Mapping the health and environmental situation in informal zones in Aleppo, Syria: report from the Aleppo household survey.

OBJECTIVES: Despite large communities living in informal zones around major cities in Syria, there is currently no information on the health and environmental situations in these areas. From May to August 2004, the Syrian Center for Tobacco Studies (SCTS) conducted the first household survey aiming to provide a baseline map of main health problems and exposures affecting these communities in Aleppo, the second largest city in Syria (2,500,000 inhabitants). METHODS: Information on 1,021 participants randomly selected using stratified cluster sampling were available (46% males, mean age 34+/-11.7, age range 18-65 years, response rate 86%), including self-reported health/disability, exposures, and saliva cotinine measurement. RESULTS: Some positive findings include better than expected access to electricity, piped water, city sewage, and the use of propane for cooking. Particular areas of concern include high fertility rates, overcrowded housing conditions, and gender inequality in education and work. Household features likely to reflect negatively on residents' health include the use of diesel chimneys for heating and lack of smoking restrictions. Overall, residents of informal zones suffer from substantial physical and mental health problems and are exposed to high levels of indoor air pollution. All seem to affect women and the elderly disproportionately, while men are more affected by smoking, occupational respiratory exposures, and injuries. Both infectious and non-infectious respiratory outcomes were very common among study participants. Chronic and degenerative disease, including CVD and joint problems, were a source of substantial morbidity among the studied communities. CONCLUSIONS: This study highlights major health and environmental specificities of marginalized populations living in Aleppo, where women seem to bear a disproportionate burden of poor health and disability. Smoking and exposure to tobacco smoke seem among the major exposures facing these populations.

Health of children working in small urban industrial shops.

AIMS: To explore associations between work status and multidimensional health indices in a sample of urban Lebanese children. METHODS: A cross-sectional survey was used to compare 78 male children (aged 10-17 years) working full time in small industrial shops, and a comparison group of 60 non-working male schoolchildren. All children lived and worked or studied in the poor neighbourhoods of three main Lebanese cities. RESULTS: Working children reported frequent abuses. They smoked and dated more than the comparison group. They also reported a higher number of injuries (last 12 months) and recent skin, eye, and ear complaints (last two weeks). Physical examination revealed more changes in their skin and nails, but no differences in height or weight compared to non-working group. A higher blood lead concentration was detected among working children, but no differences in haemoglobin and ferritin. No differences were noted between the two groups of children regarding anxiety, hopelessness, and self-esteem. The drawings of the working children, however, revealed a higher tendency to place themselves outside home and a wider deficit in developmental age when compared to non-working children. CONCLUSION: Significant differences were found between working and non-working children with respect to physical and social health parameters, but differences were less with regard to mental health. Future research should focus on (1) more sensitive and early predictors of health effects, and (2) long term health effects. The generality of findings to other work settings in the developing world should also be tested.

Doppler characterization of left ventricular diastolic function in beta-thalassaemia major. Evidence for an early stage of impaired relaxation.

AIMS: Doppler echocardiographic studies of left ventricular diastolic function in patients with thalassaemia major have shown conflicting findings. This study was undertaken to compare Doppler echocardiographic parameters of diastolic function among a group of patients with thalassaemia major, a group with thalassaemia intermedia and a group of normal individuals. METHODS AND RESULTS: 50 patients with thalassaemia major, 38 patients with thalassaemia intermedia and 29 normal subjects were studied. All had normal systolic function. The thalassaemia intermedia patients had larger body surface area and left ventricular mass index than the thalassaemia major patients but less than the controls. The ratios between peak early and late mitral diastolic flow (E/A ratio) were comparable between the three groups. The haematocrit levels were comparable in the two study groups, but the ferritin levels were significantly higher in the thalassaemia major group (P<0.001). Using multiple regression analysis to correct for the influence of heart rate, age and body surface area, we found a prolonged isovolumic relaxation time (P<0.03) and a lower E wave (P<0.001) in the thalassaemia major group as compared to the thalassaemia intermedia group. The isovolumic relaxation time also differed significantly between the thalassaemia groups and the control (P<0.001), suggesting a state of impaired relaxation most notable in thalassaemia major that is probably due to iron overload. CONCLUSION: In patients with thalassaemia major and normal systolic function who have iron overload, the earliest sign of diastolic dysfunction is an impairment in left ventricular relaxation manifested as a prolonged isovolumic relaxation time.

Immunity to chickenpox among school adolescents in Lebanon and options for vaccination.

Varicella infections cause substantial morbidity and mortality in adolescents and adults. The primary infection, chickenpox, results in lifelong immunity to chickenpox. A seroprevalence study carried on adolescents 15-18 years of age attending schools in Lebanon showed 96.6% immunity to varicella. The positive predictive value for immunity to chickenpox based on history alone was 97.4%, whereas the negative predictive value was 4.5%. Coming from a bigger family was a statistically significant predictor of immunity to chickenpox. In a developing country like Lebanon the merits and limitations of implementing universal varicella vaccination is discussed in relation to seroprevalence and socioeconomic factors.

Prevalence of hepatitis B infection markers in Lebanese children: the need for an expanded programme on immunization.

This multi-centre, cross-sectional study was designed to reveal the present status of hepatitis B infection markers among Lebanese children, and provide recommendations regarding childhood immunization policies. A total of 841 children, aged between 6 months and 6.5 years, were enrolled from Lebanon's five districts. Their sera were tested for hepatitis B surface antigen and hepatitis B core IgG. The overall prevalence of hepatitis B virus infection markers was 0.8% with increasing age-specific rates from 0% at 6 months to 1.3 % at > 5 years. There was no statistically significant association between the presence of hepatitis B markers and family characteristics or risk factors for infection. The highest prevalence rates were among children from Beirut suburbs (2.9 %) and South Lebanon (1.6%). The risk of horizontal transmission of hepatitis B to uninfected children increased substantially after the age of 2 years. An expanded programme on immunization that integrates hepatitisB vaccine during the first year of life is needed.

Determinants of elevated blood lead levels among working men in Greater Beirut.

This cross-sectional study reports the blood lead levels (BLL) among different working groups in Beirut and identifies the risk factors associated with elevated BLLs. A total of 579 men of 18 years of age or older (response rate 96%) working in Greater Beirut were interviewed. Of those, 315 (54.4%) provided a blood sample of which 291 were analyzed for lead. The mean BLL of the 134 men working in white-collar jobs (offices, retail shops) was 12.7 microg/dl (SD 3.7); statistically significantly lower than the mean BLL (18.4 microg/dl; SD 9.8) of the 157 men working in blue-collar occupations (such as gas station attendants, painters, mechanics). A blood lead level of 15 microg/dl or more was associated with blue-collar jobs, number of cigarettes smoked, commuting > or = 3 km to work, years in current occupation, and younger age. A BLL of at least 20 microg/dl was associated with eating lunch at work, in addition to blue-collar jobs, smoking, commuting, years of work, and younger age. The study findings suggest that environmental exposure (those not otherwise exposed to occupational lead) is mainly determined by smoking and exposure to leaded gasoline (commuting). Occupational exposure to lead is prevalent among a wide spectrum of Lebanese workers. Physicians are called upon to inquire more about the potential for lead exposure, especially among blue-collar workers. A policy action to improve working conditions and to phase out the use of leaded gasoline is recommended.

Patterns and predictors of employer risk-reduction activities (ERRAs) in response to a work-related upper extremity cumulative trauma disorder (UECTD): reports from workers' compensation claimants.

BACKGROUND: Despite being preventable, work-related upper extremity cumulative trauma disorders (UECTDs) remain problematic. This study is unique in its focus on predictors of employer risk-reduction activities (ERRAs) in response to a UECTD case. METHODS: Workers' compensation claimants (N = 537) completed a telephone survey about employer risk-reduction activities, workplace characteristics, safety programs, and physician recommendations for job modifications. RESULTS: Only 52% of respondents reported employer actions to investigate or reduce UECTD risk. Engineering and pace changes were prominent for keyboard workers and transfer to another job for manufacturing workers. Safety programs and physician recommendations increased the likelihood of risk-reduction activities. CONCLUSIONS: An opportunity to intervene post-injury to reduce risks for the injured worker and prevent new UECTD cases is being missed. Physician recommendations are strongly associated with specific ERRAs thought to be most effective. Educating employers and physicians about ergonomics could result in prevention of UECTDs.

The impact of occupational injury on injured worker and family: outcomes of upper extremity cumulative trauma disorders in Maryland workers.

BACKGROUND: Surveys have identified a dramatically rising incidence of work-related upper extremity cumulative trauma disorders (UECTDs). Outcome studies have addressed time lost from work and cost of compensation; omitting other significant consequences. We assess health, functional and family outcomes. METHODS: We identified 537 Workers' Compensation UECTD claimants. A computer-assisted telephone questionnaire was used to elicit symptom prevalence, functional impairment, depressive symptoms (CES-D scale), employment status. RESULTS: One to 4 years post-claim, respondents reported persistent symptoms severe enough to interfere with work (53%), home/recreation activities (64%) and sleep (44%). Only 64% of responses to the activities of daily living scale items indicated "normal" function. Job loss was reported by 38% of respondents, and depressive symptoms by 31%. CONCLUSIONS: Work-related UECTDs result in persisting symptoms and difficulty in performing simple activities of daily living, impacting home life even more than work. Job loss, symptoms of depression, and family disruption were common.

Narghile (hubble-bubble) smoking, low birth weight, and other pregnancy outcomes.

Narghile smoking, a common habit among women in many non-Western societies, is assumed by the public to be minimally harmful. This study aims at identifying the effect of smoking narghiles during pregnancy on the weight of the newborn and other pregnancy outcomes. Three groups of pregnant women were interviewed in several hospitals in Lebanon between 1993 and 1995: 106 who smoked narghiles during their pregnancy, 277 who smoked cigarettes, and 512 who did not smoke. The adjusted mean birth weight of babies born to women who smoked one or more narghiles a day during pregnancy and to women who started smoking in the first trimester was more than 100 g less than that of babies born to nonsmokers (p < 0.1). The adjusted odds ratio of having babies with low birth weight (<2,500 g) among the narghile smokers was 1.89 (95% confidence interval (CI) 0.67-5.38). The risk increased to 2.62 (95% CI 0.90-7.66) among those who started smoking narghiles in the first trimester. A stronger association and a dose-response relation were found among cigarette smokers. The association between narghile smoking and other pregnancy outcomes, especially Apgar score and respiratory distress, was also noticeable. Further research and a policy action to fight the misperception that narghile smoking is safe are both recommended.

Case-control study of cancer risk in tetraethyl lead manufacturing.

A case-control study was conducted to investigate the relative risk of cancer detection among Du Pont employees who worked in a tetraethyl lead (TEL) manufacturing area. The study's objective was to determine whether the employees' risk of developing or dying from cancer was associated with occupational exposure to TEL. All malignant neoplasms detected in the active and pensioned employee population during the period 1956-1987 were studied. TEL exposure was estimated by the following measures: ever employed in the TEL area, years of employment in TEL, TEL exposure rank, and the TEL cumulative exposure index. TEL manufacturing exposed employees to both organic and inorganic lead compounds. Because the underlying data did not permit the exposure assessment to distinguish between organic and inorganic lead, the TEL exposure measures reflect exposure to the TEL manufacturing process itself. The effects of latency, cigarette smoking habits, and exposures to other known or suspected carcinogens at the plant were also assessed. A strong association was observed between exposure to the TEL manufacturing process and rectal cancer (the odds ratio was 3.7 with 90% confidence limits of 1.3-10.2 for the analysis of ever/never exposed to TEL). An exposure-response relationship was noted with a fourfold elevation in the odds ratio at the high-very high cumulative exposure level. These patterns were even more pronounced after assuming a 10 year latency. Similar results were obtained for cancers of the sigmoid colon. These findings suggest that exposure to the TEL manufacturing process may have played a causal role in the colorectal cancer experience at the plant. This position is supported by the graded exposure-response relationships, the consistency of the results across exposure measures, the specificity of the health outcome (i.e., colorectal cancer), and the strength of the association. However, the evidence for causality is not compelling. This is the first report of an association between TEL manufacturing and colorectal cancer, and the evidence is compatible with a wide range of causal (i.e., indirect vs. direct acting; initiating vs. promoting) and noncausal (i.e., statistical and methodological bias; coincidence) interpretations.

Most common diseases treated in primary health care facilities in Lebanon.

The Lebanese Ministry of Health has requested public health experts to assess the most common health problems seen in Primary Health Care (PHC) facilities. This paper presents the results of this assessment conducted in a convenience sample of PHC centers. The assessment aimed at identifying areas of strength and gaps in the current system. Data were drawn from 23 PHC centers in various regions of Lebanon, in addition to an 8-year review of the experience of the Department of Family Medicine at the American University Hospital. In general, 46% of all visits to PHC centers did not include any kind of diagnosis. Most centers provided data on large categories of diseases without breakdown into specific entities. The most commonly identified health problems were hypertension, diabetes and asthma, in addition to eye and ear diseases, cardiologic conditions, and dermatologic problems. Other health problems included ill-defined signs and symptoms associated most likely with mental distress. Dental caries, skin and hair parasites, and respiratory tract infections topped the health problems among children. A qualitative synopsis of all data is presented. The paper highlights the limitations of the current health information system in Lebanon, and suggests corrective measures. It also presents a number of recommendations regarding the optimal use of PHC centers for health education and promotion and for disease prevention.

Work activities and the onset of first-time low back pain among New York City fire fighters.

In a prospective study of first-time low back pain among New York City fire fighters, a total of 115 cases and 109 randomly selected controls were interviewed by telephone between December 1988 and July 1989 to examine the role of recent work activities in the onset of first-time low back pain. After adjusting for known risk factors and off-duty activities, statistically significant high-risk work activities included operating a charged hose inside a building (odds ratio (OR) = 3.26), climbing ladders (OR = 3.18), breaking windows (OR = 4.45), cutting structures (OR = 6.47), looking for hidden fires (OR = 4.32), and lifting objects > or = 18 kg (OR = 3.07). Low-risk activities included connecting hydrants to pumpers (OR = 0.36), pulling booster hose (OR = 0.19), and participating in drills (OR = 0.09) or physical training (OR = 0.16). When further adjusted for exposure to smoke (OR = 13.59), a surrogate for severity of alarms, the ORs associated with high-risk activities were no longer significant. This, however, does not diminish the role of activities in the onset of low back pain. Instead, it suggests an inseparable role for activities and environmental hazards. To examine this, the risk of low back pain was measured within five work zones sequential in time relative to location and distance from a structural fire. The risk gradually increased as the fire fighter moved away from the firehouse (OR = 0.10) and closer to the site of fire (OR = 3.91).