epiH :: Epidemiology and Health

Original Article Analysis of the severity of occupational injuries in the mining industry using a Bayesian network

Mostafa Mirzaei Aliabadi, Hamed Aghaei, Omid kalatpuor, Ali Reza Soltanian, et al. Epidemiol Health. 2019;41:e2019017.

Original Article Risk factors contributing to the incidence and mortality of acute childhood poisoning in emergency department patients in Iran: a hospital-based case-control study

Hamideh Feiz Disfani, Mostafa Kamandi, Seyed Mohammad Mousavi, Sayyed Majid Sadrzadeh, et al. Epidemiol Health. 2019;41:e2019016.

Abstract: OBJECTIVES:
Occupational injuries are known to be the main adverse outcome of occupational accidents. The purpose of the current study was to identify control strategies to reduce the severity of occupational injuries in the mining industry using Bayesian network (BN) analysis.
METHODS:
The BN structure was created using a focus group technique. Data on 425 mining accidents was collected, and the required information was extracted. The expectation-maximization algorithm was used to estimate the conditional probability tables. Belief updating was used to determine which factors had the greatest effect on severity of accidents.
RESULTS:
Based on sensitivity analyses of the BN, training, type of accident, and activity type of workers were the most important factors influencing the severity of accidents. Of individual factors, workers’ experience had the strongest influence on the severity of accidents.
CONCLUSIONS:
Among the examined factors, safety training was the most important factor influencing the severity of accidents. Organizations may be able to reduce the severity of occupational injuries by holding safety training courses prepared based on the activity type of workers.

Abstract: OBJECTIVES:
Since poisoning is one of the most important preventable factors contributing to the hospitalization and death of children who present to emergency departments, this study was carried out to investigate the risk factors contributing to the incidence and mortality of acute childhood poisoning.
METHODS:
This hospital-based case-control study included 243 cases and 489 controls, drawn from daily admissions to the emergency departments of the included hospitals according to the inclusion and exclusion criteria.
RESULTS:
Gastrointestinal poisoning was the most common poisoning type, found in 87.7% of subjects, and medications were the most common cause of poisoning (49.8%). Multiple logistic regression analysis showed that a history of poisoning (odds ratio [OR], 10.44; 95% confidence interval [CI], 5.58 to 19.51; p<0.001) and the availability of poisonous substances (OR, 8.88; 95% CI, 5.41 to 14.56; p<0.001) were among the most important predictors of childhood poisoning. Respiratory poisoning (OR, 6.72; 95% CI, 1.40 to 32.07; p<0.05) and the presence of addiction in the family (OR, 4.54; 95% CI, 1.10 to 18.68; p<0.05) were the most important predictors of mortality among children with poisoning.
CONCLUSIONS:
Addiction and the presence of physical or psychological disorders in family members, a history of poisoning, and the availability of poisonous substances were significantly associated with the incidence of childhood poisoning and resultant mortality.

Original Article Risk factors associated with the recent cholera outbreak in Yemen: a case-control study

Fekri Dureab, Albrecht Jahn, Johannes Krisam, Asma Dureab, et al. Epidemiol Health. 2019;41:e2019015.

Original Article Assessment of the risk factors associated with multidrug-resistant tuberculosis in Sudan: a case-control study

Adel Hussein Elduma, Mohammad Ali Mansournia, Abbas Rahimi Foroushani, Hamdan Mustafa Hamdan Ali, et al. Epidemiol Health. 2019;41:e2019014.

Abstract: OBJECTIVES:
The cholera outbreak in Yemen has become the largest in the recent history of cholera records, having reached more than 1.4 million cases since it started in late 2016. This study aimed to identify risk factors for cholera in this outbreak.
METHODS:
A case-control study was conducted in Aden in 2018 to investigate risk factors for cholera in this still-ongoing outbreak. In total, 59 cholera cases and 118 community controls were studied.
RESULTS:
The following risk factors were associated with being a cholera case in the bivariate analysis: a history of travelling and having had visitors from outside Aden Province; eating outside the house; not washing fruit, vegetables, and khat (a local herbal stimulant) before consumption; using common-source water; and not using chlorine or soap in the household. In the multivariate analysis, not washing khat and the use of common-source water remained significant risk factors for being a cholera case.
CONCLUSIONS:
Behavioural factors and unsafe water appear to be the major risk factors in the recent cholera outbreak in Yemen. In order to reduce the risk of cholera, hygiene practices for washing khat and vegetables and the use and accessibility of safe drinking water should be promoted at the community level.

Abstract: OBJECTIVES:
The emergence of multidrug-resistant tuberculosis (MDR-TB) is a major challenge for the global control of tuberculosis (TB). The aim of this study was to determine the risk factors associated with MDR-TB in Sudan.
METHODS:
This case-control study was conducted from May 2017 to February 2019. Patients newly diagnosed with MDR-TB were selected as cases, and controls were selected from TB patients who responded to first-line anti-TB drugs. A questionnaire was designed and used to collect data from study participants. Logistic regression was used to evaluate associations between risk factors and MDR-TB infection. The best multivariate model was selected based on the likelihood ratio test.
RESULTS:
A total of 430 cases and 860 controls were selected for this study. A history of previous TB treatment (adjusted odds ratio [aOR], 54.85; 95% confidence interval [CI], 30.48 to 98.69) was strongly associated with MDR-TB infection. We identified interruption of TB treatment (aOR, 7.62; 95% CI, 3.16 to 18.34), contact with MDR-TB patients (aOR, 5.40; 95% CI, 2.69 to 10.74), lower body weight (aOR, 0.89; 95% CI, 0.87 to 0.91), and water pipe smoking (aOR, 3.23; 95% CI, 1.73 to 6.04) as factors associated with MDR-TB infection.
CONCLUSIONS:
Previous TB treatment and interruption of TB treatment were found to be the main predictors of MDR-TB. Additionally, this study found that contact with MDR-TB patients and water pipe smoking were associated with MDR-TB infection in Sudan. More efforts are required to decrease the rate of treatment interruption, to strengthen patients’ adherence to treatment, and to reduce contact with MDR-TB patients.

Methods Network meta-analysis: application and practice using R software

Sung Ryul Shim, Seong-Jang Kim, Jonghoo Lee, Gerta Rücker Epidemiol Health. 2019;41:e2019013.

Original Article Comparison of estimates and time series stability of Korea Community Health Survey and Korea National Health and Nutrition Examination Survey

Ji Son Ki, Ho Kim Epidemiol Health. 2019;41:e2019012.

Abstract: The objective of this study is to describe the general approaches to network meta-analysis that are available for quantitative data synthesis using R software. We conducted a network meta-analysis using two approaches: Bayesian and frequentist methods. The corresponding R packages were “gemtc” for the Bayesian approach and “netmeta” for the frequentist approach. In estimating a network meta-analysis model using a Bayesian framework, the “rjags” package is a common tool. “rjags” implements Markov chain Monte Carlo simulation with a graphical output. The estimated overall effect sizes, test for heterogeneity, moderator effects, and publication bias were reported using R software. The authors focus on two flexible models, Bayesian and frequentist, to determine overall effect sizes in network meta-analysis. This study focused on the practical methods of network meta-analysis rather than theoretical concepts, making the material easy to understand for Korean researchers who did not major in statistics. The authors hope that this study will help many Korean researchers to perform network meta-analyses and conduct related research more easily with R software.

Abstract: OBJECTIVES:
In South Korea, there are two nationwide health surveys conducted by the Korea Centers for Disease Control and Prevention: the Korea Community Health Survey (KCHS) and Korea National Health and Nutrition Examination Survey (KNHANES). The two surveys are directly comparable, as they have the same target population with some common items, and because both surveys are used in various analyses, identifying the similarities and disparities between the two surveys would promote their appropriate use. Therefore, this study aimed to compare the estimates of six variables in KCHS and eight variables in KNHANES over a six-year period and compare time series stability of region-specific and sex- and age-specific subgroup estimates.
METHODS:
Data from adults aged 19 years or older in the 2010-2015 KCHS and KNHANES were examined to analyze the differences of estimates and 95% confidence interval for self-rated health, current smoking rate, monthly drinking rate, hypertension diagnosis rate, diabetes diagnosis rate, obesity prevalence, hypertension prevalence, and diabetes prevalence. The variables were then clustered into subgroups by city as well as sex and age to assess the time series stability of the estimates based on mean square error.
RESULTS:
With the exception of self-rated health, the estimates taken based on questionnaires, namely current smoking rate, monthly drinking rate, hypertension diagnosis rate, and diabetes diagnosis rate, only differed by less than 1.0%p for both KCHS and KNHANES. However, for KNHANES, estimates taken from physical examination data, namely obesity prevalence, hypertension prevalence, and diabetes prevalence, differed by 1.9-8.4%p, which was greater than the gap in the estimates taken from questionnaires. KCHS had a greater time series stability for subgroup estimates than KNHANES.
CONCLUSIONS:
When using the data from KCHS and KNHANES, the data should be selected and used based on the purpose of analysis and policy and in consideration of the various differences between the two data.

Review Efficacy of miltefosine compared with glucantime for the treatment of cutaneous leishmaniasis: a systematic review and meta-analysis

Sohrab Iranpour, Ali Hosseinzadeh, Abbas Alipour Epidemiol Health. 2019;41:e2019011.

Original Article Nutrient intake patterns and breast cancer risk among Jordanian women: a case-control study

Reema Fayez Tayyem, Reema Ibrahim Mahmoud, Muna Hussien Shareef, Lina Salah Marei Epidemiol Health. 2019;41:e2019010.

Abstract: Cutaneous leishmaniasis (CL) is most common form of leishmaniasis and is characterized by ulcerative skin lesions. The objective of this study was to conduct a systematic review and meta-analysis of clinical trials that compared the efficacy of miltefosine and glucantime for the treatment of CL. We searched the following databases: Cochrane, PubMed, Embase, Scopus, Web of Science, ProQuest, Cochrane Central Register of Controlled Trials, International Clinical Trials Registry Platform search portal of World Health Organization, Sid, Irandoc, Magiran, and clinicaltrials.gov. We used keywords including “miltefosine,” “glucantime,” and “Leishmania.” The quality of studies was assessed using the Cochrane risk of bias tool. A random-effects model was employed for the analysis. We assessed heterogeneity by the chi-square test and the I2 index statistic. When heterogeneity was present, meta-regression analyses were performed. The Egger method was used to assess publication bias; when it was significant, the trim-and-fill method was used to test and adjust for publication bias. A total of 1,570 reports were identified, of which 10 studies were included in the meta-analysis. In the meta-analysis, there was no significant difference between the efficacy of miltefosine and glucantime; however, subgroup analysis showed that, regarding parasite species other than Leishmania braziliensis, miltefosine was significantly superior to glucantime (intention to treat; relative risk, 1.15; 95% confidence interval, 1.01 to 1.32). In the meta-regression, only the glucantime injection type was significant at the p=0.1 level. The Egger test found statistically significant publication bias; however, including the 3 missing studies in the trim-and-fill analysis did not change the results. This meta-analysis found that miltefosine seems to be more effective than glucantime, at least in species other than L. braziliensis, for treating CL.

Abstract: OBJECTIVES:
Breast cancer (BC) is the most common type of cancer worldwide. Globally, BC is rapidly becoming a major common health problem among women. This study aimed to evaluate the association between nutrient intake patterns and BC risk among Jordanian women.
METHODS:
A total of 400 Jordanian women 20-65 years of age were recruited in this case-control study. Two hundred women recently diagnosed with BC were matched in age, income, and marital status to 200 BC-free women. A food frequency questionnaire was used to assess nutrient intake patterns.
RESULTS:
In this study, 3 nutrient intake patterns were identified: a high vitamin C and β-carotene nutrient intake pattern; a high calcium, phosphorus, and vitamin D nutrient intake pattern; and a high-fat nutrient intake pattern. A significant increase in BC risk was associated with the high vitamin C and β-carotene nutrient pattern (the highest for the fourth quartile; odds ratio [OR], 5.42; 95% confidence interval [CI], 2.11 to 13.91; ptrend=0.001). In the high calcium, phosphorus, and vitamin D nutrient pattern, a significant inverse trend was detected for the risk of BC. The high-fat nutrient pattern showed a significant direct association with BC risk in the third (OR, 3.88; 95% CI, 1.58 to 9.51) and fourth (OR, 3.87; 95% CI, 1.53 to 9.77) quartiles (ptrend=0.001).
CONCLUSIONS:
A significant increase in BC risk was detected for the high vitamin C and β-carotene nutrient intake pattern and the high-fat nutrient intake pattern. However, for the high calcium, phosphorus, and vitamin D nutrient intake pattern, a significant inverse trend was observed.

Original Article Geospatial analysis and epidemiological aspects of human infections with Blastocystis hominis in Mazandaran Province, northern Iran

Shabnam Asfaram, Ahmad Daryani, Shahabeddin Sarvi, Abdol Sattar Pagheh, et al. Epidemiol Health. 2019;41:e2019009.

Methods Intervention meta-analysis: application and practice using R software

Sung Ryul Shim, Seong-Jang Kim Epidemiol Health. 2019;41:e2019008.

Abstract: OBJECTIVES:
Blastocystis hominis is a very common large intestinal protozoan with global prevalence in humans and non-human hosts. No precise statistics exist regarding the geographical distribution of Blastocystis that would enable the identification of high-risk communities. Therefore, the current research aimed to characterize the spatial patterns and demographic factors associated with B. hominis occurrence in northern Iran.
METHODS:
The current study was performed among 4,788 individuals referred to health centers in Mazandaran Province, from whom stool samples were obtained. Socio-demographic data were gathered using a questionnaire. Samples were examined by a direct wet mount, the formalin-ethyl acetate concentration technique, and trichrome staining. Moran local indicators of spatial association and a geographically weighted regression model were utilized to analyze the results.
RESULTS:
Generally, the infection rate of Blastocystis parasites was 5.2%, and was considerably higher in the age group of 10-14 years (10.6%) than in other age groups (p=0.005). Our data showed important associations between the occurrence of B. hominis and age, residence, job, contact with domestic animals, anti-parasitic drug consumption, and elevation above sea level (p<0.001).
CONCLUSIONS:
The current study characterized for the first time the infection rate and risk of B. hominis in the north of Iran, and produced a prediction map. It is expected that this map will help policymakers to plan and implement preventive measures in high-risk areas and to manage already-infected patients.

Abstract: The objective of this study was to describe general approaches for intervention meta-analysis available for quantitative data synthesis using the R software. We conducted an intervention meta-analysis using two types of data, continuous and binary, characterized by mean difference and odds ratio, respectively. The package commands for the R software were “metacont”, “metabin”, and “metagen” for the overall effect size, “forest” for forest plot, “metareg” for meta-regression analysis, and “funnel” and “metabias” for the publication bias. The estimated overall effect sizes, test for heterogeneity and moderator effect, and the publication bias were reported using the R software. In particular, the authors indicated methods for calculating the effect sizes of the target studies in intervention meta-analysis. This study focused on the practical methods of intervention meta-analysis, rather than the theoretical concepts, for researchers with no major in statistics. Through this study, the authors hope that many researchers will use the R software to more readily perform the intervention meta-analysis and that this will in turn generate further related research.

Methods Diagnostic test accuracy: application and practice using R software

Sung Ryul Shim, Seong-Jang Kim, Jonghoo Lee Epidemiol Health. 2019;41:e2019007.

Methods Dose-response meta-analysis: application and practice using the R software

Sung Ryul Shim, Jonghoo Lee Epidemiol Health. 2019;41:e2019006.

Abstract: The objective of this paper is to describe general approaches of diagnostic test accuracy (DTA) that are available for the quantitative synthesis of data using R software. We conduct a DTA that summarizes statistics for univariate analysis and bivariate analysis. The package commands of R software were “metaprop” and “metabin” for sensitivity, specificity, and diagnostic odds ratio; forest for forest plot; reitsma of “mada” for a summarized receiver-operating characteristic (ROC) curve; and “metareg” for meta-regression analysis. The estimated total effect sizes, test for heterogeneity and moderator effect, and a summarized ROC curve are reported using R software. In particular, we focus on how to calculate the effect sizes of target studies in DTA. This study focuses on the practical methods of DTA rather than theoretical concepts for researchers whose fields of study were non-statistics related. By performing this study, we hope that many researchers will use R software to determine the DTA more easily, and that there will be greater interest in related research.

Abstract: The objective of this study was to describe the general approaches of dose-response meta-analysis (DRMA) available for the quantitative synthesis of data using the R software. We conducted a DRMA using two types of data, the difference of means in continuous data and the odds ratio in binary data. The package commands of the R software were “doseresmeta” for the overall effect sizes that were separated into a linear model, quadratic model, and restricted cubic split model for better understanding. The effect sizes according to the dose and a test for linearity were demonstrated and interpreted by analyzing one-stage and two-stage DRMA. The authors examined several flexible models of exposure to pool study-specific trends and made a graphical presentation of the dose-response trend. This study focused on practical methods of DRMA rather than theoretical concepts for researchers who did not major in statistics. The authors hope that this study will help many researchers use the R software to perform DRMAs more easily, and that related research will be pursued.

Original Article Socioeconomic inequalities in obesity among Korean women aged 19-79 years: the 2016 Korean Study of Women’s Health-Related Issues

Eunji Choi, Ha Na Cho, Da Hea Seo, Boyoung Park, et al. Epidemiol Health. 2019;41:e2019005.

Perspective Health effects of exposure to radon: implications of the radon bed mattress incident in Korea

Songwon Seo, Wi-Ho Ha, Jin-Kyu Kang, Dalnim Lee, et al. Epidemiol Health. 2019;41:e2019004.

Abstract: OBJECTIVES:
While the prevalence of obesity in Asian women has remained stagnant, studies of socioeconomic inequalities in obesity among Asian women are scarce. This study aimed to examine the recent prevalence of obesity in Korean women aged between 19 years and 79 years and to analyze socioeconomic inequalities in obesity.
METHODS:
Data were derived from the 2016 Korean Study of Women’s Health-Related Issues. The chi-square test and logistic regression analysis were used to analyze the associations between socioeconomic factors and obesity using Asian standard body mass index (BMI) categories: low (<18.5 kg/m2 ), normal (18.5-22.9 kg/m2 ), overweight (23.0-24.9 kg/m2 ), and obese (≥25.0 kg/ m2 ). As inequality-specific indicators, the slope index of inequality (SII) and relative index of inequality (RII) were calculated, with adjustment for age and self-reported health status.
RESULTS:
Korean women were classified into the following BMI categories: underweight (5.3%), normal weight (59.1%), overweight (21.2%), and obese (14.4%). The SII and RII revealed substantial inequalities in obesity in favor of more urbanized women (SII, 4.5; RII, 1.4) and against of women who were highly educated (SII, -16.7; RII, 0.3). Subgroup analysis revealed inequalities in obesity according to household income among younger women and according to urbanization among women aged 65-79 years.
CONCLUSIONS:
Clear educational inequalities in obesity existed in Korean women. Reverse inequalities in urbanization were also apparent in older women. Developing strategies to address the multiple observed inequalities in obesity among Korean women may prove essential for effectively reducing the burden of this disease.

Abstract: Radon is a naturally occurring radioactive material formed by the slow decay of uranium and thorium found in the earth’s crust or construction materials. Internal exposure to radon accounts for about half of the natural background radiation dose to which humans are exposed annually. Radon is a carcinogen and is the second leading cause of lung cancer following smoking. An association between radon and lung cancer has been consistently reported in epidemiological studies on mine workers and the general population with indoor radon exposure. However, associations have not been clearly established between radon and other diseases, such as leukemia and thyroid cancer. Radiation doses are assessed by applying specific dose conversion coefficients according to the source (e.g., radon or thoron) and form of exposure (e.g., internal or external). However, regardless of the source or form of exposure, the effects of a given estimated dose on human health are identical, assuming that individuals have the same sensitivity to radiation. Recently, radiation exceeding the annual dose limit of the general population (1 mSv/yr) was detected in bed mattresses produced by D company due to the use of a monazite-based anion powder containing uranium and thorium. This has sparked concerns about the health hazards for mattress users caused by radiation exposure. In light of this event, this study presents scientific information about the assessment of radon and thoron exposure and its human implications for human health, which have emerged as a recent topic of interest and debate in society.

Original Article Dietary patterns, nutrition, and risk of breast cancer: a case-control study in the west of Iran

Behjat Marzbani, Javad Nazari, Farid Najafi, Behnaz Marzbani, et al. Epidemiol Health. 2019;41:e2019003.

Original Article A large outbreak of Salmonella enterica serovar Thompson infections associated with chocolate cake in Busan, Korea

Youngduck Eun, Hyesun Jeong, Seungjin Kim, Wonseo Park, et al. Epidemiol Health. 2019;41:e2019002.

Abstract: OBJECTIVES:
Unhealthy dietary patterns are the most important changeable risk factors for breast cancer. The aim of this study was to assess the relationship between dietary patterns and the risk of breast cancer among under-50 year women in the west of Iran.
METHODS:
All women under 50 years old with pathologically confirmed breast cancer between 2013 and 2015 who were referred to oncology clinics in the west of Iran, and 408 under-50 women referred to other outpatient clinics who were without breast or other cancers at the time of the study and 2 years later were selected as the control group. The data were collected using the middle-aged periodical care form of the Iranian Ministry of Health and analyzed using univariate and multivariate logistic regression in Stata.
RESULTS:
The most powerful risk factor for breast cancer was fried foods; the odds ratio of consuming fried foods more than once a month for breast cancer was 4.5 (95% confidence interval, 2.1 to 9.4). A dose-response model indicated that increasing vegetable and fruit consumption up to 90 servings per month decreased the odds of breast cancer, but consuming more than 90 servings per month increased the risk.
CONCLUSIONS:
Inadequate consumption of vegetables and consumption of soft drinks, industrially produced juices, fried foods, and sweets were identified as risk factors for breast cancer. In response to these findings, it is necessary to raise awareness and to provide education about healthy diets and the need to change unhealthy dietary patterns.

Abstract: OBJECTIVES:
This study aimed to reveal the epidemiologic characteristics of the outbreak of gastroenteritis caused by Salmonella enterica serovar Thompson in Busan Metropolitan City and to identify points for improvement to prevent of food-borne disease outbreak.
METHODS:
This was a case-control study. The control group comprised asymptomatic students in the same classes of the cases. The presence or absence of symptoms, ingestion of each food provided by school meal service, and commonly ingested foods in addition to those foods in meal service were investigated. Moreover, specimens collected from rectal swab, preserved foods, and environmental surface were tested.
RESULTS:
Of the 6,092 subjects, 1,111 (1,083 students, 22 school personnel, and 6 foodservice employees) were included in the case group; this corresponded to an 18.4% attack rate. Symptoms included diarrhea (n=1,051, 94.6%), abdominal pain (n=931, 83.8%), febrile sensation (n=502, 45.2%), and vomiting (n=275, 24.8%). The epidemic curves of each 10 schools were unimodal. Investigation of food intake showed a significantly high odds ratio for chocolate cake in 5 out of the 10 schools. Laboratory test detected Salmonella enterica serovar Thompson both in rectal swab specimens of 9 schools and in collected preserved chocolate cakes of 9 schools. Pulsed-field gel electrophoresis test result showed that Salmonella enterica seorvar Thompson isolated from human and foods were the same.
CONCLUSIONS:
The source of infection for the Salmonella enterica serovar Thompson outbreak in the 10 schools of Busan Metropolitan City is chocolate cake. Traceback investigation for origin of contaminated food in food-borne disease outbreak and safety control during food production should be more enhanced.

Review Freshwater snails as the intermediate host of trematodes in Iran: a systematic review

Samira Dodangeh, Ahmad Daryani, Mehdi Sharif, Shirzad Gholami, et al. Epidemiol Health. 2019;41:e2019001.

Abstract: Freshwater snails, as the first intermediate hosts of trematodes, can cause health hazards in animals and humans. Recently, the World Health Organization has included Iran in a list of 6 countries known to have serious problems with fascioliasis. In addition, cercarial dermatitis is a job-related disease that is seen often in paddy workers, agricultural labourers, and fishermen in Iran, particularly in Mazandaran Province. Many studies have been conducted in Iran to survey larval trematodes in freshwater snails. However, to the best of our knowledge, no comprehensive data exist regarding infections in gastropods. Therefore, the aim of the present study was to estimate the types and prevalence of cercarial infections in snails in Iran. Electronic English-language and Persian-language databases were searched to identify 24 published articles reporting the prevalence of trematode infections in snails (9 species from 6 families) in various provinces of Iran. In total, 4.4% of gastropods were infected with the larval stages of trematodes. According to the studies reviewed in this meta-analysis‚ the highest infection prevalence was found in Radix auricularia (9.9%). Twelve larval species of trematodes were identified, and the highest prevalence of cercariae was found for Echinostomatidae cercariae (4.3%). Among the provinces explored, West Azerbaijan had the highest prevalence of infected snails (16.9%). The presence of trematodes in snails could pose a serious health problem in Iran. Thus, further studies are necessary to characterize these infections in other provinces.

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