This is a cross sectional descriptive community-based study. The aim was to assess the prevalence of anaemia among quranic schoolchildren in khalawi Wad EL Magboul village, rural Rufaa, Gezira State, central Sudan.A sample of 180 male participants were included in the study. Informed consent was obtained. Venous blood samples were obtained to measure the hematological parameters and blood films for malaria parasites. Urine and stool analyses were also done. Data were analyzed using SPSS.The mean age of participants was 12.31 years (SD +/- 2.26). The mean Hb value was 11.75g/dl and it was statistically significant correlation when compared with the mean Hb reference value (13.5g/dl) P value 0,000 (95% CI). Regarding period of stay in the khalwa up to the time of the study, 88 (49.28%) for one year, 54 (30.24%) for 2 years, 22 (12.32%) for 3 years and 16 (8.96%) for more than 3 years. About 77 students (42.78%) were pale on clinical examination. The Mean Cell Hemoglobin (MCH) mean value was 25.58 pg ( 3.55). Many conditions known to be associated with anemia were found; 49 students (27.2%) had a positive blood films for falciparum malaria, 14 students (7.8%) were found to have haematuria and ova of S. haematobium, In169 students (93.4%) stool examination was negative , while 11 students (6.6%) had intestinal worms (Enterobius vermicularis).Majority of the study participants had iron deficiency anaemia, followed by haemolytic, macrocytic and sickle cell anaemia. This might have negative health and educational implications. Khalawi  are traditional religious schools, they are very popular in Sudan. The Khalawi (Quran Schools) and Maseeds (Mosques) played and are still playing great roles in designing the consciences of the people of Sudan. They were the available institutions where people learnt teachings of Islam as well as the formal education. Most of them were established by Shiekhs and well-wishers. That distinguish those institutions is that most of them were established in remote and isolated spots of land where no one wanted to live. The idea behind that choice was that those pious men wanted quiet and calm areas so that they could devote most of their time for worshiping and learning. As time passed, those remote and holy places turned into towns and cities . KhalawiAnaemia is defined as a reduction in the haemoglobin concentration of the blood below normal for age and sex. It is the most common disorder of the blood. However, it can include decreased- oxygen binding ability of each haemoglobin molecule due to deformity or lack in numerical development as in some other types of haemoglobin deficiency. Anaemia is a public health problem that affects populations in both developing and developed countries. Its primary cause is iron deficiency, but a number of other conditions, such as malaria, parasitic infestation, other nutritional deficiencies, and haemoglobinopathies are also responsible, often in combination. It occurs with major consequences for human health as well as social and economic development, and it is an indicator of both poor nutrition and poor health. Measuring Hb is frequently used as a proxy indicator of iron deficiency. The World Health Organization (WHO) has suggested levels of haemoglobin below which anaemia is said to be present. These levels are < 11g/dL (110 g/L) in children aged 1-2 years and < 11.2g/dL (112g/L) in children aged 3-5 years and less than 13.5g/dl in children aged 6-12 years.Khalawi students are a heterogeneous group with different ethnic and sociocultural backgrounds. This study will open up a venue for other health-related studies to explore and evaluate such learning environment. There are many such khalawi in Sudan which might benefit from this study. The general objective was to determine the prevalence of anaemia among Quranic school students in Wad El Magboul Khalawa in Eastern Gezira state in the period from December 2012 - July 2013. The specific objectives were to: determine the prevalence of anaemia among; identify the common types of anaemia; identify the mean Hb level; identify the possible common cause(s) of anaemia among the study group.Study design: A cross-sectional analytical community based study.Study area: The study was carried out in Gezira state, Wad EL Magboul village, Quranic schools . Wad EL Magboul is a small village about 15 km to the south east of Rufaa town. Wad EL Magboul Khalawi are considered as one of the popular Khalawi, not only in Gezira state, but also in Sudan because the students or (Heiran) usually come from different places of Sudan. The Khalawi hostels consist of 15 rooms, each room contains from 5 - 10 students being from the same area or region. From 1925 to 1960 these Khalawi were built in Al dweneeb village where several small Khalawi were branched from there and since 1960 the Khalawi were transferred to Wad EL Magboul in Rufaa rural locality where the current Khalawi are now exist. from different places and of different ages. Two diets meals are served, breakfast and dinner which are made mainly from dura porridge (Assida) with a curry made from lentils or beans.Study Population: Quranic school students (Heiran) studying in Khalawi Wad El Magboul. The total number of students (Heiran) at the time of the study was about 180 students.Inclusion criteria: Being male, any student in Khalawi Wad El Magboul lived at least for one year, age between 8 to 18 years.Exclusion criteria: Students living at home but studying in khalawi Wad El Magboul; Those who are receiving treatment to any type of anaemia or taking hematinics as prophylaxis; Any student more than 18 years or less than 8 years old; Those who lived for less than a year.Sampling : A comprehensive convenient sampling method  was adopted. A total of 180 quranic male students (Heiran) were studied.Blood samples taking and preparations: All the 180 students were screened for complete blood count (CBC); peripheral blood smears and reticulocyte count. They also were screened for serum ferritin, BFFM, urine and stool analysis. This analysis was conducted at the medical laboratory, faculty of medicine, university of Gezira, departments of haematology and microbiology. 5 ml of venous blood sample were collected from an antecubital vein by a 5ml syringe from each student and divided in EDTA and plain tubes to perform CBC, peripheral blood smears, reticulocyte count, thick film for malaria and serum ferritin level. The site of collection was cleaned using 70% alcohol and left to dry. An elastic tourniquet was applied to the arm for a period not exceeding one minute to avoid haemoconcentration. 2.5 ml of blood was taken into a container with 0.05ml (K2 EDTA) as an anticoagulant with a concentration of 1.5- 2.2 mg/ml and then the sample gently mixed. 2 ml of blood was delivered in a plain tube, after clot, and then centrifuged; the serum was taken to another plain tube to perform serum ferritin level. Urine and stool samples were also taken in appropriate plastic containers to perform urine and stool analysis. The blood samples were tested within 2 hours of sample collection using an automated blood cell counters  with a flow cytometry using a laser light to perform full blood count: white blood cell counts (WBCs), red blood cell counts (RBCs), haemoglobin concentration (Hb), hematocrit (Hct), mean corpuscular volume(MCV) , mean corpuscular haemoglobin (MCH) , mean corpuscular haemoglobin concentration (MCHC), and platelet counts (PLTs). It is calibrated by a standardized commercially prepared calibrators. The World Health Organization (WHO) has suggested levels of haemoglobin below which anaemia is said to be present. These levels are < 11g/dL (110 g/L) in children aged 1-2 years and < 11.2g/dL (112g/L) in children aged 3-5 years and less than 13.5g/dl in children aged 6-12 years [Making a blood film: Preparation of thin blood films was performed. The frosted glass slides were cleaned free of grease. A drop of blood was placed near frosted end of the slide and a cover glass spreader was applied at an angle of 45 degrees, in front of the drop of blood, and moved making a thin blood film and was then allowed to dry. Then they were labeled with the participant’s number and date of sample collection. The films were then fixed in absolute methanol for 10- 20 minutes. The films were placed horizontally on the staining rack and flooded with Leishman's stain and left for 5 minutes. A double volume of buffer 7.2 was added with gentle blowing over the surface without touching the film surface. The films were left for another 8 minutes and then washed off with buffered 7.2. The back of the slide was cleaned using cotton dipped in alcohol and then left to dry. The same method of preparing the blood film for red cell morphology is used for preparing films for reticulocyte count but the stain used here was methylene blue: 2 or 3 drops of the dye solution were delivered into a 75 x 10 mm plastic tube by means of a plastic Pasteur pipette. 2-4 volumes of the patient’s EDTA-anticoagulated blood were added to the dye solution and mixed. The mixture was kept at 37°C for 15-20 min. The red cells were resuspended by gentle mixing and films were spread on glass slides in the usual way, then they were examined when dried without fixing or counterstaining. An area of film was chosen for the count where the cells are undistorted and where the staining is good. The x100 oil-immersion objective lens was used to count the cells. At least 100 reticulocytes had been counted and at least 10 fields were examined to determine the average number of red cells per field.Examination of the blood films: The identification of the specimen was checked and matched with the corresponding full blood count (FBC) form. The films were examined macroscopically to confirm adequate spreading followed by microscopic examination. A low power field (10 objective) was used to assess the quality of the stain and a (40 objective) to determine the suitable area for blood film examination. The differential white blood counts were performed manually using the oil emersion lens. At least one 100 cells were examined. The manual differential white blood cells were compared with the automated differential white blood cells. The morphology of the red cells regarding the staining character, shape, size of the cells and the presence of nucleated red blood cells was recorded. The platelets were examined and estimation of their number, size, morphology and presence of aggregates were commented on.Determination of serum ferritin: Serum ferritin was determined manually using colorimeter by adding 2 volumes (2 ml) of reagent A to 1 volume (1ml) of reagent B (working reagent). Then the working reagent and the instrument were brought to 37°C. Zeroing of the instrument by distilled water was done. Then 1ml from the working reagent to 30µl of the sample was pipetted into a cuvette which was mixed and inserted into the instrument and the stopwatch was started. Then the absorbance at 540 nm after 10 seconds (A1) and after 5 minutes (A2) was recorded.Thick films for malaria: Thick blood films for malaria were also made and stained with the standard Giemsa, and then microscopically examined using oil immersion.Urine analysis: Explanation to the patient for the need to collect the urine was done. The containers were labeled with the date, the name and number of the patient, and the time of collection. As soon as possible, the specimen was delivered. Urine for sugar and acetone was examined by the dipstick method, then about 5 ml of well mixed urine aseptically was transferred to a labeled conical tube and was centrifuged at 500-1000 g for 5 minutes. The supernatant fluid (by completely inverting the tube) was poured into a second container not the original one. Then, a wet preparation from the remaining sediment was done and microscopically was examined using the x10 and x 40 objective.Stool analysis: Stool analysis was done and the appearance of the specimen has been described . Then a drop of fresh physiological saline on one end of a slide was placed, and a small amount of fresh specimen was mixed with the drop of saline. Then the preparation was covered with a cover glass and microscopically was examined using the x10 and x 40 objectives with the condenser iris closed sufliciently to give good contrast. The specimen was examined for motile E. histolytica trophozoites containing red cells, motile G. lamblia trophozoites, motile Strongyloides larvae, and the eggs and cysts of parasitic pathogens.Statistical analysis: The results were analyzed using statistical software package of social sciences (SPSS) version 16 and descriptive data were expressed as means and percentages with P value 0,05. 95% confidence interval of the difference Chi square test = 1.57.Ethical clearance: Ethical approval was obtained from the University of Gezira ethical committee and permissions from the medical laboratory and khalawi Wad EL Magboul authority. Target population was informed about the study objectives and was consented prior filling questionnaires. Confidentiality and privacy of target population was guaranteed.A total of 180 subjects, aged between 8-18 years with a mean age of 12.31 years (SD +/- 2.26) were enrolled in the study.The study group subjects were mainly from Hausa (67.8%), next to that was Gaaleen (10%), Tama (7.8%), Misseria (6.7%), Habbania (3.3%), Fur (1.7%), Massalit (1.7%) and Rizegat (1.1%) .All the students were from the rural areas. Of them 141 students (84.6%) were found to be from poor families, while 39 students (15.4%) belonged to families of moderate socioeconomic status. About 136 students (75.56%) were coming from families consisting of 5- 10 members, while 36 students (20%) came from families consisting of more than 10 members and only 8 students (4.44%) of families consisting of less than 5 members. The type of diet for all the students didn’t contain meat or vegetables, because they eat the same type of food every day (twice a day) which contains mainly dura and beans. The monthly pocket money for 150 students (83.34%) was found to be irregular, while only 30 students (16.66%) had their adequate money. Regarding period of stay in the khalwa up to the time of the study, 88 (49.28%) for one year, 54 (30.24%) for 2 years, 22 (12.32%) for 3 years and 16 (8.96%) for more than 3 years. During this period, the frequency of home visits was variable. The home visit for 161 students (89.16%) was once a year, and they stay there for an average of one month. While the home visit for 15 students (8.4%) was 3 monthly during which they stayed for 1- 2 weeks. Only 4 students (2.24%) had monthly visits to their home and most of them stay for about one week. The knowledge about anaemia among the students was varying. Some students 23/180 (12.88%) had some knowledge about anaemia as they are having anaemia before. About 49students (27.44%) know about but didn’t have anaemia before, while 108 students (60.48%) had no knowledge about anaemia at all. The majority of the students 177/180 (98.2%) had no history of chronic disease, while 3 students (1.8%) were found to have a positive history of recurrent mild epistaxis. The majority of the students,  were not admitted to hospital at all, while 19 students (10.56%) were hospitalized with different diseases: malaria, 10 students (5.6%), 2 students (1.11%) had a history of hospitalization due to acute appendicitis and 3 students (1.67%) due to gastroenteritis, while 4 students (2.22%) due to Schistosomiasis.Clinical examinations revealed pallor in 77 students (42.78%). None of the students had organomegaly or jaundice. Also there were no hair, eye, mouth or nail changes detected among the participants.Blood films for malaria showed that 49 students (27.2%) had a positive blood films for falciparum malaria. Urine analysis revealed that 164 students (91.1%) had clear urine, 14 students (7.8%) were found to have haematuria and ova of S.haematobium, while 2 students (1.1%) were found to have pyuria. In169 students (93.4%) stool examination was negative, while 11 students (6.6%) had intestinal worms (Enterobius vermicularis) 3 /µl +/- 1.52 standard deviation, with a minimum value of 1.60 x 103/µl and maximum value 14.30 x 103/µl. 93.9% (169 cases) had normal WBCs between 3-9x103The mean white blood cell counts value was found to be 5.19 x 10 6 /µl +/- 0.560 standard deviation, with a minimum value of 3.10 x 10 6 /µl and maximum value of 6.45 x 106µ/l The mean RBCs value was found to be 4.54 x 10Normochromic normocytic red cells were found in 49 cases (27.4%), dimorphic blood films in19 cases (10.6%), anisocytosis, with predominant microcytic hypochromic cells in 103 cases (57.68%), macrocytes in 7 cases (3.9%), sickle cells in 5 cases (2.8%), target cells in 9 cases (5.04%), polychromatic cells in16 cases (8.96%) nucleated red blood cells in 14 cases (7.84). Marked rouleaux formation was detected in 9 cases (5.04). No autoagglutination was detected in the smears The mean Hb value was found to be 11.75 g/dl (SD 1.87), with a minimum value of 7.50 g/dl and maximum value of 15.40 g/dl The mean PCV value was found to be 36.59% +/-3.51% standard deviation with a minimum value of 24.90% and maximum value of 45.40% The mean MCV value was found to be 77.83 fl +/-8.11standard deviation with a minimum value of 58.60 fl and maximum value of101.00 fl. 104 cases (58.24%) had MCV in the range of 78-86 fl .The MCH mean value was found to be 25.58 pg +/-3.55 standard deviation with a minimum value of 17.70 pg and maximum value of 34.10pg. 125 cases (69.4%) had MCV in the range of 25- 30 pg  Figure .The MCHC mean value was found to be 32.96 g/dl +/- 2.22 standard deviation with a minimum value of 22.10 g/dl and maximum value of 36.30 g/dl 3 /µl +/- 120.60 standard deviation with a minimum value of 25.00 x 103 /µl and maximum value of 723.00 x 103 /µl (3 /µl. Aggregates were found in 52 cases (29.5%). Giant forms were found in 13 cases (7.2%).The platelets mean value was found to be 317 x 10 103 /µl . Most ofThe reticulocyte count mean value was found to be 1.55% +/- 1.32% standard deviation with a minimum value of 0.20% and maximum value of 7%, . 38 caseThe Serum ferritin mean value was found to be 50.31 µg/l +/-49.58 standard deviation, with a minimum value 0.00 µg/l and maximum value 300.00 µg/l. 101 cases (56.11%) had low ferritin, while none had ferritin >300 µg/l, . AccordiAnaemia is a common health problem that affects populations in both developing and developed countries. Its primary cause is iron deficiency, but a number of other conditions, such as malaria, parasitic infection, other nutritional deficiencies, and haemoglobinopathies are also responsible, often in combination. The WHO Global Database on Anaemia can be used to describe the nutritional status of populations and to identify the needs for interventions to prevent and control anaemia . This is. Also there was significant correlation between the low serum ferritin when cross tabulated with the type of diet, . Seven cases (3.9%) presented with white blood count less than 3 x 103µ/L  most probably due to chronic or viral infection. White blood count more than 9 x 103µ/L was observed in 4 children (2.2%) dominated by neutrophils which was suggestive of pyogenic infection. Hypersegmented neutrophils were observed in 5 cases (2.8%), suggestive of mixed deficiency. The eosinophils percentage of more than 6% was observed in 14 subjects (7.84%), this eosinophilia probably reflects parasitism (e.g. Schistosomiasis). 5 children (2.8%) presented with platelets counts less than 150 x103µ/l (thrombocytopenia), may be due to asymptomatic malaria parasitisaemia. Aggregates were found in 52 cases (29.5%) and part of this may be due to the presence of inappropriate clots. Thrombocytosis with platelet counts more than 450 occurred in 25 subjects (13.9%) accompanied by low MCV and low MCH (suggestive of iron deficiency) which is one of the causes of thrombocytosis. Very commonly, the platelet count is slightly above the high limits of normal in iron deficiency anemia. This effect was classically postulated to be due to high erythropoietin levels in the body as a result of anemia, cross-reacting to activate thrombopoietin receptors in the precursor cells that make platelets. Such slightly increased platelet counts present no danger, but remain valuable as an indicator of iron deficiency. The likely causes of anaemia in the study may include: nutritional deficiency-major cause; Parasitic infestation ; Rarely hereditary causes.There was significant relation with the mean Hb value of the screened subjects which was found to be 11.75 g/dl  when compared with the mean Hb reference value (13.5 g/dl) The higher prevalence of iron deficiency anaemia, as noticed in the present study, may be attributed to inadequate food intake, poor stores and other nutritional deficiencies among these children. Childhood anaemia continues to be a significant public health problem in school children and iron deficiency either alone or in combination is the commonest nutritional cause of anaemia. Pure macrocytic anaemia in quranic schoolchildren aged 8-11years due to vitamin B12 or folate deficiency is not detected, but there is a possibility of mixed deficiency in this age.Students of primary education in the developing countries are prone to anemia.The most common type of anemia among primary schools is the “iron deficiency anemia”.This study added that students of informal education “e.g. traditional Quraanic schools” are subject to develop anemia;Also there were many associated contributing factors to the development of anemia.


Mycobacterium tuberculosis infection due to insufficient infection control practices. We conducted a cross-sectional study to explore the prevalence of TB and its associated risk factors among HCWs in Chinese TB facilities.China is one of 22 countries with a high tuberculosis (TB) burden in the world. Healthcare workers (HCWs) have a high risk of contracting Two hundred and forty-one TB facilities employing a total of 9663 HCWs were selected from 12 provinces in China to represent healthcare settings at the provincial, prefectural, and county levels. Structured questionnaires were used to collect information on TB infection control practices and HCWs in those facilities. Data was double entered into EpiData 3.1; TB prevalence and associated risk factors were analyzed using SPSS 21.0 with bivariate and multivariate regression models.OR: 6.17, 95% CI: 1.35–28.28), being a nurse , implementation of 0–9 items of management measures , and implementation of 0–1 items of ventilation measures .The results showed that 71 HCWs had been diagnosed with TB, accounting for a prevalence of 760/100 000. The multivariate analysis showed that associated risk factors included belonging to the age group of 51 years and above  contains supplementary material, which is available to authorized users. Please see Additional file Mycobacterium tuberculosis (MTB) and remains one of the major problems threatening public health worldwide [Tuberculosis (TB) is caused by the bacillus orldwide . There worldwide .China is one of 22 high TB burden countries for both TB and multidrug resistant TB cases –4. The fTuberculosis is primarily a respiratory infectious disease; infection is airborne and transmitted via aerosols. Healthcare workers (HCWs) that are exposed to MTB have a 10- to 20-fold risk of contracting TB than the general population –8. The pDespite the World Health Organization establishing an international policy that aims to protect HCWs from acquiring TB , infectiStudy conducted in 22 TB facilities in three Chinese provinces provided a general understanding on the implementation of TB infection control policies and associated risk factors for TB infection in HCWs , 12. ThiBased on the composition of HCWs at the different facilities, stage of the implementation of TB infection control measures, and willingness to be involved in this study, healthcare facilities from four eastern provinces ; four central provinces ; and four western provinces  were enrolled in the study. In each province, facilities from three prefectures were included and from each prefecture, facilities from four counties were included.In order to reflect the organizational and structural heterogeneities of healthcare facilities in China, the TB facilities were selected as follows: (i) one TB dispensary and one TB specialized hospital from each provincial level; (ii) one TB dispensary or one infectious disease hospital from each prefectural level; (iii) one specialized hospital or general hospital with a TB ward from each prefectural level and; (iv) one TB dispensary with an outpatient department or designated hospital with an outpatient department, or general hospital with a TB ward from each county level. In total, 241 facilities were enrolled in this study.All the HCWs in these facilities including administrative staff, doctors, nurses, and medical technicians were enrolled. Both long-term and temporary employees were included. In total, 9663 HCWs participated in this study.Data were collected via structured questionnaires between February and October 2013.Provincial-level staff members were trained on the principles and practices of TB infection control by researchers from the Department of Science and Technology at the Chinese Centre for Disease Control and Prevention (China CDC). Those working in provincial facilities were responsible for collecting the data in all facilities (“investigators”) following training and assessment by the China CDC. The structured questionnaires were designed in accordance with the Chinese standard practice procedures for TB infection control  and inclThe questionnaire for healthcare facilities contained 11 sections  and checked for coincidence rate, abnormal values, and logical errors by trained data entry clerks.P ≤ 0.2) were retained in the multivariate regression analysis. Then, forward selection of variables was used in the multivariate regression model, and odds ratios (ORs) and their 95% confidence intervals (CIs) were determined.Data were analyzed using SPSS 21.0 . The associations between the prevalence of TB and its risk factors were assessed by bivariate regression analysis. In the bivariate analysis, variables . Therefore, the final analysis was undertaken using data provided by 212 facilities and 9336 HCWs.Of the 212 survey sites, 30.7% were in eastern China, 34.0% were in central China, and 35.3% were in western China. To break it down further, 71.7, 22.2, and 6.1% of the sites were at the county, prefectural, and provincial levels, respectively. Of all the sites, 78.8% were TB dispensaries and only 3.3% were TB specialized hospitals; 46.2% had wards, outpatient departments, and laboratories; and 92.0% had TB prevention departments  and 31.8% were below 30 years of age. In terms of education, 39.9% had a bachelor’s degree, 31.1% had a junior college degree, and only 4.7% had a master’s degree. The average duration of employment in all facilities was 16.7 years (range 1–64 years); 25.4% worked in TB prevention facilities for less than 5 years and 26.1% worked for more than 26 years. In terms of qualifications, 33.4% had a primary professional qualification and 11.4% had a senior professional qualification. Of all the HCWs, 35.1% were doctors and 28.4% were nurses , 28 doctors (39.4%), eight administrative staff members (11.3%), and five medical technicians (7.0%). Of the 71 TB cases, 28 (39.4%) were male and 43 (60.6%) were female; 28 (39.4%) were 30 years old or less. Five (7.0%) of the 71 TB cases were classified as sputum smear-positive and two (2.8%) were sputum-culture positive. In contrast, three (4.2%) had no bacterial evidence. In terms of outcome, 50 (81.7%) had been cured, while 13 (18.3%) were still under treatment upon the survey’s completion  had carried out suspected symptom screening for healthcare visitors. Moreover, 92.3% (12/13) of provincial facilities successfully implemented this practice. Of all the facilities, 99.1% (210/212) had implemented TB infection control evaluation, but only one measure was evaluated in 66.0% (140/212) of the facilities. Of the facilities, 39.6% (84/212) conducted administrative implementation, with 17.0% (36/212) conducting 1–9 administrative measures. Almost all facilities  had appropriate ventilation systems and 94.3% (200/212) implemented 2–4 measures. In addition, 36.3% (77/212) conducted implementation of ultraviolet germicidal lamps installation with proper maintenance (see Table P > 0.05) was found between educational status .The overall prevalence of TB among HCWs was 760/100 000 (71/9336 × 100 000). The TB prevalence of males was 851/100 000 and of females it was 711/100 000. The TB prevalence of non-smokers was 756/100 000 and of smokers it was 973/100 000. No statistical significance  and nurses were considered a very high-risk group . Implementation of 0–9 items of administrative measures  and of 0–1 items of ventilation measures  were shown to be risk factors for TB  9/100 000, 18. ForThe prevalence of TB among HCWs in eastern China (612/100 000) was lower than that in the west (889/100 000) and central China 919/100 000); both of the latter are considered developing areas when compared to the east. The prevalence in the three areas was also higher than that in the general population  /100 000;, and a hNurses were likely to acquire TB in our study, corroborating existing literature (e.g. a study conducted in the Limpopo province of South Africa) . SeveralTuberculosis prevalence among HCWs was associated with administrative control implementation of TB infection control measures, environmental control measures, personal protection . China pIn this study, the implementation of administrative measures and appropriate ventilation was associated with TB prevalence among HCWs. Lack of good practice in terms of implementation of administrative measures  and the absence of appropriate ventilation systems  increased the risk of TB.Our study had limitations that may have impacted on the general validity of the findings. Firstly, facilities were not randomly selected—purposive and typical sampling can cause selection bias. Secondly, data on HCWs were collected by provincial staff members using either personal files or interviews, and false or outdated information may have been collected. Thirdly, HCWs could have been infected either in TB facilities or in the community, and the fact this distinction was not established may have overestimated the prevalence of infection as a result of occupational exposure. Fourthly, not all TB-infected HCWs had microbiological confirmation and this could have also led to overestimation of prevalence. Finally, the cross-sectional design of our study was not ideal to infer causality.This was the first large national survey conducted on TB prevalence among HCWs in China. We confirmed that TB prevalence among HCWs is higher than in the general population and is associated with age, professional category, and implementation of managerial infection control measures and ventilation systems in TB facilities. Our study indicates a pressing need to strengthen TB infection control practices in China.Additional file 1:Multilingual abstract in the five official working languages of the United Nations. (PDF 433 kb)


Conclusions: There is a low rate of HIV disclosure to infected children, and it was found to be lower for younger children. We recommend improving efforts for disclosure counseling to caregivers in pediatric HIV clinics.Aims: To determine the rate of HIV status disclosure, caregivers’ reasons for non-disclosure, and factors influencing disclosure among a sample of HIV-infected children in Enugu, southeast Nigeria. Methods: Data were collected prospectively via a questionnaire on HIV-infected children and their caregivers who visited the pediatric HIV clinic of the University of Nigeria Teaching Hospital between July 1, 2012, and June 30, 2013. The data analysis was performed using Statistical Package for the Social Sciences version 19 software. Results: Caregivers of 107 children  were enrolled in the study. There were 53 (49.5%) boys and 54 (50.5%) girls. HIV status had been disclosed to 31 (29%) of them. The major reason for non-disclosure was the child being considered too young. Age ( Most pediatric HIV infections occur perinatally; therefore the infected child is obviously unaware of his or her HIV status. ‘Disclosure’ implies revealing, making known, making public and/or sharing information on an issue FMoH . Discloset al. The American Academy of Pediatrics advises that disclosure of HIV infection status to children and adolescents take into consideration age, psychosocial maturity, complexity of family dynamics, and clinical context  recommends that pediatric HIV disclosure start as early as at 5–7 years old  and viral load were obtained from the child’s medical records.Caregivers and HIV-infected children visiting at the University of Nigeria Teaching Hospital pediatric HIV clinic were included in the study.Caregivers who declined consent were excluded.t-test was used to compare means and 95% confidence interval (CI) reported. All reported p-values were two sided with p < .05 considered significant.The data analysis was conducted using Statistical Package for the Social Sciences software . Descriptive statistics were used to report quantitative variables such as age, while qualitative variables such as socioeconomic class were reported using proportions. Chi-square and Fisher’s exact tests were used to test for a significant association of categorical variables. Fisher’s exact test was used if the expected number in a cell of a two-by-two table was less than five. The quantitative data were tested for normality using the Shapiro–Wilk normality test. Student’s Ethical approval was obtained from the Health Research and Ethics Committee, University of Nigeria Teaching Hospital, Enugu.A total of 107 HIV-infected children were enrolled in the study. Mean age was 10.1 ± 3.1 years and there were 53 boys and 54 girls. Fifty-nine children (55.1%) were orphaned, and 45 (42.1%) were in World Health Organization (WHO) clinical stage 2 of the disease. Of all participants, 101 (94.4%) were on highly active antiretroviral therapy (HAART). χ2= 0.492, p = .528). The mean age at HIV disclosure was 11.52 ± 2.25 years. The mean ages of children who were aware or unaware of their status were 13.5 ± 18 years and 8.8 ± 2.5 years, respectively (p < .001). Status had been disclosed to 0%, 6.3%, 44% and 85.7% of the 29 children aged 5–7, 8–10, 11–13 and 14–16 years, respectively (p < .001), as given in < 10 years knew their status, while 31 of 61 (50.8%) aged ≥10 years knew . The mean age at HIV diagnosis was 6.39 ± 2.92 years among the disclosed group and 3.80 ± 2.74 years among the non-disclosed group (p < .001). Two of 12 children (16.7%) from the upper social class and 16 of 43 (37.2%) from the lower social class knew their status . Status had been disclosed to 20 of 59 (33.9%) orphans and 11 of 48 (22.9%) non-orphans . The mean age for caregivers’ suggested disclosure was 12.15 ± 2.20 years .HIV status had been disclosed to 31 of the 107 children (29%). Seventeen of 53 boys (32.1%) and 14 of 54 girls (25.9%) knew their status (p = .088), as given in 3 and 784.96 ± 601.43/mm3 among those who did not (p = .008). p = .048). As shown in Four of 33 (12.1%) children in WHO clinical stage 1 or 2 of the disease and 22 of 76 (28.9%) in stage 3 or 4 knew their status (Fisher’s exact test, et al.et al.et al.et al.et al.et al. The present study showed that HIV status had been disclosed to only about one-third of the subject children. This figure is similar to that in studies conducted in Thailand (Oberdorfer, Puthanakit, Louthrenoo, Charnsil, Sirisanthana & Sirisanthana Another possible reason for the low disclosure rate found in the present study is poor implementation of WHO recommendations and guidelines for disclosure to HIV-positive children in Nigeria. Evidently there is insufficient counseling for parents/caregivers on the disclosure process. This was evident in both the late mean age at disclosure and the caregivers’ suggested mean disclosure age of 12.15 ± 2.20 years. Disclosure counseling for caregivers needs to be streamlined in comprehensive management of pediatric HIV/AIDS in Nigeria.et al.et al.et al.et al.et al.The mean age of HIV disclosure was 11.5 ± 2.3 years, compared with the 10.6 and 10.7 years reported in studies in western Kenya and northwest Ethiopia, respectively (Negese, Addis, Awoke, Birhanu, Muluye, Yifru, We found no significant difference in the proportion of boys versus girls whose HIV status has been disclosed to them. Although in most African cultures boys are traditionally expected to exhibit stronger coping mechanisms, this may not in fact be applicable. Disclosure was more likely to have occurred among children whose HIV was diagnosed at an older age. This may be because sick and older children are capable of asking questions about their illness following repeated hospital visits and hospitalizations. Severity may have played some role in disclosure, as our findings did show that the mean baseline CD4 count was significantly lower in children whose status had been disclosed to them than in those to whom it had not. Caregivers may have been compelled to disclose status to help the children’s coping mechanisms and support their adherence to treatment.et al. Contrary to findings in other studies (Ledlie et al. (Interestingly, the OR of HIV disclosure rate was threefold among children from lower socioeconomic class compared with their counterparts from the upper socioeconomic class. Obermeyer et al.  argued tThe present study found a low rate of HIV status disclosure to HIV-infected children. Caregivers expressed concern that the children in their care were too young to know their status. Such tendencies underscore the need for inclusion of disclosure counseling of caregivers as part of comprehensive pediatric HIV management protocols in Nigeria.


KRAS gene, found in approximately 53% of metastatic colorectal cancer (mCRC) cases, can render epidermal growth factor receptor (EGFR) inhibitors ineffective. Regional differences in these mutations have been reported. This is the first study which aims to describe the pattern of KRAS mutations in a Sri Lankan cohort of mCRC patients.Activating mutations in the KRAS genotypes detected in mCRC patients which have been maintained in an anonymized database were retrospectively analyzed. Of the 108 colorectal tissue samples tested, 25 (23.0%) had KRAS mutations. Overall, there were 68 (63.0%) males and 40 (37.0%) females. Among the KRAS positive cases, there were 14 (56.0%) males and 11 (44.0%) females. Their age distribution ranged from 29 to 85 years with a median age of 61 years. There were 15 patients (60.0%) with point mutations in codon 12 while 10 (40.0%) had a single mutation in codon 13. The most common KRAS mutation identified was p.Gly13Asp (40.0%), followed by p.Gly12Val (24.0%). Other mutations included p.Gly12Cys (12.0%), p.Gly12Ser (12.0%), p.Gly12Asp (8.0%), and p.Gly12Arg (4.0%). The codon 13 mutation was a G>A transition (40.0%), while G>T transversions (32.0%), G>A transitions (24.0%), and G>C transversions (4.0%) were found in the codon 12 mutations. The frequency of KRAS mutations was similar to that reported for Asian patients. However, in contrast to several published studies, the G>A transition in codon 12 , was not the most common mutation within codon 12 in our cohort. This may be a reflection of the genetic heterogeneity in the pattern of KRAS mutations in mCRC patients but valid conclusions cannot be drawn from these preliminary findings due to the small size of the study sample.The  KRAS) gene, an important member of the EGFR signalling cascade, can acquire activating mutations in exon 2 codons 12 and 13 in approximately 35.0–45.0% of the CRC cases, rendering EGFR inhibitors ineffective  according to the manufacturer’s protocol. The samples were specifically chosen by a pathologist to include predominantly tumor cells without significant necrosis or inflammation. The sequences of codons 12 and 13 of the k et al. . This isKRAS genotype using standard descriptive statistics. Associations between variables were tested through Fisher’s Exact Test. All p values below 0.05 were considered statistically significant.Data were analysed with respect to age groups, gender, and the KRAS mutations. The remaining 83 (77.0%) samples had the wild-type allele. Overall, there were 68 (63.0%) males and 40 (37.0%) females. Among the KRAS positive cases, there were 14 (56.0%) males and 11 (44.0%) females. Their age distribution ranged from 29 to 85 years with a median age of 61 years. There were 15 patients (60.0%) with point mutations in codon 12 while 10 (40.0%) had a single mutation in codon 13. The most common KRAS mutation was NM_004985.3:c.38G>A; NP_004976.2: p.Gly13Asp (40.0%), followed by c.35G>T; p.Gly12Val (24.0%). The distribution of the different KRAS mutations identified in Sri Lankan mCRC patients is shown in Table KRAS cases. Figure KRAS (G>A) transitions and (G>T) and (G>C) transversions identified in the Sri Lankan cohort.The colorectal tissue samples of 108 patients were tested. Of these, 25 (23.0%) tested positive for KRAS mutation pattern according to gender correlated well with the overall KRAS mutant type. The p.Gly13Asp (c.38G>A) mutation had the highest frequency in both males (16.0%) and females (24.0%). The gender distribution of the KRAS genotypes is shown in Fig. KRAS genotypes and the gender . The highest percentage of mutant KRAS cases was found in the 50–59 years age group. The stratification of the mutant KRAS genotypes according to age groups is shown in Fig. KRAS genotypes and the age groups . Multiple mutations in the same individual were not detected in any of the patients in this cohort.The  females 4.0%. TheKRAS mutation frequencies in Asian, European, and Latin American mCRC patients were reported to be 24.0, 36.0 and 40.0%, respectively [The ectively .KRAS mutation types are p.Gly12Asp, p.Gly12Val and p.Gly13Asp, accounting for almost 70.0% of all mutations. Overall, a similar pattern was seen in this study where these 3 mutations accounted for 72.0% of all the KRAS mutations. The most common single mutation (40.0%) identified in our cohort was a G>A transition in codon 13 , as opposed to mutations in codon 12 which have been reported in several Caucasian and Asian studies. Furthermore, our findings indicated a relatively lower frequency (8.0%) of the G>A transition in codon 12 . However, it should be noted that our sample size was too small to draw meaningful conclusions regarding these variations. A larger study with sufficient numbers would be required to derive meaningful results to determine whether these variations are valid.Previous studies , 6, 7 haKRAS mutations among 99 Japanese mCRC patients was reported to be 37.4% (37/99) [KRAS mutations were detected in 33.3% (30/90) of the CRC tumor samples using the DNA sequencing method [KRAS somatic mutations were detected in the CRC tissue samples of 31.5% (16/51) patients [KRAS mutations in mCRC patients. However as stated earlier, valid conclusions cannot be drawn regarding these variations due to the limitations of this study.The frequency of  37/99) . Similar7/99 . Sipatients . Accordipatients , 14–19. KRAS mutations in patients with KRAS wild-type using direct sequencing alone (30 tumors among 168) [KRAS mutations within genetically heterogeneous tumors may explain the low-frequency KRAS mutations detected by the direct sequencing method [KRAS exon 2 analysis may actually harbour undetected extended RAS mutations in codons 59, 61 (exon 3), or codons 117 and 146 (exon 4) [Another factor that may influence the results is the method of detection and the sample type. Pyrosequencing, a real-time, non-electrophoretic, nucleotide-extension sequencing and next generation sequencing techniques, have been shown to be efficient in various applications in comparison to direct sequencing. A study demonstrated that pyrosequencing detected 17.9% of the ong 168) . It is bg method . It is i(exon 4) , 23.KRAS genotypes and clinicopathological variables such as age, gender, tumour location, tumour histopathology, and metastasis while other studies observed no significant effects [KRAS genotypes and the patients’ age and gender in this study. However, significantly higher mutation rates in well-differentiated tumours and tumours located at the distal end of the colon were observed in the Indian cohort.Some studies have reported significant differences between the  effects , 11. Sim effects , no signKRAS mutation at 23.0% indicating that this testing is crucial for targeted therapy management in mCRC in Sri Lanka. Using KRAS testing to restrict the use of EGFR-inhibitor therapy would help to select the appropriate patients and avoid administration of unnecessary, ineffective and toxic treatments to patients who would not benefit from them. However, the present study had a number of limitations. Most importantly, it was a retrospective study, the sample size was small and clinico-pathological parameters of the tumour were not available for analysis. In addition, other biomarkers, such as KRAS exon 3 or 4, NRAS, or BRAF mutations were not evaluated. It is recommended that future studies be undertaken with larger samples to correlate the KRAS genotype with the clinicopathological parameters in Sri Lankan patients with mCRC. Analysis of other homologues such as NRAS and downstream signalling effectors such as BRAF, would also be valuable.Our preliminary findings suggest a frequency of the


For episodes of wheezing, children of overweight/obese mothers and who were exposed to particulate matter less than 2.5 μm (PM2.5) in the first trimester had an adjusted incidence rate ratio (IRR) ) of 1.85 (1.23–2.78), 1.76 (1.08–2.85) and 1.90 (1.10–3.27) in quartile (Q) 2–4, with reference to Q1. This association is seen in the second trimester for bronchiolitis/bronchitis. The risk of ear infection in the first year of life was associated with exposure to PM2.5 in the first trimester with adjusted Odds Ratio (adjOR) (95% CI) = 7.64 (1.18–49.37), 11.37 (1.47–87.97) and 8.26 (1.13–60.29) for Q2–4, and similarly in the second year with adjOR (95% CI) = 3.28 (1.00–10.73) and 4.15 (1.05–16.36) for Q2–3. Prenatal exposure to air pollution has an enhanced impact on childhood respiratory health, and differs according to maternal pre-pregnancy BMI.Prenatal exposure to air pollution is associated with childhood respiratory health; however, no previous studies have examined maternal pre-pregnancy body mass index (BMI) as a potential effect modifier. We investigated whether maternal pre-pregnancy BMI modified the association of trimester-specific air pollution divided into quartiles of exposure (Q1–4) on respiratory health in the Growing Up in Singapore towards healthy Outcomes (GUSTO) study ( In particular, exposure to PM10 or PM2.5 has been extensively studied, due to their ability to travel deep into the inhaler’s lungs and cause serious health issues [The World Health Organization (WHO) recently announced that environmental risk factors such as air pollution, water contamination and inadequate hygiene contributed annually to nearly 1.7 million child deaths . In the or death . Alarmin in 2015 . Air polh issues . The sush issues .10, NO2 and SO2 during the preconception, perinatal and postnatal periods has been associated with high prevalence of early childhood eczema, asthma and allergic rhinitis, with the strongest association between NO2 and eczema seen during first trimester exposure [A study group in China found that exposure to air pollutants such as PMexposure ,8. They exposure .10 exposure [2 during gestation [2 exposure during gestation was shown to have an insignificant effect on the respiratory health of the offspring [The lung functions in newborns were significantly affected when mothers were exposed to air pollution during gestation . Increasestation . Howeverffspring .2.5 peaked at 471 [The air quality in Singapore has generally been satisfactory, with occasional negative influence from forest fires due to the slash-and-burn agricultural practices of neighboring countries. According to the data published by the Ministry of the Environment and Water Resources (MEWR) Singapore, during the study period of 2006 to 2016, the pollutant standards index (PSI) was categorized as good and moderate on most of the days (>94% of days per year), except for 2 separate years . Singapod at 471 . In addid at 471 .Maternal pre-pregnancy body mass index (BMI) has been found to be associated with offspring’s respiratory health later in life. Positive correlation has been reported for illnesses such as wheezing and asthma in children up to the first 8 years of life ,20,21,22Hence, we aim to investigate the association between mothers exposed to air pollutants during trimesters of pregnancy and the respiratory health issues faced by the offspring at 2 years of age, as some respiratory health conditions such as bronchiolitis typically occurs during the first 2 years of life.The study population for this investigation was drawn from the Growing Up in Singapore towards healthy Outcomes (GUSTO) study. It is a longitudinal birth cohort study in Singapore, focusing on the developmental origins of metabolic diseases and neurodevelopment. The recruitment took place at two sites, the KK Women’s and Children’s Hospital (KKH) and the National University Hospital (NUH) in Singapore, between June 2009 and September 2010. The 1237 recruited women were at least 18 years old, attending antenatal care at either of the hospitals and were Singapore citizens or Singapore permanent residents with homogenous parental ethnic background . Details of the study have been discussed elsewhere . The stu2.5) concentration in µg/m3. PSI, which is an indicator of air quality developed by the United States Environmental Protection Agency (USEPA), reflects five pollutants in the ambient air, namely particulate matter witokeh a diameter of less than 10 µm (PM10), sulphur dioxide (SO2), nitrogen dioxide (NO2), carbon monoxide (CO) and ozone (O3). The PSI is reported on a scale of 0 to 500, with 0–50 considered good, 51–100 moderate, 101–200 unhealthy, 201–300 very unhealthy and above 300 as hazardous. PM2.5 was obtained as an average measured from eight stations with representation from urban stations—P03 Environment Building, P20 Bishan ITE, P28 Temasek Polytechnic, industrial stations—P17 Stagmont Camp, P31 Pandan Reservoir, suburban station—P24 Yishun ITE and roadside stations—P15 Ngee Ann Polytechnic and P32 Chin Swee. Data was extracted between 1 January 2009 and 31 December 2013.The environmental air pollutant data was provided by the National Environment Agency (NEA) of Singapore. The exposure measures provided were the daily 24-h nation-wide average pollutant standards index (PSI), and fine particulate matter with a diameter of less than 2.5 µm  to divide the entire pregnancy into three trimesters. The first trimester was defined as day 1 to day 90 of pregnancy, the second trimester as day 91 to day 180, and the third trimester as day 181 to delivery. Exposure to daily 24-h nationwide average PM2.5 and PSI) were categorized into quartiles with the lowest quartile (<25 percentile) treated as a reference group. In model 1, adjustments were made for covariates of clinical relevance and classical risk factors including maternal age at delivery, ethnicity , parity (nullipara: reference vs. multipara), maternal education (university: reference vs no education/primary/secondary and post-secondary/pre-university), history of presence of maternal atopy, maternal smoke exposure during pregnancy and ETS, gestational age, baby gender (boys: reference vs. girls), birth weight. Model 2 controlled for effect of the air pollutant in other trimesters and model 3 was further performed to adjust for child postnatal smoke exposure and postnatal PM2.5 and PSI exposure.We employed multivariable Poisson regression for episodes of wheezing and bronchiolitis/bronchitis ascertained from birth to 2 years of age; results are presented as incidence rate ratios (IRRs) and 95% confidence intervals (CI). The air pollutants  with 95% CI.Potential effect modification by pre-pregnancy BMI was assessed by including multiplicative interaction terms with the risk factor scores to the fully-adjusted model. Stratified analyses were then performed in participants with a BMI of <23 and ≥23, as the Asian cut-point for overweight/obese.All statistical analyses were performed with IBM SPSS version 24.0 .p = 0.005) was significantly associated with the presence of any respiratory conditions listed above. Maternal age at delivery, ethnicity, educational attainment, parity, maternal smoking during pregnancy and ETS, maternal pre-pregnancy BMI, gestational age, gender, birth weight and passive smoke exposure were not significantly associated with a child’s respiratory health.Out of the 1255 recruited women, 1190 of them delivered singleton infants and 953 children completed the 2-year visit. 2.5 and PSI were 17.92 (1.31) and 35.15 (1.01), respectively. Levels in the first and second trimesters were similar but the average PM2.5 and PSI values in the third trimester were significantly lower than those in the first trimester (p < 0.001) due to 7.9% of the participants having preterm deliveries before 37 weeks.The air pollution exposure levels during the entire pregnancy and across the three trimesters are summarized in 2.5 and PSI divided into quartiles during each trimester of pregnancy and episodes of wheezing by 2 years of age. A total of 29.2% of toddlers had at least one episode of wheezing. The median episodes (IQR) of wheezing were 2 , with one child having a maximum of 19 episodes in the first 2 years of life. In model 1, we found that exposure to PM2.5 and PSI in the first and third trimester was associated with increased episodes of wheezing.2.5 in first trimester with PM2.5 in second trimester), ranging from −0.672 to 0.268. PM2.5 and PSI were, however, strongly correlated within each trimester, with a correlation of 0.909 to 0.928. Therefore model 2 further adjusted for the effects of PM2.5 or PSI in other trimesters. The effect of PM2.5 in the same trimester was, however, not adjusted for if the main analysis was on PSI, and vice versa. In model 2, we found that the association of episodes of wheezing and PM2.5 was consistently significant with adjusted IRR (95% CI) = 1.56 (1.18–2.06) in the highest quartile (Q4) in the first trimester and 1.56 (1.07–2.28) in the third trimester. The association with PM2.5 in the second trimester was no longer significant after multi-trimester adjustment. Likewise, PSI remained significantly associated in the first and third trimester. Across the trimesters, the pollutants were weakly or moderately correlated with each other  from birth to 2 years of age. The association of PM2.5 with episodes of wheezing was significant in the first and third trimester with IRR (95%) = 1.60 (1.08–2.38) in Q4 of the third trimester. The effects of PSI can be seen in the first trimester with IRR (95%) = 1.47 (1.14–1.90) and 1.68 (1.20–2.34) in Q2 and Q4 respectively.In model 3, we proceeded to adjust for postnatal factors, including ETS and ambient air pollution  were at an increased risk of developing more episodes of wheezing. In model 3, these children whose mothers were exposed to Q2, 3, and 4 of PM2.5 in the first trimester had an IRR (95% CI) of 1.85 (1.23–2.78), 1.76 (1.08–2.85) and 1.90 (1.10–3.27) respectively, indicating that PM2.5 exposure in the first trimester may increase the episodes of wheezing in toddlers.In addition, we conducted stratified analyses to assess effect modification by maternal pre-pregnancy BMI as the interaction term 2.5 and PSI in quartiles during each trimester of pregnancy and episodes of bronchiolitis/bronchitis by 2 years of age. In model 2 with multi-trimester adjustment, we found that the associations of episodes of bronchiolitis with PM2.5 and PSI were significant with adjusted IRR (95% CI) = 2.29 (1.34–3.89), 3.71 (2.05–6.70), 2.37 (1.38–4.09) in Q2–4 for PM2.5 in the second trimester. This effect was amplified when only the overweight and obese mothers were taken into account. As a comparison, the adjusted IRRs (95% CI) were now doubled or tripled to 5.19 (2.20–12.24), 11.06 (4.12–29.65), 4.84 (1.90–12.36), respectively, for PM2.5 Q2–4. The same pattern was observed in the second trimester when further adjustments were made for postnatal factors in model 3.Bronchiolitis/bronchitis occurred in 13.7% of the children, with a median (IQR) of 1  episodes. 2.5 and PSI in quartiles) during pregnancy and ear infection, prolonged cough, pneumonia and rhinitis at 1 and 2 years of age. The risk of ear infection in the first year of life was associated with exposure to PM2.5 in the first trimester with adjusted OR (95% CI) = 7.64 (1.18–49.37), 11.37 (1.47–87.97) and 8.26 (1.13–60.29), respectively, for Q2–4, and similarly in the second year with adjusted OR (95% CI) = 3.28 (1.00–10.73) and 4.15 (1.05–16.36) for Q2 and 3. The association between exposures to air pollutants were significant only for the highest quartile (Q4) of PM2.5 and PSI in the first trimester for prolonged cough at 1 year old. As the incidence of pneumonia was low (1.8%), no significant associations were found. On the contrary, despite a high incidence of rhinitis (44.5%), we did not find statistically significant associations with air pollution.We further examined effects of air pollution on the occurrence of other respiratory health outcomes. 2.5 and PSI in the first trimester increasing the episodes of wheezing, while exposure to air pollution in the second trimester was positively associated with episodes of bronchiolitis/bronchitis. In addition, we found evidence suggestive that children of overweight or obese mothers had a higher likelihood of developing more episodes of wheezing and bronchiolitis. These associations remained significant after adjusting for potential confounders, including pollutants in other trimesters and postnatal exposure.Our prospective birth cohort study showed that maternal exposure to ambient air pollutants during pregnancy was associated with respiratory disease in young children. We identified trimester-specific effects with exposure to higher quartiles of PM2.5 exposure in the first trimester. An increased risk of prolonged cough was similarly seen in children whose mothers were exposed to the highest quartile of PM2.5 and PSI in the first trimester, although this effect was observed only in the first year of life. These positive associations were found although PM2.5 was well within the mean concentration guideline and PSI was generally within “good” ranges as stipulated by the air-quality guidelines established by the WHO [Ear infections in 1- and 2-year-old children were associated with PM the WHO .2.5 and stress during the first trimester had higher risk of current wheeze (relative risk (95% CI) = 1.35 (1.00–1.83)) [2 and benzene prenatally, especially during the second trimester  1.08 (1.02–1.15), wheezing = 1.05 (0.99–1.11), ear infection = 1.16 (0.98–1.37); for benzene exposure, LRTI = 1.10 (1.01–1.20), wheezing = 1.02 (0.96–1.09); ear infection = 1.13 (1.00–1.27)) [2 exposure during pregnancy and common respiratory diseases among young children such as LRTI, wheezing as well as persistent cough during the first year of life [Our findings are in line with several other studies ,29,30,310–1.83)) . Based o0–1.27)) . The INM of life .−2 increase in maternal BMI, 2.3% more wheezing days (95% CI 1.01–1.04%) was observed in the first year of life, and 3.3% more healthcare visits for wheezing illnesses (95% CI 1.00–1.07%) until 5 years of age [2 was associated with children’s current severe asthma  and late-onset wheezing  at 7 years of age [Associations between maternal pre-pregnancy BMI and childhood respiratory conditions have been examined previously ,21. A UKs of age . A larges of age . However3 to 150 µg/m3 [Although Singapore has experienced recurrent acute haze crisis due to forest fire from neighboring countries, only a handful of studies have evaluated the relationship between air pollution exposure and health outcomes in Singaporeans. Chew et al. reported a positive correlation between air pollutant levels in 1990-4 and emergency room visits for acute asthma in young children . Another50 µg/m3 . Despite2, the variation of air quality across the island is not significant [2, NO2, CO and O3 to represent the ambient air pollution. We note that it is important to investigate the role of these individual pollutants as their effects have been observed in other studies [We acknowledge several limitations in this study. Firstly, despite the possible spatial and temporal variations of outdoor air pollutant, the exposure was not categorized based on each participant’s home or work addresses but was averaged across the country. This method was employed as the National Environment Agency (NEA) of Singapore specified that due to Singapore’s small geographical size of 719 kmnificant . Secondl studies ,11,32. T studies . Another studies . In addi studies . However studies . Finally studies . As we fIn conclusion, our prospective birth cohort study showed that maternal exposure to ambient air pollution during pregnancy was associated with the incidence of respiratory health issues in the offspring. We found trimester-specific effects with effect modification by maternal pre-pregnancy BMI. Our findings support the DOHaD hypothesis that early risk factors causally influence predisposition to health and disease, although the underlying mechanism requires further investigation. This work highlights the need for more effective measures of air pollution control and prenatal care to minimize exposure to air pollution during pregnancy. More work in this birth cohort is needed to determine whether exposure to air pollution during fetal life is associated with the development of other diseases, including asthma, at later ages.


Cataract is the leading cause of blindness in developing countries and identification of the barriers to accessing treatment is essential for developing appropriate public healthcare interventions. To evaluate the barriers to cataract surgery after diagnosis and assess the postoperative outcomes in Sao Paolo State, Brazil.This prospective study evaluated cataract patients from 13 counties in São Paulo State in 2014. Cataract was diagnosed in the community by a mobile ophthalmic unit and patients were referred to a hospital for management. Gender, age, distance to the hospital and local municipal health structure were evaluated as possible barriers. Data were analyzed for postoperative outcomes and the impact on blindness and visual impairment.p=0.000). There was a statistically significantly decrease from 17 (11.8%) blind patients and 55 (38.2%) visually impaired patients at presentation to 2 (1.4%) and 5 (3.5%) patients respectively after treatment (p=0.000).Six hundred patients were diagnosed with cataract with a mean age of 68.8±10.3 years and 374 (62.3%) were females. Two hundred and fifty-four (42.3%) patients presented to the referral hospital. One hundred forty-four (56.7%) underwent surgery, 56 (22.0%) decided not to undergo surgery, 40 (15.7%) required only YAG-Laser and 14 (5.5%) required a spectacle prescription only. Visual acuity increased statistically significantly from 1.07±0.73 logMAR at presentation to 0.25±0.41 logMAR at the final visit after intraocular lens implantation (Less than half of the individuals with cataract presented to the hospital for surgery. Among the patients who underwent treatment, there was an overall decrease in the number of blind individuals and visually impaired individuals. The barriers to cataract surgery were older age, greater distance to the hospital, municipalities with fewer inhabitants and less ophthalmic services. Cataract surgery is a leading cause of blindness in developing countries . In 2010Barriers to access cataract surgery differ by regions and include, gender, fear of surgery, status of visual disability, educational level, visual needs, distance from the care provider, cost and lack of an escort/caretaker .Sistema Único de Saúde – SUS) that provides surgery without cost to those in need [Brazil has a universal public health system . This study was approved by the Ethics Committee of the Faculdade de Medicina de Botucatu – UNESP, Sao Paulo, Brazil and adhered to the tenets of the Declaration of Helsinki. All study subjects signed a consent form.A cross-sectional prospective survey was performed in the southwest region of São Paulo State, Brazil, involving patients who were screened at a Ophthalmic Mobile Unit (OMU) in 2014. SUS covered all the costs for treatment. Patients were screened in 13 municipalities  was evaluated using an illuminated Snellen E chart and the values were converted to the logarithm of the minimum angle of resolution (logMAR) for statistical analysis. The Snellen to logMAR conversion was as follows: counting fingers, hand movement, light perception and without light perception corresponded to 2.10, 2.40, 2.70 and 3.00, respectively . The WHOAll participants underwent an objective and subjective refraction with an autorefractor  and a manual refractor . Slit lamp biomicroscopy  was performed to evaluate the anterior segment and the posterior segment using a 90 D Volk lens. For patients who did not achieve good vision with refraction, a dilated examination was performed  for comprehensive evaluation of the lens and fundus. Intraocular pressure (IOP) was measured with air-puff tonometer . For patients with IOP over 20 mmHg, Goldmann tonometry was performed to confirm the air-puff tonometry readings .To ensure consistency, survey staff were trained, periodically monitored and the equipment was calibrated regularly. All data collection sheets were pretested.After the ophthalmic exam, patients diagnosed with cataract or pseudophakia with posterior capsule opacification (PCO) were referred to the HCFMB for further examination, YAG  laser or surgery and an appointment was scheduled. The municipalities provided transportation to the hospital on the day of the appointment.At the hospital, the patient underwent another ophthalmic examination. Biometry was performed using the IOLMaster 500  and IOL calculations targeted emmetropia in all eyes. In eyes with dense cataracts that precluded optical biometry, the axial length was measured with an ultrasonic biometer  and the IOL power was calculated with the IOLMaster.Patients underwent phacoemulsification or extracapsular cataract extraction (ECCE) based on surgeon preference. All patients underwent IOL implantation.To analyze demographics and outcomes after treatment, the data obtained at the OMU visit were transferred to an Excel spreadsheet . The electronic medical records from the hospital were used to collect data on the diagnosis, surgical procedure and postoperative outcome and transferred to an Excel spreadsheet.per capita income and number of inhabitants, were obtained from the Instituto Brasileiro de Geografia e Estatística – 2010 (IBGE) [National data were consulted to determine possible barriers for evaluation in this study relating to patient adherence to the proposed treatment. The socioeconomic and demographic data of the assisted municipalities, such as Human Development Index (HDI), p<0.05.Data analysis was performed with SPSS 22.0 software . The frequency, mean and standard deviation were calculated. Normally distributed data were analyzed by the Kolmogorov-Smirnov and Shapiro-Wilk tests. Statistical significance was indicated by During the study period, 600 patients from 13 participating municipalities were diagnosed with cataract or PCO and referred to the HCFMB. The mean age of the patients was 68.8 ± 10.3 years, of which 374 62.3%) were female, 46 (7.7%) were blind and 202 (33.7%) were visually impaired (Table .3% were p=0.004) . Attendance was statistically associated with visual impairment (p=0.000) but not blindness (p>0.05) (Table Two hundred and fifty-four 42.3%) patients presented for scheduled care. Presentation to the referral hospital varied between 16% to 63% among the municipalities. Younger patients had a statistically greater tendency to present to the referral hospital  underwent surgery in at least one eye, 56 (22.0%) did not undergo surgery due other ophthalmic comorbidities or because the patient refused surgery, 40 (15.7%) were pseudophakic with PCO that required YAG capsulotomy, and 14 (5.5%) had milder lens opacities and reasonable VA with spectacle correction and remained under observation.p<0.000). Prior to YAG laser treatment there were four (10.0%) blind patients and 11 (27.5%) visually impaired patients. After YAG capsulotomy there was a statistically significant reduction in the number of blind patients to zero and visually impaired patients to 2 (2.0%) .YAG capsulotomy was performed in 65 eyes of 40 patients, resulting in a statistically significant improvement in VA from 0.93±0.73 logMAR before capsulotomy vs 0.25±0.46 logMAR after capsulotomy, Of the 56 patients who did not undergo surgery, 27  had surgery postponed due to mild lens opacity, 17 (30.4) were lost to follow-up before surgery and 9 (16.1%) refused surgery.p=0.000). The mean improvement is VA was -0.86 logMAR, which is equivalent to 8 lines on an early treatment of diabetic retinopathy study (ETDRS) chart.A total of 253 surgeries were performed, of which 245 were phacoemulsification and 8 were extracapsular cataract extraction (ECCE), all with IOL implantation. There was a statistically significant increase in VA from 1.07±0.73 logMAR (20/225 Snellen acuity) preoperatively to 0.25±0.41 logMAR (20/32 Snellen acuity) at last postoperative visit (p=0.000) and the postoperative VA .Of the patients who underwent surgery, 37 (14.6%) had an associated ocular comorbidity and, in 32 (12.6%) of these patients the comorbidity caused the low VA. The most common comorbidity was, age-related macular degeneration (AMD) in 11 (33.4%) cases. Comparison of groups with and without comorbidities justifying the low VA indicated, statistically significant differences in the preoperative VA . Of those who remained blind or visually impaired after phacoemulsification, 4 (57.1%) the low VA could be explained by an ocular comorbidity.Preoperatively 17 (11.8%) patients who underwent phacoemulsification in at least one eye were classified as blind and 55 (38.2%) were considered visually impaired. There was a statistically significant decrease after phacoemulsification to 2 (1.4%) blind patients and 5 (3.5%) patients who were visually impairment  eyes. At the final postoperative visit the mean spherical was -0.32 ± 1.13 D , the mean cylindrical was -1.02 ± 1.02 D (range -9.00 D to 0.00 D) and the mean spherical equivalent was -0.83±1.11 D (range -3.88±2.13).p<0.000).There were 209 patients who underwent cataract surgery and YAG capsulotomy, of whom 21 (10.0%) were blind and 16 (7.6%) were visually impaired prior to treatment. After treatment, there was a statistically significant decrease in the number of blind patients to 2 (0.9%) and 7 (3.3%) remained visually impaired , there was a statistically greater distance to the hospital , a statistically higher per capita income  and statistically lower population .For patients who did not present for their scheduled visits, the municipal HDI was statistically significantly higher . Additionally, patients who did not attend had statistically significantly more blindness prevention programs , statistically better local coverage by ophthalmic surgeons , statistically greater availability of ophthalmic equipment at municipal primary healthcare facilities  and statistically better municipal hospital services and infrastructure to perform phacoemulsification .Regarding the municipality health structure, 84.2% of patients who did not present for the scheduled visit had ophthalmologists in their municipality of origin, compared to 92.3% of those who attended (p>0.05).The outcomes of this cross-sectional study of cataract patients indicated that those who presented to the referral hospital were younger and mainly females. This observation is similar to other Brazilian studies –13 and iIn the current study, a relatively low number of patients (42.3%) diagnosed with cataract (based on the OMU screening) presented to the specialized hospital for phacoemulsification or YAG capsulotomy.p<0.000). Hence, despite the low patient presentation rate for referral, the treatment was effective and achieved the WHO criteria. The WHO recommends a maximum of 5.0% of patients with best corrected visual acuity less than 20/400 (blindness) after cataract surgery.In the entire study sample, 10.0% of patients were blind and 7.6% were visually impaired at presentation. After treatment, there was a statistically significant decrease in blindness to 0.9% of patients and 3.3% of the patients were visually impaired (A British study of 127,658 patients reported an improvement in VA from 0.63 logMAR at baseline to 0.16±0.30 logMAR after cataract surgery . The VA The number of surgeries, the quality of surgery and the final VA are all factors for achieving the goal of Vision 2020. Access to healthcare services is another barrier despite the strategy of approaching patients in their hometown using an OMU and detecting individuals who require surgery. For example, despite these initiatives, only 42.3% of the screened patients presented to the specialized hospital in the current study.Our analysis of the social, economic and demographic characteristics and the health structure of the municipalities indicated that greater distance from the hospital, with higher HDI, higher per capita income and a lower municipal population were most unlikely to present to the referral hospital. These characteristics can be considered the barriers to treatment of cataracts in Sao Paolo State, Brazil. Interestingly the same barriers were reported in a rural region of China  and in cThere are an average 62 ophthalmologists per 1 million inhabitants in Latin America and this number is increasing. Therefore, there are an adequate number of ophthalmologists for coverage of cataract surgery . HoweverThere are some limitations to the present study, including the lack of data on the best-corrected VA for all patients and that the barriers were not analyzed individually. Separate analyses of the barriers were not performed because we collected generalized data regarding the study population. However, there is a relative paucity of data from studies evaluating a Brazilian sample with an OMU. Hence, the outcomes of the current study provide data that can be used to allocate adequate resources and develop public healthcare initiatives.The outcomes of the current study indicate that the elimination of cataract as a cause of blindness and/or visual impairment in Brazil requires greater coordination between the municipality and the regional tertiary hospital to ensure greater uptake of surgery.Less than half of the patients diagnosed with cataract in municipalities using an OMU actually presented to a specialized hospital for treatment despite referral. However, the outcome of phacoemulsification was encouraging, resulting in a significant reduction of blind and visually impaired patients.The main barrier to attendance were advanced age, greater distance to the specialized hospital and municipalities with lower populations. However, the presence of blindness prevention programs, ophthalmic surgeons, available ophthalmic equipment at healthcare centers and hospital with the resources to perform phacoemulsification may be factors that reduce adherence to appointments at a specialized hospital.


To evaluate the optic disc area and cup area in a normal population over 40 years of age.This prospective study was performed in Eskişehir. Fundus photographs were obtained using a nonmydriatic fundus camera. Planimetric measurements of the optic disc and cup area were performed with VK-2 digital imaging software. Optic nerve parameters were then compared between sex and age groups.2 in the right eyes and 2.89 (2.55-3.25) mm2 in the left eyes (p<0.001). The median cup area of the subjects was 0.46 mm2 (0.33-0.64 mm2) in the right eyes and 0.44 mm2 (0.33-0.61 mm2) in the left eyes (p<0.001). The differences in disc and cup area between male and female subjects were not statistically significant (p>0.05).A total of 3,038 subjects were evaluated. Mean age was 56.6±10.4 years (range 40-91 years). The median disc area of the subjects was 2.87 (2.53-3.23) mmWe report the normal distribution of disc area and cup area measurements and their association with age and sex. There is also a pronounced interindividual variability of disc size due to ethnic variation, equipment used and physicians making the evaluation.7Morphological changes in the optic nerve head have diagnostic value for many systemic and ocular disorders. Disc size and cup-to-disc ratio are important parameters in the assessment of disc damage in glaucoma.Since data on disc parameters in the Turkish population are scarce, the present investigation was conducted to examine optic disc and cup areas in Turkish people over 40 years of age.This study was a population-based study conducted in Eskişehir. We evaluated both eyes of subjects over age 40 who were reached through registrations in the Health Centers in one township (Kaymaz) and three districts  of Eskişehir. After obtaining informed consent, a questionnaire was performed by a professional technician who had more than five years of experience in ophthalmology. Ocular and systemic pathologies as well as demographic factors such as age and sex were noted. Intraocular pressure was measured by Tono-pen  and central corneal thickness by Pacline pachymeter . Fundus photographs were then taken by a KOWA  nonmydriatic fundus camera. Pupils were not dilated. A total of 3,038 subjects with sufficient media clarity to permit good quality fundus photographs underwent photography.The fundus images of 3,038 cases were assessed by planimetric measurements using 45º photographs. Borders of the discs and cups were manually marked at 12 points by a researcher and a line was automatically generated by the VK-2 digital imaging software . The cupThe study population was divided into four groups according to age: 40-49 years; 50-59 years; 60-69 years; and over 70 years. Both eyes of all cases were evaluated. Eyes with glaucoma and eyes without clear fundus images that prevented reliable planimetric assessment were excluded from the study.th (Q1) and 75th (Q3) percentiles for non-normally distributed variables. Kolmogorov-Smirnov and Shapiro-Wilk tests of normality were used to check the normality of variable distributions. Independent variables that did not show normal distribution were compared using Kruskal-Wallis and Mann-Whitney U tests. Wilcoxon Signed Ranks test was used for the dependent non-normally distributed variables. A value of p<0.05 was accepted as significant. SPSS 21.0 program was used for statistical analysis.Descriptive statistics were used to describe each variable. The descriptive statistisics were demonstrated with n (sample size), mean and standard deviation for continuous variables, and n (sample size), median and 25A total of 2,862 right and 2,856 left eyes of 3,038 subjects were evaluated. There were 2,241 female and 797 male subjects in the study. Overall mean age was 56.6±10.4 years (range 40-91 years). The mean age of female subjects was 55.6±10.1 years and the mean age of the male subjects was 59.2±10.5 years. Mean intraocular pressure in right and left eyes was 16.2 mmHg and 16.1 mmHg, respectively. The frequency of tilted disc, alpha and beta atrophies was 0.94%, 22% and 7.45%, respectively.2 in the right eyes and 2.89 (2.55-3.25) mm2 in the left eyes (p<0.001). Median disc areas in females were 2.87 (2.57-3.32) mm2 and 2.90 (2.60-3.24) mm2 in right and left eyes respectively. Median disc areas in males were 2.87 (2.53-3.23) mm2 and 2.89 (2.55-3.25) mm2 in right and left eyes respectively. The difference between male and female subjects was not significant .The median disc area of the subjects was 2.87 (2.53-3.23) mmDisc areas according to the age groups are given in Disc areas were observed to be larger in the younger and older age groups (p>0.05), but the difference was only found to be significant between 60-69 vs 70+ groups in female subjects (p=0.029) .2 (median 0.46 mm2) in the right eyes and from 0.33 to 0.61 mm2 (median 0.44 mm2) in the left eyes (p<0.001). Median cup areas in females were 0.45 (0.34-0.63) mm2 and 0.44 (0.33-0.61) mm2 in right and left eyes respectively. Median cup areas in males were 0.46 (0.32-0.63) mm2 and 0.45 (0.33-0.61) mm2 in right and left eyes respectively. The difference between male and female subjects was not significant (p=0.49 and p=0.73 for right and left eyes respectively).Optic cup area ranged from 0.33 to 0.64 mmThere was a significant correlation between disc area and cup area in the right and left eyes (p<0.001).9Optic nerve head assessment is important in many ocular and systemic diseases, especially in glaucoma, which is a well known preventable cause of blindness. To detect early pathological changes in the optic nerve head, one must know the normal distribution of its parameters. There are many studies in this area, but almost none in Turkish population.10In this study we evaluated optic disc and cup area in a Turkish population. We used a nonmydriatic fundus camera to evaluate the optic nerve head of the subjects. It is a noninvasive, noncontact imaging technique that does not require pupillary mydriasis. Fundus cameras have become increasingly automated and they include computer-assisted digital analysis of the optic nerve head. Computer-assisted techniques have improved intra-observer reproducibility and inter-observer consistency.2). In the Beijing Eye study performed on the Chinese population, mean disc area was 2.65 mm2 (1.03-7.75 mm2). In the Indian population it was 3.37 mm2 (2.04-4.7 mm2). In all of these studies, planimetric measurements were used.12 Marsh et al.7 showed that the mean optic disc area was significantly smaller in white and Hispanic subjects than in African-Americans. Durukan et al.13 found the mean disc area to be 2.12 mm2 in a normal Turkish population, but the measurements were done using a confocal scanning laser ophthalmoscope (HRT II), and this may explain the difference from our study. Thomas et al.14 compared HRT and planimetric findings and concluded that disc area is measured smaller by HRT than by planimetry (2.24 vs 2.58 mm2). It is well known that the technique and equipment used have an important influence on measurement results.We found the mean optic disc area to be 2.88 mm2 . Varma et al.15 studied 3,387 normal American subjects and concluded that males had larger discs than females in both the white and black populations. In contrast, there are other studies which do not support this evidence.16In our study, the mean disc area was 2.89±0.45 mm13 found a significant difference between subjects over and under 60 years of age, with larger disc areas in subjects over 60 years. In a postmortem study performed by Quigley et al.,8 no relation was found between age and disc size. The same results were found in the Beijing Eye Study and Baltimore Study.15,17 This may show that the effect of age on disc size may vary among different nations.We did not find a significant difference between age groups in terms of disc area or cup area. The only significant difference was observed for disc area between the 60-69 and 70+ age groups in female subjects, which might be coincidental. Durukan et al.2 and we did not find any significant differences in the measurements between sexes. Similar results were observed by Durukan et al.13 In a study by Xu et al.,9 the mean cup area of a Chinese population was larger than that of our population, which may be attributable to ethnic differences.In our study, mean cup area was measured as 0.45 mmThere are some limitations of this study. The evaluation technique requires a high degree of subjective judgment and slight differences in settings used may cause variation between centers. Keratometric readings of patients’ corneas or measurements of the axial lengths were not available; therefore, an individual correction for the magnification of the optics of the eye was not possible.We report the normal distribution of disc area and cup area measurements in the Turkish population. Disc area and cup area did not vary significantly between male and female subjects or between different age groups.Ethics Committee Approval: Approval number 2008/263, Informed Consent: It was taken.Peer-review: Externally and internally peer-reviewed.