Epidemiology of Hepatitis C Virus in the Arabian Gulf Countries: Systematic Review & Meta-Analysis of Prevalence

HIGHLIGHTS

• HCV prevalence is at around 1% in the Arabian Gulf region.
• Higher prevalence in expatriate populations reflects prevalence in origin countries.
• Evidence of ongoing HCV transmission through exposures linked to medical settings.
• Injecting drug use does not appear to be the dominant contributor to HCV incidence.

OBJECTIVE:

To systematically review and synthesize epidemiological data on hepatitis C virus (HCV) in the Arabian Gulf countries, and assess the country-specific prevalence among nationals and expatriate populations.

METHODS:

We conducted a systematic review of HCV antibody prevalence and incidence in the Arabian Gulf countries based on the items outlined in the PRISMA statement. Meta-analyses were conducted incorporating inverse variance weighting and using a random-effects model to pool summary estimates of HCV prevalence among general population groups, for nationals and the entire resident population.

RESULTS:

We identified 557 prevalence measures and one incidence measure in the Arabian Gulf countries. 

HCV prevalence among nationals was 0.24% in the United Arab Emirates (UAE), 0.44% in Kuwait, 0.51% in Qatar, and 1.65% in Saudi Arabia. No data was available for Bahrain and Oman. Among the entire resident populations, HCV prevalence was 0.30% in Bahrain, 0.41% in Oman, 1.06% in Qatar, 1.45% in Kuwait, 1.63% in Saudi Arabia, and 1.64% in UAE. Higher prevalence was observed among expatriate populations such as Egyptians. Among high risk populations, HCV prevalence was as high as 78.6% in the multi-transfused and 74.6% in people who inject drugs.

CONCLUSIONS:

National-level HCV prevalence in the Arabian Gulf region is comparable to global levels. Higher prevalence is found in specific expatriate populations reflecting the prevalence in their countries of origin. Most exposures appear to occur in high risk groups and are often linked to medical care.

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By:  Mohamoud YA1, Riome S1, Abu-Raddad LJ2.

• 1Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar.
• 2Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar; Department of Healthcare Policy and Research, Weill Cornell Medical College, Cornell University, New York, New York, USA; College of Public Health, Hamad bin Khalifa University, Qatar Foundation, Education City, Doha, Qatar. Electronic address: lja2002@qatar-med.cornell.edu.
• Int J Infect Dis. 2016 Mar 17. pii: S1201-9712(16)30999-7. doi: 10.1016/j.ijid.2016.03.012.

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Attitude of Saudi Arabian Adults Towards Consanguineous Marriage

Background: 

Research on the attitudes of Saudi adults towards consanguinity is scarce. The study aimed to explore the attitudes towards consanguinity and its associations with socio-demographic characteristics in a sample of Saudi adults.

Methods: 

A cross-sectional study was conducted using a self-administered questionnaire. A total of 386 outpatient waiting-area attendees at King Abdul-Aziz Medical City-Riyadh were included. Participants were asked about their socio-demographic characteristics, attitude towards consanguinity and the reasons behind this.

Results: 

The positive attitude towards consanguinity among the study respondents was 48.1% with 95% confidence interval (42.91–53.33%). Social and traditional culture (59.9%) were found to be the predominant reasons for favoring consanguinity in Saudi Arabia. Evidence against a positive attitude towards consanguinity was noted in respondents who received medical information about consanguinity versus those who had not received medical information (42.3% vs. 57%, p-value = 0.008). According to the multivariate logistic model, the odds of a positive attitude towards consanguinity were 2 times higher for males (adjusted odds ratio [aOR]: 2.2; 95% CI: 1.147, 4.290) and 4.1 times higher in respondents in consanguineous marriages (aOR: 4.1; 95% CI: 2.350, 7.156). The odds of a positive attitude towards consanguinity were 50% less in respondents who received health information on consanguinity compared to those who had not received health information about consanguinity (aOR: 0.50; 95% CI: 0.253, 0.863).

Conclusion: 

One in every two Saudi adults favors consanguinity however, Saudi men and women differ in their attitudes towards consanguinity. Receiving health information on consanguinity was associated with a negative attitude towards this practice.

...Consanguinity is a worldwide issue, but particularly so in the Middle East. Saudi Arabia was ranked as the second highest Arab country to have a high frequency of consanguineous marriage, with the prevalence varying in different studies from 22–55%.² Exploring the attitude towards consanguineous marriages and its health-related issues among Saudis is an attempt to clarify such a problem and suggest some solutions. In this study, the positive attitude towards consanguinity among the respondents was high, with approximately half of the respondents having a positive attitude towards consanguinity...

Full article at:   http://goo.gl/P3wxM1

By:  Omar A. Alharbi, 1 Walaa A. Al-Shaia, 2 Abdulaziz A. Al-Hamam, 3 Hala M. Al-Marzoug, 4 Anwar E. Ahmed, 5 andMuhammed Bagha 6

¹College of Medicine, King Saud University, Riyadh, Saudi Arabia

²College of Applied Medical Sciences, University of Dammam, Dammam, Saudi Arabia

³College of Medicine, King Faisal University, Al Ahsaa, Saudi Arabia

⁴College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

⁵College of Public Health and Health Informatics, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

⁶King Abdullah Specialist Children Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia

E-mail: as.dem.ahgn@nademha; Email: ude.ucv@5ademha

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8 Depressing/Uplifting Things We Learned About Women This Year

Via:   http://goo.gl/QuVg5q 

Hepatitis C Virus and HIV Infections among People Who Inject Drugs in the Middle East and North Africa: A Neglected Public Health Burden?

People who inject drugs (PWID) are a key population at risk of hepatitis C virus (HCV) and HIV infections. Globally, 63% of PWID are HCV infected [1, 2] and 19% are HIV infected [2], leading to an estimated 10 million and 3 million HCV- and HIV-infected PWID, respectively [1–3]. The Middle East and North Africa (MENA), a region comprising 23 countries from Morocco in the West to Pakistan in the East, is at the centre of major drug production and trade, creating a context of vulnerability to injecting drug use [4]. PWID in MENA are a large, mostly young and stigmatized population experiencing a substantial HCV and HIV burden, with potential for even further HIV epidemic growth. Yet, they lack access to comprehensive and confidential HCV and HIV testing, prevention and treatment services.

Below:  Median HCV prevalence among people who inject drugs in the Middle East and North Africa as per available studies [6]. Error bars represent the lower and upper bounds of the interquartile range if more than one data point was available per country.

Full article at:   http://goo.gl/qK72Up

By:   Ghina R Mumtaz,§,1,2 Helen A Weiss,3 and Laith J Abu-Raddad1,4

¹Infectious Disease Epidemiology Group, Weill Cornell Medical College – Qatar, Cornell University, Qatar Foundation – Education City, Doha, Qatar

²Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom

³MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom

⁴Department of Healthcare Policy and Research, Weill Cornell Medical College, Cornell University, New York, NY, USA

^§Corresponding author: Ghina R Mumtaz, Infectious Disease Epidemiology Group, Weill Cornell Medical College – Qatar, Cornell University, Qatar Foundation – Education City, P.O. Box 24144, Doha, Qatar. Tel: +(974) 4492 8406. Fax: +(974) 4492 8422. (Email:ude.llenroc.dem-rataq@6002mig) 

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Prevalence of Seven Sexually Transmitted Organisms by Multiplex Real-Time PCR in Fallopian Tube Specimens Collected from Saudi Women With & Without Ectopic Pregnancy

BACKGROUND:

Ectopic pregnancy (EP) is associated with maternal morbidity and occasionally mortality during the first trimester. A history of sexually transmitted infection (STI) and pelvic inflammatory disease have been implicated as major risk factors for EP. Our aim was to measure the prevalence of Chlamydia trachomatis (CT), Neisseria gonorrhoeae, Mycoplasma genitalium (MG), Ureaplasma parvum/urealyticum, Gardnerella vaginalis, Trichomonas vaginalis and herpes simplex virus (HSV)-1&2 in Fallopian tubes collected from EP and the results were compared with those obtained from total abdominal hysterectomy (TAH) and tubal ligation.

METHODS:

This was a prospective case-control study and tubal samples were collected from 135 Saudi women recruited from 3 centres in the Western region as follow: 84 EPs, 20 TAH and 31 tubal ligations. Multiplex TaqMan PCR was performed using an IVD CE kit for the simultaneous detection of candidate pathogens following DNA extraction.

RESULTS:

Infections were detected in 31.8 % of the 135 participants either as single (11.1 %) or co-infections (20.7 %) and the frequencies were significantly higher in EP (42.85 %) compared with control (13.72 %). The rates of CT (27.4 %; P = 0.001); MG (20.2 %; P = 0.009) and HSV-1/2 (21.4 %; P = 0.01) were significantly higher in EP. No significant difference between the study groups was observed for the other pathogens (P > 0.05). Binary logistic regression also showed that infection with ≥ 2 pathogens (OR 4.9; 95 % CI: 2.2 - 11.6; P = 0.006), CT (OR 3.07; 95 % CI: 1.3 - 12.3; P = 0.002), MG (OR 2.3; 95 % CI: 1.1 - 8.6; P = 0.03) and HSV-1/2 (OR 1.7; 95 % CI: 0.75 - 5.7; P = 0.004) were associated with a significantly higher risk of developing EP.

CONCLUSIONS:

STIs are frequent in the upper genital tract of Saudi women during the reproductive age and, CT, MG and HSV-1/2 were more prevalent in EP. The observed high rates of co-infection advocate the necessity of establishing national guidelines and/or screening program utilising multiplex PCR approach for the detection of common STIs among high risk groups in the kingdom. Further studies are needed to measure the adverse reproductive outcomes associated with STIs in Saudi Arabia.

Table 1

Principle inclusion and exclusion criteria for the study groups

Control group		Case group
Inclusion criteria	Exclusion criteria	Inclusion criteria	Exclusion criteria
Saudi	Non-Saudi	Saudi	Non-Saudi
Patient age ≥ 18 and ≤ 42 years.	Patient age < 18 or > 42 years.	Patient age ≥ 18 and < 40 years.	Patient age < 18 or > 40 years.
Cyclic women with a history of previous intrauterine pregnancy and no history of hydrosalpinx or ectopic pregnancy	Women with abnormal menstrual cycle, history of infertility treatment, history of PID, endometriosis and previous ectopic pregnancy.	Ectopic pregnancy following spontaneous conception	Ectopic pregnancy following assisted conception, using IUD, History/symptoms of urogenital infection (e.g. vaginal discharge, dysuria, PID, etc.)
Clinical decision to undertake total abdominal hysterectomy (TAH) for benign disease not affecting the Fallopian tubes and endometrium	Vaginal or subtotal hysterectomy	Singleton pregnancy	Multiple/heterotopic pregnancy
Clinical decision to undertake tubal ligation for sterilisation	Use of IUD ≤ 1 year prior to operation	Clinical determination that the patient is haemodynamically stable	Symptoms and signs of hypovolemia

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By:   Ashshi AM1, Batwa SA2, Kutbi SY3, Malibary FA4, Batwa M5, Refaat B6.

• 1Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Al Abdeyah, Makkah, PO Box 7607, KSA. aashshi@yhaoo.com.
• 2Obstertics and Gynaecology Department, Maternity and Children Hospital, Al-Aziziyah, Jeddah, KSA. sarahbatwa@hotmail.com.
• 3Obstertics and Gynaecology Department, Maternity and Children Hospital, Al-Aziziyah, Jeddah, KSA. seham.alkutbi@yahoo.com.
• 4Obstertics and Gynaecology Department, Maternity and Children Hospital, Al-Aziziyah, Jeddah, KSA. fzmilly12345@gmail.com.
• 5Al-Thager General Hospital, Jeddah, KSA. mbatwa@hotmail.com.
• 6Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Al Abdeyah, Makkah, PO Box 7607, KSA. bassem.refaat@yahoo.co.uk. 

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Violence Against Wives: A Silent Suffering in Northern Saudi Community

Violence against women is a worldwide epidemic. It may take different forms depending on history, culture, background, and experiences, but it causes great suffering for women, their families, and the communities in which they live. Despite its high prevalence, no previous studies that have been conducted in Arar, northern area of Kingdom of Saudi Arabia (KSA), addressing this issue could be traced.

The aim of this study was to measure the prevalence and determinants of violence experienced by ever-married women attending primary health centers in Arar city, Northern Border, KSA.

This study is a cross-sectional study conducted during the period from January to June 2014 in Arar city in the Northern Province of the KSA. Data were collected through an interviewer-administered questionnaire. A total of 208 wives (184 currently married, 16 divorced, and eight widowed) attending five randomly selected primary healthcare centers in Arar, KSA, were interviewed. Collected data provided information on both physical and emotional violence.

The study revealed that the overall prevalence of domestic violence in the studied group was 80.7 and 100.0% for physical and psychological violence, respectively. On studying the reasons for physical violence, half (50%) of the participants reported no clear cause, 19.2% reported failure to adequately care for children (such as cleaning, feeding, and dressing), and 7.8% reported causes related to poor scholastic achievement and couple conflict about appropriate approaches of upbringing of children. Suspicion on wife's fidelity was the most common form of psychological violence (21%). The perpetrator was the husband in 76.9% of cases and the husband's family was the perpetrator in 3.8% of cases. Physical violence was significantly higher during the first 10 years of marriage compared with other durations. University-educated husbands showed significantly lower percentage of physical violence against women compared with those of other educational levels.

Violence against women was highly prevalent in Arar city. Inadequate care of children and poor scholastic achievement were the most common reasons of physical violence, whereas financial conflicts and suspicion of wife's fidelity were the most common reasons for psychological violence. We recommend awareness programs aiming at educating current and future couples, and proper training of healthcare providers for assisting cases experiencing violence against women.

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By:  Abo-Elfetoh NM1, Abd El-Mawgod MM.

• 1Public Health and Community Medicine Department, Faculty of Medicine, Sohag University, Sohag b Public Health and Community Medicine Department, Faculty of Medicine, Al-Azhar University, Assiut, Egypt c Public Health and Community Medicine Department, Faculty of Medicine and Applied Medical Sciences, Northern Border University, Arar, Kingdom of Saudi Arabia.

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Human Immunodeficiency Virus & Viral Hepatitis among High-Risk Groups: Understanding the Knowledge Gap in the Middle East & North Africa Region

To identify gaps in the existing knowledge on single, dual and triple infections of human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) in the Middle East and North Africa (MENA) region among men who have sex with men (MSMs), female sex workers (FSWs), injecting drug users (IDUs) and prisoners.

We performed an extensive literature search on articles published on the topic in the 25 countries of the MENA region. PubMed database was used as the main search engine. Case reports, case series, qualitative studies, editorials, commentaries, authors’ replies and animal studies were excluded. Original articles and reviews dealing with the prevalence of HIV, HBV and HCV and their co-infection were included. Data on population type, sample size, age and markers of infections were extracted from the relevant studies.

HIV, HBV and HCV are blood-borne viruses with similar modes of transmission. The categories of people at high risk of acquiring HIV-1, HBV and HCV commonly include: MSMs, FSW and IDUs. It is well established that HIV-positive individuals co-infected with HBV or HCV suffer from liver pathology associated with morbidity and mortality. Moreover, HIV-infected individuals do not respond well to treatment for HBV or HCV and hence are at increased risk of hepatic toxicity. Consequently, co-infection of HIV-positive individuals with HBV and/or HCV is a global health problem of significant magnitude. Our review reveals the paucity of epidemiological data for key populations in many countries of the region. Limited number of studies exists in the MENA region on the status of HIV, HBV and HCV and their co-infections among prisoners, MSMs and FSWs. Evidence support the continued increase of the HIV epidemic among MSMs. In addition to the lack of studies on MSMs and FSWs in the MENA region, our review highlights the lack of data on the practices, characteristics, or the status of HIV infection and viral hepatitis among male sex workers selling or exchanging sex for money.

The MENA countries are in urgent need of advanced research and strengthening of the data collection systems and reporting practices of these infections among key populations.

Table 1

Human immunodeficiency virus, hepatitis B virus and hepatitis C virus and their co-infection status among prisoners from Middle East and North Africa countries between 2005 and 2015

Country	n	Mean age/age	HIV (%)	HBV (%)	HCV (%)	HIV-HBV co-infection (%)	HIV-HCV co-infection (%)	Triple infection (%)	Ref.
Egypt	500	41.0	0.0	9.8	15.8	0.0	0.0	0.0	[14]
Iran	160	16.6	0.6	0.6	NS	0.0	NS	NS	[15]
	392a	35.9	17.0	4.5	80.5	0.8	14.5	0.8	[16]
	358b	34.7	0.0	6.1	8.1	0.0	0.0	0.0	[17]
	163	34.5	0.0	7.4	7.4	0.0	0.0	0.0	[18]
	249a	35.4	15.1	4.7	64.8	1.1	14.3	1.1	[19]
	150a	31.4	42.5	18.9	75.9	NR	NR	NR	[20]
Lebanon	580	31.7	0.2	2.4	3.4	0.0	0.0	0.0	[21]
Libya	6371	> 16	18.2	6.9	23.7	NR	NR	1.5	[22]

aAmong prisoners who inject drugs;

bDrug-related convictions; n: Sample size; NR: Not reported; NS: Not studied. All numbers were rounded to the nearest 1. HIV: Human immunodeficiency virus; HBV: Hepatitis B virus; HCV: Hepatitis C virus.

Table 2

Human immunodeficiency virus, hepatitis B virus and hepatitis C virus and their co-infection status among female sex workers and men who have sex with men in Middle East and North Africa countries between 2005 and 2015

Country	n	Mean age/age	HIV (%)	HBV (%)	HCV (%)	HIV-HBV co-infection (%)	HIV-HCV co-infection (%)	Triple infection (%)	Ref.
FSWs
Lebanon	103a	≥ 18	0.0	0.0	0.0	0.0	0.0	0.0	[23]
Libya	69a	≥ 15	10.1	2.9	7.2	0.0	4.3	0.0	[24]
Turkey	130	38.9	0.0	3.1	0.8	0.0	0.0	0.0	[25]
MSM
Lebanon	101a	≥ 18	1.0	1.0	0.0	0.0	0.0	0.0	[23]
Libya	227a	≥ 15	5.3	3.1	8.4	0.0	4.4	0.0	[24]

aNon-adjusted prevalence using respondent-driven sampling method. All numbers were rounded to the nearest 1. HIV: Human immunodeficiency virus; HBV: Hepatitis B virus; HCV: Hepatitis C virus.

Table 3

Human immunodeficiency virus, hepatitis B virus and hepatitis C virus and their co-infection status among injecting drug users in Middle East and North Africa countries between 2005 and 2015

Country	n	Mean age/age	HIV (%)	HBV (%)	HCV (%)	HIV-HBV co-infection (%)	HIV-HCV co-infection (%)	Triple infection (%)	Ref.
Cyprus	40	25-31	0.0	0.0	50.0	0.0	0.0	0.0	[27]
Iran	202	-	NR	NS	52.0	NS	9.4	NS	[28]
	417	≥ 17	24.4	NS	80.0	NS	24.0	NS	[29]
	258	28.8	18.8	NS	65.9	NS	NR	NS	[30]
	233	32.3	7.7	22.7	40.3	4.7	6.4	4.7	[31]
	117a	< 30	0.7	0.7	59.0	0.0	0.0	0.0	[32]
	899	33.9	10.7	50.7	34.5	7.8	8.7	6.5	[33]
	100	17-58	19.0	6.0	56.0	NR	15.0	5.0	[34]
	268	37.0	10.8	6.0	39.2	NR	NR	NR	[35]
	153	30.7	5.9	22.9	59.5	2.0	5.2	1.3	[36]
	539	35.3	NR	NR	NR	0.0	1.1	NR	[37]
	200	36.5	1.5	4.5	12.0	0.0	0.0	0.0	[38]
	1327	26.5	20.2	NS	13.5	NS	NR	NS	[39]
	518	35.2	15.5	3.7	69.5	0.6	11.2	0.6	[16]
Israel	743	33.8	1.9	8.6	69.3	NR	NR	NR	[40]
Lebanon	106a	≥ 18	0.9	2.8	52.8	0.0	0.0	0.0	[44]
Libya	328a	≥ 15	87.1	4.5	94.2	4.2	83.2	NR	[41]
Palestine	192	41.3	0.0	2.6	43.8	0.0	0.0	0.0	[42]
Saudi Arabia	297	31.0	0.7	6.1	37.7	NR	NR	NR	[43]

aEstimated prevalence using respondent-driven sampling method. All numbers were rounded to the nearest 1. n: Sample size; NR: Not reported; NS: Not studied; HIV: Human immunodeficiency virus; HBV: Hepatitis B virus; HCV: Hepatitis C virus.

Table 4

Human immunodeficiency virus, hepatitis B virus and hepatitis C virus and their co-infection status among different populations from Middle East and North Africa countries between 2005 and 2015

Country	n	Mean age/age	HIV (%)	HBV (%)	HCV (%)	HIV-HBV co-infection (%)	HIV-HCV co-infection (%)	Triple infection (%)	Ref.
HIV infected individuals
Iran	64	-	-	-	-	18.8	NS	NS	[49]
	168	38.7	-	-	-	NS	87.5	NS	[50]
	1338	32-42	-	-	-	NS	78.0	NS	[51]
	106	36.6	-	-	-	20.8	67.0	NR	[52]
	80	37.0	-	-	-	11.3	33.8	25.0	[53]
	130	50.2	-	-	-	11.5	77.0	9.2	[54]
	391	-	-	-	-	14.5	72.0	7.9	[55]
	201	36.0	-	-	-	44.3	67.2	36.3	[56]
	1444	38.4	-	-	-	NS	78.4	NS	[57]
Morocco	503	39.0	-	-	-	29.4	5.4	NR	[58]
Sudan	358	35.0	-	-	-	26.8	NS	NS	[59]
Turkey	949	37.9	-	-	-	0.0	0.9	0.0	[60]
Blood donors
Cyprus	5057	34.5	0.0	3.0	0.5	0.0	0.0	0.0	[61]
Iran	6499851	-	< 0.1	0.6	0.1	NR	NR	NR	[62]
	2026628	38.0	< 0.1	0.4	0.1	NR	NR	NR	[63]
UAE	592	-	1.2	67.2	31.6	NR	NR	NR	[64]
Others
Cyprus
Soldiers	12488	34.5	0.0	2.2	0.5	0.0	0.0	0.0	[61]
Iran
HBV patients	264	41.6	0.4	-	4.5	0.4	NR	NR	[65]
HIV infected patients’ partners	168	33.2	NR	NS	NR	NS	9.5	NS	[50]
Non-injecting drug users	336	28.5	1.5	5.6	4.5	1.2	0.9	0.9	[31]
Referral from behavioral counseling center	379	29.7	4.0	2.9	35.6	0.8	3.4	0.3	[66]
Libya
General Population	9170	34.0	0.2	3.7	0.9	< 0.1	0.1	< 0.1	[67]
Medical waste handlers	300	-	0.0	2.3	2.7	0.0	0.0	0.0	[68]
Non-Medical waste handlers	300	-	0.0	0.3	0.0	0.0	0.0	0.0	[68]
Turkey
ER patients	1000	51.7	0.0	5.0	1.8	0.0	0.0	0.0	[69]
In and out-patients	97000-225000	-	0.3	33.9	1.2	NR	NR	NR	[70]

All number were rounded to the nearest 1. n: Sample size; NR: Not reported; NS: Not studied; HIV: Human immunodeficiency virus; HBV: Hepatitis B virus; HCV: Hepatitis C virus.

Full article at:  http://goo.gl/FW5TbL

  

By:  Nada M Melhem, Nour Rahhal, Rana Charide, Khalil Kreidieh, and Rolla El-Khatib

Nada M Melhem, Khalil Kreidieh, Rolla El-Khatib, Medical Laboratory Sciences Program, Faculty of Health Sciences, American University of Beirut, Beirut 1107-2020, Lebanon

Nour Rahhal, Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut 1107-2020, Lebanon

Rana Charide, Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut 1107-2020, Lebanon

Author contributions: Melhem NM designed and wrote the paper; Rahhal N, Charide R and Kreidieh K reviewed the literature, prepared the tables and contributed to the write-up; El-Khatib R critically read the manuscript.

Correspondence to: Nada M Melhem, PhD, Assistant Professor of Infectious Diseases, Medical Laboratory Sciences Program, Faculty of Health Sciences, American University of Beirut, 325 Van Dyck Hall, 11-0236 Riad El Solh, Beirut 1107-2020, Lebanon. bl.ude.bua@nmehlem

Telephone: +961-1-350000-4699 Fax: +961-1-744470

 

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