epiH :: Epidemiology and Health

Original Article Association of appendicular skeletal muscle mass with carotid intima-media thickness according to body mass index in Korean adults

Ji Eun Heo, Hyeon Chang Kim, Jee-Seon Shim, Bo Mi Song, et al. Epidemiol Health. 2018;40:e2018049.

Original Article Application of a non-parametric non-mixture cure rate model for analyzing the survival of patients with colorectal cancer in Iran

Mehdi Azizmohammad Looha, Mohamad Amin Pourhoseingholi, Maryam Nasserinejad, Hadis Najafimehr, et al. Epidemiol Health. 2018;40:e2018045.

Abstract: OBJECTIVES:
The combined effects of obesity and appendicular skeletal muscle (ASM) on atherosclerosis, especially in middleaged populations, remain poorly understood. This cross-sectional study investigated the effects of ASM on carotid intima-media thickness (IMT) according to body mass index (BMI) in middle-aged Korean adults.
METHODS:
Herein, 595 men and 1,274 women aged 30-64 years completed questionnaires and underwent health examinations as part of the Cardiovascular and Metabolic Disease Etiology Research Center cohort. ASM was measured via bioelectrical impedance analysis and adjusted for weight (ASM/Wt). IMT was assessed using B-mode ultrasonography; highest quartile of IMT was defined as gender-specific top quartile of the IMT values. Higher BMIs was defined as a BMI over 25.0 kg/m2 .
RESULTS:
Compared to the highest ASM/Wt quartile, the lowest ASM/Wt quartile was significantly associated with highest quartile of IMT in men with lower BMIs (adjusted odds ratio [aOR], 2.78; 95% confidence interval [CI], 1.09 to 7.13), but not in those with higher BMIs (aOR, 0.59; 95% CI, 0.24 to 1.91). In women, there was no significant association of low skeletal muscle mass with highest quartile of IMT, regardless of BMI.
CONCLUSIONS:
Low appendicular skeletal muscle mass is associated with carotid arterial wall thickening in men with lower BMIs, but not in men with higher BMIs. Our findings suggest that the risk of atherosclerosis may be low in middle-aged Korean men with appropriate body weight and skeletal muscle mass maintenance.

Abstract: OBJECTIVES:
Colorectal cancer (CRC) patients are considered to have been cured when the mortality rate of individuals with the disease returns to the same level as expected in the general population. This study aimed to assess the impact of various risk factors on the cure fraction of CRC patients using a real dataset of Iranian CRC patients with a non-mixture non-parametric cure model.
METHODS:
This study was conducted on the medical records of 512 patients who were definitively diagnosed with CRC at Taleghani Hospital, Tehran, Iran from 2001 to 2007. A non-mixture non-parametric cure rate model was applied to the data after using stepwise selection to identify the risk factors of CRC.
RESULTS:
For non-cured cases, the mean survival time was 1,243.83 days (95% confidence interval [CI], 1,174.65 to 1,313.00) and the median survival time was 1,493.00 days (95% CI, 1,398.67 to 1,587.33). The 1- and 3-year survival rates were 92.9% (95% CI, 91.0 to 95.0) and 73.4% (95% CI, 68.0 to 79.0), respectively. Pathologic stage T1 of the primary tumor (estimate=0.58; p=0.013), a poorly differentiated tumor (estimate=1.17; p<0.001), a body mass index (BMI) between 18.6 and 24.9 kg/m2 (estimate=−0.60; p=0.04), and a BMI between 25.0 and 29.9 kg/m2 (estimate=−1.43; p<0.001) had significant impacts on the cure fraction of CRC in the multivariate analysis. The proportion of cured patients was 64.1% (95% CI, 56.7 to 72.4).
CONCLUSIONS:
This study found that the pathologic stage of the primary tumor, tumor grade, and BMI were potential risk factors that had an impact on the cure fraction. A non-mixture non-parametric cure rate model provides a flexible framework for accurately determining the impact of risk factors on the long-term survival of patients with CRC.

Original Article Current status of newborn hearing screening in low-income families in the southeastern region of Korea

You Sun Chung, Su-Kyoung Park Epidemiol Health. 2018;40:e2018044.

Brief communication Prophylactic efficacy of probiotics on travelers’ diarrhea: an adaptive meta-analysis of randomized controlled trials

Jong-Myon Bae Epidemiol Health. 2018;40:e2018043.

Abstract: OBJECTIVES:
The aim of this study was to analyze the current status and problems of hearing screening tests for newborns in low-income families in the southeastern Korea.
METHODS:
This study analyzed data from the Ministry of Health and Welfare’s project on the early detection of hearing loss in newborns in low-income families in the southeastern Korea (2011-2015).
RESULTS:
The referral rate was 1.33, 1.69, and 1.27% in Daegu, Gyeongbuk, and Ulsan, respectively. The confirmatory test rate was 36.09, 23.38, and 52.94% in Daegu, Gyeongbuk, and Ulsan, respectively. The incidence of hearing loss (adjusted) was 0.41, 0.62, and 0.41% in Daegu, Gyeongbuk, and Ulsan, respectively. After confirming hearing loss, newborns with hearing handicaps were mostly lost to follow-up, and rehabilitation methods, such as hearing aids or cochlear implants, were not used. The screening tests were performed within 1 month of birth, and the confirmatory tests were generally performed within 3 months of birth. However, more than 3 months passed before the confirmatory tests were performed in infants with risk factors for hearing loss in Gyeongbuk and Ulsan.
CONCLUSIONS:
Hearing screening tests were conducted in newborns from low-income families in southeastern Korea who received a coupon for free testing, but the newborns that were referred after the screening tests were not promptly linked to the hospitals where confirmatory tests were performed. Furthermore, hearing rehabilitation was not consistently performed after hearing loss was confirmed. To successful early hearing loss detection and intervention, a systematic tracking system of hearing loss children is needed.

Abstract: OBJECTIVES:
The 2017 guideline for the prevention of travelers’ diarrhea (TD) by the International Society of Travel Medicine suggested that ‘there is insufficient evidence to recommend the use of commercially available prebiotics or probiotics to prevent or treat TD.’ However, a meta-analysis published in 2007 reported significant efficacy of probiotics in the prevention of TD (summary relative risk [sRR], 0.85, 95% confidence interval [CI], 0.79 to 0.91). This study aimed to synthesize the efficacy of probiotics on TD by updating the meta-analysis of double-blind, placebo-controlled, randomized human trials.
METHODS:
The search process was conducted by the adaptive meta-analysis method using the ‘cited by’ and ‘similar articles’ options provided by PubMed. The inclusion criteria were double-blind, placebo-controlled, randomized human trials with hypotheses of probiotics as intervention and TD as an outcome. The adaptive meta-analysis was conducted using Stata software using the csi, metan, metafunnel, and metabias options.
RESULTS:
Eleven articles were selected for the meta-analysis. The sRR was 0.85 (95% CI, 0.79 to 0.91) and showed statistical significance. There was no heterogeneity (I-squared=28.4%) and no publication bias.
CONCLUSIONS:
Probiotics showed statistically significant efficacy in the prevention of TD.

Original Article Predicting needlestick and sharps injuries and determining preventive strategies using a Bayesian network approach in Tehran, Iran

Hamed Akbari, Fakhradin Ghasemi, Hesam Akbari, Amir Adibzadeh Epidemiol Health. 2018;40:e2018042.

Review Article A review of methods to estimate the visibility factor for bias correction in network scale-up studies

Aliakbar Haghdoost, Milad Ahmadi Gohari, Ali Mirzazadeh, Farzaneh Zolala, et al. Epidemiol Health. 2018;40:e2018041.

Abstract: OBJECTIVES:
Recent studies have shown that the rate of needlestick and sharps injuries (NSIs) is unacceptably high in Iranian hospitals. The aim of the present study was to use a systematic approach to predict and reduce these injuries.
METHODS:
This cross-sectional study was conducted in 5 hospitals in Tehran, Iran. Eleven variables thought to affect NSIs were categorized based on the Human Factors Analysis and Classification System (HFACS) framework and modeled using a Bayesian network. A self-administered validated questionnaire was used to collect the required data. In total, 343 cases were used to train the model and 50 cases were used to test the model. Model performance was assessed using various indices. Finally, using predictive reasoning, several intervention strategies for reducing NSIs were recommended.
RESULTS:
The Bayesian network HFACS model was able to predict 86% of new cases correctly. The analyses showed that safety motivation and fatigue were the most important contributors to NSIs. Supervisors’ attitude toward safety and working hours per week were the most important factors in the unsafe supervision category. Management commitment and staffing were the most important organizational-level factors affecting NSIs. Finally, promising intervention strategies for reducing NSIs were identified and discussed.
CONCLUSIONS:
To reduce NSIs, both management commitment and sufficient staffing are necessary. Supervisors should encourage nurses to engage in safe behavior. Excessive working hours result in fatigue and increase the risk of NSIs.

Abstract: Network scale-up is an indirect size estimation method, in which participants are questioned on sensitive behaviors of their social network members. Therefore, the visibility of the behavior affects the replies and estimates. Many attempts to estimate visibility have been made. The aims of this study were to review the main methods used to address visibility and to provide a summary of reported visibility factors (VFs) across populations. We systematically searched relevant databases and Google. In total, 15 studies and reports that calculated VFs were found. VF calculation studies have been applied in 9 countries, mostly in East Asia and Eastern Europe. The methods applied were expert opinion, comparison of NSU with another method, the game of contacts, social respect, and the coming-out rate. The VF has been calculated for heavy drug users, people who inject drugs (PWID), female sex workers (FSWs) and their clients, male who have sex with male (MSM), alcohol and methamphetamine users, and those who have experienced extra-/pre-marital sex and abortion. The VF varied from 1.4% in Japan to 52.0% in China for MSM; from 34.0% in Ukraine to 111.0% in China for FSWs; and from 12.0% among Iranian students to 57.0% in Ukraine for PWID. Our review revealed that VF estimates were heterogeneous, and were not available for most settings, in particular the Middle East and North Africa region, except Iran. More concrete methodologies to estimate the VF are required.

Original Article Androgen deprivation therapy is associated with decreased second primary lung cancer risk in the United States veterans with prostate cancer

Kyungsuk Jung, Jong Chul Park, Hyunseok Kang, Johann Christoph Brandes Epidemiol Health. 2018;40:e2018040.

Original Article The association between aggression and risk of Internet gaming disorder in Korean adolescents: the mediation effect of father-adolescent communication style

Eunjin Kim, Hyeon Woo Yim, Hyunsuk Jeong, Sun-Jin Jo, et al. Epidemiol Health. 2018;40:e2018039.

Abstract: OBJECTIVES:
We investigated whether androgen deprivation therapy (ADT) in prostate cancer patients was associated with a decreased risk for second primary lung cancer in US veterans.
METHODS:
Prostate cancer diagnoses in the US Veterans Affairs Cancer Registry between 1999 and 2008 were identified. Use of hormonal therapy and diagnoses of second primary lung cancer were determined from the registry. Synchronous prostate and lung cancers, defined as 2 diagnoses made within 1 year, were excluded from the analysis. Cancer-free survival was estimated using the Kaplan-Meier method and hazard ratios were estimated using Cox proportional hazard models.
RESULTS:
Among the 63,141 identified patients with prostate cancer, 18,707 subjects were eligible for the study. Hormonal therapy was used in 38% of patients and the median follow-up period was 28 months. ADT use was associated with longer lung cancer-free survival in prostate cancer patients (log-rank p=0.01). After adjusting for age, race, smoking and prostate cancer stage, ADT use was associated with decreased lung cancer risk by 15, 21, and 24% after 1, 2, and 3 years, respectively.
CONCLUSIONS:
ADT in prostate cancer patients may be associated with decreased second primary lung cancer risk among US veterans.

Abstract: OBJECTIVES:
Open and supportive communication between parents and children is known to reduce adolescents’ delinquent behavior. Recently, the risk of Internet gaming disorder (IGD) has been increasing in adolescents. The purpose of this study was to investigate the mediating effects of parent-child communication styles on the relationship between adolescent aggressiveness and risk of IGD.
METHODS:
Participants in this study were 402 first-year students from 4 middle schools in Seoul who enrolled in the Internet user Cohort for Unbiased Recognition of gaming disorder in Early adolescence (iCURE) and completed baseline assessment in 2016. The structural equation model was constructed based on an aggression questionnaire, the Internet game use-elicited symptom screen, a mother-child communication inventory, and a father-child communication inventory.
RESULTS:
Adolescents’ aggressiveness was found to be related to their risk of IGD. The father-child communication style mediated the relationship between aggression and risk of IGD. However, the mother-child communication style had no mediating effect.
CONCLUSIONS:
Our findings suggest that fathers should make an effort to improve open and positive communication skills with their children, because the father-child communication style plays an important role in the relationship between adolescent aggressiveness and risk of IGD.

Original Article Spatial inequalities and predictors of HIV/AIDS mortality risk in Hamadan, Iran: a retrospective cohort study

Somayeh Momenyan, Amir Kavousi, Jalal Poorolajal, Narges Momenyan Epidemiol Health. 2018;40:e2018038.

Original Article Knowledge of and attitudes toward HIV/AIDS among Iranian women

Ehsan Zarei, Roghayeh Khabiri, Maryam Tajvar, Shirin Nosratnejad Epidemiol Health. 2018;40:e2018037.

Abstract: OBJECTIVES:
Understanding the geographic variation of HIV/AIDS mortality risk and human immunodeficiency virus (HIV) infection could help identify high-burden areas. The aim of our study was to evaluate the effects of predictors of the time interval between HIV diagnosis to death, while accounting for spatial correlations across counties, and to assess patterns of spatial inequalities in the risk of HIV/AIDS mortality in Hamadan Province, Iran.
METHODS:
This retrospective study was conducted on 585 patients. The outcome in this study was the time period between the date of HIV/AIDS diagnosis and the date of death. A Weibull regression model with spatial random effects was used.
RESULTS:
According to multivariate analysis, there were significant associations between age, tuberculosis co-infection, and marital status and the risk of death. In terms of spatial inequalities, a cluster of counties was identified with a somewhat higher death hazard in the north, northwest, northeast, and central regions. Additionally, a cluster with a somewhat lower hazard was identified in the south, southwest, southeast, and west regions.
CONCLUSIONS:
The spatial pattern of HIV/AIDS death risk could reflect inequalities in access to antiretroviral therapy and public health services. Our results underscore the importance of attention to vulnerable groups in urban areas.

Abstract: OBJECTIVES:
This study investigated the knowledge of Iranian women about HIV/AIDS and whether they had accepting attitudes towards people living with human immunodeficiency virus (HIV), and sought to identify factors correlated with their knowledge and attitudes.
METHODS:
The data analyzed in the present study were taken from Iran’s Multiple Indicator Demographic and Health Survey, a national survey conducted in 2015. In total, 42,630 women aged 15-49 years were identified through multi-stage stratified cluster random sampling and interviewed. Associations of the socio-demographic characteristics of participants with their knowledge and attitudes were examined using multiple logistic regression analysis.
RESULTS:
The majority (79.0%) of Iranian women had heard about HIV/AIDS, but only 19.1% had a comprehensive knowledge. In addition, only 15.4% of women had accepting attitudes toward people with HIV. Being older, married, more highly educated, and wealthier were factors associated with having more comprehensive knowledge of HIV/AIDS, and living in urban areas was associated with having more positive attitudes toward people with HIV.
CONCLUSIONS:
The relatively poor knowledge of Iranian women and the low prevalence of accepting attitudes toward people living with HIV highlight the need to develop policies and interventions to overcome this issue, which would be a basis for further prevention of HIV/AIDS in Iran.

Perspective Vitamin D supplementation as a control program against latent tuberculosis infection in Korean high school students

Eun Hee Kim, Jong-Myon Bae Epidemiol Health. 2018;40:e2018035.

Original Article The coverage rates for influenza vaccination and related factors in Korean adults aged 50 and older with chronic disease: based on 2016 Community Health Survey data

Kyeong Hyang Byeon, Jaiyong Kim, Boyoung Choi, Bo Youl Choi Epidemiol Health. 2018;40:e2018034.

Abstract: The prevalence of latnet Mycobacterium tuberculosis infection (LTBI) in the first-grade high school students in South Korea was 2.1%, which was the lowest level at congregated settings in 2017. For LTBI cases refusing anti-tuberculosis (TB) medication or having poor compliance, additional support should be considered. Eight systematic reviews concluded that vitamin D (VD) deficiency is a risk factor for TB. While three of four South Korean adolescents were VD deficiency, VD supplementation could be a practical remedy to protect LTBI students of refusing anti-TB medication or having poor compliance.

Abstract: OBJECTIVES:
This study aims to identify the coverage rates for influenza vaccination and related factors depending on chronic disease in Korean adults aged 50 and older.
METHODS:
The 2016 Korea Community Health Survey was used for analysis. Chi-square test was performed to investigate the coverage rates for influenza vaccination depending on chronic disease, and a multiple logistic regression analysis was used to identify the factors associated with influenza vaccination, by chronic disease.
RESULTS:
In men with ≥1 chronic disease, 39.8% of 50-64 years of age, and 86.8% of elderly (over 65 years of age) received influenza vaccination. In women with ≥1 chronic disease, 58.7% of 50-64 years of age, and 89.9% of elderly (over 65 years of age) received influenza vaccination (p<0.001). The chronic diseases associated with influenza vaccination were hypertension (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.19 to 1.37), diabetes (OR, 1.41; 95% CI, 1.28 to 1.55) in men aged 50-64, hypertension (OR, 1.34; 95% CI, 1.20 to 1.49), diabetes (OR, 1.17; 95% CI, 1.02 to 1.33), chronic cardiovascular disease (OR, 1.31; 95% CI, 1.07 to 1.60) in elderly (over 65 years of age). In women aged 50-64, hypertension (OR, 1.39; 95% CI, 1.30 to 1.49), diabetes (OR, 1.51; 95% CI, 1.35 to 1.68), chronic cardiovascular disease (OR, 1.31; 95% CI, 1.05 to 1.64), and hypertension (OR, 1.55; 95% CI, 1.40 to 1.71), diabetes (OR, 1.27; 95% CI, 1.12 to 1.43) in elderly (over 65 years of age).
CONCLUSIONS:
Populations in aged 50-64 are recommendation subject for vaccination or classified as high-risk group in case with chronic disease. Though subject over 60 years old is age close to the elderly, the coverage rates for vaccination was low. It is necessary to devise strategies to raise the coverage rates for vaccination.

Obituary Obituary: Dr. Hyun-Sul Lim’s (1952-2018) life as an epidemiologist, occupational and environmental medicine researcher, and family physician

Sun Huh Epidemiol Health. 2018;40:e2018033.

Original Article Spatial modeling of cutaneous leishmaniasis in Iranian army units during 2014-2017 using a hierarchical Bayesian method and the spatial scan statistic

Erfan Ayubi, Mohammad Barati, Arasb Dabbagh Moghaddam, Ali Reza Khoshdel Epidemiol Health. 2018;40:e2018032.

Abstract

Abstract: OBJECTIVES:
This study aimed to map the incidence of cutaneous leishmaniasis (CL) in Iranian army units (IAUs) and to identify possible spatial clusters.
METHODS:
This ecological study investigated incident cases of CL between 2014 and 2017. CL data were extracted from the CL registry maintained by the deputy of health of AJA University of Medical Sciences. The standardized incidence ratio (SIR) of CL was computed with a Besag, York, and Mollié model. The purely spatial scan statistic was employed to detect the most likely highand low-rate clusters and to obtain the observed-to-expected (O/E) ratio for each detected cluster. The statistical significance of the clusters was assessed using the log likelihood ratio (LLR) test and Monte Carlo hypothesis testing.
RESULTS:
A total of 1,144 new CL cases occurred in IAUs from 2014 to 2017, with an incidence rate of 260 per 100,000. Isfahan and Khuzestan Provinces were found to have more CL cases than expected in all studied years (SIR>1), while Kermanshah, Kerman, and Fars Provinces were observed to have been high-risk areas in only some years of the study period. The most significant CL cluster was in Kermanshah Province (O/E, 67.88; LLR, 1,200.62; p<0.001), followed by clusters in Isfahan Province (O/E, 6.02; LLR, 513.24; p<0.001) and Khuzestan Province (O/E, 2.35; LLR, 73.71; p<0.001), while low-rate clusters were located in the northeast areas, including Razavi Khorasan, North Khorasan, Semnan, and Golestan Provinces (O/E, 0.03; LLR, 95.11; p<0.001).
CONCLUSIONS:
This study identified high-risk areas for CL. These findings have public health implications and should be considered when planning control interventions among IAUs.

Original Article Functional disorders of the lung and symptoms of respiratory disease associated with occupational inhalation exposure to wood dust in Iran

Masoud Neghab, Zeinab Jabari, Fatemeh Kargar Shouroki Epidemiol Health. 2018;40:e2018031.

Original Article Substance abuse behaviors among university freshmen in Iran: a latent class analysis

Kourosh Kabir, Ali Bahari, Mohammad Hajizadeh, Hamid Allahverdipour, et al. Epidemiol Health. 2018;40:e2018030.

Abstract: OBJECTIVES:
The possible adverse respiratory effects of airborne pollutants in sawmills have not been thoroughly investigated in Iran. Additionally, the extent to which workers are exposed to this organic dust and its associated bioaerosols has not been extensively quantified. Likewise, the predominant bacterial and fungal species associated with wood dust have not been characterized. The present study was undertaken to address these issues.
METHODS:
One hundred male individuals exposed to wood dust and 100 unexposed male subjects were investigated. They completed a standardized respiratory symptom questionnaire and underwent spirometry testing. Additionally, airborne concentrations of respirable and inhalable dust particles, bacteria, and fungi were measured.
RESULTS:
The mean concentrations of inhalable and respirable dust particles, bacteria, and fungi were found to be 2.44, 6.76 mg/m3 , 756.38, and 299.15 colony-forming units/m3 , respectively. The predominant Gram-negative bacteria in the sawmills included the Pseudomonadaceae, Klebsiella pneumoniae, and Rhinoscleromatis spp., and the predominant fungi consisted of the zygomycetes and Aspergillus spp. Respiratory symptoms were significantly more prevalent among exposed workers. Significant cross-shift decrements were noted in some pulmonary function parameters. Similarly, pre-shift spirometry results indicated that some pulmonary function parameters were significantly lower in the exposed group.
CONCLUSIONS:
Exposure to wood dust and its bioaerosols was associated with significantly higher prevalence of respiratory symptoms and both acute (i.e., partially reversible) and chronic (i.e., irreversible) decrements in the functional capacity of the lung. Additionally, the characterized bioaerosols did not differ significantly from those isolated in other parts of the world.

Abstract: OBJECTIVES:
Substance abuse behaviors among university freshmen in Iran are poorly understood. This study aimed to identify, for the first time, subgroups of university freshmen in Iran on the basis of substance abuse behaviors. Moreover, it examined the effects of socio-demographic characteristics on membership in each specific subgroup.
METHODS:
Data for the study were collected cross-sectionally in December 2013 and January 2014 from 4 major cities in Iran: Tabriz, Qazvin, Karaj, and Khoramabad. A total of 5,252 first-semester freshmen were randomly selected using a proportional cluster sampling methodology. A survey questionnaire was used to collect data. Latent class analysis (LCA) was performed to identify subgroups of students on the basis of substance abuse behaviors and to examine the effects of students’ socio-demographic characteristics on membership in each specific subgroup.
RESULTS:
The LCA procedure identified 3 latent classes: the healthy group; the hookah experimenter group; and the unhealthy group. Approximately 82.8, 16.1, and 2.1% of students were classified into the healthy, hookah experimenter, and unhealthy groups, respectively. Older age, being male, and having a family member or a close friend who smoked increased the risk of membership in classes 2 and 3, compared to class 1.
CONCLUSIONS:
Approximately 2.1% of freshmen exhibited unhealthy substance abuse behaviors. In addition, we found that older age, being male, and having a close friend or family member who smoked may serve as risk factors for substance abuse behaviors.

Original Article Prevalence of disrespect and abuse of women during child birth and associated factors in Bahir Dar town, Ethiopia

Biresaw Wassihun, Leul Deribe, Nadia Worede, Teklemariam Gultie Epidemiol Health. 2018;40:e2018029.

Original Article Ambient air quality and subjective stress level using Community Health Survey data in Korea

Myung-Jae Hwang, Hae-Kwan Cheong, Jong-Hun Kim, Youn Seo Koo, et al. Epidemiol Health. 2018;40:e2018028.

Abstract: OBJECTIVES:
Disrespect and abuse are an often-unacknowledged cause of maternal mortality and morbidity globally. The objective of this study was to assess the prevalence and associated factors of disrespect and abuse of women during childbirth at a health facility in the town of Bahir Dar, Ethiopia.
METHODS:
In this community-based cross-sectional study, 422 mothers were interviewed from March 1 to 30, 2017 using a systematic random sampling technique with the kth value of 23 calculated based on the number of households in each sub-city and the expected sample size from sub-cities. Data were collected using a structured face-to-face interview questionnaire. EpiData version 3.1 was used to code and enter data, which were analyzed using SPSS version 22. Descriptive statistics were calculated for each variable, and binary logistic regression analysis with 95% confidence intervals (CIs) was carried out to determine the associations between predictor variables and outcome variables.
RESULTS:
A total of 410 women participated in the study, with a response rate of 97.2%. The overall prevalence of disrespect and abuse was 67.1% (95% CI, 63.0 to 72.0). Disrespect and abuse were more prevalent in women with a monthly income less than 2,000 Ethiopian birr (adjusted odds ratio [aOR], 1.74; 95% CI, 1.08 to 2.80), mothers who stayed in a health facility after delivery (aOR, 5.14; 95% CI, 2.23 to 11.82), those who received care at a governmental hospital (aOR, 2.49; 95% CI, 1.15 to 5.40), and those who attended fewer than 4 antenatal care visits (aOR, 1.97; 95% CI, 1.15 to 3.40).
CONCLUSIONS:
The prevalence of disrespect and abuse was high in this study setting. To decrease the prevalence of this phenomenon, appropriate interventions should be designed, focusing on increasing the number of antenatal care visits, increasing the incomes of mothers, and improving the relationship between health workers and mothers during mothers’ stay at health facilities.

Abstract: OBJECTIVES:
Air pollution causes various disease in exposed populations, and can lead to premorbid health effects manifested as both physical and psychological functional impairment. The present study investigated the subjective stress level in daily life in relation to the level of air pollution.
METHODS:
Data from the Community Health Survey (2013), comprising 99,162 men, and 121,273 women residing in 253 healthcare administrative districts, were combined with air pollutant concentration modelling data from the Korean Air Quality Forecasting System, and were stratified by subjective stress levels into five strata for multiple logistic regression. Levels of exposure were divided into five quintiles according to the annual concentration of nitrogen dioxide (NO2), and were analyzed using a single-pollutant model using NO2 concentration only, and a multi-pollutant model adjusted for the concentration of particulate matter <10 μm in diameter.
RESULTS:
Analysis of men and women in various age groups showed the highest odds ratio (OR) for subjective stress level at the highest NO2 concentration quintile in men and women aged 30–64 years (men: 2.91; 95% confidence interval [CI], 2.12 to 4.01; women: 1.82; 95% CI, 1.32 to 2.51). As the NO2 concentration quintile increased, the OR increased. Men showed higher ORs than women in all strata.
CONCLUSIONS:
In the present study, annual NO2 concentrations were found to be associated with subjective stress levels. This association was especially clear among socioeconomically active men and women aged 30-64 years.

Cohort profile The Mysuru stUdies of Determinants of Health in Rural Adults (MUDHRA), India

Padukudru Anand Mahesh, Komarla Sundararaja Lokesh, Purnima Madhivanan, Sindaghatta Krishnarao Chaya, et al. Epidemiol Health. 2018;40:e2018027.

Original Article Pre-hypertension and the risk of diabetes mellitus incidence using a marginal structural model in an Iranian prospective cohort study

Ahmad Khosravi, Mohammad Hassan Emamian, Hassan Hashemi, Akbar Fotouhi Epidemiol Health. 2018;40:e2018026.

Abstract: Between 2006 and 2010, in 16 randomly selected villages in rural areas of Mysore district, in south India, 8,457 subjects aged 30 and above were screened for symptoms of chronic respiratory disease. Of the 8,457 subjects, 1,692 were randomly invited for further evaluation of lung function and chronic obstructive pulmonary disease (COPD) by spirometry, and 1,085 of these subjects underwent lung function assessments for prevalent COPD and its risk factors. These 1,085 subjects, who were then aged between 35 and 80 years, constituted the Mysuru stUdies of Determinants of Health in Rural Adults (MUDHRA) cohort. Among other findings, threshold of biomass fuel smoke exposure suitable for use as a dichotomous risk factor for the diagnosis of chronic bronchitis was established, with a minimum biomass smoke exposure index of 60 found to be significantly associated with an elevated risk of developing chronic bronchitis. Five years later (between 2014 and 2016), 869 of the 1,085 participants were followed up with repeat lung function assessments for incident COPD and all-cause mortality. A subset of these participants (n=200) underwent blood tests for vitamin D levels, antioxidant activity, an assessment for anxiety and depression, and another subset (n=98) underwent a bioplex assay for 40 serum cytokines.

Abstract: OBJECTIVES:
The aim of this study was to evaluate the effect of pre-hypertension and its sub-classification on the development of diabetes.
METHODS:
In this cohort study, 2,941 people 40 to 64 years old without hypertension or diabetes were followed from 2009 through 2014. According to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)-7 criteria, we classified participants into normal and pre-hypertension groups. The effect of pre-hypertension on the 5-year incidence rate of diabetes was studied using inverse probability of treatment weighting. We modeled the exposure and censored cases given confounding factors such as age, sex, body mass index, smoking, economic status, and education.
RESULTS:
The 5-year incidence rate of diabetes among people with pre-hypertension and those with normal blood pressure (BP) was 12.7 and 9.7%, respectively. The risk ratio (RR) for people with pre-hypertension was estimated to be 1.13 (95% confidence interval [CI], 0.90 to 1.41). The RRs among people with normal BP and high-normal BP, according to the JNC-6 criteria, compared to those with optimal BP were 0.96 (95% CI, 0.73 to 1.25) and 1.31 (95% CI, 1.01 to 1.72), respectively.
CONCLUSIONS:
Our results showed that participants who had higher levels of BP (high-normal compared to optimal BP) had a higher risk of diabetes development. With regard to the quantitative nature of BP, using the specifically distinguishing of stage 1 hypertension or high-normal BP may be a more meaningful categorization for diabetes risk assessment than the JNC-7 classification.

Original Article Knowledge, attitudes, and behavioural risk factors regarding zoonotic infections among bushmeat hunters and traders in Nsukka, southeast Nigeria

Kingsley Uchenna Ozioko, Chris Ikem Okoye, Rose Nduka Obiezue, Raymond Awudu Agbu Epidemiol Health. 2018;40:e2018025.

Original Article Geographical distribution of health indicators related to snake bites and envenomation in Morocco between 1999 and 2013

Faiçal El hattimy, Fouad Chafiq, Hinde Hami, Abdelghani Mokhtari, et al. Epidemiol Health. 2018;40:e2018024.

Abstract: OBJECTIVES:
In light of the dramatic spread of Ebola virus in some parts of Africa and the 2014 outbreak in Nigeria, a study was conducted to evaluate bushmeat dealers’ knowledge and attitudes about zoonotic infections and the risk of transmission to humans.
METHODS:
A cross-sectional survey was conducted in a community in Nsukka, southeast Nigeria. Hunters (n=34) and bushmeat traders (n=42) were interviewed. A semi-structured questionnaire was used to generate the data. The Fisher exact test was used to evaluate the significance of differences between these groups.
RESULTS:
Only 11.8% of the hunters, as compared to 35.7% of the traders, had no knowledge of possible causes of zoonotic infections (p<0.05). However, 64.7% of the hunters, compared to 38.1% of the traders, were ignorant regarding the responsibility of public health personnel and veterinarians (p<0.05), and 76.5% of the hunters compared to 42.9% of the traders were ignorant regarding the existence of zoonoses in Nigeria (p<0.05). A statistically significant difference was also found between these groups regarding the risk of contracting an infection from ectoparasites (p<0.05). The attitudes of respondents towards zoonotic diseases did not differ significantly between the groups.
CONCLUSIONS:
The level of awareness about zoonotic diseases was low in this area, underscoring the need for interventions.

Abstract: OBJECTIVES:
Envenomation from snake bites is a significant cause of morbidity and mortality worldwide. The aim of this study was to describe the epidemiological features of snake bites in Morocco and to evaluate time-space trends in snake bite incidence, the mortality rate, and the case-fatality rate.
METHODS:
This is a retrospective study of snake bite cases reported to the Moroccan Poison Control Center between 1999 and 2013.
RESULTS:
During the study period, 2,053 people were bitten by snakes in Morocco. Most victims were adults (55.4%). The average age of the patients was 26.48±17.25 years. More than half of the cases (58.1%) were males. Approximately 75% of snake bites happened in rural areas, and 85 deaths were recorded during this period. The incidence of snake bites remained generally steady over the 15-year period of this study, with a marked increase noted since 2012. The mortality rate has increased slightly, from 0.02 deaths per 100,000 inhabitants in 1999 to 0.05 in 2013. The geographical distribution of snake bite cases in the regions of Morocco showed that Tanger-Tétouan had the highest annual incidence of snake bites (1.41 bites per 100,000 inhabitants). However, the highest annual mortality rates were recorded in the Guelmim-Es Semara and Souss-Massa-Drâa regions (0.09 deaths per 100,000 inhabitants for both regions).
CONCLUSIONS:
The geographical distribution of the incidence, mortality, and case-fatality rates of snake bites in Morocco showed large disparities across regions during the three 5-year periods included in this study, meaning that certain areas can be considered high-risk for snake bites.

Cohort profile Korea HIV/AIDS Cohort Study: study design and baseline characteristics

Bo Youl Choi, Jun Yong Choi, Sang Hoon Han, Sang Il Kim, et al. Epidemiol Health. 2018;40:e2018023.

Original Article Mortality from aluminum phosphide poisoning in Kermanshah Province, Iran: characteristics and predictive factors

Seyed Mohammad Navabi, Jafar Navabi, Abbas Aghaei, Zahra Shaahmadi, et al. Epidemiol Health. 2018;40:e2018022.

Abstract: The number of persons infected by HIV/AIDS has consistently increased in Korea since the first case of HIV/AIDS infection in 1985 and reached 15,208 by 2016. About 1,100 new patients with HIV/ AIDS infections have emerged every year since 2013. In Korea, the Korea HIV/AIDS Cohort Study was established for the evidenced-based prevention, treatment, and effective management of patients infected with human immunodeficiency virus (HIV) in December 2006. This study monitored 1,438 patients, who accounted for about 10% of all patients with HIV/AIDS in Korea, for 10 years with the following aims: (1) to develop an administrative system for the establishment of a HIV/AIDS cohort-based study; (2) to standardize methodologies and the case report forms; and (3) to standardize multi-cohort data and develop a data cleaning method. This study aims to monitor at least 1,000 patients (excluding those for whom investigation had been completed) per year (estimated number of patients who can be monitored by January 2018: 939). By December 2016, the sex distribution was 93.3% for men, and 6.7% for women (gender ratio, 13.9:1.0), and 98.9% of all participants were Korean. More than 50.0% of the participants were confirmed as HIV positive after 2006. This study reports competitive, long-term research that aimed to develop policies for the prevention of chronic infectious diseases for patients with HIV. The data collected over the last decade will be used to develop indices for HIV treatment and health promotion.

Abstract: OBJECTIVES:
Aluminum phosphide (ALP), also known in Iran as rice tablets, is one of the most effective rodenticides used to protect stored grain. However, ALP poisoning regularly causes mortality in humans. The aim of this study was to evaluate the characteristics and predictive factors of mortality from ALP poisoning.
METHODS:
This study evaluated all patients with ALP poisoning referred to Imam Khomeini Hospital in Kermanshah Province, Iran from 2014 to 2015. For each patient, the following information was recorded: age, sex, the number of tablets consumed, the number of suicide attempts, the time elapsed from consumption to treatment, blood pressure, blood pH, HCO3 levels, and PCO2 . Differences between the survivors and non-survivors of ALP poisoning were analyzed using univariate logistic regression and multivariate analysis.
RESULTS:
In this study, 48 patients were male and 29 patients were female (total: 77 patients). The average age of the survivors and non-survivors was 28.7 and 31.3 years, respectively. All cases (100%) of ALP poisoning were intentional, with the goal of committing suicide. The main predictive variables of mortality from ALP poisoning were blood pressure, blood pH, and time elapsed from consumption to treatment.
CONCLUSIONS:
The likelihood of mortality in patients with ALP poisoning can be predicted using blood pressure, blood pH, and time elapsed from consumption to treatment. These findings may help healthcare providers take more effective measures to treat patients with ALP poisoning.

Original Article Associations between dietary risk factors and ischemic stroke: a comparison of regression methods using data from the Multi-Ethnic Study of Atherosclerosis

Seyed Saeed Hashemi Nazari, Yaser Mokhayeri, Mohammad Ali Mansournia, Soheila Khodakarim, et al. Epidemiol Health. 2018;40:e2018021.

Original Article Prevalence, awareness, treatment, control, and risk factors of hypertension among adults: a cross-sectional study in Iran

Maryam Eghbali, Alireza Khosravi, Awat Feizi, Asieh Mansouri, et al. Epidemiol Health. 2018;40:e2018020.

Abstract: OBJECTIVES:
We analyzed dietary patterns using reduced rank regression (RRR), and assessed how well the scores extracted by RRR predicted stroke in comparison to the scores produced by partial least squares and principal component regression models.
METHODS:
Dietary data at baseline were used to extract dietary patterns using the 3 methods, along with 4 response variables: body mass index, fibrinogen, interleukin-6, and low-density lipoprotein cholesterol. The analyses were based on 5,468 males and females aged 45-84 years who had no clinical cardiovascular disease, using data from the Multi-Ethnic Study of Atherosclerosis.
RESULTS:
The primary factor derived by RRR was positively associated with stroke incidence in both models. The first model was adjusted for sex and race and the second model was adjusted for the variables in model 1 as well as smoking, physical activity, family and sibling history of stroke, the use of any lipid-lowering medication, the use of any anti-hypertensive medication, hypertension, and history of myocardial infarction (model 1: hazard ratio [HR], 7.49; 95% confidence interval [CI], 1.66 to 33.69; p for trend=0.01; model 2: HR, 6.83; 95% CI, 1.51 to 30.87 for quintile 5 compared with the reference category; p for trend=0.02).
CONCLUSIONS:
Based primarily on RRR, we identified that a dietary pattern high in fats and oils, poultry, non-diet soda, processed meat, tomatoes, legumes, chicken, tuna and egg salad, and fried potatoes and low in dark-yellow and cruciferous vegetables may increase the incidence of ischemic stroke.

Abstract: OBJECTIVES:
Hypertension (HTN) is an important risk factor for cardiovascular disease. Considering the importance of this disease for public health, this study was designed in order to determine the prevalence, awareness, treatment, control, and risk factors of HTN in the Iranian adult population.
METHODS:
This cross-sectional study was conducted among 2,107 residents of Isfahan, Iran. Samples were selected through multi-stage random cluster sampling in 2015-2016. The outcome variable was HTN, determined by measuring blood pressure in the right arm via a digital arm blood pressure monitor. Awareness, treatment, and control of HTN were assessed by a validated and reliable researcher-developed questionnaire. Other demographic and clinical variables were assessed via a demographic questionnaire.
RESULTS:
The overall prevalence of HTN was 17.3% (18.9 and 15.5% in men and women, respectively). The prevalence of HTN increased in both genders with age. The prevalence of awareness of HTN among people with HTN was 69.2%, of whom 92.4 and 59.9% were taking medication for HTN and had controlled HTN, respectively. Logistic regression identified age, body mass index, having diabetes and hyperlipidemia, and a positive family history of HTN as determinants of awareness of HTN.
CONCLUSIONS:
The results showed that HTN was highly prevalent in the community, especially in men and in middle-aged and older adults. Approximately 30.8% of patients were unaware of their disease, and there was less awareness among younger adults. Despite the high frequency of taking medication to treat HTN, it was uncontrolled in more than 40.1% of patients. Health policy-makers should therefore consider appropriate preventive and therapeutic strategies for these high-risk groups.

Original Article Effects of human and organizational deficiencies on workers’ safety behavior at a mining site in Iran

Mostafa Mirzaei Aliabadi, Hamed Aghaei, Omid Kalatpour, Ali Reza Soltanian, et al. Epidemiol Health. 2018;40:e2018019.

Original Article Sleep quality and associated factors among the elderly living in rural Chiang Rai, northern Thailand

Weerakorn Thichumpa, Nopporn Howteerakul, Nawarat Suwannapong, Visasiri Tantrakul Epidemiol Health. 2018;40:e2018018.

Abstract: OBJECTIVES:
Throughout the world, mines are dangerous workplaces with high accident rates. According to the Statistical Center of Iran, the number of occupational accidents in Iranian mines has increased in recent years. This study investigated and analyzed the human and organizational deficiencies that influenced Iranian mining accidents.
METHODS:
In this study, the data associated with 305 mining accidents were analyzed using a systems analysis approach to identify critical deficiencies in organizational influences, unsafe supervision, preconditions for unsafe acts, and workers’ unsafe acts. Partial least square structural equation modeling (PLS-SEM) was utilized to model the interactions among these deficiencies.
RESULTS:
Organizational deficiencies had a direct positive effect on workers’ violations (path coefficient, 0.16) and workers’ errors (path coefficient, 0.23). The effect of unsafe supervision on workers’ violations and workers’ errors was also significant, with path coefficients of 0.14 and 0.20, respectively. Likewise, preconditions for unsafe acts had a significant effect on both workers’ violations (path coefficient, 0.16) and workers’ errors (path coefficient, 0.21). Moreover, organizational deficiencies had an indirect positive effect on workers’ unsafe acts, mediated by unsafe supervision and preconditions for unsafe acts. Among the variables examined in the current study, organizational influences had the strongest impact on workers’ unsafe acts.
CONCLUSIONS:
Organizational deficiencies were found to be the main cause of accidents in the mining sector, as they affected all other aspects of system safety. In order to prevent occupational accidents, organizational deficiencies should be modified first.

Abstract: OBJECTIVES:
This study aimed to characterize the prevalence of poor sleep quality and to identify associated factors among community-dwelling elderly individuals in northern Thailand.
METHODS:
A cross-sectional study was conducted among 266 randomly selected elderly people in a sub-district in rural Chiang Rai Province, northern Thailand. The participants were interviewed using the Thai version of the Pittsburgh Sleep Quality Index (PSQI).
RESULTS:
Roughly 44.0% of the participants had poor sleep quality (PSQI score, >5), 9.4% used sleep medication, 27.1% had poor family relationships, and 12.0% had mild depression. Multiple logistic regression analysis indicated that being female (odds ratio [OR], 1.74; 95% confidence interval [CI], 1.10 to 3.02), a higher education level (OR, 3.03; 95% CI, 1.34 to 6.86 for primary school; OR, 2.48; 95% CI, 1.31 to 5.44 for higher than primary school), mild depression (OR, 2.65; 95% CI, 1.11 to 6.36), and poor family relationships (OR, 3.65; 95% CI, 1.98 to 6.75) were significantly associated with poor sleep quality.
CONCLUSIONS:
The prevalence of poor sleep quality among the elderly was moderately high. Healthcare providers should regularly conduct screenings for sleep quality and depression; provide sleep health education; and conduct interventions to encourage participating in family activities, resolving conflicts, sharing ideas, and making compromises within the family.

Original Article Is inadequate play area in schools associated with overweight among students in Addis Ababa, Ethiopia? A comparative cross-sectional study

Tsedey Moges, Bereket Gebremichael, Solomon Shiferaw, Robel Yirgu Epidemiol Health. 2018;40:e2018017.

Review A systematic review and meta-analysis of the prevalence of toxoplasmosis in hemodialysis patients in Iran

Masoud Foroutan, Ali Rostami, Hamidreza Majidiani, Seyed Mohammad Riahi, et al. Epidemiol Health. 2018;40:e2018016.

Abstract: OBJECTIVES:
The prevalence of childhood obesity has more than doubled since it was formally recognized as a global epidemic in 1997. With the increasingly dwindling space for private schools in Ethiopia, unresolved concerns exist among the public regarding the possible effect of limited play areas in schools on overweight/obesity. This study intended to determine and compare the levels of overweight/obesity among adolescents in private schools with and without adequate play area in Addis Ababa, Ethiopia.
METHODS:
A school-based comparative cross-sectional study was conducted among 1,276 adolescents. Twenty private schools were grouped into 2 groups based on the size of the play area. Data were collected using a pre-tested questionnaire and anthropometric measurements and analyzed using descriptive statistical tests and logistic regression.
RESULTS:
The magnitude of overweight/obesity was significantly higher in schools with inadequate play area (19.4%; 95% confidence interval [CI], 16.4 to 22.7) than in schools with adequate play area (14.6%; 95% CI, 11.9 to17.5). Inadequacy of the play area was also positively associated with overweight/obesity in the multiple logistic regression analysis (odds ratio [OR], 1.62; 95% CI, 1.05 to 2.51). Using private car transportation to and from school (OR, 2.27; 95% CI, 1.13 to 4.57), father’s educational status (secondary school and above: OR, 2.54; 95% CI, 1.14 to 5.62), and middle wealth quintile (OR, 2.54; 95% CI, 1.50 to 4.33) were other factors significantly associated with overweight/obesity.
CONCLUSIONS:
Inadequate play area in schools was an important contributor to overweight/obesity. Sedentary behavior was also significantly associated with overweight/obesity.

Abstract: OBJECTIVES:
Toxoplasmosis is a parasitic disease that occurs worldwide, with a wide range of complications in immunocompromised patients. This systematic review and meta-analysis was performed to evaluate the seroprevalence of Toxoplasma gondii among patients undergoing hemodialysis in Iran.
METHODS:
We searched English and Persian databases for studies reporting T. gondii seroprevalence in Iranian hemodialysis patients through December 31, 2017. Inclusion and exclusion criteria were applied.
RESULTS:
A total of 10 studies containing 1,865 participants (1,048 patients and 817 controls) met the eligibility criteria. Immunoglobulin G (IgG) antibodies against T. gondii were found in 58% (95% confidence interval [CI], 46 to 70) of hemodialysis patients and 40% (95% CI, 31 to 50) of healthy controls, while immunoglobulin M (IgM) antibodies were found in 2% (95% CI, 0 to 6) of hemodialysis patients and 0% (95% CI, 0 to 1) of healthy controls. The meta-analysis showed that hemodialysis patients were significantly more likely to be seropositive for IgG (odds ratio [OR], 2.04; 95% CI, 1.54 to 2.70; p<0.001) and IgM (OR, 2.53; 95% CI, 1.23 to 5.22; p<0.001) antibodies against T. gondii infection than healthy individuals.
CONCLUSIONS:
The current study revealed a high prevalence of T. gondii infection in hemodialysis patients. Since hemodialysis patients are immunocompromised and T. gondii can cause serious clinical complications, we recommend that periodic screenings for T. gondii infection should be incorporated into the routine clinical care of these patients.

Original Article Distribution and larval breeding habitats of Aedes mosquito species in residential areas of northwest Ethiopia

Getachew Ferede, Moges Tiruneh, Ebba Abate, Wondmeneh Jemberie Kassa, et al. Epidemiol Health. 2018;40:e2018015.

Original Article Asymptomatic Middle East Respiratory Syndrome coronavirus infection using a serologic survey in Korea

Yeong-jun Song, Jeong-Sun Yang, Hee Jung Yoon, Hae-Sung Nam, et al. Epidemiol Health. 2018;40:e2018014.

Abstract: OBJECTIVES:
The Aedes mosquito is a vector for transmitting many arboviruses. Knowledge of the breeding habitat of this vector is vital for implementing appropriate interventions. Thus, this study was conducted to determine the breeding habitats and presence of Aedes mosquito species in the study areas.
METHODS:
A house-to-house cross-sectional survey of Aedes mosquito breeding habitats was carried out in Metema and Humera, Ethiopia, in August 2017. All available water-holding containers present in and around houses were inspected for the presence of immature stages of Aedes mosquitoes, and they were collected and reared to the adult stage for species identification. In the larval survey, the house index, container index, and Breteau index were computed as risk indices.
RESULTS:
Of the 384 houses surveyed for the presence of Aedes mosquito larval breeding, 98 were found to be positive for larvae. During the survey, a total of 566 containers were inspected, of which 186 were found to be infested with Aedes mosquito larvae, with a container index of 32.9, a house index of 25.5, and a Breteau index of 48.4. The most common Aedes mosquito breeding habitats were discarded tires (57.5%), followed by mud pots (30.0%). Of the 1,077 larvae and pupae collected and reared, Aedes aegypti (49.3%), Ae. vittatus (6.5%), and Culex species (44.2%) were identified.
CONCLUSIONS:
Discarded tires were the most preferred breeding habitats for Aedes mosquitoes. Moreover, Ae. aegypti, the main vector of dengue and other arboviruses, was identified for the first time in this region, suggesting a high potential for arbovirus transmission in the study areas.

Abstract: OBJECTIVES:
The rates of asymptomatic infection with Middle East Respiratory Syndrome (MERS) coronavirus vary. A serologic study was conducted to determine the asymptomatic MERS infection rate in healthcare workers and non-healthcare workers by exposure status.
METHODS:
Study participants were selected from contacts of MERS patients based on a priority system in 4 regions strongly affected by the 2015 MERS outbreak. A sero-epidemiological survey was performed in 1,610 contacts (average duration from exposure to test, 4.8 months), and the collected sera were tested using an enzyme-linked immunespecific assay (ELISA), immunofluorescence assay (IFA), and plaque reduction neutralization antibody test (PRNT). Among the 1,610 contacts, there were 7 ELISA-positive cases, of which 1 exhibited positive IFA and PRNT results.
RESULTS:
The asymptomatic infection rate was 0.060% (95% confidence interval, 0.002 to 0.346). The asymptomatic MERS case was a patient who had been hospitalized with patient zero on the same floor of the hospital at the same time. The case was quarantined at home for 2 weeks after discharge, and had underlying diseases, including hypertension, angina, and degenerative arthritis.
CONCLUSIONS:
The asymptomatic infection was acquired via healthcare-associated transmission. Thus, it is necessary to extend serologic studies to include inpatient contacts who have no symptoms.

Review Road dust and its effect on human health: a literature review

Raihan K. Khan, Mark A. Strand Epidemiol Health. 2018;40:e2018013.

Original Article Income-related inequality in completed suicide across the provinces of Iran

Mohammad Hassan Kazemi-Galougahi, Asieh Mansouri, Samaneh Akbarpour, Mahmood Bakhtiyari, et al. Epidemiol Health. 2018;40:e2018012.

Abstract: The purpose of this study was to determine the effects of road dust on human health. A PubMed search was used to extract references that included the words “road dust” and “health” or “fugitive dust” and “health” in the title or abstract. A total of 46 references were extracted and selected for review after the primary screening of 949 articles. The respiratory system was found to be the most affected system in the human body. Lead, platinum-group elements (platinum, rhodium, and bohrium), aluminum, zinc, vanadium, and polycyclic aromatic hydrocarbons were the components of road dust that were most frequently referenced in the articles reviewed. Road dust was found to have harmful effects on the human body, especially on the respiratory system. To determine the complex mechanism of action of various components of road dust on the human body and the results thereof, the authors recommend a further meta-analysis and extensive risk-assessment research into the health impacts of dust exposure.

Abstract: OBJECTIVES:
The aim of this study was to measure income-related inequality in completed suicide across the provinces of Iran.
METHODS:
This ecological study was performed using data from the Urban and Rural Household Income and Expenditure Survey-2010 conducted by the Iranian Center of Statistics, along with data on completed suicide from the Iranian Legal Medicine Organization in 2012. We calculated the Gini coefficient of per capita income and the completed suicide rate, as well as the concentration index for per capita income inequality in completed suicide, across the provinces of Iran.
RESULTS:
The Gini coefficients of per capita income and the completed suicide rate in the provinces of Iran were 0.10 (95% confidence interval [CI], 0.06 to 0.13) and 0.34 (95% CI, 0.21 to 0.46), respectively. We found a trivial decreasing trend in the completed suicide incidence rate according to income quintile. The poorest-to-richest ratio in the completed suicide rate was 2.01 (95% CI, 1.26 to 3.22). The concentration index of completed suicide in the provinces of Iran was -0.12 (95% CI, -0.30 to 0.06).
CONCLUSIONS:
This study found that lower income might be considered as a risk factor for completed suicide. Nonetheless, further individual studies incorporating multivariable analysis and repeated cross-sectional data would allow a more fine-grained analysis of this phenomenon.

Original Article Factors related to cancer screening behaviors

Boyoung Choi, Tae Rim Um, Kwang-Soo Lee Epidemiol Health. 2018;40:e2018011.

Original Article Socioeconomic disparities and difficulties to access to healthcare services among Canadian children with neurodevelopmental disorders and disabilities

Sana Raouafi, Sofiane Achiche, Maxime Raison Epidemiol Health. 2018;40:e2018010.

Abstract: OBJECTIVES:
This study aimed to investigate the factors related to cancer screening behaviors (CSB).
METHODS:
The 2014 Korean Community Health Survey used for analysis. The dependent variable was CSB, and the independent variables were demographic, health behavioral, and regional factor. Propensity score matching (PSM) used to control health behavior and regional factors, which were influencing CSB. For statistical analysis, chi-square test and logistic regression analysis used.
RESULTS:
Logistic regression analysis after PSM showed that gender, age, marital status, educational level, monthly household income, employment type, alcohol drinking, smoking, body mass index group, chronic disease, and subjective health status influenced the CSB, there were statistical differences.
CONCLUSIONS:
To improve cancer screening (CS), it is necessary to educate individuals on the need for CS and to carry out a personalized CS program based on an individual’s demographic status and health behavior.

Abstract: OBJECTIVES:
The aims of this study were to identify the associations of levels of severity of neurodevelopmental disorders and disabilities (NDD/D) in children with their household socioeconomic status (SES) and their frequency of visits to a healthcare provider, and to examine how the severity of disability varied with these determinants among NDD/D subgroups, in order to inform possible social policy changes and to improve access to the healthcare system.
METHODS:
Data from the 2006 Participation and Activity Limitation Survey on children aged 5-14 years, collected by Statistics Canada, were analyzed (n=7,072 and weighted n=340,340). Children with NDD/D constituted those with impairments in motor, speech, neurosensory, and psychological functioning, as well as those who had issues with learning/cognition and social interactions. The weighted sample size for this group was n=111,630 (total sample size for children with limitations: n=174,810). We used logistic regression to assess the associations of household SES and frequency of visits to a healthcare provider with disability level. We included NDD/D subgroups as interaction terms in the model. Multiple correspondence analysis (MCA) was conducted to develop a profile of disability level.
RESULTS:
After-tax low income, family assistance, out-of-pocket expenses, needing but not receiving health services from a social worker, condition of the dwelling, and residential location were associated with the severity of NDD/D. Using MCA, 2 disability profiles could be identified based on access to healthcare, household income status, and condition of the dwelling.
CONCLUSIONS:
More social interventions are needed to reduce difficulties in accessing healthcare and to diminish the socially determined health inequalities faced by children with NDD/D.

Original Article Relationship between happiness and tobacco smoking among high school students

Maryam Ataeiasl, Parvin Sarbakhsh, Hossein Dadashzadeh, Christoph Augner, et al. Epidemiol Health. 2018;40:e2018009.

Original Article The effects of water-pipe smoking on birth weight: a population-based prospective cohort study in southern Iran

Shahrzad Nematollahi, Mohammad Ali Mansournia, Abbas Rahimi Foroushani, Mahmood Mahmoodi, et al. Epidemiol Health. 2018;40:e2018008.

Abstract: OBJECTIVES:
Recent research has described negative relationship between happiness and habitual smoking among adolescents. No study of this relationship has been conducted among Iranian adolescents. The aim of the present study was to characterize the relationship between happiness and cigarette or hookah smoking among a sample of high school students.
METHODS:
A sample of 1,161 10th-grade students in Tabriz (northwest Iran) was selected by multi-stage proportional cluster sampling. Participants completed a self-administered multiple-choice questionnaire including information on cigarette smoking, hookah smoking, happiness score, substance abuse, self-injury, general risk-taking behavior, attitudes towards smoking, socioeconomic information, and demographic characteristics. An ordinal logistic regression model was used for data analysis.
RESULTS:
It was found that 5.9 and 5.0% of students were regular cigarette smokers and regular hookah smokers, respectively. After controlling for potential confounders, higher happiness scores were found to protect students against more advanced stages of cigarette smoking (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.97 to 0.99; p=0.013). However, no significant relationship was found between happiness scores and hookah smoking status (OR, 1.01; 95% CI, 0.97 to 1.02; p=0.523).
CONCLUSIONS:
Happiness scores were associated with less advanced stages of habitual cigarette smoking among high school students. Our findings underscore the necessity of conducting longitudinal or interventional studies aiming to determine the effects of enhancing happiness on preventing the transition through the stages of cigarette and hookah smoking.

Abstract: OBJECTIVES:
Consecutive community health assessments revealed that water-pipe smoking in women and impaired growth in children were among the main health concerns in suburban communities in southern Iran. The aim of the present study was to identify the effects of water-pipe smoking during pregnancy on birth weight.
METHODS:
Data from a population-based prospective cohort study of 714 singleton live pregnancies in the suburbs of Bandar Abbas in southern Iran in 2016-2018 were used in this study. Data about water-pipe smoking patterns and birth weight were collected by questionnaires during and after the pregnancy. Low birth weight (LBW) was defined as a birth weight below 2,500 g. Statistical analyses were performed using generalized linear models, and the results were presented in terms of relative risk (RR) and 95% confidence intervals (CI).
RESULTS:
Fifty (8.2%) of the study subjects smoked water-pipe. The adjusted risk of LBW increased 2-fold in water-pipe smokers (adjusted RR [aRR], 2.09; 95% CI, 1.18 to 3.71), and by 2.0% for each 1-year increase in the duration of water-pipe smoking (aRR, 1.02; 95% CI, 0.99 to 1.05).
CONCLUSIONS:
Our results showed that water-pipe smoking during pregnancy was an important risk factor for LBW in this population sample from southern Iran. The introduction of regulations onto prevent water-pipe smoking and the implementation of community health action plans aiming at empowering women and increasing women’s knowledge and awareness regarding the health consequences of water-pipe smoking are proposed.

Original Article Application of an artificial neural network model for diagnosing type 2 diabetes mellitus and determining the relative importance of risk factors

Shiva Borzouei, Ali Reza Soltanian Epidemiol Health. 2018;40:e2018007.

Perspective Interpretation of the hygiene and microflora hypothesis for allergic diseases through epigenetic epidemiology

Jong-Myon Bae Epidemiol Health. 2018;40:e2018006.

Abstract: OBJECTIVES:
To identify the most important demographic risk factors for a diagnosis of type 2 diabetes mellitus (T2DM) using a neural network model.
METHODS:
This study was conducted on a sample of 234 individuals, in whom T2DM was diagnosed using hemoglobin A1c levels. A multilayer perceptron artificial neural network was used to identify demographic risk factors for T2DM and their importance. The DeLong method was used to compare the models by fitting in sequential steps.
RESULTS:
Variables found to be significant at a level of p<0.2 in a univariate logistic regression analysis (age, hypertension, waist circumference, body mass index [BMI], sedentary lifestyle, smoking, vegetable consumption, family history of T2DM, stress, walking, fruit consumption, and sex) were entered into the model. After 7 stages of neural network modeling, only waist circumference (100.0%), age (78.5%), BMI (78.2%), hypertension (69.4%), stress (54.2%), smoking (49.3%), and a family history of T2DM (37.2%) were identified as predictors of the diagnosis of T2DM.
CONCLUSIONS:
In this study, waist circumference and age were the most important predictors of T2DM. Due to the sensitivity, specificity, and accuracy of the final model, it is suggested that these variables should be used for T2DM risk assessment in screening tests.

Abstract: The hygiene hypothesis (HH) proposed by Strachan in 1989 was expanded to explain the inverse association between the occurrence of allergy disorders and the risk of infectious diseases and parasite infestation. The microflora hypothesis (MH) suggests that gut microbial dysbiosis in early life might trigger hypersensitivity disorders. The sharing concept of both HH and MH is gene-environment interaction, which is also a key concept in epigenetics. The amalgamation of epidemiology and epigenetics has created a scientific discipline termed epigenetic epidemiology. To accomplish an era of gene-environment-wide interaction studies, it is necessary to launch a national human epigenome project.

Original Article Experiences of and barriers to transition-related healthcare among Korean transgender adults: focus on gender identity disorder diagnosis, hormone therapy, and sex reassignment surgery

Hyemin Lee, Jooyoung Park, Bokyoung Choi, Horim Yi, et al. Epidemiol Health. 2018;40:e2018005.

Review Registry-based stroke research in Taiwan: past and future

Cheng-Yang Hsieh, Darren Philbert Wu, Sheng-Feng Sung Epidemiol Health. 2018;40:e2018004.

Abstract: OBJECTIVES:
Transgender people may encounter barriers to transition-related healthcare services. This study aimed to investigate the experiences of transition-related healthcare and barriers to those procedures among transgender adults in Korea.
METHODS:
In 2017, we conducted a nationwide cross-sectional survey of 278 transgender adults, which named Rainbow Connection Project II, in Korea. We assessed the prevalence of transition-related healthcare, including gender identity disorder (GID) diagnosis, hormone therapy, and sex reassignment surgery. To understand the barriers to those procedures, we also asked participants for their reasons for not receiving each procedure. Further, this study examined their experiences of and the reasons for using non-prescribed hormone medications.
RESULTS:
Of transgender people participated in the survey, 91.0% (n=253/278) were diagnosed with GID, 88.0% (n=243/276) received hormone therapy, and 42.4% (n=115/271) have had any kind of sex reassignment surgery. Cost was the most common barrier to transition-related healthcare among Korean transgender adults. Other common barriers were identified as follows: negative experiences in healthcare settings, lack of specialized healthcare professionals and facilities, and social stigma against transgender people. Among those who had taken hormone medications, 25.1% (n=61/243) reported that they had ever purchased them without a prescription.
CONCLUSIONS:
Our findings suggest that barriers to transition-related healthcare exist in Korea and constrain transgender individuals’ safe access to the needed healthcare. Institutional interventions are strongly recommended to improve access to transition-related healthcare. These interventions include provision of programs to train Korean healthcare professionals and expansion of national health insurance to include these procedures.

Abstract: Stroke registries are observational databases focusing on the clinical information and outcomes of stroke patients. They play an important role in the cycle of quality improvement. Registry data are collected from real-world experiences of stroke care and are suitable for measuring quality of care. By exposing inadequacies in performance measures of stroke care, research from stroke registries has changed how we manage stroke patients in Taiwan. With the success of various quality improvement campaigns, mortality from stroke and recurrence of stroke have decreased in the past decade. After the implementation of a nationwide stroke registry, researchers have been creatively expanding how they use and collect registry data for research. Through the use of the nationwide stroke registry as a common data model, researchers from many hospitals have built their own stroke registries with extended data elements to meet the needs of research. In collaboration with information technology professionals, stroke registry systems have changed from web-based, manual submission systems to automated fill-in systems in some hospitals. Furthermore, record linkage between stroke registries and administrative claims databases or other existing databases has widened the utility of registry data in research. Using stroke registry data as the reference standard, researchers have validated several algorithms for ascertaining the diagnosis of stroke and its risk factors from claims data, and have also developed a claims-based index to estimate stroke severity. By making better use of registry data, we believe that we will provide better care to patients with stroke.

Review Rapid qualitative review of ethical issues surrounding healthcare for pregnant women or women of reproductive age in epidemic outbreaks

Patrik Hummel, Abha Saxena, Corinna Klingler Epidemiol Health. 2018;40:e2018003.

Original Article Physician’s awareness of lung cancer screening and its related medical radiation exposure in Korea

Seri Hong, Suyeon Kim, Mina Suh, Boyoung Park, et al. Epidemiol Health. 2018;40:e2018002.

Abstract: This article describes, categorizes, and discusses the results of a rapid literature review aiming to provide an overview of the ethical issues and corresponding solutions surrounding pregnancies in epidemic outbreaks. The review was commissioned by the World Health Organization to inform responses to the Zika outbreak that began in 2015. Due to the urgency of the response efforts that needed to be informed by the literature search, a rapid qualitative review of the literature published in PubMed was conducted. The search and analysis were based on the operationalization of 3 key concepts: ethics, pregnancy, and epidemic outbreak. Ethical issues and solutions were interpreted within a principlist framework. The data were analyzed using qualitative content analysis. The search identified 259 publications, of which the full text of 23 papers was read. Of those, 20 papers contained a substantive part devoted to the topic of interest and were therefore analyzed further. We clustered the ethical issues and solutions around 4 themes: uncertainty, harms, autonomy/liberty, and effectiveness. Recognition of the identified ethical issues and corresponding solutions can inform and improve response efforts, public health planning, policies, and decision-making, as well as the activities of medical staff and counselors who practice before, during, or after an epidemic outbreak that affects pregnant women or those of reproductive age. The rapid review format proved to be useful despite its limited data basis and expedited review process.

Abstract: OBJECTIVES:
Through a survey on perception of lung cancer screening and accompanying medical radiation exposure in Korea, the present study was to investigate its current situations and evaluate various perception of physicians regarding it in order to propose measures for improvements.
METHODS:
Medical specialists in national cancer screening institutions selected through stratified random sampling were subjected to face-to-face interview using a structured questionnaire. We investigated physicians’ perception on effectiveness of lung cancer screening depending on screening modality, selection criteria for subjects of screening, types of equipment used to screen, and perception for seriousness of adverse effects following the test. In addition, odds ratios to underestimate risk of radiation exposure from screening were calculated through logistic regression analysis.
RESULTS:
Each response that chest X-ray is effective for lung cancer screening and that smoking history is not considered prior to screening recommendation accounted for more than 60% of respondents, suggesting the chance of unnecessary screening tests. Regarding adverse effects of lung cancer screening, about 85% of respondents replied that false positive, radiation exposure, and overdiagnosis could be ignored. About 70% of respondents underestimated radiation dose from lung cancer screening, and a low proportion of physicians informed patients of radiation exposure risk.
CONCLUSIONS:
It was found that most physicians underestimated harms of lung cancer screening including radiation exposure and were lack of awareness regarding lung cancer screening. It should be noted that physicians need to have proper perceptions about screening recommendation and accompanying possible harms, for successful implementation of the screening program.

Original Article Systematic review of the published data on the worldwide prevalence of John Cunningham virus in patients with multiple sclerosis and neuromyelitis optica

Sonia Patricia Castedo Paz, Luciana Branco, Marina Alves de Camargo Pereira, Caroline Spessotto, et al. Epidemiol Health. 2018;40:e2018001.

Abstract: OBJECTIVES:
John Cunningham virus (JCV) is a polyoma virus that infects humans, mainly in childhood or adolescence, and presents no symptomatic manifestations. JCV can cause progressive multifocal leukoencephalopathy (PML) in immunosuppressed individuals, including those undergoing treatment for multiple sclerosis (MS) and neuromyelitis optica (NMO). PML is a severe and potentially fatal disease of the brain. The prevalence of JCV antibodies in human serum has been reported to be between 50.0 and 90.0%. The aim of the present study was to review worldwide data on populations of patients with MS and NMO in order to establish the rates of JCV seropositivity in these individuals.
METHODS:
The present review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and used the following search terms: “JCV” OR “JC virus” AND “multiple sclerosis” OR “MS” OR “NMO” OR “neuromyelitis optica” AND “prevalence.” These terms were searched for both in smaller and in larger clusters of words. The databases searched included PubMed, MEDLINE, SciELO, LILACS, Google Scholar, and Embase.
RESULTS:
After the initial selection, 18 papers were included in the review. These articles reported the prevalence of JCV antibodies in the serum of patients with MS or NMO living in 26 countries. The systematic review identified data on 29,319 patients with MS/NMO and found that 57.1% of them (16,730 individuals) were seropositive for the anti-JCV antibody (range, 40.0 to 69.0%).
CONCLUSIONS:
The median worldwide prevalence of JCV among adults with MS or NMO was found to be 57.1%.

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