ensure the survival of both woman and newborn. a study from tanzania also show that two kanga (standard-size cotton cloth used by women in east africa) soaked in blood represented loss of slightly more than 500 ml of blood and used this threshold in training of tbas (thatte et al., 2009). calculating the number of pieces of fabric soaked with blood or utilizing a blood collection drape to estimate excessive loss of blood are better than visual measures and can be promising strategies (thatte et al., 2009). underestimation of blood loss and postnatal bleeding are the most important factor in maternal mortality (walraven & weeks, 1999). therefore, an analogous measurement tool (e.g. using cotton cloth) should be a part of the midwives training for emergency situations, but the emphasis should be on the official methodology of measuring postnatal blood as part of training of midwives in tajikistan. i think training midwives and preparing them for assisting women in situations and conditions where sophisticated tools are not available is crucial. the perspectives of health care providers in terms of knowledge and practices of tbas show that the tbas put the health of tajik women at risk. it is therefore necessary that in the near future the tajik government should provide sbas in all remote rural areas that lack one currently. indeed, the ideal solution for improving maternal and neonatal health outcomes is recruiting midwives for remote rural areas. in tajikistan, some urban, sub-urban and even rural areas have actually excessive number of health professionals (mirzoev et al., 2007), there is a need to identify areas where tbas are the only help that tajik women can rely on and replace them gradually with sbas with a basic incentive arrangement (chi & urdal, 2018). these changes are not difficult to implement, and they should not require huge sums, because unlike other countries of the global south, majority of places in tajikistan 492 global journal of public health medicine 2021, vol 3, issue 2 gggggglo have sbas including urban and sub-urban areas which actually have excessive number of them. although there is still a high number of health professionals due to a legacy of the ussr when higher education was free, and the problem is addressing the misdistribution of health professionals. however, in the future, taking into account that an increasing number of educational institutions require students to pay for their education now, and there might be a lack of health care workers in the future, tajikistan has to train purposefully midwifes who would be willing to stay and work in rural settings and it should be a national priority (srofenyoh et al., 2016). homogeneous approach should be avoided while studying and addressing health issues in the countries of the global south because due to different socio-economic, political and historical factors, situations and environments in these countries might be different. therefore, it is absolutely crucial to avoid a homogeneous public health approach while tackling health problems in different parts of the world. it is important to use a unique, and culturally and locally appropriate strategy to effectively address public health issues in countries of the global south. tajikistan is on the right track and is currently quite successful in reducing its mmr unlike the united states. providing sbas for all its geographical settings which the tajik government can achieve by redistributing health care workers, and addressing the misdistribution of health professionals in tajikistan. this approach might also be helpful in other post-soviet countries in the central asia or caucasus. conclusion the study shows that health care professionals have extremely negative views of the use of tbas during childbirth citing their lack of medical training and knowledge, and their lax attitude towards hygiene and clean birth practices as main reasons. most health care providers believe that tbas should be banned from practicing. they argue that tbas put the lives of tajik women at risk. health care workers also argue that tbas are doing more harm than good and therefore should be replaced by sbas. analysis of the literature on the subject has revealed that very often a homogeneous and unilateral approach has been applied to different countries regardless of their socio-economic, historical and structural factors by global public health experts. however, it is important that we use an approach that is locally, structurally and culturally appropriate to address health issues in different countries of the global south taking these important aspects into consideration instead. tajikistan, as a country, can solve the issue of using tbas by rectifying the way in which the health care sector and its staffing is organized. as mentioned, tajikistan has an excessive number of health care workers, but they are distributed unequally throughout the country. the government could be able to solve the issue of the lack of maternal health care in some of its remote regions by addressing the misdistribution of health professionals throughout the country. 493 global journal of public health medicine 2021, vol 3, issue 2 gggggglo the presence of an sba at childbirth is crucial for averting maternal and neonatal mortality and morbidity and is the ideal that any health care system should strive towards in those countries of the global south that have this opportunity. granted that it is possible to achieve this easily in some countries of the global south, it should be promoted and implemented. tajikistan is on the right track and is currently quite successful in reducing its mmr. at the same time, providing sbas in these remote rural areas could further decrease its mmr indicator. the study, therefore, might benefit the field by filling the gap in the existing literature on tbas by providing health care workers’ perspectives. this will in turn, help to design comprehensive and systematic reproductive health programs to improve the maternal health of tajik women taking into account specificities of this country and other post-soviet countries in the central asia. one important aspect of such a program can be finding ways to improve the maternal and neonatal health by providing sbas in rural areas to assist the most marginalized tajik women during delivery which the tajik government can do by managing its resources properly. conflicts of interest the author declares no conflicts of interest. funding this research was supported in part by a grant from the college of social and behavioral sciences’ research support program, the northern arizona university. references • adatara, p., afaya, a., baku, e.a., salia, s. m., & asempath, a. 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(2014). trends in maternal mortality 1990-2013. https://www.unfpa.org/sites/default/files/pub-pdf/9789241507226_eng.pdf microsoft word gjphm-2022neonatal jaundice.docx 558 global journal of public health medicine 2022, vol 4, issue 1 gggggglo original research the characteristics of prolonged neonatal jaundice investigated at primary health clinics in kota bharu, kelantan hazlienor mohd hatta, mohd ikhwan azmi, nik aida nik adib, najihah mahfuzah zakria, latifah dahalan kota bharu district health office, kelantan, malaysia ministry of health *corresponding author: drhazlienor@hotmail.com abstract introduction: prolonged neonatal jaundice is affecting 15-40% of breastfed new-borns. although breastmilk jaundice is the common aetiology, undetected pathological causes could lead to unfavourable sequelae. this study described the characteristics, aetiology and burden of prolonged neonatal jaundice investigated at the primary care level in kota bharu district. methods: this crosssectional study was done from july till december 2019, involving 14 health clinics in kota bharu. selection criteria involved term new-borns at day 14 of life or preterm at day 21 of life that had visible jaundice or serum bilirubin >85µmol/l. clinical details, investigations, and management were carried out based on normal practice at the clinics. a registry was established to capture the burden. results: prolonged jaundice were detected among 22.5% [95% ci 21.5, 23.6] of new-borns attending primary health clinics in kota bharu. a total of 291 cases were further analysed; 275 (94.5%) were term newborns and 243 (83.5%) were breastfed. affected new-borns underwent blood and urine sampling with multiple follow-ups. on average, jaundice subsided within 12 days [sd=5.5, 95% ci:11.7, 13.1] after detection of this condition. majority had prolonged unconjugated hyperbilirubinemia (98.6%) and main aetiology was breastmilk jaundice (84.5%). minority had hypothyroidism (3.4%) and conjugated hyperbilirubinemia (1.7%). out of 129 cases sent for urine culture, 12 (9.3%) had significant growth, mostly e.coli. conclusion: the majority of neonates with prolonged jaundice were term and breastfed. while the main aetiology was breastmilk jaundice, other underlying pathologies were also identified. as the burden of this condition is high, multistage investigation is strongly recommended. urinary tract infections screening should be routinely considered. keywords: hyperbilirubinemia, neonatal jaundice, prolonged jaundice 559 global journal of public health medicine 2022, vol 4, issue 1 gggggglo introduction prolonged neonatal jaundice is a common condition affecting 15-40% of all new-borns (gilmour, 2004). it is defined as neonatal jaundice persisting beyond 14 days of life in a full-term infant or 21 days in a preterm baby (malaysia ministry of health, 2017). the vast majority of new-borns with prolonged jaundice has unconjugated hyperbilirubinemia, where breastmilk jaundice is identified as the major cause (agrawal et al., 2017). although breast milk jaundice is benign, easily manageable and subsided spontaneously requiring no intervention, it is a diagnosis of exclusion as prolonged neonatal jaundice may also be a manifestation of more serious diseases (preer & philipp, 2011). prolonged conjugated hyperbilirubinemia is often pathological; affecting 1/2500 live birth whereas the incidence of biliary atresia is 1:18000 in the general population (hodgson et al., 2018). it may present with dark coloured urine and pale stool but normal history and physical examination in the early stage of diseases are usual (hodgson et al., 2018). as such, late presentation and referral to tertiary centre are common resulting in delayed intervention and poor prognosis. congenital hypothyroidism, haemolytic diseases, urinary tract infections (utis), other infectious and genetic disorders are among the causes of prolonged neonatal jaundice that require prompt detection and early treatments to avoid unfavourable sequelae (agrawal et al., 2017). other aetiology of prolonged neonatal jaundice includes the inborn error of metabolism, intestinal obstruction, pyloric stenosis, glucuronyl transferase enzyme deficiency or rare conditions such as criggler-najjar or gilbert syndrome (andre & day, 2016). to date, various guidelines are implemented in different parts of the world in regards to the management of prolonged jaundice. it often includes risk assessment or red flags, a thorough history and physical examination as well as a set of laboratory investigations (rennie et al., 2010). feeding history, stool and urine colour as well as a complete physical examination are also necessary to identify the cause of prolonged neonatal jaundice (fawaz et al., 2017). the routine screening varies from as minimal as serum bilirubin with differential count to extensive combinations of multiple blood and urine investigations. this condition is often investigated by paediatricians in tertiary hospitals but in kota bharu, it is being done at primary health clinics since the introduction of the integrated plan for detection and management of neonatal jaundice in the year 2017. as a large number of new-borns are affected by this condition, the workload in managing prolonged neonatal jaundice is undeniably enormous, but to date, there is no registry available at the state or local level that can capture the reality of it. with this background in mind, this study intended to shed some knowledge on the characteristics and aetiology of prolonged neonatal jaundice, the extent of investigation required as well the current burden in managing this condition at the primary care level in the kota bharu district. methods this cross-sectional study was carried out at 14 government health clinics located in the kota bharu district. these clinics were the primary care clinics that could carry out investigations required for the management of prolonged neonatal jaundice and received referrals for the said condition from all other clinics located in the district. all term new-borns attending these clinics between july to december 2019 560 global journal of public health medicine 2022, vol 4, issue 1 gggggglo screened for prolonged neonatal jaundice were recorded in a registry established at each clinic. cases were selected for this study from the registry using systematic random sampling in which sample size and sampling interval were predetermined for each clinic based on the population size while the first case was chosen by rolling a dice. premature babies of <35 weeks or birth weight <2000g are more prone for elevated serum bilirubin and more severe sequelae at a lower level of hyperbilirubinemia (maisels et al., 2012), hence were excluded from this study. the sample size was calculated with a 5% absolute precision and 95% confidence level based on the estimated incidence of prolonged neonatal jaundice at 20%. detailed information about the neonates, physical examinations, the results of investigations done and further management were carried out based on normal practice at the clinics. the number of visits and purpose of each follow up were also recorded. obtained materials were translated into data collection forms by trained medical officers. cases enrolled in this study were followed up until jaundice resolved or until 8 weeks of life, whichever earlier. prolonged neonatal jaundice was defined as visible jaundice or total serum bilirubin (tsb) of >85 μmol/l or 5 mg/dl that persists beyond 14 days of life in a term baby or 21 days in a preterm baby (malaysia ministry of health, 2017). risk stratifications were based on the integrated plan for detection & management of neonatal jaundice (malaysia ministry of health, 2017); high risk–ill/septic looking, respiratory distress, poor feeding, lethargy, poor perfusion; moderate risk–conjugated hyperbilirubinemia, severe jaundice (tsb >300 μmol/l), new onset of jaundice after day seven of life, pale stool, dark yellow urine, poor weight gain, hepatosplenomegaly, predominant bottle-fed >50%, jaundice over one month not investigated before, other suspected medical condition, significant family history; low risk–well babies with good weight gain, exclusively breastfed or >50% breastfed, bright yellow stool, normal clinical examination. the diagnosis was determined by the attending medical officers or physicians based on the guideline. demographic, clinical characteristics and laboratory investigations were summarized and tabulated. descriptive data were expressed as mean and standard deviation for normally distributed data while categorical data were presented as frequency and percentage. the comparison of means was carried out using student’s t-test. a value of p <0.05 is considered statistically significant. the data was analysed using spssv25. the study was registered under the national medical research register (nmrr-19-1481-49038) and approved by the national medical research and ethics committee and was conducted as part of the routine management for the said condition with written consent taken from the guardian. 561 global journal of public health medicine 2022, vol 4, issue 1 gggggglo results demographic & clinical characteristic prolonged neonatal jaundice was detected among 1,407 (22.5%) out of 6,242 new-borns that attended the 14 major government health clinics in the kota bharu district. a total of 291 cases were included in this study and further analysed. the characteristics of these babies are summarized in table 1. antenatally, 106 (36.4%) of the mothers were diabetic while 5 (1.7%) had thyroid disorders. none of the cases had any family history of liver or kidney disease. all cases were screened for glucose-6phosphate dehydrogenase (g6pd) deficiency and congenital hypothyroidism at birth with one case had abnormal cord thyroid stimulating hormone (tsh) level. about 197 (67.7%) cases relied on parental reporting in regards to stool colour while 79 (27.1%) cases had history supplemented with stool chart and 15 cases (5.2%) had their stool inspected. only 3 (1.0%) cases had reported dark-coloured urine, while 2 (0.6%) other cases had pale stool, and one (0.3%) case had poor feeding, the rest of the cases had no other associated symptoms with normal physical assessments besides prolonged jaundice. upon assessment, nine (3.1%) of the cases had new-onset jaundice after day seven of life while 282 (96.9%) already had jaundice since the early neonatal period. the majority (96.2%) of neonates were assessed within the recommended time frame (at day 14 or 21 of life). table 1: the characteristic of neonates investigated for prolonged jaundice at primary health clinics in kota bharu district (n=291). characteristic n (%) age at diagnosis (days of life) 16.4 (2.5)* preterm 22.5 (3.1)* term 16.2 (1.9)* gender female 146 (50.1) male 145 (49.9) race malay 283 (97.3) chinese 4 (1.4) siamese 4 (1.4) gestation term (<37 weeks) 275 (94.5) preterm (≥37 weeks) 16 (5.5) birth weight (kg) 2.91 (0.65)* <2.50 45 (14.6) 2.50-3.99 244 (83.8) ≥4.00 2 (0.6) mode of delivery spontaneous vaginal 230 (79.0) instrumental 11 (3.8) caesarean 50 (17.2) new-onset jaundice yes 9 (3.1) no 282 (96.9) feeding status exclusive breastfeeding 243 (83.5) predominant breastfeeding 31 (10.7) predominant bottle-feeding 10 (3.4) 562 global journal of public health medicine 2022, vol 4, issue 1 gggggglo blood group ‘o’ mother yes 106 (36.4) no 185 (63.6) rhesus negative mother yes 2 (0.6) no 289 (99.4) g6pd deficiency yes 4 (1.4) no 287 (98.6) history of phototherapy for jaundice yes 85 (29.2) no 206 (70.8) history of siblings with prolonged jaundice yes 36 (12.4) no 255 (87.6) family history of blood disorder yes 8 (2.7) no 283 (97.3) parental consanguinity yes 3 (1.0) no 288 (99.0) * mean (sd) blood investigation prolonged neonatal jaundice was detected via capillaries tsb screening for 284 (97.6%) cases, while the remaining seven (2.4%) had it identified visually. as depicted in table 2, the mean capillaries tsb measured at diagnosis in preterm babies was significantly higher than in term babies. the venous tsb at detection of prolonged jaundice was less than 200μmol/l for 221 (75.9%) cases while 63 (21.6%) had tsb >200μmol/l. no severe hyperbilirubinemia exceeding 300μmol/l was observed in this study. the extent and yield of other investigations were summarized in table 3. isolated elevated alkaline phosphatase (alp) was seen in 17 (5.8%) new-borns; two were premature infants and 15 were term babies; five (1.7%) of them had an increasing trend of alp upon repeated sampling while the rest were self-limiting. a total of 397 tubes of blood samples were obtained throughout investigations; rejected samples among these were low at 7.8% mainly due to insufficient samples (4.8%) and clotted specimen (1.3%) which required resampling. 563 global journal of public health medicine 2022, vol 4, issue 1 gggggglo table 2: comparison of serum bilirubin of term and preterm new-borns investigated for prolonged jaundice at primary health clinics in kota bharu districts (n=291). characteristic mean±sd [95% ci]# p value$ mean capillaries tsb at diagnosis (µmol/l) 162.8±44.0 [157.6, 168.0] 0.004 preterm 189.3±30.5 [172.4, 206.2] term 161.3±44.9 [155.9, 166.7] mean venous tsb at diagnosis (µmol/l) 142.1±60.9 [1351, 149.1] 0.825 preterm 141.9±60.2 [134.8, 149.0] term 145..4±75.0 [105.4, 185.4] #values in parentheses are 95% confidence interval (ci) for means $analysis by student’s t-test table 3: the investigations carried out for prolonged neonatal jaundice at primary health clinics in kota bharu other than tsb and differential count (n=291). investigation n (%) contributory samples a, n (%)b haemoglobin 140 (48.1) 27 (19.3) full blood picture 1 (0.3) 0 (0.0) direct coombs test 1 (0.3) 0 (0.0) reticulocyte count 1 (0.3) 0 (0.0) alkaline phosphatase (alp) 284 (97.6) 17 (5.9) aspartate transaminases (ast) 284 (97.6) 8 (2.7) alanine transferase (alt) 284 (97.6) 19 (6.5) thyroid stimulating hormone (tsh)c 245 (84.2) 31 (12.7) free t4 (ft4)d 33 (11.3) 10 (30.3) renal profile 6 (2.1) 0 (0.0) urinalysis 225 (77.3) 29 (12.9) urine culture 129 (44.3) 12 (9.3) a reference values were based on age group available in nelson textbook of pediatrics, 21st edition edition (kliegman et al., 2019) b the percentage of contributory abnormal sample was compared to the number of each particular test c tsh values of >6 µmol/l are determined as abnormal by local laboratory d only four cases had persistent low ft4 on repeated sampling urine investigation the majority of new-borns were screened for utis (table 3) in which urine samples were obtained by either urine bag or clean catch method. a total of 129 (44.3%) cases had urine samples sent for urine culture in which 27 (20.9%) cases were screened due to poor weight gain, predominant bottle-feeding or conjugated hyperbilirubinemia. twelve (4.1%) cases had positive urine culture with significant growth (7 e.coli, 3 enterobacter sp, 2 k.pneumonia) that make out the rate of 9.3%. however, we only included the number of cases tested for bacteriuria as the denominator when assessing the rate (n=129). only one of the cases diagnosed with utis had poor weight gain, while the rest of the cases had no symptoms other than jaundice. a total of 93 (72.1%) urine specimens sent for urine culture yielded mixed or insignificant growth. out of 12 cases whose urine culture had significant growth, only five of them had abnormal urinalysis (leucocyte detected in the urine of four cases while one case had traces of leucocyte and blood). two cases that had positive urine nitrite had insignificant growth. a total of 386 564 global journal of public health medicine 2022, vol 4, issue 1 gggggglo containers of urine samples were obtained throughout investigations; rejected samples among these were 4.4% mainly due to empty containers submitted by parents (2.8%) and leaked containers (0.8%) which required resampling. management and follow-ups the cases were stratified into different risk groups of which only one (0.3%) case was high risk, 46 (15.8%) cases had moderate risk, 189 (64.9%) cases had low risk, while 55 (18.9%) cases had inadequate information to be stratified into risk categories (table 4). parental issues were observed among 22 (7.6%) cases; mainly defaulters (10), refusals for multiple blood takings (8), and difficulty in obtaining urine samples (6). on average, a new-born required three follow-up visits after the detection of prolonged neonatal jaundice. jaundice subsided within 12 days [sd=5.5, 95% ci: 11.7, 13.1] with 85 (29.2%) cases were discharged at 1-week follow-ups after being screened for the condition. jaundice subsided by the fourth week of life for 150 (51.6%) cases while 134 (46.0%) cases by the sixth week of life. only one high-risk case, five cases with persistently elevated alp and four cases with persistent hypothyroidism were referred to the tertiary centre for further investigation and management. table 4: risk stratification based on underlying risks of neonates investigated for prolonged jaundice at primary health clinics in kota bharu districts (n = 291). risk categoriese n (%) high risk poor feeding 1 (0.3) moderate risk poor weight gain 22 (7.6) new-onset jaundice 8 (2.8) predominant bottle-feeding 8 (2.8) conjugated hyperbilirubinemia 4 (1.4) dark urine 3 (1.0) pale stool 1 (0.3) low risk 189 (64.9) unknown risk 55 (18.9) eneonates may have multiple underlying risks aetiology of prolonged neonatal jaundice the majority of the neonates had prolonged unconjugated hyperbilirubinemia (98.6%) in which the main aetiology was breastmilk jaundice while 26 (8.9%) cases had underlying pathologies (table 5). four (1.4%) cases had conjugated hyperbilirubinemia but no case of biliary atresia was reported in this study. a total of 19 (6.5%) cases with moderate risk had undergone inadequate investigations to identify the causes. out of 63 cases that had tsb > 200 µmol/l, only six cases (9.5%) had underlying pathologies. out of 10 (3.4%) cases that had hypothyroidism, six cases were transient. 565 global journal of public health medicine 2022, vol 4, issue 1 gggggglo table 5: the aetiology for prolonged jaundice among neonates investigated at primary health clinics in kota bharu district, (n = 291). aetiology n (%) prolonged unconjugated hyperbilirubinemia 287 (98.6) breast milk jaundice 246 (84.5) hypothyroidism 10 (3.5) urinary tract infection 11 (3.8) sepsis 1 (0.3) unknown 19 (6.5) prolonged conjugated hyperbilirubinemia 4 (1.4) urinary tract infections 1 (0.3) transient cholestasis 3 (1.1) discussion almost one-fourth of new-borns were affected by prolonged jaundice in kota bharu. this rate is higher than a study done in perak at 15.8%(tan et al., 2019) while the prevalence is reported to be around 15-40% worldwide (laving et al., 2019). the vast majority of prolonged jaundice cases in the kota bharu district were term, breastfed and healthy new-borns, while the main aetiology was breastmilk jaundice, in keeping with other studies (agrawal et al., 2017). the rate of conjugated hyperbilirubinemia among neonates in this study was low. only a small portion of cases in this study had hypothyroidism; this could be explained by the effectiveness of the national screening program for congenital hypothyroidism done in this country allowing this pathology to be detected earlier (wong et al., 2015). primary congenital hypothyroidism occurs in approximately one in every 4000 new-borns but the incidence is much higher in malaysia that is 1 in 1170 live birth and is one of the common causes of prolonged neonatal jaundice (wong et al., 2015). in regions where new-borns screening program for congenital hypothyroidism is not done, thyroid function tests are widely recommended to be included as a routine investigation for new-borns with prolonged jaundice (honarpisheh, 2002). less than 6% of new-borns in this study had isolated elevated alp. a study conducted in scotland revealed 13.3% of infants referred for prolonged jaundice had isolated elevated alkaline phosphatase lever that required no intervention as they were self-limiting (mceleavey et al., 2007). some suggested that in the presence of normal conjugated bilirubin, the cause for prolonged jaundice in neonates with tsb <200µmol/l is mostly benign (preer & philipp, 2011). however, the majority of cases that had underlying pathology in this study had tsb <200µmol/l at the time of diagnosis. this finding is also observed by other researchers (andre & day, 2016), suggesting that tsb value should not be the only indicator for further evaluation. the current guideline recommends assessment and relevant investigation for prolonged neonatal jaundice to be conducted at 14 and 21 days for the term and preterm babies respectively (malaysia ministry of health, 2017). most neonates in this study were assessed and investigated within the recommended timeframe and earlier, compared to babies that were referred to the tertiary centre without prior investigation according to a study in perak that documented the mean age seen at hospital at 20.9 days (tan et al., 2019). the medical practitioners in this study relied on parents in regards to stool colour in most of the cases. objective assessment of 566 global journal of public health medicine 2022, vol 4, issue 1 gggggglo infant’s stool colour by either direct inspection and stool chart need to be emphasized to identify conditions associated with biliary obstruction, particularly biliary atresia (s. p. paul & kirkham, 2016). breast milk jaundice is benign, easily manageable and subsided spontaneously requiring no intervention but it is a diagnosis of exclusion, hence, combinations of blood and urine investigations are necessary to identify other pathologies (preer & philipp, 2011). as this study demonstrated that jaundice may have subsided early and extensive investigations revealed low yield, we supported the national recommendation of multistage approach to obtained serum total and direct bilirubin at two weeks of life in low-risk babies, and if still jaundiced at three weeks, to consider serum bilirubin with differential count, urine microscopy, ft4 and tsh, and fbc with reticulocyte count (malaysia ministry of health, 2017). similarly, the north american society for pediatric gastroenterology, hepatology and nutrition recommends total serum and conjugated bilirubin for 2-week-old jaundiced infants that can be delayed another week for breast-fed infants with a normal physical assessment and no history of dark-coloured urine or acholic stool (fawaz et al., 2017). meanwhile, the national institute for health & care excellence (nice) recommended that if still jaundice at three weeks, a formal investigation for prolonged neonatal jaundice should include conjugated bilirubin, full blood count (fbc), mother and baby’s blood group including direct antigen test (coombs’ test), urine culture and routine metabolic screening including for congenital hypothyroidism (rennie et al., 2010). the rate of utis in this study is 9.3% in which urine culture was not considered as a routine investigation for prolonged jaundice in the kota bharu district. the overall global prevalence of utis among newborns with prolonged jaundice is around 11% but it greatly varies worldwide; ranging from 0.2% in the united kingdom (steadman et al., 2016) to as high as 53.9 % in iran (tola et al., 2018). the debates among researchers are ongoing in regards to utis screening methods among new-borns with prolonged jaundice. although utis may present with low-grade fever, poor feeding, grunting, lethargy, diarrhoea and vomiting; it was diagnosed among 7.5% of afebrile, asymptomatic, jaundiced new-borns (s. paul, 2012). this study along with other researchers supports the recommendation by nice to include urine culture in routine screening for prolonged neonatal jaundice (chen et al., 2011; s. p. paul & kirkham, 2016; rennie et al., 2010) while some others recommended otherwise (chowdhury et al., 2015; steadman et al., 2016). in the current study, over half of the urine samples that yielded significant growth had normal urinalysis; in concordance with other studies (chen et al., 2011; s. p. paul & kirkham, 2016). urine bag is convenient to collect urine in the primary health clinic setting and the clean-catch method is recommended by nice (rennie et al., 2010) but the majority of samples taken by these methods in this study yielded insignificant or mixed growth. further training and improvisations of these methods need to be done to minimize the risk of contamination as although urine catheterization had better yield, it is more invasive, costly and not applicable in a busy clinic setting. these infants will need further investigations and extra follow-ups compared to non-jaundiced infants with the possibility of multiple sampling due to difficulty in obtaining samples; highlighting the need to enhance resources at primary health clinics to cater for this common condition. as extensive 567 global journal of public health medicine 2022, vol 4, issue 1 gggggglo investigations are costly with low yield, as well as the workforce implication on the primary care facilities, they should not be done routinely for all jaundiced new-borns. more health personnel should be skilled to obtain clinical specimens to reduce the need for resampling. regular training by laboratory technicians regarding the needs and importance of fulfilling sample’s criteria, proper specimen’s handling and transportation are important to minimize the rejection of samples. the limitation of this study was that we weren’t able to report the true incidence of prolonged neonatal jaundice as some new-borns may be investigated directly at the tertiary centre, at private facilities or other districts. however, to our knowledge, this is the first study that describes the characteristic of prolonged neonatal jaundice and captures its burden in the district for a better understanding and management of the said condition. conclusion the vast majority of prolonged neonatal jaundice cases in kota bharu district were term, breastfed and healthy new-borns, while the main aetiology was breastmilk jaundice. although this condition is a common occurrence while the major cause is benign, the evaluation for other underlying pathology is of importance. early recognition and intervention may prevent unfavourable sequelae in neonates with underlying pathology. further studies need to be done to assess the magnitude of utis among infants with prolonged jaundice and the need to screen for it as part of routine investigation of this condition. the cost-effectiveness, workforce implication and difficulty of obtaining samples in infants need to be considered while investigating this condition, hence, multistage approaches are recommended. as the burden of prolonged neonatal jaundice is high, appropriate allocations of resources are necessary. acknowledgement we would like to thank the director general of health malaysia for his permission to publish this article. the authors would also like to express their gratitude and thanks to the kota bharu district health office along with the district’s family medicine specialists, medical officers and nurses for their contribution, cooperation, and support. conflicts of interest the author declares no conflicts of interest. 568 global journal of public health medicine 2022, vol 4, issue 1 gggggglo references • agrawal, v., goyal, a. k., sharma, j. n., & yadav, m. d. 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(2018). prevalence of uti among iranian infants with prolonged jaundice, and its main causes: a systematic review and metaanalysis study. journal of pediatric urology, 14(2), 108-115. https://www.jpurol.com/article/s1477-5131(18)30026-3/fulltext • wong, s. l. j., jalaludin, m. y., zaini, a. a., samingan, n., & harun, f. (2015). congenital hypothyroidism: an audit and study of different cord blood screening tsh values in a tertiary medical centre in malaysia. advances in endocrinology, 2015, 387684. https://doi.org/10.1155/2015/387684 microsoft word gjphm-2022 chronic hepatitis-2.docx 664 global journal of public health medicine 2022, vol 4, issue 2 gggggglo original research factors associated with chronic hepatitis-c virus infection in a rural area of thanjavur district, state of tamilnadu,india – across -sectional study. d. ramprakash1* d arunachalam2 shanmugha priya1 vinoth raman3 1 department of community medicine, thanjavur government medical college, thanjavur, tamil nadu, india. 2 department of community medicine, aarupadaiveedu medical college and hospital, puducherry, india. 3deanship of qualityand academic accreditation,imam abdulrahman bin faisal university,saudi arabia. *corresponding author:subashstat@gmail.com abstract introduction: viral hepatitis is a critical public health problem that can cause both acute and chronic liver disease in today's environment. hepatitis c is a viral infection with a high global incidence and prevalence. hcv could be transmitted through blood. the most frequent serious disease in the world is hcv infection. according to the most recent estimates of disease burden, seroprevalence has increased to 2.8% during the previous 15 years, amounting to >185 million infections worldwide. methods: a cross sectional study conducted in a rural field practice area of thanjavur medical college to assess the prevalence of hcv and its associated factors. about 130 hcv cases were registered in the phc of our rural field practice area. we included all the cases in that field practice area. results: the study comprised 130 hcv patients, all of whom were males (aged 45±18.7 years), with ages ranging from 20 to 70 years. the majority (60%) were over 60 years old. the majority of the responders were between the ages of 60 and 70 years old. there were 97 (65%) males and 53 (35%) females among the 150 participants. in terms of where they lived, 44 (34%) were urban patients and 86 (66%) were rural patients. factors that are related with chronic hcv are age, gender, residence, occupation, education, marital status, history of hospitalizations, drug addiction, travel abroad were found to be statistically significant. conclusion: there were no significant differences in risk factors between control and hcv patients. hcv infection is just one of several obstacles that must be overcome in order to provide appropriate medical care to illness patients. the findings of this study show that sera from patients with alcoholic hepatitis interfere with the normal functioning of the liver; chronic alcoholism is the primary reason. except for those who remain positive for hbsag, hepatitis c virus infection has little effect on the development of chronic liver disease in heavy drinkers. keywords: viral hepatitis; chronic hepatitis-c virus; risk factors, statistical analysis 665 global journal of public health medicine 2022, vol 4, issue 2 gggggglo introduction hepatitis c virus (hcv) infection is a leading cause of liver disease-related morbidity and mortality worldwide, and it is a major public health concern. hepatitis caused by hcv has become a major increasing infectious disease problem, with an estimated 200 million people worldwide affected (sievert et al., 2011). hcv is responsible for 20% of acute hepatitis, 70% of chronic hepatitis, 40% of end-stage cirrhosis, and 60% of hepatocellular cancer in developed countries. it has become one of the leading causes of liver transplantation (benvegnu et al., 1997; ). hcv is found in 0.2 to 2% of people all around the world (narahari et al., 2009). antibodies against the hepatitis c virus (hcv) are present in 1-.5% of the indian population (choudhry et al., 1995). hepatitis c virus infection kills roughly two lakh people every year, with 3.8% of post-transfusion patients, 3% of acute viral hepatitis, 18% of chronic liver disease, and 20% of hcc patients infected (narang a et al., 1995) . according to some workers, the prevalence of hcv-related chronic liver disorders ranges from 5-35%. hepatitis c is one of the most common diseases in the world, with around 185 million people infected with the virus. hepatitis c virus is the second most common cause of chronic disease and, as a result, the most common cause of liver cancer and liver transplantation (perz jf et al., 2006). hepatitis c virus (hcv) infection affects approximately 177 million people globally and is a leading cause of liver disease (nguyen et al., 2007). hcv prevalence estimates in southeast asian countries range from 2.0% to 3.8% (ratanasuwan et al., 2004 & ishida t et al., 2022), 12.5% in patients with chronic liver disease (pramoolsinsap c et al., 1992), and more than 90% in injecting drug users (luksamijarulkul et al., 1996). approximately 10% to 20% of chronic hcv infection cases will develop cirrhosis, with 1 percent to 5% progressing to hepatocellular carcinoma within 30 years of their initial infection, regardless of beginning place or risk factor. hcv is transferred mostly through direct contact with contaminated human blood. intravenous and percutaneous drug use, transfusion of blood products, haemodialysis, and unprotected intercourse with a couple of intercourse partners are all high-risk factors for hcv infection (xia x et al., 2008). blood transfusion used to be the main risk factor for acquiring hcv infection before routine anti-hcv screening of blood donors (alavian et al., 2022; (ambrozaitis a et al., 1995). in affluent nations, the risk has decreased significantly with the development of reliable assays for hcv screening in blood donors (allain jp et .al.,1996). hcv infection is now most commonly caused by intravenous drug misuse has been identified as the most common viral infection affecting iv drug users (aceijas c et al., 2007). idus represent the most vital corporations at risk of being infected with hcv (aceijas c et al., 2007; thakral b et al., 2006), the latter being recognized as the most common viral infection affecting idus, due to sharing contaminated needles and syringes, and various injection equipment, use of shooting galleries, cocaine use, unprotected sexual activities, and sharing shaving equipment. the hcv incidence rate in idus is varied in different parts of the world, however manipulating this virus in this high-risk group as a way in the health system can help prevent the infection from spreading to the general population(stark k et al 1997; alavian sm et al 2022). 666 global journal of public health medicine 2022, vol 4, issue 2 gggggglo hepatitis c virus (hcv) is a widely recognized disease that causes significant morbidity and mortality cooke gs et al., 2013). according to the most recent estimates of disease burden, seroprevalence has increased to 2.8% during the previous 15 years, equal to >185 million infections worldwide(mohd hanafiah et al 2013). according to who data, there are 188 million people worldwide who are infected with hcv, with around 18 million people in india being infected. in addition, india has around 12.5 million hcv carriers (geneva 2017). in alcoholic patients, persistent hcv is linked to numerous morphological, epidemiological, physiological, biochemical, and immunological changes. such data will undoubtedly be required as a foundation for any future programs developed for diagnosing and treating chronic hcv. this knowledge will also aid in acquiring a far better understanding of the etiology of chronic hcv, which will result in advancements in the format of pharmaceuticals of choice to prevent and treat this condition. the study's goals were to determine the prevalence of risk factors for chronic hepatitis-c virus infection in the community in and surrounding thanjavur district, tamil nadu, india. methods a cross-sectional study conducted in our rural field practice of tanjore district. the research was conducted in thanjavur, india, at the department of community medicine, government medical college, thanjavur district, and tamil nadu state. this research took place over six months, from september 2021 to march 2022. from the previous survey done in the phc it had been found that there were about 130 hcv positive cases were found in out rural field practice area. after obtaining the informed consent, a semi structured questionnaire was applied to collect the information the various factors that may influence the hcv among the study participants. the study was conducted after obtaining the ethical committee approval. the data collected is entered in ms excel and statically analysis was done using the spss software. results the study comprised 130 hcv patients, all of whom were males (aged 45±18.7 years), with ages ranging from 20 to 70 years. the majority (60%) were over 60 years old. the majority of the responders were between the ages of 60 and 70 years old. there were 97 (65%) males and 53 (35%) females among the 150 participants. in terms of where they lived, 44 (34%) were urban patients and 86 (66%) were rural patients. table 1 and figures 1-3 illustrate the prevalence of hcv in relation to various parameters. 667 global journal of public health medicine 2022, vol 4, issue 2 gggggglo table 1: demographic factors associated with the prevalence of hcv patients and control parameters hcv patients (n=130) ‘p’ value n % age in years 0.001 20-30 10 8 31-40 18 14 41-50 28 21 51-60 14 11 61-70 60 46 gender 0.001 male 82 76 female 48 24 residence <0.001 rural 86 66 urban 44 34 education 0.000 high levels 58 45 low levels 72 55 marital status 0.001 married 78 60 unmarried 52 40 economic status 0.09 good 38 29 medium 22 17 low 70 54 smoking habit 0.05 smoker 88 68 non smoker 42 32 alcohol intake 0.05 daily drinkers 42 32 weekly drinkers 72 56 monthly drinkers 16 12 history of surgery 0.135 yes 112 86 no 18 14 history ofhospitalization <0.001 668 global journal of public health medicine 2022, vol 4, issue 2 gggggglo yes 96 74 no 34 26 history of blood transfusion 0.326 yes 93 72 no 37 28 drug addiction <0.001 yes 104 80 no 26 20 dental procedures 0.122 yes 36 28 no 94 72 traveling abroad <0.001 yes 53 41 no 77 59 abnormal urine test <0.001 yes 102 78 no 28 22 *level of significant at p<0.05 level of significant the distribution of hcv patients by residence is shown in table 1. 86 of the 130 hcv patients live in rural areas, while 44 live in urban areas. rural areas account for 15 of the 20 healthy persons, while urban areas account for 5. there are 58 individuals with a high level of education and 72 patients with a low level of education in the hcv patient population. six of the twenty healthy people have a high education level, whereas 14 have a low education level. it illustrates the hcv patient distribution based on marital status. there are 78 married patients and 52 unmarried ones. 16 of the 20 healthy persons are married, and 4 are single. (a) (b) 20-30 31-40 41-50 51-60 61-70 0 2 4 10 20 30 40 50 60 70 n o. o f h c v p at ie nt s an d co nt ro l age in years hcv control male female rural urban high levelslow levels married unmarried 0 20 40 60 80 100 marital statuseducationresidence n o. o f h c v p at ie nt s an d co nt ro l gender hcv control 669 global journal of public health medicine 2022, vol 4, issue 2 gggggglo (c) (d) figure 1: the distribution of hcv patients and control based on parameters (a) age in years (b) gender, residence, education, marital status (c) economic status (d)smoking habit figure 2: the distribution of hcv patients based on alcohol intake it shows the distribution of hcv patients according to their socioeconomic position. there are 38 good patients, 22 medium patients, and 70 low patients out of 130 hcv patients. out of 20 healthy persons, four have a good economic standing, six have a medium status, and ten have a low status. there are 98 smokers and 42 non-smokers among the patients. they show how hcv patients are distributed according to their socioeconomic status. there were 42 daily drinkers among the 130 hcv patients, 74 weekly drinkers, and 14 monthly drinkers. the findings are consistent with those of other studies [23-26]. good medium low 0 10 20 30 40 50 60 70 80 n o. of h c v p at ie nt s an d co nt ro l economic status hcv control non smoker 42 (32%) smoker 88 (68%) mo nth ly dr ink er s 16 (1 2% ) weekly drinkers 72 (55%) daily drinkers 42 (32%) 670 global journal of public health medicine 2022, vol 4, issue 2 gggggglo figure 3: the distribution of hcv patients based on risk factors it observed that the hcv infection were higher in the age group of >60 (46%) and lower <20 (8%) which was statistically significant (30.5±41.72; p=0.001). the majority of the respondents (68 %) are female and less than half of the respondents are male (32 %). the rural hcv patients were (50.5±50.2; p=0.000) in higher than urban area (24.5±27.58; p=0.000) as compared with healthy people, which is further compared with the control values (hoang dm et al 2003). education status indicated a higher proportion of hcv patients with control (45% vs. 30%; 32±36.77; p = 0.000) and a lower proportion (55% vs. 70%; 43±41.01) were observed (pham s et al., 1994). the married patients (41±52.33; p=0.001) were infected with hcv than unmarried (34±25.46; p=0.001) as associated with non-hbv infection patients. good socioeconomic status of hcv patients with control (29% vs. 20%; 21±24.04; p = 0.09) and a lower status of (54% vs. 50%; 40±42.43) were presented. the value of 68% (88/130) smokers and 32% (42/130) non-smokers had hcv infection. alcoholic’s patients were at daily drinkers (32%) two times more than monthly drinkers (16%) getting risk of hcv infection (espinosa m et al 2004). a p-value greater than 0.05 is considered statistically not significant between hcv patients and control. studies of risk factor of hcv infection have been predominating when compared to the healthy people [30-33]. the statistical analysis was carried out using the spss 21.0 software tool. the average and standard deviations were calculated. analysis of variance was used to examine the data (anova). statistical significance was defined as a probability level (p-value) of less than 0.05. all values were reported as means standard deviations. to examine the differences between one group (hcv patients) and another, the anova test was used (healthy people). yes no yes no yes no yes no yes no yes no yes no 0 5 10 15 40 60 80 100 120 140 su rge ry ab no rm al uri ne te st tr av eli ng ab roa d de nta l p ro ce du res dr ug ad dic tio n blo od tra ns fus ion n o. o f h c v p at ie nt s an d co nt ro l ho sp ita liz ati on hcv control 671 global journal of public health medicine 2022, vol 4, issue 2 gggggglo conclusion among alcoholics, the prevalence of chronic hcv infection rises. age, sex, education, occupation, place of living, and kind of housing were all collected from the study's findings, as well as hcv rna, positive hbsag, and anti-hbs antibody levels in any additional family members. the prevalence of hcv infection was discovered among the risk variables. there were no significant differences in risk factors between control and hcv patients. hcv infection is just one of several obstacles that must be overcome in order to provide appropriate medical care to illness patients. the findings of this study show that sera from patients with alcoholic hepatitis interfere with the normal functioning of the liver; chronic alcoholism is the primary reason. except for those who remain positive for hbsag, hepatitis c virus infection has little effect on the development of chronic liver disease in heavy drinkers. to summarize, inform public health planning, health service provision, the formulation of hcv policy guidelines, and the implementation of hcv programming to minimize hcv transmission and related disease. conflicts of interest the author declares no conflicts of interest. references • aceijas, c., & rhodes, t. (2007). global estimates of prevalence of hcv infection among injecting drug users. the international journal on drug policy, 18(5), 352–358. https://doi.org/10.1016/j.drugpo.2007.04.004 • alavian, s. m., gholami, b., & masarrat, s. (2002). hepatitis c risk factors in iranian volunteer blood donors: a case-control study. journal of gastroenterology and hepatology, 17(10), 1092–1097. https://doi.org/10.1046/j.1440-1746.2002.02843.x • allain, j. p., kitchen, a., aloysius, s., reeves, i., petrik, j., barbara, j. a., & williamson, l. m. (1996). safety and efficacy of hepatitis c virus antibody screening of blood donors with two sequential screening assays. transfusion, 36(5), 401–405. https://doi.org/10.1046/j.15372995.1996.36596338024.x • benvegnu, l., pontisso, p., cavalletto, d., noventa, f., chemello, l., & alberti, a. (1997). lack of correlation between hepatitis c virus genotypes and clinical course of hepatitis c virus-related cirrhosis. hepatology research: the official journal of the japan society of hepatology, 7(2), 144–144. https://doi.org/10.1016/s0928-4346(97)85790-8 • choudhry, v. p., & acharya, s. k. (1995). hepatitis b, c & d viral markers in multitransfused thalassemic children: long-term complications and present management. indian journal of pediatrics, 62(6), 655–668. https://doi.org/10.1007/bf02825110 • cooke, g. s., lemoine, m., thursz, m., gore, c., swan, t., kamarulzaman, a., ducros, p., & ford, n. (2013). viral hepatitis and the global burden of disease: a need to regroup. journal of viral hepatitis, 20(9), 600–601. https://doi.org/10.1111/jvh.12123 • espinosa, m., martn-malo, a., ojeda, r., santamara, r., soriano, s., aguera, m., & aljama, p. 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(2002). prevalence of hepatitis b and c virus infection in rural ethnic populations of northern thailand. journal of clinical virology: the official publication of the pan american society for clinical virology, 24(1–2), 31–35. https://doi.org/10.1016/s1386-6532(01)00222-0 • luksamijarulkul, p., & plucktaweesak, s. (1996). high hepatitis c seroprevalence in thai intravenous drug abusers and qualitative risk analysis. the southeast asian journal of tropical medicine and public health, 27(4), 654–658. • narahari, s., juwle, a., basak, s., & saranath, d. (2009). saranath d. infection genetics and evolution, 9, 643–645. • narang, a., kar, p., & chakravarty, a. (1993). hcv infection in a north indian hospital. indian journal of gastroenterology: official journal of the indian society of gastroenterology, 12(4), 156. • perz, j. f., armstrong, g. l., farrington, l. a., hutin, y. j. f., & bell, b. p. 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(1997). history of syringe sharing in prison and risk of hepatitis b virus, hepatitis c virus, and human immunodeficiency virus infection among injecting drug users in berlin. international journal of epidemiology, 26(6), 1359–1366. https://doi.org/10.1093/ije/26.6.1359 • thakral, b., marwaha, n., chawla, y. k., saluja, k., sharma, a., sharma, r. r., minz, r. w., & agnihotri, s. k. (2006). prevalence & significance of hepatitis c virus (hcv) seropositivity in blood donors. the indian journal of medical research, 124(4), 431–438. microsoft word gjphm-2022 tinitus harva.docx 646 global journal of public health medicine 2022, vol 4, issue 2 gggggglo review research tinnitus: a comprehensive review of treatment modalities saif yahya1, mohammed i. aladul1,2, haimn a. tawfiq1 1college of pharmacy, ninevah university, mosul, nineveh, iraq. 2college of pharmacy, university of mosul, mosul, nineveh, iraq. *corresponding author: m.i.m.aladul@uomosul.edu.iq abstract tinnitus is caused by auditory dysfunction, and it affects about 10 -15% of the adult population. fortunately, in most cases, it is not dangerous however, in 20% of cases it can be life-disturbing especially with aging. several types of therapies have been found to have a rule in the management of tinnitus including voice therapy, vagus nerve stimulation, hyperbaric oxygen therapy as well as a pharmacological intervention using several medications such as anesthetic, anticonvulsant, antidepressant anxiolytic, and antihistamine. the focus of treatment for tinnitus should include the annoyance associated with the tinnitus. therefore, tinnitus retraining therapy (trt) principle which includes meticulous diagnosis, educational counselling, and sound base therapy should be followed in all patients. the optimal results in the management of tinnitus can be achieved by proper counselling and patient education, in addition to providing an acoustic environment and the use of drugs that control some of the symptoms associated with tinnitus. keywords: tinnitus, tinnitus retraining therapy (trt), anesthetic, acoustic environment 647 global journal of public health medicine 2022, vol 4, issue 2 gggggglo introduction tinnitus refers to a sound that is not caused by an external sound source, this means that only a person with tinnitus can hear a sound in the ear that can be whistling or humming (ziai et al., 2017). it is estimated that 10-15% of the population has tinnitus, but most do not treat it, this is due to a lack of knowledge and the fact that most people do not know who to turn to (mccormack et al., 2016). some cases are mild, but some require more specific treatment to address potential long-term effects. these may include sleep and concentration disorders, stress, or social isolation (ziai et al., 2017). tinnitus is often described as ringing in the ears, but it can also occur as a buzzing, rattling, or whistling sound, or just general noise in the ears. the sound can always be the same or vary and can only affect one or both ears (schlee et al., 2018). millions of people find tinnitus distressing, but few are aware of the various methods that can help them manage tinnitus to reduce irritation (phillips & mcferran, 2010; hoekstra et al., 2011; meng et al., 2011; baldo et al., 2012; bennett et al., 2012; hobson et al., 2012; hilton et al., 2013; espinosa-sánchez et al., 2014; hoare et al., 2014; person et al., 2016). although there is no cure for tinnitus, there are several effective counseling and management techniques available. the goal of sound therapy is to reduce awareness of tinnitus by providing the ears with sounds that actively mask and divert attention away from it (roberts et al., 2013). over time, the brain is trained to ignore tinnitus because a lack of attention allows the brain to classify it as irrelevant and confuse it with the background (weisz et al., 2005). if a person has both tinnitus and hearing loss, using a hearing aid makes it easier to listen in general and helps reduce awareness of ringing in the ears (cuny et al., 2004). according to møller (2016), phonakr hearing aids also provide additional support for tinnitus by providing sounds that can be used in sound therapy. stress and anxiety can make tinnitus worse, so they should be brought under control to prevent tinnitus from growing worse. adequate night sleep, smoking cessation, and exercise are good for health, so they are helpful in the fight against tinnitus (dawes, et al., 2020). impact of tinnitus certain types of tinnitus are associated with hearing loss caused by aging. with aging, the number of nerve fibers in the ears decreases, this can often cause hearing problems associated with tinnitus (møller, 2016). loud noise is one of the most common causes of tinnitus. if people have been exposed to loud music, the sounds of shots or explosions, or loud construction or garden machinery, they may have symptoms of tinnitus (bennett et al., 2012; hoare et al., 2014; mccormack et al., 2016). sometimes blockages caused by ear wax can cause tinnitus (el-shunnar et al., 2011). certain medications can cause tinnitus (scherer et al., 2019). in this case, tinnitus is a side effect rather than a disease. in addition, upper respiratory tract infections and jaw joint (tmj) can induce tinnitus-like symptoms. 648 global journal of public health medicine 2022, vol 4, issue 2 gggggglo people are sometimes faced with situations where a patient says they have had tinnitus after starting a medication and would like to know that that medication may be the cause of the tinnitus (seligmann et al., 1996). it is difficult to give such a clear and reasoned answer to this question. there can be numerous reasons why tinnitus has started. it usually results from a combination of several factors over a longer period (mcferran et al., 2019). recent events, such as starting taking medication could be the initiation of the tinnitus, but on the other hand, it may have nothing to do with the onset of tinnitus (seligmann et al., 1996). nevertheless, some particular change in life, such as starting medication, is easily linked in thought to tinnitus that started at the same time (salvi et al., 2021). however, tinnitus is quite a common ailment and also nowadays medications are used in great amounts. these together naturally increase their likelihood of occurring at the same time. nevertheless, tinnitus is very rare compared to many other drug-induced side effects. however, they have been repeatedly reported, suggesting that tinnitus may be linked to the side effects of certain medications (henry et al., 2014). the ototoxicity of certain drugs is the cause of tinnitus. ototoxicity refers to damage to the inner ear due to ingestion of or exposure to certain drugs or chemicals (henry et al., 2014; salvi et al., 2021). it can lead to the destruction of sensory hair cells in the inner ear and thus cause hearing loss and tinnitus (claussen, 1996). the damage and consequent hearing loss and tinnitus may be permanent or temporary, depending on the drug, its dose, and the length of the course. such drugs include e.g. aspirin, quinine, non-steroidal anti-inflammatory drugs, certain antibiotics, cytostats, and diuretics (claussen, 1996). however, there are far more drugs that have not been shown to have an ototoxic effect in studies (claussen, 1996; henry et al., 2014; salvi et al., 2021). nevertheless, their association has been reported and has also been mentioned as a side effect of many such drugs. such drugs include e.g. statins, antihypertensive, and antidepressants (claussen, 1996). however, the causal link between these is unclear, but their effect cannot be completely ruled out either. it can be a complex and longterm combination of very many factors where the effect of the drug is either minor or significant (langguth et al., 2019). the onset of tinnitus with medication can also be a mere coincidence. one significant factor may be that the disease itself is a major stressor that initiates and intensifies the body’s stress response. the stress response is known to play a significant role in tinnitus and there are strong indications of its possible effect on the onset of tinnitus (mazurek et al., 2015). no medication prescribed by the doctor should be stopped or changed on people's own. the doctor should be informed if people suspect that the medicine has caused tinnitus. under no circumstances should tinnitus be underestimated as a side effect, as tinnitus can have serious consequences (kleinjung & langguth, 2020). primarily, it would be a good idea to find out if there is a connection between medication and tinnitus. this can be seen, for example, by taking a break from medication to find out its effect on tinnitus. the effect of changing the dose size should also be investigated. medication can be critical to the illness, so taking a break is out of the question (hall et al., 2019). people should try other similar medicines. however, it is especially important to weigh tinnitus as a side effect of the consequences of untreated disease (kim et al., 2015). 649 global journal of public health medicine 2022, vol 4, issue 2 gggggglo drug therapy for tinnitus there are many causes of tinnitus ringing in the ear or humming. up to half of the population has to experience transient tinnitus and up to half a million patients live chronically with the problem (heller, 2003). tinnitus can occur as a result of ear disease or noise injury, for example. it can start after dental treatment or as a side effect of some medications (crummer & hassan, 2004). there are numerous causes of tinnitus, so there are different treatments. tinnitus can come from dizziness problems, for example. when a person tries to keep himself upright, the necks also stiffen and are in a bad position (crummer & hassan, 2004). the first and most cost-effective treatment is to try thus called postdizziness treatment, which can also help with tinnitus. according to crummer and hassan (2004), tinnitus can also come as a result of ear disease. the cause may be, for example, inflammation. a common cause of tinnitus is also noise injury. those exposed to loud noise, for example in an explosion accident, can be treated with hyperbaric oxygen therapy immediately after the accident. on the other hand, treating teeth, biting, and biting problems can also make tinnitus go away (crummer & hassan, 2004; widen & erlandsson, 2004). voice therapy voice therapy is one of the basic pillars of tinnitus treatment for all levels of tinnitus: in mild tinnitus, it is usually sufficient to avoid silence by enriching the sound environment and the knowledge that voice therapy can be controlled by covering up, i.e. masking, tinnitus whenever it feels disturbing (arts et al., 2016). the goal of voice therapy in acute tinnitus is to help prevent subconsciously easily sensitized nerves and in chronic tinnitus to make the patient tolerate the tinnitus so that it no longer harms patients and thus causes no anxiety or fear and thus reduces the stress response it causes (kochilas et al., 2020). voice therapy for tinnitus consists of three parts. enriching, masking, i.e. masking, and customized sound therapy for the sound environment. enriching the sound environment means adding a muffled background noise if it is not naturally sufficient, such as indoors and especially in the evenings (hobson et al., 2012; hoare et al., 2014). the purpose is not to consciously listen to the sounds of the environment, but to allow them to unknowingly suppress tinnitus to the unheard status. this helps focus on other chores and makes it easier to fall asleep (hobson et al., 2012). suitable sound sources for enriching the sound environment include radio (music or noise), alarm clock, fan, refrigerator, humidifier, and other electrical devices that maintain a steady sound (møller, 2016). masking means covering the tinnitus with an external sound source and is recommended whenever the tinnitus is disturbing. this avoids the intensification of tinnitus in the acute phase and the exacerbation of the resulting stress reaction and other symptoms. in chronic tinnitus, masking enrichment of the sound environment can make tinnitus unnoticeable, and thus habituation or habitation can take place more easily (hobson et al., 2012). chronic tinnitus does not aim to completely cover the tinnitus, but only partially and thus reduce the contrast. natural water sounds such as a shower, a crackling rain, the roar of waves, a waterfall, and a fountain are best for covering (ziai et al., 2017). people can also use music. tailor-made sound therapy is sound material made individually based on the hearing and tinnitus profile, which is to be listened to according to the treatment schedule for 2-3 hours a day. 650 global journal of public health medicine 2022, vol 4, issue 2 gggggglo because it is a learning process, it requires repetition and commitment to a long-term and daily treatment program to succeed. the sound material is best suited for music, but it can also be natural sounds such as rain sounds and other water noises, wind sounds, sea sounds, and the singing of birds. by the principles of music therapy, the sound should be pleasant, not overbearing, music, and even preferably pleasing music (kronenberg et al., 1992; mccormack et al., 2016). vagus nerve stimulation (tvns) vagal nerve stimulation is intended to affect the stress response caused by tinnitus. through the electrode attached to the ear bundle, i.e. the tragus, the vagus stimulator device provides a slight electrical current that stimulates the small ear branch of the vagus nerve. it plays a key role in the function of the parasympathetic part of the autonomic nervous system. it regulates all the functions of the body. stimulation of the vagus nerve thus stimulates the parasympathetic autonomic system and at the same time attenuates the sympathetic system and thereby the production of stress hormone secreted by the adrenal glands, and thus anxiety and fear do not dominate the mind (schlee et al., 2018). reducing stress relieves tinnitus because stress hormone-enhanced tinnitus decreases due to decreased bioelectrical activity. vagus nerve stimulation also has a general sedative and relaxing effect, and side effects are very minor and not permanent. hyperbaric oxygen therapy (hbot) hyperbaric oxygen therapy (hbot) is often helpful in the acute phase of tinnitus if treatment is started less than six weeks after the onset of tinnitus. in acute tinnitus, we recommend hyperbaric oxygen therapy if the tinnitus does not show signs of attenuation within a week. also in the case of long-lasting tinnitus, treatment comes into question if the tinnitus has worsened. in the treatment, the patient breathes 100% oxygen at an overpressure of 1.0 to 1.5 bar, which corresponds to a diving depth of 10 to 15 meters. the treatment increases the oxygen content of the inner ear fluids by about 500% and thereby provides the inner cells of the inner ear with optimal conditions for the spontaneous repair of damage (bennett et al., 2012). pharmacological therapies some drug therapies normally prescribed for tinnitus are not specific for tinnitus, drugs are used with the specific purpose of fighting the anxiety and depression resulting from the onset of tinnitus (langguth et al., 2019; kleinjung & langguth, 2020). among the drugs normally used: 1. vasoactive drugs these drugs work by increasing blood flow both systemically and locally (acheson et al., 2009). 2. local anesthetics – it causes motor paralysis and temporary sensory reversibly blocking the conduction of the nerve impulse. they can cause side effects on the central nervous system, such as convulsions, dizziness, nausea, drowsiness, tremors, and vision changes (rosenberg et al., 1998). 651 global journal of public health medicine 2022, vol 4, issue 2 gggggglo 3. melatonin: some controlled studies have evaluated the melatonin administration effects in patients with tinnitus. while no significant changes were found in the perception of tinnitus in treated subjects compared to placebo, it appears that melatonin can improve patients' sleep disturbance (mcferran & phillips, 2007). 4. homeopathic medicines the homeopathic medicines used in patients with chronic tinnitus did not show greater efficacy of these medicines compared to placebo (hoekstra et al., 2011). 5. anticonvulsants – as tinnitus condition is often associated with the hyperactivity of the auditory system, anticonvulsants such as carbamazepine, could be potentially used for tinnitus (baldo et al., 2012). it is because anticonvulsants tend to enhance the activity of the gaba neurotransmitter to substantiate the inhibition of the central auditory system. 6. antidepressants – studies have demonstrated a high association between depression and tinnitus condition. therefore, antidepressant drugs are used to relieve tinnitus-associated depression, anxiety, and stress. the use of nortriptyline, a tca (tricyclic antidepressant), tends to reduce the tinnitus loudness, depression scores, and tinnitus disability scores among patients suffering from serious tinnitus conditions (kim et al., 2021). 7. antihistamine – antihistamine drugs are used to treat significant factors contributing to the onset of tinnitus condition. as consistent physical pressure extending towards the cochlea often leads to tinnitus condition, antihistamine could reduce the tinnitus incidence by lowering the pressure in the tympanic cavity. moreover, antihistamines tend to provide a drying effect to the auditory tubes, therefore, improving their function during tinnitus (salvi et al., 2009; jufas & wood, 2015). some common side effects of these drugs include anxiety, sedation, etc. 8. anxiolytics – anxiolytics such as benzodiazepines (bdzs), tend to bind with the gammaaminobutyric acid (gaba) receptors while reinforcing its inhibition activity. benzodiazepines tend to inhibit the tinnitus from extending toward the acoustic centers. moreover, bdzs also promote sleeping while reducing the expression of anxiety associated with tinnitus (salvi et al., 2009; jufas & wood, 2015). some prominent side effects of bdzs include personality changes, sedation, memory failure, and drug dependence. 9. calcium channel blockers – the development of tinnitus is often triggered due to the concentrations of calcium within or outside of the cochlear cells. however, some studies have also indicated the contradictory effects of some calcium channel blockers such as nimodipine, among patients suffering from tinnitus (salvi et al., 2009; jufas & wood, 2015; kim et al., 202). 652 global journal of public health medicine 2022, vol 4, issue 2 gggggglo sound enrichment therapy on a physical and psychological level, music has a dual psychotherapeutic effect. music evokes specific sensations and moods, it can trigger unconscious mechanisms, it can help to strengthen the ego, and it can act as a bridge between the conscious and unconscious, allowing the impulses and complexes that cause conflicts and neuro-psychic disorders to emerge at the conscious level, unblocking repressions and resistances through the cathartic tension-liberation process (36-40). the limbic cortex, which is connected to the orbitofrontal-mesial cortex, the septal nuclei, the amygdala, the hypothalamus, some nuclei of the mesoncephalus, and the pons, is the nerve pathway's fulcrum; the various sections of the limbic system are then connected (hobson et al., 2012; hoare et al., 2014; arts et al., 2016; kochilas et al., 2020). as a result, listening to musical works with relaxing effects, limited variations, and very uniform tones is related to some relaxation activities. these tapes are recorded at a constant frequency that must match the frequency of the patient's tinnitus. the fundamental note or basic sound, which is comparable to tinnitus, blends with the melody to provide a welcome break from the monotony (hobson et al., 2012; hoare et al., 2014; arts et al., 2016; kochilas et al., 2020). in any event, great effort is taken to select tunes that are unrelated to memories or specific situations encountered in everyday life (works, famous songs, advertisements, soundtracks, etc.). sound therapy aids habituation by reducing the influence of tinnitus and neuronal activity in the auditory system, as well as the auditory system's connection to the limbic and autonomic systems. as a result, the intensity of the tinnitus and related activities decreases, making tinnitus habituation easier (hobson et al., 2012; hoare et al., 2014). conclusion medical examinations are appropriate if tinnitus develops rapidly, is associated with other symptoms such as dizziness or rapid hearing loss or is unilateral or fluctuates with the heart rate. examination of a patient with tinnitus may also be appropriate to determine if the cause is a treatable disease, such as meniere’s disease or otosclerosis. in addition to the tinnitus retraining therapy (trt) treatment mentioned above, tinnitus can be treated with sound treatments that use noise or, for example, natural tones, to cover the tinnitus and refresh the auditory pathway. there is no reliable research evidence for drug treatments for tinnitus. for some, medication to improve blood circulation in the inner ear either by the direct effect of vasodilators that result from the relaxation of smooth muscle in the arteries e.g., nitrate, or through the blockage of some vasoconstriction pathways e.g., calcium and angiotensin. in meniere's disease, a dehydration medication may still be helpful. in some cases, people with very disturbing tinnitus can be helped by treating side effects such as depression and insomnia. 653 global journal of public health medicine 2022, vol 4, issue 2 gggggglo tinnitus is a phantom sensation that occurs when damage or dysfunction of a mussel causes hyperactivity of the auditory neural network, first in the auditory nuclei of the brainstem, then higher up in the auditory canal area. almost everyone has tinnitus, most just don't notice it. if negative and frightening emotions are associated with tinnitus, the body's normal adaptation to tinnitus is prevented, the disruption of tinnitus is subconsciously intensified, and stress response may develop. close connections of the auditory pathway to the limbic system can cause sleep disturbances, anxiety, and depression. all tinnitus patients should be treated according to trt principles, and the target should be the patient, not the symptom. treatment should focus on reducing the annoyance, not just eliminating the phenomenon. therefore, proper teaching and counselling are a mainstay of tinnitus treatment, which should be combined with acoustic treatment, which is considered specific treatment, and possibly medical supportive treatment. conflicts of interest the author declares no conflicts of interest. references • acheson, a., rayment, s., eames, t., mundey, m., nisar, p., scholefield, j., & wilson, v. g. 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(2017). tinnitus patients suffering from anxiety and depression: a review. the international tinnitus journal, 21(1), 68-73. microsoft word gjphm-2022climate change 2 .docx 579 global journal of public health medicine 2022, vol 4, issue 1 review research impact of climate change on abundance, distribution, and survival of aedes species: systematic review lavanyah sivaratnam.1, chin mun wong1, diana safraa selimin1, rozita hod1, sazaly abu bakar2, hasanain faisal ghazi3, mohd rohaizat hassan1 1department of community health, faculty of medicine, universiti kebangsaan malaysia, cheras, 56 000, kuala lumpur, malaysia. 2department of tropical infectious diseases research &education center (tidrec), medical microbiology, faculty of medicine, university malaya medical centre, jalan universiti, lembah pantai, 50603 kuala lumpur, federal territory of kuala lumpur. 3 college of nursing, al-bayan university, baghdad, iraq. *corresponding author: rohaizat@ppukm.ukm.edu.my abstract introduction: aedes species is a common vector that causes various types of infection. one of the factors that can affect their distribution is the climate change. identifying the components of climate change that can affect this distribution and how they affect it can aid in predicting and controlling the aedes species distribution. methods: systematic search on articles related to the impact of climate change on aedes species distribution was conducted using four databases namely cochrane library, pubmed, ovid medline and science direct. all the articles which were published within year 2014 till 2019, was then assesses by using the prisma checklist 2009 guided by the inclusion and exclusion criteria set. results: ultimately, 19 articles inclusive of six cross-sectional studies, six modelling and seven ecological studies were subjected to narrative and objective quality analysis using newcastleottawa scale. each component of climate change – rainfall, temperature, humidity and wind velocity were examined on its relational impact towards vector aedes species distribution and survival. all studied climate components showed a unidirectional effect on the distribution and survival of aedes species temperature range 3.4oc-34.2oc, humidity <70%, post rainfall (<70mm) and low wind velocity related to increased vector aedes species distribution, abundance and survival. quality assessment yielded 17 high quality articles and two moderate quality. conclusion: climate change affects the aedes species distribution and survival. by incorporating the knowledge on the effects of each 580 global journal of public health medicine 2022, vol 4, issue 1 component of climate change aedes species vector control effort, a more objective and effective mitigation can be achieved. keywords: aedes species, climate change, impact, rainfall, dengue, aedes aegypti, aedes albopictus, vector abundance, vector survival, vector distribution introduction aedes species is the vector for seven important communicable diseases that are causing a pandemic in humans and other reservoir hosts, including dengue fever, chikungunya, zika virus, yellow fever, west nile fever, ross river fever and murray valley encephalitis (cavrini et al., 2009; walter reed biosystematics unit, 2011). aedes aegypti is a small to medium-sized mosquito of 4 to 7 millimetres (yimer, beyene, & shewafera, 2016). the adult aedes aegypti has white scales on the dorsal surface of that thorax resembled the shape of a violin or lyre while adult aedes albopictus have one central white stripe at the top of the thorax. the abdomen of aedes species is generally dark brown to black, some with white scales, the proboscis and the tip of the abdomen of the aedes species come to a point, which is characteristic of all aedes species (carpenter & lacasse, 1995; cdc, 2006; cutwa & o’meara, 2007). generally, the females are larger than males, which can be distinguished by small palps of white or silver scales at tip. the female mosquitoes have sparse short hairs while mouthparts are modified for blood feeding; while male mosquitoes have plumose antennae and their mouthparts are modified for nectar feeding (yimer et al., 2016). the female aedes aegypti feed almost exclusively on human blood only for the reason of oviproduction, other than that, the mosquito survived long with food other than blood (zettel & kaufman p., 2013). feeding on humans generally occurs at one to two hours intervals, preferring to bite typically from below or behind, usually the feet and ankles (yimer et al., 2016). the female aedes aegypti are active biters, they are read to feed when the environment are favourable (zettel & kaufman p., 2013). aedes albopictus is an aggressive diurnal feeder feeding on a wider variety of hosts than the aedes aegypti , they often present near human habitat, breeds well in artificial containers around the human habitat such as standing water bodies, coconut / durian shells, empty tins, opened water storage containers, as well as in natural containers such as leaf axils of water-holding plants like the bromeliads, or tree holes (mu˜nnoz, eritja, alcaide, & al., 2011). the aedes albopictus populations is capable to resist desiccation in temperate regions by produce diapausing eggs to curb the freezing cold winter season; and can feed on a wider diversity of vertebrate hosts by facilitating the establishment of enzootic arbovirus transmission cycles as a bridge vector in the america continent from spill-over of dengue virus of sylvatic cycles in asia (motoki et al., 2019). with this, aedes albopictus has a larger geographical distribution than aedes aegypti (la ruche, dejour-salamanca, & debruyne, 2010). after taking a complete blood meal, female mosquitoes produce an average of 100 to 200 eggs per batch placed at varying distances above the water line, usually clutching at two or more sites (yimer et al., 581 global journal of public health medicine 2022, vol 4, issue 1 2016). the number of eggs produced is dependent upon the volume of blood meal feed. females can produce up to five batches of eggs during a lifetime (yimer et al., 2016). the adult aedes aegypti life span can range from two to four weeks depending on environmental conditions. aedes aegypti comes in three polytypic forms: domestic, sylvan and per domestic. the domestic form breeds in urban habitat, often around or inside houses. the sylvan form is a more in rural form, breeds in tree holes and forests while the per domestic form thrives in environmentally modified areas such as coconut groves and farms (maricopa county environmental services, 2006). the increasing vector-animal-human interaction has diverged the sylvatic cycle of transmission into the form of domestic, anthropophilic and phagic transmission forms (powell & tabachnick, 2013). various natural habitat displacement and habitat creation by human activities, climate change and transmission tetrad (vector, agent, host, environment interaction) have successfully enlarged the distribution of aedes species the region away from its originality (shragai t, tesla b, murdock c, & lc., 2017). aedes aegypti and aedes albopictus seem to have different susceptibilities to zikv, feeding rates, and feeding preferences, as aedes aegypti feeds more often and almost exclusively on human as compared to aedes albopictus which feeds on a broader range of hosts (caminade c, mcintyre km., & ae., 2017). therefore, given equal mosquito and human densities, regions with aedes aegypti will have a higher affinity for denv, zikv, chkv and yfv, but since aedes albopictus extends beyond the range of aedes aegypti into more temperate regions, it is more often found as the aedes species which carry flavivirus transmission risk (caminade c et al., 2017). extreme weathers more than 50% of the earth’s climate change was a result of anthropogenic activities and is happening at a rate faster than the earth ecosystem can recover (stocker et al., 2013). intergovernmental panel on climate change forecasts an increase in world average temperature by year 2100 within the range 1.4 ºc –5.8ºc since year 1995; and the global temperature is rising at the rate of 0.5ºc annually since year 1970 (mcmichael, woodruff, & hales, 2006), more remarkably seen at higher latitudes areas. this leads to extreme weather events in a more frequent, severe and higher variable mode (hainesa, kovatsa, campbell-lendrumb, & corvalanb, 2006; mcmichael et al., 2006). the mortality rate related to extreme weather is well established and represented by the u-shape / j-shape curve, where median temperature (the thermo comfort zone) has the lowest death rate, and the mortality rate increases in exponential relationship with the rise of temperature, also to lesser extent, the fall to low temperature (abdul rahman, 2009; hainesa et al., 2006; mcmichael et al., 2006). in a warming climate, extreme events like floods and droughts are likely to become more frequent. more frequent floods and droughts will affect water quality and availability. increases in drought in some areas may increase the frequency of water shortages and lead to more restrictions on water usage. an overall increase in precipitation or rain may create greater flood potential. rising sea levels, meanwhile, 582 global journal of public health medicine 2022, vol 4, issue 1 heighten flood dangers for coastal farms, and increase saltwater intrusion into coastal freshwater sources making those water sources too salty for irrigation or drink (backlund, janetos, & schimel, 2008). precipitation also can washes-off pesticide from the agricultural site and spread the pesticide to water sources such as underground water thus making it contaminated. same as food supply, extreme climate can result in greater water source spoilage and disrupt water distribution, water storage, transport and dissemination. climate change in relation to vector distribution flood / rain fall related vector borne diseases like dengue fever, malaria, leptospirosis, chikungunya endemics are more prevalent in the country and worldwide; through the development of more breeding sites, contamination of surface run-off and poor hygiene practice during the disaster. urbanization brings forth more complex human-vector interaction epidemiologically and ecologically, account for the worsen endemicity (world health organization & united nations environment programme, 2007). the illegal logging activities may result in malaria virus transmission via rural-urban vector-human interaction (world health organization & united nations environment programme, 2007). mosquito aedes species usually live between the latitudes of 35°n and 35°s below an elevation of 1000m at both natural and artificial terrestrial and aquatic habitats (nc. dom, abu, & rodziah, 2013). climatic factors are strong environmental drivers for arbovirus disease transmission, this is particularly true for factors such as environmental temperature, relative humidity and rainfall patterns (rodo, pascual, & doblas-reyes, 2013). the risk of viral transmission from aedes species is highly sensitive to climate. temperature impacts the ectoderm’s internal body temperature, hence directly affecting the mosquito physiology (e.g., immunity) (murdock, blanford, & luckhart, 2014), the mosquito development, survival, reproduction, biting rates (ciota, matacchiero, & kilpatrick, 2014), vector competence and extrinsic incubation periods) (ciota et al., 2014). in hot and dry climates, aedes albopictus eggs may be more susceptible to desiccation, thus becoming less competitive to aedes aegypti (shragai t et al., 2017). this capacity of vector-borne disease transmission and affinity of transmission are influenced by the mean number of blood meals in a typical mosquito’s remaining lifespan after mosquitoes were infected (shragai t et al., 2017). urbanization further changes the natural habitat of both mosquitoes and of human, as well as climate suitable for the vector survival and transmission (pincebourde, murdock, & vickers, 2016). temperature, humidity, and the number of breeding sites in the city appeared heterogenous, vary depending on the economic status of the landowner or resident, mosquito control, zoning, and cultural norms. micro environmental niche in the urban that turn out to be the mosquitoes hotspots are usually congested area with high population density, limited space, poor hygiene, sanitation and suboptimal sewage management; and these niches are often inhabited by human population with higher vulnerability to infection due to low socioeconomic and low sociodemographic status (shragai t et al., 2017). 583 global journal of public health medicine 2022, vol 4, issue 1 modelling and prediction of vector survival environmental niche modelling is usually used to predict suitability for disease transmission for aedes species. modelling uses disease prevalence report against hypothesized environmental covariates to derive future potential of vector distribution (messina et al., 2016). for example, modelling results indicate that temperature conditions related to the 2015 el niño climate phenomenon were exceptionally conducive for aedes species mosquito-borne transmission of zikv over south america (caminade c et al., 2017). regions with model prediction of high zikv transmission risk has high correlation with the subsequent large outbreaks occurring in brazil, colombia and venezuela in year 2015–2016. this optimum thermal zones show largest simulated biting rates and lowest mosquito mortality rates and the shortest extrinsic incubation period in year 2015 (caminade c et al., 2017). the sub-saharan africa regions demonstrated continuous suitability for zikv survival since the 1950s (messina et al., 2016). nevertheless, the interpretation of relationships between mosquito abundance and land-use patterns is not as straight forward. the variation occurs due to different categorizations of landscapes used, such as the percent of vegetative coverage, human population density, outdated geographical map, map resolution. the inaccuracy is complicated by inappropriate scales used to quantifying these patterns. when large regions are used, the over broad geography may not appropriately representing the microclimate and available habitats within the regions, obscuring pattern of transmission (shragai t et al., 2017). with climate change being recognized fast as a determinant of health, this has become utmost important to estimate the effect of weather on vector borne diseases (roy, gupta, chopra, meena, & aggarwal, 2018). even though various control measures have been done, vector borne cases are still persistent which is likely due to the changing climate that is not factored to our control measures. there is no recent review done on the effect of climate change on aedes species distribution globally. being able to anticipate vector abundance in relation to the changing climate, a better vector control can be implemented. the review aims to understand how each component of climate change impacts the distribution and survival of vector aedes species. methods literature search systematic search related to relevant articles from four major search engines using boolean search strategy, search engines including cochrane library, pubmed and ovid medline and science direct, retrieving all articles published from year 2014 until 2019. prisma checklist 2009 is used to describe the workflow of articles search for this study (page mj et al., 2021). the keywords used to search for the articles are stated in table 1. table 1: initial keyword search using p.i.c.o. strategy 584 global journal of public health medicine 2022, vol 4, issue 1 keyword concepts alternative patient / problem aedes sp aedes sp or dengue cases or dengue haemorrh#gic fever cases or chikungunya cases or yellow fever case or zika case or flavivirus case intervention comparison climate change in sea current rain fall or current temperature or current wind direction outcome vector distribution vector survival vector distribution or aedes sp new case or pattern of aedes sp. distribution or vector aedes sp. evolution or vector life cycle or vector transmission or vector survival boolean strategy keyword search: as the keyword combination did not yield sufficient search result after two rounds of boolean strategy keyword search, contraction using a set of new keywords was done. aedes sp or dengue cases or dengue haemorrh#gic fever cases and rain fall or temperature or wind direction and distribution or new case or pattern or evolution or transmission or survival inclusion criteria for the article search including: (1) full text, primary research articles on prevalence of vector-borne diseases in relation to climate change (2) reported at least one outcome of the vector distribution due to climate change (3) articles published from year 2014 – 2019. exclusion criteria set were: (1) reviewed articles of no original research work empirical data (2) entomology with no association to climate change (3) knowledge, attitude, practice studies (4) clinical treatment (5) pharmaceutical study (6) vector distribution other than aedes species the articles obtained from the keyword search were first screened by titles to exclude totally irrelevant articles, then abstracts of the articles to look for p.i.c.o. criteria. when full texts are retrieved, it was assessed for relevance to include our inclusion and exclusion criteria. in total, there is a total of 440 articles retrieved based on boolean search strategy, 36 accepted by title and further subjected for abstract screening yielding 31 articles. after excluding one duplicate article and eight that did not fit the inclusion criteria, a total of 22 articles were subjected for full text review. in the review, three more articles were excluded due to irrelevant content. the final full article reviewed and proceeded for analysis was 19. the progress of screening and selection is described through the prisma flow chart in error! reference source not found.. 585 global journal of public health medicine 2022, vol 4, issue 1 gggggglo figure 1: prisma flow chart results & discussion characteristic of study a total of 19 articles which consist of six cross-sectional, six modelling and seven ecological studies were finalized for full text analysis. the articles are mostly from europe and asia. amongst which 17 articles studied on temperature in relation concerning vector survival, eight on rainfall, eight on humidity, two on seasonality change and one on wind velocity. table 2 provides a narrative review on the study design, tools, variables used, outcome of vector and challenge / limitation / public health implications. total of 11 studies using ovitrap for mosquitoes sampling, the other eight uses secondary data from meteorology data, environmental survey or geographical intelligence systems. table 3 provide the narrative analysis summary of various climate components effect on vector aedes species distribution and survival. nine studies reported on rainfall, where 55.5% (n=5) studies shows inverse relationship of rainfall with aedes sp abundance, with each 1mm increase of rainfall contribute to 1% increase in vector abundance, up to 70mm. nine studies were done on humidity, 66.7% (n=6) studies reported increased humidity will lead to increase in aedes sp vector abundance, (betanzos-reyes, rodríguez, romero-martínez, sesma-medrano, & rangel-flores, 2018) specified that humidity range 30-70% is 586 global journal of public health medicine 2022, vol 4, issue 1 gggggglo suitable for vector survival, and consistently supported by (da cruz ferreira et al., 2017) that humidity beyond 70% leads to reduction of vector survival. seventeen studies studied effect of temperature with aedes sp abundance and survival, 94.1% (n=16) supported that increase temperature proportionate to the increase of vector abundance, but (limper et al., 2016) provided contrast opinion. the lowest temperature recorded for vector increment was 3.4oc (taber, hutchinson, & smithwick, 2017), and temperature maximum for increased vector was 34.3oc by (das et al., 2014). review supported the jshape relationship between temperature and vector abundance and survival, (phung, talukder, rahman, shannon, & cordia, 2016) reported with every 1˚c increment, there will be an additional 11% risk to get dengue infection (proxy to vector survival). only three studies reviewed on wind velocity in relation to aedes sp survival, all studies show inverse relationship. table 2: narrative review of characteristics of studied articles n o author/ year country study design tool variables outcome challenge / limitation / public health implication 1 barrera et al. 2019 (barrer a, amador , aceved o, beltran, & munoz, 2019) puerto rico (us territory) comparat ive cross sectional (2014/201 6) mosquito collection mosquito density rainfall temperatur e relative humidity accumulated rain significantly influenced mosquitoes density (reduced during rain fall and increase post rain) comparing the results with a previous study may not be comparabl e as the number of samples, sampling tools, techniques and analysis may differ. 2 roy et al. 2018 (roy et al., 2018) india cross sectional study secondary data laboratory confirmed cases rainfall temperatur e relative humidity 1. relative humidity was associated with burden of positive dengue cases 2. dengue admission was preceded by heavy rain 4–6 weeks earlier -limited number of paediatric cases 3 xiang et al. 2017 (limper china modelling dengue notification system data clinical and laboratory confirmed cases rainfall 1. positive temperature -dengue association s were nonclimatic data was not accounte 587 global journal of public health medicine 2022, vol 4, issue 1 gggggglo et al., 2016) meteorologi cal data temperatur e relative humidity sunshine duration wind velocity found for both tmax and tmin at the range of 21.6– 32.9°c and 11.2– 23.7°c 2. relative humidity was positively associated with dengue; however, a negative association was observed during extremely humidity. 3. extreme rainfall and high wind velocity are associated with reduced cases. d for in this model as data was not available 4 phung et al. 2016 (phung et al., 2016) vietnam modelling secondary data dengue cases rainfall temperatur e relative humidity 1. a 1 ̊c increase in temperatu re increased the dengue risk 11% (95%ci, 9-13) at 14 weeks and 7% (95%ci, 6-8) at 58weeks. 2. a 1% rise in humidity increased dengue risk 0.9% (95%ci, 0.2-1.4) at lag 1-4 and 0.8% (95%ci, 0.2-1.4) at uses mean value of climate factors rather than minimu m, maxim um or diurnal . 588 global journal of public health medicine 2022, vol 4, issue 1 gggggglo lag 5-8 weeks 3. a 1 mm increase in rainfall increased dengue risk 0.1 % (95%ci, 0.05-0.16) at lag 1-4 and 0.11% (95%ci, 0.07-0.16) at lag 5-8 weeks 5 limper et al. 2016 (dhimal , gautam , joshi, o’hara, & ahrens, 2015.) netherland s modelling distributed lag nonlinear model secondary data dengue cases, rainfall, temperatur e, relative humidity, sunshine duration lower temperatures lead to higher rates of infection -data for dengue cases is obtained by month unlike climate changes by week. 6 william s et al. 2015 (william s et al., 2015) malaysia modelling mechanistic entomology and disease model – secondary data dengue cases daily temperatur e increase in temperature resulted in an overall decrease in dengue activity model unable to predict future number of dengue cases 7 im nurinzulkifli et al. 2015 (im nurinzulkifli. et al., 2015) malaysia cross sectional study mosquito collection hlc – human landing catch mean number of ae. albopictus mosquitoes and meteorologi cal parameters -mosquito population correlated significantly with humidity & temperature -no significant correlation of mosquito species with temperature and humidity 8 taber e.d et. al. 2016 (ciota et al., 2014) pennsylva nia, usa modelling geographic information systems (gis) over 10 years risk of dengue virus transmissio n using a model that captures the probability of -ae. albopictus population density -monthly pattern of population increase correlate with bg sentinel traps was not used during earlier part of the study, given lower yield of ae. 589 global journal of public health medicine 2022, vol 4, issue 1 gggggglo transmissio n temperature 3.4-32.7oc -winter temperatures limit aedes sp. egg survival albopictus catch evaluation of temperate ae. albopictus population s helps in developme nt of better biological models of denv transmissio n. 9 dutto m. & mosca a. 2017 (dutto & mosca, 2017) northwest ern italy cross sectional study environmen tal risk assessment interview, larvae sampling indoor mosquito breeding sites -for ae albopictus only low external temperature (winter, 26oc) restricted vector survival, encourage indoor vector survival insufficient survey sites to define real entity of winter presence of aedes species in the area and the associated risk of vectortransmitted diseases 10 rodrigu es et. al. 2015 (grech et al., 2019) brazil cross sectional study mosquito collection portable electrical catcher female aedes aegypti & ae. albopictus over number of residents for intradomicili ary and peridomicili ary premises strong association between no. of female adult mosquitoes and the number of residents in both intradomiciliar y and peridomiciliar y premises 77% (p = 0.000) female adult aedes sp intradomiciliar y premises and and 48% female adult aedes sp peridomiciliar y premises due to mean high probability of humanvector contact can increase possible transmissio n and spread of the den virus. part of the aedes sp mosquito behaviour is the adaptability to vast differentiat ed environme nts 590 global journal of public health medicine 2022, vol 4, issue 1 gggggglo rainfall (p=0.001) min temperature in both types of premises contributes to 40% of no. of female mosquitoes entomologi cal indicators of adult females should be use for vector control 11 marta r.h.s et. al. 2018 (marta, 2018) brazil cross sectional study mosquito collection using ovitrap rainfall and temperatur e oviposition rates seasonal variation (min, max temperatures significantly associated with oviposition rate of both aedes sp. cumulative rainfall (weekly) not associated with vector abundance ae. aegypti, closely associated with inhabited region (more human); ae. albopictus was more closely associated with area with a greater vegetation coverage 12 sadie j.r. et. al. 2019 (sadie j. r., colin j. c., erin, & leah, 2019) usa modelling general circulation models – secondary data temperatur e mosquito range shifts track optimal temperature ranges for transmission (21.3–34.0˚c for ae. aegypti; 19.9–29.4˚c for ae. albopictus -poleward shift pattern observed significant reductions in climate suitability at southeast asia and west africa are expected for ae. albopictus climate change will lead to increased net and new exposures to aedesborne viruses both aedes species vary in transmissio n rate under climate change, ae. aegypti endures wider range of climate change, but intermediat e climate changes 591 global journal of public health medicine 2022, vol 4, issue 1 gggggglo make ae. albopictus a more suitable survival and successful competitor 13 dhimal et al. 2014 (dhimal , gautam , kreß, & müller, 2014) nepal ecologica l study entomologi cal survey: adult mosquito collection by using bgsentinel and cdc light traps number of mosquitoes per trap and meteorologi cal parameters temperature, rainfall and relative humidity had significant effects on the mean number of a. aegypti per bgsentinel trap: • each degree rise in temp increased female a. aegypti abundanc e (ß = 1.63; 95% ci = 1.34– 1.98; p,0.001) • every increased in rainfall (mm) reduced abundanc e (ß = 0.94; 95%ci =0.92– 0.97; p,0.001) • every increased humidity (%) also reduced abundanc e (ß= 0.59; 95%ci=0. 44–0.77; p,0.001). no significant effect of rainfall and temperature ae. aegypti and ae. albopictus established stable population s up to the middle mountains of nepal, but not in the high mountain localities. ae. aegypti and ae. albopictus trapped even when minimum temperatur es had dropped to 8oc suggesting a considerab le adaptive capacity of local ae. aegypti and ae. albopictus population s to low temperatur es à for better planning and scaling-up of mosquitoborne disease control programm es in the mountaino us areas of nepal that had 592 global journal of public health medicine 2022, vol 4, issue 1 gggggglo on the number of aedes eggs per ovitrap (p.0.05). humidity had significantly negative effects on the mean number of aedes eggs per ovitrap (b = 0.83; 95%ci = 0.71–0.97; p,0.001). previously been considered risk free increase temp shorten the extrinsic incubation period of pathogens, lead to increases in biting frequency and extensions of the average life span of mosquitoe s è increas ing temp can make temper ate regions of nepal vulnera ble to df epidem ic 14 da rocha taranto et al. 2015 (m. f. da rocha taranto et al., 2015) brazil ecologica l study mosquito egg collection by using ovitrap average monthly temperatur e and precipitatio n was compared with the number of eggs collected in each month the presence of the vector was significantly influenced by temperature variation (p < 0.05) rainfall provided physical and climatic conditions favourable to the development of eggs and to the increased survival of the mosquito. however, the higher temperatur es provided better conditions for mosquito breeding, thus greater probability of transmittin g denv 593 global journal of public health medicine 2022, vol 4, issue 1 gggggglo extreme rainfall conditions are not associated with vector presence over time, as the pattern may result from the elimination of larvae from overflowing containers. 15 betanz osreyes et al. 2018 (im nurinzulkifli. et al., 2015) mexico ecologica l study mosquito egg collection by using ovitraps correlation between climate variables eg. weekly report of temperatur e (average, minimum and maximum), rainfall (mm accumulate d) and relative humidity (rh, percentage) and ovitraps data daily mean temperature, relative humidity and rainfall parameters were associated with mosquito egg abundance: significant correlation was seen between the weekly aedes egg counts with: the mean weekly egg counts (wec): increased with 12oc to 18oc, but decreased as temperature increased beyond this point. similar at rh between 30 and 70% and increased as humidity increased beyond 70% increased as rainfall increased up to 70mm, but unchanged with further time lags between egg counts and dengue incidence could be useful for prevention and control interventio ns. this time lag represents an opportunity to use ovitrap monitoring as a predictive tool for dengue fever incidence increments. 594 global journal of public health medicine 2022, vol 4, issue 1 gggggglo increases in rainfall 16 da cruz ferreira et al. 2017 (da cruz ferreira et al., 2017) brazil ecologica l study mi-dengue system (intelligent dengue monitoring, or mosquitra ps) daily rainfall, temperatur e parameters (minimum, average and maximum), and average relative humidity -dengue incidence adult mosquito abundance was strongly seasonal, with low infestation indices during the winters and high infestation during the summers. weekly minimum temperatures above 18 °c were strongly associated with increased mosquito abundance, whereas humidity above 75% had a negative effect on abundance. continuous monitoring of dengue vector population allows for more reliable predictions of infestation indices. the adult mosquito infestation index was a good predictor of dengue occurrence . weekly adult dengue vector monitoring is a helpful dengue control strategy especially in subtropical areas 17 bezerra et al. 2016 (bezerr a et al., 2016) brazil ecologica l study adult female aedes albopictus (and other aedes sp.) were caught using bgsentinel full version®tra ps -rainfall, temperatur e (minimum, maximum and average) and relative humidity -the fieldcaught ae. albopictus collected females the fieldcaught denvinfected ae. albopictus 1. minimum temp of 12.123.2degc (r=0.34, p< 0.0001 and maximum temp of 18.634.2oc (r=0.25, p= 0.004) were correlated with the fieldcaught ae. albopictus (n=511) in four different periods and districts. neither the rainfall nor relative humidity was associated inverse association between the number of human dengue cases and fieldcaught denvinfected ae. albopictus à in brazil, possible that ae. albopictus would be a less efficient denv vector 595 global journal of public health medicine 2022, vol 4, issue 1 gggggglo with the fieldcaught ae. albopictus collected females 2. none of the climate variables were correlated with the fieldcaught denvinfected ae. albopictus (n = 79) in four different periods and districts 18 dhimal et al. 2015 (dhimal et al., 2015.) nepal ecologica l study entomologi cal survey: collecting aedes spp. larvae -daily rainfall, temperatur e and relative humidity significant effects of climatic variables on the mean abundance of each mosquito species: 1. aedes aegypti: each degree rise in mean temperature increased ae. aegypti abundance (β = 1.23; 95% ci = 1.18– 1.29; p< 0.001) increased rainfall reduced abundance (β = 0.99; 95%ci = 0.99–0.99; p<0.001) increased relative humidity reduced the vector abundance (β = 0.91; 95% ci = 0.85– 0.98; p<0.05). abundance of denv vectors with mean temperatur e ranging from 10– 25°c: shorten the extrinsic incubation period of pathogens, lead to increases in biting frequency and extensions of the average life span of mosquitoe s 596 global journal of public health medicine 2022, vol 4, issue 1 gggggglo 2. aedes albopictus: an increase of mean temperature had a positive effect (β = 1.12; 95% ci = 1.06– 1.20; p<0.05), total rainfall had a significant negative effect (β = 0.99; 95% ci = 0.99–0.99, p<0.001) relative humidity had a significant positive effect (β = 1.21; 95% ci = 1.08–1.35, p<0.001) 19 das et al. 2014 (das et al., 2014) india ecologica l study ovitrap surveillance larvae density per trap data on max. temperatur e (tmax), min. temperatur e (tmin), morning relative humidity (0830 h), evening relative humidity (1730 h, total rainfall 1. positive and significant correlations to vector density: maximum temperature (r = 0.45; p = 0.01) mean temperature (r = 0.408; p = 0.021) minimum temperature (r = 0.381; p = 0.032). the relationshi ps established between the weather parameters and the abundance of dengue vectors in the study areas could provide valuable inputs for the developme nt of a decision support system for dengue esp. in northeaste rn india. however, disease outbreaks also 597 global journal of public health medicine 2022, vol 4, issue 1 gggggglo depend on factors such as the source of infection, susceptible human population apart from vector density and climate all the climate factors were associated with at least one outcome of vector distribution or vector survival. error! reference source not found.3 analysed on the summative effect of each climate components to the vector survival / distribution. objective analysis of quality of the studies was assessed using newcastle-ottawa scale, with score range from 6 to 9 as described in table 4. total of 16 articles were rated as of good quality, two others with moderate quality of evidence from the objective quality assessment. table 3: summarised effects of climate components on vector distribution / survival no. study rain humidity temperature wind velocity 1. barrera et al. 2019 (barrera et al., 2019) ↓ abundance of aedes sp. during rain ↑ abundance of aedes sp. after rain 2. roy et al. 2018 (rodrigues et al., 2015) ↑ humidity ↑ dengue cases 3. xiang et al. 2017 (oliveira custódio et al., 2019) ↓ dengue cases during extreme rainfall ↑ humidity ↑ dengue cases extreme humidity ↓ dengue cases ↑ dengue cases during: tmax: 21.6˚c-32.9˚c tmin: 11.2˚c -23.7˚c extreme wind velocity will ↓ dengue cases 4. phung et al. 2016 (taber et al., 2017) ↑ 1mm rain ↑ 0.1% dengue cases 1% ↑ humidity will ↑ 0.9% risk to get dengue 1˚c ↑ in temp. will ↑ 11% risk to get dengue 5. limper et al. 2016 (rodo et al., 2013) ↓ temp. will ↑ dengue cases 6. williams et al. 2015 (williams et al., 2015) ↑ temp. will ↑ dengue cases 598 global journal of public health medicine 2022, vol 4, issue 1 gggggglo 7. im nurin-zulkifli et al. 2015 (im nurin-zulkifli. et al., 2015) ↑ humidity ↑ dengue cases ↑ temp. ↑ dengue cases 8. taber e.d et. al. 2016 (liuhelmersson, stenlund, & wilder-smith, 2014) optimal temp. between 3.4˚c32.7˚c will ↑ aedes sp. winter temp. limit egg survival 9. dutto m. & mosca a. 2017 (dutto & mosca, 2017) ↓ temp. during winter (2˚c-6˚c) will ↓ aedes sp. survival outdoor, and ↑ aedes sp. indoor 10. rodrigues et. al. 2015 (xiang et al., 2017) ↑ rainfall will ↓aedes sp. density ↓ temp. will ↓ aedes sp. 11. marta r.h.s. et. al. 2018 (marta, 2018) 1˚c ↑ in min. temp. will ↑ 8% abundance of aedes sp. 1˚c ↑ in max. temp. will ↑ 7% abundance of aedes sp. for ae. albopictus, the abundance ↑ in summer, winter & autumn for ae. aegypti, the abundance ↑ in spring 12. sadie j.r. et. al. 2019 (sadie j. r. et al., 2019) ↑ ae. aegypti during temp. between 21.3˚c-34˚c ↑ ae. albopictus during temp. between 19.9˚c-29.4˚c 13. dhimal et al. 2014 (powell & tabachnick, 2013) ↑ rainfall will ↓ abundance of aedes sp. ↑ humidity: ↓ abundance of aedes sp. ↓ aedes sp. eggs ↑ temp. will ↑ aedes sp. 14. da rocha taranto et al. 2015 (m. f. da rocha taranto et al., 2015) ↑ rainfall ↑ aedes sp. eggs extreme rainfall will ↓ abundance of aedes sp. eggs ↑ temp. will ↑ aedes sp. eggs 15. betanzos-reyes et al. 2018 (walter reed biosystematics unit, 2011) ↑ rainfall up to 70mm will ↑ aedes sp. eggs rainfall > 70mm will have no change in aedes sp. eggs ↑ humidity 30-70% will ↑ abundance of aedes sp. eggs humidity > 70% will ↓ abundance of aedes sp. eggs ↑ aedes sp. eggs during temp. between 12˚c-18˚c ↓ aedes sp. eggs during temp. >18˚c - 599 global journal of public health medicine 2022, vol 4, issue 1 gggggglo 16. da cruz ferreira et al. 2017 (da cruz ferreira et al., 2017) ↑ humidity >75% will ↓ abundance of aedes sp. ↑min. temp. >18˚c will ↑ abundance of aedes sp. abundance of aedes sp.: ↓ in winter ↑ in summer 17. bezerra et al. 2016 (bezerra et al., 2016) ↑ ae. albopictus during: min. temp. between 12.1˚c-23.2˚c max. temp. between 18.6˚c-34.2˚c 18. dhimal et al. 2015 (dhimal et al., 2015.) ↑ rainfall will ↓ abundance of aedes sp. ↑ humidity will ↓ abundance of aedes sp. ↑ temp. will ↑ abundance of aedes sp. 19. das et al. 2014 (das et al., 2014) ↑ max temp. between 21.6˚c34.3˚c will ↑ abundance of ae. albopictus larvae density table 4: newcastle ottawa quality assessment scale n o study selection comparability outcome quality score rep rese ntati ven ess of the sam ple sam ple size nonrespo ndents ascerta inment of the exposu re (risk factor) the study control s for the most importa nt factor the study control for any additio nal factor asses sment of the outco me statisti cal test 1. barrera et al. 2019 (barrera et al., 2019) * * * ** * 6 2. roy et al. 2018 (dhimal et al., 2014) * * * ** * 6 3. xiang et al. 2017 (xiang et al., 2017) * * ** * ** * 8 4. phung et al. 2016 (zainon, mohd rahim, roslan, & abd samat, 2016) * * * * ** * 7 5. limper et al. 2016 (limper et al., 2016) * * ** * ** * 8 6. williams et al. 2015 (williams et al., 2015) * * ** * ** * 8 7. im nurinzulkifli et al. 2015 (im nurin-zulkifli. et al., 2015) * * * * ** * 7 600 global journal of public health medicine 2022, vol 4, issue 1 gggggglo 8. taber e.d et. al. 2016 (taber et al., 2017) * * ** * ** * 8 9. dutto m. & mosca a. 2017 (dutto & mosca, 2017) * ** * ** * 7 1 0. rodrigues et. al. 2015 (rodrigues et al., 2015) * * * ** * ** * 9 1 1. marta r.h.s. et. al. 2018 (marta, 2018) * * * * ** * 7 1 2. sadie j.r. et. al. 2019 (sadie j. r. et al., 2019) * ** * * * 6 1 3. dhimal et al. 2014 (dhimal et al., 2014) * * * * ** * 7 1 4. da rocha taranto et al. 2015 (m. f. da rocha taranto et al., 2015) * * ** * ** * 8 1 5. betanzosreyes et al. 2018 (á. f. betanzosreyes et al., 2018) * * ** * ** * 8 1 6. da cruz ferreira et al. 2017 (da cruz ferreira et al., 2017) * * ** * ** * 8 1 7. bezerra et al. 2016 (bezerra et al., 2016) * * ** * ** * 8 1 8. dhimal et al. 2015 (maricopa county environmental services, 2006) * * ** * ** * 8 1 9. das et al. 2014 (das et al., 2014) * * ** * ** * 8 601 global journal of public health medicine 2022, vol 4, issue 1 gggggglo climate components and recommendation of vector control rainfall findings showed that extreme rainfall will cause reduction in vector abundance (martinelle ferreira da rocha taranto et al., 2015; dhimal et al., 2015.; dhimal et al., 2014; rodrigues et al., 2015; xiang et al., 2017), but the abundance increases post rainfall. this could be due to its catastrophic effects on a local population of vectors by constant washing of soil by flooding, reducing the vector habitat, leads to an inverse relation to vector intensity (epstein, 2004). rainfall up to 70mm is found to be the optimal for mosquito breeding, thus supportive factor towards aedes species abundance in the environment (ángel francisco betanzos-reyes et al., 2018). a study done in kuala lumpur concluded that there was strong association between dengue cases and monthly rainfall, where incidence always preceded by rainy season (aziz et al., 2014). in tirunelveli, india where city has poor rainfall stored water in various containers for daily use, in which these containers became the main breeding habitats for aedes mosquito, the situation is similar to root cause of urban dengue in petaling jaya district, malaysia (zainon et al., 2016). this result provided privilege of vector control which is in contrast with the conventional belief that rainy season causes increased in vector abundance, as 10mm rainfall and humidity of 30-70% only contributes to 1% of increased vector abundance (phung et al., 2016). therefore, increasing awareness for search and destroy of stagnant water bodies post rainfall is an effective measure to prevent vector breeding, as rainfall does not contribute to the increase of vector abundance, but the human activities do. temperature temperature change will lead towards change in incidence and prevalence of disease pattern by adjustment of vector’s biting rates, human contacts, and also the vector abundance (figueroa, 2015). amazingly, vector aedes species adapt well to temperature changes by changing their geographic distributions, and there is evidence that some have produced genetic adaptation to increasing temperatures (patz et al., 2003). any increase in the temperature will cause increase in growth rate of vectors, and decrease the extrinsic incubation period which may prolonged the pathogen’s transmission period (figueroa, 2015). the feeding frequency (estimated by biting rates), longevity of the mosquitoes and the time to virus replication (extrinsic incubation period) are highly sensitive to environmental temperature conditions (caminade, mcintyre, & jones, 2017). both the aedes species and viral life cycle exhibit non-linear relationships of transmission with temperature. a parabolic relationship with temperature is exhibited, where maximum biting performance occurs at optimum thermal zones, while lower or higher temperature than the optimum thermal zones exhibits lower vector performance in zero order, similar to previous findings (liu-helmersson et al., 2014). our review showed that optimum temperature range of tmin 3.4˚cto tmax 34.3˚c (minimum and maximum temperatures) is suitable for vector aedes sp survival. at different temperature regimens the length of the aedes aegypti life cycle showed variety of development rate. faster development of life cycle recorded at temperature of 34◦c than at 32◦c, while most larvae found to be dead at temperature of 36◦c (mohammed & chadee, 2011). a study done also found almost the same findings, in which immature aedes sp stage dead when temperature more than 34.5◦c (chadee & martinez, 2016). malaysia weather is predicted to have 0.6 602 global journal of public health medicine 2022, vol 4, issue 1 gggggglo 1.2ºc rise of surface temperature in the next 50 years (1969-2009) and projected to increase another 1.5-2.0ºc by year 2050 (begum, march 1, 2017; ministry of natural resources and environment malaysia, 2015). this is clear evidence that climate conditions alterations such as global warming in sub-tropical countries has resulted in a regional temperature closer to the thermal optima, explaining the increased vector-borne disease transmission. at the same time, global warming of geopolitical regions of current flavivirus endemicity which is conducive to mosquito-borne diseases transmission may experience lower rate of disease transmission as the warming temperatures might move the environment away from the thermal optimum that becomes less favourable to the aedes sp survival (shragai t et al., 2017). understanding temperature-vector survival relationship, health advises to modify time to daily outdoor activity, such rubber harvesting, palm oil harvesting and working in construction to noon hours where temperature peaks beyond the thermal comfort zone 3.4-34.2oc may reduce human-vector contact. heat modality above 34oc can be used to destroy the vector habitat. humidity the acceptable range for aedes species survival would be around 30-70mm. the annual cumulative precipitation with is higher would strongly increase transmission for not only denv but also zikv (messina et al., 2016). in malaysia, there was an average increase of 17% in one-hour duration and 29% in three hours duration of precipitation intensity in 2000-2017 when compared to 1971-1980) and is projected to experience increment in frequency of extremes weather within wet cycles (-5 to +9 ºc change in peninsular malaysia, -6 to +11 ºc in sabah and sarawak) by year 2050 (begum, march 1, 2017; ministry of natural resources and environment malaysia, 2015). in the subtropics country of brazil, an increase in humidity of more than 75% showed a reduction of aedes species density, similar to our review (da cruz ferreira et al., 2017). the development cycle of larvae and pupae is also affected with the changing of humidity, where it varied from 5 to 42 days, with an average of 9.4 days at 24.3 °c and 62% relative humidity but an increase relative humidity reduced the duration of development cycles (oliveira custódio et al., 2019). absolute humidity would also restrict the distribution from the drier areas and increase in coastal areas, this will lead to an increase in vector importation due to human and trade movement. since humidity beyond 70% does not favour survival of vector, in which malaysia is having 70-72% of humidity and humidity is always associated with monsoon season; search and destroy activity should be intensify during dry season in april-september yearly, such as elimination of plastic containers, tyres, durian shells and coconut husks outdoor by the residence as well as local sewage management company and the local authority, dengue cases can be controlled. this is correlate with the data of increased dengue cases in selangor and johor compared to other states for the past 5 years in malaysia, where both states have undergone rapid urbanization in recent years, which has introduced problem of worsen irrigation, sewage management due to increased population density and further displacement to high-risk environment, with pre-existing vulnerability due to low socioeconomic status. 603 global journal of public health medicine 2022, vol 4, issue 1 gggggglo by picking up this strong point, communication for behavioural impact strategy used by the health authority (combi) shows important role in vector control for aedes species both globally and in malaysia. wind velocity in malaysia, the optimum speed for survival and breeding of the mosquitoes are 0.05 ± 0.01 m/s. higher wind speed will contribute to immature mosquitoes (n. dom & abu, 2013), whereas a slower wind speed will facilitate the production of larvaedes in argentina, the average speed of more than 3km/h will lead to a reduced density in that area (grech et al., 2019). since the wind velocity affects the flight range of aedes species mosquitoes, utilizing meteorological data in conjunction to wolbachia release shall synergizes the success of biological control. wolbachia infection to aedes species aim to induce wingless female mosquito aedes offspring, in which a high windspeed background can produce synergistic effect with it for the reduction of vector abundance. having the optimal speed would help in the successful dispersion of the wolbachia.(liu, sun, wang, & guo) strengths the strength to this review is that no recent review on climate change in association with vector distribution or survival was done to the best of our knowledge. secondly, specific analysis is done on different climate components in relation to vector distribution and survival. recommendations of vector control are tailored to malaysia setting utilizing review of climate change components. the quality of articles is being accessed narratively and objectively; combining articles on ecology, entomology, modelling and vector prevalence worldwide and the recommendations of vector control are tailored to local situations. limitations limitations encountered included only limited representative articles from southeast asian countries, particularly malaysia, mmodeling studies gave general estimation without considering variation in microenvironment niche and also that most entomological / genetic studies that relates to climate change do not directly associate to prevalence of disease during study period. lastly would be the possible dilutional effect of outcome from non-pathogenic carrying aedes species has been controlled by article selection / inclusion. conclusion in conclusion, we can conclude that climate components like rain fall, temperature, humidity, wind velocity and season affects the distribution of aedes species among all the components, the one that has the most effect on the mosquito density are the rainfall and temperature. climate change expanded 604 global journal of public health medicine 2022, vol 4, issue 1 gggggglo the transmission zone of dengue by latitude and altitude. therefore, the climate factors should be considered in the planning and implementation process of mosquito control and prevention. by the implementation, improved outbreak prediction and detection through coordinated epidemiological, meteorological and entomological surveillance can be achieved. also, by understanding their distributions, new technologies can be developed to reduce vector density and vector borne diseases. list of abbreviations aedes aegypti : aedes aegypti prisma: preferred reporting items for systematic review and meta-analysis zikv: zika virus denv: dengue virus chkv: chikungunya virus yfv: yellow fever virus p.i.c.o.: population, intervention, comparison, outcome combi: communication for behavioral impact conflicts of interest the author declares no conflicts of interest. references • abdul rahman, h. 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