Seroepidemiology of hepatitis B virus infection in Saudi children 8 years after a mass hepatitis B vaccination programme.

OBJECTIVES: On October 1 1989, a programme was begun in Saudi Arabia in which the HBV vaccine was added as the 'seventh' primary immunogen of the Extended Programme of Immunization (EPI). In 1990, another programme was launched by the Ministry of Health to vaccinate all school children. Eight years after this mass vaccination programme, the efficacy of HBV vaccine was evaluated in a community-based study. METHODS: A community-based study was carried out in Saudi children in urban and rural areas, covering all the regions of Saudi Arabia. After informed consent, blood samples were obtained and tested for HBV markers. RESULTS: Among 4791 vaccinated Saudi children aged 1-12 years, only 15 were found to be HbsAg-positive (0.31%). HbsAg-positivity was 0.16% in children vaccinated at birth compared with 0.7% in those vaccinated at school entry. The overall HbsAg carrier rate dropped from 6.7% in 1989 to 0.3% in 1997 (P<0.00001). Similarly, there was a significant reduction in the prevalence of anti-HBc from 4.2% in 1989 to 0.46% in 1997 (P<0.00001). The overall seroconversion rate to HB vaccine among 4087 Saudi children up to 12 years of age was about 77%. Seroconversion rate in those vaccinated at birth was 77% compared with 71% in those vaccinated at school entry. After 8 years of receiving the third vaccine dose, close to 65% of the children had an anti-HBs titre of more than 10 IU/l compared with about 28% who had an anti-HBs titre of more than 100 IU/l after the same period. CONCLUSION: The result of this study demonstrates the tremendous impact of the mass HB vaccination programme on the seroepidemiology of HBV infection in Saudi Arabia. The ultimate goal of preventing HBV-related chronic liver disease and hepatocellular carcinoma in Saudi Arabia is foreseeable in the near future.

Hepatitis A in Saudi Arabia: A comparative sero-epidemiological study.

Full text is available as a scanned copy of the original print version.

Stroke register: experience from the eastern province of Saudi Arabia.

A stroke registry was established in the Eastern Province of Saudi Arabia with an estimated population of 750,000 inhabitants of whom 545,000 are Saudi citizens. The register started in July 1989 and ended in July 1993. The Gulf war led to its interruption from August 1990 to August 1991. Four hundred eighty-eight cases (314 males, 174 females) of first-ever strokes affecting Saudi nationals were registered over the 3-year period. The crude incidence rate for first-ever strokes was 29.8/100,000/year (95% CI: 25.2-34.3/100,000 year). When standardized to the 1976 US population, it rose up to 125.8/100,000/year. Ischemic strokes (69%) predominated as in other studies but subarachnoid hemorrhage (SAH) was extremely rare (1.4%). The important risk factors were: systemic hypertension (38%), diabetes mellitus (37%), heart disease (27%), smoking (19%) and family history of stroke (14%). Previous transient ischemic attacks (3%) and carotid bruits (1%) were uncommon. The 30-day case fatality rate was 15%. The study showed that the age-adjusted stroke incidence rate for Saudis in this region is lower than the rates reported in developed countries but within the range reported worldwide. The pattern of stroke in Saudi Arabia is not different from that reported in other communities with the exception of the low incidence of SAH. The risk factors are similar to findings in other studies except for the high frequency of diabetes mellitus in our cases. The lower mortality rate was probably due to the younger age of the population and the availability of free medical services for management of cases.

Biliary leak: Endoscopic management.

The objective of this study was to evaluate the effectiveness of endoscopic treatment in patients with biliary leak. The study was performed at King Khalid University Hospital in Riyadh. We used retrospective analysis of the complete records of 18 patients with biliary leak treated endoscopically over a period of 10 years. The mean age was 41.11 +/- 14.54 years. Ten were male. The leak was complicating cholecystectomy, biliary surgery for hydatid cysts and road traffic accidents in 15, two and one patients. Of the 17 patients cystic duct remnant in 11, common bile duct in three and intrahepatic duct in four patients. Of the 17 patients who had endoscopic papillotomy (EPT), this procedure was combined with stenting in 11, with stone retrieval in two, with stone retrieval and stenting in three and with dilatation of a stricture in one patient. Another patient was treated with a stent without papillotomy. In all patients, the leak healed and the stent was removed after a mean stenting duration of 65.12 +/- 41.89 days. No complications were encountered in this group of patients. Endoscopic management of biliary leak is a simple, safe and effective therapeutic method. Therefore, we recommend its application as first-line management of biliary leaks.

Community survey of neurological disorders in Saudi Arabia: Results of the pilot study in Agrabiah.

A pilot study of the Agrabiah area in Al-Khobar was undertaken to field test study methodologies and identify possible limitations and constraints to a planned community survey for neurological disorders in the Eastern Province of Saudi Arabia. The survey used a pre-tested questionnaire administered by trained personnel to all subjects living within 50 blocks randomly selected from the 198 inhabited ones in the area. Subjects with abnormal responses on screening were then evaluated by neurologists using specific guidelines and criteria to establish the diagnosis of neurological disease. One thousand four hundred and eighty-five subjects (98.3% of all eligible subjects) were screened: 227 (15%) had abnormal responses. Of the 202 subsequently evaluated by neurologists, 178 had definite neurological disease. The overall crude prevalence rate (PR) per 1000 population for neurological morbidity was 120.5 (95% confidence limits [CL] 103.5 to 136.5). Headache syndromes (PR 99.7, CL 83 to 114.7) were common. The other common disorders were seizures (PR 10.2, CL 5.1 to 15.3), peripheral nerve disorders (PR 2.7), and stroke (PR 2.0). Mental retardation and cerebral palsy were the main pediatric problems with PRs of 1.4 and 0.7 respectively. Our results show that a community survey for neurological disorders is feasible in Saudi Arabia and the modified questionnaire was a good screening instrument (sensitivity 94.7%, specificity 96.8%). However, the findings on the pattern and prevalence of neurological disorders need to be viewed with caution, particularly against the background of the scope of the study and the small number of subjects assessed. Cultural practices, local time and social events, and climatic conditions significantly affected community participation and the coverage achieved by the study. These factors should be considered when planning community surveys in Saudi Arabia and other environments with similar sociocultural settings.

Refractory duodenal ulcer.

Refractory or intractable ulcer is defined as an ulcer that fails to heal completely after eight to twelve weeks, despite appropriate treatment with a modern antiulcer therapy in a compliant patient. Refractory ulcer should be suspected in individuals diagnosed to have peptic ulcer if their symptoms persist longer than usual: occurrence of complications or simply their ulcers fail to heal, since up to 25% of such patients remain asymptomatic. Conditions associated with refractory ulcer include noncompliance, continuous consumption of nonsteroidal anti-inflammatory drugs, acid hypersecretion, smoking. male gender and other factors with questionable role like advanced age, large ulcer size, prolonged duration of symptoms and the presence of complication like bleeding. Nonpeptic ulcers like tuberculosis, malignancy, Crohn's disease and primary intestinal lymphoma should always be considered in the differential diagnosis. Colonization with H. pylori which is well-known as a cause of frequent recurrences, has not been linked with refractoriness. Patients with refractory ulcers must undergo thorough re-evaluation including repeated endoscopies, obtaining biopsies for microbiology and histology and determination of serum-gastrin level. Once diseases with identifiable etiologies have been ruled out, aggressive medical management with single or multiple antiulcer drugs should be instituted. Such treatments will virtually heal all refractory ulcers. Surgery should be reserved for patients whose ulcers fail to respond to optimal medical therapy or those who develop complications necessitating surgical intervention.

Pattern of chronic liver disease in the eastern province of Saudi Arabia. A hospital-based clinicopathological study.

During the period 1982-1990, 544 patients with clinical evidence of liver disease were admitted to King Fahd University Hospital, Al-Khobar, Saudi Arabia. Besides routine laboratory and sonographic investigations, all were subjected to either a needle liver biopsy, laparoscopy or a laparotomy. The tissue diagnoses were as follows: liver cirrhosis 17.3%, periportal fibrosis 14.3%, metastatic cancer 12.9%, primary hepatoma (hepatocellular carcinoma: HCC) 12.1%, hepatic granuloma 11.2%, chronic active hepatitis 7.7%, chronic persistent hepatitis 2.2%, fatty liver 7.2%, hydatid liver disease 4.6% and others 2.8%. In 7.7% the histology was normal. These results will be discussed and compared with results reported in local and international literature.

The microbiology of acute diarrhoeal disease in the eastern province of Saudi Arabia.

A prospective study of acute diarrhoeal diseases in the Eastern Province of Saudi Arabia was carried out over a 19-month period to determine aetiology, risk factors and other epidemiological characteristics. Of the 853 subjects studied, 344 were cases and 509 controls. More cases were seen in children than in adults. Enteric pathogens were detected in 49% of the cases, but none in the controls. Of the pathogens, 68% were bacterial with Salmonella (34%) and Shigella species (14.7%) being the most common; Campylobacter jejuni emerged as an important cause especially in adults. Contrary to most reports, rotaviruses were responsible for only 11.5% of the cases in children. Entamoeba histolytica (13.5%) and Giardia intestinalis (10.4%) were parasites commonly detected. Shigella organisms were the only pathogens that were isolated in hospital cases without being isolated in cases from the community.

Prevalence of hepatitis B surface antigenemia among patients with schistosoma mansoni.

This case-control study was designed to determine the prevalence of persistent hepatitis B surface antigenemia (HBsAG) among patients with schistosoma mansoni and to rationalize their vaccination against hepatitis B virus (HBV) infection. Seventy consecutive patients with a confirmed diagnosis of schistosoma mansoni were matched for age, sex, nationality, and residence (for Saudis only) with 70 healthy controls. Despite identical mean ages, sex, and nationality distribution, 18 schistosomiasis patients (26%) had positive HBsAg as compared with only three of the controls (4%). The odd ratio for HBsAg antigenemia among patients as compared to controls was 7.73 (95% confidence interval (CI) = 2-35.01, P = 0.0004. Neither sex nor nationality had any influence on the positive rate for HBsAg found in schistosomiasis patients. Patients with schistosomiasis and a concomitant positive HBsAg had significantly more derangement of their hepatic enzymes (14 out of 18; 78%) as compared with those without this viral serological marker (22 out of 52; 42%) (odd ratio - 4.77; 95% CI=1.22-20.11; P = 0.009). I have concluded that patients with schistosoma mansoni are exposed to a higher risk of acquiring HBV infection and that concomitant schistosomiasis and HBV infection has a deleterious effect on hepatic enzymes as well as other liver functions. Prospective evaluation of the preventive role of HBV vaccine among these patients is warranted.

Abdominal tuberculosis in Saudi Arabia: a clinicopathological study of 65 cases.

The clinical and pathological features of 65 patients with abdominal tuberculosis obtained during a 7-yr period were analyzed and the diagnostic procedures critically evaluated. The diagnosis was histologically confirmed in 59 patients. In two more patients, the diagnosis was based solely on a positive ascitic fluid culture for tubercle bacilli. The remaining four patients responded dramatically to anti-tuberculous chemotherapy given on suspected laparoscopic findings in cases in which no biopsy was taken. Laparoscopy was found to be safer and superior to laparatomy and is recommended as an initial investigation in the diagnostic work-up of patients in whom tuberculous peritonitis is suspected. Furthermore, the finding of granulomatous inflammation in peritoneal biopsy is a justification for immediate therapy in such patients. This is particularly valid in endemic areas if one considers the risks of delaying treatment of these patients.

A community survey of neurological disorders in Saudi Arabia: the Thugbah study.

We report the findings of a total population survey of Thugbah community in the Eastern Province of Saudi Arabia (SA) to determine its point prevalence of neurological diseases. During this two-phase door-to-door study, all Saudi nationals living in Thugbah were first screened by trained interviewers using a pretested questionnaire (sensitivity 98%, specificity 89%) administered at a face-to-face interview. Individuals with abnormal responses were then evaluated by a neurologist using specific guidelines and defined diagnostic criteria to document neurological disease. The questionnaire was readministered blind by a neurologist to all those with abnormal responses and a 1-in-20 random sample of those without abnormal responses, respectively. The family members of an individual with an abnormal response were also screened to improve accuracy. A total of 23,227 Saudis (98% of the eligible subjects) were screened and those residing in Thugbah on the reference date (22,630) were used to calculate the point prevalence rates. Forty-two percent of those screened were in the first decade of life and only 1.5% were more than 60 years old. There were marginally more females (50.2%) than males (49.8%). Consanguineous marriages especially between first cousins were present in 54.6%. The demographic characteristics of Thugbah community were similar to those in other parts of SA. The overall crude prevalence ratio (PR) for all forms of neurological disease was 131/1,000 population. All subsequent PRs are per 1,000 population. Headache syndromes were the most prevalent disorder (PR 20.7). The PR for all seizure disorders was 7.60, and the epilepsies (6.54) were more frequent than febrile convulsions (0.84). Mental retardation, cerebral palsy syndrome, and microcephaly were common pediatric problems with PRs of 6.27, 5.30 and 1.99, respectively. Stroke, Parkinson's disease, and Alzheimer's disease were uncommon with respective PRs of 1.8, 0.27 and 0.22. Central nervous system (CNS) malformations (0.49) such as hydrocephalus and meningomyelocele were more prevalent than spinal muscular atrophy (0.13), congenital brachial palsy (0.13) and narcolepsy (0.04). Multiple sclerosis was rare (0.04). Osteoarthritis and low back pain syndromes were the main non-neurological conditions seen. The major medical diseases that may be neurologically relevant were diabetes mellitus, hypertension, and connective tissue disorders.(ABSTRACT TRUNCATED AT 400 WORDS)

[Cerebrovascular disorders in young adults in Saudi Arabia. A study of 136 cases]. / Accidents vasculaires cérébraux des adultes jeunes en Arabie Saoudite. Etude de 136 cas.

We report our experience of stroke in 136 young adults aged from 18 to 45 years seen in the Eastern Province of Saudi Arabia over a 10-year period. They constituted 25% of all our stroke cases. Thirty-eight percent were Saudi nationals and 62% expatriates. Males largely outnumbered females. The frequency of cerebral infarction (54%) was not very different from that of intracranial hemorrhage (45%). Atherosclerosis and embolism of cardiac origin were the major causes of infarction. The main causes of intracranial bleeding were arterial aneurysms, arteriovenous malformations and hypertension. However, the causes of 29% of ischemic strokes and 44% of hemorrhagic ones remained undetermined. Interethnic comparison of the causes showed that hemorrhages were significantly more frequent in Far East immigrants. Sixty five percent of cerebral infarctions in Asiatic patients remained of undetermined origin. The local variant of sickle cell gene did not seem to play a major role in the pathogenesis of stroke in the Saudi young adult. These data are commented and compared with similar reported data. The influence of the demographic structures of the Saudi population and immigrants communities is analyzed.

Tuberculous peritonitis: the value of laparoscopy.

The laparoscopic and pathological diagnoses of 43 patients who underwent abdominal laparoscopy for various indications are presented. Major indications for the laparoscopy included hepatomegaly in 32 patients, ascites in 28, and pyrexia of unknown origin (PUO) in 18 patients. A combination of two or more of these indications was a more common feature. The most frequently encountered laparoscopic diagnoses were tuberculosis and chronic liver disease (16 patients each), followed by cancer (9 patients). However, on pathological examination of peritoneal or liver biopsy tissue and on follow-up, tuberculosis was confirmed in 12 patients, chronic liver disease in 14 patients and hepatocellular carcinoma in 11 patients. No complications were encountered during the laparoscopy. Our findings indicate that abdominal laparoscopy is a safe, quick and inexpensive diagnostic tool, particularly when appropriate and adequate tissue is taken for pathological examination. In such instances, laparoscopy would save an unnecessary laparotomy, especially where tuberculosis and cancer are considered in the differential diagnosis.

Evaluation of students' performance and examination procedures in final certifying examinations in internal medicine (1982-1988).

We conducted a retrospective analysis to evaluate the performance of 459 students on their final certifying examination in internal medicine. These examinations were taken during 1982 through 1988, and the failure rate was 17.6%. Two hundred and five students (44.6%) received grade D (60-69% of the total marks) and 139 (30.1%) grade C (70-79% of total marks). Only 7.7% of the students scored higher (80% or more). A temporal trend has been observed in that a higher percentage of lower grades and lower percentage of higher grades has been observed in recent (1986-1988) compared with earlier (1982-1984) years. Female students generally performed on a par with males, though males students performed better on multiple choice questions (MCQs). The analysis also showed lower mean scores for the essay, oral, and clinical components in recent (1986-1988) than in earlier (1982-1984) years. In studying the interrelationships between different examination components, the MCQs were found to have the highest correlation with other procedures. A lower correlation was observed for clinical examination. Factor analysis also showed that MCQs had the highest and clinical examinations the lowest factor loading. Low correlation and factor loading were also noted for the essay portion. While in the newly implemented curriculum the essay paper has been wisely eliminated, our data suggest that the traditional clinical examination should be replaced by a more objective and structural method. Our analysis may serve as a guide for formulation of final certifying examinations in medical schools throughout the Kingdom.

A single nocturnal dose of famotidine for the treatment of duodenal ulcer: evaluation of efficacy and safety.

The efficacy and safety of a single nocturnal dose of famotidine (40 mg) was evaluated in 30 consecutive patients of duodenal ulcer (DU). Three patients were lost for follow-up and therefore were excluded. The mean age of remaining 27 patients was 34.3 (+/- 9.9) years and male to female ratio was 8:1. The mean size of the DU was 1.21 (+/- 0.79) cm. After a 4-week therapy all patients showed significant improvement and repeat endoscopy in 24 out of 27 patients (89%, 95% confidence interval; 78% to 100%) showed healed ulcer. Clinical assessment of pain relief at 4-week showed significant drop in the mean score of baseline daytime (from 1.85 to 0.13) and baseline nocturnal pain (from 1.70 to 0.10) (p less than 0.0001 and less than 0.0001, respectively). Also shown was the significant decrease in the mean gastrointestinal symptoms score from 5.89 at baseline to only 0.89 at 4-week (p less than 0.0001). Despite that all those who failed to show ulcer healing at 4-week were smokers, logistic regression analysis could not identify smoking or any other risk factors as adverse predictors of ulcer healing. None of the patients experienced significant side effects or adverse reactions. We conclude, that a single nocturnal dose of famotidine is a practical, highly effective and safe approach for the management of DU.

Pattern and ethnic variations in stroke in Saudi Arabia.

We report our observations in 427 stroke patients (305 Saudis, 122 non-Saudis with an age range of 14 months to 85 years) seen in a tertiary hospital in the eastern province of Saudi Arabia over an 8-year period. Of these patients, 115 (27%) were between 18 and 45 years old, and constituted the "young stroke patients" for this study. The hospital frequency for the young was 5/10,000 inpatients. In general, there was a male preponderance, with a male:female ratio of 2.2:1 and 7:1 for Saudis and non-Saudis, respectively. Ischemic stroke (55%) was more frequent than hemorrhagic stroke (25%), and the stroke was unspecified in 20%. The main etiologic factors were hypertension, diabetes mellitus and cardiac disorders. In the young population, the frequencies of hemorrhagic and ischemic strokes were similar. In this group, the main causes of intracerebral hemorrhage were aneurysms and arteriovenous malformations, while arteriosclerosis and embolism of cardiac origin were responsible for the ischemic strokes. In Saudis, the stroke types were 59% ischemic, and 17% hemorrhagic, as against 45 and 48% in non-Saudis, respectively. Most ischemic strokes were found in Saudis (78%). Intracerebral hemorrhage accounted for 63% of all hemorrhagic strokes, and was more frequent in Saudis but subarachnoid hemorrhage was three times more common in non-Saudis. In the young stroke patients, interethnic comparison showed that individuals from the Far East were nine times more likely to have hemorrhagic than ischemic stroke compared to the others (odd's ratio = 8.7), and the etiology of ischemic stroke remained undetermined in 67% of those from the Indian subcontinent.(ABSTRACT TRUNCATED AT 250 WORDS)

Stroke in a tertiary hospital in Saudi Arabia: a study of 372 cases.

Epidemiological studies have shown a consistent downward trend in the incidence and mortality of stroke in industrialized communities. There are however no reports on the pattern of stroke in Saudi nationals and expatriates in Saudi Arabia. The types and etiologies in 372 subjects (262 Saudis, 110 non-Saudis) are described. Males outnumbered females in the ratios of 2.2:1 and 8.2:1 for Saudis and non-Saudis, respectively. The frequency of stroke increased steadily with age until the 7th decade in Saudis but dropped sharply after the 6th in expatriates. The frequency of stroke types in Saudis was ischemic (61%), hemorrhagic (17%) and unspecified (22%) as against 46, 47, and 7% respectively in non-Saudis. Intracerebral hemorrhage was more frequent than subarachnoid hemorrhage (SAH) and was encountered more often in Saudis than in non-Saudis; SAH was 3 times more common in expatriates than in Saudis. The major predisposing factors for stroke were hypertension, diabetes mellitus, and cardiac disorders. Abnormal hemoglobinopathies, especially sickle cell anemia, were rare. The differences observed in the age and sex distribution and in the stroke pattern between Saudi nationals and expatriates most likely reflect the demographic structure existing in Saudi Arabia.

Pattern of upper gastrointestinal disease in the eastern province of Saudi Arabia. Endoscopic evaluation of 2,982 patients.

The records of 2,982 patients who were subjected to upper gastrointestinal (UGI) endoscopy were retrospectively analyzed. All patients were seen at King Fahd Hospital of the University, Al-Khobar during the period 1982-1986. All were adult patients with a mean age of 46 years, of whom two thousand nine (67.4%) were males. The commonest endoscopic diagnosis was chronic gastritis (21.4%) followed by duodenal ulcer (17%) and chronic oesophagitis (11.7%). Of 1,256 biopsied patients a 'histologically normal' diagnosis was obtained in 565 (45%) from all sites. However, chronic non-specific superficial gastritis (22.6%) followed by chronic duodenitis (17.5%) constituted the two commonest histological diagnoses. Helicobacter pylori was identified histologically on the gastric mucosa of 72% of patients with superficial chronic active gastritis, with or without associated peptic ulcer disease. Duodenal ulcers followed by oesophageal varices were the two commonest diagnoses encountered in 200 patients presenting with UGI bleeding. These results are discussed and compared to those of other studies.