Principles of

Epidemiology

Dr. Yehia Abed

ProfessorThird
of Public
EditionHealth
Al - Quds University
2020
Founder Dean Faculty of Public Health
 Principles of

Epidemiology

By
Dr. Yehia Abed
Professor of Public Health
Al - Quads University

Third Edition

2020
 Dedication

I dedicate this book for the memory of the founders of Public Health
in the Gaza Strip, those I had the honor to work closely during their
life. Namely, I remember Dr. Khairy Abo Ramadan, Dr. Naim Ali
Hassan, Dr. Mohmed Abo Shaban, Dr. Botrous Arminios, Dr. Sameh
Shaheen, Dr. AbdEl Hamid Genaina, Dr. Kamal Abdallah, Dr. Abd El
Jabar El Tebe and Mr. Ahmed Morad.

They spent all their life to initiate public health activities to ensure
good health for the Palestinians. Forever we will remember them for
their patience, moral, and unending scarifies they made through the
difficult time at Gaza.

I
 Acknowledgment
First, I thank Allah for helping me every moment during my life of
educational marsh inside and outside my loved country Palestine. I
would like to express my deep gratitude and sincere thanks to my
teachers in Assiout, Jerusalem and Baltimore during my medicine,
master and doctorate studies.
Moreover, I would like to thank all academic and administrative
staff at the School of Public Health, Al-Quds University in Jerusalem
and Gaza and for the academic staff at Al Azhar University and
Islamic University for their love, respect, support and for their
inspiration and guidance during my work.
Also, many thanks and deep respects for all the health care
providers in the Palestinian Ministry of Health, UNRWA and NGOs
with their different positions for sharing work during my 40 years’
experience of health work with them at different and difficult
stages. Without their hard-sustainable work, public health words
remain meaningless. Thanking them for doing the work and leaving
the chances for academics to talk about their achievements.
Besides, I would like to express my deepest appreciation and
special thanks to my students in the faculties of medicine,
pharmacy, science and for master students in public health,
community mental health and environmental health for their
endless and friendly support, enthusiasm and energetic
commitment during the classes and their contribution to this book.
Thanks to Maha ElBana, Ahmed El Khodary and Safa Hewar for
editing the text.
A special word of thank for my family members for the considerable
patience and the help they provided me while conducting my work.

Yehia Abed

II
 Introduction
This is a new version of this book; we aggregate the epidemiological
subjects in four chapters: General concepts and health indicators,
Epidemiological studies, Clinical Epidemiology, and Epidemiology
and health policy. In the first part, we review the history of
Epidemiology, the definition of health and diseases, health services
and health indices. The second part deals with the study types and
design of the Epidemiological studies, measurements of risk in
Epidemiological studies and exploration for accuracy factors for the
studies such as cofounders, bias and interaction between the study
variables. The third part is clinical epidemiology with a focus on
Screening tests, Epidemiology of communicable diseases,
Epidemiology of Non-Communicable Diseases, Epidemiology of
Nutrition and Epidemiology of Reproductive Health. The fourth part
includes areas related to Epidemiology and Health Policy and
includes “from data to decision making”, “Planning for health” and
“Evaluation of health services”.
Principles of Epidemiology Parts and Chapters
1. General concepts and Health indicators
Chapter 1: General concepts
Chapter 2: Health Indices
2. Epidemiological Studies
Chapter 3: Measurement of Risk
Chapter 4: Study types and design
Chapter 5: Association
3. Clinical Epidemiology
Chapter 6: Screening
Chapter 7: Epidemiology of communicable diseases
Chapter 8: Communicable Diseases Control in the Gaza Strip
Chapter 9: Epidemiology of non-communicable diseases
Chapter 10: Environmental Epidemiology
Chapter 11: Epidemiology of Nutrition
Chapter 12: Reproductive Epidemiology
4. Epidemiology and Health Policy
Chapter 13: Planning for health
Chapter 14&15: From data to decision making
Chapter 16: Evaluation of health services

III
 Abbreviations
ANOVA Analysis of Variance
ARI Acute Respiratory Infections
ASR Age Standardized Rate
BCG Bacillus of Calmet & Gurin
BMI Body Mass Index
CBR Crude Birth Rate
CD Communicable Disease
CDC Centers for Disease Control and Prevention
CDR Crude Death Rate
CEE/CIS Central and Eastern Europe/Commonwealth of Independent
States
CI Confidence Interval
CVD Cardiovascular disease
DBP Diastolic Blood Pressure
DHS Demographic and Health Surveys
DPaT Diphtheria acellular Pertussis Tetanus
DPT Diphtheria Pertussis Tetanus
EIP WHO Evidence and Information for Health Policy Cluster
EMRO Eastern Mediterranean Region Office
EPI Expanded Program of Immunization
GFR General Fertility Rate
GS Gaza Strip
GIS Geographical Information System
HAV Hepatitis A Virus
HBV Hepatitis B Virus
HCV Hepatitis A Virus
HIB Haemophilus Influenza type b
HIS Health Information System
ICD-10 International Statistical Classification of Diseases 10
IMR Infant Mortality Rate
IPV Inactivated Polio Vaccine
LASSAME Countries in Latin America and the Caribbean, sub-Saharan
Africa and the Middle East
LDL-c Low Density Lipoprotein Cholesterol
MCH Maternal and Child Health

IV
MDG Millennium Development Goal
MHIS Managing Health Information system
MMR Measles, Mumps and Rubella
MMR maternal mortality ratio
MOH Ministry of Health
MPH Master of Public Health
NCD Non-Communicable Disease
NGOs Non-Governmental Organizations
OECD Organization for Economic Co-operation and Development
OR Odds Ratio
PCBS Palestinian Central Bureau of Statistics
PHC Primary Health Care
PMDF proportion maternal among deaths of women of reproductive age
RAMOS reproductive age mortality study TFR total fertility rate
RR Relative Risk
SBP Systolic Blood Pressure
SPSS Statistical Package for Social Sciences
T. T Tetanus toxoid
TG Triglycerides
TOPV Trivalent Oral Polio Vaccine
UN United Nations
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
UNRWA United Nation Relief and Works Agency for Palestinian Refuges
US United States

USA United States of America

WB West Bank
WHO World Health Organization

V
 Table of contents
Dedication
Acknowledgment
Introduction
Abbreviations
Table of contents
PART 1: General concepts and Health indicators 1
Chapter 1: Concepts and definitions 1
Objectives of Epidemiological Investigations: 5
Epidemiological Triangle 8
Immunity 9
Prevention of disease 12
Steps in the epidemiological approach to study problem? 14
Exercise 1 16
Chapter 2: Health Indices 18
Indirect health indices 19
Crude Birth Rate (CBR) 26
Somatic Characters: 27
Morbidity 30
Mortality 31
Infant mortality rate 34
Maternal Death 35
Adjusted Rates 37
Exercise (2 - 5) 38
PART 2: Epidemiological Studies
Chapter 3: Measurement of Risk 43
Relative Risk 44
Odd’s Ratio 45
Exercise 6 -7 48
Chapter 4: Epidemiological Studies 52
Descriptive Studies 52
Prospective Study 55
Case-Control Study 56
Cross-Sectional Study 61
Randomized Clinical Trials (RCTs) 64

VI
Ecological Studies 67
Exercise 8 – 9 67
Chapter 5: Association 70
Bias 71
Confounder 72
Interaction 76
Causal Association 81
Exercise 12 84
PART 3: Clinical Epidemiology
Chapter 6: Screening 85
Validity 85
Reliability 87
KAPA 89
Validity and Reliability in Health Research 89
Exercise 13 – 14 91
Chapter 7: Epidemiology of Communicable Diseases 91
Means of spread of the disease 95
Investigation and control of an epidemic 100
Steps of an outbreak investigation 103
Exercise 15 103
Chapter 8: Communicable Diseases in Gaza 107
Common reported communicable Diseases 113
Treatment services 132
Immunization Program 133
Surveillance 138
Research Studies 141
Public Law 142
Chapter 9: Epidemiology of Non-Communicable Diseases 150
Epidemiological Transition 150
Prevalence of NCDs 155
Risk Factors for NCDs 158
NCDs Intervention strategies and policies 167
Chapter 10: Environmental and occupational epidemiology 174
Environmental Exposures 175
Environmental Exposure Assessment 176
Environmental effects associated with environmental exposures 177
Exercise 16 182

VII
Chapter 11: Nutrition epidemiology 183
Food intake assessment 184
Anthropometric measurements 185
Micro Nutrient Malnutrition 189
Nutrition Policies and strategies 193
Chapter 12: Reproductive epidemiology 196
Women Health Indicators 197
Reproductive Health 198
Maternal Health Services 201
Maternal Mortality 203
Exercise 17 – 18 216
PART 4: Epidemiology and Health Policy
Chapter 13: Epidemiology and health planning 219
Planning in Palestine 222
Strength and Weakness of Planning in Palestine 228
Lessons Learned in the process of planning 229
Chapter 14: Simple Basic SPS 230
How to create an SPSS data file? 230
Data Transformation: Compute – Recode 234
Statistical Analysis 236
Cross Tabulation: Chi-Square test 237
Compare Means (t-test and ANOVA) 238
Exercises 19 239
Chapter 15: Data Management and analysis 240
Central Location and Dispersion 244
Hypothesis testing – P value Regression 249
Calculation of Chi sq test 252
t students test 253
ANOVA 256
Correlation and regression 257

VIII
Chapter 15: Evaluation of Health Services 260
Health System 260
Evaluation Models 262
Types of Evaluation 264
Evaluation Research 271
Clinical Audit 273
Qualitative Research Analysis 278
Bibliography, Author Publications, Academic Supervision 279

IX
 Part One
General concepts and Health indicators
Chapter 1
General Concepts

• History

• Definition of health and diseases

• Health Services

History of Epidemiology
Epidemiology is recently used extensively in all the branches of
medicine and other social sciences. During the second half of the 20th
century, epidemiology subspecialties start to be used in different
universities and research centers mainly: Epidemiology of
communicable diseases, non-communicable disease, cancer, nutrition,
and perinatal epidemiology. In reality, what do we see in modern
epidemiology is the accumulation of experience in this field for
thousands of years. Here are some demonstrative examples.
Epidemiology and Hippocrates (C460 – C370):
Hippocrates is a physician recognized as the father of medicine. He
stated that: “Whoever wishes to investigate medicine properly should
proceed thus. In the first place, to consider the seasons of the year, and what
effects each of them produces. When one comes into a city in which he is a
stranger, he should consider its situation, how it lies as to the winds and the
rising of the sun. One should consider most attentively the waters, which the
inhabitants use, and the ground, and the mode in which the inhabitants live,
and what are their pursuits. Whether they are fond of drinking and eating to
excess, and given to indolence, or are fond of exercise and labor”1

1 (Hippocrates, 1938; quoted in Hennekens and Buring, 1987)

1
Simply before 2500 years, Hippocrates linked the internal environment
of the man with the external environment including the season, the
water and the ground. Medicine was not a disease and a drug and it
was not individual health, it was the health of the population and their
lifestyle.

Epidemiology and Koch postulates:

Koch postulated these scientific points regarding causation of diseases
• The microorganism must be observed in every case of the
disease.

• It must be isolated and grown in pure culture.

• The pure culture must when inoculated into a susceptible animal,

reproduce the disease.

• The microorganism must be observed in and discovered from the

experimentally diseased animal.

Koch postulates are the base for the recent epidemiology of non-
communicable diseases but not for application for all diseases.

Epidemiology and John Snow:

John Snow investigated the epidemic of Cholera in London city and
reported the major findings below. Table 1.1 shows the death rate
among 3 groups of the population based on their water sources. The
findings indicate that source 1 has higher death rates than others.
Snow's finding pointed to source 1 as a source of the epidemic.
Furthermore, Snow demonstrated the distribution of deaths around the
water pumps (graph 1.1). At that time, the epidemic was ended after
giving the advice to boil water before drinking (Snow, 1936).

2
 Table1.1: Cholera death rate per thousand by the source of
drinking water during the London cholera epidemic
Water Supply Population Cholera Deaths Death Rate
per1000
Source (1) 167,654 844 5.0
Source (2) 19,133 18 0.9
Both Sources 300,149 652 2.2
Total 486,936 1,514 3.1

Figure 1.1: Distribution of cholera deaths around the sources of

drinking water during the London cholera epidemic

Snow’s Cholera Map

Figure 1.2: Trends of Tuberculosis Mortality through 100 years

The Decline in Tuberculosis Death rate

3
Modern Epidemiology: Figure (1.2) shows the marked decline in
mortality from Tuberculosis from the mid-nineteenth century long before
the discovery and development of anti-tuberculosis medications. This
was explained by the improvement of Nutrition and general living
conditions (McKeown, 1979). Others contribute such reduction to
specific public health as interventions on factors such as urban
congestion actually played a major role (Szreter, 1988).

Health and Disease

Health: World Health Organization (WHO, 1946) defined health as: "a
state of complete physical, mental and social well-being and not merely
absence of disease". A broader definition of Health is: "A state of
balance between external and internal to reach a state of complete
physical and social wellbeing." Internal factors are referred to as
biological, hereditary, physiological and psychological factors, while
external factors are referred to as social, demographic, financial and
environmental factors.
Public Health: “Is the art of keeping a suitable environment for the
population to live free from disease or disability." It is the health of
groups and not individual cases e.g. school health, environmental
health, and child health. It deals with the determinants of health as
defining risk factors for a specific health problem.
Epidemiology
A. Definition: Epidemiology is defined as:
“Study of distribution and determinants of health,
diseases, and injuries among the human population."

Epidemiology is a science that is not dealing only with diseases but the
main concern is the distribution and the determinants of health,
diseases, and injuries among the human population. Two major terms
have to be clarified, distribution and determinants.

4
Distribution: Distribution of the events by time, place and persons.
This distribution is advisable for all epidemiological studies and
investigations.
Determinants: Any factor, whether an event, characteristic, or other
definable entity, that brings about change in a health condition, or in
other defined characteristics.
Practical definition of Epidemiology is seeking intervention policies Last
JM (2000) defined Epidemiology as: "The study of the distribution and
determinants of health-related states or events in specified populations,
and the application of this study to control of health problems". By this
definition, “Last JM” is calling for control of the health problem following

the Epidemiological investigations.

B. Objectives of Epidemiological Investigations:

[Link] the extent of diseases

[Link] of etiology and mode of transmission of diseases
3. Study the natural history of disease
4. Develop a basis for preventive program
[Link] 6. Foundation for Public policy

1. Determine the extent of diseases: Epidemiological studies reveal

the extension of a problem in the community. That could be a disease,
accident or one of the determinants or risk factors for health.
Accordingly, health policymakers and health professionals are familiar
with the most common prevalent problems and the most common risk

factors associated with these problems in the community.

2. Investigation of etiology and mode of transmission of
diseases: In most countries as soon as one of the infectious diseases
appears in the community, expert teams start the process of
investigation in a trial to identify the etiology of that event and to
describe the mode of transmission of the disease. A traditional example
is the occurrence of food poisoning in one community; the first question

5
will be what the cause of the event is? Is it chemical or biological? If
biological, what type of bacteria caused that event? The second
question will be, what is the mode of transmission is it food, or drink?
What type of food or drink? What are properly the risk factors for the
event? In all events, efforts continue to explore the etiology and the
mode of the transmission of the event.
3. Study natural history of disease: Natural history of the
disease is the sequence of events and path of the organism since
entrance the body, invasion of tissues, the appearance of signs and
symptoms and finally exits from the human body. Epidemiology could
follow each of these stations inside the human body. Such information
is the bases for control measures, to know when and where
intervention is possible.
4. Develop a basis for the preventive program: studies in Palestine
showed the presence of goiter among the schoolchildren. The study
leads to the adaptation of a policy to implement salt iodization. The
same for anemia as a public health problem, steps are going on in
Palestine towards flour fortification with iron to prevent anemia among
the population. Water fluoridation is the third example of the use of
epidemiology for preventive programs.
5. Evaluation: Epidemiological approaches are used for the
evaluation of health programs. To evaluate MCH services in Gaza Strip
a triangulation of quantitative and qualitative research designs were
implemented. Most of evaluative studies depend on measurable
indicators that could be compared through time and in different
localities.

6. Foundation for Public policy: Epidemiological studies reveal

different risk factors for public health problems. When these factors are
proved and directed towards causality; public policy setting is
formulated and implemented. For example, smoking prevention in
public places is a result of epidemiological studies that demonstrated

6
the risk of smoking for cancer and other respiratory and cardiovascular
diseases.
To summarize all the objectives of Epidemiology Figure (1.3) shows an
imaginary example of a disease (x) reported in six geographical areas.

Figure 1.3: Summary of the objectives of the Epidemiological studies

x x x x x
x x xx x x
x x x

Distribution

Comparison

Risk Factors
? Association.
? Causation

Intervention.....

............................. Evaluation...

1. It examines the distribution of disease (x) in different geographical

areas.
2. Epidemiological studies compare the distribution of the disease and
examine variation between the different areas.
3. Applications of epidemiological studies help identification of the risk
factors associated with the occurrence of the disease (x) reported in
the six localities.
4. Furthermore, epidemiology examines the presence of associations
between the disease (x) and the identified risk factors. In addition,
whether these associations are statistically significant or not.

7
5. Further investigations of the detected associations may lead to
causality between the factors and the disease (x).
6. Interventions are recommended to overcome and minimize the
hazards of the detected risk factors.
7. Finally, epidemiology is helping to set evaluation for the
interventions recommended. Evaluation is a measurement of desirable
and undesirable effects.

Epidemiological Triangle
This triangle explains the relationship between three major
components: Agent - Host - and Environment.

Host

Agent Environment

A- Agents:
These are examples of some biological agents and the possible diseases
for each:
1. Biological agents
1.1 Viruses: viral hepatitis A&B, poliomyelitis, influenza, viral
meningitis, herpes simplex.
1.2 Rickettsia: Q fever, Rocky Mountain spotted fever.
1.3 Bacteria: Tuberculosis, Salmonellosis, Brucellosis, and
Streptococcal infections.

8
1.4 Mycosis (fungi): Ringworm (Tinea capitis), Athlete's foot (Tinea
pedis), Candidiasis, Cryptococcosis, Aspergillosis.
1.5 Protozoa: Malaria, Amebiasis, Giardiasis, Cryptosporidiosis.
1.6 Helminths: Intestinal parasites (Ascariasis- pinworms- tapeworms),
Schistosoma.
2. Chemical agents: Pesticides, Kerosene, and chlorine
3. Physical agents: Exposure to heat or cold, Radiation
4. Mechanical agents: Road accidents, falling down and wars
5. Physiological agents: Nutrients and Hormones
6. Psychological factors
B. Host:
There are variations between different hosts in their reaction to getting
diseases. Variation in the characters of the host is an important
determinant of getting disease. Malnourished children are liable to get
infection more than the well-nourished
Personal characteristics: Age, Sex and Genetics
Nutritional status and Immunity
Immunity:
It is the resistance of the host to a disease agent. Immunity is defined
by the CDC as the ability of the human body to tolerate the presence of
a foreign material indigenous to the body (most microbes are identified
as foreign). This ability provides protection from most of the infectious
diseases by the immune system. Immunity to a microbe is usually
indicated by the presence of antibodies to that organism. Immunity
classification is demonstrated in Figure 1.5.
Non-Specific:
Skin, Mucous membrane, Phagocytosis

Specific:
Passive (Natural - Artificial)
Active (Natural - Artificial)

9
 Figure 1.5 Classification of Specific Immunity

Immunity

Passive Active

Natural Artificial Natural Artificial

Specific immunity is for a specific type of antigen while non-specific is

referred to as the ability of the body to tolerate the presence of an
antigen. Active immunity is the immunity produced by the human body
while passive immunity is produced outside then introduced to the
human body. Both types of artificial immunity could be manufactured
and purchased.

Passive immunity:
Passive immunity is the transfer of antibodies produced by one human
or other animal to another. Passive immunity provides protection
against some infections, but this protection is temporary.
Passive immunity could be passive natural as the trans-placental
transmission of antibodies from the mother to her baby. Antibodies are
transported across the placenta during the last 1-2 months of
pregnancy. A second example is the presence of antibodies in human
milk. These antibodies are naturally present in human milk and give
immunity to the child passively.
An example of passive artificial immunity is giving Anti -tetanic
serum or other types of sera. These sera are prepared in the

10
laboratories outside the human body (artificial) and give the human a
temporary immunity passively.

Active immunity:
Active immunity is referred to as immunity produced by the human
body and passive immunity is referred to as immunity formed outside
the person's body. Natural immunity is formed or received without
artificial intervention made by health staff.
According to the CDC, Active immunity is the stimulation of the immune
system to produce antigen-specific humoral (antibody) and cellular
immunity. Unlike passive immunity which is temporary, active
immunity usually lasts for many years, often for a lifetime (CDC, 2013).
Active immunity could be Natural or Artificial.
One example of active natural immunity is to acquire active immunity
after having a natural disease. In general, once persons recover from
infectious diseases, they could be immune to those diseases. The same
results could be achieved after exposure to subclinical doses of a
microbe as exposure to typhoid bacilli.
Examples for active artificial immunity include most of the vaccines
given to the public in general and specifically for children to improve
their immune status.
C. Environment:

The term environment is wide, in this text we refer to three major

components of the environment that influence directly the health status
of the population:
• Physical environment

• Social environment

• Biological environment

The physical environment includes climate, topography and all the

mechanical conditions surrounding the population. The relationship

11
between physical environment and humans could be a direct
relationship as an effect of cold injury syndrome among newborns
during winter and sunstroke during summer months. The major
component of the relationship between the physical environment and
disease is indirect through variation of morbidity and mortality due to
changes in the physical environment.
The social environment: Socio-economic factors are major
determinants of the health status of the population – years of
education, Rural vs. Urban residency and population density are major
socio-economic factors that contribute to health status. Occupational
health focuses on the relationship between the working environment
and the work associated with diseases. Cultural aspects including
traditional habits and religion influence the balance between health and
disease among the population. Based on these facts social
environment is an essential component of the epidemiological triangle.
Biological environment: includes all living harmful and living
beneficial things including, plants, animals and organisms regardless of
their size. The biological environment influences health status
favorably or unfavorably by different mechanisms either directly or
indirectly.

Prevention
Any person regardless of his age, sex or locality is exposed to events
(Actions) that could be followed by undesirable events (complications).
Primary prevention is referred to all steps taken to avoid the occurrence
of the action, while secondary prevention includes all efforts aiming to
minimize the complication of specific actions. Tertiary prevention is the
utilization of the remaining capacity of the body function to keep a
state of balance with the external environment in spite of the
complications.
Figure 1.4 shows the explanation for the level of prevention in relation
to the occurrence of events and the possibility of complications.

12
 Figure 1.4 Levels of the Prevention

Action Complication

Primary Secondary Tertiary

Primary prevention includes all measures to prevent the occurrence

of the undesired event (disease or injury). All the promotive services
are considered as primary prevention. Promotive services include good
nutritional practice, physical fitness, and exercise. A second example
of primary prevention is immunization against infectious diseases.
Health education for healthy people is primary prevention, where public
awareness is improved towards the prevention of occurrence of a public
health problem that could endanger the health. Other examples of
primary prevention include safe water and food supply, safe working
conditions and healthy housing.
Secondary prevention includes measures taken to discover the
events early and subsequently, management is easier and
complications are less. All screening programs such as routine physical
examinations and screening for breast cancer and for cervix cancer are
secondary health services. Giving Oral Rehydration Solution (ORS) to
children with diarrhea is a measure to prevent complications of that
event and considered secondary prevention. So, these measures do
not prevent the occurrence of the event but minimize their sequences.
Tertiary Prevention aims to utilize the remaining body functions to
compensate for the functions that could not be maintained due to the
failure of primary and secondary prevention. Examples of tertiary
prevention include rehabilitation of a patient with limb amputation or

changing occupation in case of a road accident.

13
 Epidemiology and Health Services
Types of Health services
1. Promotive 2. Preventive

3. Curative 4. Rehabilitation
Promotive health services are concerned with the promotion of the
health status of the population. These services aim to maintain the
human body in well-functioning status such as improvement of the
nutrition by taking healthy food that provides the body with the
required nutrients and avoiding an excess of undesirable food items. A
second example is the physical exercises that ensure the fitness of the
body and improve the circulation to ensure enough blood supply for the
vital organs in the human body. Promotive health services are not the
responsibility of the health sector only but require the participation of
other sectors such as education, social welfare, and sports clubs.
Preventive health services are activities aim to prevent an action
that could badly influence health status. In this text, we refer to the
bad influence as a disease or injury. These events could be cured or
lead to disability or death. Preventive health services are classified as
primary prevention, secondary prevention or tertiary prevention.
Curative Health Services: These services could be given in primary
health care centers or inside hospital departments. These services
could be medical or surgical interventions. Care is given to manage
acute or chronic problems. Health professions including doctors and
nurses are only authorized to provide these services.
Rehabilitation Health Services: Rehabilitation centers with
specialized staff are responsible for the provision of these services.
Rehabilitation could be integrated with the primary health care
activities or inside the hospital. The modern trend is to conduct these
activities within community-based programs.

14
Epidemiological approach to study a problem
Dealing with the health problem in the community requires qualified
staff with basic epidemiology training to apply these steps:
1. Initial observation (clinical or Laboratory): This is the first crucial
step to know about the occurrence of the problem through media,
health staff, scientific reports or any other source of information. It is
essential first to know that it is true information by logic and by double-
check.
2. Definition of the problem, in case of diseases, try to identify any
available information as Clinical (symptoms and signs), lab findings,
Pathology or any specific etiological factor.

3. Descriptive Epidemiology: Try to look provisionally for the

available data and categorize your variables based on the three
traditional descriptive domains: time, place and persons.
4. Analytic Epidemiology: -
a. Identify an association.
b. Refine & Test hypothesis.
5. Experimental Epidemiology
6. Epidemiological Reasoning: Is there a statistical association?
Describe the characteristic of groups and characteristics of
Individuals then check for Inferences (Possible causal
relationship.)
7. Identification of Risky groups: Factors associated with
increased risk and Preventive efforts, screening programs, and
early detection

15
 Exercise (1)
1. Epidemiology is:
A. A science, which deals with the inquiry of infectious diseases and their
different classifying ways.
B. A science, which deals with a natural history of a disease and its causes of
the population.
C. A science, which deals with the inquiry of the spread of health and illness
state of the population.
D. A science deals with communicable and non-communicable diseases in the
community.
E. Answer (a) and (b) are correct and complete one another.
2. The observation unit in Epidemiology is:
A. The person who is ill with an infectious disease.
B. A group of healthy persons and sick persons.
C. A person who is ill with a chronic disease.
D. Group of community diseased persons.
E. A group of people ill with a specific disease.
3. Epidemiology is in charge of all the following subjects except:
A. Attack of specific diseases to a specific population.
B. Health policies for health services.
C. The health state and incidence of disease.
D. Follow up of a disease of a specific patient and the result of their treatment
E. The health danger connected with environmental factors and behavioral
factors.
4. In Epidemiology, the incubation period may be defined as the:
A. Time it takes to recover from an infectious disease.
B. Period which begins at the entrance of an infectious agent to the body until the
person recovers.
C. The time period for the infectious agent is in the host.
D. Time between the entrance of the infectious agent and the appearance of signs
or symptoms of the disease.
E. All are correct statements
5. Endemic disease means:
A. Permanent finding in a number of cases.
B. Appearance of disease at the same time in a neighborhood area.
C. The appearance of a number of cases above the expectation.
D. Unusual increase in a number of cases in a defined area.
E. Appearance of disease according to a definite period.

16
6. Tertiary prevention of mental disorder involves:
A. Early diagnosis and prompt treatment to prevent sequels and limit disability
B. Hospitalization for mentally disturbed individuals who are unable to function
under the stress of everyday life.
C. Individual psychotherapy, since groups are not able to shape behavior as well
as individual therapists.
D. Screening large population groups followed by appropriate treatment.
E. Psychiatric rehabilitation designed to produce behavior that will enable the
mentally disturbed individual to function in society.
7. Which of the following is considered as a secondary preventive measure?
A. Infant vaccination.
B. Giving instructions and health education.
C. Vitamin A and D distribution in MCH centers.
D. A mammogram-screening test for breast cancer.
E. Rehabilitation of a patient with limb amputation.
8. An example of tertiary prevention is:
A. A talk to a group of pregnant women on the importance of a balanced diet.
B. A clinical examination for early detection of a dislocated hip injury.
C. Immunization against poliomyelitis.
D. Changing occupation in case of road accident.
E. Pre-employment examination.
9. Primary prevention attempts to:
A. Reduce the extent and severity of health problem to their lowest possible level
B. Focus on the general promotion of health
C. Help people to discover their own problems
D. Seek, detect and treat existing problems early
E. Prevent the occurrence of health problems

17
 Chapter 2
Health Indices

In this chapter, we will demonstrate several indicators used in health

sector. The included indicators are examples of the most important
used indicators; while hundreds of indicators could be used to serve
specific health issues. The goal of this chapter is to explore the
importance and use of number of indicators, the method it is calculated
and the interpretation of these factors.
Health Indicator: Health indicator is defined as “A measure that
reflects, or indicates, the state of health of persons in a defined
population” e.g. the infant mortality rate. It can be used to describe a
situation that exists and to measure change or trends over a period.
Most indicators are calculated as rates; here we will differentiate
between three common terms: Ratio, proportion and rate.
A: Ratio: For example, if we have 4 males and 6 females in a class.
Ratio will express the relationship between two figures: 4 M, 6 F
The ratio of Male to Female = 2:3
B: Proportion: Proportion is a specific type of Ratio in which the
numerator is included in the denominator. In the same previous
example, proportion of males in the class is 4/10 and the proportion of
females is 6/10.
C: Rate: A rate measures the probability of occurrence of some
particular event. A rate is of the form: (x/y) x k
Rate = Number of Events in Specific Period X K

Specified Population at risk of these events

K = 10X, Where
- x = Number of times an event has occurred during a specific interval of time.
- y = Number of persons exposed to the risk of the event during the same interval.
- k = some round number (100; 1,000; 10,000; 100,000; etc…) or base, depending
upon the relative magnitude of x and y.

18
Importance of health indices:
Health indices are used to serve one or more of these areas
• Knowledge: Health indices help for better understanding of the
health status of the population and analysis of the present
situation in the country.

• Making Comparison by Place and Time: Health indices are

important to identify and compare the health status in different
countries and to compare the different sites in a defined country.
Time trends for each health indicator could be demonstrated
through years and measure changes over time.

• Planning: Health indices are used to prioritize areas for

interventions and used to monitor and evaluate health programs.

Direct and indirect Health indices:

The direct health indices are groups of indicators that measure major
events in the human life such as his birth, growth, sickness and death.
While the indirect health indices are groups of indicators reflecting the
surrounding of human that influence health status.

1- Indirect Health Indices:

Socioeconomic status Gross National Product (GNP)
Environment Health services

Indirect Health Indices are factors influence the population health by

indirect way. Rich, educated employed people have better chances of
survival and less chances of disease occurrence. They have the chance
to eat well and to have good housing condition and access to health
services as needed. Nationally there are indicators to measure
demographic and socioeconomic status as population density, Domestic
General Product (GDP) per capita, unemployment rate and poverty

19
rate. A second group of indicators measures the environmental health
status including access to safe water, safe waste and sewage disposal
and breathing air free from pollution. Unhealthy environment affects
passively the population health status. Third group of indicators
measures the availability and access to health services.
Table 2.1: Gaza Key indirect health indicators2
Indicator 2011/12 2016/17 2020

Population size 1.6 million 2 Million 2.2 Million people

people people

Population Density 4.400 people 5.500 / KM

2
6.200 / KM
2
2
/KM

GDP per Capita 1.165 US $ 1.038 $ 1.058$

Unemployment Rate 29% 42% 44.4%

Energy - % of demand met 60% 26-46% 25-71%

Water - % of aquifer safe 10% 3.8% 0%

for drinking

Health hospital beds per 1.8 1.58 Over 1.000 additional

hospital beds needed
1.000 people

Health doctors per 1.000 1.68 1.42 Over 1.000 additional

doctors needed
people

Demographic indicators
Population size, structure and distribution are important components of
the population health. Demography is the science dealing with these
characteristics among the population. Commonly used indicators are
population density, percentage of children under 15 years old,
percentage of aged people, Male to female Ratio. In table (2.1)
population density in the Gaza Strip is 5,500 persons per Km2, the
density in the Gaza Strip is 10 folds higher than the West Bank.
Socio-economic indicators
We use more than one indicator used to measure the socioeconomic
status of the population including years of education, monthly income,

2 UN, 2017, Gaza 10 years later

20
Domestic General Product (GDP) per capita, unemployment rate and
poverty rate. Figure (2.1) shows that in Gaza the GDP is around 1000 $
per capita and unemployment rate is 42%. The most commonly used
indicators are:
1. Annual DGP per capita: figure (2.1) shows that in Palestine DGP
remained constant around 1,500 $ in the last 20 years, with
marked variation between Gaza (1,000 $) and the West Bank
(2000$).
Figure 2.1: Annual DGP (US $) per capita

It is worthy to say that DGP in Israel is 34,000 $ per capita3, 30 folds

higher than Gaza.
2. Poverty Rate
PCBS report (2017) indicated that poverty in Gaza strip is 29.2% of
the total population. Poverty in increasing by time and the gap
between the Gaza Strip and the West Bank is large; the rate is 53% in
Gaza and 13.9 in the West Bank (Figure 2.2).
3. Unemployment Rate
Through 5 years’ unemployment jumped in Gaza from 29% to 42%,
this indicator is a bad indicator for deterioration of the socioeconomic
situation in the Gaza strip and subsequently deterioration of health.

3
[Link]

21
 Figure 2.2: Poverty in Palestine4

GAZA

West Bank

Environmental indicators:
Environmental indicators including access to safe water, safe waste and
sewage disposal and breathing air free from pollution. Here is a
summary for the water status in Gaza strip as measured by related
indicators.
Water Resources in Gaza Strip: Although more than 97 per cent of
households in the Gaza Strip are using desalinated water for drinking
purposes, still number of households are using domestic water as an
alternative resource for cooking and for drinking5. Groundwater is the
main source of water for the Palestinians in Gaza Strip and provides
more than 90% of all water supplies. The main aquifer system in Gaza
is the Coastal Aquifer. The Coastal Aquifer in the Gaza Strip receives an
average annual recharge of 50-60 MCM/y mainly from rainfall, while
the annual extraction rate of this aquifer complex is estimated at 185
MCM in 20126.
Water Quantity and Quality in Gaza Strip: The dramatic
deterioration of water quality in Gaza poses a grave public health threat
4
Palestinian Central Bureau of Statistics, 2018. Household Expenditure and Consumption Survey (October 2016,
September 2016). Press release on living standards in Palestine: expenditure, consumption and poverty. Ramallah -
Palestine.
5UNICEF, 2017. WASH assessment at household level in the Gaza strip. July 2017
6Palestinian Water Authority, 2012. STATUS REPORT OF WATER RESOURCES IN THE OCCUPIED
STATE OF PALESTINE-2012

22
and forms a major challenge for the Palestinian water sector. Based on
WHO recommendation, water quantity standards is 100 l/c/d, while the
estimation of water supply in the Gaza Strip is about 90 l/c/d7.
An assessment conducted in Gaza Strip in 2015 revealed that 68 per
cent of drinking water at the household level is biologically
contaminated8. The extracted water from aquifer is not suitable for
human use, this forced Gazans to purchase desalinated water from
private trucking, more than 90 percent of households in Gaza relay on
private trucking as source of drinking water, which consider as a
financial burden on families9. The main causes of heavily polluted
aquifer along the Gaza Strip are due to untreated sewage and landfills
infiltration, seawater infiltration, fertilizer run-off from agricultural land
and septic tanks in households10. According to the Palestinian Water
Authority (PWA) expects demand for water from the aquifer to increase
by 60 percent by 2020, while the UN confirms that Gaza aquifer could
be unusable by 2016 and irrevocably damaged by 202011. Over-
exploitation of the Coastal Aquifer Gaza’s groundwater has become
saline, and the salinity levels are above the WHO’s standards of 250
milligrams per liter (mg/L)12.
Water Born diseases: Over 90% of water in Gaza does not meet the
internationally accepted standards for human use. This increase the risk
of health problems associated with deteriorated water quality13.
Furthermore, 90-95% of water wells are contaminated with higher than
acceptable levels of nitrates and [Link], nitrate, TDS,
fluoride and sodium concentration ranges from 2 to 9 times the WHO

7 Palestinian Water Authority, 2014. Gaza Water Resources Status Report 2013/2014, 2014.
8 Norwegian Refugee Council, ‘’Desalinated Water Chain in the Gaza Strip, From Source to Mouth’’, 2015.
9 UNICEF, 2018. Humanitarian needs overview. UNICEF
10 Groundwater pollution in Gaza. Source: Fanack after PWA, 2011.
11 United Nations Country Team (UNCT). Gaza in 2020: A Liveable Place? August 2012. Op. cit.
12 PWA, 2014a. Gaza Water Resources Status Report, 2013/2014, December 2014. Available
at: [Link] accessed 10 March 2015.
13 UNRWA (United Nations Relief Works Agency), 2009. Epidemiological Bulletin for Gaza Strip, February

2009. Available at: [Link]

accessed 1 May 2015.
14 PWA, 2014b. Gaza Strip: No Clean Drinking Water, Not Enough Energy, and Threatened Future, March

2014. Available at [Link]/pdf/pwa_gaza_water_fact_sheet_3-[Link], accessed 15 April 2015.

23
standards in 92% of the southern wells15. Besides, around seven per
cent of households in Gaza Strip aren‘t aware which water sources are
safe for drinking and cooking, and this misuse of domestic water can
cause serious waterborne diseases (UNICEF, 2017).
According to PCBS, 2018, 1 out of 10 persons in Gaza use improved
drinking water16. Most children (99.4%) and all mothers did not know
what dental fluorosis is and had not received information about it. The
majority (99.7%) did not know dental fluorosis’ causes or prevention.
Concerning the public perception of dental fluorosis, 87.7% of the
children and 88.6% of mothers did not have a problem with fluorosed
teeth colour17.
Availability and Access to health services
Important determinant of health is the availability of the health services
in the country and population access to the services. This is measured
by number of indicators describing the unit per 1000 population. The
units include beds, doctors, nurses and other health profession per
1000. Access is classified to geographical access measured by distance
needed to reach the services and quality access if the patient can reach
high quality health services. Political access reflects whether public can
be referred or reach the services without barriers. Based on the WHO
report (2016) figure 2.3 shows Israeli responses to patients’ requests
for travel permits for health treatment, 2011-201618. During the year
2016 only 60% of permission to the Palestinian patients to reach WB
health facilities were proven. The same graph shows that at the same
year 20% of WB patients could not get permissions to move inside the
West Bank or to reach Israeli hospitals

15Eman Mokhamer (2009) Salinity of Drinking Water and Its Association with Renal Failure in the Southern
Part in the Gaza [Link]
16PCBS, 2018. Preliminary Results of the Population, Housing and Establishments Census 2017 Preliminary Census
Results, PHC 2017

17Abuhaloob L, Abed Y (2014) Knowledge and Public Perception of Dental Fluorosis in Children Living in Palestine. Oral
Hyg Health 2 (3): 133. doi: 10.4172/2332-0702.1000133

18 World Health Organization (2016}. Right to health: crossing barriers to access health in the occupied Palestinian territory, 2016

24
 ‫‪Figure 2.3: Patients permit approval in WB and Gaza 2011 - 16‬‬

‫‪GAZA‬‬

‫‪West Bank‬‬

‫‪2. Direct Health Indices: Figure 2.4‬‬

‫‪Birth‬‬ ‫‪Growth‬‬ ‫‪Sick‬‬ ‫‪Death‬‬

‫‪A‬‬ ‫‪B‬‬ ‫‪C‬‬ ‫‪D‬‬

‫‪A. Birth Rate‬‬ ‫‪B. Growth: Somatic Character‬‬

‫‪C. Morbidity Rates‬‬ ‫‪D. Mortality Rates‬‬
‫يم‬
‫ح ِِ‬ ‫ن َّ‬
‫الر ِ‬ ‫حمـَ ِِ‬ ‫للا َّ‬
‫الر ْ‬ ‫م ّ ِِ‬ ‫س ِِ‬ ‫بِ ْ‬
‫ل ثُ َِّ‬
‫م‬ ‫ف ًِ‬
‫ط ِْ‬
‫م ِ‬ ‫ك ِْ‬‫ج ُ‬ ‫ن علقةَ ثُ َِّ‬
‫م ُي ْ‬
‫خرِ ُ‬ ‫م ِم َْ‬ ‫طفةَ ثُ ََّ‬ ‫م ِمن نُّ ْ‬ ‫هوَ الَّ ِذي خلق ُكم ِمن تُرابَ ثُ ََّ‬ ‫ُ‬
‫ل ولِتبْلُ ُغوا‬ ‫من َ‬
‫ق ْب ُِ‬ ‫فى ِ‬ ‫و َّ‬
‫من ُي َت َِ‬‫نكم َّ‬ ‫م ُِ‬ ‫خا َ‬
‫و ِِ‬ ‫ش ُيو ً‬ ‫كونُوا ُ‬ ‫م ثُ َِّ‬
‫م لِ َت ُ‬ ‫د ُ‬
‫ك ِْ‬ ‫غوا أَ ُ‬
‫ش َّ‬ ‫لِ َتبْلُ ُ‬

‫ون (سورة غافر ‪)67:‬‬ ‫م ت ْع ِقلُ َ‬ ‫مى ولعلَّ ُك َْ‬ ‫ل ُّمس ًّ‬ ‫أج ًَ‬

‫مَ‬ ‫ِن علقةَ ثُ َّ‬ ‫م م َْ‬ ‫م مِن ن ُّ ْ‬

‫طفةَ ثُ ََّ‬ ‫اكم مِن تُرابَ ثُ ََّ‬ ‫الب ْعثَِ فإنَّا خل ْقن ُ‬ ‫م فِي ر ْيبَ مِنَ ْ‬ ‫اس إِن ُكن ُت َْ‬ ‫يا أيُّها ال َّن َُ‬
‫ِ‬
‫مى ثُ َِّ‬
‫م‬ ‫م ما نشاء إِلى أجلَ ُّمس ًّ‬ ‫م ونُق َُِّر فِي ْ‬
‫اْلرْحا َِ‬ ‫مخَ َلَّقةَ وغ ْي َِر ُمخلَّقةَ لِ ُنب ِينَ ل ُك َْ‬ ‫ضغةَ َُّ‬ ‫م ْ‬‫مِن َُّ‬
‫مرِِ‬ ‫ع ُ‬ ‫ل ْ‬
‫ال ُ‬ ‫ذ ِِ‬ ‫من ُي َردِ إِلَى أَ ْر َ‬ ‫ِنكم َّ‬ ‫وم ُ‬ ‫فى َ‬ ‫و َّ‬
‫من ُي َت َ‬ ‫ِنكم َّ‬‫وم ُ‬ ‫م َ‬‫ك ِْ‬‫د ُ‬ ‫ش َّ‬‫غوا أَ ُ‬‫م لِ َتبْلُ ُ‬
‫ل ثُ َِّ‬
‫ِف ًِ‬ ‫مط ْ‬ ‫ك ِْ‬‫ج ُ‬ ‫نُ ْ‬
‫خرِ ُ‬
‫ت وأنبت َْ‬
‫ت مِن‬ ‫اهت َّز َْ‬
‫ت ورب َْ‬ ‫ْض هامِد ًَة ف ِإذا أنز ْلنا عل ْيها ْ‬
‫الماء ْ‬ ‫د ع ِْلمَ ش ْي ًئا وترى ْ‬
‫اْلر َ‬ ‫َلِكَ ْيلَ ي َْعلَمَ مِن ب ْع َِ‬
‫ُك َِ‬
‫ل ز ْوجَ ب ِ‬
‫هيجَ (سورة الحج ‪)5:‬‬

‫‪A. Natality Rates:‬‬

‫‪Natality rates measure the frequency of births (Crude Birth Rate) and‬‬
‫‪the probability of births (Fertility Rates), intervals between births and‬‬
‫‪the places of birth. Fertility Rates will be discussed in chapter 12.‬‬

‫‪25‬‬
Crude Birth Rate (CBR)
Definition: The number of live births in a calendar year per the number
of mid-year population during the same period, multiplied by 1,000.
Number of live births
CBR = ‫ ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬x 1,000
Mid-year population

Importance of Birth Rate:

Table 2.2: Birth rate (BR) and Infant Mortality Rate (IMR) per
1000 in selected countries (WHO - 1996)

Country B.R. I.M.R

Afghanistan 53.4 154.4
Uganda 51.1 112.8
Somalia 50.0 111.9
Jordan 37.5 29.7
Egypt 26.1 54.4
Turkey 21.9 43.7
England 11.9 6.1
Sweden 10.9 5.1

In this table, compare three groups of countries:

Group 1: Afghanistan – Uganda - Somalia
Group 2: Jordan – Egypt – Turkey
Group 3: England – Sweden
What is common for each group?
Describe the relationship between Birth Rate and Infant Mortality Rate.

Demographic Gap:
Undeveloped Developing Developed

Births High High Low

Deaths High low Low
Outcome Balance  Balance
Demographic Gap

26
B. Somatic Characters:

1. The percent-age of newborn with low birth weight (LBW) - less than
2500 grams
2. Anthropometric measurements
Weight /Age Height/Age
Weight/Height Body Mass Index (BMI)
Head circumference, arm circumference and abdominal circumference

In children the three, most commonly used anthropometric indices to

assess their growth status are weight-for-height (wasting), height-for-
age (stunting) and weight-for-age (underweight).

These anthropometric indices can be interpreted as follows:

Low weight-for-height: Wasting or thinness indicates in most cases a
recent and severe process of weight loss, which is often associated with
acute starvation and/or severe disease. However, wasting may also be
the result of a chronic unfavorable condition. Provided there is no
severe food shortage, the prevalence of wasting is usually below 5%,
even in poor countries. Typically, the prevalence of low weight-for-
height shows a peak in the second year of life. Lack of evidence of
wasting in a population does not imply the absence of current
nutritional problems: stunting and other deficits may be present.
Low height-for-age: Stunted growth reflects a process of failure to
reach linear growth potential as a result of suboptimal health and/or
nutritional conditions. On a population basis, high levels of stunting are
associated with poor socioeconomic conditions and increased risk of
frequent and early exposure to adverse conditions such as illness
and/or inappropriate feeding practices. Similarly, a decrease in the
national stunting rate is usually indicative of improvements in overall
socioeconomic conditions of a country. The worldwide variation of the
prevalence of low height-for-age is considerable, ranging from 5% to
65% among the less developed countries. In many such settings,

27
prevalence starts to rise at the age of about three months; the process
of stunting slows down at around three years of age, after which mean
heights run parallel to the reference. Therefore, the age of the child
modifies the interpretation of the findings: for children in the age group
below 2-3 years, low height-for-age probably reflects a continuing
process of "failing to grow" or "stunting"; for older children, it reflects a
state of "having failed to grow" or "being stunted". It is important to
distinguish between the two related terms, length and stature: length
refers to the measurement in recumbent position, the recommended
way to measure children below 2 years of age or less than 85 cm tall;
whereas stature refers to standing height measurement. For
simplification, the term height is used throughout the database to cover
both measurements.
Low weight-for-age: Weight-for-age reflects body mass relative to
chronological age. It is influenced by both the height of the child
(height-for-age) and his or her weight (weight-for-height), and its
composite nature makes interpretation complex. For example, weight-
for-age fails to distinguish between short children of adequate body
weight and tall, thin children. However, in the absence of significant
wasting in a community, similar information is provided by weight-for-
age and height-for-age, in that both reflect the long-term health and
nutritional experience of the individual or population. Short-term
change, especially reduction in weight-for-age, reveals change in
weight-for-height. In general terms, the worldwide variation of low
weight-for-age and its age distribution are similar to those of low
height-for-age (WHO, 2009).

Body Mass Index (BMI):

Body Mass Index is an indicator for the nutritional status of children,
adolescents and adults. There is a general agreement among
researchers, the Body mass index (BMI) is recommended way to
estimate body fat for populations and are widely used in

28
epidemiological studies for their simplicity. The body mass index is the
preferred method for assessing the body weight. The body mass index
formula evaluates body weight relative to height. It is a useful, indirect
measure of body composition, because in most people it correlates
highly with body fat. Therefore, we concluded that, BMI is a convenient
and reliable indicator for obesity. Body mass index, which is calculated
by dividing weight in kilograms (kg) by height in meters (m) squared
(height x height). The BMI values are age-independent and the same
for both sexes; however, BMI may not correspond to the same degree
of fatness across different populations due, to different body
proportions. Therefore, ideally, additional tools, such as waist
circumference and waist-hip ratio, should also be used to assess
obesity (WHO, 2011).
2.2 Classification of obesity: Obesity and overweight classified
according to BMI after consultation of group of WHO expert in this field
in the year 1997. The below table presented these classification (WHO,
1997).
Table 2.3: WHO Classification of BMI
WHO Popular BMI
Risk of co-morbidities
classification Description (kg/m2)
Low (but risk of other
Under weight Thin <18.5
clinical problem increased )
Normal weight Normal 18.5 - 24.9 Average
Over weight ≥ 25.0
Pre obese Overweight 25 - 29.9 Increased
Obese Class I Obese 30.0 - 34.9 Moderate
Obese Class II Obese 35.0 - 39.9 Severe
Obese Class III Morbid obese ≥ 40.0 Very severe

C. Morbidity:
Morbidity is referred to any departure, subjective or objective, from a
state of physiological or psychological well-being. Morbidity rates
measure the frequency of illness within specific populations. Time and
place must always be specified. The most commonly used morbidity

29
rates include: prevalence, point prevalence, period prevalence,
incidence and attack rate as described below.
Sources of morbidity data:
A. Health centers B. Hospitals
C. Laboratories D. Survey.
Incidence:
Incidence measures the rapidity with which a disease occurs or the
frequency of addition of new cases of disease. Incidence is always
calculated for a given period for a defined geographical area.
Prevalence:
Prevalence measures the frequency of all current cases of disease (old
and new) and is of two types:
(1) Point Prevalence: Point prevalence measures the frequency of all
current cases of a disease (old and new) at a given instant in time.
(2) Period Prevalence: period prevalence measures the frequency of
all current cases of disease (old and new) for a prescribed period.
Prevalence = Incidence X Duration.
(3) Cumulative (long life) prevalence: Occurrence of disease during life
Attack Rate:
An attack rate is an incidence rate usually expressed as a percent, used
for particular populations, and observed for limited periods, as in an
epidemic. Examples where attacks rate is applied include food born
outbreak in restaurants or schools.
Attack Rate= Number of new cases X 100
Population at Risk
Secondary attack rate:
It is a measure of the frequency of new cases of a disease among the
contacts of a known case.
Secondary attack rate=
Number of cases among contacts of primary cases X 100
Total number of contacts

30
Example:
Thirty cases of measles occurred among 600 primary school children. All the children
contacts for the thirty cases were followed up. The total number of the children was
120. Nine children new cases reported during the follow up.
Attack Rate = 30 X 100 = 5%
600
Secondary attack rate = 9 X 100
(120-30)

= 9 X 100= 10%
90
D- Mortality:
Mortality rates measure the frequency of deaths within specific
populations and are calculated for a given time interval and place.
Several general and specific formulae are used to describe mortality as
shown below. The main source of mortality data is death certificates.
Causes of death: As defined by the World Health organization, the
underlying cause of the death as indicated in the death certificate. It is
defined as: a) The disease or injury, which initiated the train of morbid
events leading directly to death. OR:
b) The circumstances of the accident or violence, which produced the
fatal injury.

Measurement of Mortality rates:

The mortality rates could be general, specific or special
General Mortality Rate:
As measured by the Crude Death Rate (CDR)
Specific Mortality Rates:
These rates are specified for sex, Age, or Cause as coded by the
International Classification of diseases 10th Edition (ICD 10)
Standardized = Adjusted: Direct - Indirect

Special Mortality Rates:

• Infant Mortality Rate • Post Neonatal Mortality Rate

• Neonatal Mortality Rate • Maternal Mortality Rate

31
Crude Death Rate (CDR):
Definition: The number of all deaths occurring in a calendar year per
the number of midyear population during the same period, multiplied
by 1,000.
Total number of deaths
CDR = ‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬ x 1,000
Mid-year population

Cause specific Death Rate

This is defined as the mortality rate from a specified cause for a
population. The numerator is the number of deaths attributed for this
cause during a specified period, and the denominator is the size of the
population at the midpoint of the time interval.
Deaths attributed to a specific disease
Cause specific Death Rate =------------------------------------X K
Mid-Year population
(NB: In cause specific death rate K = 100,000)

Palestinian Ministry published in the 2005 annual report details of

mortality trend due to specific diseases. The report shows that
Accidents: had been increased from 9.1 per 100,000 in 1995 to 14.5
per 100,000 in 2005; and for Diabetes mellitus it has been increased
from 7.9 per 100,000 in 1995 to 8.6 per 100,000 in 2005. On the other
hand specific mortality for Pneumonia and other respiratory diseases
have been decreased from 31 per 100,000 in 1995 to 18.5 per 100,000
in 2005
Case Fatality Rate
Case fatality Rate is the proportion of persons with a particular
condition who die from that condition. The numerator is the number of
deaths among cases, and the denominator is the number of the
incident cases.
Number of deaths among specific disease
Case Fatality Rate = -------------------------------------------- X K
Number of the reported cases for the same disease

32
Case fatality is a measure of the severity of a disease, in sever diseases
as Rabies the case fatality is high and reach up to 100%, while in flue it
does not reach one percent.
Proportionate Mortality
1. It is the proportion of deaths in a specified population over some
time attributable to different causes. Each cause is expressed as
a percentage of all deaths and the sum of the causes must add to
100%.

Deaths due to specific disease

Proportionate Mortality = -------------------------------
Total Deaths during the same period

Proportionate Mortality is important indicator to identify the major risk

factors for death in a specific community. It is essential measure used
for health planning where it explores the main causes requiring
interventions. The indicator could be used for follow up of intervention

policies.
Figure (2.5) demonstrates the main reported causes of death in
Palestine for the year 2005, it is clear that heart diseases, cerbro
vascular diseases and cancer are the main causes.
Figure 2.5: Leading causes of Deaths among Palestinians 2005 -
Proportionate Mortality19

19 Source: MOH, (2006): The state of Health in Palestine, Annual Report 2005, Palestine

33
Infant mortality
The death of a live-born infant before his first birthday
Infant mortality rate:
The number of infant deaths occurring in a calendar year per the
number of live births occurring during the same period, multiplied by
1,000.
Neonatal death rate:
The number of deaths of a live-born infant from birth to <28 days of
life occurring in a calendar year per the number of live births occurring
during the same period, multiplied by 1,000. The first 7 days is called
the early neonatal period and the following 21 days is known as late
neonatal period. Risk of death during the early neonatal period is
higher than the risk during the late neonatal period.
Post neonatal death rate
The number of deaths of a live-born infant after 28 days of life and
before his first birthday occurring in a calendar year per the number of
live births occurring during the same period multiplied by 1,000.
Fetal death:
As defined by the world health organization; "death before the
complete expulsion or extraction from its mother of a product of
conception, irrespective of the duration of pregnancy. The death is
indicated by the fact that after such separation, the fetus does not
breathe or show any other evidence of life such as beating of the heart,
pulsation of the umbilical cord, or definite movement of voluntary
muscles. "This definition includes stillbirths, spontaneous abortions,
and miscarriages as fetal deaths.
Fetal mortality rate
The number of fetal deaths divided by sum of the number of live births
plus the number of fetal deaths in a specified period, multiplied by
1,000
Perinatal Mortality Rate: (PMR)
Perinatal period is the period around the time of delivery so it includes

34
the early neonatal period and the stillbirths. It is defined as the rate of
deaths occurs after 28 weeks of gestation till the 7th day after birth

Deaths form 28th week of gestation

till the 7th day after birth
PMR= ‫ ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬x 1000
No. of still births + No. of live births
Maternal Death:
The death of a woman while pregnant or within 42 days of termination
of pregnancy, irrespective of the duration and the site of the
pregnancy, from any cause related to or aggravated by the pregnancy
or its management but not from accidental or incidental causes.
(For more details, see ICD-10 manual, vol. 2)
Maternal mortality rate is calculated by dividing maternal deaths by the
number of Women of reproductive age multiplied by 100,000.

Measurement of maternal mortality:

Maternal mortality is measured by one of the three widespread
measures (WHO, 2004):
1. Maternal mortality ratio
2. Maternal mortality rate
3. Lifetime risk of maternal death
1. Maternal mortality ratio:
Maternal mortality ratio is defined as the number of maternal deaths
during a given period per 100,000 live births during the same period. It
is calculated as the following:

Maternal deaths
MM Ratio =---------------------- X 100,000
Total live births
This is the most commonly used measure where data availability and
accuracy to calculate this measure is better than data required for
other measures. This measure reflects the probability of death once a
woman becomes pregnant.

35
2. Maternal mortality rate:
Maternal mortality rate is defined as the number of maternal deaths in
a given period per 100,000 women of reproductive age during the same
period

Maternal deaths
MM Rate =--------------------------------- X 100,000
Women of reproductive age

This measure reflects the probability of women death during

reproductive period.

3. Lifetime risk of maternal death:

Lifetime risk of maternal death is a cumulative risk over the
reproductive lifetime. For each pregnancy the lady is exposed to the
risk again. Each time the risk is higher. Approximately life time risk is
calculated by multiplying the maternal mortality rate by the length of
the reproductive period (around 35 years). More details of the Maternal
Mortality and Near Miss Morbidity are described in Chapter 12.

Perinatal

LMP
20 24 28 32 36W 7 28d
1 year

Early Intermed. Late Neonatal Post Neonatal

Fetal Death Infant Mortality

Source: Mausner JS, Bahn AK (1974)

36
 Adjusted Rates
Summary Rates have gone statistical transformation to permit fair
comparison between groups differing in some characteristics that may
affect the risk of the disease.
Direct Adjustment:
1. A standard population is chosen arbitrarily.
2. Age specific Rate is calculated for each of the comparison population.
3. Expected deaths in each of the comparison population can be
obtained by multiplying their age specific Rate by the standard
population in the same age group.
4. Age adjusted Rate can be calculated by dividing expected deaths by
the standard population.
Example

Population A Population B
Age Group Population Death Rate Population Death Rate
------------- ------ ---- ----------- ---- -----
1 1000 20 20 4000 80 20
2 6000 60 10 4000 40 10
3 1000 60 60 4000 240 60
------ ------- ---- ---- -------- ------
Total 8000 140 17.5 12000 360 30

Q1: Summarize the facts in the table.

Q2: Choose a standard population:
Could be A, B, OR (A+B)
Q3: Look for age specific Rate for both population
if not calculated, calculate these rates.
Q4: Taking standard population A+B, calculates expected deaths in each age group in
the two populations.

Standard Population A Population B

------------- ------------------ -------------------
Rate Expected death Rate Expected deaths
------- ------------ ---- -----------
5000 20 100 20 100
10,000 10 100 10 100
5000 60 300 60 300
--------- ---- ------ ----- -------
20,000 25 500 25 500

Q5: Comment on Death Adjusted rate for the two populations.

Q6: If the age specific rates for the two populations are different.
What are your expectations?

37
 Indirect Adjustment
Indication:
1. Small numbers of deaths in one group lead to unstable age specific
rates.
2. If age specific rates are unknown.
Method:
1. Select the standard population.
Usually the larger, or of developed country, or one who is accurate
2. Apply age specific death rates of the standard population to the
population of interest, and then calculate the expected deaths.
3. Standardized Mortality Ratio (SMR) relates the observed deaths to
the total expected deaths.

Example
Standard Population Population (X)
--------------------------- --------------------------
Age group Specific death rate Population Expected death Observed
------------- ------------------------ -------------- ---------------
1 20 1000 20 30
2 10 2000 20 20
3 20 500 10 5
----- ---
50 55
Now, to calculate Standardized Mortality Ratio (SMR):

Observed 55
SMR = --------------------------------- = --------- = 1.1
Expected 50

Question: When SMR = 1, when lower than 1 and when it is higher

38
 Exercise (2)
This table shows the distribution of Population in two Countries (A & B) by age group.
In the same table, Number of deaths in each age group is mentioned.

Mortality Rates in two Populations (Rates per 1000)

Population A. Population B.
AGE MID N. OF AGE MID N. OF AGE
GROUP YEAR DEATHS SPECIFIC YEAR DEATHS SPECIFIC
POP. RATE POP. RATE
0-4 355,700 1,015 91,300 544
5- 14 699,800 143 166,800 66
15-19 279,000 145 65,100 38
20-24 262,800 177 52,500 42
25-34 546,200 394 76,000 53
35-44 374,800 464 42,800 72
45-64 584,900 4,347 41,400 315
65-74 217,400 6,838 9,200 335
75+ 121,800 11,467 6,100 562
1. Calculate crude Death Rate for each population.
Crude Death Rate (A) =
Crude Death Rate (B) =
2. Comment on your finding?
..............................................................................................................
3. Calculate Age Specific Death Rate for Population (A) & (B).
“Fill your calculation in the table”

4. Comment on your calculation for age specific Death Rate:

.............................................................................................................
5. Using World Standard Population 1966 as a standard Population, Calculate age
adjusted death rate for Population “A “and Population "B".
6. What is your conclusion?

Table 2.4: Standard World population

Age-group Population
0-4 years 12,000
5-9 years 10,000
10-14 years 9,000
15-19 years 9,000
20-24 years 8,000
25-29 years 8,000
30-34 years 6,000
35-39 years 6,000
40-44 years 6,000
45-49 years 6,000
50-54 years 5,000
55-59 years 4,000
60-64 years 4,000
65-69 years 3,000
70-74 years 2,000
75-59 years 1,000
80-84 years 500
85+ years 500
Total 100,000
Source: Segi (1960)

39
 Exercise (3)
Choose one of the reproductive health indicators for each of these tasks:
A. Measurement of Antenatal Care

B. Measurement of Natal Care

C. Measurement of Postnatal Care

D. Measurement of Utilization of Family planning practices.

1. Define the numerator in each

2. Define the denominator in each

3. Mention the source of the data you need from your health center to calculate
these indicators?

4. Do you think that data is needed from outside the health center? If yes,
mention the needed data and the possible sources

Exercise (4)
1. Post-neonatal mortality has been most closely linked to:
A. Maternal health before pregnancy
B. Events during delivery
C. Environmental factors
D. Mental health during pregnancy
E. Events during the early neonatal period

2. The correct rank order for the four leading causes of infant Death in
Gaza strip are:
A. Diarrhea, Pneumonia, Congenital anomalies, Prematurity
B. Congenital anomalies, Prematurity, Diarrhea, Pneumonia
C. Congenital anomalies, Prematurity, Pneumonia, Diarrhea
D. Pneumonia, Prematurity, Congenital anomalies, Diarrhea
E. Prematurity, Pneumonia, Congenital anomalies, Diarrhea

3. The most common cause of death among school children is:

A. Accidents
B. Pneumonia
C. Meningitis
D. Rheumatic fever
E. Measles

4. Among the measurement of examination of state of population health, the

most sensitive indicator is:
A. Rate of raw mortality
B. Rate of sickness
C. Rate of hospitalization
D. Rate of infant mortality
E. Rate of malnutrition

40
5. Neonatal Mortality rate for babies:
A. The numbers of deaths of babies till the age of one year out of 1,000 live
deliveries.
B. The numbers of deaths of babies till the age of 28 days out all infant deaths in
the same year.
C. The numbers of babies till the age of one year who died during the same year.
D. The numbers of babies' deaths till the age of one year out of all the deliveries.
E. The numbers of deaths of babies till the age of 28 days out of 1000 live
deliveries.
6. The incidence rate for an illness is the:
A. Relative rate for an illness at a given time
B. Number of new cases that occur during a given time divided by the number of
persons exposed or at risk at that same time
C. Number of new and old cases occurring in a given population at a given time
D. Number of people at risk of becoming ill during epidemics
E. Number of people at risk of becoming ill during the year
7. The mortality rate is an indicator of the health of population as:
A. It is sensitive indicator for population growth
B. It acts as a sensitive measurement of the condition of Sanitation, quality of
care and level of education
C. It reveals the cause of death, enabling planning programs to indicate a specific
disease.
D. Points out the poor reporting of deaths and thus the importance of improving
statistic methods.
E. Points out our success to meet people’s health needs
8. Of the following mortality rates, which two use the same denominator?
a) Crude mortality rate b) Age-specific mortality rate c) Sex-specific mortality
rate d) Race-specific mortality rate. e) Cause-specific mortality rate.
A. a + b
B. a + c
C. a + d
D. a + e
E. None of the above
9. Of the following mortality rates, which use the same denominator?
a) Infant mortality rate b) Neonatal mortality rate c) Post-neonatal mortality rate
d) Maternal mortality rate
A. b + c
B. a + b + c
C. a + d
D. All of them
E. None of them
10. In a recent survey, investigators found that the prevalence of Disease
(A) was higher than the prevalence of Disease (B). The incidence and
seasonal pattern of both diseases are similar. Explanations consistent
with this observation include:
A. Patient recover more quickly from Disease A than from Disease B
B. Patient recover more quickly from Disease B than from Disease A
C. Patient dies quickly from Disease A but not from Disease B.
D. Patient dies quickly from Disease B but not from Disease A.
E. Both answer B and answer D is correct

41
11. Both incidence and prevalence can be represented by the formula
(x/y) X 10n for a specified period. The primary difference between
incidence and prevalence is in:
A. x
B. y
C. 10n
D. The period of reference
E. None of them

12. During the second week of February, 87 persons in a small community

(population 460) attended a social event which included a meal prepared
by several of the participants. Within 3 days, 39 of the participants
became ill with a condition diagnosed as Sallmonellosis. The attack rate
among participants was:
A. 0.45/100
B. 8.5/100
C. 18.9/100
D. 44.8/100
E. Cannot be calculated from the information given

(Questions 13-16)
A new screening program was instituted in a certain country. The program
used a screening test which is effective in detecting cancer Z at an early
stage. Assume that there is no effective treatment for this type of cancer
and, therefore, that the program results in no change in the usual course of
the disease. Assume also that rates noted are calculated from all known
cases of cancer Z and that there were no changes in the quality of death
certification of this disease.

13. What will happen to the apparent incidence rate and the apparent
prevalence rate of cancer Z in the county during the first year of this
program?
A. Incidence rate will increase and prevalence rate will remain constant
B. Incidence rate will decrease and prevalence rate will remain constant
C. Incidence rate will remain constant but prevalence rate will increase
D. Both incidence rate and prevalence rate will increase
E. Neither incidence rate nor prevalence rate will change

14. What will happen to the apparent prevalence rate of cancer Z in the
county the first year of this program?
a. Prevalence rate will increase
b. Prevalence rate will decrease
c. Prevalence rate will remain constant.
15. What will happen to the apparent case fatality rate and mortality rate of
cancer Z in the county the first year of this program?
A. Case fatality rate will increase
B. Case fatality rate will decrease
C. Case fatality rate will remain constant.
D. Mortality rate will increase
E. Mortality rate will decrease

42
16. What will happen to the apparent Mortality rate of cancer Z in the county
the first year of this program?
a. Mortality rate will increase
b. Mortality rate will decrease
c. Mortality rate will remain constant.

Exercise (5)

The Health Minster asked the director of preventive health services to

comment on recent article in a local newspaper. According to the
article, the death rate of the city has risen steadily for twenty years.
The newspaper states that a change in the city administration is needed
to stop this disgraceful situation, which is the result of governmental
mismanagement. The director of preventive health services has the
following data available upon which to base a reply. Write a brief
outline or summary of what you think the reply should be.

Population and deaths by age

1985, 1995, 2005
_______________________________________________________
1985 1995 2005
-------------------- ------------------- ---------------
AGE Pop. Deaths Pop. Deaths Pop. Deaths
------- ---------- ------ ---------- ------ ---------- ------
0-4 5,000 30 6,000 33 8,000 40
5-14 7,000 11 8,000 10 10,000 10
15-29 20,000 44 25,000 50 30,000 50
30-49 30,000 195 50,000 315 80,000 480
50-69 30,000 600 60,000 1080 100,000 1700
-------- --------- ------- --------- ------ ----------- ------
Total 92,000 880 149,000 1488 228,000 2284
--------------------------------------------------------------------------
Crude death Rate 9.57 9.99 10.02
___________________________________________________

43
 Part 2
Epidemiological Studies
Chapter 3
Risk and Measurement of Risk in Epidemiological studies
Risk: Risk is defined as the probability that an event will occur, e.g.
that an individual will become ill or die within a stated period or age.
The term is usually used regarding unfavorable events.
Risk factors: Risk factors are defined as variables facilitating the
occurrence of disease. Cardiovascular diseases are risks for humans
while smoking, obesity and hypertension are risk factors for
cardiovascular diseases. Risk factors are classified into modifiable and
non-modifiable risk factors. Non-modifiable risk factors are those we
cannot change by an intervention such as age and sex, while modifiable
risk factors could be changed by intervention e.g. hypertension is a risk
factor for cerebrovascular accidents and can be changed or modified by
an intervention. Risk factors could be a predisposing factor for disease
e.g. obesity is a predisposing factor for diabetes mellitus. All
predisposing factors are internal factors while risk factors could be
internal or external factors.
Measurement of risk: We cannot measure the risk of the event due
to specific exposure; therefore, other measures are used. These
measures depend on a comparison between the incidence of the event
among those who are exposed to specific exposure and those who are
not. Measurement of risk is an important tool in epidemiology. It is
essential to identify the risk under observation among different groups.
A comparison of the risk among the group could reveal the magnitude
of this risk. Measurement of the risk could be for one group (absolute
risk) or for comparing more than group (Attribute risk and relative risk)
Absolute Risk: Absolute Risk is measured by the incidence of an event
(disease) in a population. This can indicate the magnitude of the risk

44
associated with a certain exposure. The main implications of absolute
risk are in both clinical and public health policies.
Attributable Risk: Attributable Risk is the proportion of disease
incidence that can be attributed to a specific exposure.
The incidence in the exposed group that is attributable to the exposure
can be calculated by subtracting:
(Incidence in Exposed) - (Incidence among non-Exposed)
Proportional Attributable Risk: Proportion of the total incidence in
the exposed group that is attributable to the exposure can be
calculated by:
(Incidence in Exposed) - (Incidence among non-
Exposed)
Proportion AR = -----------------------------------
Incidence in Exposed
Attributable risk for the total population can be calculated by the
same formula (instead of incidence in expos. use incidence in Total
population). Try to write the formula and think in one example of how
this formula could be used in public health programs. This proportion is
called (by different epidemiologists) as the following:
• The Attributable risk percent (Hennekens; Greenberg; most people at
CDC)
• Attributable proportion for the exposed population (Rothman)
• Attributable fraction for the exposed (Kelsey-Thompson-Evans)
• Etiologic fraction in the exposed (Miettinen; Kleinbaum-Kupper-
Morgenstern)
• Excess fraction (Greenland)
• Proportion Attributable risk (Gordis)
Relative Risk: Relative Risk is the ratio of the incidence of events in
exposed individuals to the incidence of events in non-exposed
individuals.
Incidence in Exposed population
Relative Risk (RR) = ______________________________
Incidence in Non-Exposed population

45
What is the meaning of? RR=1 RR>1 RR<1
When Relative Risk equals one, the incidence among the exposed and
non- exposed is equal and therefore there will be no association
between the suspected risk factor and the disease. When Relative Risk
is higher than one the chance of the disease among the exposed is
higher than the chance of the disease among non-exposed and this
indicates a positive association. Higher values reflect a stronger
association. When the relative risk is lower than one the incidence
among exposed is lower than the non-exposed and the association is
negative.
The incidence of Rickets is lower among children who are exposed to
sunlight. There is a negative association between exposure to sunlight
and the occurrence of rickets. Another example is the lower incidence
of diseases among children who are exposed to the vaccine.
Odds Ratio (OR):
(Relative Odds, Cross Product Ratio)
The odds of an event can be defined as the ratio of the number of ways
the event can occur to the number of ways the event cannot occur
(P/1-P).

Diseased Healthy
Exposed A B
Non-Exposed C D
OR = A/B / C/D = AD/CB
Try to calculate OR for case-control study and prospective study.
In prospective studies, the Odds Ratio is the ratio of the odds of
exposed people developing the disease to the odds of non-exposed
people developing the disease.
In retrospective studies, the Odds Ratio is the ratio of the odds of the
cases having been exposed to the odds of the controls having been
exposed.
OR for more than one category of exposure:

46
OR calculation is not limited to 2X2 tables, where it can be calculated
for more than one exposure level or different exposures. The minimum
exposure (Baseline category or Reference category) will be the baseline
for calculation as shown in the table below
Diseased Non-diseased OR
Exposure 1 A B (AF) / (BE)
Exposure 2 C D (CF) / (DE)
Non-Exposed E F 1
What is the confidence interval for OR and R.R.?

Confidence Interval for OR (or RR):

Odds Ratio measures the risk in a sample of the population. The
question will be: can we generalize this risk for all the population? The
confidence interval is a measure used to indicate that OR for that risk
among the population will be between the values in the confidence
interval. Accordingly, the confidence interval will tell whether the OR
value is statistically significant or not. When OR value is one, there is
no association. If the confidence interval contains (1) this indicates
obscene of the association at this point and subsequently, the
association is not statistically significant.
Figure 3.1 below shows a summary of the interpretation of OR values

Negative Association Positive Association

OR

0.2 0.4 0.6 0.8 1 1.5 2.0 3 3.5 4 4.5

0.5 2.5
(0.3 -----0.7) (1.8------3.4) S.S.

(0.9 -------------------3.5) [Link].

SS = Statistically Significant SNS = Statistically Not Significant OR = Odds Ratio

Odds Ratio is a measure of association between two variables. The

value (1) means the absence of association or equality of the events.

47
Values above one mean positive association and values below one
mean negative association, as you move far from (one) the value of
OR will be higher and the association will be stronger.
Example: when OR =2.5 there is a positive association. If all the
confidence interval values are more than one e.g. (1.8-3.5), this
means that all the values in the interval reflect positive association and
this association is statistically significant and it is not due to chance.
On the other hand, suppose that OR is 2.5 and the confidence interval
is (0.9-3.5) in this case the interval will contain values less than one
and values one beside the values higher than one. So, we cannot claim
positive association and such positive association is not statistically
significant. On the other hand, if the OR value is below one e.g. 0.5,
this is a negative association if all values in the confidence interval
below one, the association will be statistically significant

Examples
OR Confidence Statistically
Interval Significant
2.5 (1.8-3.5) S.S.
2.5 (0.9-3.5) N.S.
0.5 (0.3-0.7) S.S.
0.5 (0.4-1.2) N.S.

Optional: Confidence intervals are calculated using the formula shown below

Upper 95% CI=e^[ln (OR)+1.96√ (1/a+1/b+1/c+1/d)]

Lower 95% CI=e^[ln (OR)−1.96√ (1/a+1/b+1/c+1/d)]

48
 Exercise (6)
In a prospective study, 1000 children were followed for exposure to
radiation therapy. 400 were exposed and 600 were not exposed. Among
exposed children, 12 children developed blood diseases and 6 cases were
developed the same diseases among non-exposed. Construct a 2x2 table and
calculate:
1. Absolute Risk:

a. Incidence among all the children

b. Incidence among the Exposed children

c. Incidence among the non-exposed children.

2. Attributable Risk: (I. Exp. - I. non-Exp.)

3. Proportional Attributable Risk

4. Relative Risk : Incidence Exposed /Incidence non-Exposed

5. Odds Ratio: AD / BC

Exercise (7)
1. All the following statements about the absolute risk of disease are true
EXCEPT:
A. Absolute risk could be measured by the incidence of the disease

B. Absolute risk is the probability that a healthy individual will develop the
disease during a specified period

C. Absolute risk is the underlying rate from which Relative Risk is derived

D. Absolute risk is the underlying rate from which Attributed Risk is derived

E. Absolute risk is the ratio of incidence of the disease among those exposed to
the relevant risk factor to the incidence of the disease among those with no such
exposure
2. RR measures which of the following?
A. The probability that a person who is exposed to a certain risk factor will
develop the disease in Question

B. How much more likely it is that patient who has the disease has been exposed
to a particular risk factor compared to health Individual

C. The incidence of the disease

D. The magnitude of the association between a disease (or other health-related

outcome) and suspected risk factor

E. The prevalence of the disease

3. An occupational safety officer knows that the Relative Risk of non-
Hodgkin's lymphomas following exposure to a particular industrial chemical
is 12.5 what can he conclude from this information?
A. A worker who must routinely handle large Quantities of the chemical in
question has a very high probability of developing a malignant lymphoma

B. It is unlikely that the observed association between exposure to the chemical

and non-Hodgkin's lymphomas is due to random chance

C. The incidence of non-Hodgkin's lymphomas varies among workers exposed to

the chemical

49
 D. A worker who must routinely handle large quantities of chemical is 12.5 times
more likely to a malignant lymphoma than a worker who is not exposed to the
chemical

E. Malignant lymphoma cannot occur unless the concentration of chemicals is 12.5

times higher than the standard concentration

4. 4. All of the following statements about Attributable Risk (AR) are true
EXCEPT:

A. AR is a measure of absolute risk (incidence) that can be attributed to a

particular risk factor

B. AR is calculated as a probability of diseased and exposed minus probability of

diseased and non-exposed.

C. AR is the excess risk of disease experienced by those exposed to risk factor

D. AR is called Risk fraction

E. AR can be Directly computed in all types of Epidemiological studies

5. OR is an estimate of RR only if which of the following conditions exists

A. The Disease is relatively rare in the general population (in Both the
exposed and non-exposed populations)

B. The incidence rates are computed from the results of a prospective cohort
study

C. The data were collected using a case-control study

D. The rate of exposure to the risk factor is relatively low among both cases
and controls

E. None of the statements is true

6. If the relative risk for the association between a factor and a

disease observed in a study of all cases of the disease is equal to or
less than 1.0, then:
A. There is no association between the factor and the disease.

B. The factor protects against the development of the disease.

C. Either matching or randomization has been unsuccessful.

D. The comparison group used was unsuitable and a valid comparison is not
possible.

E. There is either no association or a negative association between the factor

and the disease.

Question 7 - 8
The table below depicts data on food poisoning outbreak following a back to
school party attended by 200 medical students
Ate food Did not Eat Food
Ill Not ill Totals Ill Not ill Totals
Salad 90 30 120 20 60 80
Fish 67 33 100 43 57 100
Totals 157 63 220 63 117 180

50
7- What is the RR of developing food8 8. What is the RR of developing food
poisoning after Salad consumption? poisoning after eating Fish?
A. 90/120 A. A. 1.56

B. 20/80 B. B. 2.03

C. 20/60 C. C. .75

D. 90/30 D. D. 3.0

E. Can not be calculated E. E. Cannot be calculated

Question 9-12
In a case-control study examination, the relationship between developmental disorder
and prenatal exposure to cocaine, the hospital records of 1000 infants diagnosed with
a developmental disorder and 1000 control infants were inspected for proven
maternal cocaine abuse. As the following table shows, of the 1000 children with a
developmental disorder, 800 were born to mothers known to have abused cocaine
during their pregnancy, compared to 300 of the control infants.
Developmental Disorder
Maternal Cocaine Use Present Absent Totals
Present 800 300 1100
Absent 200 700 900
Totals 1000 1000 2000

9- What is the absolute risk of developmental disorder among infants

exposed to cocaine in utero?
A. 9.33

B. 3.27

C. .73

D. .80

E. it cannot be computed from the given data

10- What is the OR of developmental disorder given exposure to cocaine?

A. 9.33

B. 3.26

C. .73

D. .80

E. it cannot be computed from the given data

11- What is the RR of developmental disorder given exposure to cocaine?

A. 9.33

B. 3.27

C. .73

D. .80

E. RR cannot be computed from the given data

12- What is the Prevalence of developmental disorders?

A. .50

B. .55

51
 C. .73

D. .80

E. Cannot be computed from the given data

Question 13-16
In a cross-sectional study of the relationship between smoking and anxiety, 1000
people were simultaneously classified according to smoking status (smokers or
nonsmokers) and the current level of anxiety (high or low). As is summarized in the
table below, 300 of these individuals were found to have a high level of anxiety, 500
were identified as smokers, and 200 were smokers who also reported a high level of
anxiety
Anxiety Level
High Low Totals
Smokers 200 300 500
Nonsmokers 100 400 500
Totals 300 700 1000

13- What is the incidence of high anxiety levels among the study
participants?
A. .30
B. . 50
C. . 40
D. .20
E. This cannot be computed from the given data

14- What is the prevalence of high anxiety levels?

A. .30
B. 50
C. .40
D. .20
E. This cannot be computed from the given data

15- What is the RR of high anxiety for smokers compared to nonsmokers?

A. 2.67
B. 2.0
C. .3
D. .40
E. RR is impossible to estimate unless the prevalence and incidence of high
anxiety levels are approximately equal

16. What is the OR?

A. 3.3
B. 2.67
C. 2.0
D. .20
E. OR cannot be computed from the given data

Question 17-20
One hundred children known to have been exposed to a high level of lead during the
first 12 months of life were followed for 15 years; 40 developed an affective disorder.
A similar group of 100 children who were not exposed to high lead levels during the
first 12 months of life was also followed over the same period. Five of these children
developed an affective disorder. The data regarding the relationship between lead
exposure and the disorder are summarized in the following table.

52
 Affective Disorder
Present Absent Total
Exposed to lead 40 60 100
Not Exposed to lead 5 95 100
Total 45 155 200
17- What is the incidence of affective disorders among those exposed to high
levels of lead during the first 12 months of life
A. .20

B. . 50

C. . 40

D. .225

E. This cannot be computed from the given data

18- What is the RR of developing affective disorders for those exposed to

high levels of lead during the first 12 months of life, compared to those with
no such exposure?
A. 12.67

B. 8.0

C. .23

D. .40

E. This cannot be computed from the given data

19- What is the OR for affective disorders for those exposed to high levels of
lead during the first 12 months of life, compared to those with no such
exposure?
A. 12.67

B. 8.0

C. .23

D. .40

E. Or cannot be computed from the given data

20. What is the attributable risk (AR) for the affective disorder given lead
exposure?
A. .40

B. . 05

C. . 35

D. 8.0

E. AR cannot be computed from the given data

53
 Chapter 4
Epidemiological Studies20
1. Descriptive Studies
2. Analytic Studies
2A- Experimental
2B- Observational
1- Retrospective 3- Cross Sectional
2- Prospective 4- Ecological

1. DESCRIPTIVE STUDIES: These studies are concerned with

organizing and summarizing health-related data according to time,
place, and person. Generally, descriptive studies could be one or more
of these types:
• Description of the study population based on Characteristics of
Person – Time – Place

• Incidence and prevalence studies

• Case Reports

• Case series Reports

Case Report: It is frequent to publish in health journals a description

of specific unusual events. If the study population is one person, we
call this work a "Case Report"
Example: "ten years old child admitted to the Pediatric hospital with
deep coma, no history of injuries, gastric lavage was done, lab results
revealed normal blood chemistry. Chemical examination of the gastric
contents shows a specific toxic substance. The child recovered six
hours after drug administration and gradual improvement started."

20Classifications and designs are adopted from Dr. Gordis L., Epi classes 1989Now available as Gordis L.
(2008) Epidemiology, ISBN-10: 1416040021 | ISBN-13: 978-1416040026 | Edition: 4th, Saunders

54
Case Series Reports: This is a common situation among physicians
where they use to gather pieces of information about their patients.
More than one study variable is considered and frequency of events
could be presented and classified by the universal variables as age,
sex, place of living. Laboratory results could be presented in such
reports. Cases could be asked about previous exposures
retrospectively. It is worthy to state that this is not a cases control
"Retrospective" design because of the absence of controls that used for
comparison of the experience.
2. Analytic Studies
2A. Experimental: These studies are known as Randomized
Clinical Trials were exposed and non exposed randomized groups are
followed for some time and the outcome is compared for the two
groups.
2B. OBSERVATIONAL STUDY: Epidemiological study in situations
where nature is allowed to take its course. Changes or differences in
one characteristic are studied concerning changes or differences in
others, without the intervention of the investigator. The following
figure (4.1) shows the four major types of observational
epidemiological studies. The main difference is the start point. In
prospective studies, we start from exposure to the outcome while in
retrospective studies we start by the outcome and go back to examine
previous exposures. In cross-sectional studies, we examine exposure
and outcome at the same time.
Professor Fathallah21 summarized the main characteristics of the
analytical studies in WHO Regional Publications Eastern Mediterranean
Series 30 - A Practical Guide for Health Researchers as follow:
"For an analytical study, the investigators may do a cross-sectional
study or a longitudinal study. In a cross-sectional study, the
investigators may study all postmenopausal women admitted to the

21Fathalla M. F., Fathalla M. M. (2004) WHO Regional Publications Eastern Mediterranean Series 30. A
Practical Guide for Health Researchers, Regional Office for the Eastern Mediterranean, Cairo

55
hospital over a defined time. For each woman, they record whether she
received or did not receive hormonal therapy and whether she had or
did not have endometrial cancer. The advantage of this study is that it
can be done rapidly. It gives more evidence than a simple descriptive
study. However, the two groups of patients may not be comparable.

Figure 4.1: Types of Observational Epidemiological Studies

Prospective

Exposure Outcome

Cross-Sectional
Retrospectiv
e
Retrospective

In a longitudinal observational study, the investigators may do a

prospective study or a retrospective study. For a prospective study, a
cohort of two groups of postmenopausal women is followed up: one
group already receiving hormone replacement therapy and another
matched group not receiving this therapy. For a retrospective study, a
case-control design can be selected. A group of women who have
recently developed endometrial cancer (cases) and a group of women
with similar characteristics and did not develop endometrial cancer
(controls) is identified. The use of hormone replacement therapy in

56
each woman in the case group and the control group is determined to
assess exposure history. The advantage is that the study can be done
relatively quickly. The disadvantage is that the two groups may still not
be completely similar. Other variables may influence the outcome and
may be difficult to exclude."

Prospective Study
(Cohort study)
This is a type of observational analytic study. Enrollment into the study
is based on exposure characteristics or membership in a group. The
outcomes such as Disease, death, or other health-related outcomes are
then ascertained and compared for those who were exposed and those
who were not (Figures 4.2 and 4.3).
Figure 4.2: Prospective study start by exposure

Exposure Outcome
Figure 4.3: Prospective Study Design

Study Population

Exposed Non-Exposed

Diseased Healthy Diseased Healthy

Cohort is defined as a well-defined group of people who have had a

common experience or exposure, who are then followed up for the
incidence of new diseases or events, as in a cohort or prospective
study. A group of people born during a particular period or year is
called a birth cohort.

57
 Analysis of prospective studies:
Develop Don’t Total
Disease
Exposed A B A+B
Non-Exposed C D C+D

Incidence among Exposed = A/A+B

Incidence among non-Exposed = C/C+D
Relative Risk = Incidence among Exposed
Incidence among non-Exposed
In prospective studies, we can also calculate Odd’s Ratio (OR)

Case-Control Study
“Retrospective”
A case-control study is a type of observational analytic epidemiological
investigation in which subjects are selected based on whether they do
(case) or do not (controls) have a particular disease under study.
This means that enrollment into the study is based on the presence of
an outcome (case) or absence of the same outcome as a disease
(control).
In Case-Control Study the investigator starts with a group of subjects
who have already experienced a problem of concern (cases), and then
he selects a second group of people who have not (controls). Both
groups are compared to the history of exposures. Using the
retrospective design to describe the act referring to that case and
control in terms of antecedent of factors believed to cause the group
difference (Polet, Hungler, 1993). These types of studies explore more
than one exposure for a single outcome.
Case-control study offers many advantages for evaluating the
association between an exposure and a disease. A case-control study
is efficient in both time and costs, relative to the other analytic
approaches it also allows for the evaluation of a wide range of potential
etiologic exposure that might relate to a specific disease as well as the

58
interrelationship among affected and non-affected individual (Charles
and Julie 1987). Altman summarized the main Advantages as: "The
prime advantages of the case-control studies are practical, relatively
simple, requires few subjects, and logistics are easy and less
expensive" (Altman, 1999).
Example 1: El-Shanti A. (2002) conducted a study to identify maternal
risk factors for low birth weight at Shifa hospital in Gaza. The study
included 125 cases and 125 controls. " The case is defined as " any
single alive newborn weight less than 2500 gm at birth regardless of
the gestational age or health status". For each case, a control is
selected with the same condition except that weight is 2500 gm or
more. Both cases and controls were compared for the maternal status.
The study demonstrated those maternal factors strongly associated
with LBW were: Young maternal age at marriage, less education,
unemployment, extended family, social problems maternal stress and
consanguinity.

Example 2: Clinical based case-control study was carried out in Gaza

city to identify risk factors for rickets among Palestinian children (Abu
Awad S. 2000). The researcher identified 86 cases and identified 2
controls for each case matching for age, sex and locality. The study
results show that low birth weight and premature infants are at a
greater risk of developing rickets. Receiving vitamin D significantly
decreases the chance of getting the disease. Exposures to sunlight
minimize the risk of rickets. The study reveals a statistically significant
association between the disease and maternal Illiteracy, family size,
consanguineous marriage, and inadequate pregnancy spacing.
Example 3: In Hebron city, Amro A. (2000) conducted a case-control
study to investigate the risk factors of stroke among the Palestinian
population. He selected 40 hospital admitted cases and 40 healthy
controls matched for age and sex. The main identified risk factors were
Current hypertension history of cardiac problem regular consumption of
diet and inadequate regular sport or physical activities.

59
 Figure 4.4 Retrospective Study Design

Outcome Exposure

Case Control
Study

Cases Controls

Exposed Non-Exposed Exposed Non-Exposed

Analysis in case control studies:

Cases Controls

Exposed
Non-Exposed A B
C D
Odd of exposure among cases = A / C
Odd of exposure among controls = B / D
Odd’s Ratio = AXD
BXC

Selection of Cases and controls

A. Selection of cases: During the selection of cases investigators
have to consider these important aspects:
1. Diagnostic criteria: There should be specific criteria for the
diagnosis of the case. These criteria are based on the operational
definition of the disease or the condition under investigation. It could
be as simple as defining anemic children as those who have hemoglobin
values less than 11-gm/ 100-ml blood. Complex criteria are used

60
depending on clinical and/ or laboratory findings as to the criteria used
to define meningitis or rheumatic fever.
2. Sources: Cases could be selected from hospitals or the general
population. Severe cases are hospital cases while simple or chronic
diseases are more common in the community. Records could be used
as a sampling frame for case selection.
3. Incident and prevalent cases: Prevalent cases are cases that
appear more than once during the research process. A diabetic patient
could appear more than one time in the study affecting the pattern of
the disease among the population.
B: Selection of controls: Apparently selection of controls is easier
than controls. Control selection is a difficult process and may be
difficult more than case selection. These points have to be considered
in control selection:
1. Comparability to the cases except having the disease: Controls
have to be similar to cases as possible as the investigator can, except
having the disease or the condition under investigation.
2. Representative of all non-diseased population: Selection of
controls should not be from a sector that is known to be healthy more
than other sectors. Controls have to represent all non-diseased
populations regardless of their status if they are comparable with the
cases.
3. Practical: The selection process should be practical otherwise the
investigator will be blocked by difficulties such as feasibility, availability
of controls and shortage of funds. The time factor is an important
factor for a study to be a practical one.
4. Sources of control: The investigators choose controls from one
or more of these sources:
a) Population of defined area.
b) Hospital patients either directly or from records.
c) Neighbors: different approaches are used to select controls
from neighbors such as a walk. a phone or a letter.

61
d) Friends or associates of cases are easy to participate in.
e) Siblings, spouses, and relatives are willing more than other
groups to participate as controls.
5. Methodological issues: We refer to some issues in control
selection.
A - Matching: Group matching and individual matching is used. Group
matching is used when a group of people as a class in a school is
exposed to an event under investigation. In this case, a similar class
could be used as a control and the investigator compare the group of
cases with the control group. Individual matching is applied by the
selection of one or more control for each case. Matching is faced with
problems such as:
a) Matching for many variables make it difficult to find appropriate
control.
b) We cannot explore possible association of the disease with any
variable on which cases and controls have been matched where cases
and controls will be similar for this variable.
c) Multiple controls: More than one control could be selected. They are
either similar or different types. In case of similar controls two, three
or even four controls could be chosen for each case. We can select two
different types of controls. For example, on the study of risk factors for
persistent diarrhea among children two types of controls were selected.
The first group is selected from healthy children and the second group
is children with acute diarrhea.

Differences between Prospective and Retrospective studies are

demonstrated in table 4.1

62
 Table 4.1: Advantages and disadvantages of case-control vs.
prospective studies
Case-control Prospective

Sample size Smaller Larger

Costs Less More
Staff Less More
Study time Short Long
Rare disease advantage disadvantage
Rare exposure disadvantage advantage
Exposures Multiple exposures One exposure
Outcomes One outcome Multiple outcomes
Progression, No Yes
spectrum of illness
Disease rates Cannot measure Can be measured
Relative Risk Cannot be measured Can be measured
Odds Ratio Can be measured Can be measured
Recall bias +++ +
Loss to follow-up + +++
Selection bias + +++

Cross-Sectional Study
Cross-sectional studies are useful for descriptive purposes and give
insight into the association between variables in the study. Cross-
sectional studies are described as studies in which exposure and
disease information is collected at the same point in time (Kramer and
Boivin, 1988; Last 1988). Since exposure and outcome are measured
at the same point in time, it is difficult to say which comes first. Cross-
sectional studies are generally carried out over a short period (Coggon
et al, 1993) and the study expenses are relatively low.
A community-based cross-sectional study is the most suitable study
design to achieve the study objectives since it can be used to describe

63
differences in prevalence rates among those with varying levels of
exposure (Brownson and Petitti, 1998). It is chosen because they are
economical and cheap and at the same time it can describe the nature
of the study objectives. Additionally, cross-sectional studies examine
exposure and outcome at the same time, and they can give some
indicators about the association among different exposures and the
outcome under investigation.
Cross-sectional study designs are regularly used both descriptively and
analytically. The distinction between description and analysis is
frequently blurred in cross-sectional studies that have a particularly
important role in planning and evaluating public health programs.
In a cross-sectional study, prevalence rates of disease among those
with varying levels of exposure are measured and sometimes
compared between groups. Cross-sectional studies can be used
descriptively, to describe differences in prevalence between groups, or
analytically, to test hypotheses. Cross-sectional study designs are
generally less useful in studying disease causation but are very
important in public health planning and evaluation.
Interpretation of cross-sectional studies in terms of etiology is clear
only for potential risk factors that will not change as a result of the
disease, such as ABO blood groups or HLA antigens.

Example 1: Abu Ryya F. (1999) completed a cross-sectional study to

determine the prevalence of low back pain (LBP) among health
professionals at the health department, UNRWA, Gaza
The main results revealed that 71% of the interviewed staff reported a
history of LBP at some time of life and 37.1%-point prevalence at the
time of applying the questionnaire. The same study indicates that
psychosocial factors, sitting posture, and bending activities are risk
factors for LBP.
Example 2: El-Kariri M (1999) selected Urban and Rural communities
to identify the rate of customary consanguineous marriage in the Gaza

64
Strip and the associated health conditions. The prevalence of
consanguineous marriage was 49.4%. This condition is associated with
couple fertility, maternal and child morbidity and mortality.

Example 3: A cross-sectional study was carried out in four central

primary health care centers in three Governorates in the Gaza Strip.
The study sample included parents of 288 children aged 36 months and
less who were diagnosed as acute respiratory infection. The study aims
to describe the patterns of antibiotics prescription and to determine
factors associated with antibiotic prescription. Study results show an
overuse and misuse of antibiotics in treating pediatric acute respiratory
infections, where 77.8 of the diseased children received antibiotics
while it was unnecessary for 77% of those who received the antibiotics.
Antibiotics were described more to older children, high-income families,
to city's children and children with fever (El Khoudary S. 2002).
Example 4: Cross-sectional studies could be used to examine
knowledge, Attitude, and Practices (KAP) of a specific sector of the
population towards certain public health problems. Shaheen A. (2003)
conducted a cross-sectional study to assess KAP among farmworkers
who apply spraying insecticides in Jericho district.
Example 5: Cross-sectional studies could be conducted for data
collected retrospectively. Turk K. (2003) examined the role of
helicobacter pylori infection Gastrointestinal diseases in the West Bank-
Palestine through six years (1995-2000) cross-sectional study where
data were collected retrospectively for all pathological reports of the
biopsies taken from a patient who underwent Esophageo – Gastro –
Dudenoscopy collected from six medical centers
Experimental Epidemiology
1. Randomized Clinical Trials

2. community Trials

65
 Randomized Clinical Trials (RCTs)
There is a great similarity between Cohort studies and randomized
clinical trials where both of them start by exposure measurement and
process of follow up for both exposed and non-exposed groups for the
outcome events. The major difference between Cohort studies and
RCTs is the process of the allocation for the exposed and the non-
exposed groups where Randomization is applied in the process of
allocation. Randomization gives higher chances of similarity between
the exposed and the non-exposed, except their differences in exposure
of interest. Figure 4.5 summarizes the process of conducting RCTs,
where randomization among the study population is done to select the
exposed group (treated) and those who are not exposed (not treated).
Then each group is followed for the outcome such as improvement or
reported complications. Differences in rates between the treated and
not treated are calculated.

Figure 4.5 Randomized Clinical Trials Design

Study Population

Randomization

Treated Non-Treated

Improv Not Improv Not

ed improved ed improved

66
The same design is applied to compare 2 treatment approaches.
Randomization is done to select group 1 with treatment A and group 2
with treatment B, then both groups are compared for the outcome.

Table 4.2: Types and Examples of Clinical Trials22

Type Example

Therapeutic: 1. Lazar treatment for diabetic Retinopathy

2. Simple mastectomy for Breast Cancer.
Intervention: 1. Antihypertensive drugs to reduce the risk of
developing a stroke.
2. Physical exercise for decreasing the risk of
myocardial infarction.
Preventive: 1. BCG vaccination for tuberculosis.
2. Isoniazid for prevention of tuberculosis.

The most famous RCT is a London physician Aspirin study where all
London physicians were randomized for taking Aspirin or placebo. The
study findings demonstrated the importance of daily Aspirin to reduce
cardiovascular and cerebrovascular accidents. Similar findings are
reported in Physicians' Health Study in the USA (The Steering Committee of
the Physicians' Health Study Research Group,1989) Lilienfeld A. (1980)
summarized different uses of RCTs (Table 4.6) where RCTs could be
used in therapeutic, interventions and preventive trials. Examples are
demonstrated in the table.

Ethical issues in RCTs:

The most sensitive issue in RCTs is the ethical issue where serious
questions could face such studies. Is it ethical to introduce new
medication for the public? Is it ethical to deprive a group of people from
treatment? Is it ethical to take medication blindly? Table 4.7
demonstrate these aspects.

22 Lilienfeld A. (1980)

67
Table 4.3: Ethical Considerations in a clinical Trial23
1. Is the proposed treatment safe (unlikely to bring harm) to the
Patient?
2. For the sake of a controlled trial, can a treatment ethically be
withheld from any patient in the doctor’s care?

3. What patients may be brought into a controlled trial and allocated

and to any of the different treatments?
4. Is it ethical to use a placebo or dummy treatment?
5. Is it proper for the trial to be in any way blind?

Community Trials
Community trials are defined as “Experiments that involve communities
as a whole, whether they are conducted in animals or humans”. There
are two major differences between Randomized clinical trials and
community trials.
First: Randomization is not performed in community trials while it is
essential for Randomized clinical trials.
Second: In a community trial, the group as a whole is collectively
studied while in RCT individual either the control or the experiment
group is studied.
Community trials are either Animal community OR Human Community
Trials. In animal trials group of animals (as mice's, rabbits) are used to
explore the association between exposure and outcome. The human
community trials are conducted when the community as a whole is
exposed to a specific event.
Example of Community Trials:
1. Introduction of fluoride to water to decrease the frequency of
dental caries.

2. Flour fortification with iron to reduce the prevalence of anemia.

23 Adapted from Bearman (1976)

68
 3. Effect of fly control to reduce the occurrence of diarrheal
diseases.

Ecologic Studies:
By applying ecologic studies, the investigator is measuring the
exposure information collected on a group rather than on individuals.
This type of study explores relationships between the environmental
factors surrounding the population and the probability of the occurrence
of undesirable events. Generally, Ecological studies have been
regarded as an inexpensive but unreliable method for studying
individual-level risk factors for disease.
For example, (Neil P. 2003) stated: “rather than go to the time and
expense to establish a cohort study or case-control study of fat intake
and breast cancer, one could simply use national dietary and cancer
incidence data and, with minimal time and expense, show a strong
correlation internationally between fat intake and breast cancer”
Example 1: Abu Safia Y. (1994) demonstrated a correlation between
water salinity and mortality due to renal diseases. The researcher
analyzes the Mortality data gathered by Gaza Health Service Research
Center and the water chemical composition from the Public Health
Department. Gaza Governorates with higher water salinity reported
higher renal disease mortality rates.

69
 Exercise (8)
A. Case Series Report:
B. Case-control study (Retrospective).
C. Clinical trial
D. Cohort study (Prospective)
E. Case report.
----------------------------------------------------------
MATCH UPPER PART (A, B, C, D, E)
WITH THE LOWER PART (1, 2, 3, 4, 5)
--------------------------------------------------------------
1. A total of 300 newly diagnosed patients with laryngeal cancer are allocated to
treatment with either surgical excision alone or surgical excision plus radiation
treatment.
2. A 39 - year- old man who presents with a mild sore throat, fever, malaise, and
headache is treated with penicillin for presumed streptococcal infection. He
returns after a week with hypotension, fever, rash, and abdominal pain. He
responds favorably to chloramphenicol after a diagnosis of Rocky Mountain
spotted fever is made.
3. A total of 3500 patients with thyroid cancer are identified and surveyed by
patient interviews regarding past exposure to radiation.
4. A total of 10,000 Vietnam veterans, half of whom are, known by combat records to
have been in areas where agent orange was used and half of whom are known
to have been in areas where no Agent Orange was used, are asked to give a
history of cancer since discharge.
5. Patients admitted for carcinoma of the stomach are age and sex-matched with
fellow patients without a diagnosis of cancer and surveyed as to smoking
history to assess the possible association of smoking and gastric cancer.

Exercise (9)
1. All the following are advantages of the case-control study design EXCEPT:
A. It is easier to identify a sufficient number of diseased subjects for this type
of study than a cohort study

B. This design is more particular for studying rare diseases

C. This design is subject to fewer ethical concerns than a prospective cohort

study

D. This design is less vulnerable to bias than other observational study

designs

E. This design is less expensive than a cohort study

2. Descriptive Epidemiology includes all except:

A. What.

B. Who

C. When

D. Where

E. Why

70
3. The Framingham study, in which a group of residents has been
followed since the 1950s to identify occurrence and risk factors for
heart disease, is an example of which type(s) of study?
A. Ecological
B. Descriptive
C. Prospective
D. Case-control
E. Randomized clinical trial
4. The Cancer and Steroid Hormone (Cash) study, in which women with
breast cancer and a comparable group of women without breast
cancer were asked about their prior use of oral contraceptives ("the
Pill"), is an example of which type of study?
A. Ecological
B. Descriptive
C. Prospective
D. Case-control
E. Randomized clinical trial

Question 5-10
A large medical center's oncology program reported an increasing number of
cases of pancreatic cancer during a certain month. The hospital's
epidemiologist decided to conduct a research study on the problem. Tumor
registry records were searched to identify all cases of pancreatic cancer
during five years; cancer patients were matched with patients treated for
other diseases during the same five-year period. All subjects in the study
were questioned about lifestyle factors including drinking (alcohol) and tea
and coffee consumption. The resulting data are as follows:

DATA
Lifestyle Variable Cancer Patients Other Patients
Men Women Men Women
Alcohol 185 120 270 260
Tea Drinking 140 110 230 225
Coffee Drinking 190 140 270 240
Note Total Number of male Cancer patients = 200
Total Number of female Cancer patients = 150
Total Number of male patients (other diseases) = 300
Total Number of female patients (other diseases) = 300

5. What type of study is this? 6. Does this study have an exposure

A. Experimental status variable?
B. Case-control A. No
C. Intervention B. Yes, lifestyle
D. Clinical trial C. Yes, disease type
E. Cohort D. Yes, the sex of the patient
E. Insufficient information to answer
this question

7. Does this study have a disease status variable?

A. No
B. Yes, lifestyle
C. Yes, cancer
D. Yes, the sex of the patient
E. Insufficient information to answer this question

71
 Which Number best approximates risk associated with:
8. Alcohol Drinking
Men 5. Women
A. 2.11
A. 0.21
B. 0.92
B. 1.37
C. 0.71
C. 2.11
D. 0.62
D. 0.62
E. 1.37
E. 0.92

9. Tea drinking
6. Men 7. Women

A. 3.50 A. 0.92

B. 1.37 B. 1.37

C. 0.71 C. 3.50

D. 2.51 D. 0.71

E. 0.92 E. 3.50

10 Coffee Drinking
8. Men Women
A. 2.11
A. 0.63
B. 0.94
B. 2.11
C. 3.50
C. 0.94
D. 0.63
D. 1.02
E. 1.02
E. 3.50

11. Which factor has the strongest association with cancer for both men
and women?
A. Alcohol consumption

B. Tea drinking

C. Coffee drinking

D. The factors show no variation in the association

E. Not enough information to determine.

72
 Chapter 5
Association
Association explains the relationship between two variables; we define
one as "Dependent" and the second as "independent". Association is
present when dependent variable changes as a response to change in
the independent variable. Other variables and methodological issues
could influence this relationship; therefore, we have to consider these
ten points when we examine the association between variables.

[Link] and independent 5. Is it statistically significant?

variables 6. Is it due to error?

2. Presence of an association 7. Is it due to the confounder?

3. Is it positive or negative? 8. Is it a direct association?

4. Is it a strong or weak 9. Examine for interaction

association? 10. Is it a causal association?

1. Dependent and independent variable: The first step to examine

an association is to identify correctly both the dependent and the
independent variable(s):
Dependent variable: It is the outcome variable(s) or the variable of
interest or variable of concern or variable(s) whose values are a
function of another variable (s) (called independent variable(s) in the
relationship understudy).
Independent variable: An exposure, risk factor, or other
characteristic being observed or measured that is hypothesized to
influence an event or manifestation (the dependent variable).
Example: In risk factors for anemia study, our dependent variable is
anemia and all the risk factors as independent variables.
2. Presence of an association: The easiest way to examine the
presence or absence of an association is to check for differences
between groups. If one variable change (independent) and the second
(Dependent) increase or decrease due to this change, we can say:

73
there is an association. For example, in anemia study, if the value of
Hemoglobin changes when the given iron amount change, we consider
this an association.
3. Positive or negative Association: Positive and negative
associations are referred to the changes in the relationship between the
dependent and independent variables. If the change is in the same
direction, it is a positive association. If one increase and the other
decrease it is a negative association.
4. Strong or weak association: We measure the strength of the
association by Relative Risk (RR) or by calculation of Odd's Ratio (OR).
There is a wide range for values of OR and RR, but in all cases, the
value (one) means the absence of the association. As the (RR) or (OR)
value is higher or lower than (one) the strength of the association is
higher. All values less than one mean a negative association and all
values higher than one mean a positive association. A strong
association is leading towards causality more than a weak one. We
have to be careful in the interpretation of the strong association as a
statistically significant one. Weak associations could be statistically
significant while a strong one is not.
5. Is it statistically significant?
It is not essential for each association to reach a statistically significant
level. Investigators have to state whether there is an association or
not, then they have to state whether the hypothesized differences are
statistically different. This is measured by a statistical test and
measuring the "P" value. The calculation of confidence interval is a
second method to measure statistical significance.
Important: Go back to graph 3.1 page 47 and examine the previous 4 points

6. Is it due to error? Errors could be classified as Random error and

Systematic error. A Random error is a fluctuation around a true value
because of sampling variability, while Systematic error (non-random or
bias) is any effect during investigation or inference lending to
produce results that systematically depart from the true value

74
A. Random Errors: We face is an error in these conditions
1. Individual biological variations.
2. Sampling errors.
3. Measurement errors.
B. Systematic Errors
Bias is defined as any effect during the collection, analysis or
interpretation of information that leads to a systematic error in one
direction.
Types: 1. Selection bias.
2. Measurement (classification) bias.
Selection bias
Systematic difference between the characteristics of the people
selected for a study and the characteristics of those who are not.
Examples:
o Respondent to smoking studies: Heavy smokers do not respond

o The response of people from different social classes: Poor people

underestimate income and rich people worry from taxes

o Workers exposed to formaldehyde: Worker absence results in bad

estimation of conjunctivitis in formaldehyde factories

o Healthy worker effect: Healthy workers do not represent the

population

Measurement bias
Measurement bias occurs when the individual measurements or
classification of disease or exposure are inaccurate.
Examples:
o Recall bias: People forget past events

o Interviewer bias: By dealing with interviewees differently

o Reporting bias (Deny Bias): Denying Alcohol and narcotics

o Laboratory testing: Variation in results readings

75
 6. Is it due to the confounder? "Confounding is confusion, or
mixing, of effects; the effect of the exposure is mixed together
with the effect of another variable, leading to bias". The Latin
origin of the word is "confounder" which means "to mix together"
Confounder is a variable related to both disease and exposure.
Confounder is another variable (exposure) that exist in the study
population and is associated with both the disease and the
exposure under study. Schlesselman (1982) defines confounder:
"A confounder (Confounding variable) is an extraneous variable
that satisfies both of two conditions (1) It is a risk factor for the
study disease; and (2) It is associated with the study exposure but
is not a consequence of exposure".

Example: Figure 5.1 Confounder

EXPOSURE DISEASE
Coffee drinking Cancer Pancreas

CONFOUNDER
Cigarette smoking

In figure 5.1 apparently, there is an association between coffee

drinking and cancer pancreas. Cigarette smoking is a third variable
associated with both the exposure (coffee drinking) and the outcome
variable (cancer pancreas). It is believed that smoking is a confounder
of this association. Control for the confounder will cancel the
association between coffee drinking and cancer pancreas.

76
 Confounder control

Control at the design stage Control at the analysis stage

• Randomization (Conventional approaches)
• Restriction • Stratified analyses

• Matching • Multivariate analyses

Newer approaches: Graphical approaches using DAGs, Propensity scores,

Instrumental variables, Marginal structural models

Randomization: By randomization, the researcher is trying to reduce

potential confounding by generating groups that are comparable with
respect to known and unknown confounding variables, both known and
unknown confounders are distributed evenly among those who are
exposed and those who are not exposed to the exposure of interest.
This is only appropriate for intervention studies.
Restriction: During the planning of the study, the investigator
eliminates variation in the suspected confounder by only recruiting one
group and not the other. For example, if gender is confounder one
study can include only males (or females). The advantages of
restriction are the straightforward method used, convenient and being
inexpensive. Disadvantages of restriction in the limitations for the
number of eligible subjects limits the ability to generalize the study
findings and impossible to evaluate the relationship of interest at
different levels of the confounder
Matching: Involves the selection of a comparison group that is forced
to resemble the index group with respect to the distribution of one or
more potential confounders. Matching is commonly used in case-control
studies when we match for age, controls are selected in a similar age of
the cases.
Stratifications: When cofounder is suspected, evaluate the exposure-
disease association within each stratum of the suspected confounder.

77
Assume that gender is suspected confounder; we evaluate the
exposure disease for males and for females.

Control for the confounder by stratification

Calculate OR for the crude table: For Crude

example, the relationship between
smoking and heart disease
Crude OR
Calculate OR for each stratum (M and F)
If strata specific OR are similar
calculate adjusted OR* OR 1 (Males) OR2 (Females)
If Crude OR = adjusted OR confounder
is unlikely
If both OR are not equal confounding is
likely
*if not similar: interaction is suspected

Multivariate Analysis: Stratified analysis works well only in the

presence of one or two confounders. If the number of potential
confounders is large, multivariate analyses offer the real solution. Can
handle large numbers of confounders simultaneously based on
statistical regression “models” as logistic regression or multiple linear
regression.

Exercise (10)
For Epidemiology students
One student has to brief the class in 5 minutes for one of these newer
approaches:
• Graphic
• al approaches using DAGs
• Propensity scores
• Instrumental variables
• Marginal structural models

8. Is it a direct association? The association could be due to the

intermediate variable. When Smoking is associated with Low Birth
Weight (LBW) and the latter is associated with Infant Mortality, the

78
 LBW is an intermediate variable and the association between smoking
and infant mortality is not a direct association.
Intervening Variable: This is a variable on the causal pathway
between exposure and outcome. It is called an intermediate variable or
intervening variable. It differs from the confounder where an
intervening variable is a part of the causality chain; therefore, it is not
wise to control for such type of variables. Figure 6.2 explains the
association between Alcohol consumption and myocardial infarction. It
is observed that three intervening variables as a part of the chain of
causality: Hypertension, high cholesterol, and increased Body Mass
Index.
Figure 6.2: Intervening variable

Alcohol Hypertension Myocardial

Consumption High cholesterol Infarction
High Body Mass
Index

HyperCholesteremia

Exposure Intervenin Outcome

g

Statistics cannot distinguish between a confounder and an intervening

variable, although in reality, they are different.

9. Interaction (Effect modification – Joint effect)

An effect of interaction occurs when a relationship between the
dependent variable (Y) and the independent variable (A) is modified by
a second independent variable (B). In simple words when I have two
risk factors (A and B) affecting a disease (Y), the joint effect of A&B is
different from the sum of both individual effects.

79
In the graph besides, there is a
hypothetical example where basic
risk (2) for the disease Y that can
occur even in absence of the
assumed risk factors A (3) and B (4).
If factor A is present, the risk will be
5 (sum of basic risk (2) and risk
attributed to A (3). For factor, B the
risk is 6 (2+4). Now, if Both factors
are present (A&B) then check the
expected risk: the basic risk (2) +
Risk attributed to factor A (3) + Risk
attributed to factor B (4). If it is 9,
this means the absence of
interaction. If the value is more or
less, that means the presence of
interaction

Interaction could be biological or statistical interaction. Biological

interaction is defined as: “the interdependent operation of two or more
biological causes to produce, prevent or control an effect”24.
Interaction occurs when the effect of a risk factor (A) on an outcome
(Y) is not homogeneous in strata formed by a third variable (B), that
this called effect modifier. Differences in the effect measure for one
factor at different levels of another factor1. This is often called "effect
modification". We use the term biological interaction to refer to the
effect that can happen inside the human body. How our bodies react
when exposed to the risk A or B and what type of interaction is present
if both risks (A and B) are present? The term statistical intervention is
used when a comparison between observed and expected joint effects
of risk factors (A&B) and the disease (Y). Interaction occurs when the
observed joint effects of the risk factor (A&B) and third variable (Y)
differs from that expected because of their independent effects. This is
often called "statistical interaction".

24Porta, Dictionary, 2008

80
 A. When there is no + =
A B
interaction, the joint
effect of risk factors A & A+B
+
B equals the sum of their Expected
independent effects: Observed

B. When there is a positive + =

A B
interaction (synergism). The
observed joint effect of risk (Expected)
A+B
factors A & B is greater than the +
expected on the basis of A+B ∞
summing the independent +
(Observed)
effects of A & B
C. When there is a negative
interaction (antagonism), the + =
A B
observed joint effect of risk
factors A & B is smaller than the
A+B (Expected)
expected on the basis of
+
summing the independent
A+B (Observed)
effects of A & B +
Two models are used additive or multiplicative, where interaction is
considered when there is a deviation from additive or multiplicative
joint effects. Statistical interaction occurs when the incidence of
disease in the presence of two or more risk factors differs from the
incidence expected to result from their individual effects25.
Risk Measurement: As described before the major two ways for risk
measurement are: A. Difference of risks OR Attributable Risk
B. Ratio of risks: we use Odds Ratio (OR) or Relative Risk (RR)
Statistical interaction can be measured based on the ways that risks
are calculated (modeling). When risk difference is used, risks are
considered to act in an additive way. When the ratio is used, risks are
considered to act in a multiplicative way.

25 Mac Mahon, 1972

81
Additive Model for (Incidence)

This table shows the relation of incidence Factor A

of disease (Y) and risk exposure. Calculate - +
Risk Difference (Attributable Risk AR), The Factor - 2 5
Basic risk is 2. B + 9 ?
AR for Factor A = 9 – 2 = 7 then AR for
Factor B = 5 – 2 = 3
What is the expected incidence when Both
Factors (A&B) are present?
The expected incidence when A&B are present = (Basic risk + AR for
factor A + AR for factor B) = 2 + 7 + 3 = 12
If the observed incidence (?) is 12: this mean absence of interaction.
Higher values (>12) mean positive interaction (Synergism) and lower
values (<12) mean negative interaction (Antagonism).
Example of (Biological) Interaction: Cigarette smoking and radon
exposure are two possible risk factors for lung cancer

Is there an interaction between cigarette smoking Smoking Radon Lung Cancer

and radon exposure with regard to lung cancer? incidence
If the risk of lung cancer from cigarette smoking is /1000
the same among those who were exposed to radon
No No 1
and those who were not exposed to radon, then
No Yes 5
there is no interaction between the two risk factors.
If the risk differs in the two groups, then there is an Yes No 10
interaction Yes Yes 50
Basic Risk = 1. Checking for the Attributable Risk (AR):
Smoking AR = 10 – 1 = 9 & Radon AR = 5 – 1 = 4, So Expected
incidence for both risk = Basic Risk (1) + Smoking AR (9) + Radon AR
(4) = 14
Observed incidence is higher than 14 (50/1000); therefore, there is a
synergistic interaction in the additive model. Multiplicative Model for
Odds Ratio OR Relative Risk

Expected Relative Risk for A+B in a Factor A

Multiplicative Model = - +
Expected RR for A+B = RR for A only x RR Factor B - 1.0 3.0
for B only + 5.0 ?
The expected RR for having both A and B =
3.0 x 5.0 = 15.0

82
If the observed risk (or incidence) for having both A and B is equal to
the expected, then there is no interaction
If the observed risk (or incidence) for having both A and B is greater
than the expected risk (or incidence), then there is a synergistic
interaction
If the observed risk (or incidence) for having both A and B is less than
the expected risk (or incidence), then there is an antagonistic
interaction. Example: Relative Risk of Oral Cancer from Smoking and
Alcohol Consumption26

The expected RR for smoking and drinking Smoking

alcohol = 1.53 x 1.23 = 1.88 - +
Observed RR (5.71) is higher than the Alcohol - 1.00 1.53
Expected RR (1.88)
+ 1.23 5.71
Check for interaction 5.71 > 1.88 Suggest
synergistic interaction in the multiplicative
model

The second example of the multiplicative effect of aflatoxin in chronic

hepatitis B patients on the development of liver cancer where RR of
liver cancer from hepatitis B infection alone was 7.3 and RR of liver
cancer from aflatoxin exposure alone was 3.4. RR of liver cancer from
both was 59.427
Confounder versus Interaction: Confounding is a problem we want
to eliminate in our study by control during study design or during
statistical analysis. By stratification, we can compare crude vs. adjusted
effect estimates. Interaction is a natural occurrence that we want to
describe and study further. Interaction is detected by comparing
stratum-specific estimates.

Importance of interaction in public health

26 Rothman K, Keller A. (1972). The effect of joint exposure to alcohol and tobacco on the risk of
cancer of the mouth and pharynx. J Chronic Dis 25:711-716.
27 Qian GS, Ross RK, Yu MC, et al. (1994). A follow-up study of urinary markers of aflatoxin

exposure and liver cancer risk in Shanghai, People’s Republic of China. Cancer Epidemiol
Biomarkers Prev 3:3-10.

83
 In real life, disease occurrence can result from exposure to more than
one risk factor and the interaction between different risk factors.
Elimination of one risk factor will decrease the chances of disease
occurrence attributed to this risk factor and the interaction between this
factor and other risk factors.

Exercise (11)
Some years ago, several studies were published showing an association
between reserpine (a drug used to lower blood pressure) and breast cancer in
women. Since obesity is associated both with breast cancer and with
hypertension (elevated blood pressure), the suspicion arose that the
association between reserpine and breast cancer could be secondary to the
effect of obesity. Assume that a cohort study had been conducted to address
this question and produced the following data:

Annual age-adjusted incidence of breast cancer per 100,000 women by

reserpine status and obesity
Reserpine use
- + Total
Obesity - 4.10 6.40 4.22
+ 8.30 12.50 8.72

Answer the following questions based on the above data (ignore

considerations of statistical significance and precision). For each answer cite
the most relevant figures from the table, allowing for the possibility that one
factor affects the observed relation between the other factor and breast
cancer risk.
a. Is reserpine a risk factor for breast cancer?
b. Is obesity a risk factor for breast cancer?
c. Is there an interaction between reserpine use and obesity?
d. Is the association between reserpine and breast cancer attributable to
obesity? What is the impact of this result on public health?

10. Is it a causal association? Causality is determined by

1. Strength 6. Biological plausibility

2. Study design 7. Specificity
3. Temporal sequence 8. Experimental approach
4. Dose-response relationship 9. Removal of the exposure
5. Consistency reduces the outcome

84
1. Strength of the Association: Commonly the researcher asks
whether the association is strong or weak. The best measure for the
strength of the Association is the measurement by Odds Ratio or
Relative Risk. When the value is far away from "One" the association is
Stronger. Strong Association is indicative of causality while the weak
association is far away from Causality.
2. Study design: The Randomized clinical trials are less exposed to
bias than other studies and accordingly the rank of causality in these
studies is higher than the rank in both prospective and case-control
studies. The cross-sectional study is ranked as the weakest studies to
demonstrate causality as it is described under the correct temporal
relation.
3. Correct temporal Sequence relationship: To ensure causality we
have to be sure that exposure precedes the disease. Cross-sectional
studies, confuse antecedents and consequences more than other study
designs, where exposure and outcome are measured at the same time
and we cannot judge who comes first, the exposure or the outcome. In
other words, when we examine the relationship between the dependent
variable (A) and independent variable (B), it is not easy to be sure,
whether (B) comes after A. The questions will be: are we sure that A
comes first? Why not the opposite? For example, in cross-sectional
studies when we examine the relationship between urinary tract
infection (UTI) and diarrhea, we are not sure that UTI is preceding
diarrhea, where scientifically it is known that diarrhea could be
complicated with dehydration and subsequently oliguria and UTI.
Based on this situation we cannot describe the causality of UTI for
diarrhea diseases. This problem is solved by the application of
prospective studies where during the initial study stage we chose
people exposed to the risk (A) and a group of people who are not
exposed to that risk and follow both groups for the occurrence of the
outcome (B).

85
4. Dose-Response Relationship: If the outcome changes (increase
or decrease) by the change of the exposure dose, we say there is a
dose-response relationship. Studies showed that when a number of
smoked cigarettes increases the chances of cancer lung increases. The
author studied the risk factors for anemia among children in Gaza. In
this study (Abed Y. 1992) he found that the amount of tea is associated
with both the anemia percentage and with the mean hemoglobin of
children. When tea consumption is high, the prevalence of anemia is
high. The proportion of anemic children among those who do not drink
tea is 39.6%. This percentage increases to 44.2 % in children who
receive 1 cup of tea per day and to 52.8 % in children who receive 2
cups of tea or more per day. The difference in percentage reaches a
statistically significant level (P = 0.02). The mean hemoglobin for the
same groups decreases gradually. Those who don't drink tea have
mean hemoglobin 11.4 gm/100 ml (SE=0.14). Mean hemoglobin
decreases to 11.1 gm/100 ml (SE 0.09) among children who receive 1
cup of tea per day and down to 10.8 gm/100 ml (SE = 0.11) for
children who consume two cups or more per day. The difference
between these means is statistically significant (P = 0.003). Analysis
for linear trend in proportions shows that there is a statistically
significant suggestion of a dose-response relationship between anemia
and the amount of tea given to children per day (Chi sq = 8.1 P-value = 0.004).

4. Consistency: Evidence of causality increase when different

investigators using different research designs throughout periods

through the years describe similar findings. Consistency evidence

developed when the relationships between smoking and cancer lung
were examined by different investigators in different localities in the
world and by the use of different study designs.

5. Plausibility: Plausibility means consistent with current knowledge

of the distribution and underlying biological mechanism with the

86
disease. Studies demonstrated an association between drinking tea and
anemia (Abed, 1993). In reality, tea has tannic acid which participates
in iron compounds and reduces iron absorption with subsequent anemia
occurrence.

6. Specificity: The relationship between two variables is called specific

when a single suspected cause is linked to a single effect.

7. Experimental approach: The experimental approach is the

strongest design support causality. Randomized Clinical Trial is coming
with evidence stronger than cross-sectional, retrospective or
prospective studies.

8. Removal of the exposure reduces the outcome: when fluoride

level is reduced in a community used to take high fluoride
concentration, we are expecting a reduction of the prevalence and
severity of dental fluorosis.

87
 Exercise (12)
1. The report of an epidemiologic study described the
association between a particular exposure and a particular
disease as: a weakly positive association, but not statistically
significant. The data most consistent with this statement is:
A. Odds ratio = 10.0, (Confidence interval=0.9 - 20)

B. Odds ratio = 1.5, (Confidence interval=1.2 - 1.9)

C. Relative risk = 1.8, (Confidence interval=1.6 - 2.2)

D. Relative risk = 10.0, (Confidence interval=0.7 - 22)

E. Odds ratio = 1.8, (Confidence interval=0.8 - 2.1)

2. If the relative risk for the association between a factor and

a disease observed in a study of all cases of the disease is
equal to or less than 1.0, then:
A. There is no association between the factor and the disease.

B. The factor protects against the development of the disease.

C. Either matching or randomization has been unsuccessful.

D. The comparison group used was unsuitable and a valid

comparison is not possible.

E. There is either no association or a negative association

between the factor and the disease

88
 Part 3
Clinical Epidemiology
Chapter 6: Screening
Definition: Screening is defined as Identification of unrecognized
disease by application of tests, examinations or other procedures that
applied rapidly to sort out apparently well persons who probably have a
disease from those who probably do not (not diagnostic).
Aims: 1. Determination of the frequency or natural history of a
condition
2. Infectious disease prevention and public protection
Screening Test: Validity:
The validity of the test is measured by sensitivity and specificity.
Sensitivity is the ability of a test to identify correctly those who have
the disease. Specificity is the ability of a test to identify correctly those
who do not have the disease.
Population
Disease Healthy

True Positive False Positife

Test Positive
(T.P) ( F.P )

Negative False negative True negative

( F.N ) ( T.N )

(T.P + F.N) (F.P + T.N)

True Positive (T.P)

Sensitivity = ---------------------------------
All Diseased (T.P + F.N)

True Negatives (T.N)

Specificity = ----------------------------------
All Healthy (T.N + F.P)

True Positives (T.P)

Positive Predictive Value = -------------- ------------
All positives (T.P + F.P)

89
 True Negatives (T.N)
Negative Predictive Value = -------------- ------------
All Negatives (T.N + F.N)

Example: Examination of Blood Sugar

Diabetics Free Total
Test Positive 350 1900 2250
Test Negative 150 7600 7750
Total 500 9,500 10,000
Sensitivity = 70 % Specificity = 80 %
Positive Predictive Value = 350/2250 = 15.5%
Negative Predictive Value = 7600/7750 = 98%

Two stages of screening for Diabetes

1. Blood Sugar
Disease Health
+ A B A+B
- C D C+B
A+C B+D Total
2. Glucose tolerance
+ A1 B1
- A2 B2
A B A+B
Diabetics Free Total
Test Positive 315 190 505
Test Negative 35 1710 1745
Total 350 1,900 2,250
Net Sensitivity = 315 = 63 %
500
Net Specificity = 7600 + 1710 = 98 %
9500
Principles of early disease detection
Wilson and Jungner of the World Health Organization proposed the
following 10 principles of successful mass screening programs in
196828:

28Wilson J. and Jungner G. (1968), Principles and practice of screening for disease, Public
Health paper No. 34: 26 - 27, WHO

90
1. The condition sought should be an important problem.

2. There should be an accepted treatment for patients with

recognized diseases.

3. Facilities for diagnosis and treatment should be available.

4. The natural history of the condition to be sought should be
adequately understood.
5. There should be a recognizable latent or early symptomatic
stage.
6. There should be a suitable test or examination.
7. The test or examination should be acceptable to the population.
8. There should be an agreed policy on whom to treat as patients.
9. Case finding should be a continuing process.

10. The cost of early diagnosis and treatment should be economically

balanced concerning total expenditure on medical care.

Behavioral factors affecting participation in the screening

program.
1. Threat of the disease
2. Relevancy to the people
3. Expected actions

Reliability
(Reliability = repeatability = precision)

A reliable screening test is one that gives consistent results when the
test is performed more than once by the same individual under the
same circumstance is. Variation results from:
1. Intra-subject variation: Biologic variation of individual
2. Observer variation
A. Types: 1. Intra-observer 2. Inter-observer
B. Quantitative expression of observer variation
1. Percent agreement 2. Kappa

91
 1. Overall Percent Agreement

Observer no. 1
Normal Suspect Abnormal

Normal A B C

Observer Suspect D E F
no. 2
Abnormal G H I

A+E+I
Percent Agreement = ___________ X 100
Total

Physician no. 2
Abnormal Normal Total %

Abnormal 16 2 18 (40%)

Physician Normal 16 11 27 (60%)

no.1
Total 32 13 45 100%

% (71%) (29%)

16 + 11
Percent Agreement = ________ X 100 = 60%
45

Physician no. 2
Abnormal Normal Total %

Abnormal 12.8* 5.2 18 (40%)

Physician Normal 19.2 7.8 27 (60%)

no.1
Total 32 13 45 (100%)

% (71%) (29%)
* 12.8 is the product of 71% X 18
Agreement due to chance = (12.8 + 7.8) / 45 = 45.8%

2. Kappa
Kappa tells us by how much does the observed agreement exceeds that
which would be expected by chance alone. It is calculated in this way:

92
 (Percent observed agreement) - (percent agreement expected by chance)

Kappa= -------------------------------------------------------
100% - (percent agreement expected by chance)

60% - 45.8% 14.2%

= ------------------ = ------------ = 0.26
100% - 45.8% 54.2%

Landis and Koch (1997) suggested that:

Kappa < 0.4 poor agreement

Kappa 0.4 - 0.75 good agreements
Kappa > 0.75 excellent agreement

Validity and Reliability

In research

Validity and Reliability

XX X X
XX
X X

A- Valid a nd Re liable B- Valid NOT Reliable

XX
XX X

X
X

C- Reliable NOT Valid D- NOT Valid NOT Re liable

93
 Validity
In simple words, validity is how far we are accurate in our
measurement. Validity of a measure refers to the degree to which it
measures what is designated to measure (Abramson, 1994). In other
words, validity is "to measure exactly what we are intending to
measure".
[Link] Validity: content validity is defined as the extent to which a
test reflects the variables it seeks to measure (Holm and Liwelly,
1986). This necessitates a review of the variable measures;
internationally recognized criteria for measurements are preferable.
Adaptations of an instrument for local use are commonly used by local
experts and necessitate improvement of the validity by other experts.
Holm considered that content validity requires judgment matter that
the items reflect the defined variable. Practically it is advised that the
investigator is given enough chance to construct his instrument (As a
questionnaire).

To improve the content validity, the questionnaire is distributed to 10-

15 experts to review the instrument. One of the benefits of pilot
studies is the improvement of content validity.
Since instruments are used for measurements, validity is defined as
“the degree to which an instrument measures what is supposed to
measure (Polit, 2004).
2. Construct Validity: This type of validity answers the question
about the link between the conceptual definitions and the operational
definitions of the variables and determines if the instrument measures
the theoretical construct to be measured (Burns and Groves 1997). In
the research process, more than one item (factor) is used to measure
the domain of interest. To examine and subsequently improve the
construct validity Factor Analysis is used. Factor analysis is statistical
testing that examines interrelationships to identify a cluster of

94
variables that are most closely linked together (Burns and Groves
1997).

The main difference between content validity and construct validity is

the method by which we conduct validity measurement. Content
validity depends mainly on the subject estimate of the measurement
based on personal judgment while construct validity uses statistical
testing such as factor analysis.
Internal validity: Measured by the power to control for bias
confounders. External validity: Strength with which generalization can
be made of the study findings to other settings.

Reliability
Reliability is referred to as repeatability or how far the investigator(s)
will repeat the same measurement if the investigations are conducted
more than one time. Last defined Reliability as "the degree of stability
exhibited when a measurement is repeated under identical conditions".
Reliability refers to the degree to which a measurement procedure can
be replicated. Lack of reliability may arise from divergences between
observers or instruments of measurement or instability of the attribute
being measured (Last JM, 2000). Burn (1997) stated that “any
measure to be reliable, it should give the same result each time the
situation or factor is measured.”
To improve Reliability, we minimize inter-observer variations and intra-
observer variations by:
• Standardization of the procedures of the measurements

• Training of the observers

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 Exercise (13)
1. All of the following Statements about screening tests are
true EXCEPT
A. They are used as a basis for therapy.

B. They are performed on apparently healthy individuals.

C. They are measured by sensitivity and specificity

D. They are applicable to large numbers of individuals.

E. They are performed for diseases amenable to therapy before

the onset of symptoms.

2. Surveillance activities focused on animal populations are not

usually intended to:
a) Detect changes in the size and distribution of reservoir
populations.

b) Detect changes in the size and distribution of vector populations.

c) Detect disease agents that might be present.

d) Detect epizootic (outbreaks of disease in animals)

e) Substitute for surveillance of morbidity in humans.

Exercise (14)
"X" is a common disease among children with a prevalence rate of ten
percent. A screening test of 1000 children shows that 200 children
were positive for this test. Only 80 children out the 200 were true
positive. A second screening test was done for the 200 positive children
of the first test. The second screening reveals 80 positive children
among them 70 are true positive.
Calculate the net sensitivity and net specificity of these two stages of
screening.

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 Chapter 7
Epidemiology of communicable diseases

Definitions of some relevant terms:

Sanitation: Control of environmental Disinfection: Killing of pathogens.
factors affecting health Germicidal: Substance kills microorganisms
Hygiene: Practices conducive to and spores.
good health Bactericidal: Substance kills bacteria.
Cleaning: Remove dirt Bacteriostatic: Substances inhibits bacterial
Sterilization: Destruction of all living growth.
organisms.

Incubation Period: The period between exposure to the agent and

onset of infection (with symptoms or signs of infection).
Secondary Attack Rates: The rates of infection among exposed
susceptible after exposure to an index case, such as in a household or
school.
Persistent Infection: A chronic infection with continued low-grade
survival and multiplication of the agent.
Latent Infection: An infection with no active multiplication of the
agent, as when the viral nucleic acid is integrated into the nucleus of a
cell as a provirus. In contrast with persistent infection, only the genetic
message is present in the host, not viable organisms.
In-apparent (or sub-clinical) Infection: An infection with no clinical
symptoms usually diagnosed by serological (antibody) response or
culture.
Herd Immunity: The immunity of a group or community. The
resistance of a group to invasion and spread of an infectious agent,
based upon the resistance to infection of a high proportion of individual
members of the group. The resistance is a product of the number of
susceptible and the probability that those who are susceptible will be
exposed to an infected person. Figure 7.1 shows an example of the
population immune status in two communities. In community "A"
people are protected by high vaccination coverage, while in community
"B", presence of a high percentage of unvaccinated people helps spread
of infection in the community.

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 Figure 7.1: Herd immunity

Community (A) Community (B)

x= Vaccinated
O= Non-Vaccinated

High vaccine coverage Low vaccine coverage

Characteristics of infectious diseases agents

• Infectivity • Toxigenicity

• Pathogenicity • Resistance

• Virulence • Antigenicity

Infectivity: Infectivity refers to the capacity of the agent to enter and

multiply in a susceptible host and thus produce infection or disease.
Polio and measles are diseases of high Infectivity. The secondary attack
rate is used to measure infectivity.
Pathogenicity: Pathogenicity refers to the capacity of the agent to
cause disease in the infected host. Measles is a disease of high
pathogenicity (few sub-clinical cases) whereas polio is a disease of low
pathogenicity (most cases of polio are sub-clinical). The proportion of
infected individuals measures pathogenicity with clinically apparent
disease.
Virulence: Virulence refers to the severity of the disease (i.e. whether
sever clinical manifestations are produced). The rabies virus, which

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almost always produces fatal diseases in humans, is an extremely
virulent agent. A measure of virulence is the proportion of total cases
that are severe. If the disease is fatal, virulence can be measured by
the case fatality rate (CFR).

Figure 7.2: Variation of the disease virulence

In-apparent mild moderate severe fatal

TUBERCULOSIS

MEASLES

RABIES

Toxigenicity: Toxigenicity refers to the capacity of the agent to

produce a toxin or poison. The pathologic effects of the agents for
diseases such as botulism and shellfish poisoning result from the toxin
produced by the microorganism itself.
Resistance: Resistance refers to the ability of the agents to survive
adverse environmental conditions. Some agents are remarkably
resistant, such as the agents responsible for coccidioidomycosis and
hepatitis. Others are extremely fragile, such as the gonococcus and
influenza viruses. Note: the resistance is also applied to the host.
Antigenicity: antigenicity refers to the ability of the agent to induce
antibody refers to an infection’s ability to produce immunogenicity,
which Agents may or may not induce long-term immunity against
infection. For example, repeated re-infection is common with
gonococci, whereas re-infection with the measles virus is thought to be
rare. There are variations in a number of antigens between organisms,
measles has one antigen while polio has 3 antigens (type 1, 2 and 3),
hepatitis b has three antigens (surface, core, and e antigen) at the
same time influenza have series of antigens for A, B, and C subtypes.

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 Means of spread of the disease
1- Horizontal: a) Contact: direct - indirect
b) Food and drinks
c) Air d) Vector
2- Vertical
The direct contact is the direct exposure to a person or animal or its
waste products. This includes mucous membrane to mucous
membrane and skin to skin. Direct contact includes also droplet
spread, e.g., sneezes and coughs. An example of Indirect contact is
the airborne infection where the organisms are suspended in air as the
Legionnaire’s disease.
A vehicle is a non-living intermediary such as food, water, biologic
product, or vomit (inanimate objects such as handkerchief, bedding,
surgical scalpel, etc.) that conveys the infectious agent from its
reservoir to a susceptible host.
A vector is a living intermediary, most often an insect or arthropod
(such as mosquito, flea, or tick), that conveys the infectious agent from
its reservoir to a susceptible host. Transmission may be either
mechanical or biological.
Vertical transmission: When an infection is transmitted from a
pregnant woman to her baby, the route is called vertical transmission,
HIV and Herpes infections are examples of this type of infection.

Reservoirs of infection:
The reservoir of an agent is the habitat in which an infectious agent
normally lives, grows, and multiplies.
1. Human 2. Animal
3. Water 4. Soil
1. Human: Man is the main reservoir for infection, from either
clinical diagnosed cases or carriers. The case is referred to as a person
or a group of people with a particular disease, health disorder, or
confirmed infectious condition that capable to distribute the organism
during any stage of their illness.
Carrier is a person without apparent disease who harbors a specific

100
infectious agent and is capable of transmitting the agent to others. The
carrier is described as an asymptomatic carrier where infection is in-
apparent. Carriers could be incubatory carriers if they are infectious
during the incubation period. Convalescence and post convalescence
carriers are known to be infectious during and after the recovery
period. The carrier state may be of short or long duration (transient
carrier or chronic carrier)
2. Animal: Some infectious agents are primarily infecting animals
but at the same time, these agents are pathogenic to the man.
Accordingly, animals could be a reservoir for infections where the
microorganisms or the parasites could be distributed and infect the
man. Rabies, Brucellosis, Tetanus, Plague Taenia Saginata, and T.
Solium are examples of such agents
3. Water: Water as a vehicle is an excellent reservoir especially for
a number of enteric diseases.
4. Soil: Clostridium tetani is an example of how soil could be a
reservoir for infection.
Portal of Entry of infection:
A. Gastrointestinal B. Respiratory
C. Genitourinary D. Skin
Portal of entry is an essential element in the natural history of any
infectious disease. When we are familiar with the portal of entry, we
can plan for prevention policy. Most of the enteric diseases entered
through the gastrointestinal system such as Typhoid, Dysentery,
Cholera and most of the Diarrheal diseases. The Respiratory system is
responsible for the entry of the upper and lower respiratory infections,
including acute and chronic respiratory infections. In some of the
infectious diseases as measles, the portal of entry is the nasopharynx
and not the skin. Sexual Transmitted Diseases (STDs) are transmitted
through the genitourinary tract. Skin is the portal of entry either by
direct contact as the different skin diseases or indirectly either by
injection (HIV and Hepatitis) or insect bites (Malaria).

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Portal of Exit: Exit of organism could by one of these sites
a. G.I.T: feces - vomits

b. Respiratory: nose and throat secretions

c. Blood, urinary or through skin

Figure 7.3: Disease transmission cycle29

AGENT

Disease producing microorganisms, such as

HBV, HIV and Mycobacterium tuberculosis (Tb)

SUSCEPTIBLE RESERVOIR
HOST
Person who can become infected Place where the agent lives, such as in or on
blood, humans, animals, plants, the soil, air or
water

PLACE OF ENTRY PLACE OF EXIT

Where the agent enters the next host Where the agent leaves the reservoir
(Usually the same way it left the old host) (host)

METHOD OF
TRANSMISSION
How an agent travels from place to place (or person to
person)

Just to return back to the epidemiological triangle concept, the

transmission of a disease requires the presence of agent causing the
disease and a host for the disease, that could be human or animal and
good environment ensuring entrance of the organism. Figure 7.3
explains the different stations during the transmission of the disease.
Understating these steps can help prevention of disease occurrence as
demonstrated in figure 7.4 where, when the three components of the

29 Adapted from WPRO/WHO, 1990

102
triangle are suitable the chance of infection is high. Removal or break
of one of the components will minimize the chance of infection.

Figure 7.4: Epidemiological triangle

(Disease Transmission Occurs When the Circles Intercept AT X)

ENVIRONMENT

HOST AGENT

TRANSMISSION PREVENTION

ENVIRONMENT

X
HOST AGENT

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 Investigation and control of an epidemic

Definitions:
The occurrence in a community or region of cases of an illness or other
similar event clearly in excess of what is normally expected. Three
terms are commonly used: epidemic, outbreak, and clusters.
Epidemic: The occurrence of more cases of disease than expected in a
given area or among a specific group of people over a particular period.
Outbreak: This term is the same as an epidemic. Sometimes the
health workers preferred this term, as it may escape sensationalism
associated with the word epidemic. The term "epidemic" has been more
frightening to the public than "outbreak," so most field investigators
have used the latter term when talking to the press or public. Besides
this, some prefer to use this term for localized events as parties and
use an epidemic for the generalized events.
Cluster: The term cluster is an aggregation of cases of a disease or
other health-related condition, which are closely grouped in time and
place. The number of cases may or may not exceed the expected
number; frequently the expected number is not known. When the
number in the cluster exceeds the expected number, the term epidemic
is preferred.
Causes of an epidemic:
The major Known causes of the reported epidemics are:
1. Food and water-borne outbreak: E. Coli, Salmonellosis
2. Communicable diseases: Cholera, Influenza, Measles, Hepatitis, Polio
or meningitis
3. Toxic substances: contaminated food, insecticides
Sources of information:
The information about a recent epidemic is mainly from these sources:

1. Community leaders 4. Health information and

2. Health workers in PHC surveillance
3. Hospitals 5. Laboratories.

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 Describing the epidemic
The description of the epidemic is essential for health workers and for
policymakers. These questions are essential to give a full description of
the epidemic:
1. What is the disease-causing the outbreak?
2. What is the source?
3. What is the mode of transmission?
4. How the epidemic is explained?
Epidemic curve
Epidemic curve defined as a histogram that shows the course of a
disease outbreak or epidemic by plotting the number of cases by time
of onset. The epidemic curve requires a proper number of cases and
the proper definition of the epidemic period. Epidemic Period is
defined as a time period when the number of cases of the disease
reported is greater than expected.
Types of Epidemic curve:
• Point source = common source

• Extended point source

• Propagated epidemic

Figure 7.5

Epidemic curve
Point source outbreak
No. of cases
10
9
8
7
6
5
4
3
2
1
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Date

Point source = common source: An outbreak that results from a

105
group of persons being exposed to a common noxious influence, such
as an infectious agent or toxin. If the group is exposed over a relatively
brief period, so that all cases occur within one incubation period, then
the common source outbreak is further classified as a point source
outbreak (Figure 7.5).
Extended point source: In some common source outbreaks, persons
may be exposed over a period of days, weeks, or longer, with the
exposure being either intermittent or continuous (Figure 7.6).
Figure 7.6

Epidemic curve
Continuous source outbreak
No. of cases
10
9
8
7
6
5
4
3
2
1
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Date

Propagated epidemic: An epidemic that does not have a common

source, but instead most properly spreads from person to person
(Figure 7.7).
Figure 7.7

Epidemic curve
Person to person outbreak

No. of cases

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Date

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 Steps of an outbreak investigation
1. Prepare for fieldwork.
2. Establish the existence of an outbreak.
3. Verify the diagnosis.
4. Define and identify cases.
a. Establish a case definition.
b. Identify and count cases.
5. Perform descriptive Epidemiology.
6. Develop hypotheses.
7. Evaluate hypotheses.
8. As necessary, reconsider/refine hypotheses and execute additional
studies.
a. Additional epidemiological studies.
b. Laboratory and environmental studies.
9. Implement control and prevention measures.
10. Communicate findings.

Exercise (15)
Based on WHO exercise
Analyze the following problem:
Background: In early September 1959, in the city of Meknes,
Morocco, upon waking up in the morning, a rug weaver noticed that he
could not move his arms or his legs. During the preceding day, both he
and his wife had experienced pain in the muscles of the back, arms,
and legs, which had subsequently vanished.
The man tried to awaken his wife, who experienced similar difficulties in
moving her extremities. The paralysis increased throughout the day
and by nighttime, she was disabled as her husband. During that week,
ten other families in Meknes experience the same problem, affecting
husbands, wives, children and sometimes all the members of a family.
By 18 September, approximately 200 cases were being reported daily.
In December, the number of persons afflicted exceeded 9,000 and
continued to rise.

Epidemiological Investigation:
In order to obtain a better knowledge of the problem, a complete
neighborhood of 10,000 persons was studied, the neighborhood was
studied. The neighborhood was representative of the city of Mekness in
that it included Muslims, Christians, Jews and all social classes. Fifty

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percent of the population of the neighborhood was male. A total of
3,000 cases were identified.

RESULTS
Cases by age and sex
Age group Male Female
0-9 80 70
10-19 110 120
20-29 360 540
30-39 220 540
40-49 140 380
50-59 70 320
60 and over 30 160
Cases by Socioeconomic class
Social class Number of cases Number of inhabitants
High 10 2 000
Middle 1 100 3 000
Poor 1 880 3 000
Very poor 10 2 000
Total 3 000 10 000
Cases by Religion Affiliation
Religion Cases Inhabitants
Muslim 2 800 4 000
Christian 200 4 000
Jewish 0 2 000
Total 3 000 10 000

Notes: a. There was a regiment with 100 soldiers in the area studied, two of these
became ill B. Evidence of disease was observed in several dogs.

Question 1: Select the response you consider most correct.

1. Do you consider that according to the information provided an
epidemic occurred in Meknes?

a. ___ Yes, because animals and people were involved.

b. ___ No because it did not spread to the soldiers in the regiment.

c. ___ Yes, because the incidence of the disease was greater than its usual rate of
occurrence in the population.

d. ___Yes, only because of the number of cases. A disease normally involving a

great number of cases is considered an epidemic, regardless of the time
period.

e. ___ No, although important due to a large number of cases, it was not a known
disease and it, therefore, is not characterized as an epidemic.

2. Why do you think the neighborhood study was conducted?

a. ___ Due to the limited ability of the health authorities, who should have been
caring for a large number of ill persons.

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 b. ___ In order to learn about the epidemiological characteristics of the disease
that could lead to the identification of the causal agent, with a higher
degree of accuracy.

c. ___ Because the country’s data registration and epidemiological information

systems were poorly structured.

d. ___ Because studies of this kind are always conducted when the frequency of a
disease increases, in order to learn about the population’s ability to
accept the solution to the problem.

3. The results of this study indicate that:

a. ___ The disease occurs with higher frequency in men of very poor social class,
regardless of religious affiliation.

b. ___ The disease was equally distributed among men and women below 20 years
of age, but more cases occurred in adult women and principally among
children.

c. ___ The disease occurred mostly among poor Muslims and more men than in
women.

d. ___ The disease occurred more among Muslims, more among women than men,
and was more frequent in persons between 20 and 40 years of age.

4. The incidence rate among men (IRM) and women (IRW) is the
following:

a. ___ IRM= 333 per thousand

IRW= 666 per thousand

b. ___ IRM= 100 per thousand

___ IRW= 200 per thousand

c. ___ IRM= 200 per thousand

IRW= 400 per thousand

5. The incidence rate for Christians was:

a. ___ 66 per thousands.

b. ___ 50 per thousands.

c. ___ 20 per thousands.

d. ___ Unobtainable.

6. Which of the following etiologies could explain the whole

epidemiological picture?

a. ___ Infection due to an unknown virus that is transmitted with great speed
among persons and animals.

b. ___ Infection spread by insects.

c. ___ Toxic, disseminated through a common source, possibly food.

d. ___ Toxic or infectious spread from person-to-person and from persons to

animals.

Question 2: List the steps required to investigate a similar outbreak

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Question 3: What other investigations are required to reach the diagnosis?

Question 4: At this stage can we recommend preventive measures? Explain Why?

Explanatory commentaries
The illness attacked the Muslims more than the Christians but no Jew was taken ill. It
is difficult to think of a virus which respects religious beliefs. Another curious fact was
that the disease did not attack wealthy persons. It affected the poor, but the poorest
among the poor also escaped.
The investigation concerning the group of soldiers showed that those two had taken
ill, had been outside the barracks during the previous days. Food contamination had
been suspected as the only difference between the soldiers was the fact that those
two had eaten outside of the barracks.

Investigation of the Agent:

One housewife brought to the doctors' attention the fact that she had bought "Le
Cerf" cooking oil. She did not see the dark color of the oil. She threw out the fritters
cooked in the oil, which were heartily devoured by the dog. Observing that nothing
happened to the dog, the woman decided to eat the fritters and continued using the
"Le Cerf" oil. Two weeks later, the woman, her husband, their children, and the dog
were paralyzed.
Chemical analysis of the “Le Cerf” oil, bought in the shops of Meknes, revealed it
contained TRI-ORTHO-CRESIL-PHOSPHATE (TOCP).
TOCP is an integral part of oil used to clean weapons and is very neurotoxic.
It was discovered that some merchants had bought surplus oil, discarded from the
Nouasseur United States Air Force nearby Casablanca during the month of March
1959. There was a large quantity of oil, part of which contained TOCP as an additive.

Explanation of the facts:

With the discovery of the causal agent and of the mechanism of contamination, the
epidemiological facts were explained:
Only the poor Moroccans used it because it was cheap. The poorest escaped because
they were unable to buy any kind of oil, even the cheapest.
The Jews used only vegetable oil because of their different dietary habits.
The women between twenty and fifty years, children and the elderly of both sexes
were more susceptible because they ate all their meals at home, while the adult men
had at least one meal away from home.

Continuation of the Epidemic:

The most shocking thing occurred after the towns of Meknes and Rabat had been
alerted against the use of the contaminated oil. Some of the unscrupulous
merchants, on observing that their sales had decreased in those towns, sent their
stocks of oil to more remote towns where the news had not arrived yet. King
Mohammed V and the Moroccan Assembly decreed the death penalty for those
persons who knowingly sold the oil.

Following this directive, 800 tons of oil were confiscated and 27 businesspersons
arrested. The epidemic ended.

Consequences:
The nerve tissue destroyed by TOCP does not recover. For many years, Meknes and
other cities had to bear the burden of thousands of paralyzed persons.
Of the 10000 victims, 600 were confined to bed, and about 8000-needed intensive
rehabilitation for a long time. It is easy to imagine the difficulties faced by a poor
country like Morocco where this situation added to the everyday public health
problems.

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 Chapter 8
Visions towards Communicable Diseases Control in the
Gaza Strip
Abstract
For years, communicable diseases (CDs) were the main cause of death
in developing countries. Most of the CDs are preventable. The main
objective of this study is to recommend strategic steps toward
elimination and control of the communicable diseases by review the
occurrence, demonstration of the trends and exploring current control
policies of the CDs in the Gaza Strip (GS). The Author reviewed
published and unpublished CDs data available in the records and the
official publications issued by both Palestinian MOH and UNRWA. This
stage was followed by validation of the available data by conducting
site visits including MOH Epidemiology Department. Qualitative
research was done using Key informant interviews including the DG of
Primary Health Care in Gaza and key people involved in data gathering,
analysis and dissemination from both governmental and UNRWA health
sectors. The study results highlighted two facts in epidemiology of the
CDs in GS, the first one is the clear decline in the incidence of the
vaccine-preventable diseases and the second fact is the marked
increase of the environment-related CDs. Recently, vaccines
preventable diseases are controlled as Measles and Diphtheria while
Polio is eradicated. Few cases of tetanus, Tuberculosis, and Hepatitis B
are reported but marked reduction in their incidence is observed. The
under-reporting is a continuous problem where recently most STDs are
not reported. The major problems are the environmental-related CDs
where UARI and Diarrheal diseases are markedly increased.
Respiratory diseases have their impact on morbidity, hospital
admissions and mortality, especially among children. Unsafe water
supply and improper sewage disposal are the two major risk factors for
diarrheal diseases. Improvement of the surveillance system is needed
in all the Palestinian health care facilities. Active steps are required that

111
need to be implemented as a basic component of the planned
developmental activities. These steps are categorized as follows: Firstly
supporting Health promotion, secondly to continue and develop disease
prevention and management policies. The third is acting for
Environmental Protection in cooperation with the main players and
finally to conduct management reform for the CDs control departments
in the PHC.
Background
The Gaza Strip (GS) is one of the most intense areas all over the world.
The 365 square kilometers have 1.9 million inhabitants with more than
5,000 people per square kilometer (PCBS, 2018). The age group (0-14
years) comprises 43.8% of the total population at the end of 2011. The
average household size in the GS is 6.3 persons in the same year. The
GS consists of five governorates: North Gaza, Gaza, Mid Zone,
KhanYounis and Rafah. Gaza is the largest governorate in terms of
population, which has more than half a million inhabitants. MOH reports
indicate that the crude birth rate is 38.3 per thousand and the crude
death rate is 3.9 per thousand. The infant mortality rate is 17.1 per
thousand (MOH 2011).
The Israeli siege which has been enforced on the GS since 2006 lead to
destruction of the economic status that has been leading to high level
of unemployment (28.7%) and poverty rate 38% of the population as
reported by the Palestinian Central Bureau of Statistics30 (PCBS, 2012).
National Account Indicators for the Palestinians in the year 2011
showed that the Gross Domestic Product (GDP) per capita in GS is US$
1,061 compared to $ 1,955 in the West Bank (WB). Gross National
Income (GNI) per capita is $ 1,156.6 per capita compared to $ 2,131.5
in the WB. Such a situation has been maximized over crowdedness and

30 PCBS (2012), Palestinian Central Bureau of Statistics, Palestine in Figures 2011, Ramallah – Palestine

112
poverty and lead to the deterioration of the health status at the Gaza
Strip (PCBS, 2012, MOH, 2011).
The Primary Health Care (PHC) is the backbone of the health services
in GS. The network of PHC centers covers all localities in the Strip and
administrated by the Ministry of Health (MOH), UNRWA and Non-
Governmental Organizations (NGOs). One of the most successful PHC
programs is the immunization program with coverage rate
approximately reaches 100% of all the targeted children. In each
district, an Epidemiology Section with qualified trained staff is capable
to investigate the occurrence of the notifiable infectious diseases. The
referral system ensures reference of cases from PHC to hospital
services in the Strip when cases require hospitalization. Recently 5
Tuberculosis (TB) management units are added to investigate and
manage TB cases in the community.
According to the Palestinian Health Information center in GS, there are
29 hospitals at the end of 2010. The secondary health care service is
mainly run by the Palestinian MOH, which operates 13 hospitals, of
which 8 are general hospitals. Five of them are regional hospitals, one
is located in Gaza City (Shifa Hospital), one is in Der El Balah at the
Middle area (Al Aqsa Hospital) and Kamal 'Odwan Hospital in the
North), and the other two in KhanYonis City in the South (Nasser
Hospital and the European Hospital). The other five are specialized
hospitals; three of them are pediatric hospitals, (Nasser pediatric, Dora
Pediatric and Rantisi Specialized Pediatric Hospital). The other two are
a maternity hospital in Rafah (Tal Essultan) and a surgical hospital in
Beit Hanoun.

For centuries, communicable diseases were the main cause of death

around the world and Life Expectancy at Birth was often limited by
uncontrolled epidemics. The leading cause of disease burden was
pneumonia, diarrhea, and prenatal conditions. After the Second World
War, vaccination, sanitation and antibiotics use improved life

113
conditions, therefore, Life Expectancy increased. Five decades ago,
infectious diseases were the most common in Palestine, especially in
the Gaza Strip. For example, in 1969 the two main causes of infant
mortality were gastroenteritis (36%), and respiratory infection (31%),
which then accounted for two-thirds of child death.
Most of the communicable diseases (CDs) are admitted either in
pediatric hospitals or internal medicine departments in the general
hospitals or treated in PHC services. Pediatric Hospitals are dealing with
most diarrheal and respiratory infections among children. In each
department, there is an isolation room specified for admissions of
specified CDs as meningitis.
There are two major environmental problems in GS; improper sewage
management and unsafe water supply. Sewage overflows in streets
and unmanaged sewage are drained into the sea, this results in major
public health problems mainly enteric diseases and parasitic
infestations (Al Shawa 2007, Al Hendi, 2008). The underground water
is the main source of water that provides residents of the Gaza Strip
with drinking and domestic purposes. This has been faced a decadence
in both quality and quantity for many causes for many years, such as
limited annual rainfall, increased urbanization which led to a decrease
in the quantity recharge of the aquifer, and a steady increase in
population (CMWU, 2010). Thus, GS is suffering from environmental
troubles such as water salinity and contamination of underground
sources of water, which is making it a good field for enteric diseases.
According to WHO standers, most GS wells produce non-potable water.
MOH reported that one of the most important environmental
determinants of health is the quality of drinking water and about 95%
of the water withdrawn in the Gaza Strip is polluted and invalid for
drinking (MOH, 2010).
Recently due to the successful immunization program, the CDs of
childhood are largely controlled. Both measles and polio have been
under full control where Polio has been eradicated from Palestine and

114
we certified by WHO as free from Polio since 2006. However, some CDs
such as tuberculosis and zoonotic diseases such as brucellosis, persist
in spite of the marked drop in their incidence. There are high levels of
poverty, bad sanitation and overcrowding, diarrheal diseases and acute
respiratory infections are common.
Objectives:
1. To review the occurrence and to demonstrate trends of
communicable diseases in the Gaza Strip.
2. To identify factors that possibly affect the control of communicable
diseases.
3. To explore current policies used to control communicable diseases.
4. To recommend strategic steps toward prevention and control of
communicable diseases.
Methodology
In this report, the researcher is concerned with the review of
published and unpublished data available about CDs in the records
and the official publications. The available data of communicable
diseases are found in the annual reports issued by both Palestinian
MOH and UNRWA in the GS. Recently, the Health Department in
UNRWA produces a regular monthly Epidemiological report for the CDs
registered in the UNRWA health services. Epidemiology Department
at the MOH issues a more comprehensive Quarterly Epidemiological
Bulletin that covers the registered CDs in both Governmental and
UNRWA health services and other health care providers. Most of the
communicable disease research studies cover a single specific aspect
for CDs including incidence and risk factors for a given disease under
investigation, an International organization such as WHO reports
mainly depend on the locally produced reports.
In this report, the researcher reviewed most of the available CD
reports produced by the health care providers. This stage was followed
by validation of the available data by conducting site visits including
MOH Epidemiology Department where the database is available for the

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reported CDs in Gaza. Key informant interviews, including the DG of
Primary Health Care in Gaza and with key people involved in data
gathering, analysis, and dissemination from both governmental did
qualitative research and UNRWA health sectors. Key informative
interviews were not limited to validation of data but further to reveal
reasons set behind successes and failures, and future vision for the
control of the CDs in Palestine. The available data are constructed in
tables to serve the purpose of this report. The author used the
available data of 2001 and 2011 to compare the trend of the CDs in
the past 11 years. Marked events during the years are reported. Views
of the key informants are expressed to specified strategic issues.
Main Findings
1. Current Status

During the fourth quarter of 2011, a total of 47,141 cases of notifiable

CDs were reported to the MOH epidemiology department which
constituted a more than 25% increase compared with the same quarter
of 2010 (34,801 cases). This increase was mainly related to the
increase in the number of cases of Diarrhea, Upper Respiratory Tract
Infection (URTI) and viral conjunctivitis. These diseases were ranked as
the top three prevalent CDs (MOH, 2012). Probably this increase is due
to the improvement of the reporting system. During this period, none
of the following infection was recorded: acute poliomyelitis, diphtheria,
measles, and malaria (except 5 imported cases).
2. Change in the trend

Based on table 8.1 there are three patterns of changes in the CDs
First group: Diseases remained under control in the last 10 years such
as poliomyelitis, Measles, Diphtheria, Pertussis, Rubella, and Tetanus.
Second group: Diseases have been under control and their incidence
is going down as Brucellosis, Hepatitis (all types), Mumps and
Tuberculosis.

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 Third group: Diseases have been increasing by the time such as
Meningitis, Diarrhea diseases and Respiratory diseases as it will be
explained.
Table 8.1: Distribution of reported communicable disease and their rates per
100,000 Palestine 2001-2011
2001 2011 Changes
Number Rate Number Rate percent
1 Acute Flaccid 7 1.2 6 0.8 - 33%
Paralysis
2 AIDS/HIV 4 0.4 5 0.3 - 25%

3.1 Meningococcal 106 8.9 151 9.4 + 6%

Meningitis
Haemophilus 9 0.75 0 0

3.2 Other Bacterial 110 9.2 346 21.6 + 135%

3.3 Viral Meningitis 411 34.3 799 49.9 +45%

4 Brucellosis 23 1.7 13 0.8 - 53%
5.1 Hepatitis A 793 66.08 423 26.4 - 60%
5.2 Hepatitis B 855 71.2 375 23.4 - 67%
5.3 Hepatitis C 93 7.7 71 4.4 - 43%
6 Pertussis (Whooping 23 1.9 0 0 ??
Cough)
8 Rubella 13 1.08 0 0 ?
9 [Link] 198 16.5 0 0 ?
10 Chicken Pox 9200 766.6 4030 251.8 - 67%
11 Mumps 104 8.6 91 5.6 - 35%
13 Shigellosis 19 1.5 17 1.06 - 29%
14 Pulmonary TB 12 1 13 0.8 - 20%
15 Extrapulmonary TB 9 0.75 10 0.6 - 20%
16 Typhoid 360 30 169 10.5 - 65%
&paratyphoid
17 Diarrhea<3 34678 28% 51667 33% + 5%
18 Diarrhea>3 12660 1055 30037 1877.3 + 78%
19 Bloody diarrhea 10104 1684 6826 426.6 - 75%
20 Influenza + URTI 16991 1415.9 55098 3443.6 + 140%
21 Pneumonia 7407 617.2 6158 384.8 - 38%
Source: Epidemiology Department – MOH – Database for the CDs
Denominator in 2001 is 1.2 million and in 2012 1.6 million unless identified (e.g <3
years)

3. Common Reported Communicable diseases

3.1 Tuberculosis (TB)

The reported data demonstrate a low incidence of Tuberculosis in GS
where the annual incidence range between 1-2 per 100,000
inhabitants, Aged people are exposed to the risk of infection more than
young. Males have higher chances of infection than Females. Table

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(8.1) indicates a drop in the incidence of the disease from 1.2 to 0.8
per 100,000.
EMRO report stated that between 20 and 25 new TB cases were
reported annually from the GS. Untreated active pulmonary TB carries
a case fatality ratio (CFR) of 65% within 5 years. In the acute phase of
this emergency, the main concern of the TB program is the
continuation of treatment, which is likely to be hampered by drug
supply problems and loss of contact with patients (EMRO, 2009).
During Key Informant Interview epidemiologist stated "I think now TB
is not an emergency disease and is treated at home”
In the year 1999 Adverse Events Following Immunization (AEFI) with
BCG vaccination, and post BCG complications among Palestinian infants
and children in the Gaza strip were studied (Awad R., 1999). The study
showed an incidence rate of complications among infants 14.7/1000
during the year 1997 compared to 1.3/1000 in the following year. The
study shows that the high rate of BCG complications was due to using a
more reactogenic type of BCG vaccine batch 2611-11 combined with
incorrect administering of the vaccine. The study recommended
purchasing vaccines from a credible source in addition to continuous
training on BCG vaccination regularly and restricting providing BCG
vaccination only to trained staff nurses (Awad R., 1999).

Proper surveillance System for Tuberculosis and the

used BCG vaccine by Continuous use and application of
the AEFI surveillance system will improve safe vaccine
coverage, BCG administration and prevent post BCG
complications. Purchasing vaccines from a credible
source is essential.

3.2 Poliomyelitis
In the 1970s, the incidence of poliomyelitis in the Gaza strip was high,
even among immunized children with 3 or 4 doses of oral polio vaccine
(OPV). Two epidemics with an incidence rate of 18 per 100,000 were
reported. This was thought to be that was interference with

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enteroviruses in the environment. A combined program of OPV and
inactivated polio vaccine (IPV) was instituted in GS in 1978 and the
incidence of polio was declined dramatically. The potential of fresh
entry of wild poliovirus may occur via persons who may have personal
protection but may still shed the virus due to inadequate enteric
immunity. Besides, the recent combined program protects against
vaccine-associated poliomyelitis where initial IVP dose precedes the
OPV. The combination of OPV and IPV provides an important alternative
strategy at worldwide effort to eradicate poliomyelitis (Tulchinsky T,
Abed Y 1994). In recent years, immunization coverage of infants
increased to a level estimated at 95 percent and paralytic poliomyelitis
has been controlled, despite exposure to wild poliovirus from
neighboring countries. This experience suggests that a wide coverage
using the combination of IPV and OPV is an effective vaccination policy
that may make eradication of polio is possible even in developing areas
(Tulchinsky T., Abed Y. 1989). In 2009, there were 4 cases of Acute
Flaccid Paralysis (AFP) with an incidence rate of 0.61 per 100,000
children less than 15 years (MOH, 2011). Graph (8.1) shows the 3
stages of Polio in Gaza Strip; the stage of endemicity before 1974,
followed by two major epidemics 74 and 76 and the third is a stage of
control towards eradication.
Figure 8.1: Poliomyelitis Cases in GazaStrip1967 – 1993

80
No. OF CASES

60

40

20

0
77

79

81

83

85
75

87

93
91
89
73
67

69

71

YEAR

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 WHO (2012) stated, “Poliomyelitis is targeted for eradication. Highly
sensitive surveillance for acute flaccid paralysis (AFP), including
immediate case investigation, and specimen collection are critical for
the detection of wild poliovirus circulation with the ultimate objective
of polio eradication. AFP surveillance is also critical for documenting
the absence of poliovirus circulation for polio-free certification”

3.3 Measles
In Gaza and the West Bank, the immunization of infants against
measles began in 1973 and 1976, respectively. Before 1978 measles
used to be Endemic Disease in Gaza with the seasonal variation of case
occurrence, meanwhile, measles Vaccination Coverage was less than
50%. Local analysis of admission data in the Nasser Pediatric Hospital
by then revealed that 35% of the measles admitted cases were for
children under one year of age. Such findings supported the 9-month
measles vaccine policy. In spite of improving vaccine coverage to
exceed 90% of all children, a major measles epidemic occurred during
1981 – 1982. The epidemic started with older children and then
younger children were involved. Around 5000 children were affected
and investigations revealed that 50% of them got measles vaccine. The
epidemic was severe and resulted in 72 deaths. The last measles
epidemic was in 1987 followed by a call for 2 dose policy for measles
control wherein 1988 second dose of (MMR) was added to the
vaccination schedule at age of 15 months to all children. It becomes
clear that the benefits of several alternative immunization strategies
considerably exceed their costs (Tulchinsky T, Abed Y 1990)31. The
1990/91 epidemic began in Ramallah district in the West Bank in the
second week of November 1990. It was followed three weeks later by

31 Tulchinsky T., Abed Y., Ginsberg G., Shaheen S., Friedman J.B., Schoenbuam M.L., and Slater P.E. (1990) Measles in
Israel, the West Bank, and Gaza: Continuing Incidence and the Cases for a New Eradication Strategy. Reviews of
infectious Disease 12:951-957

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an outbreak among Bedouins in the Negev, with subsequent spread to
other districts in Israel while Gaza escaped this epidemic (Tulchinsky T,
Abed Y 1992)32. Recently the 9th-month dose is canceled and MMR is
given at age 12th and 18th month.
Figure 8.2 shows the distribution of cases of Measles in the Gaza Strip
during the years 1969 – 1993, where the disease used to be endemic in
the country with epidemic waves within years as the epidemic of 1971
with around 6000 cases. The second stage was the initiation of the
measles vaccination with variable responses affected by measles
vaccine coverage and the number of doses given. Two major
epidemics were reported (82 – 83) and during the year 1988.

Graph 8.2: Cases of Measles in Gaza Strip 1969 – 1993

6.0
[Link] CASES (Thousands)

5.0

4.0

3.0
CASES
2.0

1.0

0.0
71

87

89
85

91

93
83
79
67

69

73

77
75

81

YEAR

No marked measles outbreak was reported for more than 20

years. Any suspected case of measles should be sent to
laboratory confirmation.

32 Tulchinsky TH, Belmaker I., Raabi S., Acker C., Arbeli Y., Lobel R., Abed Y., Toubassi N., Goldberg E., and Slater P. E.
(1992). Measles during the Gulf War: A public health threat in Israel, the West Bank, and Gaza. Public Health Review
20:285- 296 unpublished master's thesis, Al-Quds University, Gaza

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3.4 Viral Hepatitis
Control of hepatitis is one of the success stories in Palestine where a
marked drop in incidence rates have been reported in the 3 types A, B,
and C in spite of variation in their epidemiology. Studies in the MOH
targeted all students who have to attend the Epidemiology Department
to get a medical certificate by screening for Hepatitis B surface antigen
(18 years post-vaccination), anti-HCV and HIV. A total of 426 subjects
were included in the study. All of the subjects were negative for
Hepatitis B and HIV and only four students (0.94%) were Anti-HCV
positive (MOH – Epidemiology Department).
Table 8.1 showed a drop in the incidence of hepatitis A from 66 per
100,000 to 26.4, and a drop in hepatitis B from 71.2 to 23.4 and a drop
in hepatitis C from 7.7 to 4.4 during the last 11 years. More specific
details about the epidemiology of each type are given.

Hepatitis A Virus (HAV)

Epidemiological survey of viral Hepatitis was conducted in 1999 to
determine the prevalence rate of anti-HAV in a representative sample
of 396 school children in the Gaza Strip. The prevalence of anti-HAV
was 93.7% (95% CI: 91.3, 96.1%). Stratifying the prevalence by age
showed that 87.8% (95% CI: 78.6, 97%) were HAV antibody positive
by the age of 6. By the age of 14, almost 98% (95% CI: 92.7, 100%)
were HAV antibody positive. This means that the majority of HAV
infection is still taking place in early childhood, when it is usually
asymptomatic and of little clinical significance. The results refuted the
shifting epidemiology theory and recommend that a vaccination
program against HAV infection is not yet needed. Since this survey, the
debate is continued between public health personnel and researchers
concerning the need for the introduction of Hepatitis A vaccine as a part
of the national immunization program (Yassin K., 2001).
In Palestine, both WB and the GS, the reported incidence rate of
hepatitis A is about 108 per 100.000 annually throughout the last

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years. The overall prevalence rate of anti-HAV IgG is 86.1% and
ranging between 98.6% in North Gaza Governorate to 63.3% in
Bethlehem Governorate (MOH, 2005). In 2007, 841cases were reported
with an incidence rate of 59 per 100,000 of the population. In 2009,
MOH has reported 678 cases of hepatitis A with an incidence rate of
47.1 per 100,000 population. This number has been declined to 423
cases with an incidence of 26.4 per 100,000 in the year 2011 (MOH,
2009, 2011).
Hepatitis B Virus (HBV)
In the Gaza Strip, the incidence rate of hepatitis B cases was 71.2 per
100,000 in 2001 which was dropped to 23.4 in the year 2011. The low
incidence and prevalence of HBV is due to the effectiveness and
efficiency of the vaccination program among infants and other groups
at high risk, in addition to the success of health education programs
and the importance of early detection and management. Screening of
HBV was carried out among 46,906 blood donors in the year 2003. The
prevalence rate of HBV was 2.4%. Besides, 34,470 blood samples were
examined for hospital admitted patients with a prevalence rate of
5.3%, in 2009, there were 357 carriers with an incidence rate of 24.8
per 100,000 populations. In 2007, there were 412 carriers with an
incidence rate of 29 per 100,000 of the population.
Vaccination is an effective tool to protect against HBV, besides over
90% of the susceptible children were protected after three doses of
vaccination. Evaluation of the Hepatitis B immunization program for
children in GS reveals that 5 -15% of children were not protected. The
risk factors for no-respond to vaccines were classified into: Socio-
demographic as Residency, mother education level, level and type of
immunization place and Health status factors as birth weight, history of
hospitalization before vaccination, history of infection besides
nutritional status feeding during immunization. The study
recommended further studies to decrease none- respondent infants to
HB vaccination (Barhoom Sh., 2007).

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A second study focused on risk factors of HBV infection among women
in reproductive age in Gaza North Governorate. Educational and
working status, type of work, place of dental intervention, place of
surgical operation, and tattooing are the main risk factors for HBV in
women. The study recommended screening all women at childbearing
age in Gaza North Governorate and the researcher suggested that a
mass vaccination campaign of women in reproductive age in addition to
their children is recommended (Khalid Abu Ali 2008).
Hepatitis C Virus (HCV)
In the year 2001, the reports of the prevalence rate of HCV cases
showed 7.8 per 100,000, it was dropped to 4.4 in the year 2011. The
results showed Palestinians enjoy a very low prevalence rate of HCV
infection. In spite of this low prevalence, the seriousness of the
disease and its complications make it one of the major public health
problems in Palestine. The largest study for Hepatitis C prevalence and
risk factors covered blood donors; 70,170 blood samples were
examined in addition to 33,223 blood samples for high-risk groups in
the hospitals and the Central laboratory were examined. The
prevalence rate of Hepatitis C among blood donors in the Gaza Strip
dropped from 4.0 per thousand in 2002, to 2.4 per thousand in 2005.
The study results showed in spite of the unstable political situation in
Palestine all over the study period, surveillance system continues to be
successful, giving a message that surveillance system is essential
during a time of war as well as the time of peace. Continuity of HCV
surveillance is an essential step to control the disease (Abed, 2008).
Risk Factors of Hepatitis C in the Gaza Strip, Palestine were studied. It
was found that the main risk factors have a statistical significance level,
they are: Travelling abroad especially to Egypt, blood transfusion,
having surgery, having tattooing, dentist visits for treatment, using
unsterile injection. While not statistically significant risk factors were in
Gaza Strip were: blood donation, health organization workers, having
insulin injection, undergoing caesarian section, using analgesics

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parentally, hemodialysis, making sure that barber changing the razor,
practicing illegal sex, sharing family with teeth brush, razor, and nail
cutter. This study could be a model to define the risk factors
associated with hepatitis C in a developing close community as Gaza.
Such a study and similar studies will be a base for a successful
intervention program to reduce the prevalence rate of hepatitis C in
Gaza, and in similar countries (Rusrus Rushdi, 2005).

Gaza results show that blood and procedures dealing with blood are the major
risk factors for HCV and HBV in Palestine, improvement of HCV and HBV
screening will minimize the risk of the disease. Risk factors related to personal
hygiene, daily practices are under control in Gaza, and Interventions are easy
at low cost to eliminate the disease. Immunization for HBV should continue.
Availability of new, cheap, safe oral vaccine HAV for children raised the issue
of adding HAV to the table of discussion.

3.5 Other vaccine-preventable diseases

No major events reported for other vaccine-preventable diseases as
Diphtheria, Pertussis, and Rubella except localized outbreaks of rubella
and mumps. In spite of these facts, few questions will remain for
discussion
• Do we investigate or report these diseases properly?
• Do we report all the Adverse Effect For Immunization (AEFI)?
• Is it the time to look for other types of Pertussis vaccine?
• Do we keep follow up to the sero-survey results?
The Chairman of the Palestinian Pediatric Association recently wrote;
“We in Palestine have recently witnessed an increase in the number of
reported cases of Pertussis as reported by the preventive medicine
department.” He referred to a recent article from the New England
Journal of medicine that sheds the light on possible explanations for the
resurgence of this disease. And he continues: “It will be interesting to
study the incidence of Pertussis among Jerusalem population who has

125
been receiving DTaP and compare it with that in the West Bank where
DPT has remained in use in our EPI program.” Literature presented the
occurrence of Pertussis epidemics in the USA in spite of the
development of new vaccines using acellular Pertussis components
(DTaP). It is of particular concern at present is the fact that DTaP
vaccines are less potent than DTP vaccines (James, 2012).

This message directs attention to the importance of proper surveillance

for Pertussis by appropriate diagnosis, complete notification and identify
strategies for the use of the best option for the Pertussis vaccination
policy.
3.6 Brucellosis
The magnitude of the brucellosis problem in the Gaza Strip and the
exposure to risk factors among cases were investigated. The incidence
of brucellosis in 1996 was 8/100 000. The incidence of brucellosis in
2001 was 1.7 per 100,000 and in 2011 was 0.8/100 000 in Gaza Strip.
The age-specific incidence rate was approximately equal in all age
groups, with a mean age of infection of 20 years. Cases were reported
from all districts, with a particularly high incidence in the Mid-zone
district and Gaza City, and most cases had onset of illness in spring and
summer. The main reported risk factor was the consumption of milk
and milk products, especially homemade cheese (70.4%), and 22.2%
of cases were among families raising animals. The proportion of chronic
and relapsing cases was very high (17%).
The main species causing brucellosis in the Eastern Mediterranean
Region (EMR) are Brucella melitensis and B. abortus, and the main
reservoirs of infection in most countries are sheep and goats, and to
some lesser extent cattle, buffaloes and camels. Research suggests
that B. melitensis biotypes 1 and 3 are responsible for most cases in
animals in Palestine. The researcher suggested importing the animals
from countries that are reported as Brucellosis free countries (Awad R.,
2005, Bahtity, 2005).

126
 Surveillance for Brucellosis is essential. Health education, proper
pasteurization of milk and boiling cheese, and animal vaccinations
proved to be efficient measures to control Brucella.

3.7 Meningitis:
The most common type of meningitis in GS is viral (aseptic) meningitis
that is increasing by time while Haemophilus meningitis forms the
lowest proportion of the diseases. Other bacterial types such as
pneumococcal are more common than meningococcal.
For viral meningitis in 2001, 411 cases were reported in GS with an
incidence rate of 34.3 per 100,000, wherein 2011, 799 cases were
reported with an incidence rate of 49.9 per 100,000 inhabitants.
During the same compared periods, meningococcal meningitis in 2001,
were 106 cases with an incidence rate of 8.9 per 100,000 population
and in 2011, the number of reported cases was 151with an incidence
rate of 9.8 per 100,000. Other bacterial meningitis in 2001 reported
cases were 110 cases with an incidence rate of 9.2 per 100,000
population. In 2011, the cases jumped to 346 cases with an incidence
rate of 21.6 per 100,000. Director of preventive medicine stated that:
“There is a shift of cases from north to south where recently more
cases are reported from KhanYounis and Rafah”.
The famous outbreak of viral Meningitis in 1997 was reported by the
WHO in its annual report. Most cases were children 2-5 years old. There
were no deaths due to the outbreak. The disease varied according to
the age-sex seasoning with a peak in May. The fact that there are no
deaths reflects the strength and the preparedness of the Palestinian
health care system.
A study of Epidemiology of Neisseria (Meningococcal) Meningitis among
children in Gaza Strip was completed to identify the incidence and
distribution of the risk factors among children less than 15 years, and
to assess the association between the laboratory results and the

127
severity of the disease. The incidence was 17.8/100,000 with variation
according to sex, age, governorate, and socio-demographic and
economic status. The strains of Neisseria Meningitis were resistant to
penicillin (12.3%), ampicillin (15%), and sulfonamide (47.7%), where
it was sensitive to cephalosporin, chloramphenicol, and rifampicin (Abu
Shaban, 2006).

By the introduction of the Hib vaccine and pneumococcal

vaccine, we expect a marked drop in bacterial meningitis,
but this does not solve the problem of viral meningitis that
requires massive health education and improvement of
socioeconomic conditions including nutrition and housing.

3.8 Respiratory infections

Acute Respiratory Infections (ARI) including pneumonia affect all the
population and mainly young and aged. Children and newborns are
particularly at risk and have an increased risk of death from
pneumonia. The main risk factors include crowding, poor ventilation,
indoor smoke, malnutrition and lack of proper exclusive breast-feeding.
Any disruption of MCH services also means fewer babies receive
supplements of vitamin A, a highly effective preventive intervention
against ARI. Acute malnutrition is a major contributing factor to
morbidity and mortality from CDs such as ARI, particularly in children
(UNRWA 2007, EMRO, 2009). More than 60,000 cases of Influenza and
pneumonia were reported in Gaza Strip during the year 2011; under-
reporting is still a major problem. A recent report compares the cases
of URTI in health service centers in Gaza Strip during the years 2009 -
2011. Figure 8.3 below shows that the number of cases is already
doubled during the year 2011. One interviewed Epidemiologist
explained this as follows: “The high number of reported cases during
2011 explained by reporting not only influenza cases but also all URTI
cases”. Improvement of reporting is one reason for this increase but

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overcrowding and increased traffic movement with subsequently
increased air pollution is the major risk factors.
Figure (8.3): Distribution of Upper Respiratory Tract Infection in
the Gaza Strip, years 2009-201133

The use of Antibiotics in pediatrics' acute respiratory infections in

Primary Health Care Centers in the Gaza Strip was studied. The study
showed an overuse and misuse of antibiotics in treating pediatric acute
respiratory infections. About (77.8%) of the study children were
prescribed antibiotics, and (77.7%) of these antibiotics were
unnecessary. The main factors that increased parent satisfaction during
the physician consultations were complete examination of the child
(94.2%) and good communication between the parents and the
physicians (72.4%). These results highlight the complicated problem of
the inappropriate use of antibiotics. Great efforts are needed such as
intervention educational programs to the public, training programs, and
workshops to the medical staff, in addition to more research in this field
(Khoudary S., 2002)

There is a marked increase in respiratory infectious diseases

among the GS population. Improvement of environmental
conditions, housing, Road Traffic and keeping good nutrition are
needed to overcome this major problem, proper management of
cases by application IMCI protocols will minimize complications
33 MOH (2011): Epidemiological Bulletin Vol. 1, No. 2; 2011
among children.
129
3.9 Food and Waterborne diseases
Enteric Diseases
The risk of outbreaks of water and foodborne diseases is currently high.
The risk increases, if water, sanitation and food control services are not
properly controlled. The main pathogens of concern are
Campylobacter, Salmonella, Shigella, Leptospira, Rotavirus, as well as
other enteropathogens such as Entamoeba histolytica and hepatitis A
and E. The last Cholera epidemic was reported in the GS 1994. OCHA
estimated that 80% of the water supply in the GS is unsafe for drinking
(OCHA). Sewage treatment has been disrupted by the war where
sewage overload resulted in overflow in the streets (EMRO, 2009).
Table (9.1) shows that enteric diseases including diarrhea and bloody
diarrhea are the most common reported CDs especially among children
below 3 years. The recent MOH bulletin shows a marked increase in
the reported number of diarrheal diseases in the Gaza Strip during the
last 4 years (Figure 8.4).
Centre for Disease Control (CDC) estimates that each year roughly 1 in
6 Americans (or 48 million people) gets sick 128,000 are hospitalized,
and 3,000 dies of foodborne diseases. The 2011 estimates show that
foodborne bacteria and viruses are causing the most illnesses in the
United States, as well as estimating the number of foodborne illnesses
without a known cause (CDC, 2012).
In the GS, research was conducted in 2006 to identify Salmonella
prevalence in fresh, chilled, and frozen poultry (chicken and turkey).
The study showed that fresh and chilled poultry were contaminated
with Salmonella, 19.2%, and 18.8%, respectively. Fresh, chilled and
frozen poultry that had total plate count exceeding level accepted by
Palestinian Standard (PS) were 2.4%, 21.9%, and 3.8 respectively with
an average of 5.5%. The study demonstrated a statistically significant
relationship between poultry contamination with Salmonella,
Staphylococcus aureus, or E. coli and type of workplaces where the

130
semi-automated slaughterhouse had lower contamination (4.2%) than
small-scale places (20.7%).

Figure 8.4: Distribution of diarrheal diseases in the Gaza strip, years

2007-201034

For research purposes, it is recommended to carry out larger and

national wide similar studies to have registered national data about
Salmonella, its serotypes and its prevalence in food items (Humaid
Mahmoud, 2006).

Environmental protection is the key to the control of the enteric

diseases, safe water, and proper sewage system will minimize the
enteric hazards. We recommended imposing and enacting laws and
regulations regarding inspection and surveillance of poultry and
other food items for foodborne pathogens particularly Salmonella.
Automated poultry slaughterhouses, raise awareness of persons
dealing with poultry processing for adopting good hygienic
practices and improving the outdoor environment are
recommended.
3.10 Intestinal Parasites
In 1979 Abed pointed to the high prevalence of parasites among the
Palestinian children in Jabalia village (Abed, 1979). The prevalence of
intestinal parasites continues to be high where Al Astal (2004)
examined 1,370 children in Khan Younis Governorate, Gaza Strip. The

34 UNRWA: Epidemiological Bulletin Vol. 1, No. 2; 2011

131
age of the children ranged from 6 to11 years. A total of 20.9% of the
children examined were infected. The general prevalence of intestinal
parasites was 34.2%. Different types of intestinal parasites were
detected during this survey: Ascaris lumbricoides (12.8%), Giardia
lamblia (8.0%), Entamoeba histolytica 7.0%, Entamoeba (3.6%),
Trichuris trichiura (1.6%) and Hymenolepis nana (1.0%) of the total
examined children (Al Astal 2004). The prevalence of intestinal
parasites among school children in Gaza city, Beit Lahia villages and
Jabalia refugee camp "Gaza Strip" was estimated by examining 432
stool samples from school children aged 6- 11 years old. Of the 432
stool samples, 125 were found to be positive with a prevalence of
(28.9%) among the examined school children (Basel Kanoi 2006).
The occurrence of Gastrointestinal Parasites among pre-school children,
Gaza, Palestine was completed and the study showed 16.6% of the
studied children were infected with intestinal parasites and Infection
with Giardia lamblia showed the highest prevalence (10.3%) among the
studied children (Hendi 2008).
Shawa in 2004 examined Intestinal Parasites Infections in Refugees
Camps In the Gaza Governorates, Palestine where a total of 58,206
stool specimens have been examined in parasitological laboratories of
eight refugee camps in Gaza Governorates at UNRWA health centers.
Results revealed an overall prevalence of 19%. The high prevalence
was noticed in the Rafah refugee camp (20%) and the lowest
prevalence was 15% in Gaza city (Shawa 2004). Laboratories reported
more than 13,000 cases positive for intestinal parasites in the year
2011 (Table 8.1).

Studies in the Gaza strip reveal that intestinal parasites

infestation is a common public health problem affecting all
localities among school and preschool children with
prevalence rate around 20%. Interventions are required by
ensuring a proper sewage system, safe water, and personal
hygiene education.
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3.11 Skin diseases:
Prevalence and risk factors for skin diseases among primary school
children in the Gaza Strip were examined. The results showed that skin
conditions are very common in children and half of them (48.5%) are
affected. The prevalence of skin diseases is higher among males
(55.9%) than females (42.8%), the differences between males and
females are statistically significant. Pityriasis alba and pediculosis (lice)
had the highest prevalence rates of all skin disorders (23.5%, 9.5%
respectively). Males had a higher frequency of pityriasis alba (34.8%)
than did females (13.6%), But females had a higher frequency of head
lice (16.2%) than males (1.2%). There is a strong significant
difference in presence of Pityriasis Alba and pediculosis lice among
males and females. Another diagnosis was eczematous diseases 4.2%
followed by infectious diseases (3.6%) and scabies (0.8 %). Other
diseases include pigmentary patches, insect bites, drug eruptions,
vitiligo, cheilosis, spares hair was 7.2%. The study has revealed that
the top five skin disorders on the list are pityriasis alba, Pediculosis
Lice, Eczematous Diseases, Infectious Diseases, and Scabies. They
comprised 85.1% of the skin conditions encountered, Pityriasis Alba
causes accounted for 47.7% of all cases, and Pediculosis Lice causes
accounted for 19.6%. The study revealed that more than 85% of the
disorders can be grouped into fewer than six categories. The results
showed that the children who share combs, towels, beds, covers,
clothes, and socks with others are more likely to be affected by skin
diseases than those who do not share. The study concluded that the
prevalence of skin diseases among schoolchildren in the Gaza strip was
very high (Naim Rafat, 2006).

we recommended the introduction of a preventative health

education program among schoolchildren at different levels, their
families, and teachers on skin diseases, these finding are
important in designing training programs for medical teams
involved in the delivery of primary health care services in
developing countries such Palestine, where about half of the
population is less than 15 years of age.

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3.12 Sexually Transmitted Diseases (STDs)
Historically STDs are not notified in Palestine because of the sensitivity
of this subject. There is a marked variation in figures that appeared in
the reports over the years. New cases of STDs increased from 7,961
cases in 2000 to 20,401 cases in the year 2004 with an annual
average incidence rate of 365.3 per 100,000 in the last five years.
Surely, such an increase is not true and resulted from reporting
changes.
Distribution of cases by region showed that 17,858 cases were reported
in West Bank (87.5%) with an incidence rate of 776.3 per 100,000 and
2,543 cases in Gaza Strip (12.5%) with an incidence rate of 190.2 per
100,000, Gaza Strip proportion forms only 5% of the cases in 2003
(MOH 2004, 2005). This is another example of improper reporting;
simply there is no proper explanation for the large differences between
Gaza and the WB.
Acquired Immuno-Deficiency Syndrome (AIDS) & HIV infections: the
most worry is given for AIDS & HIV infections. Acquired Immune
Deficiency Syndrome (AIDS) and HIV is a rare event in Palestine where
few cases are reported each year.

Figure 8.5: Distribution of New HIV\ AIDS Reported Cases & Cumulative No.
of Reported Cases, Palestine 1988- 201735

35 MOH (2018) Health Annual Report, Palestine, 2017

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Table (8.2) shows that the incidence of HIV/AIDS was 0.4 / 100,000 in
2001 and dropped to 0.3 in the year 2011. Graph 8.5 shows that the
total number of AIDS cases throughout 30 years (1988 – 2017) was 98
cases with an average of three cases per year. Out of the 98 cases 38
are still alive, 53 died and 7 cases are unknown.

It is clear and evident that AIDS/HIV is not a public health

problem in Palestine while other STDs are a major problem. The
under-reporting of STDs problem was obvious and needs further
interventions in the domain of STDs services and human
resources especially in GS. Proper improvement of STDs
surveillance in GS is highly needed.

4. Treatment services for communicable diseases

Most of the communicable diseases such as chickenpox, mumps, and
enteric diseases are recognized clinically and treated at the PHC level.
Basic laboratory tests for Brucellosis, typhoid, and meningitis are
available in the hospital laboratories and the central laboratory. Lab
fasciitis for viral diseases are lacking. Fever under investigation, Cases
of meningitis, Brucellosis and typhoid are hospitalized. The new guide
for TB is to be treated at home and only severe cases must be
hospitalized. Protocols of management are present for Tuberculosis
but not for all communicable diseases.
In cooperation with WHO and UNICEF, the MOH adopted and developed
Integrated Management of Child Illness (IMCI) protocols. Management
of diarrheal diseases and acute respiratory infections are included in
IMCI based on international standards. A researcher evaluated the
implementation of the IMCI protocols in the GS and the study results
showed a low percentage of the trained staff for IMCI. Among the
trained staff few are practicing IMCI principles in case management.
The study revealed a low level of compliance with the implementation
of the protocols in general, especially with the classification step (25%)

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and the treatment step (40%) according to the protocols. Of the study
population, 49% reported currently using the protocols in their practice.
Only 15% of the physicians got copies of protocols and 53% had
received training on the protocols. IMCI supervision and follow up is not
well established (Hamad B, 2005). During an interview with the
Director-General PHC /Gaza, he stated: "The concept of IMCI is
excellent while the procedure of implementation is not satisfactory”. He
continued: “The name is "integrated" but in reality, it is not integrated
with other MCH activities, we have to revise our program". MOH
initiated steps to establish national protocols for CDs management
including protocols for T.B., meningitis; Brucellosis and HIV treatment.
A limited number of protocols are available in the official offices and not
in hospitals or PHC centers.

Greater efforts are required to gather the study reviews and

modify the available management protocols for the common CDs.
Enough copies and sufficient training on the use of national
protocols are needed to improve physician's practices. Designing
and implementing more in-service training, provision of the
needed equipment and supplies, empowering the management
capacity of the health care system such as follow up, supervision
and referral services are needed.
5. Immunization Program

Childhood immunization in Palestine has received major emphasis over

many years. This has resulted in an expanded immunization program
(EPI) which includes a broad range of vaccines with coverage of over
95% of infants and school-age children. The immunization program is
under continuous review of international and national experts in this
field. There have been no differences between the immunization
programs implemented at governmental clinics in Gaza and the West
Bank and UNRWA clinics since 1995.

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As recommended by WHO, the immunization program is conducted to
cover the following infectious diseases: Diphtheria, Pertussis, Tetanus,
Hepatitis B, Polio, Measles and Tuberculosis as well as German measles
and Mumps. Recently, Haemophilus Influenza, Pneumococcal, and Rota
antigens are added to the immunization program.
During 1992/1993 routine immunization for hepatitis B for all newborns
was instituted in Gaza and the West Bank. The vaccine was also
provided to UNRWA Health Service Centers and all hospitals. Hepatitis
B vaccination is also given voluntarily for medical and paramedical
personnel who are at risk of exposure to this virus.
The immunization coverage rate for Gaza for all vaccines was 96.1%.
Measles and MMR (the coverage rate in Gaza for Measles was 93.2%
and for Measles, Mumps and Rubella (MMR) was 82.18%) were the
antigens that contributed to the drop in the overall coverage among
12-23 months old children (PCBS, 1996). Regarding the Tetanus
toxoid (T.T) coverage rates among pregnant women (PCBS, 1996), a
health survey indicated 21.7% coverage for any T.T dose among
currently pregnant women and 35.5% among those who had a child
during the last five years. This may or may not indicate a lack of
protection for newborns.
Vaccines are provided from different sources such as MOH, UNICEF,
and WHO. The situation regarding the availability of vaccines to cover
all populations is generally good and immunization activities are regular
in the MOH and UNRWA clinics.
Based on the 2004 Maram / USAID Immunization Coverage
Assessment Study in the Palestinian land, coverage for booster doses of
DPT4, TOPV4 and MMR is around 90%. Most children who missed
immunizations had missed one or two immunization (43% and 25%
respectively), based on their immunization cards. The missed vaccines
tended to be booster doses of DPT4 and TOPV4. The report explored
the causes for dropout where mostly due to misunderstandings of the
mother about the age requirement for their children’s immunizations,

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the immunization schedule itself, and the child’s illness as a
contraindication for immunization (Maram, 2005, Abu Hamad 2005).
Change in the Immunization schedule should be minimized as possible
as we can and the addition of new antigens necessitates proper
campaign to make the public-oriented with the changes in the
schedule.
Table (8. 3)
Immunization Schedule - Palestine 2018
Age Vaccine

Birth HB - BCG
1 Month IPV1
2 Month Penta1* / IPV2/ PCV1 / OPV1 /Rota 1
4 Month Penta2 / PCV2 /OPV2/ Rota 2
6 Month Penta3 / OPV3)
12 Month MMR1 / PCV3
18 Month MMR2 / DPT4 / OPV4
6 Years OPV5 /DT
15 Years Td
*Penta Vaccine = (HB+DTP+Hib)

Table 8.3 shows the currently modified and used immunization program
in GS &WB where new antigens are introduced and including HIb
(2007) pneumococcal vaccines (2012) and recently Rotavirus vaccine.
Penta Vaccine includes HB vaccine, Hib vaccine and the triple vaccine
(DTP). Hepatitis A vaccine is not included and the measles 9-month
dose is not given more, where 2 MMR is given at age 12 and 18
months.
Vaccination Program Fund:
The International organizations commendably kept funding the national
immunization program since 1994 in the GS and WB. In 1996 the MOH
decided to include the immunization budget within the ministry budget

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and purchased the vaccine for the years 96,97 and 98 besides some
donation from WHO. The Japanese International Cooperation services
funded the vaccines for the years 2000, 2001. The USAID funded the
program for the years 2003-2004 and Oman for the year 2005.
Different UN Agencies including UNICEF participated in funding the
vaccinations program for the years 2009, 2010 and 2011.
The vaccination budget (5 million $) is a part of the MOH budget. The
new pneumococcal vaccine has been introduced in the year 2012 with a
fund by RVF around $ 3,000,000 for one year with commitment from
MOH to continue this vaccine in the coming years. Cost-effective
studies for all the newly introduced vaccines need to be conducted as
soon as possible. Immunization program funding is unstable. It is
luckily true that the Palestinian land was not left without funding the
vaccination program at any time.
According to the Palestinian Public Health Law, the MOH is the
responsible body for the health of the Palestinian population. Control of
infectious diseases is one of the major tasks of the MOH.
Therefore, there should be a yearly-defined budget for the control of
infectious diseases including the provision of vaccines, disposables, and
the training activities.
The immunization activities are controlled by the National Expanded
Program of Immunization Committee with members from MOH,
UNRWA, universities, and the Pediatric Association, the committee has
regular meetings every 3rd month and the Committee responds to any
threats of possible epidemics. The Committee is keeping good
communication and cooperation with the 2 related Committees: The
Committee of Polio Eradication and the Committee For Measles
Elimination. During interviews, it was clear that the Infectious Disease
Control Committee is not working in harmony with the EPI Committee.
Transport and cold chain:
All the purchased or donated vaccines reach the Palestinian land
through Ben Gurion Airport in two packages one is to the WB and the

139
other is to GS. Traditionally, the amount is divided 40% to Gaza and
60% to the WB.
Electromagnetic tags monitor all vaccines; vaccine vial monitors (VVM)
and cold chain card monitor (CCM). The vaccines are stored in a central
vaccine store equipped with an efficient cooling system and standing by
generations as an alternative source of energy at times of electricity
cut. The system is linked with an alarm system for risk detection.
Inside GS the two providers for vaccines are UNRWA and the
governmental services. UNRWA receives its package from the Gaza
vaccine stores. Distribution of the vaccines to the PHC centers is
undertaken according to a regular schedule. A specially equipped car
and specialized public health staff are allocated to this purpose.
Training: most of the PHC health workers attended short training
courses by local and international trainers funded by UNICEF and WHO.
Senior staff participates in WHO meetings through EMRO in Cairo.
Surveillance system for EPI Program:
1. The surveillance system mainly depends on routine weekly
reporting and both quarterly and annual reports from UNRWA and
governmental PHC centers.

2. Follow up system is applied in the health center by application of

central registry towards computerization of the childhood
immunization schedules; phones and home visits are applied for
follow up of delayed children.

3. Adverse events following immunization (AEFI) for all vaccines and

specifically post BCG complications are investigated. The
processes of investigations are not covering all AEFI with all
antigens, so expansion of the list is needed.

4. Sero survey for vaccine antigens was completed in 2004,

revealed a low level of seroconversion for measles, Rubella and
Mumps. Following the Sero survey results, MMR campaigns were
completed in the WB (2005) and the GS (2009). The last sero-

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 survey was completed in the year 2010. The results are not
disseminated.

One major issue is to restructure the different committees

dealing with infectious disease control, EPI, and surveillance
committees. One committee with a specialized subcommittee
with identified terms of reference, a regular meeting will
ensure better control of CDs. Local training courses have to be
expanded regularly with a fixed MOH budget. The key
informants think that the priority should be given for medical
waste disposal for the different vaccines and used syringes &
Surveillance
needles. System for CDS
Communicable disease surveillance is the routine ongoing collection,
collation, analysis, interpretation, and dissemination of health data. It
serves two key functions, early warning of potential threats to public
health and program monitoring functions.
National guideline for CD surveillance:
Based on key informant interview there is a national guide for CDs
surveillance, prepared by the Epidemiology Department – MOH in
coordination with UNRWA, WHO, and local experts. The Guidelines
describe the operational definitions of the notifiable CDs in Palestine.
The groups of the notified diseases are described in the national
guide. Group (A) required immediate notification by phone, Group (B)
are notified weekly and the group (C) are notified monthly, forms of
notifications for specific diseases are included in the guide, The
guidelines are available in all the PHC centers and most staff
concerned in PHC are oriented with their components.
The epidemiology department is one of the main PHC departments in
Primary Health Care. MOH has a central office staffed by qualified
experts who supervise the epidemiological activities in the five district
offices. The central office gathers the reports of CDs from the district
offices and the governmental hospitals, at the same time UNRWA

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 operates a surveillance system for the same groups of the CDs
reported in UNRWA clinics. In UNRWA, monthly CDs bulletin reports all
the notified diseases and compare them with the same period in the
previous 2 years. Alert status for specific diseases is considered when
the reported cases exceed the mean of the previous years by 2
standard deviations (SD) and alarm status when the excess of cases
exceeds mean 3 SD. The total of these reports is added to the MOH
quarterly epidemiological bulletin. Email has become an excellent tool
for the dissemination of the MOH and UNRWA health services
regularly, during the last year.
Key informant interviews revealed several important issues to be
strengthened and supported including computerization of the CDs'
investigation sheets where such effort would facilitate further
investigations of the disease spread in the community. Also, they seek
further training of the PHC and hospital staff for the surveillance
system.
The health management information system for NCDs is not
computerized properly except in UNRWA centers where e_ health is
implemented in 7 PHC centers. The available computers are used to fill
excel sheets for the notified diseases. Local staff is capable to build a
computerized database for CDs. We recommend further statistical
analysis by the uses of statistical soft packages and encourage
exchange and dissemination of the findings on regular bases. Key
informant interviews in both government and UNRWA showed that
active steps are completed to achieve proper surveillance of
communicable diseases. These steps include:
1. Publication of the national surveillance guidelines for control of the
communicable diseases, these guidelines are prepared by local
experts in the GS and WB and supported by WHO.
2. Developing unified forms for notifications of the infectious diseases,
these forms include general and specific forms, General forms are
classified to 3 levels, find attached. Some selective diseases have

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 specific investigation forms such as Brucellosis, Tuberculosis and
Acute Flaccid Paralysis (MOH, 2009).
3. Communicable diseases control committees: A national
committee to control communicable diseases is formed by local
experts in medicine, infectious diseases, epidemiology, laboratories
and pharmacy besides key administrative staff. The committee does
not meet regularly on fixed scheduled dates. The meetings are held on
an ad-hoc basis at times of epidemic threats occur. Members present
health services in UNRWA and Governmental besides University
experts. Also, there are other two specialized committees, the first for
poliomyelitis eradication and the second for measles elimination. The
polio eradication committee follows up each flaccid paralysis
investigation to exclude any poliomyelitis case. Measles elimination
committee is anticipating any occurrence of suspected cases of
measles and ensures lab testing. At the same time, changes in Rubella
trends are reported, the committee follows all changes happen to both
measles and rubella in coordination with WHO and EMRO.
A report in June 2012 shows that during the first six months of the
year 2012, a total of 25 suspected cases of measles are reported in
Palestine and all sent to lab testing where no single suspect was
confirmed.
4. Training: Both WHO and UNICEF provide funding and support to
conduct training to health service providers with an emphasis on
changes in trends of communicable diseases, cold chain, vaccine
antigens in use and surveillance for communicable diseases.
Dissemination of information is biased where for years the reports
reach the high administrative level including Minister and the directors
and not the service providers in hospitals and primary health care
centers. Recently Email is used to distribute the epidemiological report
to national and international experts and for all the PHC centers and
hospitals. UNRWA distribution list includes health professions in
Government and UNRWA besides international health bodies. Reports

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are available at the web page of MOH and UNRWA
([Link] or [Link]

Active steps have been completed to upgrade the

surveillance system for the CDs in Palestine. More efforts
are needed to improve the computerization of the system
and expand the training of the health teams in both
hospitals and the PHC. The terms of references for the
scientific committees need to be revised.

6. Infectious Diseases Research Studies

MOH and PCBS reports are the main source of information for research
in infectious diseases. The local universities and educational
institutions succeeded to cover a limited number of research studies of
CDs and tackled specific subjects as brucellosis, hepatitis, Salmonella,
meningitis, Diarrheal diseases, Parasites, and immunization.
A report described priority for research in the area of communicable
diseases was issued in 1998. The author thinks that this report has
kept its validity and its value until today. The document explained the
situation of CDs during the past fifty years where the Palestinian health
system has been severely fragmented resulting in both lacks of
experience in health professionals and lack of interest in further
research. Research in the area of infectious diseases is important as the
Palestinian land is exposed to risk factors such as overcrowding, poor
sanitary conditions, political unrest and shortages in health facilities.
The author describes six priorities for infectious disease research in
Palestine, they are:
1) To carry out a national health survey,
2) To upgrade the epidemiological surveillance system,
3) To support the diagnostic facilities,
4) To develop and update training of manpower,

144
5) To increase inter-sectoral coordination and international cooperation
in the field of infectious disease control and
6) To conduct research activities assessing prevalence and incidence
and risk factors of various diseases (Abed Y.1998).

In summary, the most important step is to build infrastructure for

research to enable the Palestinian Researchers to perform their
studies according to accepted international standards.
Establishment of the Palestinian National Research Council is a
bottom line step to build the regulatory mechanisms between
Palestinian Research bodies on one hand, and the international
organizations, Universities in the USA, Europe, and Arab countries.

7. Public Health Law

The Palestinian Public Health law no. (20) for the Year 2004 was
published on April 23, 2005.
Chapter One puts general principals as a definition of Infectious
Disease, Epidemic disease, The Infected Person, The Suspected person,
and Quarantine. In Article three and accordance with the law, all
officials are required to inform the Ministry about all information related
to deliveries, deaths, and infectious diseases that have to be reported.
Article Six describes the role of the MOH in the implementation of
preventive vaccination programs, to ensure the quality of vaccines
during transportation, storage, and usage, and to ensure free
preventing services by not charging any fees in return for vaccination
or immunization of children or pregnant women. According to the law
(Article seven), parents or those who are the legal guardians of the
child should meet the terms of the vaccination programs formed by the
Ministry.
The Ministry of Health shall take the responsibility of combating
infectious diseases, epidemics, and inherited diseases by all means

145
 possible, and monitor the rates of spread of those diseases; by
collecting the relevant data (Article Nine). The next article describes
the measures to stop the spread of the disease through: Imposing
vaccination or needed medication, Confiscate and destroy all material
contaminated with the disease, or materials that could be a source of
the spread of the disease, in coordination with the competent bodies
and to bury the dead in the manner they deem fit (PNA 2004).
Palestinian MOH is the main body responsible for the health of the
Palestinian people. MOH in cooperation with national and international
parties has to set strategies to ensure the implementation of laws
protecting the population from hazards.
Discussion
This review tried to highlight the status of the CDs in GS and the main
gaps in the process of control measures to ensure the prevention and
control of these diseases. There is a well-organized program to control
CDs including vaccine provision, case management, and surveillance
system. Communicable diseases in Palestine are divided into three
groups according to their epidemiological importance:
A. Vaccine-preventable diseases including Tuberculosis, Poliomyelitis,
Diphtheria, Pertussis Tetanus, Measles, German measles, Mumps,
Hepatitis B, Haemophilus influenza and pneumococcal
[Link] related diseases including HIV, Hepatitis C
B. Environment-related diseases resulted from unsafe water use,
improper sewage disposal, unsafe food, and overcrowding. This group
includes different enteric diseases and acute respiratory diseases. Two
facts are clear in the epidemiology of the CDs in GS, the first one is
the clear decline in the incidence of the vaccine-preventable diseases
and the second fact is the marked increase of the environment-related
CDs.
Some Vaccine-preventable diseases are controlled as Measles and
Diphtheria while Polio is eradicated. Few cases of tetanus, Tuberculosis,

146
and Hepatitis B are reported but marked reduction in their incidence is
reported.
The behavioral related communicable diseases without available
vaccines such as STDs including HIV and Hepatitis C are under control
where the public is oriented with their hazards and methods of
prevention. The public awareness is supported by great efforts to
ensure safe blood transfusion. Safe blood is the blood that has been
tested and found negative for HIV, HBV, HCV, and syphilis, in addition
to appropriate compatibility of testing for the intended patients under
appropriate medical supervision. Scientists call for a quality assurance
system at all stages of the blood transfusion chain (Tapko2007).
The major problems are the environmental-related CDs where ARI and
Diarrheal diseases are markedly increased. Respiratory diseases have
their impact on morbidity, hospital admissions and mortality, especially
among children. At this stage, preventive measures such as
improvement of nutrition, housing conditions and giving care for
personal hygiene are the possible interventions. The situation for
diarrheal diseases is different where they have an impact on morbidity
and hospital admissions but not on mortality where the proportional
mortality from diarrheal diseases does not reach 1% of the total
mortality.
Unsafe water supply and improper sewage disposal are the two major
risk factors for diarrheal diseases. Interventions should include safe
water provision and proper sewage disposal. Municipalities, local health
councils and UNRWA’s environmental health program control the
quality of drinking water, provide sanitation and carry out vector and
rodent control in cities villages and refugee camps, thus reducing the
risk of epidemics (UNRWA, 2012). Personal hygiene and proper food
preparation are easy and cheap measures to implement for both
diarrheal diseases and ARI prevention. Proper case management
minimizes the risk of complications and death, especially among
children.

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Compared with the Eastern Mediterranean Region countries, Palestine
is in a good position in the control of infectious diseases. We are one of
the countries that succeeded to ensure immunization coverage
exceeding 95% of the targeted population. Palestinian land adopted IPV
and TOPV system to control Polio before 35 years and succeeded to be
free from Polio by the year 1984. No single case of measles is reported
in the last 10 years while cases are still reported in Afghanistan, Sudan,
and other countries (EMRO measles elimination sheet)
In spite of the financial troubles facing the Palestinian Authority, we still
are keeping a free immunization program covering the traditional six
antigens: T.B., Polio, Diphtheria, Pertussis, Tetanus, and Measles
besides giving MMR to cover Mumps and Rubella. Hepatitis B vaccine is
given for all newborns since Jan 1993. Recently 2 new antigens are
given: Hib and Pneumococcal vaccines. In spite of all the crises in the
Palestinian, a positive aspect can be observed in Palestine; it is the full
commitment to keeping the development of the EPI.
The immunization program is successful in implementation, however,
frequent changes and adding more antigens have to be considered
taking into consideration the cost of the vaccines, the sustainability of
the program, acceptance by the public and the overload for the health
staff in the PHC centers. Efforts of the Immunization Committee have
to be fully integrated with the Communicable Diseases Control
Committee. Surveillance systems for immunization and the adverse
effects of vaccines should be integrated with the surveillance system of
the CDs in general.
Training and workshops to control CDs are completed by the support of
international bodies and the activities should be sustained by the local
fund. IMCI guidelines should be revised to fit the local communities
and fully integrated into MCH activities.
Epidemiology Department activities have to be expanded to cover both
communicable and non-communicable diseases. Improvement of the
surveillance system necessitates more commitment from the health

148
care providers working in the field to notify each communicable
disease, regular feedback and report dissemination from the central
offices to the periphery will improve the staff commitment. Most of the
infrastructure of the surveillance system in Palestine is available and
working. Active steps to support and strengthen the system are
needed.

Factors of success to control the communicable diseases:

1. Presence of legislation where the Palestinian Public Health Law
ensures the responsibility of the MOH for control of the
communicable diseases and protects the public from their hazards.
2. The commitment of the leadership in the health sector to control
communicable diseases is a second success factor where leadership
in the Governmental ministries and different health care providers
should be concerned with the control of the CDs.
3. Positive Public response to immunization programs and the strong
influence of the Religious factor that is calling for general
cleanliness, sickness prevention, and safe sex.
4. Availability of the health services with easy access to free services
in the PHC centers served by the Government and UNRWA, and
easy access to hospital services in the hospitals as distributed in the
five Governorates in GS. Functioning lab facilities in the PHC,
hospitals and the central public Health laboratory facilitate keeping
continuity of disease identification, surveillance, and proper control.
5. Availability of expert staff in medicine, pediatrics, epidemiology,
microbiology and public health. Epidemiological services are should
be available in each Governorate. Active scientific committees of the
local staff working in Government, UNRWA and the Universities play
an active role in the control.
6. Support of international health organizations such as WHO and
UNICEF for control activities. Their role is markedly important either
in vaccine provision or facilitating vaccine provision by the Donor

149
 community. They keep supporting most of the training activities
either inside or outside Palestine.

Main obstacles facing control of communicable diseases:

1. The first and major obstacle is the financial problem of which is
preventing the allocation of the required budget to ensure regular
planned preventive measures including the regular purchase of the
vaccines and the related disposable consumables.
2. Uncontrollable overcrowding of the population especially in the
refugee camps where the population density is one of the highest in
the world.
3. Deterioration of the environmental conditions mainly sewage and
Garbage disposal systems and safe water provision for the entire
population.
4. Gaps in the surveillance system mainly in the reporting system,
timely analysis of the data and proper dissemination of the reports
at the proper time.

Recommendations:
Active steps are required to implement as a basic component of the
planned developmental activities. These steps are categorized as
follows:
1. Supporting Health promotion

2. Continue and Develop Disease prevention and management

policies

3. Acting for Environmental Protection in cooperation with the main

players

4. Management Reform for the CDs control departments

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 1. Supporting Health promotion: Health education is the right of
each individual from childhood to the end of life. Subjects of health
education should emphasis on improving personal hygiene and to
avoid overcrowding. Proper nutrition is an essential component for
the control of communicable diseases where under-nutrition is a
major risk factor for the occurrence of the disease and increases the
chances of complications.

2. Continue and Develop Disease prevention and management

policies:

2.1 Infection control: to ensure proper work of the infection control

committees inside PHC facilities hospitals and the private and NGO
facilities. Efforts are needed to take strict measures in medical
procedures, including operations, endoscopies, catheterization, blood
transfusion, dental intervention, nebulizer use, and even simple
dressing procedures. This can be possible through adopting a new
policy to develop epidemiology multidisciplinary teams of the hospital
staff in hospitals to pursue the sources of nosocomial infections and
CDs in hospital media.

2.2 To sustain the high immunization coverage against vaccine-

preventable diseases to continue to achieve over 95% of infants and
school-children are immunized.

2.3 To keep immunization schedule review under the supervision of

the National Communicable Disease Control Committee and to put on
the agenda of the committee Pertussis vaccine policies pneumococcal
vaccine continuity and HAV vaccines.

2.4 Surveillance system: to strengthen the current surveillance

system by the adoption of the national surveillance guidelines and
orientation of the health staff by workshops, seminars and continuing
education activities.

2.5 Continuous training of the health care providers for different

151
protocols and guidelines used to manage and control the CDs.

2.6 Improve the health information system in terms of timely data

collection, analysis, dissemination of reports and feedback.

2.7 Establishment of the National treatment protocols for the most

CDs

2.8 Review the IMCI protocols and to ensure Integration of the

program with the MCH activities in both technical and administrative
aspects, and adoption of the appropriate treatment protocols of the
CDs in general, and for Diarrheal and respiratory infections in
particular.

3. Acting for Environmental Protection in cooperation with the main

players:
3.1 Adequate supply of safe water and to ensure proper solid waste
and sewage disposal: this component is the responsibility of the
municipalities and the public. Safe water and proper sanitation is the
key to control of most of the enteric diseases and minimize the chances
of epidemics occurrence.
3.2 Safe food supply by adequate support of the public health
laboratory and proper epidemiological investigations to each of the
foods associated with health risk.
4. Reform Management for the CDs control departments
4.1National community for CDs ought to be the highest authority to set
policies for supervising and follow up to all CDs control activities.
Regularly planned activities have to be the base for the committee
work.
4.2 Epidemiology department has to cover CDs and NCDs, active
surveillance is needed to validate the surveillance system and to keep a
surveillance system for the CDs and the AEFI.

152
4.3 Support the link between Epidemiology Department and the
Immunization program.

Just when we succeed to control the

vaccine preventable diseases, other
list of infections have been emerged.

New Emerging and Re-emerging Infectious Diseases

Definition of Emerging and Re-emerging
New Emerging Infectious Diseases are those whose incidence in
humans has increased in the past 2 decades or threaten to increase in
the near future.
Emerging: Newly identified & previously unknown infectious agents
that cause public health problems either locally or internationally
Re-emerging: Infectious agents that have been known for some time,
had fallen to such low levels that they were no longer considered public
health problems & are now showing upward trends in incidence or
prevalence worldwide

153
Importance of Emerging Diseases
• Serious impact of public health: the disease could kill people, and
sometimes we don’t know what it is, how it how transmitted, how
we could prevent or treat it, and who could get sick from it.

• Potential for international spread: The disease could affect

travelers, who could ‘export’ the disease to other countries.

Global overview
• The impact of communicable diseases has greatly increased
during the last 30 years due to:

• Reasons related to human demographics and behavior Huge

increase of international travel and commerce, technology and
industry, Economic development and land use.

• Microbial adaptation and change and breakdown of public health

measures. As result, new pathogens emerge, known pathogens
acquire resistance, and everyone can be infected at any time. It
is a global threat, and as no institution has all capacities, a strong
and organized partnership is needed to address the problem.

Regional overview
The burden of emerging and epidemic prone diseases is on the increase
in many counties of the EMRO. Major epidemic prone diseases affecting
the region include meningitis, cholera and other epidemic diarrheal
diseases, viral hemorrhagic fevers, measles, Influenza and malaria.

Meningitis
Meningitis accounts for 25 000 deaths and 1,472,000 disability –
adjusted life years (DALYS) annually in the region. Meningococcal
meningitis is endemic in several countries. Epidemic Meningococcal
disease is of special importance to Sudan, being one of the African

154
meningitis belt counties, and Saudi Arabia, the land of pilgrimage,
during the past 5 years, Meningococcal meningitis epidemics were
reported from Afghanistan, Djibouti, Pakistan. Saudi Arabia AND Sudan.
In addition, an outbreak of Meningococcal meningitis was reported from
Somalia for the first time in 2001-2002

Cholera
Along the past decade, cholera outbreaks used to hit Afghanistan, Iraq
and Somalia yearly. Cholera outbreaks were also occasionally reported
from the Islamic Republic of Iran. however, the burden of cholera in the
region seems to be greatly under estimated. Several countries still
decline to report cholera for fear of travel and trade embargos. Instead
, acute gastroenteritis, acute watery diarrhea and summer diarrhea are
frequently reported. Although the burden of other epidemic –prone
diarrheal diseases, such as typhoid fever and shigellosis, is not well
known, occasional incidents show that these illnesses constitute a real
public health problem in several countries of the region.

Hemorrhagic fevers
Several viral hemorrhagic fevers have emerged as a major problem in
the region. Outbreaks of crimean-cango hemorrhagic fever (CCHF)
are frequently reported by Afghanistan, Islamic Republic of Iran, Iraq
and Pakistan, Dengue fever seems to be present in several countries
in the Arabian Peninsula ‫ شبه الجزيرة العربية‬and the horn of Africa and has
been confirmed for the first time in Yemen in 2002. Ebola hemorrhagic
fever, frequently flaring up in the sub-Saharan Africa, could re-emerge
in Sudan, where it was first recognized in 1976, Rift Valley fever,
which was confined to sub-Saharan Africa, has spread north to pose a
continuous threat to Egypt since 1977,and east to affect Saudi Arabia
and Yemen in 2000.

155
Influenza and others

SARS Cases Total: 8,439 cases, 812 deaths,

19 February to 5 July 2003 30 countries in 7-8 months

Europe: Russian Fed. (1)

Canada (243) 10 countries (38)
Mongolia (9)
Korea Rep. (3)
USA (72) China (5326)
Macao (1)
Kuwait (1)
Hong Kong (1755) Taiwan (698)
India (3)
Colombia (1) Viet Nam (63) Malaysia (5)
Indonesia (2)
Singapore (206)
Brazil (3) Philippines (14)

Thailand (9)
South Africa (1)
(
Australia (5)
New Zealand (1)

Source: [Link]/sars

156
 Examples of New Emerging Diseases
Source: NATURE; Vol 430; July 2004;

Exercise: A recent (December 2019) Epideic of Nobail Caronia Virus

appeared in China. Dicuss the Aetiological factor, the signs and the
symptoms, and Both prevention and treatmen for this disease.

157
 Chapter 9
Epidemiology of non-communicable diseases

1. Epidemiological Transition
2. Risk factors for NCDs
3. Major NCDs
4. Intervention strategy and policies

1. Epidemiological Transition
Introduction
The group of Non-communicable diseases is a major public health
problem affecting millions in the world and progressively increased in
terms of morbidity, mortality, and disability. In Palestine Diabetes
Mellitus and cardiovascular diseases form the major component of the
Palestinians morbidity and mortality. Community-based interventions
are required to minimize problems associated with such diseases and
their complications.
Definition of Epi Transition: “Simply it is change of diseases and
their determinants time in specified community through time”
Epidemiological Transition: For centuries, communicable diseases were
the main cause of death around the world and Life expectancy was often limited
by uncontrolled epidemics. The leading cause of disease burden was pneumonia,
diarrhea and prenatal condition. After the Second World War, vaccination,
sanitation, and antibiotic use improved the living condition and life expectancy
increased. Non-communicable diseases (NCDs) started causing major problems
in industrialized countries (Heart disease, Cancer, Diabetes, Chronic pulmonary
and mental disease). By 2020 it is predicted that NCDs will account for 80% of
the global burden of disease, causing seven out of 10 deaths in a developing
country. Graph (9.1) shows how the disease pattern changed between 1990 and
2010 besides prediction for the year 2020. There is a decrease in CDs, a sharp

158
increase in NCDs and a slight rise in accidents. Analysis of mortality data in West
Bank reveals the burden of NCDs and the problem increase by age (Graph 9.2).
Graph 9.1: Projected trends in the number of deaths by broad
cause group in developing countries

NCDs

CDs

Injuries

Graph 9.2: Distribution of Mortality Rates by Age Group —

Palestinian Territories, West Bank, 1999-200336

Epidemiological Transition in Palestine

All over the world, there is Epidemiological transition from
communicable to non-communicable diseases, while in Palestine the
process is more complicated where we have:
• Sharp increase in Non-communicable Diseases.

36 Niveen M.E. Abu-Rmeileh, Chronic Dis 2008;5 (4).

[Link]

159
 • Remaining communicable diseases as Diarrhea and Respiratory
infections due to deteriorated environmental conditions.

• Non-interrupted war injuries keeping accidents and their

consequences of morbidity, disabilities, and mortality as a major
component in the health record for Palestinians.

Control of the CDs

Examples of communicable Diseases control in Palestine
• Polio last case 1982

• Measles last epidemic 1987 – 1988

• Last Diphtheria case 1976

• Last cholera epidemic 1994, only one death 1981 epidemic

• In 1977, 40% of child deaths were due to Gastroenteritis, NOW it

is less than 1%

• Tetanus and tetanus neonatorum is under control.

Palestinians experienced success in the control of CD and in this text

we will review shortly 3 success stories, to control polio, measles, and
mortality due to diarrheal diseases. Experience in polio control was
expressed with low-Quality Research but high Importance for control of
the disease and children saving. Our findings showed that, in 1974,
40% of paralyzed children with polio received at least 3 doses of
T.O.P.V. and this percentage increased to 60% during the 1976
epidemic. Based on this simple finding, we concluded that the Oral polio
vaccine fails to prevent disease occurrence. Subsequently, the decision
we took to change the vaccination policy. As a result, the disease was
controlled and the last case was reported in 1982.
In Gaza and the West Bank, the immunization of infants against
measles began in 1973 and 1976, respectively. Before 1978, measles
used to be an endemic disease in Gaza with the seasonal variation of

160
case occurrence, meanwhile, measles Vaccination Coverage was less
than 50%. Data analysis of the Naser Pediatric Hospital data revealed
that 35% of the measles admitted cases were for children under one
year of age. Such findings supported the 9-month measles vaccine
policy. In spite of improving vaccine coverage to exceed 90% of all
children, a major measles epidemic occurred during 1981 – 1982. The
epidemic started with older children and then younger children were
involved. Around 5000 children were affected and investigations
revealed that 50% of them got measles vaccine. The epidemic was
severed and resulted in 72 deaths. The last measles epidemic was in
1987 followed by a call for a 2-dose policy for measles control wherein
1988 second dose of (MMR) was added to the vaccination schedule at
age of 15 months to all children. It becomes clear that the benefits of
several alternative immunization strategies considerably exceed their
costs (Tulchinsky T, Abed Y 1990). The 1990/91 epidemic began in
Ramallah district in the West Bank in the second week of November
1990. It was followed three weeks later by an outbreak among
Bedouins in the Negev, with subsequent spread to other districts in
Israel while Gaza escaped this epidemic (Tulchinsky T, Abed Y 1992).
Recently the 9th-month dose is canceled and MMR is given at age 12th
and 18th month.
The third success story is the reduction of diarrheal disease mortality.
Infant Mortality Review was done in 1978; our findings revealed that
around 40% of the total deaths during the first year of life in Gaza Strip
was contributed to diarrheal diseases. The conclusion was: the
diarrheal disease was the main cause of death among infants in Gaza
Strip and interventions are required. Since the change in environmental
condition was difficult to achieve primary prevention, the Oral
Rehydration Solution campaign started in 1978. A reduction in infant
deaths due to diarrheal diseases, and the reduction in hospital

161
admissions for infant diarrheal diseases are attributed to the increased
use of ORS because of the ORS promotion program37.

Major Current Health Hazards

Recently, the pattern of disease in Palestine is different and the most
common public health problems are:
• Non-communicable Diseases

o Diabetes Mellitus

o Hypertension

o Cancer

o Chronic Respiratory Diseases

• Accidents

• Psychological disturbance

Based on MOH annual report (2018), NCDs are the main causes of
mortality among the Palestinian as shown below.
The 10 leading cause of deaths in West Bank – Palestine 201738

1- Cardiovascular diseases (30.3) 6- Respiratory system diseases

2- Cancer deaths (14.7%) (5.6%)
3- Cerebrovascular diseases 7- Accidents (4.5%)
(11.7%) 8- Congenital malformation (2.9%)
4- Prenatal conditions (9.3%) 9- Infectious disease (2.8%)
5- Diabetes mellitus (9.0%) 10- Digestive (2.2%)

Table (9.1) shows that cardiovascular diseases are the main killer
(30.3%), followed by Cancer (14.7%). Stroke resulting from
cerebrovascular diseases is the third cause of death.

37 Lasch, E.E., 'Abed, Y., Guenina, A., Hassan, N.A., Abu 'Amara, I., and 'Abdallah, K. (1983) Evaluation of the Impact of
Oral Rehydration Therapy on the Outcome of Diarrheal Disease in a Large Community. Israeli Journal of Medical Sciences
1983; 19: 995-997.
38 Ministry of Health, PHIC, Health Status, Palestine, 2017, July 2018

162
 Table 9.1: Leading Causes of Death in Palestine 2014 – 2017

Cause of Death 2014 2015 2016 2017

CVD 29.5 27.5 30.6 30.3

Cancer 14.2 13.8 14.0 14.7

Stroke 11.3 9.9 12.8 11.7

Perinatal 5.2 6.9 8.0 9.3

Diabetes 8.9 5.4 8.0 9.9

Non-Communicable Diseases “NCDs”

WHO Gaza 2010-2011 STEP Survey showed that more than half
(61.7%) of Palestinians aged 15–64 years are overweight and 32.5% of
them have high levels of cholesterol. Regarding smoking, 26.6% of
men smoke tobacco daily and 82% of people (92.6% in women) do not
engage in any vigorous physical activity and survey results indicate that
unhealthy behaviours start early age. In the Gaza Strip, the number of
patients with NCDs is increasing consistently by approximately 5% per
year. Prevalence of patients diagnosed with diabetes mellitus and
hypertension among served population ≥40 years of age was 20.7% for
the former and 15.1% for the latter39.
The rise of HTN “hypertension” and DM “Diabetes Mellitus” in Gaza has
been driven by primarily three major risk factors: tobacco use, physical
inactivity, and unhealthy diets. These preventable risk factors of NCDs
affect large number of people living in the Strip.
Complications of chronic diseases including NCDs represent a high
proportion of referrals by the Ministry of Health in both number and
cost40.
Although there is insufficient data available on the overall incidence and
prevalence of diabetic foot among diabetic patients in Gaza, the
numbers of diabetic foot complications are still rising41.

39
UNRWA (2015). Annual report 2015. Health department
40
WHO (2016b). Health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan

163
UNRWA Analysis for drugs expenditure revealed 46.0% was spent on
medicines for the treatment of NCDs42.

Nutrition
Despite of multiple health program, rates of anaemia and malnutrition
have increased in the last years, and the reasons behind this increase
are multifactorial. Child health and nutrition experts said that these
rates reflect the critically disadvantaged situation and emergency
situations in the Gaza Strip43. In 2006, WHO mentioned that iron
deficiency anaemia rates in the Gaza Strip were as high as 54.7%
among children44. Iron deficiency anaemia “Hb<11g/dl” among
pregnant women who attended government MCH clinics in 2003 was
20.9%7. Among pregnant women attending UNRWA antenatal clinics, it
was 38.3%45. Anaemia among women in the Palestinian Territories is
around average for the region. Anaemia has been shown to increase
with age. In one study it was found that a middle child born within 18
months of an older and a younger sibling was significantly more likely
to be anaemic46. Anaemia was also found to increase with number of
pregnancies, reaching 48% in women with 11 or more pregnancies.
However, the percentage of women aged 15-49 years taking iron was
only 7.1%8.
According to the Palestinian Ministry of Health “MoH” (2005) report 47,
women who are constantly pregnant or lactating are likely to become
nutrient depleted and to pass on this depletion to their children. There
is evidence that reproductive practices are related to anaemia in
women. A number of nutrition-related protocols have been developed
on behalf of the MoH. These include the following: 1) Integrated
Management of Childhood Illnesses which covers many aspects of

41
Isleem EA, Aljeesh Y (2015) Evaluation of Diabetic Foot Management in the Gaza Strip. International Journal of Diabetes
Research. 4(4): 73-79
42
UNRWA (2017). Annual report 2016. Health department
43
Qouta S and Odeh J (2005) The Impact of Conflict on Children: The Palestinian Experience. J Ambulatory Care Manage
44
WHO (2006) [Link]
45 Ministry of Health. Health Status in Palestine. Ministry of Health Annual Report 2003. 2004.
46
Palestinian Central Bureau of Statistics, Birzeit University, and United Nations Children's Fund. Nutrition Survey - 2002. 2003.
Ramallah, PCBS.
47
MOH (2005), The state of nutrition, West Bank and Gaza Strip.
[Link]

164
nutrition including breast feeding, complementary feeding, growth
monitoring, iron deficiency anaemia, management of malnutrition,
micronutrient supplementation and counselling mothers. 2) National
Reproductive Health Guidelines and Protocols that include
breastfeeding, adolescent nutrition and nutrition counselling for
pregnant and lactating mothers. 3) MARAM protocols on breast-feeding,
infant and young child feeding “IYCF”, growth monitoring and
promotion, micronutrient supplementation and the management of
maternal and child iron deficiency anaemia9. The protection, promotion
and support of appropriate nutrition status during pregnancy and IYCF,
the protection of non-breastfed infants, and 6-month exclusive
breastfeeding remain as important component of child and women
health.
Mental Health and Psychosocial Support “MHPSS”
The 51-day armed conflict of July-August 2014 had a severe impact on
wellbeing of the Palestinian people living in Gaza and created a
humanitarian crisis. Mental health is another concern in Gaza due to
the political, social, economic situation people are living in. According to
OCHA48, at least 373,000 children have been directly affected by death
within their close family and/or destruction of their homes. Vulnerable
groups, including children, women, people with pre-existing mental
health conditions and people with disabilities are at risk for developing
mental health concerns and many will benefit from community based
mental health and psychosocial support programs. Individuals with
mental disorders have an increased risk of suffering from comorbid
physical illness because of diminished immune function, poor health
seeking behaviour, non-compliance with prescribed medical regimens,
and barriers to obtaining treatment for physical disorders.

48
OCHA (2014) Gaza Crisis Appeal. [Link]

165
According to WHO survey49 to measure the prevalence of psychological
distress among 500 adult patients in 5 Primary Health Care (PHC)
centres in Gaza Strip, as well as to identify associated demographic risk
factors and the ability of General Practitioners (GPs) to identify patients
with psychiatric problems using the General Health Questionnaire
(GHQ-12). The results of the study reveal that 37% of adult patients
that sought PHC services showed psychological distress. Older patients
showed higher rates of prevalence
(70%), Patients with chronic conditions (51.8%) as compared to
patients with no chronic conditions (32. 3%).The results of the survey
also showed that the ability of the GPs in PHC centres to identify
psychiatric problems was very limited. According to UNRWA50 the rates
of behavioural, emotional and post-traumatic stress have been shown
as high as 35% to 40% (with often much higher rates for children living
in camps and those exposed to continuous and extensive forms of
violence, such as house demolition etc).
The Palestinian National Mental Health Policy Strategy (2015-2019)51
has strategic priority actions including integration of delivery of
evidence-based interventions for priority mental conditions in PHC;
Scaling up of community mental health care; Interventions for mothers,
children and adolescents with mental health problems; and
dissemination of strategies to improve mental health literacy, reduce
stigma and discrimination, and promote evidence based interventions
strengthening the mental health of the population.
Community – Based Rehabilitation “CBR”
According to the PCBS in 2012, around 7% of the population in Gaza
are people with disabilities. In addition, it is estimated that 10% of the
injured are due to recent conflicts and they may have a long-term or
permanent impairment. It is important that comprehensive services are
49
WHO, (2009). Gaza Health Assessment.

50
Mahoney. J., (2009). The Need for Mental Health Services for Populations Served by UNRWA

51
Palestine Ministry of health (2015). National Mental Health Strategy Palestine 2015-2019. [Link]

166
provided to people with disabilities as part of the humanitarian
response. Currently, there is PKU program which is early detection to
avoid mental retardation, and recently there is a program to detect
hearing defects for all new-borns in governmental and UNRWA clinics.
CBR services range from health care, rehabilitation services, provision
of assistive devices and items, to psychosocial support (which often
improves the quality of the rehabilitation while ensuring faster results)
as well as livelihood support. In addition, the restrictions on purchasing
devices, technical aids and spare parts, and the limited resources of
children with disabilities “CWD”, all of these factors affect the
accessibility of CWD to required health services.

Prevalence of NCDs
There is a variation in the reported prevalence of NCD in different
reports. These differences could be real or artifact. When the
prevalence is mentioned, directly look for the year (variation by time)
and look for the age groups (variation by age) and so on as will
demonstrated below.
A. Diabetes Mellitus
Diabetes Mellitus is defined as Fasting plasma glucose ≥ 7.0 mmol/L
(126 mg/dl OR 2-h plasma glucose≥ 11.1 mmol/L (200 mg/dl) OR
HbA1c ≥ 6.5%. Any variation in these cuts of points will change the
prevalence rate. For the prevalence of Diabetes, MOH reports estimate
the prevalence between 7 – 10 percent of the total population (All ages
are considered). UNRWA Reports as shown in Figure (9.3) prevalence
of Diabetes is 15.1 percent of the served population 40 years and older.
WHO estimated prevalence of Diabetes 13.7 in the Eastern
Mediterranean Region aged 18 years and above (Table 9.2). PCBS
completed WHO steps survey 2011 – 2012 and reported 14.3%
Diabetes among population 15 - 64 years52

52 PCBS: Palestine STEPS Survey 2010-2011

167
Graph 9.3: Prevalence (%) of patients diagnosed with type I and II diabetes
mellitus and hypertension among the served population ≥40 years of age,
201553

Table 9.2: Estimated prevalence and number of people with diabetes

(18y+)54

53 UNRWA Annual Report 2015

54 WHO

168
 B. Hypertension
Hypertension is defined as a systolic blood pressure of 140 mmHg or
greater and/or diastolic blood pressure of 90 mmHg or greater under
satisfactory conditions of measurement. Based on UNRWA figure (9.3),
the prevalence of hypertension among Palestinians (40 years and
above) is 20.7% in both WB and Gaza. The prevalence of hypertension
is around 27% in EMR for adults aged 18 years and over (Figure 9.4).
It is worthy to see in the figure, males are affected more than females
and poor countries are suffering more than rich countries.
Figure 9.4: Age-standardized prevalence of raised blood pressure in adults
aged 18 years and over by WHO region and World Bank income group,
comparable

C. Cancer

The reported Cancer incidence rate is increasing in Palestine. A recent

(2018) report from MOH shows that Cancer incidence in the West Bank
is jumped from 53.7 to 113.7 per 100,000 (Graph 9.5). Data from
Cancer Registry in MOH offices in the Gaza strip (Graph 9.6) shows a
gradual increase of the cancer prevalence, the rate jumped from 64.2
to 89.0 per 100,000 population. The age-adjusted rate is 164 per
100,000 due to a high proportion of young age among the Palestinian
population. The chances of females to get cancer is higher than males.
The most common cancers among males are colorectal, lung, leukemia,
lymphoma, prostate and urinary bladder. Among females, the most
common is breast cancer followed by colorectal, thyroid, lymphoma,
leukemia and uterus cancer. Pediatric cancers are mainly: leukemia,

169
Brain, Bone, lymphoma, and neuroblastoma.
Graph 9.5: Reported Cancer Incidence Rate per 100,000 population West
Bank Palestine 201755

Graph 9.6: Cancer Prevalence in Gaza per 100,000 56

Cancer Incidence Rate per 100,000 in Cancer age adjusted rate per 100,000
Gaza Strip 20011 – 2016

Most common cancers by Gender Proportion of common Pediatric

2015 – 2016 Cancer 2015 – 2016

55 Ministry of Health, PHIC, Health Status, Palestine, 2017, July 2018

56 MOH – Gaza 2018

170
 2. Risk Factors for Non-Communicable Diseases
Occurrence of most of the NCDs is contributed to common and known
risk factors related to lifestyle. The main identified risk factors are
tobacco use, unhealthy diet, and physical inactivity. Prevention of
these risk factors minimizes the chances of occurrence of NCDs mainly;
Hypertension, Diabetes Mellitus, cancer and chronic obstructive lung
diseases.
Common NCDs Preventable risk factors
related to lifestyle
1. Hypertension and Cardiovascular 1. Tobacco use,
2. Diabetes Mellitus 2. Unhealthy diet
3. Cancer, 3. Physical inactivity
4. Chronic Obstructive Pulmonary
Diseases
The prevention of these diseases should, therefore, have a common
focus of controlling these risk factors in an integrated manner
Figure (9.7) demonstrates the major known risk factors for NCDs. As
seen the risks are multifactorial, therefore; intervention to control NCDs
have to consider all preventable risk factors
Figure 9.7: Conceptual Framework for Determinants of Non-
Communicable Diseases (Adapted from Hadaf S.)

Non-communicable
Diseases

Demographic Socioeconomic Lifestyles Health profile

Age Education (Physical (Chronic

Gender Occupation inactivity) Diseases)
(Marital Income Smoking Medication
Status) (Dietary (Duration of
Residency Habit) Disease)
Stress Family History

171
WHO reports consider two groups of risk factors for NCDs, behavioral
and metabolic as seen below57

Behavioral risk factors Metabolic Risk Factors

• Tobacco use. • Overweight and obesity

• Unhealthy diet. • Blood hypertension

• Physical inactivity. • Dyslipidemia

• Raised blood glucose

PCBS and MOH completed a stepwise survey in Palestine from 2010 –

2011. The table below indicates the measured value for each risk
factor.
Table 9.3: Steps WHO survey In Palestine (15-64 years), 2010-2011

WHO Indicators Palestine Gaza Strip

Both sex M F Both M F

% of current smoker 20.2 37.6 2.6 13.5 26.9 0.2

% who ate less than 5 serving of fruit and 85.9 85.4 86.5 95.7 94.7 96.3
or vegetable on average /day
% with low levels of activity <600MET- 46.5 33.8 59.2 48.0 37.2 59.0
min per week
% with high levels of activity >3000MET- 31.6 42.8 20.4 24.8 31.1 18.4
min per week
2 57.8 55.2 60.7 61.7 56.9 67.2
% of overweight BMI≥ 25kg/m
2 26.8 23.3 30.8 31.8 26.4 37.9
% of obesity BMI≥ 30 kg/m

Raised BP≥ 140/90 or on treatment 35.3% 36.0 35.6 44.8 45.3 44.2

Raised BP≥ 140/90 not on treatment 24.7% 29.2 20.0 19.1 21.4 16.9

% with impaired FB≥126mg/dl 5.8% 5.8 5.8 5.5 6.2 4.9

% with raised FBS≥126mg/dl or on 8.5% 9.5 7.6 8.4 9.5 7.3

treatment
% with raised cholesterol≥190mg/dl or 36.5% 35.8 37.3 32.5 30.1 34.8
on statin

57 [Link]/nmh/publications/ncd-status-report-2014/en/

172
 1. Smoking and oral tobacco use
Smoking's negative effect is probably the single most powerful lifestyle
measures. It is the most preventable risk factor. Globally, it increases the risk
of death from lung cancers (71%), heart disease and stroke (10%), and
chronic respiratory disease (42%). On average, smoking costs 13 years of life
to a male smoker and 14 years to a female smoker (UCSF Medical Center,
2011). Additionally, environmental tobacco smoke (ETS) and smoking during
pregnancy also harm others. Secondhand smoking (SHS) is the smoke that
fills restaurants, offices or other enclosed spaces when people burn tobacco
products such as cigarettes and water pipes. There is no safe level of SHS.
Smoke-free laws protect the health of non-smokers (Scollo et al., 2003). SHS
causes 600,000 premature deaths per year (WHO, 2011b). In 2004, children
accounted for 28% of the deaths attributable to SHS (WHO, 2011b). In
adults, SHS causes serious CVDs and respiratory diseases, including CHD and
lung cancer. In infants, it causes sudden death, while in pregnant women; it
causes low birth weight (WHO, 2011b). Exposure to smoke - SHS - increases
the risk even for non-smokers, despite this; it is common throughout the
world. Some countries have legislation restricting tobacco advertising, and
regulating who can buy and use tobacco products, and where people can
smoke (UCSF Medical Center, 2011).
The risk of CVD in smokers is proportional to the number of cigarettes smoked
and how deeply the smoker inhales, and it is greater for women than men.
The risks of pipe and cigar smokers seem to fall between those of
non-smokers and cigarette smokers. (RR 1.3, 95% CI 1.1 to 1.5) for IHD,
with a dose-response relation (Padwal et al., 2001)
According to WHO (2004), smoking is responsible for about 12% of male
deaths and 6% of female deaths in the world, while almost one in every eight
deaths among adults aged 30 years and over. On the other hand, a total of
tobacco-attributable deaths are projected to rise to almost 10% of all deaths
globally in 2030 (WHO, 2008b). Furthermore, as inferred in the literate,
smoking is currently a very important determinant of CVDs mortality among
men in all regions of the world and women in industrialized countries. The
proportion of CVDs deaths caused by smoking exhibited large variations
among different regions in the world. CVDs mortality among men smokers
were from ≤10% of total CVDs mortality in Sub-Saharan Africa and parts of

173
Latin America and the Western Pacific to ≥23% in industrialized regions of
Europe and North America, while among women smokers were from ≤5% of
total CVDs mortality in the developing world to >20% in North America.
Smoking also caused large numbers of deaths from cerebrovascular disease in
several developing regions (Yusuf et al., 2001). Additionally, cigarette
smoking can repeatedly produce a temporary rise in BP of approximately 5-10
mmHg. This effect may be most prominent with the first cigarette of the day
in habitual smokers (NSRC, 2008).
However, research indicated that regular smokers have lower BP than non-
smokers; this may be due to weight loss associated with smoking. Experts
agree that smoking should be avoided in any person with HBP because, it can
substantially increase the risk of secondary CVDs complications such as
atherosclerosis, enhance the progression of kidney disease, and increases the
chances of men having erectile dysfunction (NSRC, 2008). According to WHO,
smoking is increasing in many low and middle-income countries, while slowly
decreasing in many high-income countries. Additionally, death rates for
smoking-caused diseases are lower in low-income countries. This reflects the
lower past smoking rates in low-income countries (7.2%) in comparison with
the higher past smoking rates in high-income countries 17.9% (WHO, 2004).
Furthermore, according to WHO Stepwise data of risk factors from selected
countries in the EMR (2003 - 2007) to highlight the current situation of
smoking found that the highest level was in Jordan (29%) followed by Syrian
Arab Republic (24.7%), while the lowest level registered in Oman (9.3%)
followed by KSA (11%). The prevalence rate of smoking in Iran was 13%,
Sudan 12%, Egypt 18%, Kuwait 20.6% and Iraq 21.6% (WHO, 2011a).
Additionally, a study conducted in Bahrain by Abdul- Wahab et al., (2002)
mentioned that the prevalence of smoking habit was 29.5% of the male
subjects aged 19 years and more reported to be regular smokers compared to
18.6% of the females. As for the type of smoking, 72.1% of the males
reported smoking cigarettes and 96% of the females reported to smoke
shisha. Besides, Majid et al., (2005) mentioned that the health benefits of
smoking cessation occur faster for CVDs than other diseases. This is in
agreement with other studies mentioned that policies that prevent and reduce
smoking should be immediate for motivating global tobacco control efforts
such as the Framework Convention on Tobacco Control so large benefits for

174
reducing cardiovascular mortality (Cohen et al., 2004; Pruss- Ustun et al.,
2004; Rehm et al., 2004; USDHHS, 2001).
Table 9.4: Percentage of Smokers by Sex and Region, 2015

Youth aged (15-29 Y.) 201558 Steps survey 2011 (15 – 64)

Palestine WB Gaza Palestine Gaza

Both Sex 23.5 29.5 14.0 Both 20.2 13.5

Males 40.9 49.5 26.6

Males 37.6 26.9
Females 5.4 8.1 1.0
Females 2.6 0.2

In Palestine, smoking rates are estimated based on Steps survey 2011 (15 –
64) with smoking rate 37.6 among males and 2.6 among females. In Gaza the
rate is lower (26.9 for males and 0.2 for females. PCBS published a recent
report for smoking among youth (2015) where around half (49.5%) of the
youth in WB and quarter (26.6%) of youth in Gaza are smokers. As seen in
the table (9.4) female youth smoking is higher than Gaza (8.1 versus 1.0%).
2. Unhealthy Diet

An unhealthy diet refers to foods or drinks that fail to provide your body with
the correct amounts and types of nutrients for maximum health. For instance,
taking too many calories and not enough fruits and vegetables is an unhealthy
diet, which can cause medical problems. An unhealthy diet is brought about
by eating food without vitamins and carbohydrates, and junk food as well. It
is a major risk factor for several chronic diseases including high blood
pressure, diabetes, abnormal blood lipids, obesity, cardiovascular diseases,
and even cancer. The amount of dietary salt consumed is an important
determinant of blood pressure levels and overall cardiovascular risk. However,
data from various countries indicates that most populations are consuming
much more salt than this.
Dietary recommendations by WHO and the Food and Agriculture
Organization (FAO):

58
[Link]

175
 • WHO recommends a population salt intake of less than 5 grams
per person per day for the prevention of cardiovascular disease.
• WHO strongly recommends reducing the intake of free sugars to
less than 10% of total energy intake and suggests that further
reduction to 5% could have additional health benefits.
• Limiting saturated fatty acid intake to less than 10% of total
energy intake (and for high-risk groups, less than 7%).
• Achieving adequate intake of dietary fiber (minimum daily intake
of 20 g) through regular consumption of wholegrain cereals,
legumes, fruits, and vegetables.

• WHO is currently updating its guidelines on fat intake and

carbohydrates intake, which will include recommendations on
dietary fiber as well as fruits and vegetables.

3. Physical Inactivity
Physical inactivity is a term used to identify people who do not get the
recommended level of regular physical activity. Physical activity occurs
across different domains, including work, transport, domestic duties,
and leisure. Sedentary life is prevailing among the population mainly TV
and computer sitting. Physical inactivity is associated with most of the
non-communicable diseases. Ellulu et.al59 through explanation of
Lifestyle Habits, he recommended a simple evaluation of smoking
habits and Physical Activity Patterns for Adults.
Smoking habits evaluated based on the Behavioral Risk Factor
Surveillance System established by CDC, classified into four groups;
smoker, past smoker, passive smoker, and never smoker. Physical
activity measured based on the second Global Physical Activity
Questionnaire that established by the World Health Organization
(WHO), and it is categorized into three groups; high physical activity,
moderate, and low.

59 Mohammed S. Ellulu, Marwan O. Jalambo, Suha Baloushah, Yehia Abed Scientific Research Journal (SCIRJ), Volume
II, Issue XI, November 2014

176
Steps WHO survey In Palestine (15-64 years), 2010-2011showed that
the percentage of Palestinians with low levels of activity (<600MET-min
per week) is 46.5 (33.8% for males and 59.2% for females). Ard El
Insan (Gaza) completed a study about Adolescent Quality of life where
physical activity showed that 57.7% of Gaza Adolescents had sedentary
life (table 9.5). The percentage of sedentary life reached up to 85.5
percent of the female Adolescents60. Jalambo study61 showed that
among female sec. students 33.5% are classified sedentary, 43.4% are
low physical activity, and only 20.9 are classified active.
Table 9.5: Physical Activities among Palestinian Youth

WHO recommendations on physical activity

• It is recommended that children and youth aged 5–17 years
should do at least 60 minutes of moderate- to vigorous-intensity
physical activity daily.

• It is recommended that adults aged 18–64 years should do at

least 150 minutes of moderate-intensity aerobic physical activity
(for example brisk walking, jogging, gardening) spread
throughout the week, or at least 75 minutes of vigorous-intensity
aerobic physical activity throughout the week, or an equivalent
combination of moderate- and vigorous-intensity activity.

• For older adults, the same amount of physical activity is

recommended, but should also include balance and muscle-
strengthening activity tailored to their ability and circumstances.

60
Wahaidi AA, Abed Y, Sarsour A, Turban M. (2018) The Adolescent’s Quality of Life in the Gaza Strip: Nutritional and
Psychological Risk Factors. Food Nutr OA. (2018) Feb; 1(1):105
61
Marwan O. Jalambo, Amin Hamad & Yehia Abed (2013) Anemia and Risk Factors among Female Secondary Students
in the Gaza Strip, Journal of Public Health 21:271–278, DOI 10.1007/s10389-012-0540-9

177
4. Overweight and Obesity
Overweight and obesity are measured by Body Mass Index (BMI) that is
calculated by dividing the body weight (KG) by the height (meter)
square. Normal BMI should be between 18.5 to 24.9 kg/m2. Table 9.6
shows the classification of the status of the Body Mass Index. Other
criteria to identify weight distribution depend on the definition of
normal weight as a BMI between the 5th percentiles to the 85th for age
and sex. Overweight was defined as BMI between the 85th and 95th
percentiles, and obesity was defined as BMI greater than the 95th
percentile for age and sex. Other measurements include waist
circumference (M > 102 cm, F > 88 cm). Central Obesity is measured
by Waist Hip Ratio (WHR = 0.85 in women or = 0.90 in men).

Table 9.6: Classification of Obesity

WHO Popular BMI Risk of co-

2
Classification Description (kg/m ) morbidities

Underweight Thin <18.5 Low

Normal range Normal 18.5 - 24.9 Average
Overweight 25.0 +
Pre-obese Overweight 25 - 29.9 Increased
Obese Class I Obese 30.0 - 34.9 Moderate
Obese Class II Obese 35.0 - 39.9 Severe
Obese Class III Morbidly > 40.0 Very severe
Obese
Obesity and overweight are a growing problem all over the world,
Graph 10.8 shows that half of the females and 43.8 of males are
overweight. As seen in table 9.7 the different sectors of the Palestinian
population are suffering from obesity and overweight. Generally, two-
thirds of the population is overweight, one third are obese. This is with
the accordance of stepwise survey results (Table 9.3) where obesity in
Gaza is 31.8% (26.4 among males and 37.9 among females). Obesity
among aged exceeds 50%

178
Graph 9.8: Prevalence of being overweight (BMI 25+) in adults over18 years,
2014, by sex and WHO region62

Table 9.7 Overweight and Obesity among Gaza Population

Study Overweight % Obesity %

M. Khella (17 – 60) 34 26

M. Hobob (Aged, 2014) 28.7 56
S. Obeed (Aged 2011) 29 51
H. Jawada (Lactating) 30.5 20.6
Geshawi R., Abed Y Obesity and overweight rates in urban area,
(Women) BMC 2014 refugee camp, and rural area were found to
be 57.0%, 66.8%, and 67.5%,

Current interventions to control NCDs

1. Country Profile
2. Set of National Strategic
3. Management: Package of Essential NCDs (PEN 2013)
4. NCDs Monitoring and Evaluation

1. Country Profile
WHO STEP-wise survey

The survey is composed of three subsequent steps:

• Steps 1: Use of questionnaire: Demographic and socio-economic
status - Physical activity - Dietary pattern – Smoking - Medical
history of personal chronic disease: Hypertension, Diabetes, and
Family History

62 WHO (2016) Global report on diabetes.

179
 • Steps 2: Measurements: Blood pressure measure +
Anthropometrical parameters: High – Weight - Waist
circumference
• Steps 3: Blood samples: Total cholesterol, fasting blood sugar, or
random blood sugar.

Explanation of Lifestyle Habits: Simple Evaluation of Smoking Habits and

Physical Activity Pattern for Adults63

Smoking habits evaluated based on the Behavioral Risk Factor

Surveillance System established by CDC, classified into four groups;
smoker, past smoker, passive smoker, and never smoker. Physical
activity measured based on the second Global Physical Activity
Questionnaire that established by the World Health Organization
(WHO), and it is categorized into three groups; high physical activity,
moderate, and low.
In Palestine Steps WHO survey was done during 2010-2011 and cover
sample of the population15-64 years. Parts of the results of that survey
are mentioned before in this chapter.

2. Setting National Strategies and Plans

WHO set general global targets for prevention and control of non-
communicable diseases for all the countries64. Voluntary global targets
for prevention and control of non-communicable diseases to be attained
by 2025.
In Palestine: The Set of National Strategic Targets for NCD's for 2025
• A 10% relative reduction in premature mortality related to NCDs

• A 5% relative reduction in prevalence of insufficient physical

activity

• A 30% relative reduction in mean population intake of salt/

sodium

63 Mohammed S. Ellulu, Marwan O. Jalambo, Suha Baloushah, Yehia Abed, 2014 Scientific Research Journal (SCIRJ),
Volume II, Issue XI,
64 WHO (2014): GLOBAL STATUS REPORT on non-communicable diseases

180
 • A 30% relative reduction in prevalence of current tobacco use in
persons aged +15 years

• At least 50% of eligible people receive drug therapy and

counseling to prevent heart attacks and strokes

• An 80% availability of the affordable basic technologies and

essential medicines, including generics, required to treat major
NCDs in both public and private facilities

Table 9.8 shows comparison between the global targets and the
Palestinian targets to control NCDs by the year 2025

Table 9.8: Palestine: The Set of National Strategic Targets for NCDs for
2025 compared to Global voluntary targets

Based on these targets, Key steps in the development of an NCD action

plan are involved in the National Strategic Plan – 2016 – 2022. The
main activities cover governance, prevention, and reduction of risk
factors, health care provision, surveillance, monitoring and
evaluation65.

65 MOH National Strategic Plan – 2016 – 2022

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 3. Management: Package of Essential NCDs (PEN 201366)

Package of Essential
Non-communicable (PEN)
Disease Interventions for
Primary Health Care
in Low-Resource Settings

What are PEN Protocols?

The WHO Package of Essential Non-Communicable Diseases (PEN)

Interventions for PHC is:

• Cost-effective, evidence-based approaches to reduce the NCD

burden in Low and Middle-Income Countries (LMIC)

• Management: Pharmacological approaches AND

• Nonpharmacological approaches (lifestyle measures)

• Interventions: Population-wide Vs. Individual interventions:

Focusing mainly on early detection of NCDs, NCDs Risk factors

modification, prevention, and treatment of heart attacks, stroke,

diabetes, cancer, and asthma.

Prevention
• Public health solutions for prevention and control of NCDs for
preventions and control of NCDs.

• Comprehensive public health approaches that target the human

lifespan are required.

• Such interventions should target people in infancy, childhood,

adolescence, and adulthood

66 WHO (2013) PEN [Link]

182
Infancy: exclusive breastfeeding for 6 months, nutritionally adequate
and safe complementary feeding starting from the age of 6 months
with continued breastfeeding up to 2 years of age or beyond.
Childhood and adolescence: improve life skills education, promote
physical activity in school and society, safe and healthy foods in
schools, restrict marketing of and access to food products high in
salt/sugar/unhealthy fats; and institute tobacco and alcohol controls.
Adulthood: improve maternal nutrition, implement tobacco prevention
and cessation programs, improve availability and affordability of food,
encourage physical activity (worksites, urban design), and provide
access to effective prevention and care of risks and diseases.
Components of WHO PEN
1. Tool for assessment of gaps, capacity, and utilization of primary care
2. Tool for assessment of population coverage of NCD care
3. Templates to collect Health Information
4. Evidence-based protocols for essential NCD interventions for PHC
5. Core lists of essential technologies and medicines
6. Tools for cardiovascular risk prediction
7. Tools for auditing and costing
8. Tools for monitoring and evaluation
9. Training material
10. Aids for self-care
4. NCDs Monitoring and Evaluation
WHO set activities to ensure progress on non-communicable diseases in
countries67. Following the Political Declaration on Non-communicable
Diseases (NCDs) adopted by the UN General Assembly in 2011, WHO
developed a global monitoring framework to enable global tracking of
progress in preventing and controlling major non-communicable
diseases - cardiovascular disease, cancer, chronic lung diseases and
diabetes - and their key risk factors.

67 WHO: Global action plan for the prevention and control of NCDs 2013-2020. [Link]
action-plan/en

183
 List of 25 indicators for NCDs
Indicator 1: Unconditional probability of dying between ages of 30 and 70 from
cardiovascular diseases, cancer, diabetes or chronic respiratory diseases

Indicator 2: Cancer incidence, by type of cancer, per 100 000 population

Indicator 3: Total (recorded and unrecorded) alcohol per capita (aged 15+ years
old) consumption within a calendar year in liters of pure alcohol, as appropriate,
within the national context

Indicator 4: Age-standardized prevalence of heavy episodic drinking among

adolescents and adults, as appropriate, within the national context

Indicator 5: Alcohol-related morbidity and mortality among adolescents and adults,

as appropriate, within the national context

Indicator 6: Prevalence of insufficiently physically active adolescents, defined as less

than 60 minutes of moderate to vigorous-intensity activity daily

Indicator 7: Age-standardized prevalence of insufficiently physically active persons

aged 18+ years (defined as less than 150 minutes of moderate-intensity activity per
week, or equivalent)

Indicator 8: Age-standardized mean population intake of salt (sodium chloride) per

day in grams in persons aged 18+ years

Indicator 9: Prevalence of current tobacco use among adolescents

Indicator 10: Age-standardized prevalence of current tobacco use among persons

aged 18+ years

Indicator 11: Age-standardized prevalence of raised blood pressure among persons

aged 18+ years (defined as systolic blood pressure ≥140 mmHg and/or diastolic
blood pressure ≥90 mmHg) and mean systolic blood pressure

Indicator 12: Age-standardized prevalence of raised blood glucose/diabetes among

persons aged 18+ years (defined as fasting plasma glucose concentration ≥ 7.0
mmol/l (126 mg/dl) or on medication for raised blood glucose)

Indicator 13: Prevalence of overweight and obesity in adolescents (defined

according to the WHO growth reference for school-aged children and adolescents,
overweight – one standard deviation body mass index for age and sex, and obese –
two standard deviations body mass index for age and sex)

Indicator 14: Age-standardized prevalence of overweight and obesity in persons

aged 18+ years (defined as body mass index ≥ 25 kg/m² for overweight and body
mass index ≥ 30 kg/m² for obesity)

Indicator 15: Age-standardized mean proportion of total energy intake from

saturated fatty acids in persons aged 18+ years

Indicator 16: Age-standardized prevalence of persons (aged 18+ years) consuming

less than five total servings (400 grams) of fruit and vegetables per day

Indicator 17: Age-standardized prevalence of raised total cholesterol among persons

aged 18+ years (defined as total cholesterol ≥5.0 mmol/l or 190 mg/dl); and mean
total cholesterol concentration

184
Indicator 18: Proportion of eligible persons (defined as aged 40 years and older with
a 10-year cardiovascular risk ≥30%, including those with existing cardiovascular
disease) receiving drug therapy and counseling (including glycaemic control) to
prevent heart attacks and strokes

Indicator 19: Availability and affordability of quality, safe and efficacious essential
NCD medicines, including generics, and basic technologies in both public and private
facilities

Indicator 20: Access to palliative care assessed by morphine-equivalent

consumption of strong opioid analgesics (excluding methadone) per death from
cancer

Indicator 21: Adoption of national policies that limit saturated fatty acids and
virtually eliminate partially hydrogenated vegetable oils in the food supply, as
appropriate, within the national context and national programs

Indicator 22: Availability, as appropriate, if cost-effective and affordable, of vaccines

against human papillomavirus, according to national programs and policies

Indicator 23: Policies to reduce the impact on children of marketing of foods and
non-alcoholic beverages high in saturated fats, trans-fatty acids, free sugars, or salt

Indicator 24: Vaccination coverage against hepatitis B virus monitored by number of

third doses of Hep-B vaccine (HepB3) administered to infants Indicator 25:
Proportion of women between the ages of 30–49 screened for cervical cancer at least
once, or more often, and for lower or higher age groups according to national
programs or policies

RECOMMENDATIONS for NCDs

1. Accord greater priority to NCD prevention and control
2. Strengthen national capacity to accelerate country response
3. Create, sustain and expand health-promoting environments to
reduce modifiable risk factors
4. Strengthen and orient health systems to address NCDs
5. Promote high-quality research and development
6. Monitor trends and determinants, and evaluate NCDs and their risk
factors

185
 Chapter 10
Environmental Epidemiology

Definitions:
The simplest definition for environmental epidemiology is: "Surveillance
of persons exposed to known or suspected toxic substances, both
within and outside the workplaces" (Mark G. 1999). By this definition,
the main focus is human health and the exposures of interest are
suspected and toxic substances. Other definitions look for further
details to include determinants and distribution of the conditions among
the Human population, one stated environmental epidemiology as "The
study of the determinants and the distributions of diseases those are
exogenous to and nonessential for the normal functioning of human
beings".68

Major components of Environmental Epidemiology

As demonstrated in the drawing below (Figure 10.1), the main
components of Environmental Epidemiology are:
• Exposures:

• Outcomes

• Interventions

• Evaluation

In this chapter, we are trying to explain the relationship between these

components. Note that the basic elements in these components are
measurements of both the exposure and the outcome. The validity of
the study depends on the accuracy of both measurements. Setting
operational definitions and criteria for measurement of both exposure
and outcome is essential.

68 Adapted from Hertz-Piccioto I

186
 Figure 10.1: Components of environmental health study

1. Environmental Exposures
1.1 Types of exposures:
There are three types of environmental exposure based on the
geographical distribution of the contaminants

• Point sources

• Line sources

• Area sources

Point sources:
As the name indicates, we refer to a specific point or a locality with
definite borders. Examples of the point source are the pollution from a
factory and pollution resulted from the municipal solid waste site. In
such sources, pollution is limited for a small group of people who
always annoyed by these sites and keep complaining to the health
authorities.

187
Line sources:
The pollution, in this case, is extended for longer distances with line
shape and more people are affected. The most common example is the
Electrical Magnetic Fields (EMF) exposures from high tension power
lines. A second example is the air pollution resulted from Combustion
pollutants around high-density motorways. Recently GIS could be used
to study the effect of line source exposure on human health. An
example of GIS is the relationship between Bronchial asthma and living
beside high-density traffic roads. In this example, the first layer will
demonstrate the network of roads in a city and the second layer is the
distribution of the bronchial asthma cases. The investigator compares
the disease density around different roads.
Area sources:
This type of pollution is different from the other two types where it is
not easy to identify in a specific locality, it includes wide areas with
variation in concentration of the pollutants between the different areas.
Example of area source is the airborne combustion products from traffic
and long-range transport. This type is not limited to the traffic lines
but for the entire city or the polluted area. A second example is
pollution with volatile organic compounds contaminating underground
water reservoirs.

1.2 Environmental Exposure Assessment:

Exposure assessment is not easy to be completed; therefore; essential
elements have to be considered:
▪Assurance that the single exposure chosen has biological
relevance/rationale,

▪Latency, age and time of first exposure,

▪Complete chemical and physical characterization of the exposure,

▪Concentration or intensity of the exposure,

188
▪Total (net) duration of the exposure through the worker's job history,

▪Degree of confidence that exposure has occurred at all,

Exposure Vs. Dose:

It is essential to differentiate between exposure and dose, and it is
essential to know: what we are measuring?
Exposure: is the amount of a contaminant that a person may come
into physical contact with over a specified period.
Dose: is the amount of a contaminant that is absorbed or deposited in
an organism over a specified period. It is usually measured as mass
per unit volume or unit mass of affected tissue (e.g., blood lead levels
in µgm per deciliter). Examples of Measurement of Dose is Serum
carboxyhemoglobin as a marker for exposure to CO and Blood lead
levels in children living near major traffic arteries

Biological path and exposure route:

▪Skin by contact
▪Gastrointestinal by ingestion
▪Respiratory system by inhalation: Here there is variability between
different pollutants and factors as Dose – Diameter – Deposition –
Dissolution – Durability (Bio- persistence) will determine the biological
path.

Figure 10.2 shows the pathological path in the human body starting
from exposure until the occurrence of the disease. It is a long process
inside the human body and influenced by a group of biological factors.
This process is influenced by socio-demographic variables and
individual lifestyle factors as smoking.

189
 Figure 10.2: Biological Indicators for Exposure

Individual lifestyle factors (smoking, alcohol…)

E D
Internal Biological Early Altered
X I
dose effective Biological structure/
P S
dose effect (s) function
O E
S A
U S
R E
E Retained dose

Biomonitoring Individual susceptibility factors (genetic, sex, race,

of exposure age…)

Strategies for exposure Assessment:

▪Ascertainment of job titles: We can assess the exposure among

specified groups based on their jobs as Garage workers, benzene
station workers, teachers, and mines workers.

▪Job exposure material: In this case, we are looking to specific

material such as lead and then we identify the groups of people who
could be exposed to lead.

▪Subject by subject exposure assessment: The third approach focus on

the general population with different occupations who are exposed to
different exposures. Finally, we identify people who are exposed to
specific risks.

190
Instruments of exposure measurement:

▪Company records: Such records are reporting data about the job
description for the worker and all the reported health events during the
years of the work.

▪External measurement of exposure: These measures either direct or

indirect measurements. Examples of direct measures of Exposure is
personal monitoring in breathing zone through dosimeters and other
active or passive samplers worn by subjects.

▪ Questionnaires or works interviews are completed to obtain a history

of exposures and possible outcomes. Response rates are very
important to have accurate data.

▪Development of prediction models comparing personal measures with

area measures

3. Environmental effects associated with environmental

exposures
It is not easy to detect environmental effects associated with
environmental exposure but this could be achieved through:

▪ Environmental Epidemiology research

▪ Knowledge of potential exposures

▪ Knowledge of health risks to human from potential exposures

▪ Knowledge of symptomatology or disease occurrence

▪ Make reasonable inferences of causation in Environmental

Epidemiology

191
Environmental Epidemiology Research:
Similar to all the epidemiological studies, environmental research
studies could be descriptive or analytic and could take one of these
forms:
• Descriptive studies:

o Persons – Places – Time

o Time series analysis

o Prevalence studies

• Analytic Studies:

o Case-Control Studies

o Prospective Studies

o Randomized Clinical Trials

Knowledge of potential exposures

This could be obtained from general scientific literature, Studies of
characteristics of substances for their toxicity and carcinogenicity and
from animal experimental studies.
Knowledge of health risks to human from potential exposures
This could be by:
• Epidemiological studies

• Occupational risk studies

Knowledge of symptomatology or disease occurrence

When the investigator is willing to study specific health problems, he
should be familiar with all the clinical situations of this problem mainly
the symptoms and signs. Lead poisoning started with abdominal pain
before the development of the mental problem. The blue line on the
teeth is a diagnostic sign.
Make reasonable inferences of causation in Environmental
Epidemiology
• Strength of the Association: How great is the risk of disease
induced by a given exposure? It is measured by Relative Risk -
Odds Ratio - Standard Mortality Ratio (SMR)

• Specificity of the Association: Is a putative cause induces a

specific disease?

• Consistency of the Association: Does the relationship between

exposure and disease occur regularly in independently conducted
studies?

192
 • Temporality: Does exposure occur at a reasonable interval before
the development of the disease?

• Relationship between estimated exposure and disease

• Effect of the removal of a suspected cause

• Biological Plausibility: How the event could be explained

• Dose-response relationship

Main Epidemiological and toxicological problems in

environmental health:
• Ambient levels of toxic substances may be difficult to determine

• Body burdens may be difficult to determine

• Measurement seldom begin soon enough

• Long latency or incubation time

• Ill-define clinical effects

• Variable dose-response relationship

• Low incidence of serious adverse effects

• Confounding effects due to exposure to several toxic substances

• Occupation and exposures change

• Workers may be migratory

• Which denominator which numerator should be used?

193
 Exercise 16

1. Environmental Epidemiology is defined as:

A. Surveillance of persons exposed to known or suspected toxic substance within
the workplaces
B. Description of all the environmental factors that affect the health passively
C. Surveillance of persons exposed to known or suspected toxic substance, both
within and outside the workplaces
D. Distribution of health and diseases and their determinants among the health
workers
E. Study of the impact of chemicals on humans
2. These are examples of Line sources as environmental exposure:
A. EMF exposures from high tension power lines
B. Pollution from a factory
C. Combustion pollutants around high-density motorways
D. Municipal solid waste site
E. A & C are correct
3. The most serious type of environmental exposure is Area sources and
these are examples of this type of exposure:
A. Increase of florid level in specific water well in the city
B. Airborne combustion products from traffic and long-range transport
C. Volatile organic compounds contaminating underground water reservoirs
D. Pollution from a farm using pesticides
E. B & C are correct
4. In environmental exposure assessment of the Dose is different from
Exposure mainly by:
A. Amount of contaminant comes into physical contact
B. Amount of contaminant that is absorbed or deposited in an organism
C. The degree of the toxicity of the contaminant substance
D. The frequency of exposure
E. There are no differences
5. Carbon Mon Oxide level in the blood is determined by measurement of:
A. Serum carboxyhemoglobin
B. Level of Cholinesterase in the blood
C. Direct measurement of Phosphorus in the serum
D. No public health importance for this measurement
E. Complete blood count

6. Municipal solid waste site is considered as

A. Point source
B. Line source
C. Area source
D. Combination of the three types
E. A & B are correct
7. Environmental chemicals in the human body can be measured in:
A. Urine
B. Blood
C. Saliva
D. Either in blood or urine specimen
E. A & C are correct

194
 Chapter 11
Nutritional Epidemiology

Definition: Nutritional epidemiology is the discipline that studies the

distribution (geographic and overtime) of nutrition-related problems
and their determinants in a population (or population group).
Balanced Nutrition Contributes to:
• Child survival Nutritional Needs
• Better education
care health
• Poverty alleviation
Nutrition
• Reproductive health
food
• Sustained economic growth

• Global equity, stability, and

prosperity

Difficulties in Nutrition Epidemiology

Michael Thun (American Cancer Society) said, “With epidemiology, you
can tell a little thing from a big thing, that's very hard to do is to tell a
little thing from nothing at all". Anyhow, Nutritional Epidemiology is
faced with one or more of the listed below difficulties:
• Multiple diseases and • Everybody eats
mechanisms
• Exposure to all nutrients
• Multiple suspected exposures
• Change of culinary habits
• Long/short latency period through life

• Accumulation/acute exposure • Change of culinary habits with

globalization
• Current/past exposure
• Different composition of the
• Lack of specificity
same food item
• High/low/dosing/” food
• Inter correlation – more of
package”
one>less of other
• Small inter-individual variability
• Cooking & processes are
among individuals within the
different
community

195
 Indicators of Nutritional Status
(most frequently used)

• Anthropometric • Clinical
• Biochemical • Others
• Hematological

Assessment Methods
• Interview • Clinical diagnosis
• Food intake • Measurement
• Diseases • Anthropometry
• Observation • Biochemical tests

Food intake Assessment

(Tell me what you eat? and I tell you who you are)
• Food Frequency questionnaires • Dietary history method
(FFQ) • 24 -hour recall
• Individual Dietary Survey • Chemical analysis of diet
Methods
• Weighed dietary records
A. 24-hour recall
• Provides the MEAN consumed • Not recommended for
by the population association studies

• Recommended for cross- • Requires experienced

sectional studies (surveys) interviewers

• Repeated for variability

B. Retrospective dietary assessment methods

• Designed to assess the • “Scalable”
subject's past diet.
• Easy for participants
• Suitable for epidemiological
• high response rate
studies
• Requires less time to
• Cheaper than 24-hour recall
complete

The most important reasons why the Food Frequency Questionnaire (FFQ) is becoming the main
method in large population studies69

69 Thompson and Byers, 1994

196
 Anthropometric Indicators of Children’s Nutritional Status70

• Birth Weight • Body Mass Index

• Weight for Age • Skin folds

• Height for Age • Head Circumferences

• Weight for Height • Upper Mid Arm Circumferences

o (UMAC)

Analysis of Anthropometric data:

1. All the collected data could be entered on an Excel sheet, or using
SPSS, or other specified nutrition soft packages (see below)
2. SPSS can be used for the calculation of BMI. Select
"Transformation" then "Compute: BMI = Weight (KG) / Height2
(M). Again “Transformation” Recode BMI as continuous variable
to categorical variable (Based on WHO classification)
3. “WHO Anthro 5” is a nutrition package can be used for calculation
of the Anthropometric indicators71
4. CDC developed a soft package for Emergency Nutritional
Assessment (ENA) for SMART72. Data can be entered directly to
the package or you can select from Excel sheet the required
variables as Age, sex, weight, height and UMAC 342

70 [Link]
71 who_anthro@[Link]
72 [Link]

197
Definitions of Anthropometric indicators73

Stunting (Chronic Malnutrition): Percentage of stunting (height-for-

age less than -2 standard deviations of the WHO Child Growth
Standards median) among children aged 0-5 years

Wasting (Acute Malnutrition): Low weight for height or weight for

height more than a standard deviation of 2 below the median value of
the reference (healthy) population.

Underweight: Percentage of (weight-for-age less than -2 standard

deviations of the WHO Child Growth Standards median) among children
aged 0-5 years.

Anemia: Anemia is defined as a hemoglobin concentration below a

specified cut-off point, which can change according to the age, gender,
physiological status, smoking habits and altitude at which the
population being assessed lives. WHO defines anemia in children under
5 years of age and pregnant women as a hemoglobin concentration <
110 g/l at sea level.

Undernutrition (Malnutrition)
Undernutrition is defined as the outcome of insufficient food intake and
repeated infectious diseases. It includes being underweight for one’s
age, too short for one’s age (stunted), dangerously thin for one’s height
(wasted) and deficient in vitamins and minerals (micronutrient
malnutrition)74 (Figure 11.1).

73 [Link]
74 UNICEF, 2006. What is Undernutrition? A report card on nutrition: number 4, May 2006. Found online
[Link]

198
 Figure 11.1: Malnutrition

Target groups: Most Vulnerable Members

• Infants

• Children

• Women of reproductive age

Figure 11.2: Consequences of

malnutrition
Malnutrition is associated with
survival including morbidity and
mortality status and associated
with life quality including
intelligence and life productivity.

Macronutrient malnutrition:
Malnutrition remains a common health problem among children under 5
years worldwide. Deterioration of the nutritional status among Gaza
preschool children and the malnutrition indicators show the situation in
the Gaza Strip is the worst for several decades. UNICEF reported that
the prevalence of stunting and underweight among preschoolers in
Gaza worsened considerably between 1996 and 201075. A study
conducted recently revealed that stunting is higher than the previous

75
(UNICEF, 2010).

199
studies carried out in the Gaza Strip since 2004. The overall prevalence
of wasting, stunting and underweight was 3.5%, 15%, and 6.1%
[Link] is an agreement that the major Malnutrition
problem in Gaza is Stunting and most studies give percentage
fluctuating around 10%. Check the graphs down from UNICEF and
PCBS (Figures 11.3, 11.4.)

Figure 11.3: Prevalence of stunting among children under five,

2000 – 2011 – Palestine

Figure 11.4: Prevalence of underweight among children under five,

2000 – 2011 – Palestine

76
(Radi, et al, 2013)

200
 Micronutrient malnutrition:
1. Anemia:
Causes of iron deficiency anemia
• Inadequate intake of quality • Inhibitors
and quantity food rich in iron
• Parasitic Infection (loss of
• Low iron bioavailability blood and iron)

• Non-heme iron • Diseases

• Iron deficiency anemia reduces the ability of the blood to carry

oxygen from the lungs to the brain, muscles and other organs.

• Iron is important as a trace element in other vital functions

• This affects the body ability to do work and the brain capacity to
think and to learn

• Iron deficiency in young children leads to poor school

performance and reducing future ability to work.

Consequences of anemia
Iron deficiency reduces Effects on Infant:
• Learning ability • Stillbirth

• School performance • Infant death

• Retention rates • Brain damage

Speech & hearing abilities

Risks: Prevalence of Anemia is associated with;

• Delayed mental development in infants

• Poorer performance on cognitive tests in older children

• Anemia Reduces capacity to think & learn, school retention and school
attendance & enrolment

• 1% reduction in productivity for each 1% drop in iron status

201
• Anemia in Women of Reproductive Age: Increased risk of death for
both mother and infant

Despite multiple health programs, rates of anemia and malnutrition

have increased in the last years, and the reasons behind this increase
are multifactorial77. Child health and nutrition experts said that these
rates reflect the critically disadvantaged situation and emergencies in
the Gaza Strip. In 2006, WHO mentioned that iron deficiency anemia
rates in the Gaza Strip were as high as 54.7% among children78.
Anemia among children 12-15 months old: The overall anemia
prevalence (Hb level < 11 g/dl) among children 12-15 months old was
54.2% (45% in WB and 69.7% in GS), Gaza, Rafah, and Deir El–Balah
had the highest prevalence (79.4%, 69.9%, and 68.7% respectively).
The lowest prevalence was in Tulkarm 24.2%, Jerusalem 37%, and
Ramallah & Al - Bireh 37.9%. Around 62% of reported cases of anemia
are mild anemia (hemoglobin level 10 ≤ Hb g/dl). Moderate anemia (7
≤ Hb g/dl < 10) forms around 38.3% of reported cases, with a very
small number (0.1%) of severe anemia where hemoglobin level is
below 7 g/dl. The Palestinian Micronutrient Survey 2013 reported that
in the Palestinian communities 30.7% of children 6-59 months old were
anemic, 27.8% were nutritionally stunted and 5.6% were wasted.
Anemia percentage varies from one year to another year and from one locality in
the Gaza strip to another area. When figures come from clinics usually it is high
while figures from community surveys are lower, age group gives different values
for example Micro Nutrient survey, 2013 is giving Anemia 34% among 2 – 5
children and it is 45% in the first year of life. Figure 11.5 shows anemia rates
among Palestinian infants during the years 2006 – 2011. Table 11.1 presents
prevalence of Anemia among children and pregnant women in Gaza by different
studies, Anyhow, regardless of variation in percentage, there is a public

77
Qouta, S. and Odeh, J., 2005. The Impact of Conflict on Children: The Palestinian Experience. The Journal of ambulatory
care management 28(1):75-9 · January 2005. Found online
[Link]
78
WHO, 2006. Health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian
Golan. Found online [Link]

202
health problem in anemia among children with rates higher than 50%
and women with rates around 40%.

Figure 11.5: Prevalence of Anemia among children 6 – 9 months,

2006 – 2010 – Palestine79

Table 11.1: Prevalence of Anemia among children and pregnant women

in Gaza Strip
Source Child Pregnant Anemia Data source
Anemia
MOH, Uncief, 201580 69.7% 40% Clinic-Based
Ashrita, 201581 50% 40% Secondary

Rima, 201582 59.6 Community

PCBS, 201183,84 DB 41 GZ 31 Gaza 40% community

Khan Younis 56%

Micro Nutrient Survey, 38 43 Community

2013
1st Y. 45%

Benefits of anemia prevention:

• improved health and work capacity

• improved efficiency of education

• reduced health care expenditure

• improved quality of life

79 [Link]

80 [Link]
81 [Link]
82 [Link]
83 [Link]
84 [Link]

203
 2. Vitamin A Deficiency

• Vitamins and minerals

Children with Vitamin A Deficiency
deficiencies affected a third of
the world's people debilitating
minds, bodies, energies, and Blind: 0.5 Million

economic prospects of nations. Exophthalmia: 3.1 million

23%⚫
• More than 250 million children
Night blind: 13.5 million
greater risk of
death
under five years are affected by
Inadequate Vitamin A:
231 million

sub-clinical vitamin A deficiency.

• Improving vitamin reduces
mortality by an average of 23%
between 6-59 months of age

Vitamin A Deficiency
• Lowers immunity
• Affects vision
• Increases incidence and severity
of illnesses
• Increases mortality rate
• Increases absenteeism

• Increases economic burden

Vitamin A deficiency is a major public health problem, where the

MARAM survey shows that only 24% of the Palestinian children are
classified normal, 22% were deficient while 54% were borderline (Table
11.2). The problem is higher in Gaza than the West Bank. Table 11.3
shows the relationship between Anemia and Vitamin A deficiency.

204
 Table 11.2: Vitamin A deficiency among children 12 – 59 months of age by
region in Palestine

Table 11.3: Vitamin A Deficiency Vs Anemia Among Children Aged 12-59

Months in Palestine

Policy and Strategies

The intervention policies for the improvement of nutrition include a
balanced mix of curative and preventive interventions. Different
strategies at the center and community levels are elaborated to modify
positively mothers and community knowledge attitude and practices
towards nutrition. It is important to distinguish between policy and
strategy. The policy is a clear statement of intent, but a strategy sets
out how, when, where and resources for implementing policy.
Nutrition-related protocols have been developed on behalf of the MoH.
These include the following:
1) MARAM protocols on breastfeeding, infant and young child feeding
"IYCF", growth monitoring and promotion, micronutrient
supplementation and the management of maternal and child iron

205
deficiency anemia85. The protection, promotion, and support of
appropriate nutrition status during pregnancy and IYCF, the protection
of non-breastfed infants, and 6-month exclusive breastfeeding remain
an important component of child and women health.
2) Integrated Management of Childhood Illnesses, which covers many
aspects of nutrition including breastfeeding, complementary feeding,
growth monitoring, iron deficiency anemia, management of
malnutrition, micronutrient supplementation, and counselling mothers.
3) National Reproductive Health Guidelines and Protocols that include
breastfeeding, adolescent nutrition, and nutrition counseling for
pregnant and lactating mothers.

Nutrition strategies:
The strategy document was assembled by the MOH with considerable
support from NGOs such as the MARAM project and Ard El Insan.
Strategic priorities outlined in the National Nutrition Strategy:
• Managing malnutrition.

• Communication strategies for behavior change.

• Support and encourage breastfeeding and appropriate

complementary feeding.

• Micronutrient supplementation for vulnerable group.

• Food fortification.

• Development of protocols and guidelines.

• Capacity building for health personnel and staff from other sectors.

• Applied research.

85 MARAM is a USAID funded program 2001 – 2005

206
 The solution
Figure 11.6: The triple strategy approach

First: Dietary modifications are changes made during food

preparation, processing, and consumption to increase the bioavailability
of micronutrients — and reduce micronutrient deficiencies—in food at
the commercial or individual/household level (Beck and Heath 2013).
One example of dietary modification is the simultaneous consumption
of iron-rich foods with ascorbic acid (vitamin C) (Gibson 2014), which
increases the amount of iron absorbed by the body. Decreasing the
amount of coffee and tea consumed with meals containing iron-rich
foods is another example of dietary modification because coffee and tea
inhibit iron absorption.
Second: Fortification: implementation of obligatory fortification of
flour and voluntary fortified products at the private sector
• Basic foods

• Widely consumed

• Centrally processed

• Not changed by addition of iron

Third: Supplementation86
• Requires: access to services, compliance, quality services, and
products

86
[Link]
modification

207
 • Reinforcement of the present supplementation of vitamin A &
D syrup for children under one year,

• Assure regular supplementation of Iron preparations for most

vulnerable groups

Conclusion: Investment in nutrition would improve:

• Infant and child health

• Women Health

• Children’s school performance

• Economic productivity

• Prevention of Non-Communicable Diseases

208
 Chapter 12
Reproductive Epidemiology

WHO Definition of Reproductive Health: WHO defines reproductive

health as a condition in which the reproductive process is accomplished
in a state of complete physical, mental, and social well-being, and is
not merely the absence of disease or disorders of the reproductive
system. It involves the interaction of four main components: 1) the
ability, particularly of women, to regulate and control fertility; 2) safe
motherhood; 3) infant and child survival, growth, and development;
and 4) safety from sexually transmitted disease87.
Reproductive health surveillance can be defined as “a component of the
health information system that permits the identification, notification,
quantification, and determination of events of reproductive health
significance for a defined period of time and specified geographic
location(s), with the goal of orienting appropriate public health
measures for disease prevention and health promotion” 88.

Three different terms are usually used with minimum differences

between them:
• Maternal Health: Referred to the period of pregnancy – Delivery
and 42 days after delivery

• Reproductive Health: Health and Health Determinants during

reproductive age 15 – 49 Years

• Women Health: All women all ages married or not –

87
Fathalla M. Reproductive health: a global overview. Ann NY Acad Sci 1991;626:1.
88
Berg C, Danel I, Mora G, editors. Guidelines for maternal mortality epidemiological surveillance.
Washington: The World Bank; 1996.

209
 Women’s Health Indicators 201789

Life Expectancy:
Figure 12.1: Life expectancy at birth in Palestine by Gender and Region90

Review of life expectancy in

Palestine revealed that “women
lives 3 Years more than men”.
This is true in both West Bank
and Gaza.

Fertility Rate
Age-specific fertility rate: (Number of live births to women of
specified age or age group in year X 1000) / Mid-year women
Population of the specified age or age group
General fertility rate: (Number of live births in year X 1000) Mid-year
Population of women of childbearing age (15-44 years or 15-49 in some
countries)
Total fertility rate: Sum of the entire age-specific fertility rate for
each year of age from 15 to 49 years. It is the average number of
children that a synthetic cohort of women would have at the end of the
reproductive period, if there were no mortality among women.

89 Ministry of Health, PHIC, Health Status, Palestine, 2017, July 2018

90 PCBS, population estimate based on 2007 census, 2012

210
TFR = Sum of [the age specific fertility rates by age group of women
(15-49) years x interval of the age groups (5)]
According to Palestinian Central Bureau of Statistics (PCBS), the total
fertility rate among women of childbearing age 15-49 years in 2017
was 4.4 births per woman in Palestine, 4.5 in Gaza Strip and 4.3 in
West Bank.

Reproductive Health: These items are selected based on studies

completed in Al Quds University School of public Health – Gaza:
1. Consanguineous Marriage
2. Anemia among pregnant women
3. Obesity and Overweight among women
4. Family Planning Impact studies
5. Family Planning KAP studies
1. Consanguineous Marriage91

The prevalence of consanguineous marriage was 49.4% (in Jabalia

camp 56.4%, in Rimal area 40.6%. It is associated with couple fertility,
maternal morbidity, and infants and children morbidity and mortality.
Appropriate counselors should be trained to undertake pilot studies of
the feasibility of screening and counseling extended families, and of
incorporating these approaches into pediatric and primary health care
services The prevalence of anemia in pregnant women was: 61.4%.
The mean was 10.6 gm/100dI. The most related variables to anemia
prevalence in Gaza Strip were consanguinity marriage, family number,
first and second trimester and LBW where LBW deliveries were of high
significant statistical relationship with anemia (P value <001). The
author recommended reinforcement of PHC anemia prevention and
intervention programs
3. Obesity and Overweight among women
Table 12.1: Distribution of overweight and obesity among women by

91 SPH Gaza, Kariri Moaeen, 2001

211
Governorates92

AREA Overweight Obesity

North Gaza 38.7% 32.3%

Gaza City 32.8% 22.6%

Mide Zone 30% 46%

Khanyounis 31.8% 34.8%

Rafah 33.3% 35.7%

4. Family Planning Impact studies

The children of mothers practicing family planning are healthier, heavier
and less exposed to accidents and neglect. Women usually practiced
family planning after they had had many children. The children of users
are enjoyed with breast-feeding for a longer period. The children of
users have received health care more than children of non-users.
5. Family Planning KAP studies93
About 75% of women participated in the study had a knowledge of
family planning, while about 64% of interviewed men did have this
knowledge. There was high percentage of approval of family planning,
about 90% of women approved the use compared to 72% of men. The
percentage of women currently using family planning was about 35%,
who had ever used family planning was 66.5%. Intra uterine devices
were the most prevalent method followed by pills. There was a
statistical significant positive relationship between women educational
level, marital age and women knowledge, practice and attitudes
towards FP. Families who are financially below poverty line are
practicing FP less than those above poverty line; they were also like to
have more children than those above poverty line. Child mortality was
more among women who have large family size, short birth interval
and young marital age. The study recommendation included,

92 SPH Gaza, Jamalat study, 2009

93 SPH Gaza, Abu Nahla Ghada, 2006

212
Empowering women, Male involvement in family planning program and
Design effective information, education and communication strategies.
The quality of care is the most critical factor which will enable the
primary health care/family planning programs to attract more clients
and improve the reproductive health among Gaza Strip population
Women Morbidity
There is no precise morbidity estimate for women. The most commonly
reported health problems during pregnancy are; infections (urinary
tract infections - UTI and reproductive tract infections), anaemia and
PIH.
MOH, UNRWA and NECC statistics shows that around 20% of
pregnancies are high risk ones. DM during pregnancy 2%, PIH during
pregnancy 12.6%
Cancer:
Figure 12.2 Tope 10 cancers among Females in West Bank 2017
(Incidence per 100,000)94

Mental Health and psychosocial:

1. A study reported prevalence of depression and anxiety disorders
among women of Childbearing age in Gaza Strip95. 461 women were
involved in the study and the main findings show that; Moderate
depression 30.2%, severe depression 3.7%, moderate anxiety 41.6%
and sever anxiety 7.2%.

94 Ministry of Health, PHIC, Health Status, Palestine, 2017, July 2018

95 SPH Gaza, Baroud Soma, 2008

213
2. Prevalence and risk factor of postpartum depression study 96 shows
that, 69% develop depression at the first 4 weeks postpartum. The
grade of severity (57%) and the main risk factors are political violence,
stress, Psychological stress (39,92%) includes; gender issues, first
pregnancy, preterm infant, attitude towards pregnancy. Physical stress
(37%) including; bleeding, abortion, vomiting and puerperal sepsis.
Social stress (35%) including; economic troubles, living inside extended
family, support of partner and employment status.
3. Violence: Numbers presented by the Al-Muntada Coalition of
Palestinian NGO’s at the Violence against Women workshop, January,
2010 showed; among unmarried women over the age of 18, 25% had
been physically abused and 52.7% psychologically abused. Among
married women, psychological abuse rose to 61.7%, while physical
abuse fell to 23.3% and sexual abuse stood at 10.5%.
Maternal Health Services
• Preconception examination • Post-natal care

• Antenatal Care • Family planning

• Natal Care • Family Health Counseling

Antenatal Care: Antenatal care is the health care given to the

pregnant women since the first month until the delivery time to ensure
safe pregnancy and safe outcome. The outcome is referred to safe
delivery and healthy newborn.
Natal Care: Natal care is referred to the care given to a woman during
delivery. Delivery sites should be hygienic, well equipped and have
qualified trained persons. These sites could be in hospitals whether
general hospitals or delivery hospitals, or in the community either in
the primary health care centers or separate maternity homes. The role
of the traditional birth attendants (Daya) is limited during this time,
due to presence of qualified health staff performing this task. Natal

96 SPH Gaza, Sammour Ayesh

214
care should not be limited to the delivered women but care should be
given to the newborn at the same time.
Natal services Availability is reasonable, challenged by the quality of
services (rationalization, standardization). The governmental hospitals
provide (64.5%) of the total number of deliveries. Private providers and
NGOs provide the rest. The average stay of woman in the hospital after
normal birth is very short. Occupancy rate at MOH, 103% at NGOs
hospitals <30%
Figure 12.3: Caesarean Sections in Gaza Table 12.2: Caesarean section rates
among UNRWA reported deliveries,
2017

50

40

30
17.0 18.0
20 15.1 15.3
15.3 19

10

0
2005 2006 2007 2008 2009 2010

Women satisfaction about delivery services provided at Shifa hospital

study97 is Analytical cross-sectional study selected 425 women who
gave birth during the data collection period (2009). The overall
satisfaction was 61.8%. There is six dimensions comprising client’s
satisfaction: Technical competency – Availability - Responsiveness of
services - Information and communication - Interpersonal manner -
Physical environment. The worst was information and communication
followed by physical environment mainly the bathrooms.
Abortions
Table 12.3: Percentages of CS and Abortions in Shifa Hospital 2009 and 2010

A Review for Maternity work in Deliveries Abortions % C.S. %

Shifa hospital showed that CS
Rate is 19% and sharp increase 2009 17445 1725 9.9 3327 19
in the Abortion Rate from 9.9%
to 16.6% 2010 21586 3589 16.6 4169 19.3

97 SPH Gaza, Etaf Ahmed, 2009

215
Post-natal care: This component is the weakest component in
maternal health care, where the percentage of women who receive this
service is relatively low. During puerperium, each woman had to be
check for signs of hemorrhage or infection. Postnatal care is given
either in the health centers or during home visits. Counseling for
family planning during post-natal care visit is recommended in this
stage.
Family planning: Each family has to decide about the desirable size of
the family and the health care providers have to help and advice for the
most appropriate and the safe method to achieve this activity. Family
planning is not family control and the best acceptable term is family
spacing by giving enough time between the pregnancies to ensure
healthy mother and healthy child.
Family Health Counseling: Each family has the right to receive health
counseling in the MCH centers and during the MCH visit. Counseling
focuses on family planning and importance of breast-feeding and the
nutrition of the women and the child. Women and children with specific
risk is in need for focus on their specific problems

Maternal mortality
Background:
Women health is one of the major concerns of the public and the health
policy makers all over the world. The main determinant of women
health is the health status during reproductive age, where women are
exposed to risks associated with the pregnancy and the delivery. In
the chapter we are intending to focus on undesirable event associated
with the process of pregnancy and delivery, that is maternal death. We
are reviewing the concept and definitions, methods of measurement
and causes of maternal mortality.
Definitions:
Based on the tenth revision of the International classification of
Diseases (ICD-10) the maternal death is defined as:

216
 “the death of a woman while pregnant or within 42 days of termination
of pregnancy, irrespective of the duration and site of the pregnancy,
from any cause related to or aggravated by the pregnancy or its
management but not from accidental or incidental causes”.98
It is clear that this definition includes all women deaths during
pregnancy, delivery or during the post-partum period (42 days) are
considered whether that is due to a disease, aggravation of a disease,
or due to intervention during delivery or abortion or surgical
intervention as cesarean sections. The only excluded causes are those
due to accidental or incidental causes such as car accident.
A skilled attendant: is a medically qualified provider with midwifery
skills (midwife, nurse or doctor) who has been trained to proficiency in
the skills necessary to manage normal deliveries and diagnose,
manage, or refer obstetric complications. Ideally, skilled attendants live
in, and are part of, the community they serve. They must be able to
manage normal labor and delivery, perform essential interventions,
start treatment and supervise the referral of mother and baby for
interventions that are beyond their competence or not possible in a
particular setting.
Skilled attendance: refers to a skilled attendant operating within an
enabling environment or health system capable of providing care for
normal deliveries as well as appropriate emergency obstetric care for all
women who develop complications during childbirth.
Skilled care is another way of expressing skilled attendance. Many
people prefer this term to avoid confusion between “skilled attendants”
and “skilled attendance”, especially when spoken.
The enabling environment describes a context that provides a skilled
attendant with the backup support to perform routine deliveries and
make sure that women with complications receive prompt emergency

98WHO, International Statistical Classification of Diseases and Related Health Problems. Tenth Revision.
Geneva, 1992.

217
obstetric care. It essentially means a well-functioning health system,
including equipment and supplies; infrastructure and transport;
electrical, water and communication systems; human resources
policies, supervision and management; and clinical protocols and
guidelines.
A traditional birth attendant (TBA): is a community-based provider
of care during pregnancy and childbirth. TBAs are not trained to
proficiency in the skills necessary to manage or refer obstetric
complications. TBAs are not usually salaried, accredited members of the
health system. Although they are usually highly esteemed
Community members and are often the sole providers of delivery care
for many women, they should not be included in the definition of a
skilled attendant for the calculation of the Millennium Development
Goals indicator.
The Dimensions of Maternal Mortality:
1. Maternal mortality is the health indicator with the most
disparity between developed and developing countries. Almost all
maternal deaths (95 per cent) occur in Africa and Asia. In her
lifetime, a woman in sub-Saharan Africa faces a 1 in 16 risk of
dying during pregnancy or childbirth as compared to a 1 in 2800
risk in the developed world

2. Nearly two-thirds of maternal deaths worldwide are due to

five direct causes: hemorrhage, obstructed labor, eclampsia
(pregnancy-induced hypertension), sepsis and complications from
unsafe abortion.

3. With an estimated 15 per cent of pregnancies resulting in

complications, all pregnancies must be considered at risk.
However, a professional health worker can treat all five of the
most life-threatening complications. Being prepared to address
complications is the key to saving the lives of mothers and
newborns. This is why skilled attendance is crucial.

218
 4. The fifth Millennium Development Goal (2000) calls for a
reduction in maternal mortality and morbidity. One of the
indicators used to track progress in meeting this goal is the
proportion of women who deliver with the assistance of a skilled
birth attendant.

5. Although data for this indicator is widely available in many

countries, definitions used for data collection may vary from
country to country. Why?

We Focus on Skilled Attendance

Historical data indicates that countries successful in reducing maternal
mortality have emphasized the role of a professional midwife or doctor
working in a health institution. This is true for both developed and
developing countries.
1. There is an inverse relationship between the proportion of
deliveries assisted by a skilled attendant and the maternal
mortality ratio in developing countries

2. In the developing world, complications from HIV/AIDS and

malaria are increasingly becoming indirect causes of maternal
death and morbidity. Maternal health services represent a
strategic entry point for addressing both malaria and HIV/AIDS in
women.

3. Skilled delivery care and emergency obstetric care can protect

millions of newborns, as well as their mothers.

Delivering into good hands

1. Since almost all maternal mortality is avoidable, the death of a
woman during pregnancy or childbirth is a violation of her rights to life
and health. A human rights-based approach to maternal mortality
reduction calls on governments to provide universal access to skilled
delivery care and emergency obstetric care. It also promotes dignity
and equity for women within the health-care system.

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 2. Investing in human resources is crucial for improving skilled
attendance at birth. Critical issues include “brain drain,” salary and
benefits, supervision and management, and skills maintenance.

3. In countries with high HIV/AIDS prevalence, the disease must be

addressed as a human resources issue as well as a public health
concern. Skilled attendants must be supported in taking universal
precautions to protect themselves.

4. Given their esteemed role within the community, TBAs can serve as
strong advocates for skilled attendance at birth if they are
appropriately linked with the health system. Programs should focus on
supporting the social role TBAs play in women’s health rather than
investing in developing their technical skills.

5. Upgrading delivery care often begins with improving the quality of

services offered in facilities. When facilities provide quality services,
they become widely used and trusted by community members.

6. There is no single approach to improving skilled attendance at birth.

Strategies must be tailored according to local context. Regardless of
the approach, the objective is to manage normal labor well and ensure
emergency obstetric care for all women who develop complications
during childbirth.

Epidemiology:
Global Maternal mortality update 201699
As shown in the table below: More than 300,000 women in the world
die each year due to complications of pregnancy and delivery. Most of
deaths (95%) occur in developing and undeveloped countries.
Table12.4: Estimates of maternal mortality ratio (MMR, maternal deaths per
100,000 live births), number of maternal deaths, and lifetime risk, by United
Nations Millennium Development Goal (MDG) region, 2015

99World Health Organization, UNICEF, United Nations Population Fund and The World Bank,
Trends in Maternal Mortality: 1990 to 2015, WHO, Geneva, 2015.

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Measures of maternal mortality:
There are three distinct measures of maternal mortality in widespread
use:
A. The maternal mortality ratio,

B. The maternal mortality rate and

C. The lifetime risk of maternal death.

The most commonly used measure is the maternal mortality ratio,

that is the number of maternal deaths during a given time period per
100,000 live births during the same time period. This is a measure of
the risk of death once a woman has become pregnant.
The maternal mortality rate, that is, the number of maternal deaths
in a given period per 100,000 women of reproductive age during the
same time period, reflects the frequency with which women are
exposed to risk through fertility.

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The lifetime risk of maternal death takes into account both the
probability of becoming pregnant and the probability of dying as a
result of that pregnancy cumulated across a woman’s reproductive
years. In theory, the lifetime risk is a cohort measure but it is usually
calculated with period measures for practical reasons. It can be
approximated by multiplying the maternal mortality rate by the length
of the reproductive period (around 35 years). Thus, the lifetime risk is
calculated as [1-(1-maternal mortality rate)2].

Approaches for measuring maternal mortality:

Commonly used approaches for obtaining data on levels of maternal
mortality vary considerably in terms of methodology, source of data
and precision of results. The main approaches are described briefly
below. As a general rule, maternal deaths are identified by medical
certification in the vital registration approach, but generally on the
basis of the time of death definition relative to pregnancy in household
surveys (including sisterhood surveys), censuses and in Reproductive
Age Mortality Studies (RAMOS).

1. Vital registration
In developed countries, information about maternal mortality derives
from the system of vital registration of deaths by cause. Even where
coverage is complete and all deaths medically certified, in the absence
of active case-finding, maternal deaths are frequently missed or
misclassified. In many countries, periodic confidential enquiries or
surveillance are used to assess the extent of misclassification and
underreporting. A review of the evidence shows that registered
maternal deaths should be adjusted upward by a factor of 50% on
average. Few developing countries have a vital registration system of
sufficient coverage and quality to enable it to serve as the basis for the
assessment of levels and trends in cause-specific mortality including
maternal mortality.

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2. Direct household survey methods
Where vital registration data are not appropriate for the assessment of
cause-specific mortality, the use of household surveys provides an
alternative. However, household surveys using direct estimation are
expensive and complex to implement because large sample sizes are
needed to provide a statistically reliable estimate. The most frequently
quoted illustration of this problem is the household survey in Addis
Ababa, Ethiopia, where it was necessary to interview more than 32,300
households to identify 45 deaths and produce an estimated MMR of
480. At the 95% level of significance this gives a confidence interval of
plus or minus about 30%, i.e. the ratio could lie anywhere between 370
and 660.10 The problem of wide confidence intervals is not simply that
such estimates are imprecise. They may also lead to inappropriate
interpretation of the figures. For example, using point estimates for
maternal mortality may give the impression that the MMR is
significantly different in different settings or at different times whereas,
in fact, maternal mortality may be rather similar because the
confidence intervals overlap.
3. Indirect sisterhood method:
The sisterhood method is a survey-based measurement technique that
in high-fertility populations
substantially reduces sample size requirements because it obtains
information by interviewing respondents about the survival of all their
adult sisters. Although sample size requirements may be reduced, the
problem of wide confidence intervals remains. Furthermore, the method
provides a retrospective rather than a current estimate, averaging
experience over a lengthy time period (some 35 years, with a midpoint
around 12 years before the survey). For methodological reasons, the
indirect method is not appropriate for use in settings where fertility
levels are low [total fertility rate (TFR) <4] or where there has been
substantial migration, civil strife, war, or other causes of social
dislocation.

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4. Direct sisterhood method
The Demographic and Health Surveys (DHS) use a variant of the
sisterhood approach, the “direct” sisterhood method.12 This relies on
fewer assumptions than the original method but it requires larger
sample sizes and the information generated is considerably more
complex to collect and to analyse. The direct method does not provide
a current estimate of maternal mortality but the greater specificity of
the information permits the calculation of a ratio for a more recent
period of time. Results are typically calculated for a reference period of
seven years before the survey, approximating a point estimate some
three to four years before the survey. Because of relatively wide
confidence intervals, the direct sisterhood method cannot be used to
monitor short-term changes in maternal mortality or to assess the
impact of safe motherhood programs. The Demographic and Health
Surveys have published an in-depth review of the results of the DHS
sisterhood studies (direct and indirect methods) and have advised
against the duplication of surveys at short time-intervals. WHO and
UNICEF have issued guidance notes to potential users of sisterhood
methodologies, describing the circumstances in which it is or is not
appropriate to use the methods and explaining how to interpret the
results.
5. Reproductive Age Mortality Studies:
The Reproductive Age Mortality Study – RAMOS – involves identifying
and investigating the causes of all deaths of women of reproductive
age. This method has been successfully applied in countries with good
vital registration systems to calculate the extent of misclassification and
in countries without vital registration of deaths. Successful studies in
countries lacking complete vital registration use multiple and varied
sources of information to identify deaths of women of reproductive age;
no single source identifies all the deaths. Subsequently, interviews with
household members and health-care providers and reviews of facility
records are used to classify the deaths as maternal or otherwise.

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Properly conducted, the RAMOS approach is considered to provide the
most complete estimation of maternal mortality but can be complex
and time-consuming to undertake, particularly on a large scale.
6. Verbal autopsy
Where medical certification of cause of death is not available, some
studies assign cause of death using verbal autopsy techniques.19
However, the reliability and validity of verbal autopsy for assessing
cause of death in general and identifying maternal deaths in particular,
has not been established.
The method may fail to correctly identify a proportion of maternal
deaths, particularly those occurring early in pregnancy (ectopic,
abortion-related), those in which the death occurs sometime after the
termination of pregnancy (sepsis, organ failure), and indirect causes of
maternal death (malaria, HIV/AIDS).

7. Census
There is growing interest in the use of decennial censuses for the
generation of data on maternal
mortality. A high-quality decennial census could include questions on
deaths in the household in a defined reference period (often one or two
years), followed by more detailed questions that would permit the
identification of maternal deaths on the basis of time of death relative
to pregnancy (verbal autopsy). The weaknesses of the verbal autopsy
method have already been noted. Nonetheless, the advantages of such
an approach are that it would generate both national and sub national
figures and that it would be possible to undertake analysis according to
the characteristics of the household.
Trend analysis would be possible because sampling errors would be
eliminated or greatly reduced.
However, data obtained from enquiries into recent deaths in the
household in a census require careful evaluation, and often adjustment.
A number of countries have used the census to generate maternal

225
mortality figures, and work is under way to assess the extent to which
such approaches may prove of value in measuring maternal mortality.
Factors affecting maternal mortality:
Socioeconomic status: Less than 18 years old, More than 35 years
old, Lives far from hospital or health facility, Positive consanguinity,
Smoking habits, Long duration of marriage with infertility and use of
ovulatory drugs, OR short prims women (less than 150 cm).
Poor obstetric history: Recurrent stillbirths, Abortions: Two or more
consecutive, first trimester abortions or second trimester abortion.
Previous early neonatal death, premature labor <24 weeks of
gestation, prolonged obstructed labor, APH or PPH, caesarian section
delivery. Other diseases as myomecotomy, scared uterus, multiple
pregnancies, Mal- presentations, previous gynecological operations
such as prolapse, fistula, and third degree tears. Pre-eclampsia,
Intrauterine growth retardation, Blood Disorders, Uterine Abnormality,
Uterine fibroid, Obesity (Maternal pre pregnancy Weight more than 85
Kg), Assisted Reproductive Techniques OR Previous infertility.
Presence of Major medical disorders: Hypertension, Cardiac
disease, Diabetes, Anemia, Bronchial Asthma, Neurological disorders,
Blood disorders or Hepatitis B carrier
Availability of Health Services: Birth attendants and Health care
facilities
Causes of Maternal Mortality:
The main direct causes of maternal mortality are:
1. Hemorrhage
2. Obstructed labor
3. Eclampsia (pregnancy-induced hypertension)
4. Infection
5. Complications from unsafe abortion
There is a variation between causes of death in developed and in
developing countries, where infection and hemorrhage are common
complications in developing countries.

226
Maternal causes could be direct or indirect, direct obstetric deaths,
resulting from obstetric complications of the pregnant state, from
interventions, omissions, incorrect treatment. Indirect obstetric
deaths, resulting from previous existing disease or disease that
developed during pregnancy and which was not due to direct obstetric
causes, but was aggravated by the physiological effects of pregnancy.

Maternal Near Miss (MNM)

Refers to a woman who nearly died but survived a complication that
occurred during pregnancy, childbirth or within 42 days of termination
of pregnancy. Aim of MNM is to identify the possible causes of Maternal
Mortality in depth.

Analysis of gathered information from Gaza (2017) shows that Infection

and Hemorrhage are the main causes. Sixteen out of 18 cases are
avoidable. The unpublished study reveals gap in referral system. Use of
application of protocols are recommended. Clinical Audit would help and
focus on the question: Are we doing the right thing?

Disaster Risk Reduction, Sexual, and Reproductive Health (SRH)

in Palestine: Minimum Initial Service Package (MISP) to be used

227
during emergency. A monitoring tool was developed to identify
preparedness and readiness to save children and women during
Emergencies. The Palestine is the only country globally to pilot the tool.
The tool examines investing in disaster risk reduction for resilience,
provision of priority SRH service for the population, presence of plans
for SRH. Health cluster have to set emergency plan (worked with
WHO), until this moment, the plan does not include child and women.
Preposition of medication and supplies, involvement of all district and
information monitoring is essential. Staff training for SRH, followed by
advocacy and reporting of the events.

Research priorities maternal health

• Risk factors associated with infection during postnatal period

• Risk factors associated with PPH

• Rising percentage of C/S in Gaza

• Prevalence and determinants of maternal Near miss

• Determinants of poor compliance to guidelines in maternity

• Determinants of “unmet need” of family planning “ qualitative

Research”

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 Exercise (17)
Mid-Year Population of women in the Reproductive Age and Number in
Gaza Strip, 1997 and 2017
Age Mid-Year Population Number of Live Births
1997 2017 1997 2017
15-19 42,874 94,037 4,872 15
20-24 36,086 97,001 11,560 3,852
25-29 33,428 84,187 10,308 18,504
30-34 27,937 61,923 7,438 18,640
35-39 20,804 49,417 4,091 10,842
40-44 13,069 40,718 1,509 5,259
45-49 8,630 30,673 149 1,468
Total 182,828 457,956 39,927 58,580

For the 2 years, 2017 and 1997

1- Calculate the crude birth rate
2- Calculate the general fertility rate and total fertility rate.
Explain how Both are different
3- Draw a chart showing age specific fertility rate among different age groups.
4- What is your conclusion
Remember:
Crude birth rate: (Number of live births) X1000/Mid-year Population
Age-specific fertility rate: (Number of live births to women of specified age or age
group in year X 1000) / Mid-year women Population of the specified age or age group
General fertility rate: (Number of live births in year X 1000) Mid-year Population of
women of childbearing age (15-44 years or 15-49 in some countries)
Total fertility rate: Sum of the entire age-specific fertility rate for each year of age
from 15 to 49 years. It is the average number of children that a synthetic cohort of
women would have at the end of the reproductive period, if there were no mortality
among women.

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 Exercise (18)

The data given in this exercise is not real, it is for an imaginary city in Palestine
named "Beet El Salam" with total population 160,000 inhabitants. The city records
for the year 2017 show that, total number of live births is 6400 and the total reported
deaths is 800 cases. Among all deaths 128 died during their first year of life.
(A)
1- Calculate the Crude Birth Rate (CBR) for Beet El Salam city. What is the
importance of the CBR as an indicator for measurement of the health status?

2- From the Given data can you calculate the Crude Death Rate? If Yes: Calculate
this rate and if No: explain why you cannot do such calculation?

3- Based on question 2 you were informed that Crude Death Rate in Finland is 9 per
thousand. Could this be true? If yes, explain how?

4- Calculate Infant Mortality Rate (IMR) for Beet El Salam city. What is the
importance of IMR?

5- If we know that 50% of infant deaths occurred during the first 28 days of life.
Calculate both neonatal and post neonatal mortality rates in Beet El Salam

6- What are the health policy implementations could be derived from calculation of
neonatal and post neonatal mortality rates?

(B)
The health officer in Beet El Salam is welling to know the number of women in
reproductive age (15 – 49 Years) in his city, but data was not available. The health
officer contacted the Central Bureau of Statistics who advised to use the attached
population structure for all the Palestinian population for the year 2017.

1. Was it important to know the exact number of the women in reproductive age in
Beet El Salam? If Yes: mention two uses for this number.
2. From the attached population structure estimate the number of women in
reproductive age in Beet El Salam city.
3. Health records show that 600 women were diagnosed as Candidiasis during the
year 2003. Calculate the incidence rate for Candidiasis among women in
reproductive age.
4. The Family planning nurse informed you that Intra Uterine Devices (IUD) users
are 800 women, the pills user are 400 women and 100 families are Condom users.
A) Draw a pie chart showing Distribution of contraceptive use.
B) Calculate the Contraceptive Prevalence Rate

230
5. During the year 2017 contraceptive complication were reported among 32 IUDs
users, 20 pills users and 8 condom users.
A) Based ONLY on the given information what is the impression you got about
contraceptive complications.
B) Using the given data in question (4) Calculate the complication rate for each
type of the used contraceptives.
C) What are your conclusions?

6. The Family planning nurse informed you that the numbers of women who
continue to use the service are distributed as: (IUD) users are 700 women, the pills
users are 200 women and 90 families are Condom users.
A) Calculate the Continuing User Rate, based on the number of women continue
receiving the service
B) Mention five possible causes for the drop in the use of contraceptive in Beet El
Salam City.
C) State three recommendations to improve Continuing User Rate.

Distribution of population by age group and sex, Palestine 2017

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 Chapter 13
Health Policy and Planning
Lessons learned from Strategic Planning in Palestine
‫بسم هللا الرحمن الرحيم‬
”‫” أفمن يمشي مكبا على وجهه أهدى أمن يمشي سويا على صراط مستقيم‬
"Is then one who walks headlong, with his face groveling, better guided
or one who walks evenly on a straight way?" (El Molk: 22)

Planning Definition: Planning is an evaluation of goals and the

development of a system by which those goals can be achieved.
Planning is the process of anticipating future occurrences and problems,
exploring their probable impact, and detailing policies, goals,
objectives, and strategies to solve the problems. This often includes
preparing options documents, considering alternatives, and issuing final
plans100.

Planning Cycle: Planning is a continuous process depends mainly on

situation analysis based on scientific basis using the health indicators
described in epidemiology text. Based on these indicators the strategic
planners are setting their main priorities, goals, and objectives. These
lines are the key strategic areas for future interventions where
programs are formulated to serve the main objectives. This step is
followed by the implementation process. The real implementation
should be accompanied by a monitoring process during all the stages of
implantation. Monitoring depends on the process indicator. The final
step is to evaluate all the implanted activities and their impact on the
health status of the community. The evaluation will bring a new list of
priorities by the new situation analysis and the cycle continue as
demonstrated in figure 13.1.

100 ([Link]

232
 Figure 13.1: The Strategic Planning Cycle

Situation Analysis

Priority, goal, and

Evaluation objective setting

Implementation and
Monitoring Key strategic directions

Programming

Strategic Plan: The process of comprehensive, integrative program

planning that considers at a minimum:
• The future of current decisions,

• Overall policy,

• Organizational development, and

• Links to operational (Action) plans

Interim Action Plan (IAC):

The Interim Action Plan addresses the immediate and short -term (One
to Three years) health needs during the specified period. The Interim
Action Plan entails several aspects of what constitutes an integrated
and comprehensive health system: Human resources; health facilities
upgrading; and the expansion of the administered range of services.
Moreover, the Interim Action Plan is presented to all funding agencies
in order to divide the budgetary requirements for the implementation of
these projects among such agencies.

233
Contingency Planning: Contingency Planning means the development
of a management plan that uses alternative strategies to ensure project
success if specified risk events occur.
Needs: The term “needs” is used to describe the need for humanitarian
or development interventions to bridge the gap between identified
deficits and the envisioned future situation of a sector or country.

Figure 13.2: Population needs is the center of planning

Needs assessment: Needs assessments were first introduced by

humanitarian agencies, involving the definition of basic needs, the
identification of deficits in the fulfillment of these needs (based on
standards, and considering vulnerability, risks, and capacities), and the
assessment of required external assistance to close these deficits.
Needs assessments for recovery and developmental purposes take a
broader view of needs, including institutional, policy and infrastructure
issues. Planning should focus on population needs and not institute
needs (Figures 13.2, 13.3).

234
 Figure 13.3: Analytical Model of the Deficit Analysis 101

Importance of Needs Assessments

• Review the country needs to get the country back on track
toward sustainable development to secure financial support for
this process, as the country torn by conflict will usually not be
able to finance this from its own resources.

• In addition, in most cases, the international community has an

inherent interest in supporting the stabilization of countries
emerging from conflict.

• Therefore, while the dimension and extent of needs assessments

are subject to differing approaches, there is a clear rationale for
obtaining a comprehensive assessment of the country’s needs
before considering funding possibilities.

Outcome of Needs Assessment:

• Provides donors, national authorities, and non-governmental
organizations (NGOs) and other stakeholders, with a
comprehensive and fairly objective estimate of needs;

• High international visibility resulting in more substantial financial

pledges for recovery and reconstruction;

101Practical Guide to Multilateral Needs Assessments in Post-Conflict Situations. A Joint UNDG, UNDP and World Bank
Guide, prepared by GTZ with the support of BMZ

235
 • International consensus on the priorities of the different sector
leading to less program overlap and more coherence between
donors;

• Measurement to help overcome the country situation in the

context of recovery and reconstruction;

• Increased political momentum and support for the peace process;

• Increased legitimacy of the national authorities.

Planning in Palestine
History, Strength, and Weakness
Stages of Health Planning in Palestine:
Stage 1: Development of the National Health Plan 90 - 95
Stage 2: Development of interim action plans
94 – 95: First interim action plan
96 – 98: Second interim action plan
99 – 03: Five-year Strategic Health plan
Stage 3: Emergency plans 2001 – Ongoing
Stage 4: Initiatives for Future planning
2004 - Ongoing

The National Health Plan

Stage 1: Development of the National Health Plan (90 – 95(
Preparation for the National Health Plan 1990:
• In July 1992, the Palestinian Council of Health (PCH) was
established. PCH became responsible for the coordination of the
delivery of health services and the implementation of the National
Health Plan.

• On 13 September 1993, the Palestine Liberation Organization

(PLO) and the Israeli government signed a declaration of
principles. According to this agreement, a transfer of authority

236
 took place from the Israeli Military Government and its civil
administration to the authorized Palestinians.

• On the 17th of May 1994, Palestinians took over the responsibility

of health in the Gaza Strip.

• In December 1994, the Palestinians took over the responsibility

of health in the West Bank.

• Since then, the Palestinian health authority (MOH) immediately

embarked on a program aimed at ensuring continuity of services
and rehabilitating the systems, equipment, and infrastructure.

Within the framework of attaining "Health for All by the year 2000"; the
plan calls for the development of three major areas,
• Disease prevention;

• Health promotion; and

• Health protection

In addition to developing the national health system, public financing,

and improvement of curative services, which constitute the focus of
current health care in Palestine.

Based on recommendations by workshop participants from the

community and health care providers, specific priorities, objectives,
strategies to various fields, and levels of care were formulated. This
information on thirty priority areas of health is intended to provide the
basis for more specific action and implementation plans. The five
priorities of health care development are defined as
• Health system development and management

• Primary and basic secondary health care

• Human resource development

• Environmental health

237
 • Linkage and support of health care of Palestinians in the
Diaspora.

MOH has set up the following policies to guide the development of all different health
sectors:
1. Primary Health Care will represent the backbone of the system, with special
emphasis on education and prevention of high technology curative services. However,
in the interim period, there is a requirement for an initial capital investment in the
Secondary health sector as well.
2. Rehabilitation of the health care system without disruptions, the process of
rehabilitation must be a gradual and systematic one. The National Health Plan and the
Interim Action Plan provide the framework for all related health activities.
3. Rehabilitation of the health system has to be a joint and collaborative effort
between the Authority, NGOs, UNRWA agencies and the community. The team
approach will be adopted at all policy and service levels.
4. Quality of care will be stressed at all levels. The quality of services cannot be
overemphasized, and the increasing numbers of clinics and programs at the expense
of quality must be controlled.
5. Non- government and private sectors will be supported and strengthened. The
NGOs and the Private sector will continue to fill the most crucial gap in the sector.
Their development is important for the system as a whole. Policies will be pursued to
strengthen this sector.
6. Regulations and standards will govern the delivery of all aspects of care. Our role in
setting national policies and standards for personnel, facilities, and materials is a top
priority.
7. MOH is committed to universal health insurance through cost-effective services.
Health care is a right; a number of options for the health insurance system are
currently under study.
8. The continuation of services for the Palestinian population abroad is a priority
concern.
9. Special attention on all relevant programs should be paid to the status of women,
children, handicapped and the poor.
10. Human resources development must proceed carefully in parallel with national
programs aimed at the establishment of national standards and proficiency testing,
stressing quality and continuing education.

The Interim Action Plan

(Addressing immediate health needs for Palestinians 1996 – 1998)
Objective I: To support the National Health Authority in managing the health sector
effectively and efficiently;
Objective II: To upgrade the level of health care services;
Objective III: To formulate a detailed five- year implementation plan based on the
NHP.
Objective I: To support the National Health Authority in managing the health
sector effectively and efficiently.
Specific Objectives:
a. To assess and plan for health needs;
b. To set policies and establish standards

238
c. To monitor and evaluate service provision
d. To coordinate health services
e. To manage government health services effectively.
Activities:
1. Institutional development of the Palestinian Health Authority
2. Human Resources Development
3. Health Management Information System and Communication
4. Quality of Health care
5. Essential National Health research
Objective II
To upgrade the level of health care services
Specific Objectives:
a. To establish health care centers in defined deprived communities

b. To renovate and expand the existing health care services

c. To upgrade the health care facilities

d. To introduce new vital services.

Activities:
• To define priorities for establishment of new Health Care facilities especially in
deprived localities

• Renovation of the existing government health services buildings

• Improvement of health care services with special emphasis on P.H.C.

• Furnish and equipping the existing government health facilities according to

the immediate needs

• Establishment of central public health laboratory

• Upgrading the blood bank services

• Establishment of emergency medical services

• Support and expansion of health education activities

• Improvement of community mental health program

• Establishment of Rehabilitation center in Palestine

• Exploration of nutritional status and needs of the population by establishment

of nutrition center

239
 Five-Year Strategic Health plan (1999 – 2003
Scope of the Five-Year Plan:
• Institutional Capacity Building

• Primary Health Care

• Secondary and tertiary health services

• Support Services

• Format for each component of the plan: Brief

situation analysis, Strategy, and objectives,
Challenges of risk assumptions

Action plan (1998-2003)

What will be done at a certain time by those in a certain place using certain resources
by a certain method?
What are the monitoring mechanisms?
What are the evaluation measures?
A. Institutional Capacity Building
This part included: Management Structure and Organizational Framework, Health
Management Information System (HMIS), Health Research, Human Resources
Development & Management, Quality of Health Care, Health Finance, Health
Insurance, Health Law, Legislation, and Regulations, Technical Assistance &
International Cooperation
B. Primary Health Care
This component includes PHC National Goals, Objectives and Strategies, Family
Medicine, Women's Health and Development, Mother and Child Health (MCH), Major
Child Survival National Programs, School Health, Environmental Health, Occupational
Health and Safety, Road Safety Medical National Program, Oral and Dental Health,
Mental Health and Mental Disorders, Aging and Elderly Health,
Nutrition, Epidemiology, Health Promotion and Education and Rehabilitation

C. Secondary and tertiary health services

• Situation Analysis

• National Goals and Objectives

• Buildings and beds

240
 • Emergency Medical Services

• Support Services

a. Laboratories and Blood Banks

b. Radiology

c. Pharmaceuticals Services

d. Procurement, Storage, and Distribution

e. Maintenance

MOH Medium Term Development Plan- MTDP (2006-2008)

1- Developing the health financial system towards achieving comprehensive health
insurance and sustainability and efficiency in financing.
2. Strengthening the MOH stewardship role in the Palestinian Health Care System.
3. Assuring the availability and accessibility to health care services and giving priority
to primary health care and public health services.
4. Improving the quality of health care services.
5. Developing health human resources (HHR)

Strength and Weakness of Planning in Palestine

Strength:
• Availability of National Health Planning Documents

• Most plans are National

• Availability of records and registry

• Qualified staff to conduct the work

• International support

• National enthusiasm to plan

Weakness:
• Political unrest

• Failure to complete previous plans

• Lack of inter-sectoral coordination

241
 • Lack of Donor coordination

• Lack of Performance Monitoring Plan (PMP)

Security Vs Human Security

Security: The protection of state borders and institutions from external
threats.
Human Security: protection of the physical safety and integrity of
individuals and communities,

Performance Monitoring Plan (PMP)

Performance Monitoring Plan (PMP) is a management tool for
measuring and assessing the performance of the plan against expected
results. The PMP is designed to:
• Measure the progress and achievements of the plan components
over the life of the plan;

• Allocate resources under the plan and design activities with

maximum potential impact;

• Identify areas for improvement; and

• Communicate results with both the Authority and the Donors

PMP includes these areas:

• The expected results of the plan, and indicators designed to
measure their achievement;

• The sources of performance measurement data and methods for

data gathering;

• Assumptions about the indicators and potential constraints and

limitations to their measurement; and

• The schedule of performance reporting

242
Lessons Learned in the process of planning
• Planning is a continuous process

• Ask: Do we need a National Health Plan?

• Ask: What type of plans do we need?

• Planning should focus on population needs NOT institution needs

• Need assessment is essential for planning

• Performance Monitoring Plan (PMP) is an important component of

planning

• All the stakeholders have to work hand by hand for utilization of

the strength points mainly the use of the available documents
and data and to make sense of the data by drawing information
used for decision making

• Call for the International and National bodies to avoid all the
obstacles associated with the weak points in planning in
Palestine.

• Learn from success and failures and to remember Winston

Churchill words: "The farther back you can look, the farther
forward you are likely to see."

243
 Chapter 15
Data Management and Analysis
Data management is an essential component of scientific research.
Basic knowledge of computer and statistics is required to enable the
researcher to achieve the objectives of the study. The availability of
statistical soft packages as Statistical Package of Social Science (SPSS)
is of great help for researchers but should be used carefully. A
common mistake is to call for computer commands without following a
logical plan for data management. The plan includes:
1- Coding and Data entry

2- Data processing

3- Statistical examination

Importance of Statistics for Research:

Basic Knowledge of statistics is essential for all the research steps. It is
not statistical analysis only but the art of data management including
three major items:
1. Study design and Data collection: This includes sampling process,
study procedures and forms preparation in the best possible way.
2. Description of the characteristics of the groups using reduction
summary and presentations.
3. Data analysis: The basic procedure is to conduct cross-tabulations
between two or more of the study variables and to apply the relevant
statistical tests.
Data Analysis
First step is to revise the main study components and to look for:
1- Study title 2- Objectives 3- Method of your study
Statistical Analysis will deal with your research questions
How do you start the analysis?
Before running your computer ask these questions

244
1. Where is your data? Is data available in records, sheets or computer
diskettes? Is it a Database File (DBF)?
What is the name of the file? And where it is located?
Be sure that you are dealing with the last version of your data.
2. Data cleaning: As soon as you are sure that the data file is present,
complete and relevant to the statistical package you are using, you
have to start data cleaning. The simplest way to clean your data is the
general view by simple frequency of the data variables to check for
missed and incorrect distributions. In this stage, you start looking for
the continuous variables (as age) and to plan for recoding to groups
(age groups)
3. What are the study variables? Identify your dependent variable
(s) and the independent variable (s). Check the variables whether
continuous or discrete.
4. Generally, these are the main 3 stages in the analysis
• Descriptive analysis by frequency distribution
• Inferential analysis by Cross tabulations and examining the
relationships
• Application of the relevant statistical tests
These 3 stages are described here:
1. Descriptive Statistics
1.1 Frequency and distribution: In this stage, you can describe the
study variables and present your findings as
• Number and Percentage
• Histogram, Charts or Pie
1.2 Measures of Central Tendency and dispersion
By measuring the Mean (Average), the Median, the Mode, and
the Standard deviation, these measures are done only for
continuous variables and will be described below.
2. Cross-tabulation:
Cross tabulation is conducted for two variables or more. Usually,
it explains the relationship between dependent and independent

245
variables. Try to keep the dependent variable in columns and the
independent variables in rows. In such distribution, we advise
calculating row percentage. Other options are used when the
researcher feels it is needed. Avoid unnecessary tables, focus
more on the relationship between the dependent and independent
variables and try to construct tables to answer the study research
questions.
3. Statistical testing:
3.1 Simple and common tests:
The common tests used for statistical testing are the Chi-square
test for categorical variables and the 't' test for continuous
variables.
Example: To explore the risk factors for anemia, Hemoglobin was
coded as a continuous variable and different groups were
compared for the mean hemoglobin and the 't' test was used for
statistical significance testing. The study population was
categorized as: Anemic and non-anemic and the two categories
were compared for different groups and Chi-Square was used for
testing.
3.2 Measurement of Risk:
As mentioned before Relative Risk and Odds Ratio are used to
measure the strength of the risk. Calculation of the confidence
interval for them measures the statistical significance of the
association. Remember that relative risk is not calculated in the
case-control study.

3.3 Advanced Statistical Analysis:

Before going to advance statistical testing, you have to select

the proper statistical test based on your definition for both the
dependent and the independent variables. Table 14.1 will be a
good guide to select a suitable test:

246
 Table 15.1: Common statistical tests by variable type
Dependent Independent Statistical Analysis
Categorical Categorical Chi-Square
Continuous 2 categories “t” test
3+ categories ANOVA
Continuous Correlation, Regression
Discrete + ANCOVA
Continuous
Dichotomous Discrete Logistic Regression
(0,1)
Discrete (count) Continuous Log-linear Regression
Discrete (Rate) Continuous Log-linear Regression

In the coming pages, the author is trying to explore some of these

statistical techniques based on his own experience and simple statistical
textbook (Swinscow T.D.V., 2002) and they include:
Measures of central tendency central location and dispersion
Hypothesis testing – P-value Calculation of the Chi-square test
"t students test" Analysis of variance “ANOVA”
Correlation and regression

1. Measures of Central Tendency

Central Location and Dispersion

Table 15.2: Preferred measures of central location & dispersion

Type of distribution Central location Dispersion
Normal Mean SD
Skewed Median Inter-quartile range
Exponential or Logarithmic Geometric Mean ?

This observation set will be used to facilitate understanding of some

essential concepts in measuring central tendency
5, 3, 9, 7, 1, 3, 6, 8, 2, 6, 6
Minimum Value = 1 Maximum Value = 9
Range = Maximum Value - Minimum Value = 9 – 1 = 8
Mean (Average)
Mean (Average) = Sum of the Observation values
Number of observations

247
In the previous observation set
Sum = 56, Number of observations = 11, Mean = 5.1
Median
Median: Value that divides a distribution into two equal parts.
1. Arrange the observation by order 1,2,3,3,5,6,6,6,7,8,9.
2. Median = No. + 1 = 11+1 = 6
2 2
So, median is the 6th observations = 6
When number is even e.g. Number of observations = 10
Median = 10+1 = 5.5
2
= 5th observation + 6th observation = 5+6 = 5.5
2 2
Mode
Mode: The most frequent value.
" 6" is the most frequent value. Bimodal distribution is referred to as
the presence of two most frequent values.
Table 15.3: Weighted Mean
Village No. of Children Mean age (month)
1 54 58.6
2 52 59.5
3 49 61.2
4 48 62.5
5 48 64.5
251 61.2

(n1 X x1) + (n2 X x2) + ....

Weighted Mean = ------------------------------- ----------------
N

Geometric mean
Mean of a set of data measured on a logarithmic scale.
Logarithmic scale is used when data are not normally distributed and
follow an exponential pattern (1,2,4,8,16) or logarithmic pattern
(1/2,1/4,1/8…)
Geometric mean equals:

248
Anti-Log for average of sum log of the values
Or: Anti Log (1/n ∑ Log Xi)
So to calculate the Geometric mean (table 14.4)
1-calculate sum of the logarithm of each value
2-calculate average by dividing the sum of Log values by number of
these values
3-calculating of the anti-log will give the geometric mean

Table 15.4: Example for the calculation of the geometric mean

Sample Dilution Title
1 1:4 4
2 1:256 256
3 1:2 2
4 1:16 16
5 1:64 64
6 1:32 32
7 1:512 512

Calculate the geometric mean:

1. Sum of Log (4, 256, 2, 16, 64, 32, 512) =10.536
2. Average = 10.536 / 7 = 1.505
3. Anti-Log average =32
Accordingly, geometric mean =32
The geometric mean is important in the statistical analysis of data
following the previously described distribution such as sero-survey
where titer is calculated for different samples.

Stem and leaf

We describe three items
First – Drawing stem and leaf
Second – Five number summary
Third – Box and whisker plots
Application of the three items will be on this theoretical example:
The recorded systolic blood pressure for 13 patients was as follows:
136, 140, 142, 162, 124, 130, 130, 156, 136, 144, 128, 122,132

249
 First – Drawing stem and leaf
1. Look for the Minimum value (122) and the maximum value (162).
2. Arrange the values by order between Minimum and Maximum
values.
122, 124, 128, 130, 130, 132, 136, 136, 140, 142, 144,
156, 162
3. The stem will be 12, 13, 14, 15, 16
4. Distribute the leaves as follow:
Stem Leaves
16 2
15 6
14 024
13 00266
12 248
Second – Five number summary
Calculate Range = Maximum – Minimum = 162 – 122 = 40
Calculate Median = (n + 1) / 2 = (13 + 1) / 2 = 7th value = 136
Calculate Q1(lower hinge) = (n + 1) / 4 = (13 + 1) / 4 = 3.5
= (128 + 130) /2 = 129
Calculate Q3 (upper hinge) = 3(n + 1) / 4 = (3 X 14) / 4 = 10.5
= (142 + 144) /2) = 143
Calculate inter quartile interval = Q3 – Q1 = 143 – 129 = 14

Median

Qs. Q1 Q3 Inter quartile

interval

Min Max Range

136
129 143 14

122 162 40

Third – Box and whisker plots

(Figure 15.1)
Fence = 1 step outside quartile
Calculate step = 1.5 X quartile interval = 1.5 X 14 = 21
Upper fence = 143 + 21 = 164 Lower fence = 129 – 21 = 108

250
 170

160

150

140

130

120

110

N.B. Any value more than 164 OR less than 108 are considered
extreme values (outside values).
Practical Exercise
Child hemoglobin was examined for 881 children. SPSS was used to explore this
variable. The output print is attached (Abed, 1992).
Descriptive for child hemoglobin (881 cases)
Hemoglobin Stem-and-Leaf Plot
(Figure 15.2)
Frequency Stem & Leaf
1.00 Extremes (=<5.5)
7.00 6.
32.00 7. 0235568
93.00 8. 0000001223345556678
100.00 9. 0000233445555566788
176.00 10. 0000000122333455555555566677788888
154.00 11. 00000022222233344444555567788
175.00 12. 0000000000001222223455555666667888
86.00 13. 0000001223456888
35.00 14. 000245&
20.00 15. 000
1.00 16.
1.00 Extremes (>=16.5)
Stem width: 1.0, Each leaf: 5 case(s) & denotes fractional leaves
Figure 15.3: Box and whisker plots for Hemoglobin
18

351
16

14

12

10

6
132

4
N= 251 881

F1
2. Hypothesis testing – P-value –
Normal distribution and Sampling
Normal Distribution: The normal distribution is the most used
statistical distribution. The principal reasons are:
• Normality arises naturally in many physical, biological, and social
measurement situations.

• Normality is important in statistical inference

Normal Distribution is bell shape with symmetrical distribution and

centered at the mean with dispersion around measured by SD.
Figure 15.4: Normal Distribution

The normal distribution is characterized by two parameters: the mean

(µ) and the standard deviation sigma. The mean is a measure of
location or center and the standard deviation is a measure of scale or
spread. The mean can be any value between ± infinity and the
standard deviation must be positive. Each possible value of µ and
sigma define a specific normal distribution and collect all possible
normal distributions that define the normal family.
Standard Normal Distribution
The standard normal distribution is a special member of the normal
family that has a mean of 0 and a standard deviation of 1. The
standard normal random variable is denoted by Z. The standard
normal distribution is important since the probabilities and quantiles of

252
 any normal distribution can be computed from the standard normal
distribution—if µ and sigma are known.
Standard Error (SE): It is a measure of the extent to which the
sample means to deviate from the true population mean. The smaller
it is closer to the true population mean. When the sample size is larger
the SE is smaller. SE is calculated from the formula:

SE = SD
√n
Confidence interval
What is the meaning of a 95% confidence interval?
This interval represents an interval of parameter values consistent with
the data. Of all intervals constructed as this one, 95% would contain
the true value of the population parameter.
Confidence interval = Estimate of parameter + (Reliability coefficient X S.E)
The reliability coefficient equal to 1.96 and often written as 2.
Attached below a cut of an output of a statistical analysis conducted by
SPSS for exploration of the age in one of the studies, the mean age is
estimated as 38.06 years. 95% confidence interval = 38.06 + (1.96 X
0.98). The result as shown in the table below, that confidence interval
ranges between (36.12 – 40.01)
Statistic SE
Mean 38.06 .98
95% Confidence Interval for Mean
Lower Bound 36.12
Upper Bound 40.01
Median 35.00
Variance 164.818
Std. Deviation 12.84
Hypothesis testing:
The null hypothesis proposes that there is no difference. It is the basis
for statistical testing. The null hypothesis is accepted if no difference is
found. If there is a difference the null hypothesis is rejected and the
alternative hypothesis is accepted.
Test of Significance
Hypothesis: A statement of belief used in the evaluation of population
values.
Null Hypothesis: A claim that there is no difference between the
hypothesized values.

253
Alternative Hypothesis: A claim that disagrees with the null
hypothesis. If the null hypothesis is rejected, we accept the alternative
hypothesis
Test Statistics: A statistic used to determine the relative position of
the hypothesized value from the mean of its distribution
Critical Region: The region on the far end of the distribution. When
the computed test statistic falls in the critical region we reject the null
hypothesis because sometimes they call it the rejection region.
Significant Level: The level that corresponds to the area in the critical
region. This area is usually small. When a test statistic falls in this area
the result is referred to as significant at  level
P-value: The area in the tail of the distribution beyond the value of the
test statistic. If P-value   we reject the null hypothesis. If P-value >
, we can't reject the null hypothesis.
In General Test of Significant: A procedure used to establish the
validity of a claim by determining whether or not the test statistic falls
in the critical region. If it does, the results are referred to as significant.
This test is sometimes called the hypothesis test.
By a statistical test of significance, one attempts to determine whether
a certain claim is valid. The claim is usually stated as a null hypothesis.
Using the data obtained in the sample one compute a test statistic and
uses it to determine whether supports the null hypothesis claim. The
basis for finding out whether the test statistic supports the null
hypothesis is the critical region. The critical region sets guidelines for
rejecting or failing to reject the null hypothesis.
Meaning of “Statistically Significant”:
Research reports often state that the results were statistically
significant (P-value< 0.05) or make some similar statements. Such a
comment means that the observed difference is too large to be
explained by chance alone. The significant level somewhat arbitrarily
selected at such values of s 0.05, 0.025, 0.01, or 0.001 is a measure
of how significant a result is.

254
The significant level  also the magnitude of error that one is willing to
take in deciding to reject the null hypothesis.
Statistically significant means that the evidence obtained from the
sample is not compatible with the null hypothesis.
3. Calculation of Chi sq test
1. Construct your table. The presented numbers are the observed
values
Table 15.5: Parasites
Anemia Positive Negative Total
Yes 40* 10 50
No 20 30 50
Total 60 40 100
Calculate the Expected values according to the formula:
Total Raw X Total Column
Expected value = ---------------------------------------
Ground Total
The value signed up (*) is calculated as follow:
Row total X Column Total 50 x 60
---------------------------- = --------- = 30
Ground Total 100
Other values can be calculated in the same way or by simple
subtraction. The expected values are presented:
Table 15.6: Parasites
Anemia Positive Negative Total
Yes 30 20 50
No 30 20 50
Total 60 40 100
Chi - square test answer the question: whether the proportions of
observed values differ significantly from expected values by
chance. It is calculated as follow:
X2 =  (O - E)2
E
O = Observed E = Expected
In the above-mentioned example:
(40-30)2 (10-20)2 (20-30)2 (30-20)2
X2 = ----------- + ------------ + ---------- + ------ = 16.67
30 20 30 20

255
Calculate degree of freedom (df) by this formula:
DF = (number of rows – 1) x (number of columns – 1)
In the above-mentioned example: df= (2-1) x (2-1) =1
By using chi-square distribution table, we can get P value. In the
above-mentioned example: p value is less than 0.001

Table 15.7: Chi square Distribution table

Dr. Yehia Abed

4. "t students test"

The t-test assesses whether the means of two groups are statistically
different from each other. This analysis is appropriate whenever you
want to compare the means of two groups.

Figure 15.5: t-test

Now to conduct the "t" test for two groups: (Treatment group = T and
Control group C), we can first calculate SE for the difference as seen
below

The same
Formula

Note: Var = Variance = (SD)2

256
Now to calculate t Value:
Difference between group means
t- Value =
Variability of groups

The same XT − XC
Formula =
SE ( X T − X C )

Degree of Freedom (DF): DF = (N1 – 1) + (N2 – 1)

Example:
We have 2 groups of treatment
Treatment A Treatment B
n 15 12
mean 68.4 83.42
SD 16.47 17.63

In this example and based on the formula t value was 2.282

DF = N1 + N2 – 2 = 15 + 12 = 25
We check for t value in the t distribution table under DF = 25
The value of 2.282 lies between P-value 0.02 and 0.05
As shown in table 13.8 this value indicates that the differences between
the 2 mains are statistically significant (P value less than 0.05).

257
 Table 15.8: t Distribution

Distribution of t (two tailed)

Probability
d.f. 0.5 0.1 0.05 0.02 0.01 0.00l

1 l.000 6.314 12.706 3l.821 63.657 636.6l9

2 0.816 2.920 4.303 6.965 9.925 31.598
3 0.765 2.353 3.182 4.541 5.841 12.941
4 0.741 2.132 2.776 3.747 4.604 8.610
5 0.727 2.015 2.571 3.365 4.032 6.859
25 0.684 1.708 2.060 2.485 2.787 3.725

The conclusion will be:

• The mean of the treatment group (Group B) is higher than the
mean of the control group (Group A)

• The difference between the two means reached a statistically

significant level (P value less than 0.05)

Applications of t-test
One sample “t” test: In this case, we compare 2 means, one in the
study e.g. mean hemoglobin of the children with external mean e.g.
11gm as defined by WHO.
Two independent samples “t” test: This is the most commonly used
and it compares the mean of 2 groups in the study. For example, we
compare the mean hemoglobin for males and females.
Paired “t” test: This is used when we have 2 reading for the same
variables as pre and post-test, or comparing pulse before and after
treatment.

258
 5. ANOVA
One Way Analysis of Variance
Statistical analysis used to compare several groups for a particular
measure. It is one way where it deals with the relationship between
one particular measure (Dependent variable) and one factor
(independent variable). The factor here forms from two groups or
more.
Why not the t-test? If we compare the main score of satisfaction
among people living in 4 villages A, B, C, and D, we can use "t" test to
compare between 2 means, this necessitates doing these tests: AB, AC,
AD, BC, BD, and CD, this means that t-test is required to be repeated 6
times to decide where is the difference? ANOVA does it in one step.
ANOVA answers the statistical question of whether the group means
differ from each other.
Data for ANOVA:
Dependent variable = Continuous
Independent variable = Discrete = Factors (strata, groups, or classes)
Variance and Degree of freedom
Variance = Sum of Squares
Total variance (df = number of subjects – 1)
Variance within groups (df = number of subjects – number of groups)
Variance between groups (df = number of groups – 1)

Variance between groups

F Ratio = ----------------------------
Variance within groups

Multiple group comparisons (Post-Hoc tests)

A significant F test does not mean that every group in the analysis is
different from every other group. Many scenarios for these differences
could be present and similarities between some are possible.
Scheffe test is used to measure the statistically significant differences
between different group means.

259
 6. Correlation and regression
Correlation
• Correlation is defined as the strength and direction of the
relationship between two variables.

• The strength and direction are measured by correlation

coefficient (r) with value ranges between (+1 and –1). The
value measures the strength and the sign indicates the
direction.

• Positive sign indicates positive correlation and negative sign

indicates negative correlation.

• If there is no relationship between the two variables coefficient

will be zero.

• The correlated variables could be presented by a scatter-

grams (Bivariate distribution).

• P-value will indicate whether a correlation is statistically

significant.

• The coefficient of determination expresses the proportion of

variance in one variable that can be explained by the variance
in the second variable.

• It is measured by squaring (r) and equal to (r2).

Regression
Regression makes use of the correlation between two variables to
explore the relationship between them. The dependent variable (Y) can
be predicted from the independent variable (X). The relationship
between (Y) and (X) should be linear. Simple linear regression explains
the relationship between two variables. Multiple regression is used

260
 when there is a correlation between a group of independent variables
(X1, X2, X3,) and the dependent variable (Y).
Regression line: This is a straight line of the relationship between two
variables. It is called “line of best fit” to the scatter-gram of the two
variables.
Regression Equation: It is the equation that describes the
relationship between the dependent variable (Y) and the independent
variable (X).
Y = a + bx
The value of (y) when (x) is zero is called the intercept and presented
by the symbol (a) or sometimes with the symbol (b0). Change in (y)
value per each unit in (x) value is called slope and presented as (b).
Confidence interval for (b) measures the statistical significant of this
value. It is calculated as follow:
C.I. = b + 2SE.
If one is included within the interval the value is not statistically
significant.
Multiple Regression
Multiple regression is used when there is a multiple correlation between
the dependent variable (Y) and more than one independent variable
(X1, X2, X3).
Multiple Regression Equation:
Y = a + b1 X1 + b2 X2 + b3 X3 + …….
Uses of Regression Analysis in Epidemiology
1. Determination of effect of independent variables (X1, X2,
X3,…. ) on the dependent variable (Y). If your dependent variable
is hypertension, you can examine the effect of smoking, obesity,
fat intake and cholesterol level on hypertension.

2. Prediction: You can predict the value (Y) when the (Xs) values are
given. For example: Using the equation:

261
 Y = 2+ 0.5 (X1) + 0.2 (X2) + 0.4 (X3)
If (X1) = 12, (X2) = 3 and (X3) = 5 then:
Y = 2 + (0.5) (12) + (0.2) (3) + (0.4) (5) = 10.6
3. Control for confounder: If an association between the dependent
variable and an independent variable is due to presence of a third
variable, this effect could be detected by regression analysis.
4. Measurement of interaction between independent variables.

Logistic Regression
Logistic Regression is used to determine which independent variables (Xs)
affect the probability of an outcome of the dependent variable. The
dependent variable should be dichotomous.
Logistic Regression Equation:
Y = a + b1 X1 + b2 X2 + b3 X3 + …….

P
Y = Log ---------- = Log OR
1–P
Odds Ratio = ey
The value (b) = Change in log odds of event per unit change in X.
The value (eb) = Odds Ratio when X changes one unit.

262
 Chapter 16
Health Services Evaluation
Definitions and Concepts:
Evaluation: Evaluation is a systematic way of learning from experience
and using the lessons learned to improve current activities and promote
better planning by careful selection of alternatives for future action.
This involves an analysis of different phases of a program: its
relevance, its formulation, its efficiency, effectiveness, and its
acceptance by all parties involved. In simple words, evaluation is the
measurement of desirable and undesirable effects of specified
intervention.
Other uses of evaluation: • To inform funders of the program whether
their contributions are being used effectively
• To inform community members and stakeholders of the project’s
value
• To provide information that can be useful in the design or
improvement of similar projects

Health System: all the activities whose primary purpose is to

promote, restore or maintain health.
What do we mean by the system?
A system is anything that consists of parts working together. The parts
(which may be machines, people, buildings, money, etc) are connected
to some central objective. The manger is concerned with ensuring that
the parts fit together well so that the objective of the whole is achieved
with the greatest possible efficiency and effectiveness “Program” and
“Project”:
Program is an organized aggregate of services, activities and
development projects directed towards the attainment of defined
objectives – for example, programs for maternal and child health, the
promotion of mental health, or cancer control

263
PROJECT is a set of related activities – a part of a plan – which is
performed during a fixed period. Usually, a project is only done once
and en finished, rather than being continuous or repetitive. One single
program could include more than one project.
Example: There is a Maternal and Child Health (MCH) program in
health NGO, this year the organization succeeded to have a project to
support the nutritional activities inside the program. By the end of the
project, the program will continue getting the benefit of the project
contribution.

Health System framework:

It is essential to understand the structure of the health system before
starting the process of evaluation. Below in Figure 15.1, a
demonstration of the six building blocks of the health system

Figure 15.1: The WHO Health Systems Framework102

102 [Link]

264
Evaluation Models:
Structure – Process - Outcome
Model 1: Donabedian Model

Process
Process
Structure
Structure
Structure Out Come
Out Come
Structure Out Come

Model 2:

Input Output
Output
Health Care System

Model 3:
Health Care System

Structure Process
Outcome
(input)
(output)

To help prioritize activities and guide resource allocation

Inputs: The resources (such as money, buildings, equipment, staff,
time) which are used by a system (or subsystem) to produce outputs
Outputs: The product of the system (or subsystem), such as improved
health of the population or lower mortality, Effectiveness is measured in
terms of outputs. However, real outputs are often difficult to measure
and we usually have to rely on "intermediate outputs" describing the

265
level of services, for example, the number of people vaccinated or the
number of visits to health centers.
Effectiveness: Effectiveness is an expression of the desired effect of a
program, service or institution in reducing a health problem or
improving an unsatisfactory health situation. Thus, effectiveness
measures the degree of attainment of the predetermined objectives
and targets of the program, service or institution.
Efficiency: Efficiency is an expression of the relationships between the
results obtained from health program or activity and the efforts
expended in terms of human, financial and other resources, health
processes and technologies, and time.
There are two types of Efficiency: Allocative and Technical Efficiency
Allocative Efficiency: We consider the allocation of resources among
interventions, as well as how markets allocate resources through trade,
production or consumption. Allocative efficiency requires that resources
are allocated to the activities in which they have the highest value,
concerns with choosing the most cost-effective set of programs or
interventions for the given level of expenditure.
Technical Efficiency: This relates to how resources are being used to
deliver a specific program or intervention. Ideally, limited resources
would be used fully so that it would not be possible to provide
additional products or services without additional input resources being
used. Technical efficiency means that there are still potential gains to
be had by re-organizing the use of existing levels of resources. Cost
analysis is one of the key tools that is used to reflect on efficiency
within an intervention. Allocative and technical efficiency put together
to give the concept of economic efficiency or simply efficiency.
What is the difference between Surveillance & Monitoring vs. Evaluation?
• Surveillance - tracks disease or risk behaviors

• Monitoring - tracks changes in program outcomes over time

• Evaluation - seeks to understand specifically why these changes

occur

266
 What Can be Evaluated?103
• Direct service interventions • Laboratory diagnostics

• Community mobilization efforts • Communication campaigns

• Research initiatives • Infrastructure-building projects

• Surveillance systems • Training and educational

services
• Policy development activities
• Administrative systems
• Outbreak investigations

Who will conduct the evaluation?104

External Evaluation: Evaluations of programs, cross-cutting issues,
instruments and projects commissioned and managed by an external
consultant, usually from the donor site.
Internal Evaluation: Evaluations commissioned, managed and/or
implemented by project partners themselves (with or without external
experts).
Types of Evaluation
The two major types of evaluation are formative and summative
evaluation. Formative Evaluation is providing information for program
improvement and Summative Evaluation is providing information to
serve decisions or assist in making a judgment about program
adaptation, continuity or expansion. Below are different types under
the two major types, formative and summative evaluation.
Formative Evaluation Summative Evaluation
• Needs Assessment Outcome Evaluations
• Evaluability Assessment Impact Evaluation
• Structured Cost-Effectiveness and Cost-
Conceptualization Benefit Analysis
• Implementation Evaluation Secondary Analysis
• Process Evaluation Meta-Analysis

103 MMWR, 1999 Framework for Program Evaluation in Public Health

104 [Link]

267
The table down explore the main differences between formative and
summative evaluation

Differences between Formative and Summative Evaluation

Formative Summative

Use Improve program Decisions for the program

Audience Managers & Staff Policy makers – Consumers

By whom Internal + External External + Internal

Characteristics Feedback to improve Information to continue –

adapt
Constraints Needed- information Standard - Criteria

Purpose Diagnostic Judgmental

Frequency Frequent Infrequent

Sample size Small Large

Questions Working - improving Result – Cost

One major difference between

formative and summative
evolution is the time factor,
where we start formative
evaluation early in the program,
while summative is more
prominent by the end of the
program

Now we are going to give a brief about some of the most common
evaluation types.
Formative Evaluation: Formative evaluation is indicated When new
programs, new interventions, new procedures, or new elements of
existing programs are proposed. Formative evaluations in the pre-
implementation and design phase of a project emphasize needs
assessment, and their data gathering may involve extensive community

268
analysis or community identification procedures in addition to inquiry
into a program setting and existing clientele. Formative evaluations are
designed to help identify needs or gaps in service, which the new
program should address or answer other questions that need to be
answered.
Needs Assessment: Used in program planning to plan for decisions
about program implementation. It is a process by which information is
collected from the target population or community to match the needs
and wants of the target audience, the program organization, and the
community.
Evaluability Assessment: When the evaluation of existing programs
is desired, an evaluability assessment should be conducted. An
evaluability assessment will determine to what extent evaluation is
possible.
In conducting an evaluability assessment, the evaluator must be able
to:
• Clarify program goals and objectives,

• Determine the extent to which the goals and objectives can be

achieved,

• What data are available or could be collected to assess program

activities,

• Determine the program performance measures and if they can be

gathered at a reasonable cost, and

• Explain how the results will be used

Process Evaluation: As programs develop, there is a need to assess

how well the implementation of the program is going and, if needed, to
make corrections. In these stages, many evaluation questions could be
asked, all having to do with program monitoring and evaluation
activities related to this problem. Answering these questions involves
process evaluation. Process evaluations include:

269
 • Documenting actual program functioning

• Measuring exposure to and diffusion of the interventions

• Identifying barriers to implementation

Process evaluation includes the identification of the target population, a

description of the services delivered, the use of resources, and the
qualifications and experiences of the personnel participating in them.
It involves determining what services were delivered, to whom, and
with what level of resources.
Outcome Evaluation
Outcome evaluation is concerned with the result of the program affect
the population's health. When process evaluation shows that the
program was implemented properly, there is often interest in
measuring the effectiveness of the actual program. Criteria for using
outcomes for evaluation include:
• Being objective, in that outcomes can be observed;

• Being measurable in ways that are reliable and valid;

• Being attributable to the intervention delivered; and

• Being sensitive to the degree of change expected by the

intervention. The outcome is a change in morbidity or mortality.

Economic Evaluation
Economic evaluation considers both the outcomes of a program and the
cost of producing those outcomes. In some cases, the most effective
program may also have the lowest cost, but it is not necessarily true
that the lowest-cost option is the most cost-effective. It is also possible
that the program that produces the most units of a given outcome may
be impractical to implement because it is so costly that it diverts too
many resources from other users, or requires more resources than are
available.

270
This process involves measuring or estimating the value of facilities,
equipment, personnel, and other resources used. Sometimes patient
time commitments and travel costs are relevant.
Types of Economic Evaluation
Cost Analysis
The simplest form of economic evaluation is a cost analysis. Because it
considers only the costs. To conduct a cost analysis the costs of a
program must be determined. Once costs are determined, there are
three common methods used for comparing the costs and
consequences of different interventions: cost-effectiveness, cost-utility,
and cost-benefit analysis.
Cost-Effectiveness Analysis (CEA)
CEA divides the net cost of a program by the outcomes produced by the
program. The outcomes chosen are generally the health effects
targeted by the program, such as cases of disease prevented or lives
saved. The result will be expressed as the net cost per unit of outcome.
Cost-Utility Analysis (CUA)
CUA is similar to CEA, except that the program outcomes are measured
in common terms across interventions, most commonly quality-
adjusted life years (QALY). With this approach, interventions that
produce different outcomes can be compared -- the different outcomes
are translated into QALYs; it is then theoretically possible to determine
the most efficient use of resources to produce the maximum amount of
health.
Cost-Benefit Analysis (CBA)
CBA is also similar to CEA, except that it places a monetary value on
the outcomes of programs. In theory, this is the broadest form of
analysis because it can be determined whether the benefits of a
program justify its costs. However, in practice, it is also limited to a
comparison of those specific costs and benefits.

271
 Types and uses of evaluation

Types of
Evaluations When to use What it shows Why it is useful

Formative • During the • Whether the proposed • It allows

Evaluation: development of a program elements are likely modifications to be
Evaluability new program. to be needed, understood, made to the plan
Assessment • When an existing and accepted by the before full
Needs program is being population you want to implementation
Assessment modified or is reach. begins.
being used in a • The extent to which an • Maximizes the
new setting or with evaluation is possible based likelihood that the
a new population. on the goals and objectives. program will
succeed.

Process • As soon as • How well the program is • It provides an

Evaluation program working. early warning for
Program implementation • The extent to which the any problems that
Monitoring begins. program is implemented as may occur.
• During the designed. • Allows programs
operation of an • Whether the program is to monitor how well
existing program. accessible and acceptable to their program plans
its target population. and activities are
working.

Outcome • After the • The degree to which the • Tells whether the
Evaluation program has made program is affecting the program is being
Objectives-Based contact with at target population's behaviors. effective in meeting
Evaluation least one person or its objectives.
group in the target
population.

272
Economic • At the beginning • What resources are being • Provides program
Evaluation: of a program. used in a program and their managers and
Cost Analysis, • During the costs (direct and indirect) funders a way to
Cost- operation of an compared to outcomes? assess cost relative
Effectiveness existing program. to effects. "How
Evaluation, Cost- much bang for your
Benefit Analysis, buck."
Cost-Utility
Analysis

Impact • During the • The degree to which the • Provides evidence

Evaluation operation of an program meets its ultimate for use in policy and
existing program goal on the overall rate of funding decisions.
at appropriate STD transmission (how much
intervals. has program X decreased the
• At the end of a morbidity of an STD beyond
program. the study population).

Indicator selection: The indicator selection is on the goals of the

program or intervention and may include input, process, outputs,
outcome and impact indicators as indicated and needed.
Input indicators: (Examples: Number of health staff involved in the
activities and number of bottles of medications distributed)
Process Indicators- measure whether the planned program activities
are being carried out (Example: Number of training sessions and
workshops held for staff of health facilities; and number of patient visits
completed)
Output Indicators Capture domains, such as knowledge & skills,
emotional well-being or social well-being, training & supervision and
procurement/medication supply (example: Number of beneficiaries
participating in psychosocial activities)
Outcome indicators seek to measure changes from intervention and
may include behaviors, knowledge and skills, attitudes or relationship
dynamics; they seek to measure what is different as a result of the
program, such as improvement in functioning, perceived

273
value/usefulness, skills learned, perceived competency. These may
need baseline values to show an outcome, such as pre or post-training
test, indicators measures in a KAP survey (example: Number of trained
staff with 80% minimum PFA knowledge and perceived competence; %
of trainees with improved knowledge)
Impact indicators measure the lasting change in people's lives or the
environment as a result of an intervention, such as improved
livelihoods, return to work and school, increased functioning, improved
health status of the population (example: improved functioning,
increased well-being/ability to cope)

The basic questions of evaluative studies

1. Requisiteness: To what extent is the care needed?
2. Quality: a. How satisfactory is the outcome? Attainment of desirable
effects (Effectiveness)? Absence of undesirable effects (harmlessness)?
b. How satisfactory is the performance of activities by the providers of
care?
c. How satisfactory is the compliance and the utilization of services by
the recipients of care?
d. How satisfactory are facilities and settings?
3. Efficiency: How efficiently are resources used?
4. Satisfaction: How satisfied are the people concerned?
5. Differential value: How do the above features differ in different
categories or groups in different circumstances?

Evaluation Research
A. Quantitative Research: This could be by on of the previously
discussed methods (Chapter 4): observation, Clinical
examination, laboratory testing, visual observation, interview
and self-administer questionnaire or documents as registry,
records or certificates. Quantitative Research could be used in
the evaluation, one example is the Study of the benefits of

274
 screening where prospective and retrospective approaches
could be used as seen below
1. Design of a non- randomized comparison (prospective studies

Screened Not Screened

Die from Do Not Die from Do Not

the die from the Die from
Disease the Disease Disease the Disease

2. Design of a case-control for evaluation

Screened in Never Screened Never

Past Screened in the Screened
Past

complication Disease without

from disease Complications

Randomized Trials
The evaluation design that is considered to produce the strongest
evidence that a program intervention or activity contributed to change
is the randomized control trial (RCT). The rationale for this design is
well established. In brief, the essence of a randomized trial lies in the
random assignment of subjects to be exposed to the intervention or to
be a control (not exposed to the intervention). By using the rule of
chance, intervention and control groups are, on average, comparable
before exposure. Because of this initial equivalence, if outcome
differences between those who do and do not receive the intervention
are statistically detected, they are highly likely to be due to the
operation or processes of the intervention.
Quasi-experiments: Although randomized trials provide the strongest
evidence about a program's effectiveness, they may not be feasible to

275
implement. RCTs are costly, time-consuming, can be subject to
methodological flaws, and may not be considered ethical to conduct if
withholding an intervention from one group may adversely affect
opportunities for improved health status. Thus, evaluators turn to the
analysis of quasi-experiments, defined generally as any research design
that does not utilize random assignment to deliberately construct an
initial equivalence between groups. Quasi-experimental designs use a
control group that is separate from the experimental group and not
randomized. When randomized trials are not possible and quasi-
experiments are substituted in their place, specific design features
usually have to be instituted to rule out or eliminate each alternate
explanation to the hypothesis of treatment effects.

Clinical Audit

What is the clinical audit?

"Clinical audit is a quality improvement cycle that involves

measurement of the effectiveness of healthcare against agreed and
proven standards for high quality, and taking action to bring practice in
line with these standards to improve the quality of care and health
outcomes."105

Clinical audit is a way to find out if health or social care is being

provided in line with standards. Clinical audit lets care providers and
patients know where their service is doing well, and where there could
be improvements. The aim is to allow quality improvement to take
place where it will be most helpful and will improve patient outcomes.

Clinical audits can look at care provided all over the country and called
National Clinical Audits (NCA). They can also be done locally in a trust,
hospital, GP practice or care home, anywhere health or social care is
provided.

105 New Principles of Best Practice in Clinical Audit (HQIP, January 2011)

276
Outcome: By following the improvement cycle, any clinician or team
should be able to see where their practice can be improved against
given benchmarks, to take action, and then to re-measure and make
further improvements.

What is the national audit? Usually, such programs collect a large

volume of data about local service delivery and achievement of
compliance with standards, and about the attainment of outcomes.
Each project is commissioned from a suitable professional or academic
group appointed based on their skills and expertise, and these are
closely monitored and supported.

Question 1. Is the purpose of your project to improve the quality of

patient care in your local setting?
Question 2. Will the project involve a comparison of practice against
standards?
Question 3. When performing your project, does it involve changes to
treatment/services?
Stages and Who should be involved in clinical audit?

As seen in the figure below clinical audit is passing 5 stages starting

by problem identification and ended by implementing changes.
Clinical audit matters to everyone involved in health and social care,
including:

• patients and service

users, careers and
relatives

• clinicians at every level,

in every profession and
discipline

• nurses

• regulatory bodies

• commissioners

• National Health Services

• the managers of health

and social care
providers

277
In real practice, the major question will be: Is there a difference
between a clinical audit and Research? Although there is a great
similarity some confusion happens between:
1. Clinical audit and patient outcomes monitoring
2. Clinical audit and a patient outcome program
3. Clinical Audit and Registries
4. Clinical Audit and Patient satisfaction surveys
5. Clinical audit and research
Shortly, we will state the major differences between clinical audit and
each of the above-mentioned items.
Clinical audit and patient outcomes monitoring
Clinical audit and patient outcomes monitoring are two closely related
activities that seek to improve patients' experiences and health
outcomes through the systematic review of healthcare delivery. They
aim to ensure that all patients receive the most effective, up-to-date
and appropriate treatment, delivered by clinicians with the right skills
and experience.

The three broad questions that clinical audit and outcomes monitoring
seek to answer can be summarized as:
1. Are patients given the best care? Are they better? Do they feel
better?
Clinical audit and a patient outcome program

Sometimes agreed good practice criteria do not exist, perhaps because

it is difficult ethically to conduct properly controlled scientific trials for a
particular aspect of patient care. In some areas of healthcare - often
concerning complex surgery - it is more direct and important to
measure outcomes following treatment. In these circumstances,
recording the results for individual patients (their outcomes) can
supplement or replace an audit of what has been done to them.

278
Clinical Audit and Registries

Registries do not usually measure performance against standards, nor

do they necessarily drive improvements explicitly. Registries detail care
provided for their client groups, the incidence and outcome of specific
conditions and procedures, and organizational responses and
treatments provided for specific conditions. They often gather
information on clinical outcomes of patients and form sources for audit
and research into the causes of variance in outcomes and other
research projects.

Clinical Audit and Patient satisfaction surveys

Patient satisfaction surveys ask patients about the treatment they have
received. Some forms of patient surveys are outcome measures, such
as PROMS (patient-reported outcome measures). Whilst these are
related to audit, are not audit in themselves. They are however vital for
assessing service quality and an excellent addition to audit.

It can be difficult to separate clinical audit and patient satisfaction

surveys, because some clinical audits involve patient surveys to help
them find out how well care is provided. Asking patients about the
treatment they have received is a vital part of the audit, as it can be
used to assess the degree to which care was offered against standards.

Difference between clinical audit and research

“Research is concerned with discovering the right thing to do

Audit is ensuring it is done right”106

1. Clinical audit tells us whether we are doing what we should be

doing and how well we are doing it. Clinical audit is about quality
and finding out if best practice is being practiced.
2. Research is about obtaining new knowledge and finding out what
treatments are the most effective. Research tells us what we
should be doing.

106 Smith, R. 1992, Audit & Research, BMJ, 305:905-6

279
 3. The National Research Ethics Service makes a clear distinction
between clinical audit and research and states that, unlike
research, clinical audit does not need approval from a research
ethics committee.
Difference Between Research and clinical audit107

Research Clinical Audit

Creates new knowledge regarding Creates knowledge of current

the most beneficial practice clinical practice and the need for
improvement
Based on an idea (hypothesis) or Based on the comparison of
explores themes practice against standards
Usually large scale over a long Usually small scale over a short
time time
May involve patients receiving a Never involves patients receiving
completely new treatment new treatment
May involve patients being given Does not affect normal treatment
different treatments of patients
Needs a statistically valid sample Does not necessarily need a
size statistically valid sample size
Extensive statistical analysis is Basic statistical analysis usually
required suffices
Results may be generalizable to a Results are usually only relevant to
wider population the area evaluated
No built-in mechanism to act on Clear responsibility to act on
findings findings through the development
of an action plan
Findings can have a wide Findings usually only influence
influence on clinical practice practice within the area evaluated

Always requires ethics committee It does not usually require ethical

approval approval.

107
COREC (2005), Differentiating Audit, Service Evaluation, and Research
[Link]/recs/guidance/[Link]

280
 Qualitative Research Analysis
Qualitative research: different approaches are used a Participatory
Rapid Appraisal (PRA), Focus groups, In-depth interviews, And SWOT
Analysis.
Qualitative Analysis: “Identify themes and topics by process of
categorization and indexing, and develop theoretical constructs and
logic from data.”
1. Manual Analysis
2. Software Analysis
3. Cut and Paste
1. Manual Analysis
1. Read the interviews carefully.
2. Group the interviews into major categories. For example, "Clinic
and Home" are referred to as the place of interview.
3. Make further categories in each of the major categories. For
example: "Rimal, Jabalia V. and Jabalia camp are referred to
localities
4. Choose the main study themes. For example, in a study for
evaluation of MCH services and utilization, these themes were
chosen: "Choice of services, quality of care, favoritism, drug
supply, issues of facilities and equipment.”
5. Group the responses and quotes.
6. Analysis write-up.
7. Summarize conclusions.
2. Software Analysis
Computer software programs: Textbase Alpha, Anthropac, ZyIndex,
Ethnography 3.0 and Q.S.R. [Link].
1. Read the data.
2. Format the data to make it software-friendly.
3. Indexing - creating a tree with nodes and branches. For example,
Node "1" is named "setting" with two branches of clinic and home. Each
branch has three localities: Rimal, Jabalia village, and Jabalia camp,

281
 Node "3" is the choice of services and so on. Each branch could contain
more than one theme.
4. Analyze the data by looking to different themes under one or more
of the nodes or branches.
5. Analysis write-up.
6. Summarize conclusions.
SWOT Analysis
Analysis of the environment in which the change could happen.
It includes these components:
1. Strength: Points that support the changes. This reflects the
benefits of the project.

2. Weakness: All issues that hinder the changes. For example,

incompetent staff or insufficient resources.

3. Opportunities: Availability of working environment that could

support the success of the changes. For example, the wishes,
expectations, demands, and enthusiasm of the staff.

4. Threat: Risks and obstacles that could endanger or delay the

changes. For example, closure of borders or political unrest.

282
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Author Publications
Professor Doctor YEHIA AWAD ABED
[Link], M.P.H., Dr. P.H.
1. Books:
1. Dr. Yehia Abed (2020): Principles of Epidemiology, Al - Quads University – School of
Public Health, Dar El Argam Gaza, 320 pages
2. Dr. Yehia Abed (2019): Epidemiology of communicable and non-communicable diseases,
Al - Quads University – School of Public Health, Dar El Argam Gaza, 268 pages
3. Dr. Yehia Abed, Yousef Al Jeesh (2018): Community Medicine and Public Health, Al -
Quads University – School of Public Health, IUG Students Library, 718 pages.
4. Hammoda Abu-Odah, Yehia Abed (2013) Risk Factors of End-Stage Renal Failure, LAP
Lambert Academic Publishing, ISBN 978-3-659-38266-6, paperback, 145 pages
5. Seham Abu Haddaf, Yehia Abed (2012): Risk Factors of Hypertension at UNRWA Primary
Health Care Centers in Gaza Governorates: Case-Control Study LAP Lambert Academic
Publishing, ISBN 978-3-659-29216-3, paperback, 260 pages
6. Wissam Abou Amer, Yehia Abed (2012): Cancer Prevention and Control - Evaluation of
the strategy in Gaza Governorates, LAP Lambert Academic Publishing, ISBN 978-3-659-
30831-4, paperback, 249 pages
7. Amal Sarsour, Yehia Abed (2012): Environmental Awareness and Attitude Among School-
Age Children in Gaza – Palestine, LAP Lambert Academic Publishing, ISBN A78-3-659-
31078-2, paperback, 161 pages
8. Amal Sarsour, Abdelnaser Omran, Yehia Abed (2012): Outdoor Environmental Health
Awareness Programmes, Quantitative and Qualitative Evaluation for the Outdoor
Environmental Health Awareness Programmes in Gaza Strip, Palestine, LAP Lambert
Academic Publishing, ISBN 978-3-659-18510-6, paperback, 257 pages
9. Marwan Jalambo, Amin Hamad, Yehia Abed (2012), Risk factors for Anemia among
female secondary students in Gaza Strip, LAP Lambert Academic Publishing, ISBN 978-3-
659-31372-1, paperback, 145 pages
10. Akram Amro, Dr. Majed Aldweik, Dr. Yehia Abed (2010): Stroke Risk Factors at Alahli
Hospital: Palestine. [Link]-10: 3639294297 ISBN-13: 978-3639294293,

293
 11. Raja Musleh, Yehia Abed, Hamouda Oda (2014), Determinants of Iron Deficiency Anemia
among Women at Reproductive Age (15-49) Years in Gaza Governorates, LAP Lambert
Academic Publishing, ISBN 978-3-659-51372-5
12. Bissan Abu Shammala and Yehia Abed (2014) Breast Cancer Screening among Female
School Teachers Gaza City 2012, LAP Lambert Academic Publishing, ISBN 978-3-659-

2. Journal Publications:

1. Dhair A, Abed Y. (2020) The Effect of Preconception Housing and Living Conditions on
Primary Infertility Among Couples in Gaza Strip, Palestine: A Case Control Study. J Health Soc Sci.
2020;5(3):355-368. DOI 10.19204/2020/thff7
2. Dhair A, Husseini MN, Abed Y (2020). The effect of nutrition-related patterns on primary
infertility among couples in Gaza Strip: A case-control study. J Health Soc Sci. 2020;5(1):113-114.
DOI 10.19204/2020/thff12
3. Yehia Abed (2020), Palestinians face COVID 19, Occupation and Siege. French Orient xxi.
[Link]
4. Yehia Abed (2020). COVID-19 in the Gaza Strip and the West Bank under the political
conflict in Palestine [Short report]. SEEJPH 2020, posted: XX June 2020. DOI:
5. AlKhaldi M; Meghari H; Alkaiyat A; Abed Y; Pfeiffer C; Marie M, et al. (2019)
vision to strengthen resources and capacity of the Palestinian health research system: a qualitativ
e assessment. East Mediterr Health J. 2019;xx (x):xxx–xx. [Link]
6. Sarsour A; Turban M; Al Wahaidi A; Abed Y; Alkahlout H. (2019) Does gender influence
food intake and physical activity pattern among Palestinian adolescents in the Gaza Strip? East
Mediterr Health J. 2019;25(10):722–727. [Link]
7. Jamee Shahwan A, Abed Y, Desormais I, Magne J, Preux PM, Aboyans V, et
al. (2019). Epidemiology of coronary artery disease and stroke and associated risk
factors in the Gaza community – Palestine. PLoS ONE 14(1): e0211131.
[Link]
8. AlKhaldi M; Alkaiyat A; Pfeiffer C; Haj‐Yahia S; Meghari H; Abu Obaid H; Ali
Shaar, Yousef Aljeesh, Marcel Tanner and Yehia Abed (2019). Mapping stakeholders
of the Palestinian Health Research System: a qualitative study. East Mediterr Health J.
2019;25(x): xxx-xxx. [Link]
9. Jamal M. Safi, Maged M. Yassina, Yasser Z. El-Nahhala, Yehia A. Abed,
Mohamed J. Safi, Hassan D. Suleiman (2019). Childhood lead poisoning in Gaza Strip,
the Palestinian Authority. Journal of Trace Elements in Medicine and Biology 54
(2019) 118–125. [Link]
10. Abed, Y. and Jamee, A. (2015) Characteristics and Risk Factors Attributed to
Coronary Artery Disease in Women Attended Health Services in Gaza-Palestine
Observational Study. World Journal of Cardiovascular Diseases, 5: 9-18, Published
Online January 2015 in SciRes. [Link]
[Link]
11. Abed Yehia, Abu-Haddaf Seham, and Jamee Amal,(2015) Nutritional Status
and Diet Intake among Hypertensive Palestinians in Gaza Strip. Merit Research

294
Journal of Medicine and Medical Sciences (ISSN: 2354-323X) 3(2): 027-035, Available
online [Link]

12. Yehia Abed, Nabil Al Barqouni, Awny Naim, Eng and Paola Manduca(2014)
Comparative study of major congenital birth defects in children of 0-2 years of age in
the Gaza Strip, Palestine, International Journal of Development Research (ISSN:
2230-9926) 4 (11): 2319-2323 [Link]

13. Yehia Abed, PH, Khalid M Abu Saman, MPH and Bassam Abu Hamad, Ph.D.
(2014), Effects of co-payment on drug rational use and cost recovery at governmental
Primary health care in Gaza, International Journal of Development Research 4 (11):
2292-2296 [Link]

14. Yehia Abed, Seham Abu Haddad (2017), Fatalities and injuries in the 2014
Gaza conflict: a descriptive study. Lancet DOI: [Link]
6736(17)32055-X. Published online August 2017

15. Yehia Abed, Seham Abu Haddad (2013) "Risk Factors of Hypertension at
Health Care Centers in Gaza Governorates," ISRN Epidemiology, vol 2013, Article ID
720760, 9 pages, 2013, DOI:10.5402/2013/720760,
[Link]

16. Amira Shaheen, Yehia Abed (2018) Knowledge, attitude, and practice among
farmworkers applying pesticides in a cultivated area of the Jericho district: a cross-
sectional study, The Lancet 02/2018; 391:S3.
[Link]

17. Mohammed Al Khaldi, Yehia Abed, Abdulsalam Alkaiyat, Marcel Tanner (2018)
Challenges and prospects in the public health research system in the occupied
Palestinian territory: a qualitative study The Lancet 02/2018; 391:S25.
[Link]

18. Heiam A Elnuweiry, Yehia Abed (2018) Risk factors for pediatric cancer in the
Gaza Strip: a case-control study, The Lancet 02/2018; 391:S13.
[Link]
6/fulltext?code=lancet-site

19. Wahaidi AA, Abed Y, Sarsour A, Turban M. (2018) The Adolescent's Quality of
Life in the Gaza Strip: Nutritional and Psychological Risk Factors. Food Nutr OA.
(2018) Feb; 1(1):105. Journal Home: [Link]
and-nutrition-open-access/[Link]

20. Albelbeisi A; Mohd Shariff Z; Chan YM; Abdul Rahman H; Abed Y. Growth
patterns of Palestinian children from birth to 24 months. East Mediterr Health J.
(2018); 24 (3):302–310. [Link]

21. Mohammed AlKhaldi, Yehia Abed, Constanze Pfeiffer, Saleem Haj-Yahia,

Abdulsalam Alkaiyat and Marcel Tanner (2018) Understanding the concept and
importance of the health research system in Palestine: a qualitative study. Health
Research Policy and Systems 16:49 [Link]

22. Mohammed AlKhaldi, Yehia Abed, Constanze Pfeiffer, Saleem Haj-Yahia,

Abdulsalam Alkaiyat and Marcel Tanner (2018) Assessing policy-makers’, academics’

295
and experts’ satisfaction with the performance of the Palestinian health research
system: a qualitative study. Health Research Policy and Systems 16:66,
[Link]

23. Mohammed AlKhaldi, Abdulsalam Alkaiyat, Yehia Abed, Constanze Pfeiffer,

Rana Halaseh, Ruba Salah, Manar Idries, Said Abueida, Ibrahim Idries, Ibrahim
Jeries, Hamza Meghari, Ali Shaar, Marcel Tanner and Saleem Haj-Yahia (2018) The
Palestinian health research system: who orchestrates the system, how and based on
what? A qualitative assessment, Health Research Policy, and Systems (2018) 16:69
[Link]

24. Ali Albelbeisi, Zalilah Mohd Shariff, Chan Yoke Mun, Hejar Abdul Rahman and
Yehia Abed (2017). Use of micronutrient powder in at-home foods for young
children (6-18 Months): A feasibility study. Pak. J. Nutr., 16: 372-377

25. Rima Rafiq El Kishawi, Kah Leng Soo, Yehia Awad Abed and Wan Abdul
Manan Wan Muda (2017). Prevalence and associated factors influencing stunting in
children aged 2–5 years in the Gaza Strip-Palestine: cross-sectional study. BMC
Pediatrics (2017) 17:210. DOI 10.1186/s12887-017-0957-y

26. Hammoda Abu-Odah, Yehia Abed, Khawal El-Nems (2017) Factors

associated with end-stage renal disease in the Gaza Strip: a case-control study.
DOI: [Link] Published online August
2017

27. Nabil Al-Barqouni, Mustafa AlKahlut, Sherin Abed, Loai Albarqouni, Yehia
Abed (2017), Effect of the 2014 attack on Gaza on the use of medical services in Al-
Nasser Pediatric Hospital: a comparative study.
[Link]
Published online August 2017

28. Rima El Kishawi*, Kah Leng Soo, Yehia Abed, Wan Abdul Manan Wan Muda
(2017). Prevalence and associated factors of physical activity among mothers in the
Gaza Strip-Palestine. JEMTAC [Link]

29. Dr. Amal Jamee, Dr. Samar AL Nahal, Dr. Awni Alshurafa and Dr. Yehia Abed
(2016), Characteristic and predictors of readmission among patients with heart
failure Gaza-Palestine, Merit Research Journal of Medicine and Medical Sciences 4 May
2016(5):242-247

30. Mohammed S. Ellulu, Ismail Patimah, Huzwah Khaza’ai, Asmah Rahmat, Yehia
Abed (2016). Obesity and inflammation: the linking mechanism and the
complications. Arch Med Sci DOI: 10.5114/aoms.2016.58928

[Link]
complications,19,27238,0,[Link]

31. Mohammed S. Ellulu, Huzwah Khaza'ai, Asmah Rahmat, Ismail Patimah, Yehia
Abed (2016) Obesity can predict and promote systemic inflammation in healthy
adults. International Journal of Cardiology 215 (2016) 318–324.

[Link]

296
32. Mohammed S. Ellulu, Ismail Patimah, Huzwah Khaza'ai, Asmah Rahmat,
Yehia Abed, Faisal Ali (2016) Atherosclerotic cardiovascular disease: a review of
initiators and protective factors. Inflammopharmacology, Experimental and
Therapeutic Studies, ISSN 0925-4692 Inflammopharmacol, DOI 10.1007/s10787-
015-0255-y

33. Mohammed S. Ellulu, Huzwah Khaza’ai, Ismail Patimah2, Asmah Rahmat and
Yehia Abed (2016), Effect of long-chain omega-3 polyunsaturated fatty acids on
inflammation and metabolic markers in hypertensive and/or diabetic obese adults: a
randomized controlled trial. Food & Nutrition Research 2016, 60: 29268 -
[Link]

34. Rima Rafiq El Kishawi1, Kah Leng Soo, Yehia Awad Abed, Wan Abdul Manan
Wan Muda (2016) Prevalence and Associated Factors for Dual Form of Malnutrition in
Mother-Child Pairs at the Same Household in the Gaza Strip Palestine, PLOS ONE |
DOI:10.1371/[Link].0151494

35. Bissan Ismail Abu-Shammala, Yehia Abed (2015), Breast Cancer Screening
in Relation to Access Barriers to Health Care System. International Journal of Science
and Research (IJSR) ISSN (Online): 2319-7064 Index Copernicus Value (2015):
78.96. Paper ID: ART20171706 DOI: 10.21275/ART20171706
[Link]

36. Bissan Ismail Abu-Shammala, Yehia Abed (2015), Breast Cancer Knowledge
and Screening Behavior among Female School Teachers in Gaza City. Asian Pacific
Journal of Cancer Prevention, 16 (17) 2015:.7707-7711 DOI:
[Link]

37. Mohammed S. Ellulu, Asmah Rahmat, Ismail Patimah, Huzwah Khaza’ai, Yehia
Abed (2015) Effect of vitamin C on inflammation and metabolic markers in
hypertensive and/or diabetic obese adults: a randomized controlled trial. Drug
Design, Development and Therapy [Link] 3405 – 3412.
[Link]

38. Rima Rafiq El Kishawi, Kah Leng Soo, Yehia Awad Abed and Wan Abdul
Manan Wan Muda (2015), Anemia among children aged 2–5 years in the Gaza Strip-
Palestinian: a cross-sectional study. BMC Public Health (2015) 15:319 DOI
10.1186/s12889-015-1652-2

39. Amal Jamee, Yehia Abed, Maryiem Ramadan, Kalid El-Rabia, Ghada Nasser
and Mohammed Hijazi (2015) Impact of Diabetes Mellitus on Coronary Artery
Disease in Women Attending Coronary Angiography in Gaza- Palestine: An
Observational Study. Cardiology and Angiology: An International Journal 4(1): 10-18,
2015, Article [Link].2015.022 ISSN: 2347-520X

40. Mohammed S. Ellulu, 1Asmah Rahmat, Yehia Abed, Suha Baloushah, Ismail
Patimahand Huzwah Khazaai, (2015) Assessment of Differences on Inflammatory and
Metabolic Indicators between Pre- and Post-Menopause Women among Hypertensive
and/or Diabetic Patients. Trends in Medical Research 10 (2): 44-50, 2015, ISSN
1819-3587 / DOI: 10.3923/tmr.2015.44.50

41. Abu-Odah H, Abed Y, Abu-Hamad B (2014) Risk Factors of Stroke in Patients

Admitted in European Gaza Hospital, Gaza Strip: A Case-Control, Study in Medical
Unit Setting. J Neurol Disord Stroke 2(3): 1073.
[Link]

297
42. Abuhaloob L, Abed Y (2014) Knowledge and Public Perception of Dental
Fluorosis in Children Living in Palestine. Oral Hyg Health 2 (3): 133. doi:
10.4172/2332-0702.1000133 [Link]
public-perception-of-dental-fluorosis-in-children-living-in-palestine-2332-
[Link]?aid=27955

43. Ahmed H. Hilles, Amal Sarsour, Ayman Ramlawi, Yehia Abed (2014),
Assessment of Sanitary Conditions in the Main Swimming Pools in Gaza Strip (2010 –
2013): Palestine, International Journal of Scientific Research in Environmental
Sciences, 2(8):261-268. Available online at [Link] ISSN:
2322-4983; ©2014 IJSRPUB, [Link]

44. Amal Jamee, and Yehia Abed, (2014) “Coronary Artery Disease in Overweight
and Obese Women in Gaza- Palestine: An Observational Study.” American Journal of
Cardiovascular Disease Research, 2( 2): 23-26. doi: 10.12691/ajcdr-2-2-2.
Available online at [Link]

45. Mohammed Ellulu, Asmah Rahmat and Yehia Abed (2014), Updates of
Overweight and Obesity Status and Their Consequences in Palestine, Pakistan Journal
of Nutrition 13 (2): 116-121, 2014, ISSN 1680-5194

46. Rima Rafiq El Kishawi, Kah Leng Soo, Yehia Awad Abed and Wan Abdul
Manan Wan Muda (2014): Obesity and overweight: prevalence and associated socio-
demographic factors among mothers in three different areas in the Gaza Strip-
Palestine: a cross-sectional study, BMC Obesity 2014, 1:7
[Link]

47. -‫) فقر الدم وعوامل الخطر عند المراهقات نف قطاع غزة‬2014( .‫يحي عوض عابد‬ ‫ي‬ ,‫أمي توفيق حمد‬‫ ن‬,‫مروان عمر جلمبو‬
‫ن‬
,‫ المجلة العربية للغذاء والتغذية‬.‫فلسطي‬31)66-53 :)

48. Ellulu M, Abed Y, Rahmat A, Ranneh Y and Ali F.(2014) Epidemiology of

obesity in developing countries: challenges and prevention. Glob Epidemic Obes.
2014; 2:2. [Link]

49. Amal Jamee, Yehia Abed (2014), Anemia Prevalence and Sociodemographic
Factors among Patient with Cardiovascular Disease in Gaza – Palestine, American
Journal of Cardiovascular Disease Research, 2014, Vol. 2, No. 1, 4-8, Available online
at [Link] © Science and Education Publishing
DOI:10.12691/ajcdr-2-1-2

50. Aamer Suliman Abu Shariaa, Zulkiple [Link], Muhamed Yusuf Khalid,
Mosbah Mansour Motawea &Yehia Awad Abed, Patients' Satisfaction with The Quality
of Health Services in The Palestinian Hospitals (Nutrition and Cleaning Services Form
A Comparative Study ‫لمرض عن جودة الخدمات الصحية نف المستشفيات الفلسطينية (خدمات التغذية وخدمات‬
‫رضا ا ن‬
‫ن‬ ‫ن‬
)‫النظافة نماذج لدراسة مقارنة بي مستشف الشفاء وغزة واالوروب‬

‘ULUM ISLAMIYYAH JOURNAL - UNIVERSITI SAINS ISLAM MALAYSIA ISSN 1675 -

5936 I e-ISSN 2289-4799, VOL.14 (DECEMBER) 2014: pp 189-220

[Link]

51. Amal Khalil SARSOUR, Abdelnaser OMRAN, Yehia Abed, Guy ROBINSON (2014)
Evaluation of an environmental health awareness program in the Gaza Strip,
Palestine. Journal of Environmental Management and Tourism, (Volume V, winter),
2(10): 249-268. doi:10.14505/jemt.v5.2(10).07

298
52. Amal Jamee, Yehia Abed, Hassan Abutawila (2013) Risk Factors of Metabolic
Syndrome among Clinic Patients in Gaza – Palestine, American Journal of
Cardiovascular Disease Research, 1 (1): 20-24, Available online at
[Link]

© Science and Education Publishing, DOI:10.12691/ajcdr-1-1-5

53. Reem Abu Shomar, Yehia Awad Abed (2013), Laboratory employees'
perception about their workload and working environment in governmental primary
health care medical laboratories, Gaza Strip (Palestine), International Journal of
Medical Science and Public Health, 2013, 2 (4): 829 – 836, DOI:
10.5455/ijmsph.2013.020720131
54. Lamis Abo Halob, Yehia Abed (2013) Dietary behaviors and dental fluorosis
among Gaza Strip children, Eastern Mediterranean Health Journal, 19 (7): 536 – 542
55. Amal Jamee, Yehia Abed & Marwan O. Jalambo (2013) “Gender Difference
and Characteristics Attributed to Coronary Artery Disease in Gaza-Palestine Global
Journal of Health Science; Vol. 5, No. 5; 2013, ISSN 1916-9736 E-ISSN 1916-9744,
Published by Canadian Center of Science and Education
56. Marwan O. Jalambo, Amin Hamad & Yehia Abed (2013) Anemia and Risk
Factors among Female Secondary Students in the Gaza Strip, Journal of Public Health
21:271–278, DOI 10.1007/s10389-012-0540-9
57. Amal Sarsour, Alshaarawi Salem, Yehia Abed, and Abdelnaser Omran
(2013). Socio-Demographic Factors: "Does It Make Difference on Children Perception
and Practice towards Environmental Health Promotion: a Case Study of Gaza Strip,
Palestine ". Archives Des Sciences", Switzerland, Geneva, DOI:
10.5593/sgem2012/s06.v2006
58. A. Omran, A. Sarsour, Y. Abed, A. Hamid Kadir Pakir (2012) Impact of
outdoor environmental health awareness program on the knowledge, attitudes, and
behaviors of children in Gaza, Palestine, by libadmin2012, the12th international
multidisciplinary scientific geo conference, [Link] sgem2012
conference proceedings/ issn 1314-2704, June 17-23, 2012, vol. 2: 577 - 584
59. Abed Yehia, Nabil Al Barqouni, Paola Manduca, Mofeed Mokhallalati, Awny
Naim, Roberto Minutolo (2012) Major structural birth defects in children aged 0–2
years in the Gaza Strip: a cross-sectional study [Link]
the-occupied-Palestinian-territory-2012 published online 8 October 2012
60. Amal Jamee, Yehia Abed (2012), Outcomes of cardiac surgery in the Gaza
Strip, occupied Palestinian territory: a cross-sectional study,
[Link]
published online 8 October 2012
61. Imad El Awour, Yehia Abed, Majdi Ashour (2012) Determinants and risk
factors of neonatal mortality in the Gaza Strip, occupied Palestinian territory: a case-
control study. [Link]
2012 published online 8 October 2012
62. Amin Hamad & Marwan O. Jalambo & Yehia Abed (2012): Comparison of
anemia between pregnant and non-pregnant adolescents in the Gaza Strip J Public
Health DOI 10.1007/s10389-012-0489-8
63. Yehia Abed, Amal Sarsor (2011): Environmental Awareness among school-
age children in Gaza – Palestine. Birzeit Water Drops - Official Bulletin of Institute of
Environmental and Water Studies (IEWS), 2011, 9: 59-71.
64. Amal Sarsor, Abdelnaser Omran, Yehia Abed (2011): Immediate and Short –
term impact of an Outdoor Environmental Health Awareness Program among Children

299
in Gaza city. Birzeit Water Drops - Official Bulletin of Institute of Environmental and
Water Studies (IEWS), 2011, 9: 22-33.
65. Lamis Abuhaloob, Yehia Abed (2011): Dental fluorosis and associated risk
factors in Gaza Strip children. Birzeit Water Drops - Official Bulletin of Institute of
Environmental and Water Studies (IEWS), 2011, 9: 93-106.

66. Abdallah H Abudayya, Hein Stigum, Zumin Shi, Yehia Abed, and Gerd
Holmboe-Ottesen (2011) Diet, nutritional status and school Performance among
adolescents in Gaza Strip, Eastern Mediterranean Health Journal, 17 (3): 218 – 225
67. Nedal Ismael Ghuneim, Yehia Abed (2010) Effects of non-fatal injuries during
the war on Gaza Strip on quality of life: a cross-sectional study. [Link] 2 July
2010 [Link]
68. Abdallah H Abudayya, Hein Stigum, Zumin Shi, Yehia Abed, and Gerd
Holmboe-Ottesen (2009) Sociodemographic correlates of food habits among school
adolescents (12–15 year) in north Gaza Strip, BMC Public Health 2009, 9:185
[Link]
69. Nora Ingdal, Dr. Malek Qutteina, Dr. Aziza Khalidi, Dr. Yehia Abed (2009).
Evaluation of Diakonia/NAD Rehabilitation Programme in the Occupied Palestinian
Territories (OPT), Jordan and Lebanon,
[Link]
t_Evaluation_june_2009.pdf
70. Kh. Abu Hamad, Y. Abed, B. Abu Hamad (2007): Risk factors associated with
preterm birth in the Gaza Strip: Hospital-based case-control study. Eastern
Mediterranean Health Journal 13 (5): 1132 – 1141
71. Abdallah Abudayya, Magne Thoresen, Yehia Abed, Gerd Holmboe-Ottesen
(2007) Overweight, stunting, and anemia are public health problems among low
socioeconomic groups in-school adolescents (12-15 years) in the North Gaza Strip.
Nutrition Research 27:762–771
72. Yehia Abed (2007): Health Sector Review, A summary report requested by
the steering committee formed of MOH, WHO, EU, World Bank, DFID and Italian
Cooperation
73. Basil Kanoa, Erian George, Yehia Abed, Adnan Al-Hindi (2006): Evaluation of
the relationship between intestinal parasitic infection and health education among
school children in Gaza city, beit-Lahia village and Jabalia refugee camp, Gaza Strip,
Palestine. The Islamic University Journal (Series of Natural Studies and Engineering)
14(2):39-49,
74. Abu Shahla A/N, Abed Y. and Abu Shahla N. (2004). Screening Programme
for Phenylketonuria in Gaza Strip: Evaluation and Recommendations. Journal of
Tropical Pediatrics 50 (2):101-105
75. Thabet A. A., Abed Y. & Vostanis P. (2004) Comorbidity of PTSD and
depression among refugee children during war conflict, Journal of Child Psychology
and Psychiatry 45 (3): 533
76. Thabet A. A., Abed Y. & Vostanis P. (2002) Emotional problems in Palestinian
children living in a war zone: a cross-sectional study. Lancet, 359, 1801-1804.

77. Thabet A.A., Abed Y. & Vostanis P. (2001). The effect of trauma on Palestinian
children and mothers' mental health in the Gaza Strip. Eastern Mediterranean Public
Health Journal, 7: 314-321

300
78. Lewando-Hundt G., Abed Y., Skeik M., El Alem A., Beckerleg, S (1999)
‘Addressing Birth in Gaza Improving Vital Registration using Qualitative Methods’
Social Science and Medicine, 48 (6): 833-843

79. Beckerleg S., Lewando-Hundt G., Abed Y., Eddama M., El Alem A., Shawaa R.
(1999) ‘Purchasing a Quick Fix from Private Pharmacies in the Gaza Strip‘ Social
Science and Medicine, 49 (11): 1489-1500

80. Abed, Y. Priorities for Infectious Disease Research in Palestine. Gaza: Gaza
Health Services Research Center, 1998: 14 pp
[Link]

81. Hundt, G., Abed, Y., El Alem, A., and Shawaa, R. (1998) Evaluation and
Improvement of Maternal and Child Preventive Health Resources and Services of
Palestinians in the Gaza Strip - Summary of Main Findings, (In Arabic and English)
[Link]

82. Lewando-Hundt G., Beckerleg S., Abed Y., El Alem A. (1997) ’Comparing
manual with software analysis in qualitative research: Undressing [Link]’ Health
Policy and Planning, 12(4): 372-380.

83. Abed, Y., El-Shawwa, R., and El-Masri, M. (1996) Gaza Persistent Diarrhea
Case-Control Study. Gaza: Gaza Health Services Research Center: 29 pp.
[Link]

84. Morag, A., 'Abed, Y., Schoub, B. D., Lifshitz, A. and Zakai-Rones, Z. (1995)
Enteric Viral Infections in Gaza Children - Incidence and Associated Factors and
Phenomena. Israel Journal of Medical Sciences; 31: 49-53.

85. Tulchinsky T.H., El Ebweini S. Ginsberg G.M., Abed Y., Montano-Cuellar D.,
Schoenbaum M., Zansky S. M., Jacob S., El Tibbi A. J., Abu Sha’aban D., Koch J, and
Melnick Y. (1994) Growth and Nutrition Patterns of Infants Associated with a Nutrition
Education and Supplementation Programme in Gaza, 1987-92. Bulletin of the World
Health Organization; 72,6: 869-875.

86. Tulchinsky T., Abed Y., Tubassi N., Handsher R., Acker C. and Melnik J.
(1994) Successful Control Of Poliomyelitis By A Combined OPV/IPV Polio Vaccine
Program In The West Bank And Gaza, 1978-93. Israel Journal of Medical Sciences
30:489-494.

87. Mumcuoglu K., Abed Y., Armenios B., Shaheen S., Jacobs J., Bar-Sela Sh. and
Richter E. (1994) Asthma in Gaza Refugee Camp Children and its relationship with
House Dust mites. Annals of Allergy, 72:163-166

88. Schoenbaum M., Tulchinsky TH, Abed Y. (1993) Gender Variation in

Nutritional Status and Intrafamily Resource Allocation Among Infants in the Gaza
Strip. American Journal of Public Health.85:965-969

89. Tulchninsky, T., Handsher, R., Melnick, J.L., Abu Shabaan, D., Neumann, M.,
Abed Y. and Budnitz, D. (1993) Immune Status to Various Strains of Wild Poliovirus
among children in Gaza Immunized with live attenuated Oral Vaccine Alone Compared
with a Combination of Live and Inactivated Vaccines. The Journal of Viral Diseases 1 (3):
5-13

301
90. Abed Y. (1993) Impact of socioeconomic and environmental conditions on child
hemoglobin in two localities in Gaza Strip, Proceeding of the First Scientific Conference
Toward a New View of Modern Problematic Issues in the Gaza Strip December 27-28,

91. Abed, Y. (1992) Risk Factors Associated with Anemia Among Children in the
Gaza Strip. Dissertation for Doctorate for Public Health, Johns Hopkins School of
Public Health, Baltimore, Maryland

92. Tulchinsky TH, Belmaker I., Raabi S., Acker C., Arbeli Y., Lobel R., Abed Y.,
Toubassi N., Goldberg E., and Slater P. E. (1992). Measles during the Gulf War: A
public health threat in Israel, the West Bank, and Gaza. Public Health Review 20:285-
296

93. Simhon A., Abed Y., Schoub B., Lasch E.E., and Morag A. (1990) Rotavirus
Infection and Rota Virus Antibody in a Cohort of Children from Gaza Observed from
Birth to the Age of one-year, International Journal of Epidemiology 19 (1): 160-163.

94. Simhon A., Lifschitz A., Abed Y., Lash E.E., Schoub B. and Morag A. (1990)
How to Predict the Immune Status of Polio Virus Vaccines - A comparison of Virus
Naturalization at a very low serum Dilution versus ELISA in a Cohort of Infants,
International Journal of Epidemiology, 19 (1): 164-168

95. Tulchinsky T., Abed Y., Ginsberg G., Saheen S., Friedman J.B., Schoenbuam
M.L., and Slater P.E. (1990) Measles in Israel, the West Bank, and Gaza: Continuing
Incidence and the Cases for a New Eradication Strategy. Reviews of infectious Disease
12:951-957

96. Tulchinsky T., Abed Y., Shaheen S., Tubassi N., Sever Y., Schonenbaum M.,
Handsher R. (1989) A Ten –year Experience in Control of Poliomyelitis through a
Combination of Live and Killed Vaccines in Two Developing Areas. American Journal of
Public Health, 79: 1648-1652.

97. Abed, Y., Edda'ma, M., Zada, I.D. (1987) Health of School Children (6 - 12
Years) in Gaza Strip Rural and Urban Localities, Presented to the WHO Training
Workshop on health services research in primary health care in the West Bank and
Gaza. Jerusalem: 37 pp.
[Link]

98. Abed, Y. and Zada, I.D. Investigation of Home Infant Deaths in Gaza Strip.
(1987) Presented to the WHO Training workshop on health services research in
primary health care in the West Bank and Gaza. Jerusalem: 12 pp.
[Link]

99. Lasch E., 'Abed Y., Marcus O., Gerichter Ch.B., and Melnick J.L. (1986)
Combined Live and Inactivated Poliovirus Vaccine to Control Poliomyelitis in a
Developing Country - Five Years After. Dev Biol Standard; 65: 137-143.

100. Abed Y., Lasch E.E., Hassan N.A., Goldberg J. (1984).Community and local
involvement in the control of infectious disease in infancy- Gaza. Public Health
Review, 12 (3-4): 340 – 343

101. Lasch E.E., Abed Y., Goldberg J., El Shawa R. (1984) Child Health Services in
Gaza - an Experiment in Integration, Public Health Review 12 (3-4): 340 – 343

302
102. Shubair M.E., Marcus O., Lash E.E., Abed Y. & Jaroushi A. (1984) Cholera In
Gaza Strip, Ann. Soc. Beige Med. Trop. 64: 199-200

103. Lasch E. E., Abed Y., Marcus O., Shbeir M., EL Alem A., and Hassan N. A.
(1984) Cholera in Gaza in 1981: epidemiological characteristics of an outbreak
Transactions of The Royal Society of Topical Medicine and Hygiene, 78:554-557

104. Lasch E. E., Abed Y., Abdulla K., El Tibbi AG., Marcus O., El Massri M.,
Handscher R., Gerichter C. B., and Melnick J. L. (1984). Successful Results of a
Program Combining Live and Inactivated Poliovirus Vaccines to Control Poliomyelitis in
Gaza, Reviews of Infectious Diseases 6:S467- 470

105. Lasch E. E., Abed Y., Gerichter C. B., El Massri M., Marcus O., Hensher R. and
Goldebum N. (1983) Results Of A Program Successfully Combining Live And Killed
Polio Vaccines. Israel Journal of Medical Sciences, 19:1021- 1023

106. Lasch E. E., Abed Y., Gunina A., Hassan N. A., Abu Amara I. and Abdallah K.
(1983) Evaluation of The Impact of Oral Rehydration Therapy on The Outcome of
Diarrheal Disease In A Large Community. Israel Journal of Medical Science, 19:995-
997.

107. Abed, Y.A. (1979) An Epidemiological Study of the Prevalence of Intestinal

Parasites and their Effect on Hb and Growth and Development in Children of Jabalia
Village, MSc Dissertation, Hadassah Medical School, Jerusalem, 94 pp.
[Link]

Academic Supervision (Ph.D. & MPH)

By Dr. Yehia Abed

1. Abeer Hassan: Nontraditional Risk Factors of Coronary Artery Disease, Al Quds University

2. Rafat radwan: Effect of Pharmaceutical Marketing on Physicians’ Prescribing practices in

the Gaza Strip, Al Quds University

3. Hala Bahlol: Women’s perceptions of the quality of care and health information based
on mother child health e-Registry, Al Quds University

4. Ashraf Abdul Raheem Abu Mhadi: A qualitative and quantitative assessment of medicine use
patterns and practices among the general public in the Gaza strip, Palestine, Universiti Sains
Malaysia

5. Amal Dohair (2020): Risk factors of primary infertility in Gaza: A Case control study, Al
Quds University

6. Hana Mossa (2020): Exploring drug-drug interactions among prescriptions for patients
discharged from internal medicine departments Governmental Hospitals: Magnitude and
correlates, Al Quds University

7. Rasha Mughani (2020): Role of International development actors in supporting resilience

of the health care system in Gaza, Al Quds University

303
8. Khaled Ali Khaled Abu Ali (2019) Prevention of Neonatal Hepatitis B Viral Infection Using
Hepatitis B Immunoglobulin and Hepatitis B Vaccine versus Hepatitis B Vaccine Alone. Doctor of
Public Health in Epidemiology High Institute of Public Health - Alexandria University

9. Dalia T. Wehedi (2019): Evaluation of Colorectal Cancer Management in the Gaza Strip

10. Mo’min Khalil Eid (2019): Evaluation of Breast Cancer Management in Gaza Strip

11. Sally M. Salha: Women’s Perspectives about Menopause in the Gaza Strip, Al Quds University

12. Samar A. Abd El-Rahman (2019): Risk Factors and Consequences of Vitamin D Insufficiency
among Females in Gaza Strip, Al Quds University

13. Mohammed El Khaldy (2018): Moving forward: Palestinian Health Research System. Swiss
Tropical and Public Health Institute (Swiss TPH) Graduated 2018

14. Ali Al Belbesi (2018) Effect of Micronutrient Supplements on Nutritional Status of Infants in
Gaza Strip, Palestine. School of Graduate Studies, Universiti Putra Malaysia (Ph.D.) Graduated
2018

15. Amal Abu Gamma (2018) Epidemiology of Cardiovascular disease and associated risk factors
in the Gaza Strip- Palestine. UNIVERSITÉ DE LIMOGES ÉCOLE DOCTORAL N°523 SCIENCES POUR
L'ENVIRONNEMENT UMR INSERM 1094 Neuroépidémiologie Tropicale, Limoges, France

16. Awatif Abd El Qader (2015) Risk Factors of Hyperlipidemia among Blood Donors in Gaza. Al
Quds University

17. Maysoon M. Abu Rabee (2015) Assessment of Injection Safety in Primary Health Care in the
Gaza Strip. Al Quds University

18. Mohammed M. Jaber (2015) Evaluation of Multidisciplinary Team Members Committee for
cancer management at Al-Shifa medical complex. Al Quds University

19. Sabri M. Hajjaj (2015) Evaluation of The Prosthetic Eye Services in Gaza Strip. Al Quds
University

[Link] El Wehadi (2015) The impact of organizational conflict on the productivity of the
Ministry of health (Case study: primary health care-Gaza strip). (Arabic)

‫برنامج إدارة الدولة والحكم الرشيد‬- ‫أكاديمية االدارة والسياسة للدراسات العليا‬

[Link] Hewar (2014): Dual Burden Malnutrition in the Gaza Strip: Co-Morbidity Pattern, Al Quds
University

22. Yehia El Nawajha (2014): Evaluation of the Computerized Appointment System at

Governmental Hospitals in the Gaza Strip, Al Quds University

23. Dalal El Khateeb (2014): Assessment of Quality Assurance Systems at the Laboratories
Services in the Gaza Strip, Al Quds University

24. Heiam A. Elnuweiry (2014): Risk Factors of Pediatric Cancer Among Palestinian Children In
Gaza Strip, Al Quds University

304
25. Lana Al Agha (2013): Survival determinants of breast cancer cases in Gaza Governorates. Al
Quds University

26. Fouad Nejim (2013): Evaluation Of Health Services Provided At Medical Services Directorate
In Gaza Strip- Palestine. ‫أكاديمية اإلدارة و السياسة للدراسات العليا بالمشاركة مع جامعة األقصى برنامج الماجستير في‬
2013 ‫( إدارة الدولة والحكم الرشيد‬Ongoing)

27. Mariam Habboub (2013): Assessment of health status and needs of the aged people in the
North Gaza Governorate, Al Quds University

28. Mohammed Mukat (2013): Assessment of Health Counselling at Public Pharmacies in Gaza
Governorates, Al Quds University

29. Lubna Sabah (2013): Evaluation of the Near East Council of Churches Health Program in Gaza:
Congruency with the international standards, Al Quds University

30. Mohammed S. S. Ellulu (2013): Effect of Omega-3 FAs and Vitamin C on Serum Level of CRP
and IL-6 among Obese Adults in Palestine, Ph. D. Nutrition Science UPM, Malaysia (ongoing)

31. Geith Salem: Impact of Specialized Training and Capacity Building Programs on Nursing
Performance at Shifa Hospital,

‫أكاديمية اإلدارة و السياسة للدراسات العليا بالمشاركة مع جامعة األقىص برنامج الماجستي نف إدارة الدولة والحكم الرشيد‬
2013 (Ongoing)

32. Bissan Ismail Abu Shammala (2013): Factors Influencing Breast Cancer Screening among
Female School Teachers Gaza city 2012. Al Quds University 2013

33. Raja Nour: Determinants of Iron Deficiency Anemia among Women at Reproductive Age in
Gaza Governorates, Al Quds University 2012

34. Linda El Najar: Mortality Trends of Congenital Anomalies among Infants in Gaza Governorates
(2000 -2010), Al Quds University 2012

35. Wala Geshta: Risk Factors of Congenital Heart Distress among Infants in Gaza Governorates:
Case-Control study, Al Quds University 2012

36. Hamouda Abo Oda: Risk Factors of End-Stage Renal Failure among Patients Undergoing
hemodialysis in Gaza Governorates: Case-Control study, Al Quds University 2012

37. Abo Rokba Mohmed: The relationship between Mental Health and Self Esteem among
Mothers of Children with Mental Disability in Gaza Governorates, Islamic University Gaza 2012

38. Mohmed El Tebe - ‫العاملي نف مراكز الرعاية االولية " محافظة غزة‬
‫ن‬ ‫ن‬
‫الوظيف لدى‬ ‫دور القيادة اإلدارية نف تنمية الرضا‬
‫ن‬
‫أكاديمية اإلدارة و السياسة للدراسات العليا بالمشاركة مع جامعة األقىص برنامج الماجستي ف إدارة الدولة والحكم الرشيد‬
2012

39. Amal Khalil Sarsour, the impact of outdoor environmental awareness program on the
knowledge, attitudes, and behaviors of children in Gaza, Palestine, (Ph.D.) Universiti Sains
Malaysia, 2012

305
40. Hatem Suliman Mohammed El Dabbakeh, Risk Assessment and Risk Perception of Coronary
Heart Disease among University Students in Gaza Strip – Palestine - (Ph.D.) High Institute of
Public Health University of Alexandria 2012

41. Mohmed Abo Raya: Risk Factors Associated with Vitamin A Deficiency among Children 12-59
Months Old Attending Ard El Insan Association –Gaza, SPH – Al Quds University 2012

42. Abu Rahma Hassan: Drug compliance and family support contribute to preventing relapse
among schizophrenia clients in Gaza Strip. IUG 2012

43. Amer Abo Shariaa:

‫أسس الجودة الشاملة إلدارة الخدمات الفندقية المقدمة للمرضى في مستشفيى‬

‫ قطاع غزة – فلسطين‬- ‫الشفاء وغزة األوروبي – دراسة مقارنة‬

Ph.D. Islamic Science University of Malaysia – Malaysia 2011

44. Rima R.R El Kishawi: Dual Form of Malnutrition in the Gaza Strip -in Palestine Territories:
Prevalence, associated determinants and women's perception of nutrition practices, Ph.D.
Candidate, Malaysia Sans University – Institute of higher studies, 2012

45. Nahla Abo Amer: Evaluation of Dietary Compliance of Patients with Celiac disease-Gaza
governorates, SPH – Al Quds University 2011

46. Mohmed Yaghi: Knowledge, Attitudes, and Practices of Tramadol Abuse among University
Students-Gaza governorates, SPH – Al Quds University in process

47. Seham Abo Hadaf: Risk Factors of Hypertension at UNRWA Primary Health Care Centers in
Gaza Governorates: Case-Control Study, SPH – Al Quds University 2011

48. Reem El Zeer: Types and trends of Pediatric Cancer in Gaza governorates during the period
from 1998 to 2010, SPH – Al Quds University 2012

49. Wissam Abo Amra: Evaluation of the current strategy for prevention and control of cancer-
Gaza Governorates, SPH – Al Quds University 2012

50. Mohmed Safi: Risk factors for lead poisoning among Palestinian children in Gaza
Governorates, SPH – Al Quds University 2011

51. Jawad Badwan: Evaluation of the current documentation of death certificates in the Gaza
Governorates, SPH – Al Quds University 2011

52. Soad Radwan: Evaluation of Community Based Rehabilitation Programs in the North and
Gaza Governorates, SPH – Al Quds University 2010

53. Manar Abo Samra: Assessment of the occupational health standards in vocational training
centers-Gaza Governorates, SPH – Al Quds University 2011

54. Haya El Rays: Colorectal cancer risk factors in Gaza Governorates, SPH – Al Quds University
2009, SPH – Al Quds University 2011

306
55. Halema El Zaaneen: Evaluation of the Referral System between Primary Health Centers an
Ahli-Arab Hospital, SPH – Al Quds University 2010

56. Emad El Awour: Determinants and Risk Factors for Neonatal Mortality in Gaza Strip, SPH – Al
Quds University 2009

57. Nedal Ghuneim: Impact of Non-fatal Injuries during Gaza Ware – Rafah Governorate, SPH – Al
Quds University 2009

58. Khitam A. Abu Znada: Assessment of the Performance of Blood Bank Laboratories in Gaza
Strip during the last Israeli aggression 2008- 2009: Blood Bank Screening and Management of
Excess Blood donations, SPH – Al Quds University 2009

59. Khalid Abo Ali: Risk factors for Hepatitis B among pregnant women in North Gaza, SPH – Al
Quds University 2009

60. Heba Khalil Jawada: Nutritional Assessment of Lactating Women in Gaza Strip, College of
Pharmacy - Al-Azhar University –Gaza 2009

61. Heba El Mahalawi: Risk factors for stunting among under FIVE children in the north of Gaza
CITY; CASE control study, College of Pharmacy - Al-Azhar University –Gaza 2009

62. Suad J. Obaid: Nutritional Assessment of Elderly people Aged 60 years or above in Gaza City
and North Gaza, College of Pharmacy - Al-Azhar University –Gaza 2009

63. Mohamed Khalil Kheila: Adult Nutritional assessment in Gaza strip, College of Pharmacy - Al-
Azhar University –Gaza 2009

64. Rasha Al Agha: Impact of LBP on activities of daily living among women with diagnosed low
back pain and attending governmental hospital in Gaza strip, Master Degree in Rehabilitation
Science Islamic University 2009

65. Hisham M. Al-Zatma: Risk factors for rehospitalizations among patients in El-Wafa Medical
Rehabilitation Hospital, Degree in Rehabilitation Science Islamic University 2009

66. Hatem Suliman Mohammed El Dabbakeh: Risk Assessment and Risk Perception of Coronary
Heart Disease among University Students in Gaza Strip, Doctor of Public Health Sciences
(Epidemiology) High Institute of Public Health, Department of Epidemiology University of
Alexandria – Egypt 2009

67. Abdallah Abudayya: The Nutritional Status among school adolescents (12-15 years) in North
Gaza Strip, Ph.D., Section of Preventive Medicine and Epidemiology, Institute of General Practice
and Community Medicine, University of Oslo, Norway 2009.

68. Najwa Mossleh: Compliance with Iron Supplementation among women during Post Natal
Period at UNRWA Clinics in The Gaza Governorates, SPH – Al Quds University 2009

69. Niveen Gadallah: Evaluation of Phenylketonuria and Hypothyroidism Newborn Screening

Program in Gaza Governorate SPH – Al Quds University 2009

70. Khalid Abu Saman: Co-payment Effect on Drug Rational Use and Cost Coverage at
Governmental PHC in Gaza Governorates, SPH – Al Quds University 2009

307
71. Eman Motawa: Characterizing Risk indicators associated with Life Cycle of World Bank Health
& Water Projects in Gaza Strip, Palestine University 2008

72. Jamalat Al- Majdalawi: Determinants of Obesity among Married Women Attended MCH
Clinics – Gaza Strip, SPH – Al Quds University 2008

73. Fuad Luzon: Quality Of Life among Stroke survivors in Gaza Strip, Master Degree in
Rehabilitation Science Islamic University 2008

74. Rasmiya Ghsoub: Evaluation of Current Screening Test for Asymptomatic Bacteriuria during
Pregnancy at First Antenatal Visit in Rimal Health Center UNRWA, Gaza, (2007) SPH – Al Quds
University 2008

75. Reem Abu Shoman: Workload Measurement in Governmental Primary Health Care Medical
Laboratories-Gaza Strip, (2007) SPH – Al Quds University 2008

76. Shehta Barhoum Evaluation of Hepatitis B Immunization Program for Children in Gaza
Governorates, Palestine, (2007) SPH – Al Quds University 2007

77. Roshdi Rossrous: Risk factors for hepatitis C among Palestinians in Gaza strip, SPH – Al Quds
University 2006

78. Ghada Abo Nahla: Knowledge, Attitudes, and Practice regarding Family Planning among
Palestinian couples in Gaza-Strip, Palestine-, SPH – Al Quds University 2006

79. Rafat Naim: Prevalence of Skin Diseases among Primary Schoolchildren in Gaza Strip, SPH – Al
Quds University 2006"

80. Amal Sansor: Environmental Awareness among School Children in Gaza Strip, SPH – Al Quds
University 2006

81. Mahmoud Homaed: Prevalence of Salmonella in poultry meat in Gaza city, SPH – Al Quds
University 2006

82. Amer Abu Shareaa: Evaluation of Hotel Services which are Provided for Patients at Shifa
Hospital Gaza Strip Palestine, ‫ عامر‬,‫تقييم الخدمات الفندقية المقدمة للمرضى في مستشفى دار الشفاء قطاع غزة –فلسطين‬
,‫ أبو شريعة‬SPH – Al Quds University 2005

83. Fayez El-Bahtety: Evaluation of Palestinian Brucellosis Control Program 1998-2001, SPH – Al
Quds University 2005

84. Bassam Shaheen: Assessment of antenatal care services provided at MOH and UNRWA clinics
in Gaza province, MCH Program SPH – Al Quds University, 2005

85. Lames Abu Haloub: Dental Fluorosis and Associated Risk Factors Among Palestinian Children
in Gaza Governorates, SPH – Al Quds University 2004

86. Samah El Sabah: Unintentional Injuries among children in Gaza Strip: An Epidemiological
Assessment, SPH – Al Quds University 2004

308
87. Iyad Nassr: A Description of the Current Sexual Rehabilitation Services and Information
Provided to Paraplegic Males of the Gaza Strip Aged Between 16 and 45 Years, SPH – Al Quds
University, 2004

88. Nahed Eid: The association between early marriage and pre-maturity among newborns in
Gaza Governorates, SPH – Al Quds University, 2004

89. Mouein Abu-Ramdan: Risk factors associated with diabetes mellitus type 2 in Gaza, SPH – Al
Quds University 2004

90. Basel El Ganoa: Effect of health education program on the prevalence of intestinal parasites
among school children, (Aqsa jointly with Ein Shams University 2004

91. Khetam Abu Hamad: Risk factors associated with preterm birth in the Gaza Strip, SPH – Al
Quds University 2003

92. Mohamed Bessiso: Prevalence of anemia among pregnant women who attended
governmental primary health care centers in Gaza Strip, 2001, SPH – Al Quds University 2003

93. Reema El-Keshaoy: Gender variation in risk factors for anemia among Palestinian children,
SPH – Al Quds University 2003

94. Silvia El Hassanat: Knowledge of Palestinian women on Breast Cancer and Breast Self-
Examination in 2 villages – East Jerusalem, SPH (WB) – Al Quds University 2003

95. Manal El Moghaber ‫دراسة تقويمية لواقع التربية الصحية فى مدارس المرحلة األساسية بمحافظات غزة فى ضوء اتجاهات‬
‫(تربوية معاصرة‬Faculty of Education, Al Azhar University 2003

96. Jehad El-Hessy: Impact of family planning programs on child health Gaza strip, Palestine, SPH
– Al Quds University 2002

97. Hanan Diab: Job Satisfaction among employed dentists in the Gaza Strip-Palestine, SPH – Al
Quds University 2002

98. Samar El-Khodary: The use of antibiotics in pediatrics’ acute respiratory infections in primary
health care centers in Gaza Strip, SPH – Al Quds University 2002

99. Amjad El-Shanty: Maternal risk factors associated with low birth weight in Gaza Strip, SPH –
Al Quds University 2002

100. Mahmoud Daher: Relation between Anemia and school performance among school child
in the Gaza Strip, SPH – Al Quds University 2002

101. Hassan Juda: Impact of Family Planning Programs on the Quality of Women’s Life in the
Gaza Strip, SPH – Al Quds University (2002)

102. Ayesh Samor: Prevalence and risk factors of postpartum depress in Gaza-Strip Palestine,
CMH Program SPH – Al Quds University 2002

103. Amira Shaheen: Knowledge, Attitude and Practice Among Farmworkers Applying
Palestine of a Cultivated Area in Jericho District, SPH (WB) – Al Quds University 2002

309
104. Raeed Abu-Warda: Compliance with Diabetes Regimen Therapy Among Diabetic Patients
Attending Governmental PHC Centres in Gaza Strip, Palestine, Instituto Superior De Sanitarian
Rome, Italy 2002

105. Abed –Rahman Omar: Evaluation of mental health services in Gaza Strip, Palestine 1999,
SPH – Al Quds University 2001

106. Hassan Abu Tawela: Patients with acute myocardial infarction: cardiac risk factor profiles
presentation, thrombolysis, and outcome Gaza- Palestine 2001, SPH – Al Quds University 2001

107. Sady Abu Awad: Risk factors associated with rickets among Gaza children under three
years old, a clinic-based case-control study, SPH – Al Quds University 2000

108. Amal El Batsh: Prevalence of dental caries and its associated factors in 7th class school
children in Gaza provinces, SPH – Al Quds University, 2000

109. Hatem Dabaka: Coronary heart disease risk factors assessment among adult population
in Gaza Strip, Hospital-Based case-control study, SPH – Al Quds University 2000

110. Akram Amro: Stroke Risk Factors in Hebron city- Al- Ahli Hospital, SPH (WB) – Al Quds
University 2000

111. Ryiad Awad: Adverse events following immunization (AEFI) BCG vaccination, and post
BCG complication among Palestinian infants and children in the Gaza strip, SPH – Al Quds
University 1999

112. Mazen Skeik: Evaluation of the Health Status in the Gaza Strip. Degree of Implementation
of the Global Strategy of Health for all By the Year 2000, ‫تقييم الوضع الصحي في قطاع غزة في إطار استراتيجية‬
2000 ‫منظمة الصحة العالمية توفير الصحة للجميع بحلول سنة‬, SPH – Al Quds University 1999

113. Faraj Abu Raya: Prevalence of low back pain among health professionals at the health
department, UNRWA, Gaza field, SPH – Al Quds University 1999

114. Nasser Jasser: Compliance of diabetic patients with a treatment regimen of diabetes at
UNRWA health centers in Gaza Strip, Palestine-1999, SPH – Al Quds University 1999

115. Mouien Karerry: Customary consanguineous marriage, and its Impact in Gaza Strip, SPH –
Al Quds University 1999

116. Nabegha Abu Shahla: Evaluation of phenylketonuria program on the Gaza Strip, SPH – Al
Quds University 1999

117. Sameer Ziara: Assessment of kindergarten children health in the southern provinces of
Palestine, in the scholastic year 1998/99, SPH – Al Quds University 1999

118. Sali Balata (health profession- Al Quds) Maternal Mortality in Gaza Strip, 1997, Faculty of
Health Profession – Al Quds University

310
 Schedule of teaching Epidemiology
1. Definition of epidemiology, History: Hippocrates, John Snow,
Doll & Hill, Prevention of disease: Primary, secondary,
tertiary, Steps in the epidemiological approaches
2. Epidemiological Triangle, Koch postulates, means of spread of
disease - Reservoirs of infection, Endemic, epidemic,
pandemic, Incubation period, immunity. Herd immunity
3. & 4. Measurement of Health and diseases, Health Indices: Birth,
life expectancy, fertility rates - Somatic characters, Morbidity,
Sources of morbidity data, incidence & Prevalence - Mortality:
sources of mortality data, crude mortality rates, specific
mortality rates, adjusted rates
5.
Measurement of risk, Absolute comparisons - Attributable
risk, Relative risk, odds ratio
6. & 7. Types of epidemiological studies, Experimental: randomized
clinical trials, Observational, descriptive studies, Analytical
studies, ecological, cross sectional, prospective, retrospective
8.
Mid-term exam

9. Association & Causation, Bias, confounders, interaction

10, 11. Clinical Epidemiology: Screening & Diagnostic tests
Validity: Sensitivity, specificity, false positives, false
negatives, predictive value, Reliability: Intra subject
variation, observer variation, intra-observer and inter-
observer, percent agreement, Kapa
12. Communicable disease Epidemiology, Epidemics, and
endemic Diseases - Chain of infection Investigation of an
epidemic – Epidemic Curves
13. Environmental and occupational epidemiology, Exposure and
dose – Dose effect relationship – Risk assessment and Risk
Management - Special features of environmental and
occupational Epidemiology
14. Epidemiology and health policy and planning. Health care
planning and evaluation – The planning cycle – Public Health
Policy practice: National Health Plan Interim Action plans
Exercise 1: Cigarette smoking - Exercise 2: Screening for HIV (CDC)

311
 Copyright
All rights reserved
‫جميع حقوق التأليف والطبع والنشر محفوظة للمؤلف‬
2018 – ‫ اإلصدار األول‬/ ‫الطبعة الثانية‬
‫ أو بأية‬,‫ أو نقله على أي وجه‬,‫ أو تخزين مادته بطريقة االسترجاع‬,‫ظر نشر أو ترجمة هذا الكتاب أو أي جزء منه‬ ُ ‫يٌح‬
.‫ اال بموافقة المؤلف الخطية‬,‫ أو بأي طريقـــة أخرى‬, ‫ أو بالتصوير‬, ‫ سواء أكانت إلكترونية او ميكانيكية‬,‫طريقة‬
No part of this book may be published, translated, sorted in a retrieval system, or
transmitted in any form or by any means, electronic or mechanical, including
photocopying, recording or using any other form without acquiring the written
approval from the publisher.

Al Quds University – School of Public Health

Dr. Yehia Abed
Mobile: 0599 404344 - Email: yabed333@[Link]

312
The Author:

Dr. Yehia Abed (MBBCh, MPH, DrPH) –

Professor of Public Health -Al-Quds
University.

Dr. Yehia Abed is a public health

physician, graduated from Johns Hopkins
University with 46 years’ experience in
senior public health positions in Palestine,
primarily with the Ministry of health as
Director of Public Health then Director
General for Research Planning and
Development.

Dr. Abed joined Al-Quds University (1997) as founder Dean of

the Faculty of Public Health. Through more than 100
publications, Abed focused primarily on research and programs
addressing children's public health issues in Gaza, including
immunization, growth, nutrition and Epidemiology of non-
communicable diseases. Abed participated in teaching at Al-
Quds University and number of institutions including Faculty of
Medicine and Faculty of Pharmacy – Nutrition programs. Thesis
supervision included 110 of Master and PHD students.