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Charbel El Bcheraoui,1 Mohammed Basulaiman,2 Mohammad A AlMazroa,2 Marwa Tuffaha,1 Farah Daoud,1 Shelley Wilson,1 Mohammad Y Al Saeedi,2 Faisal M Alanazi,2 Mohamed E Ibrahim,2 Elawad M Ahmed,2 Syed A Hussain,2 Riad M Salloum,2 Omer Abid,2 Mishal F Al-Dossary,2 Ziad A Memish,2 Abdullah A Al Rabeeah,2 Ali H Mokdad1 1Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; 2Ministry of Health of the Kingdom of Saudi Arabia, Riyadh, Saudi Arabia Background: Dietary risks were the leading risk factors for death worldwide in 2010. However, current national estimates on fruit and vegetable consumption in the Kingdom of Saudi Arabia (KSA) are nonexistent. We conducted a large household survey to inform the Saudi Ministry of Health (MOH) on a major modifiable risk factor: daily consumption of fruits and vegetables. Methods: The Saudi Health Interview Survey is a national multistage survey of individuals aged 15 years or older. It includes questions on sociodemographic characteristics, tobacco consumption, diet, physical activity, health care utilization, different health-related behaviors, and self-reported chronic conditions. We used a backward elimination multivariate logistic regression model to measure association between the Centers for Disease Control and Prevention (CDC)-recommended daily consumption of fruits and vegetables and different factors. Results: Between April and June 2013, a total of 10,735 participants completed the survey. Overall, 2.6% of Saudis aged 15 years or older met the CDC guidelines for daily consumption of fruits and vegetables. The likelihood of meeting the CDC guidelines increased with age; among women; among persons who graduated from elementary or high school or had a higher education; among residents of Makkah, Al Sharqia, Ha’il, or Jizan; among those who consumed at least two servings of meat or chicken per day; among those who visited a health care facility for a routine medical exam within the last 3 years; and among those who have been diagnosed with hypertension. Conclusion: We have showed that KSA is in dire need of improving the diet of its population. Our findings call for urgent research to understand the reasons for low fruit and vegetable consumption, focusing on price or preference in order to develop and implement culturally and country-relevant solutions to increase the consumption of fruits and vegetables. Keywords: Kingdom of Saudi Arabia, fruits, vegetables, dietary risks, diet

Despite preventive measures and initiatives, road traffic accidents are on the rise in the Kingdom of Saudi Arabia. This study aimed to investigate the emergency medical service unit's response to RTA by socio-demographic and accident-related variables in the Kingdom of Saudi Arabia. This retrospective survey included Saudi Red Crescent Authority data on road traffic accidents between 2016 and 2020. As part of the study, information on sociodemographic characteristics (e.g., age, sex, and nationality), accident-related data (type and place of the accident), and response time to road traffic accidents were extracted. Our study included 95,372 cases of road traffic accidents recorded by the Saudi Red Crescent Authority in the Kingdom of Saudi Arabia between 2016 and 2020. Descriptive analyses were performed to explore the emergency medical service unit's response time to road traffic accidents, and linear regression analyses were performed to investigate the predictors of response time. Most of the road traffic accident cases were among males (59.1%), and the age group of 25-34 years accounted for about a quarter (24.3%), while the mean age of the road traffic accident cases was 30.13 (±12.86) years. Among the regions, the capital city of Riyadh experienced the highest proportion of road traffic accidents (25.3%). In most road traffic accidents, the mission acceptance time was excellent (0-60 s; 93.7%), movement duration was excellent (<120 s; 91.1%), reaching site duration was excellent (<12 min; 57.9%), treatment start time was excellent (<120 s; 76.4%), duration at the scene was poor (>15 min; 40.8%), reaching hospital duration was good (30-60 min; 52.7%), and in-hospital duration was poor (>15 min; 44.1%). Regions, places and types of accidents, age, gender, and nationality of victims were significantly associated with different parameters of response time. Excellent response time was observed in most of the parameters except the duration at the scene, reaching hospital duration, and in-hospital duration. Apart from the initiatives to prevent road traffic accidents, policymakers should focus on strategies to improve accident response time to save lives.

Background: Road traffic injuries are a leading cause of death in Saudi Arabia. Studies have examined the impact of the COVID-19 pandemic on traffic injuries treated in healthcare institutions, but its impact on patients seeking emergency medical transport for traffic injuries remains unclear., Objective: This study aimed to determine changes in traffic injuries' distribution and outcomes among patients seeking emergency medical transport before, during, and after the COVID-19 restrictions were imposed in Saudi Arabia., Methods: This is a nationwide retrospective study of all injuries reported to the Saudi Red Crescent Authority (SRCA) between January 1 st , 2020, and May 31 st , 2021. The cases in the study were categorized based on the following three time periods: (1) Pre-restriction (January 1 to March 23, 2020), (2) restriction (March 24 to June 21, 2020), and (3) post-restriction (June 22, 2020, to May 31, 2021)., Results: A total of 142,763 cases of traffic-related injuries were recorded at the SRCA during the study period: pre-restriction, 27,811 (19.5%); restriction, 14,414 (10.1%); post-restriction, 100,538 (70.4%). Males accounted for most cases throughout the study period, but a significant increase in the number of females was observed in the post-restriction period compared with the first two timeframes (12.2% vs. 3.4% and 3.4%, respectively; P < 0.01). During the restriction period, the rate of mortality was the highest, and rollover crashes were significantly higher (18.2% vs. 14.0% and 14.6%; P < 0.01). Overall, pedestrians were almost three times more likely to die following injuries than occupants or drivers (OR = 2.7)., Conclusions: Further prevention programs to reduce traffic injuries are needed to improve traffic safety and improve population health., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Saudi Journal of Medicine & Medical Sciences.)

Objectives: We used findings from the Global Burden of Disease Study 2013 to report the burden of musculoskeletal disorders in the Eastern Mediterranean Region (EMR)., Methods: The burden of musculoskeletal disorders was calculated for the EMR's 22 countries between 1990 and 2013. A systematic analysis was performed on mortality and morbidity data to estimate prevalence, death, years of live lost, years lived with disability and disability-adjusted life years (DALYs)., Results: For musculoskeletal disorders, the crude DALYs rate per 100 000 increased from 1297.1 (95% uncertainty interval (UI) 924.3-1703.4) in 1990 to 1606.0 (95% UI 1141.2-2130.4) in 2013. During 1990-2013, the total DALYs of musculoskeletal disorders increased by 105.2% in the EMR compared with a 58.0% increase in the rest of the world. The burden of musculoskeletal disorders as a proportion of total DALYs increased from 2.4% (95% UI 1.7-3.0) in 1990 to 4.7% (95% UI 3.6-5.8) in 2013. The range of point prevalence (per 1000) among the EMR countries was 28.2-136.0 for low back pain, 27.3-49.7 for neck pain, 9.7-37.3 for osteoarthritis (OA), 0.6-2.2 for rheumatoid arthritis and 0.1-0.8 for gout. Low back pain and neck pain had the highest burden in EMR countries., Conclusions: This study shows a high burden of musculoskeletal disorders, with a faster increase in EMR compared with the rest of the world. The reasons for this faster increase need to be explored. Our findings call for incorporating prevention and control programmes that should include improving health data, addressing risk factors, providing evidence-based care and community programmes to increase awareness., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objective: No recent original studies on the pattern of diet are available for Saudi Arabia at the national level. The present study was performed to describe the consumption of foods and beverages by Saudi adults., Design: The Saudi Health Interview Survey (SHIS) was conducted in 2013. Data were collected through interviews and anthropometric measurements were done. A diet history questionnaire was used to determine the amount of consumption for eighteen food or beverage items in a typical week., Setting: The study was a household survey in all thirteen administrative regions of Saudi Arabia., Subjects: Participants were 10 735 individuals aged 15 years or older., Results: Mean daily consumption was 70·9 (se 1·3) g for fruits, 111·1 (se 2·0) g for vegetables, 11·6 (se 0·3) g for dark fish, 13·8 (se 0·3) g for other fish, 44·2 (se 0·7) g for red meat, 4·8 (se 0·2) g for processed meat, 10·9 (se 0·3) g for nuts, 219·4 (se 5·1) ml for milk and 115·5 (se 2·6) ml for sugar-sweetened beverages. Dietary guideline recommendations were met by only 5·2 % of individuals for fruits, 7·5 % for vegetables, 31·4 % for nuts and 44·7 % for fish. The consumption of processed foods and sugar-sweetened beverages was high in young adults., Conclusions: Only a small percentage of the Saudi population met the dietary recommendations. Programmes to improve dietary behaviours are urgently needed to reduce the current and future burden of disease. The promotion of healthy diets should target both the general population and specific high-risk groups. Regular assessments of dietary status are needed to monitor trends and inform interventions.

Diarrheal diseases (DD) are leading causes of disease burden, death, and disability, especially in children in low-income settings. DD can also impact a child's potential livelihood through stunted physical growth, cognitive impairment, and other sequelae. As part of the Global Burden of Disease Study, we estimated DD burden, and the burden attributable to specific risk factors and particular etiologies, in the Eastern Mediterranean Region (EMR) between 1990 and 2013. For both sexes and all ages, we calculated disability-adjusted life years (DALYs), which are the sum of years of life lost and years lived with disability. We estimate that over 125,000 deaths (3.6% of total deaths) were due to DD in the EMR in 2013, with a greater burden of DD in low- and middle-income countries. Diarrhea deaths per 100,000 children under 5 years of age ranged from one (95% uncertainty interval [UI] = 0-1) in Bahrain and Oman to 471 (95% UI = 245-763) in Somalia. The pattern for diarrhea DALYs among those under 5 years of age closely followed that for diarrheal deaths. DALYs per 100,000 ranged from 739 (95% UI = 520-989) in Syria to 40,869 (95% UI = 21,540-65,823) in Somalia. Our results highlighted a highly inequitable burden of DD in EMR, mainly driven by the lack of access to proper resources such as water and sanitation. Our findings will guide preventive and treatment interventions which are based on evidence and which follow the ultimate goal of reducing the DD burden., (© The American Society of Tropical Medicine and Hygiene.)

Background: The eastern Mediterranean region is comprised of 22 countries: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates, and Yemen. Since our Global Burden of Disease Study 2010 (GBD 2010), the region has faced unrest as a result of revolutions, wars, and the so-called Arab uprisings. The objective of this study was to present the burden of diseases, injuries, and risk factors in the eastern Mediterranean region as of 2013., Methods: GBD 2013 includes an annual assessment covering 188 countries from 1990 to 2013. The study covers 306 diseases and injuries, 1233 sequelae, and 79 risk factors. Our GBD 2013 analyses included the addition of new data through updated systematic reviews and through the contribution of unpublished data sources from collaborators, an updated version of modelling software, and several improvements in our methods. In this systematic analysis, we use data from GBD 2013 to analyse the burden of disease and injuries in the eastern Mediterranean region specifically., Findings: The leading cause of death in the region in 2013 was ischaemic heart disease (90·3 deaths per 100 000 people), which increased by 17·2% since 1990. However, diarrhoeal diseases were the leading cause of death in Somalia (186·7 deaths per 100 000 people) in 2013, which decreased by 26·9% since 1990. The leading cause of disability-adjusted life-years (DALYs) was ischaemic heart disease for males and lower respiratory infection for females. High blood pressure was the leading risk factor for DALYs in 2013, with an increase of 83·3% since 1990. Risk factors for DALYs varied by country. In low-income countries, childhood wasting was the leading cause of DALYs in Afghanistan, Somalia, and Yemen, whereas unsafe sex was the leading cause in Djibouti. Non-communicable risk factors were the leading cause of DALYs in high-income and middle-income countries in the region. DALY risk factors varied by age, with child and maternal malnutrition affecting the younger age groups (aged 28 days to 4 years), whereas high bodyweight and systolic blood pressure affected older people (aged 60-80 years). The proportion of DALYs attributed to high body-mass index increased from 3·7% to 7·5% between 1990 and 2013. Burden of mental health problems and drug use increased. Most increases in DALYs, especially from non-communicable diseases, were due to population growth. The crises in Egypt, Yemen, Libya, and Syria have resulted in a reduction in life expectancy; life expectancy in Syria would have been 5 years higher than that recorded for females and 6 years higher for males had the crisis not occurred., Interpretation: Our study shows that the eastern Mediterranean region is going through a crucial health phase. The Arab uprisings and the wars that followed, coupled with ageing and population growth, will have a major impact on the region's health and resources. The region has historically seen improvements in life expectancy and other health indicators, even under stress. However, the current situation will cause deteriorating health conditions for many countries and for many years and will have an impact on the region and the rest of the world. Based on our findings, we call for increased investment in health in the region in addition to reducing the conflicts., Funding: Bill & Melinda Gates Foundation., (Copyright © 2016 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license. Published by Elsevier Ltd.. All rights reserved.)

Objectives: We conducted a large household survey in 2013 to determine the current status of oral health practices and use of oral health services in the Kingdom of Saudi Arabia (KSA)., Methods: The Saudi Health Information Survey is a national multistage survey of individuals ≥ 15 years of age. We used a backward elimination multivariate logistic regression model to measure the association between having been to a dental clinic during the last year, and sex, age, marital status, education, time since last routine medical examination, history of diagnosis with a cardiovascular chronic condition, brushing or flossing teeth and use of Miswak (a chewing stick)., Results: Between April and June 2013, 10,735 participants completed the survey (89.4% of the households contacted). An estimated 1.5 million (11.5%) and 6.3 million (48.6%) Saudi Arabian people, ≥ 15 years of age, had visited a dental clinic for a routine check-up and for a complaint during the last year, respectively. In total, 16.3%, 85.0% and 52% of Saudi Arabian people never brush their teeth, never floss their teeth or never use Miswak, respectively. The probability of visiting a dental clinic increased with education, among individuals who brushed or flossed their teeth and who used Miswak., Conclusions: Oral hygiene practices are not common among Saudi Arabian people, and use of health care for prevention of oral disease is limited. Hence, the need for oral health promotion is pressing. The KSA Ministry of Health should develop and implement programmes, through its primary health clinics, to increase the awareness of the importance of good oral health., (© 2016 The Authors. International Dental Journal published by John Wiley & Sons Ltd on behalf of World Dental Federation.)

Purpose: Chronic diseases and their risk factors are believed to be common in the Kingdom of Saudi Arabia (KSA). Most of them require long-term management through medications. We examined patterns of medication use for chronic health conditions (CHC) in KSA based on a national survey., Methods: The Saudi Health Interview Survey was a cross-sectional nationally representative household survey of 10,735 individuals aged 15 years or older in 2013. The survey consisted of a detailed health questionnaire. Current medications for CHC were assessed and classified based on the Anatomical Therapeutic Chemical classification., Results: Among the respondents, 11.8% (standard error = 0.4) reported taking at least one medication for CHC with a mean number of 2.05 (standard error = 0.05) medication items. In addition to older age (odds ratio = 1.94 per each decade, 95%CI: 1.83-2.05) and male gender (odds ratio = 1.22, 95%CI: 1.06-1.41), those with higher income were more likely to take medication. The most common medicines were drugs used for diabetes (A10 Anatomical Therapeutic Chemical code). The top 20 drugs accounted for about 80% of all medications. Only 32.7% of medications were reported to be used exactly as prescribed., Conclusions: Compared with the prevalence of CHC in KSA, our study indicates a potential underuse of medications as well as non-adherence to the directions for use. Interventions such as improved clinical guidelines for healthcare providers to increase utilization of necessary medication and educational programs to improve patients' adherence are needed., (Copyright © 2015 John Wiley & Sons, Ltd.)

Risk factors for primary Middle East respiratory syndrome coronavirus (MERS-CoV) illness in humans are incompletely understood. We identified all primary MERS-CoV cases reported in Saudi Arabia during March-November 2014 by excluding those with history of exposure to other cases of MERS-CoV or acute respiratory illness of unknown cause or exposure to healthcare settings within 14 days before illness onset. Using a case-control design, we assessed differences in underlying medical conditions and environmental exposures among primary case-patients and 2-4 controls matched by age, sex, and neighborhood. Using multivariable analysis, we found that direct exposure to dromedary camels during the 2 weeks before illness onset, as well as diabetes mellitus, heart disease, and smoking, were each independently associated with MERS-CoV illness. Further investigation is needed to better understand animal-to-human transmission of MERS-CoV.

Background: The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age-sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development., Methods: We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time., Findings: Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6-6·6), from 65·3 years (65·0-65·6) in 1990 to 71·5 years (71·0-71·9) in 2013, HALE at birth rose by 5·4 years (4·9-5·8), from 56·9 years (54·5-59·1) to 62·3 years (59·7-64·8), total DALYs fell by 3·6% (0·3-7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6-29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non-communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries., Interpretation: Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition--in which increasing sociodemographic status brings structured change in disease burden--is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions., Funding: Bill & Melinda Gates Foundation., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Vitamin D deficiency has been correlated with several diseases and injuries including diabetes, osteoporosis, fractures, and falls. In the Kingdom of Saudi Arabia (KSA), current data on vitamin D status are lacking., Aims: To inform Saudi public health authorities on the current status of blood levels vitamin D deficiency, we analyzed data from the Saudi Health Interview Survey., Materials and Methods: The Saudi Health Interview Survey (SHIS) is a cross-sectional national multistage survey of individuals aged 15 years and above on sociodemographic characteristics, tobacco consumption, diet, physical activity, health care utilization, different health-related behaviors, and self-reported chronic conditions. A total of 10,735 participants completed a health questionnaire and were invited to the local health clinics for biomedical exams., Results: 62.65% of female Saudis and 40.6% of male Saudis aged 15 years and above are deficient in vitamin D. Out of them, less than 1% males and less than 2% females consume vitamin D supplements. Women who have never married and obese individuals are more likely to be deficient in vitamin D, compared to men who were currently married and nonobese individuals. Those consuming vitamin D supplements are less likely to be deficient in vitamin D., Conclusions: Our study showed a high prevalence of vitamin D deficiency among Saudi men and women, and the results call for an increased awareness to ensure adequate levels of vitamin D for better health in Saudi Arabia. Moreover, our findings are certainly relevant for other countries in the Gulf region or countries with similar cultures, clothing, and religions.

Self-rated health reflects a person's integrated perception of health, including its biological, psychological, and social dimensions. It is a predictor of morbidity and mortality. To assess the current status of self-rated health and associated factors in the Kingdom of Saudi Arabia, we analyzed data from the Saudi Health Interview Survey. We conducted a large national survey of adults aged 15 years or older. A total of 10,735 participants completed a standardized health questionnaire. Respondents rated their health with a five-point scale. Data on socio-demographic characteristics, chronic diseases, health-related habits and behaviors, and anthropometric measurements were collected. Associated factors of self-rated health were analyzed using a backward elimination multivariate logistic regression model. More than 77% of respondents rated their health as excellent/very good. Female sex [odds ratio (OR) 1.52, 95% confidence interval (CI) 1.24-1.88], decades of age (OR 1.35, 95% CI 1.25-1.46), diagnosed diabetes mellitus (OR 1.54, 95 CI 1.22-1.93), diagnosed hypercholesterolemia (OR 1.37, 95% CI 1.06-1.79), diagnosed hypertension (OR 1.55, 95% CI 1.22-1.96), number of other diagnosed chronic diseases (OR 1.69, 95% CI 1.41-2.03), limited vigorous activity (OR 3.59, 95% CI 2.84-4.53), need for special equipment (OR 2.62, 95% CI 1.96-3.51), and more than 3 h of daily television/computer screen time (OR 1.59, 95% CI 1.11-2.29) were positively associated with poor/fair health. Smoking, obesity, and physical inactivity were not associated with self-reported health. We found that preventable risk factors are not associated with Saudis' self-rated health. This optimistic perception of health poses a challenge for preventive interventions in the Kingdom and calls for campaigns to educate the public about the harm of unhealthy behaviors.

Background: There are not enough data on the epidemiology of asthma in the Kingdom of Saudi Arabia (KSA). We analyzed data from a national household survey conducted in KSA in 2013 to estimate prevalence, associated risk factors and control measurements of asthma., Methods: The Saudi Health Interview Survey was a cross-sectional national multistage survey of 10,735 individuals aged 15 years or older. The survey included a detailed household questionnaire and a physical exam. We used self-reported clinical diagnosis of asthma to assess prevalence of asthma., Results: The prevalence of asthma in KSA was 4.05 % (95 % confidence interval [CI]: 3.54-4.62 %). Asthma was less frequent in individuals with higher education but higher in former smokers and obese individuals. Around 76.7 % of asthma patients (95 % CI: 70.6-82.0 %) experienced an asthmatic attack, and 61.6 % (95 % CI: 54.4-68.4 %) visited a hospital/emergency room because of asthma during the past year. Asthma attack was less frequent in older patients (odds ratio [OR] = 0.78, 95 %CI: 0.59-0.96 for each decade of life). Current use of medication for asthma was highly associated with asthma attacks (OR = 9.14, 95 % CI: 3.29-25.38). Asthma attack was also more frequent in individuals who were exposed to secondhand smoking (OR = 2.17, 95 %CI: 1.05-4.45) and those who were obese (OR = 3.01, 95 %CI: 1.34-6.78)., Conclusion: Saudi Arabia has a relatively low prevalence of diagnosed asthma; however, many of the patients with known asthma do not have it under good control. Our study calls for programs to inform patients about the importance and proper means of controlling their condition. Implementing and monitoring of clinical guidelines can also help to improve asthma control among patients as well as identify undiagnosed cases.

Background: Tobacco consumption is a major risk factor for morbidity and mortality. The Saudi Ministry of Health started a national tobacco control program in 2002 with increased and intensified efforts after joining the World Health Organization Framework Convention for Tobacco Control in 2005., Methods: In order to assess the status of tobacco consumption in the Kingdom of Saudi Arabia (KSA), we conducted a survey on 10735 individuals aged 15 years or older (5253 men and 5482 women) which was performed between April and June 2013. The Saudi Health Interview Survey had a multistage sampling and was nationally representative. Data were collected through face-to-face interviews. The survey included questions on socio-demographic characteristics, tobacco consumption, diet, physical activity, health care utilization, different health-related behaviors, and self-reported chronic conditions., Results: Overall prevalence of current smoking was 12.2 % and males were more likely to smoke than females (21.5 % vs. 1.1 %). Mean age of smoking initiation was 19.1 years (±6.5 years) with 8.9 % of ever smokers starting before the age of 15 years. Daily shisha smoking was reported by 4.3 % of the population (7.3 % of men and 1.3 % of women). Around 1.4 % of population (2.6 % of men and 0.1 % of women) were daily smokers of cigarette/cigar and shisha. Receiving advice for quitting smoking by health care professionals during the last 12 months was reported by 53.2 % (95 % confidence interval [CI]: 49.8-56.5) of ever smokers. Among ever smokers, 51.3 % of individuals reportedly attempted to quit smoking during the last 12 months. Of those, 25.3 % were successful by the time of the survey. Around 23.3 % of the entire population, 32.3 % of men and 13.5 % of women, were exposed to secondhand smoke for at least one day during the past 7 days at home, work, or school., Conclusions: Although the indicators of tobacco consumption in KSA are better than most of the countries of the Middle East region and high-income countries, there are many potential areas for improvement. Our findings call for the development and implementation of programs to prevent smoking initiation and encourage quitting. To achieve its health goals, KSA may consider increasing taxation on tobacco products as well as other measures.

Introduction: It is unknown whether Saudis receive health examinations periodically. To inform health authorities on the health-seeking behavior of the Saudi population, we investigated patterns of periodic health examination (PHE) use by Saudis., Materials and Methods: We conducted a nationally representative multistage survey of individuals aged 15 years or older on sociodemographic characteristics, healthcare utilization, and self-reported chronic conditions. We used a backward elimination multivariate logistic regression model to measure associations between PHE and sociodemographic, behavioral, and health characteristics., Results: Between April and June 2013, a total of 12,000 households were contacted, and 10,735 participants completed the survey (response rate of 89.4%). Among participants, 2542 (22.9%), representing more than 2.7 million Saudis aged 15 years or older, received a PHE during the past 2 years. Moreover, 7463 (73.5%) participants, representing 9.1 million Saudis, visited a healthcare setting in the past 2 years due to illness or injury. The likelihood of receiving a PHE in the past 2 years increased with age, education, being married, consumption of five servings of fruits and vegetables per day, diagnoses of prediabetes, diabetes, or hypercholesterolemia, and a visit to a healthcare setting within the last 2 years due to an illness or an injury., Discussion: This is the first national study to investigate the use of PHE in Kingdom of Saudi Arabia (KSA) where healthcare is freely available. Few Saudis seek preventive healthcare and most healthcare visits are for injuries or sickness. KSA may reduce its health expenditures by routinizing PHE and detecting chronic conditions at early stages.

Objectives: We analysed data from a large household survey to identify barriers to healthcare in the Kingdom of Saudi Arabia., Methods: The Saudi Health Interview Survey (SHIS) is a national multistage survey of individuals aged 15 years or older. The survey combined a household questionnaire and a laboratory blood analysis. We used a backward elimination multivariate logistic regression model to measure association between (1) diagnosis, (2) treatment, and (3) control of hypertension or diabetes and sociodemographic factors, history of diagnosis with chronic conditions, and type of, and distance travelled to, the clinic last visited., Results: Between April and June 2013, a total of 10,735 participants completed SHIS and were invited to the local health clinics. Among hypertensive individuals, women, older individuals, and those previously diagnosed with diabetes and hypercholesterolaemia were more likely to have been diagnosed with hypertension than their counterparts. Among participants diagnosed with hypertension, the likelihood of being treated increased with age and education. The likelihood of having uncontrolled blood pressure despite treatment increased with education and a history of diagnosis with hypercholesterolaemia. Type of clinic visited and distance travelled to last clinic visit were not associated with diagnosis or treatment of hypertension or control of blood pressure. Similar factors were associated with the likelihood of diagnosis and treatment among individuals with diabetes. Having uncontrolled glycated haemoglobin levels, despite treatment, was less common among those who visited governmental clinics other than those of the Ministry of Health, compared with those who visited Ministry clinics., Conclusions: Our findings highlight the importance of individual characteristics in healthcare-seeking practices rather than system-based potential barriers. Saudis seem to mostly seek healthcare when sick. Hence, the Saudi Ministry of Health needs to implement a comprehensive plan including health education and investigations, to understand the barriers and bottlenecks to healthcare-seeking behaviour., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Introduction: Mammography ensures early diagnosis and a better chance for treatment and recovery from breast cancer. We conducted a national survey to investigate knowledge and practices of breast cancer screening among Saudi women aged 50 years or older in order to inform the breast cancer national health programs., Materials and Methods: The Saudi Health Interview Survey is a national multistage survey of individuals aged 15 years or older. The survey included questions on socio-demographic characteristics, tobacco consumption, diet, physical activity, health-care utilization, different health-related behaviors, and self-reported chronic conditions. Female respondents were asked about knowledge and practices of self and clinical breast exams, as well as mammography., Results: Between April and June 2013, a total of 10,735 participants completed the survey. Among respondents, 1,135 were women aged 50 years or older and were included in this analysis. About 89% of women reported not having a clinical breast exam in the past year, and 92% reported never having a mammogram. Women living in Al Sharqia had the highest rate of mammography use. Women who were educated, those who had received a routine medical exam within the last two years, and those who were diagnosed with hypertension were more likely to have had a mammogram in the past two years., Discussion: Our results show very low rates of breast cancer screening in the Kingdom of Saudi Arabia, a country with free health services. This calls for educational campaigns to improve breast cancer screening. Addressing the barriers for breast cancer screening is a public health imperative.

Introduction: Road traffic injuries are the largest cause of loss of disability-adjusted life years for men and women of all ages in the Kingdom of Saudi Arabia, but data on driving habits there are lacking. To inform policymakers on drivers' abilities and driving habits, we analyzed data from the Saudi Health Interview Survey 2013., Methods: We surveyed a representative sample of 5,235 Saudi males aged 15 years or older on wearing seat belts, exceeding speed limits, and using a handheld cell phone while driving. Male and female respondents were surveyed on wearing seat belts as passengers., Results: Among Saudi males, 71.7% reported having had a driver's license, but more than 43% of unlicensed males drove a vehicle. Among drivers, 86.1% engaged in at least one risky behavior while driving. Older and unlicensed drivers were more likely to take risks while driving. This risk decreased among the more educated, current smokers, and those who are physically active. Up to 94.9% and 98.5% of respondents reported not wearing a seat belt in the front and the back passenger seats, respectively., Discussion: The high burden of road traffic injuries in the Kingdom is not surprising given our findings. Our study calls for aggressive monitoring and enforcement of traffic laws. Awareness and proper education for drivers and their families should be developed jointly by the Ministries of Health, Interior Affairs, and Education and provided through their channels.

Objectives: In the Kingdom of Saudi Arabia (KSA), current data on diabetes are lacking, and a rise of the epidemic is feared, given the epidemiologic transition in the country. To inform public health authorities on the current status of the diabetes epidemic, we analyzed data from the Saudi Health Interview Survey (SHIS)., Methods: Saudi Health Interview Survey is a cross-sectional national multistage survey of individuals aged 15 years or older. A total of 10,735 participants completed a health questionnaire and were invited to the local health clinics for biomedical exams., Results: 1,745,532 (13.4 %) Saudis aged 15 years or older have diabetes. Among those, 57.8, 20.2, 16.6, and 5.4 % are undiagnosed, treated uncontrolled, treated controlled, and untreated, respectively. Males, older individuals, and those who were previously diagnosed with hypertension or hypercholesterolemia were more likely to be diabetic., Conclusions: Our findings call for increased awareness of pre-diabetes, diabetes, and undiagnosed diabetes in KSA. Combatting diabetes and other non-communicable diseases should be the task of the Ministry of Health and other ministries as well, to offer a comprehensive socio-cultural approach to fighting this epidemic.

Purpose: To assess the prevalence of hypercholesterolemia and its associated factors in the Kingdom of Saudi Arabia., Methods: A national multistage representative sample of Saudis aged 15 years or older was surveyed through face-to-face interviews. Data on sociodemographics, risk factors, and health information were collected, and blood sample analysis was performed. Data were analyzed using SAS 9.3 to account for the sample weights and complex survey design., Results: Between April and June 2013, a total of 10,735 participants completed the survey. Overall, 8.5% of Saudis had hypercholesterolemia. Another 19.6% had borderline hypercholesterolemia. Among hypercholesterolemic Saudis, 65.1% were undiagnosed, 2.3% were treated uncontrolled, 28.3% were treated controlled, and 4.3% were untreated. The risk of being hypercholesterolemic increased with age and among individuals who reported consuming margarine, obese individuals, and those who have been previously diagnosed with hypertension or diabetes., Conclusions: More than a million Saudis have hypercholesterolemia, and 700,000 of them are unaware of their condition which can be controlled through early detection campaigns and lifestyle change and medication. An urgent awareness and screening campaign is needed in Kingdom of Saudi Arabia to prevent and avoid disease progression toward more serious stages., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Introduction: Data on obesity from the Kingdom of Saudi Arabia (KSA) are nonexistent, making it impossible to determine whether the efforts of the Saudi Ministry of Health are having an effect on obesity trends. To determine obesity prevalence and associated factors in the KSA, we conducted a national survey on chronic diseases and their risk factors., Methods: We interviewed 10,735 Saudis aged 15 years or older (51.1% women) through a multistage survey. Data on sociodemographic characteristics, health-related habits and behaviors, diet, physical activity, chronic diseases, access to and use of health care, and anthropometric measurements were collected through computer-assisted personal interviews. We first compared sociodemographic factors and body mass index between men and women. Next, we conducted a sex-specific analysis for obesity and its associated factors using backward elimination multivariate logistic regression models. We used SAS 9.3 for the statistical analyses and to account for the complex sampling design., Results: Of the 10,735 participants evaluated, 28.7% were obese (body mass index ≥ 30 kg/m(2)). Prevalence of obesity was higher among women (33.5% vs 24.1%). Among men, obesity was associated with marital status, diet, physical activity, diagnoses of diabetes and hypercholesterolemia, and hypertension. Among women, obesity was associated with marital status, education, history of chronic conditions, and hypertension., Conclusion: Obesity remains strongly associated with diabetes, hypercholesterolemia, and hypertension in the KSA, although the epidemic's characteristics differ between men and women.

Introduction: We report the burden of disease and risk factors measured by causes of death, years of life lost attributable to premature mortality (YLLs), years of life lived with disability (YLDs), and disability-adjusted life years (DALYs) for 1990, 2005, and 2010 in the Kingdom of Saudi Arabia (KSA)., Methods: We used the Global Burden of Diseases 2010 (GBD 2010) methodology to estimate the country-level burden of disease in KSA. We used data from systematic reviews of the literature, household survey data, antenatal clinic surveillance data, reportable disease notifications, disease registries, hospital admissions data, outpatient visit data, population-based cancer registries, active screening data, and other administrative data., Results: Noncommunicable diseases and road traffic injuries became the leading cause of death and disability in KSA in 2010. Elevated body mass index was the leading risk factor for disease (7.02% for males and 4.61% for females in 2010). High glucose levels were the second leading disease risk factor for females (3.28%) and third for males (6.25%) in 2010. Preterm birth complications were the main cause for DALYs in 1990; however, in 2010, the leading cause of DALYs for males was road traffic injuries (12.40%) and for females it was major depressive disorder (7.88%)., Conclusion: KSA is facing a rising burden of noncommunicable diseases and road traffic injuries as a result of rapid changes in behaviors. Our results demonstrate the need for major intervention to reduce these burdens and to engage other sectors of the government and the community in these efforts.

Background: The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery., Methods: We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values., Findings: 292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0·3% (-1·1 to 0·6) from 1990 to 2003, and -2·7% (-3·9 to -1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0·4% (0·2-0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956·8 (685·1-1262·8) in South Sudan to 2·4 (1·6-3·6) in Iceland., Interpretation: Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa., Funding: Bill & Melinda Gates Foundation., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Remarkable financial and political efforts have been focused on the reduction of child mortality during the past few decades. Timely measurements of levels and trends in under-5 mortality are important to assess progress towards the Millennium Development Goal 4 (MDG 4) target of reduction of child mortality by two thirds from 1990 to 2015, and to identify models of success., Methods: We generated updated estimates of child mortality in early neonatal (age 0-6 days), late neonatal (7-28 days), postneonatal (29-364 days), childhood (1-4 years), and under-5 (0-4 years) age groups for 188 countries from 1970 to 2013, with more than 29,000 survey, census, vital registration, and sample registration datapoints. We used Gaussian process regression with adjustments for bias and non-sampling error to synthesise the data for under-5 mortality for each country, and a separate model to estimate mortality for more detailed age groups. We used explanatory mixed effects regression models to assess the association between under-5 mortality and income per person, maternal education, HIV child death rates, secular shifts, and other factors. To quantify the contribution of these different factors and birth numbers to the change in numbers of deaths in under-5 age groups from 1990 to 2013, we used Shapley decomposition. We used estimated rates of change between 2000 and 2013 to construct under-5 mortality rate scenarios out to 2030., Findings: We estimated that 6·3 million (95% UI 6·0-6·6) children under-5 died in 2013, a 64% reduction from 17·6 million (17·1-18·1) in 1970. In 2013, child mortality rates ranged from 152·5 per 1000 livebirths (130·6-177·4) in Guinea-Bissau to 2·3 (1·8-2·9) per 1000 in Singapore. The annualised rates of change from 1990 to 2013 ranged from -6·8% to 0·1%. 99 of 188 countries, including 43 of 48 countries in sub-Saharan Africa, had faster decreases in child mortality during 2000-13 than during 1990-2000. In 2013, neonatal deaths accounted for 41·6% of under-5 deaths compared with 37·4% in 1990. Compared with 1990, in 2013, rising numbers of births, especially in sub-Saharan Africa, led to 1·4 million more child deaths, and rising income per person and maternal education led to 0·9 million and 2·2 million fewer deaths, respectively. Changes in secular trends led to 4·2 million fewer deaths. Unexplained factors accounted for only -1% of the change in child deaths. In 30 developing countries, decreases since 2000 have been faster than predicted attributable to income, education, and secular shift alone., Interpretation: Only 27 developing countries are expected to achieve MDG 4. Decreases since 2000 in under-5 mortality rates are accelerating in many developing countries, especially in sub-Saharan Africa. The Millennium Declaration and increased development assistance for health might have been a factor in faster decreases in some developing countries. Without further accelerated progress, many countries in west and central Africa will still have high levels of under-5 mortality in 2030., Funding: Bill & Melinda Gates Foundation, US Agency for International Development., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: The Arab world has a set of historical, geopolitical, social, cultural, and economic characteristics and has been involved in several wars that have affected the burden of disease. Moreover, financial and human resources vary widely across the region. We aimed to examine the burden of diseases and injuries in the Arab world for 1990, 2005, and 2010 using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010)., Methods: We divided the 22 countries of the Arab League into three categories according to their gross national income: low-income countries (LICs; Comoros, Djibouti, Mauritania, Yemen, and Somalia), middle-income countries (MICs; Algeria, Egypt, Iraq, Jordan, Lebanon, Libya, Morocco, occupied Palestinian territory, Sudan, Syria, and Tunisia), and high-income countries (HICs; Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates). For the whole Arab world, each income group, and each individual country, we estimated causes of death, disability-adjusted life years (DALYs), DALY-attributable risk factors, years of life lived with disability (YLDs), years of life lost due to premature mortality (YLLs), and life expectancy by age and sex for 1990, 2005, and 2010., Findings: Ischaemic heart disease was the top cause of death in the Arab world in 2010 (contributing to 14·3% of deaths), replacing lower respiratory infections, which were the leading cause of death in 1990 (11·0%). Lower respiratory infections contributed to the highest proportion of DALYs overall (6·0%), and in female indivduals (6·1%), but ischaemic heart disease was the leading cause of DALYs in male individuals (6·0%). DALYs from non-communicable diseases--especially ischaemic heart disease, mental disorders such as depression and anxiety, musculoskeletal disorders including low back pain and neck pain, diabetes, and cirrhosis--increased since 1990. Major depressive disorder was ranked first as a cause of YLDs in 1990, 2005, and 2010, and lower respiratory infections remained the leading cause of YLLs in 2010 (9·2%). The burden from HIV/AIDS also increased substantially, specifically in LICs and MICs, and road injuries continued to rank highly as a cause of death and DALYs, especially in HICs. Deaths due to suboptimal breastfeeding declined from sixth place in 1990 to tenth place in 2010, and childhood underweight declined from fifth to 11th place., Interpretation: Since 1990, premature death and disability caused by communicable, newborn, nutritional, and maternal disorders (with the exception of HIV/AIDS) has decreased in the Arab world--although these disorders do still persist in LICs--whereas the burden of non-communicable diseases and injuries has increased. The changes in the burden of disease will challenge already stretched human and financial resources because many Arab countries are now dealing with both non-communicable and infectious diseases. A road map for health in the Arab world is urgently needed., Funding: Bill & Melinda Gates Foundation., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Current data on hypertension in the Kingdom of Saudi Arabia are lacking. We conducted a national survey to inform decision-makers on the current magnitude of the epidemic. We measured systolic and diastolic blood pressure of 10,735 Saudis aged 15 years or older and interviewed them through a national multistage survey. We used multivariate logistic regressions to describe sociodemographic characteristics and risk factors of hypertensive, borderline hypertensive, and undiagnosed hypertensive Saudis. We found that 15.2% and 40.6% of Saudis were hypertensive or borderline hypertensive, respectively. Risk of hypertension increased among men, with age, obesity, diabetes, and hypercholesterolemia. 57.8% of hypertensive Saudis were undiagnosed. These were more likely to be male, older, and diagnosed with diabetes. Among participants diagnosed with hypertension, 78.9% reported taking medication for their condition. About 45% of participants on medication for hypertension had their blood pressure controlled. The prevalence of hypertension and borderline hypertension is very high in Saudi Arabia. Moreover, control of hypertension is poor. With the majority of hypertensive Saudis being unaware of their condition, a national plan is needed to increase utilization of freely available screening, preventive, and medical services.

Objectives: To identify the occurrence of upper respiratory tract infections (URTI), diarrheal diseases and trauma during the Haji season, and the practice of some preventive measures by pilgrims., Methods: A cohort study during November and December 2009 among hajjis registered while visiting Primary Health Care Centers of Riyadh, Kingdom of Saudi Arabia to get mandatory meningococcal meningitis vaccination. On return from hajj, hajjis were contacted on telephone to collect information on occurrence of URTI and diarrhea along with other associated activities in Hajj., Results: Out of 1507 hajjis, 54.7% developed symptoms; 97% reported upper respiratory tract symptoms, and 9.3% reported diarrheal symptoms. Those < 40 years of age were more likely to develop an URTI. The incidence of diarrheal diseases or trauma was not statistically associated with age. No statistical difference for educational level was found for U RTI or trauma, but there was a statistically significant difference for diarrheal diseases. There was no statistical difference for nationality in relation to diarrheal diseases and trauma, but there was a statistically significant difference for URTI. There was a statistically significant difference of URTI between those pilgrims who used the face mask most of the time and those who used it sometimes., Conclusion: Upper respiratory tract infections is a common health problem among studied domestic hajjis. Generally, there is room for improvement in the adoption of preventive measures by hajjis; and there is still limited information on the use of facemasks in spite of the fact that using it significantly decreases the risk for URTI.

Background: Non-fatal health outcomes from diseases and injuries are a crucial consideration in the promotion and monitoring of individual and population health. The Global Burden of Disease (GBD) studies done in 1990 and 2000 have been the only studies to quantify non-fatal health outcomes across an exhaustive set of disorders at the global and regional level. Neither effort quantified uncertainty in prevalence or years lived with disability (YLDs)., Methods: Of the 291 diseases and injuries in the GBD cause list, 289 cause disability. For 1160 sequelae of the 289 diseases and injuries, we undertook a systematic analysis of prevalence, incidence, remission, duration, and excess mortality. Sources included published studies, case notification, population-based cancer registries, other disease registries, antenatal clinic serosurveillance, hospital discharge data, ambulatory care data, household surveys, other surveys, and cohort studies. For most sequelae, we used a Bayesian meta-regression method, DisMod-MR, designed to address key limitations in descriptive epidemiological data, including missing data, inconsistency, and large methodological variation between data sources. For some disorders, we used natural history models, geospatial models, back-calculation models (models calculating incidence from population mortality rates and case fatality), or registration completeness models (models adjusting for incomplete registration with health-system access and other covariates). Disability weights for 220 unique health states were used to capture the severity of health loss. YLDs by cause at age, sex, country, and year levels were adjusted for comorbidity with simulation methods. We included uncertainty estimates at all stages of the analysis., Findings: Global prevalence for all ages combined in 2010 across the 1160 sequelae ranged from fewer than one case per 1 million people to 350,000 cases per 1 million people. Prevalence and severity of health loss were weakly correlated (correlation coefficient -0·37). In 2010, there were 777 million YLDs from all causes, up from 583 million in 1990. The main contributors to global YLDs were mental and behavioural disorders, musculoskeletal disorders, and diabetes or endocrine diseases. The leading specific causes of YLDs were much the same in 2010 as they were in 1990: low back pain, major depressive disorder, iron-deficiency anaemia, neck pain, chronic obstructive pulmonary disease, anxiety disorders, migraine, diabetes, and falls. Age-specific prevalence of YLDs increased with age in all regions and has decreased slightly from 1990 to 2010. Regional patterns of the leading causes of YLDs were more similar compared with years of life lost due to premature mortality. Neglected tropical diseases, HIV/AIDS, tuberculosis, malaria, and anaemia were important causes of YLDs in sub-Saharan Africa., Interpretation: Rates of YLDs per 100,000 people have remained largely constant over time but rise steadily with age. Population growth and ageing have increased YLD numbers and crude rates over the past two decades. Prevalences of the most common causes of YLDs, such as mental and behavioural disorders and musculoskeletal disorders, have not decreased. Health systems will need to address the needs of the rising numbers of individuals with a range of disorders that largely cause disability but not mortality. Quantification of the burden of non-fatal health outcomes will be crucial to understand how well health systems are responding to these challenges. Effective and affordable strategies to deal with this rising burden are an urgent priority for health systems in most parts of the world., Funding: Bill & Melinda Gates Foundation., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Measuring disease and injury burden in populations requires a composite metric that captures both premature mortality and the prevalence and severity of ill-health. The 1990 Global Burden of Disease study proposed disability-adjusted life years (DALYs) to measure disease burden. No comprehensive update of disease burden worldwide incorporating a systematic reassessment of disease and injury-specific epidemiology has been done since the 1990 study. We aimed to calculate disease burden worldwide and for 21 regions for 1990, 2005, and 2010 with methods to enable meaningful comparisons over time., Methods: We calculated DALYs as the sum of years of life lost (YLLs) and years lived with disability (YLDs). DALYs were calculated for 291 causes, 20 age groups, both sexes, and for 187 countries, and aggregated to regional and global estimates of disease burden for three points in time with strictly comparable definitions and methods. YLLs were calculated from age-sex-country-time-specific estimates of mortality by cause, with death by standardised lost life expectancy at each age. YLDs were calculated as prevalence of 1160 disabling sequelae, by age, sex, and cause, and weighted by new disability weights for each health state. Neither YLLs nor YLDs were age-weighted or discounted. Uncertainty around cause-specific DALYs was calculated incorporating uncertainty in levels of all-cause mortality, cause-specific mortality, prevalence, and disability weights., Findings: Global DALYs remained stable from 1990 (2·503 billion) to 2010 (2·490 billion). Crude DALYs per 1000 decreased by 23% (472 per 1000 to 361 per 1000). An important shift has occurred in DALY composition with the contribution of deaths and disability among children (younger than 5 years of age) declining from 41% of global DALYs in 1990 to 25% in 2010. YLLs typically account for about half of disease burden in more developed regions (high-income Asia Pacific, western Europe, high-income North America, and Australasia), rising to over 80% of DALYs in sub-Saharan Africa. In 1990, 47% of DALYs worldwide were from communicable, maternal, neonatal, and nutritional disorders, 43% from non-communicable diseases, and 10% from injuries. By 2010, this had shifted to 35%, 54%, and 11%, respectively. Ischaemic heart disease was the leading cause of DALYs worldwide in 2010 (up from fourth rank in 1990, increasing by 29%), followed by lower respiratory infections (top rank in 1990; 44% decline in DALYs), stroke (fifth in 1990; 19% increase), diarrhoeal diseases (second in 1990; 51% decrease), and HIV/AIDS (33rd in 1990; 351% increase). Major depressive disorder increased from 15th to 11th rank (37% increase) and road injury from 12th to 10th rank (34% increase). Substantial heterogeneity exists in rankings of leading causes of disease burden among regions., Interpretation: Global disease burden has continued to shift away from communicable to non-communicable diseases and from premature death to years lived with disability. In sub-Saharan Africa, however, many communicable, maternal, neonatal, and nutritional disorders remain the dominant causes of disease burden. The rising burden from mental and behavioural disorders, musculoskeletal disorders, and diabetes will impose new challenges on health systems. Regional heterogeneity highlights the importance of understanding local burden of disease and setting goals and targets for the post-2015 agenda taking such patterns into account. Because of improved definitions, methods, and data, these results for 1990 and 2010 supersede all previously published Global Burden of Disease results., Funding: Bill & Melinda Gates Foundation., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex., Methods: We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions., Findings: In 2010, there were 52·8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24·9% of deaths worldwide in 2010, down from 15·9 million (34·1%) of 46·5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2·5 to 1·4 million), lower respiratory infections (from 3·4 to 2·8 million), neonatal disorders (from 3·1 to 2·2 million), measles (from 0·63 to 0·13 million), and tetanus (from 0·27 to 0·06 million). Deaths from HIV/AIDS increased from 0·30 million in 1990 to 1·5 million in 2010, reaching a peak of 1·7 million in 2006. Malaria mortality also rose by an estimated 19·9% since 1990 to 1·17 million deaths in 2010. Tuberculosis killed 1·2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34·5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1·5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12·9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1·3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5·1 million deaths) was marginally higher in 2010 (9·6%) compared with two decades earlier (8·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1·3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45-54% since 1990; ischaemic heart disease and stroke YLLs increased by 17-28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted., Interpretation: Population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis., Funding: Bill & Melinda Gates Foundation., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Quantification of the disease burden caused by different risks informs prevention by providing an account of health loss different to that provided by a disease-by-disease analysis. No complete revision of global disease burden caused by risk factors has been done since a comparative risk assessment in 2000, and no previous analysis has assessed changes in burden attributable to risk factors over time., Methods: We estimated deaths and disability-adjusted life years (DALYs; sum of years lived with disability [YLD] and years of life lost [YLL]) attributable to the independent effects of 67 risk factors and clusters of risk factors for 21 regions in 1990 and 2010. We estimated exposure distributions for each year, region, sex, and age group, and relative risks per unit of exposure by systematically reviewing and synthesising published and unpublished data. We used these estimates, together with estimates of cause-specific deaths and DALYs from the Global Burden of Disease Study 2010, to calculate the burden attributable to each risk factor exposure compared with the theoretical-minimum-risk exposure. We incorporated uncertainty in disease burden, relative risks, and exposures into our estimates of attributable burden., Findings: In 2010, the three leading risk factors for global disease burden were high blood pressure (7·0% [95% uncertainty interval 6·2-7·7] of global DALYs), tobacco smoking including second-hand smoke (6·3% [5·5-7·0]), and alcohol use (5·5% [5·0-5·9]). In 1990, the leading risks were childhood underweight (7·9% [6·8-9·4]), household air pollution from solid fuels (HAP; 7·0% [5·6-8·3]), and tobacco smoking including second-hand smoke (6·1% [5·4-6·8]). Dietary risk factors and physical inactivity collectively accounted for 10·0% (95% UI 9·2-10·8) of global DALYs in 2010, with the most prominent dietary risks being diets low in fruits and those high in sodium. Several risks that primarily affect childhood communicable diseases, including unimproved water and sanitation and childhood micronutrient deficiencies, fell in rank between 1990 and 2010, with unimproved water and sanitation accounting for 0·9% (0·4-1·6) of global DALYs in 2010. However, in most of sub-Saharan Africa childhood underweight, HAP, and non-exclusive and discontinued breastfeeding were the leading risks in 2010, while HAP was the leading risk in south Asia. The leading risk factor in Eastern Europe, most of Latin America, and southern sub-Saharan Africa in 2010 was alcohol use; in most of Asia, North Africa and Middle East, and central Europe it was high blood pressure. Despite declines, tobacco smoking including second-hand smoke remained the leading risk in high-income north America and western Europe. High body-mass index has increased globally and it is the leading risk in Australasia and southern Latin America, and also ranks high in other high-income regions, North Africa and Middle East, and Oceania., Interpretation: Worldwide, the contribution of different risk factors to disease burden has changed substantially, with a shift away from risks for communicable diseases in children towards those for non-communicable diseases in adults. These changes are related to the ageing population, decreased mortality among children younger than 5 years, changes in cause-of-death composition, and changes in risk factor exposures. New evidence has led to changes in the magnitude of key risks including unimproved water and sanitation, vitamin A and zinc deficiencies, and ambient particulate matter pollution. The extent to which the epidemiological shift has occurred and what the leading risks currently are varies greatly across regions. In much of sub-Saharan Africa, the leading risks are still those associated with poverty and those that affect children., Funding: Bill & Melinda Gates Foundation., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objectives: To identify the occurrence of upper respiratory tract infections (URTI), diarrheal diseases and trauma during the Hajj season, and the practice of some preventive measures by pilgrims., Methods: A cross-sectional study during November and December 2009 among hajjis registered while visiting Primary Health Care Centers of Riyadh, Kingdom of Saudi Arabia to get mandatory meningococcal meningitis vaccination. On return from hajj, hajjis were contacted on telephone to collect information on occurrence of URTI and diarrhea along with other associated activities in Hajj., Results: Out of 1507 hajjis, 54.7% developed symptoms; 97% reported upper respiratory tract symptoms, and 9.3% reported diarrheal symptoms. Those <40 years of age were more likely to develop an URTI. The incidence of diarrheal diseases or trauma was not statistically associated with age. No statistical difference for educational level was found for URTI or trauma, but there was a statistically significant difference for diarrheal diseases. There was no statistical difference for nationality in relation to diarrheal diseases and trauma, but there was a statistically significant difference for URTI. There was a statistically significant difference of URTI between those pilgrims who used the face mask most of the time and those who used it sometimes., Conclusion: Upper respiratory tract infections is a common health problem among studied domestic hajjis. Generally, there is room for improvement in the adoption of preventive measures by hajjis; and there is still limited information on the use of facemasks in spite of the fact that using it significantly decreases the risk for URTI.

A 2009 deployment of military units from several Saudi Arabian provinces to Jazan Province, Saudi Arabia, enabled us to evaluate exposure to Alkhurma, Crimean-Congo, dengue, and Rift Valley hemorrhagic fever viruses. Seroprevalence to all viruses was low; however, Alkhurma virus seroprevalence was higher (1.3%) and less geographically restricted than previously thought.

Background and Objectives: In April 2009, the World Health Organization (WHO) declared pandemic influenza A (H1N1) "public health emergency of international concern". On June 11, 2009, WHO raised the pandemic alert level to phase 6, indicating a global pandemic. By December 2009, more than 208 countries and territories had reported swine flu cases. The descriptive epidemiology of the first reported 100 cases of this virus in Saudi Arabia are summarized in this report., Methods: Data were collected from 1 June to 3 July, 2009 using a predesigned questionnaire. Questionnaires were filled by Field Epidemiology Training Program residents. Data for the first 100 complete cases of confirmed pandemic influenza A (H1N1) were compiled and analyzed., Results: The age of reported cases was in the range of 1 to 56 years. The highest percentage of cases was in the age group of 20 to 30 years followed by the age group of 1 to 10 years. Females represented 55% of the cases; imported cases represented 47%, 58% of whom had come via the King Khaled Airport. The most common nationalities most were from Saudi Arabia and the Philippines. The main symptoms were fever (56%), cough (54%), and sore throat and the number of cases was seen to peak from the 27 to 29 June., Conclusion: Pandemic influenza A (H1N1) is still a threat to Saudi Arabia. Thus, comprehensive and effective measures for surveillance and prevention of the disease are needed to control its spread.