epiH :: Epidemiology and Health

Original Article The relationship between maternal mental health and communication skills in children in Shiraz, Iran

Najmeh Maharlouei, Hossein Alibeigi, Abbas Rezaianzadeh, Pedram Keshavarz, et al. Epidemiol Health. 2019;41:e2019035.

Original Article Bilirubin and risk of ischemic heart disease in Korea: a two-sample Mendelian randomization study

Christina Jeon, Ji-Young Lee, Sun Ju Lee, Keum Ji Jung, et al. Epidemiol Health. 2019;41:e2019034.

Abstract: OBJECTIVES:
Child development is a significant issue in global public health, and maternal mental health (MMH) can have a remarkable effect on children’s development of communication skills. We aimed to investigate the association between MMH and communication skills in a sample of Iranian children.
METHODS:
This study was conducted in Shiraz, Iran during 2016. In total, 640 mothers who lived in Shiraz and were registered in the Fars Birth Cohort (FBC) study were invited to attend the FBC clinic with their children. A trained physician evaluated MMH using the General Health Questionnaire (GHQ). Additionally, a trained nurse assessed the children’s communication development status using the Ages and Stages Questionnaire for 60-month old children.
RESULTS:
The majority of the mothers were homemakers (82.8%) and had high school diplomas (38.9%). The mothers’ mean age was 33.7±4.6 years. Seventy-nine (12.3%) children had delayed communication skills, but no significant association was found between children’s communication skills and the mothers’ total GHQ score (p=0.43). In total, 493 mothers (77.0%) had abnormal somatic symptoms, 497 (77.7%) had abnormal anxiety/insomnia, 337 (52.7%) had social dysfunction, and 232 (36.3%) suffered from depression. Logistic regression indicated that after adjusting for confounders, the odds of delayed communication skills were 3-fold higher among the children of mothers with abnormal somatic symptoms than among other children (p=0.01).
CONCLUSIONS:
The study results confirmed that MMH had a significant impact on children’s communication skills. Moreover, maternal abnormal somatic symptoms exerted the strongest impact on the development of communication skills in 5-yearold children.

Abstract: OBJECTIVES:
Bilirubin is an endogenous antioxidant that protects cells against oxidative stress. Increased plasma levels of bilirubin have been associated with a reduced risk of ischemic heart disease (IHD) in previous studies. Nonetheless, whether those associations reflect a true protective effect of bilirubin on IHD, rather than confounding or reverse causation, remains unknown. Therefore, we applied two-sample Mendelian randomization to evaluate the causal association between bilirubin levels and IHD risk in a Korean population.
METHODS:
A total of 5 genetic variants—TRPM8 (rs10490012), USP40 (rs12993249), ATG16L1 (rs2119503), SLCO1B1 (rs4149014), and SLCO1B3 (rs73233620)—were selected as genetic instruments for serum bilirubin levels using a communitybased cohort, the Korean Genome and Epidemiology Study, comprising 33,598 subjects. We then evaluated their impact on IHD using the Korean Cancer Prevention Study-II cohort.
RESULTS:
Among the 5 instrumental variables that showed significant associations with serum bilirubin levels, rs12993249 (USP40) showed the most significant association (p<2.36×10-105). However, we found no significant association between serum bilirubin levels and IHD. Sensitivity analyses demonstrated a consistent association, suggesting that our observations were robust.
CONCLUSIONS:
Using two-sample Mendelian randomization, we found no association between serum bilirubin levels and IHD. Further studies that confirm the observed interactions among other ethnicities are warranted.

Case Report Two cases of cholera O1 in South Batinah, Oman, April 2019: lessons learned

Zayid K. Al Mayahi, Nasser Al-Shaqsi, Hamid A. Elmutashi, Ali Al-Dhoyani, et al. Epidemiol Health. 2019;41:e2019033.

Original Article Factors associated with mortality from tuberculosis in Iran: an application of a generalized estimating equation-based zero-inflated negative binomial model to national registry data

Fatemeh Sarvi, Abbas Moghimbeigi, Hossein Mahjub, Mahshid Nasehi, et al. Epidemiol Health. 2019;41:e2019032.

Abstract: Cholera represents an ongoing threat to many low-income and middle-income countries, but some cases of cholera even occur in high-income countries. Therefore, to prevent or combat cholera outbreaks, it is necessary to maintain the capacity to rapidly detect cholera cases, implement infection control measures, and improve general hygiene in terms of the environment, water, and food. The 2 cases, 1 imported and 1 secondary, described herein are broadly indicative of areas that require improvement. These cases were missed at the primary health care stage, which should be the first detection point even for unusual diseases such as cholera, and the absence of strict infection control practices at the primary care level is believed to contribute to secondary cases of infection. This report also encourages countries to ensure that rapid diagnostic stool tests are available to enable quick detection, as well as to provide information to people travelling to areas where cholera is endemic.

Abstract: OBJECTIVES:
Tuberculosis (TB) is a global public health problem that causes morbidity and mortality in millions of people per year. The purpose of this study was to examine the relationship of potential risk factors with TB mortality in Iran.
METHODS:
This cross-sectional study was performed on 9,151 patients with TB from March 2017 to March 2018 in Iran. Data were gathered from all 429 counties of Iran by the Ministry of Health and Medical Education and Statistical Center of Iran. In this study, a generalized estimating equation-based zero-inflated negative binomial model was used to determine the effect of related factors on TB mortality at the community level. For data analysis, R version 3.4.2 was used with the relevant packages.
RESULTS:
The risk of mortality from TB was found to increase with the unemployment rate (βˆ=0.02), illiteracy (βˆ=0.04), household density per residential unit (βˆ=1.29), distance between the center of the county and the provincial capital (βˆ=0.03), and urbanization (βˆ=0.81). The following other risk factors for TB mortality were identified: diabetes (βˆ=0.02), human immunodeficiency virus infection (βˆ=0.04), infection with TB in the most recent 2 years (βˆ=0.07), injection drug use (βˆ=0.07), long-term corticosteroid use (βˆ=0.09), malignant diseases (βˆ=0.09), chronic kidney disease (βˆ=0.32), gastrectomy (βˆ=0.50), chronic malnutrition (βˆ=0.38), and a body mass index more than 10% under the ideal weight (βˆ=0.01). However, silicosis had no effect.
CONCLUSIONS:
The results of this study provide useful information on risk factors for mortality from TB.

Original Article Why do some Korean parents hesitate to vaccinate their children?

Kyujin Chang, Soon Young Lee Epidemiol Health. 2019;41:e2019031.

Original Article Trends in the prevalence and management of diabetes in Korea: 2007-2017

Ji-Yeon Shin Epidemiol Health. 2019;41:e2019029.

Abstract: OBJECTIVES:
Vaccinations for infectious diseases are opposed despite their achievement, and this opposition has recently been revealed in Korea. However, research in Korea has not been vigorous. The authors studied why some Korean parents hesitate to vaccinate their children by applying the health belief model.
METHODS:
Parents who hesitate to vaccinate and parents who do not were surveyed in alternative education preschools and elementary schools. They were classified into four types of hesitancy and statistically compared.
RESULTS:
Among the 129 subjects, 43 vaccinated without hesitancy, 20 vaccinated on time with hesitancy, 32 vaccinated with a deliberate delay of one month or longer, and 34 did not vaccinate. Vaccination increased with an increase in the awareness that severe outcomes can occur when unvaccinated. Concerns about adverse reactions from vaccinations or direct/indirect experiences affected refusal. Furthermore, perceptions of the lack of meaningfulness of vaccinations, distrust of policy and safety management, influence of leaders or activists in joined organizations, and experts of Korean traditional or alternative medicine affected refusal. Explanations by doctors, text messages and mails from institutions, and concerns about disadvantages caused by not complying with government policies increased vaccination.
CONCLUSIONS:
The reasons for vaccine hesitancy and acceptance were similar to the results of international research. Health authorities and professionals should communicate sufficiently and appropriately with hesitant parents and find ways to rationally resolve social conflicts. However, this sample was small and there is little Korean research, so more in-depth and diverse researchs are needed.

Abstract: OBJECTIVES:
This study analyzed Korea National Health and Nutrition Examination Survey data from 2007 to 2017 to assess trends in the prevalence, treatment, and control of diabetes in Korean adults ≥30 years of age.
METHODS:
Prevalent diabetes was defined as a fasting plasma glucose level ≥126 mg/dL, self-reported use of anti-diabetic treatment (insulin or oral anti-diabetic drugs), or diabetes diagnosis by a physician. Target levels were defined as glycosylated hemoglobin <6.5% or <7.0%, blood pressure <130/80 mmHg, and total cholesterol <200 mg/dL. All survey waves were age-standardized to the 2005 Korean census population.
RESULTS:
Diabetes prevalence increased from 9.6% in 2007-2009 to 10.8% in 2016-2017 (p<0.001). Impaired fasting glucose prevalence significantly increased in both genders and almost every age group. Diabetes awareness and glycemic control did not show an increasing trend; however, the treatment rate and proportion of people diagnosed with diabetes achieving target blood pressure and total cholesterol levels improved from 57.2% to 63.5% (p=0.008), from 41.1% to 53.2% (p<0.001), and from 65.0% to 78.0% (p<0.001), respectively.
CONCLUSIONS:
From 2007 to 2017, the prevalence of diabetes increased moderately in Korea, whereas the diabetes treatment rate and the proportion of people diagnosed with diabetes achieving target blood pressure and total cholesterol levels improved. However, awareness of diabetes and glycemic control require significant improvements. A national-level action plan is required to raise awareness about diabetes and prediabetes, with the goal of improving glycemic control and minimizing the occurrence of adverse health outcomes.

Original Article Incidence and predictors of tuberculosis among HIV-positive children at Adama Referral Hospital and Medical College, Oromia, Ethiopia: a retrospective follow-up study

Masino Tessu Beshir, Aklil Hailu Beyene, Kenean Getaneh Tlaye, Tefera Mulugeta Demelew Epidemiol Health. 2019;41:e2019028.

Original Article Effects of a cancer prevention education program on elementary school students’ knowledge, attitude, self-efficacy, and intentions in South Korea

Su Yeon Kye, Soon-Yong Hwang, Kyung Hee Oh, Jae Kwan Jun Epidemiol Health. 2019;41:e2019027.

Abstract: OBJECTIVES:
Tuberculosis (TB) is common in children with human immunodeficiency virus (HIV), but its effect on the survival of HIV-infected children is not well understood. Therefore, the aim of this study was to assess the incidence and predictors of active TB among HIV-positive children at Adama Referral Hospital and Medical College, Oromia, Ethiopia.
METHODS:
A retrospective study was conducted over 5 years using a checklist to gather data from 428 randomly selected pediatric patient charts. The checklist was adapted from the standardized antiretroviral therapy (ART) follow-up form currently used by the institution’s ART clinic. Data were analyzed by bivariate and multivariable analysis using Cox regression proportional hazards models, as appropriate. Survival was calculated and compared using the Kaplan-Meier and log-rank tests.
RESULTS:
Of the 466 charts reviewed, 428 patient records were included in the analysis. A total of 67 new TB cases were observed during the follow-up period. Hence, the incidence rate in this cohort was found to be 6.03 per 100 child-years of observation. A baseline hemoglobin level <10 g/dL (adjusted hazard ratio [aHR], 7.04; 95% confidence interval [CI], 1.03 to 48.15), moderate wasting (aHR, 2.86; 95% CI, 1.02 to 7.99), and not receiving isoniazid preventive therapy (aHR, 8.23; 95% CI, 2.11 to 32.06) were among the independent predictors of TB occurrence.
CONCLUSIONS:
The incidence of TB was high, particularly in pre-ART patients receiving chronic care for HIV. Close followup of HIV-positive children is crucial to protect them against the development of TB. Initiating isoniazid preventive therapy, averting malnutrition, and managing anemia are also of significant importance.

Abstract: OBJECTIVES:
Most children and adolescents have low levels of cancer knowledge and awareness, and infrequently engage in preventive behaviors. This study examined the effects of a short classroom-based intervention for cancer prevention on knowledge, attitude toward cancer preventability, self-efficacy, and behavioral intentions of fifth-grade elementary school students.
METHODS:
The study was based on a pre-post-follow-up, 2-group, quasi-experimental design. Participants in the intervention group attended two 40-minute sessions on cancer prevention education and watched a music video about cancer prevention, while participants in the control group were only exposed to the music video. Self-reported knowledge, attitude toward cancer preventability, self-efficacy, and behavioral intentions were assessed 1 week pre-intervention and post-intervention, as well as 3 months post-intervention.
RESULTS:
The 3-month post-intervention results revealed partial effects, indicating that the education intervention improved knowledge and attitudes toward cancer preventability; however, no effects were observed on self-efficacy and behavioral intentions 3 months after the intervention.
CONCLUSIONS:
Long-term regular booster sessions are required to improve not only social-cognitive factors, but also behavioral intentions, which could result in behavior changes promoting cancer prevention.

Original Article Severe complications of tramadol overdose in Iran

Paria Habibollahi, Alireza Garjani, Samad Shams Vahdati, Seyyed-Reza Sadat-Ebrahimi, et al. Epidemiol Health. 2019;41:e2019026.

Review A systematic review and meta-analysis of the genetic characterization of human echinococcosis in Iran, an endemic country

Abolghasem Siyadatpanah, Davood Anvari, Amir Emami Zeydi, Seyed Abdollah Hosseini, et al. Epidemiol Health. 2019;41:e2019024.

Abstract: OBJECTIVES:
Severe complications of tramadol overdose have been reported; however, few large-scale studies have investigated this issue. Therefore, this study aimed to explore the presentation and complications of tramadol overdose in patients admitted to an intoxication referral center in northwestern Iran.
METHODS:
Patients with tramadol overdose admitted to Sina Teaching Hospital in Tabriz, Iran during 2013-2017 were included. For each patient, the following data were collected: demographics, previous drug or medication overdose, whether the patient was in the process of quitting drug use, ingested dose of tramadol and co-ingestants, Glasgow Coma Scale (GCS) score, clinical symptoms at the time of admission, and admission characteristics. Serotonin toxicity was diagnosed in patients who fit the Hunter criteria. Multiple logistic regression was performed to identify variables associated with the incidence of severe complications of tramadol overdose.
RESULTS:
In total, 512 cases of tramadol overdose were evaluated, of which 359 patients were included, with a median age of 41 years (range, 16-69) and a median tramadol dose of 1,500 mg (range, 500-4,000). The most frequent complications associated with tramadol overdose were hypertension (38.4%), tachycardia (24.8%), and seizure (14.5%). No serotonin toxicity was detected in patients. Having a GCS score <15, having taken a tramadol dose of >1,000 mg, being in the process of quitting drug use, being 30-49 years old, and male sex were significantly related to the incidence of severe complications of tramadol overdose.
CONCLUSIONS:
Although seizure was prevalent among Iranian patients with tramadol poisoning, serotonin toxicity and cardiogenic shock were rare findings.

Abstract: Human echinococcosis is an infectious disease caused by tapeworms belonging to the species Echinococcus. This parasite has a worldwide distribution and is considered a neglected tropical disease by the World Health Organization. Due to the diversity of Echinococcus spp. hosts, as well as variation in geographical, climatic, and socio-ethnic conditions, the question of the strains or genotypes of Echinococcus spp. that are involved in human infections is important. The aim of this study was to provide a summary of the available data on genotypes of Echinococcus obtained from the Iranian population. Four international databases (PubMed, Scopus, Science Direct, and Web of Science) and 4 Persian databases (Magiran, Scientific Information Database, Iran Medex, and IranDoc) were searched for cross-sectional studies that reported the genotypes of Echinococcus spp. in human echinococcosis cases using molecular methods in Iran through July 2018. The Newcastle-Ottawa Scale was used to assess the quality of the selected studies. A total of 559 cases of human cystic echinococcosis were reported in the 21 included articles. The majority of cases belonged to genotype G1 (89.2%; 95% confidence interval [CI], 80.1 to 95.8), genotype G6 (8.2%; 95% CI, 2.8 to 15.9), and genotype G3 (2.3%; 95% CI, 1.1 to 3.9). Since genotype G1 of Echinococcus appears to be the most prevalent genotype affecting humans in Iran, disease control initiatives aimed at sheep intermediate hosts may be the most beneficial. In addition, educational programs and serological screening in individuals may help reduce the national impact of the disease.

Review Protective factors of marital stability in long-term marriage globally: a systematic review

Reza Karimi, Maryam Bakhtiyari, Abbas Masjedi Arani Epidemiol Health. 2019;41:e2019023.

Original Article Individual and regional factors associated with suicidal ideation among Korean elderly: a multilevel analysis of the Korea Community Health Survey

Sang Hee Jeong, Byung Chul Chun Epidemiol Health. 2019;41:e2019022.

Abstract: OBJECTIVES:
In recent decades, due to the high prevalence of divorce in numerous countries and the detrimental aftermath thereof, it has become increasingly important to study the components of marital stability. The current study explored fundamental protective factors in long-term marriage through a systematic review.
METHODS:
Searches for relevant publications were conducted in Embase, Web of Science, PubMed, Scopus, Science Direct, Magiran, and Scientific Information Database from their inception through January 30, 2019. Through the keyword search, 1,706 articles were found, of which 25 articles remained after screening based on the eligibility criteria.
RESULTS:
The extracted protective factors associated with marital stability in long-term marriage were classified as interpersonal and intrapersonal. Notable extracted factors included spirituality and religion, commitment, sexual relationship, communication, children, love and attachment, intimacy, and conflict resolution approach. These findings show that some aspects of relationships, such as commitment, act to preserve the pillars of marriage in critical situations, while other aspects, such as intimacy, help to construct marital identity and satisfaction.
CONCLUSIONS:
The identified components of marital stability are structures that enhance a couple’s identity and sense of togetherness. Identifying the specific aspects of marital relationships that contribute to marital stability may help specialists and researchers to target specific types of marital interaction that may enhance the happiness and longevity of relationships, thereby preventing avoidable divorces.

Abstract: OBJECTIVES:
This study aimed to identify the individual and regional characteristics that influence suicidal ideation among the Korean elderly population.
METHODS:
Using data collected from the 2013 Korea Community Health Survey, a multilevel analysis was performed to establish an understanding of individual behavioral patterns and regional influences on suicidal ideation.
RESULTS:
Among the 77,407 individuals sampled, 11,236 (14.5%) elderly people over 60 years of age experienced suicidal ideation. Among individual factors, age, frequency of communication with friends, religious activity, social activity, leisure activity, trust in neighbors, subjective stress level, depressive symptoms, and subjective health status were significantly associated with suicidal ideation. The results showed that the lower the regional deprivation level, the higher the suicidal ideation odds ratio. In terms of regional size, the most significant effects were found in rural areas.
CONCLUSIONS:
This study suggested that suicidal ideation in the elderly is associated with community factors, such as the regional deprivation index, as well as personal factors.

Review Congenital toxoplasmosis among Iranian neonates: a systematic review and meta-analysis

Shahabeddin Sarvi, Tooran Nayeri Chegeni, Mehdi Sharif, Mahbobeh Montazeri, et al. Epidemiol Health. 2019;41:e2019021.

Review Impact of pharmacist-led home medicines review services on drug-related problems among the elderly population: a systematic review

Sai Krishna Gudi, Ananth Kashyap, Manik Chhabra, Muhammed Rashid, et al. Epidemiol Health. 2019;41:e2019020.

Abstract: Toxoplasmosis is a serious zoonotic disease that can lead to abortion and congenital disorders and has a widespread global distribution in humans and animals. The objective of this review was to investigate the incidence of toxoplasmosis in Iranian neonates in order to obtain a comprehensive assessment of the overall situation of the disease for use in developing future interventions. Original studies investigating the incidence of Toxoplasma gondii infections in Iranian neonates were systematically searched in a number of English-language and Persian-language electronic databases. The search process resulted in the inclusion of a total of 11 studies in the systematic review, 10 of which were entered into the meta-analysis. The reviewed articles included 2,230 Iranian neonates investigated through January 1, 2018. Based on the retrieved studies, the overall weighted incidence rates of toxoplasmosis in the Iranian neonatal population and neonates with suspected congenital toxoplasmosis were estimated to be 0.64% (95% confidence interval [CI], 0.31 to 1.09) and 4.10% (95% CI, 2.68 to 5.77), respectively, using a fixed-effects model. The findings of the reviewed studies demonstrate that the incidence of toxoplasmosis is high in Iranian neonates. Accordingly, it can be concluded that toxoplasmosis is a serious public health concern that has been ignored by the Ministry of Health. Therefore, it is essential to perform further studies, in addition to implementing screening and detection programs, using standardized methods to estimate the incidence of toxoplasmosis in Iran and to determine its associated risk factors.

Abstract: OBJECTIVES:
To address and elucidate the impact of pharmacist-led home medicines review (HMR) services on identifying drug-related problems (DRPs) among the elderly population in home care settings.
METHODS:
A comprehensive systematic search was performed using electronic scientific databases such as PubMed, Scopus, Embase, and Web of Science for studies published between January 1, 2008 and December 31, 2018, pertaining to HMR services by pharmacists for identifying DRPs.
RESULTS:
In total, 4,292 studies were retrieved from the searches, of which 24 were excluded as duplicates. Titles and abstracts were screened for the remaining 4,268 studies, of which 4,239 were excluded due to the extraneous nature of the titles and/or abstracts. Subsequently, 29 full-text articles were assessed, and 19 were removed for lacking the outcome of interest and/or not satisfying the study’s inclusion criteria. Finally, 10 studies were included in the review; however, publication bias was not assessed, which is a limitation of this study. In all studies, pharmacists identified a highly significant amount of DRPs through HMR services. The most common types of DRPs were potential drug-drug interactions, serious adverse drug reactions, need for an additional drug, inappropriate medication use, non-adherence, untreated indications, excessive doses, and usage of expired medications.
CONCLUSIONS:
HMR is a novel extended role played by pharmacists. The efficiency of such programs in identifying and resolving DRPs could minimize patients’ health-related costs and burden, thereby enhancing the quality of life and well-being among the elderly.

Original Article Health behaviors and health status of Korean middleaged men by marital status: Korea Community Health Study, 2015

Yongho Jee, Youngtae Cho Epidemiol Health. 2019;41:e2019019.

Original Article Associations between socioeconomic status and blood cadmium levels in Korea

Yongho Jee, Sung-il Cho Epidemiol Health. 2019;41:e2019018.

Abstract: OBJECTIVES:
Previous studies have shown that marital status is associated with household composition and living arrangements, which partially explain observed differences in health status according to marital status. However, due to the rapid socioeconomic and demographic transformations of the last few decades, the distribution of marital status among middle-aged adults has become more diverse. Therefore, this study aimed to obtain up-to-date information on the associations between marital status and health and to investigate the implications of these findings for conventional explanations of the health effects of marriage.
METHODS:
The data for this study were obtained from the 2015 Korean Community Health Study. We compared 4 modifiable lifestyle behaviors—smoking, alcohol consumption, physical activity, and self-rated health status—as outcome variables in association with marital status in Korean middle-aged men (age 40-44) living in Seoul and other regions.
RESULTS:
Married men showed the lowest cigarette smoking prevalence and the highest subjective health status both before and after adjusting for education and income. The odds of engaging in vigorous physical activity did not show a major difference before and after adjustment for income and education.
CONCLUSIONS:
In married men, the prevalence of cigarette smoking was lowest and subjective health status was highest, similar to previous studies. However, the prevalence of engaging in physical activity was highest in divorced/widowed/separated men. The health behaviors and health status of Korean middle-aged adults should be more closely followed, since they are representative of demographic changes in the Korean population.

Abstract: OBJECTIVES:
Although smoking is associated with both low socioeconomic status and blood cadmium (Cd) levels, the association between socioeconomic status and Cd levels remains unclear. Therefore, our study aimed to examine this association and to clarify whether smoking is a confounding or mediating variable in this relationship.
METHODS:
Data (n=7,734) were drawn from the Korea National Health and Nutrition Examination Survey (KNHANES, 2008- 2011), including years that contained data on blood Cd and urinary cotinine levels. We investigated the associations of income, education, and occupation with blood Cd levels. Smoking was investigated by categorizing participants by smoking status (never, former, and current) and pack-years into quartiles. The weekly frequency of rice and barley intake was analyzed to gain insights into participants’ dietary patterns. Additionally, urinary cotinine levels were used to ensure the validity of the smoking variables.
RESULTS:
Participants earning a low income and with less formal education had higher blood Cd levels. After controlling for smoking, the association between income and Cd levels substantially weakened. Further controlling for education, the association between income and Cd levels disappeared. However, there was a strong negative association between education and Cd levels, even after controlling for smoking history, pack-years, and urinary cotinine levels.
CONCLUSIONS:
In cross-sectional data from the KNHANES, blood Cd levels were significantly higher among those with a low income and less formal education. Smoking history contributed to, but did not fully explain, these associations.

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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