Journal of School of Public Health and

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A community-based rubella serological survey of 795 individuals selected by cluster sampling technique from rural areas of Ourmia ,the center of West Azerbaijan province located in the northwestern Iran , was carried out from December 2001 to March 2002. The aims of the study were to characterize rubella epidemiology in a representative non- immunized community in northwest Iran and also to determine national vaccination strategy against rubella. The survey comprised a seroprevalence study, with stratification by age (0-45 years) and sex. Sera from 392 female and 378 male were tested for rubella IgG antibody using enzyme linked immunosorbent assay (ELISA) technique. "Rubella seropositivity" was defined as serum rubella IgG antibody level > or =13 IU/ml. Of the 770 cases, 58.1% were seropositive. Due to mathernal derived antibodies, 100% of the newborns was seropositive. This figure decreased with time until it became zero by 9 months of age. Then from the age of 4y, it began to rise until it peaked at 93.4% in the age group of 15-19 years. Then the seropositivity decreased to 85.7% in the age group of >35 years. Of women in the reproductive age groups (15-45 years), 89.6% were seropositive. No statistically significant difference in seroprevalence was found between the two sexes. This small preliminary study indicates that like many other countries, rubella is endemic in Iran and eliminating rubella and congenital rubella syndrome in the country will require international efforts, including vaccination of preschool- and school-age children and all susceptible young adults.

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A case-control study was undertaken to determine risk factors for malnutrition in Hormozgan Province, which has the highest child malnutritionrateinthiscountry.Thestudy subjects were 6-to 30-month old children living on the outskirts of Bandar Abbas. Cases consisted of 158 children having weight-for-age Z scores under -1 by NCHS/WHO standards, controls were 258 subjects with scores over -1. Physical and anthropometrical examinations were performed and mothers interviewed for personal history and various socioeconomic variables. There was no matching procedure, but sex and age distributions were similar in the two groups. Parental education level was significantly lower in cases than controls (P=0.005) and cases were also more likely to have a history of acute disease (OR=1.66, CI%95 1.07-2.57). While father's occupational status differed somewhat between the two groups (P-0.083), other social and demographic factors such as family size, age difference between siblings, mother's occupation plus vaccination history, parent smoking habits, and the use of day-care facilities were distributed similarly between cases and controls. Early supplemental feeding (P=0.0384) and frequent health check-ups (PO.000) were found to protect against growth retardation. The link between child growth, parental education and regular health monitoring emphasizes the importance of addressing non-nutritional factors in the fight against malnutrition.

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Sulfur mustard is the most widely used chemical agent in the Iran-Iraq war .In a retrospective cohort study of 1337 soldiers with a history of sulfur mustard exposure, factors such as age, smoking habits, number of exposure episodes and the use of gas masks were determined, together with an assessment of their relationship with the occurrence of long-term pulmonary complications. The models suggested by Szklo,BresIow & Kahn were used to determine rates, rate ratios and confidence intervals. The mean age of the victims was 25.5 years (standard deviation = 9.1 years), and more than 96% had experienced only one exposure episode.
15.1% were cigarette smokers, and the majority (94.5%) had used protective gas masks at the time of exposure.
Cumulative incidence of lung complications was 31.6% the lowest rate was noted during the first year of follow-up (7.5/10000), and the highest in the 7th year (769/10000). Estimated rate ratios with 95% confidence intervals for various age groups were as follows: 1.12 (0.88-1.46) for those aged 21-25 years, 1.49 (1.1-2.01) for ages 26-30, 1.7 (1.2-2.4) forages 31-35, and 2.09 (1.55-2.77) for subjects aged 36 and above. Rate ratios with regard to other factors, i.e. more frequent versus single exposure, smoking vs non-smoking and unprotected exposure vs protective mask use were 0.69 (0.42-1.12), 1.08 (0.80-1.45) and 3.04 (2.20-4.20) respectively. Therefore, the estimated rale ratios were significant only for three out of four age groups and for those who had not worn gas masks (p<0.05). Therefore gas mask and age groups of veterans must be considered in assessing the potential consequences of a chemical attack.

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Toxoplasmosis is a common disease caused by the protozoal parasite Toxoplasma gondii. Most human cases occur by 1) eating raw or undercooked meat containing T. gondii tissue cysts. 2) ingestion of oocysts from soil and 3) vertical transmission through the placenta. Immunocompetent adults are usually asymptomatic or present with self-limited fever and lymphadenopathy. Infection acquired during pregnancy can be transmitted to the fetus and may cause mental retardation, blindness, epilepsy, and abortion. In this cross-sectional study we determined the prevalence of toxoplasma infection in residents of Meshkin-Shahr in 2001-2002. We applied a cluster sampling method to family health files in local health centers to recruit a total of 909 individuals for this study. All family members were requested to complete the study&aposs questionnaire. For each individual, two separate blood samples were collected and placed in microhematocrite tubes. Titers of anti-toxoplasma antibodies were measured by IFA with levels in excess of 1/20 taken as positive. Questionnaire information and examination results were analyzed by the SPSS software package using chi-square tests. Results of this survey show the overall prevalence of toxoplasma infection to be around 18.3%. Figures for men and women were 19.7% and 17.2%, respectively but the difference was not statistically significant. Prevalence rates show a significant association with age (greater prevalence in higher age groups) and the type of meat consumed (P<0.05). But there were no significant associations with education level, occupation-keeping cats in the house, ingestion of meat and history of previous abortions. The most frequently occurring antibody titer was 1/20 (6.9%). and frequency decreased with higher antibody titers.
This study shows that toxoplasma infection is not as common in Meshkin-Shahr as in some parts of the country, with more than 80% of individuals being seronegative. Because of the low immunity level and the risk of vertical transmission, educating the public in prevention methods could be very important.

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Human Enteroviruses replicate in gastrointestinal tract and are excreted to the sewage system through feces, so isolation of Enteroviruses from sewage can be considered as a sensitive indicator for virus cirulation in society. They are originally given the name of Enteroviruses, but the inadequacy of this term became apparent when some Coxackie and Echoviruses were also found in acute respiratory infections. Therefore, these viruses can produce acute or paraclinical infecions, the shedding of virus is more than 1010 virus per each gram of feaces. In this study, 63 sewage samples were obtained from the 6 main sewage disposal systems in Tehran by grab sampling: Direct, Pellet, Two–phase methods in 2 sensitive cell lines (Hep2 & RD) and neutralization test were used to determine Enterovirus circulation in one year. None-Typable Enteroviruses, E11 and E25 were isolated more frequently than other Entroviruses. Out of 63 sewege specimens, we isolated 13 (20.63%), 25 (39.68%) & 27 (42.83%) Enteroviruses by Direct, Pellet and Two-phase methods respectively.

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Background and Aim: Limitations of the traditional methods for assessing G*E interaction- including case-control studies- led to development of several non-traditional approaches. This study aims to assess the interaction between the genetic background (history of breast cancer in first degree relatives) and environmental influences (reproductive/menstrual factors) in patients with breast cancer we also compare the statistical efficiency and power of case-control and case-only designs in this setting.
Materials and Methods: In a matched case-control study in Mazandaran province (Iran), 250 incident biopsy-proven cases of breast cancer and 250 age-matched neighbor controls were interviewed. History of breast cancer in mother and/or sister(s) was taken as a surrogate measure of genetic predisposition, while age at first birth, parity, breast feeding, age at menarche and irregular menstruation were considered as relevant environmental factors. For the matched case-control design, we used a conditional logistic regression model to examine main effects and the G*E interaction. In the case-only design, logistic regression analysis was applied to obtain an estimate of G*E interaction, after checking for the independence assumption. We also calculated the power for detecting the interaction by matched case-control and case-only analyses.
Results: Age at first delivery did not meet the assumption of independence (p=0.02), and so was not included in the case-only analysis. No statistically significant interaction effect was seen in the case-control analysis, while case-only analysis showed significant negative interaction between disease in first-degree relatives on the one hand and parity and breast feeding on the other. We also detected a significant positive interaction between genetic predisposition and age at menarche. All the estimated 95% confidence intervals for OR in G*E interactions were narrower in the case-only analysis. For all factors, the power for detecting G*E interaction was greater in the case-only analysis compared to the case-control analysis, with ratios ranging from 1.08 to 2.23.
Conclusion: The case-only design is more efficient and powerful than the case-control design for detecting gene-environment interaction under the assumption of independence. Baseline disease risk, interactions and independent effects should be considered in using the control data for checking the assumption of independence. Considering the existence of another explanatory variable, eg. a mutant gene which may have passed unnoticed, would be the safest approach in a case-only study.

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Background and Aim: Designing, presenting and implementing a model for assessing work-related risk factors for musculoskeletal disorders and subjective pain, using a combination of Quick Exposure Check (QEC) and the Body Mapping Questionnaire in Babol city in 1382. Nowadays, Work-Related (WMSDs) are considered to be the most common occupational disorders in Iran. Because of their debilitating potential, it is necessary to find a quick, user-friendly and valid technique to assess risk factors for WMSDs in this country. The city of Babol has a larger number of industrial centers in comparison with other cities in Mazandaran province. Therefore, it is surprising that there are virtually no reports of WMSD cases in the city. There is a need for a tool capable of showing the real number of cases and evaluate WMSDs in the city.
Material and Methods: It is hoped that the Quick Exposure Check and the Body Mapping Questionnaire, when used in combination, will constitute a highly effective tool for the detection and prevention of a wide range of work-related musculoskeletal disorders. In this survey we try to show the utility and usability of a designed job assessing combination model in a factory in Babol city with at least three results.
Results: 1) We show that not only the number of WMSD cases in the city is not zero, but that there is indeed a substantial amount of disease among industrial workers. 2) According to these findings and other subjective findings of pain, it is urgent to determine the severity of the problem and to recommend appropriate ergonomic interventions (according to QEC’s action level score) accompanied by Body mapping Questionnaire as soon as possible. 3) Considering the significant correlation between QEC action level and subjective findings of pain in the Body Mapping Questionnaire, (Spearman’s rho > 0.5), the model is very useful in periodic examination of workers in factories.
Conclusion: We hope that this highly valid model (QEC/Body mapping) will prove useful in improving the health and thus the quality of the current workforce in the country.

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Background and Aim: In breach of all international conventions, Iraq frequently used chemical weapons against both military and civilian targets in its 8-year war with Iran. The most frequently used agent was sulfur mustard. The effects of mustard gas may be divided into early and late categories. Late lesions, due to the agent's mutagenic and carcinogenic potential, are mainly the results of its action on intracellular particles, probably nucleic acids. Although the occurrence of cancer has been proved following long-term exposure, the presence of a carcinogenic effect in acute, short-term contact is still in doubt.
Materials and Methods: To determine the relationship between cancer and acute exposure to mustard gas, a historical cohort study was carried out in Isfahan province, involving 500 chemically-injured soldiers with at least one episode of exposure to mustard gas. The incidence of cancer and the death rates in these subjects were compared with similar rates from i) 500 unexposed soldiers in the same area and ii) nationwide figures.
Results: All the subjects were male. The mean age in the exposed and unexposed groups were 41(±10.8), and 40(±7.6) years respectively. Within the exposed group, the mean age at first exposure was 24.1(±13) years the mean age at first injury in the unexposed group was 23(±11) years. Eighty-one percent of the cases lived in cities and 19% in rural areas. For 395 persons (84.5%) in the exposed group, education was at high school level or below. Within the same group, 481 subjects (96.2%) were married. Sixty-three people (12.6%) were servicemen and 366 (73.2%) had civilian jobs. Three cases of cancer were observed in those exposed to mustard gas. No cases occurred in the unexposed group. Ten people in exposed group and 7 in the unexposed group were dead at the time of the study. Relative risks for cancer and death were estimated at 4.02 (CI 95% = 0.45-36.1) and 1.44 (CI 95% = 0.54-3.81) respectively.
Conclusion: The results failed to show a statistically significant relationship between cancer incidence and acute exposure to sulfur mustard.

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Background and Aim: In 1991, the world health organization initiated a project to simultaneously develop an instrument for measuring quality of life in 15 countries. The study yielded two questionnaires, namely WHOQOL-100 and WHOQOL-BREF. These were intended as generic QOL measurement tools to be used in a broad range of diseases, for different degrees of disease severity, and in various cultural subgroups. The objective of the current study was to evaluate the Iranian version of the WHOQOL-BREF. This 26-item instrument comprises four domains: Physical Health, Psychological, Social Relationship, Environment and the overall QOL/health.
Material and Methods: We administered the questionnaire to 1167 adults in Tehran. The stratified sample consisted of 476 diseased subjects and 700 healthy ones. We tested the instrument's reliability (internal consistency, test-retest), discriminant validity and factorial structure.
Results: The participants had an age mean of 36.3 years (SD = 13.2) and had an average 11.5 years of education. Using Cronbach's α and intraclass correlation, all domains met the minimum reliability standards, with the exception of social relationship domain (α = 0.55). The latter could be attributed the small number of questions in this domain and the sensitive nature of the questions themselves. Since 83% of the questions show maximum correlation with their original domain, the factorial structure of the questionnaire was regarded as acceptable. The questionnaire has the ability to discriminate different groups after adjustment for confounding factors in regression analysis.
Conclusion: This study demonstrated good to excellent reliability and acceptable validity in various groups of subjects in Iran. The instrument may be used in future studies, albeit with minor modifications in the domain of social relations, as determined by expert opinion.

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Background and Aim:  One of the biggest problems faced by parents of handicapped children is the child's health care. This study investigates patterns of heath care utilization and the related factors in children with mental impairment.

Material and Methods: This cross-sectional study involved 110 children (≤14 year old) with developmental disabilities in Tehran. Parents were selected by systematic random sampling for face-to-face interview.  Statistical analysis was based on negative binomial regression.

Results: Over 99% of the surveyed children received ambulatory care and 15 % had been hospitalized over the preceding year 0.9% had never used health services. These children had utilized health services 207+18 times in a year. Among these services 38+3 were not subsidized by the State. Factors affecting service utilization were parent information (p<0.033) and referral to the proper service delivery points (p<0.029).

Conclusion: Appropriate interventions are required to address the above-mentioned factors and improve service utilization.

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Background and Aim: Undercounting is a common problem in surveillance systems and registries. One of the procedures has been used for assessing sensitivity of a surveillance system or completeness of a registry is capture-recapture method.The objective of the present study was to estimate the number of deaths due to road traffic injuries applying capture-recapture method and using three data sources: police, legal medicine organization and hospital.

Material and Methods: All of the deaths due to traffic injuries occurred within Kerman district in the year 2000 were derived from police, Shahid Bahonar hospital and Kerman legal medicine data sources. Matching cases between the lists was based on three characteristics: first name, family name and date of accident. Loglinear model was used for statistical analysis.

Results: The total number of identified cases was 471 the best fitted loglinear model estimated the actual  number of deaths as 596 (CI 95%: 543-686). Based on Iranian Statistical Center estimates, the population of Kerman district in the year 2000 has been 644673 so the cause-specific mortality rate of traffic injuries is estimated as 92 (CI 95%: 84-107) per 100,000 population. Therefore the proportion of deaths registered in police, legal medicine and Shahid Bahonar hospital are 16%, 58% and 48% respectively. The coverage of total deaths (471) is about 79%.

Conclusion: The findings showed that none of the data sources had enough coverage of all deaths due to traffic injuries. Capture-recapture estimates can help for obtaining better estimates.

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Background and Aim: Rabies, a viral and zoonotic disease, causes acute and fetal encephalitis in humans and other mammals and is a cause of death in developing countries. It is usually transmitted by animal bite, but other routes of transmission are mucus membranes, breathing, placenta, contaminated instruments, and organ implanting. This study shows the mapping of geographical distribution of animal bite cases, rabies, and death due rabies in 3 Caspian Sea littoral provinces, namely, Golestan, Mazandaran, and Gilan.

Materials and Methods: Data on human and animal rabies cases and animal bites were collected from the Reference Rabies Center of the Pasteur Institute in Tehran and the Rabies Diagnosis Section of the Amol Research Center during 2002-2007.The data was analyzed by the SPSS (11.5) software and mapping was done by Arc GIS 9.2.

Results: During the 6-year period, of the 670,743 animal bite cases reported in Iran 63890 (9.5%) had occurred in Golestan, 25,767 (3.8%) in Mazandaran, and 22,874 (3.4%) in Gilan. The distribution of animal bite cases in the 3 provinces was as follows: Agh ghala, Bandar Torkaman, Azad shahr and Kolaleh in Golestan Galugah, Behshahr, Ramsar and Neka in Mazandaran and Shaft, Masal, Siahkal and Fuman in Gilan. The data also showed that of the total 2,312 animal rabies cases, in Iran, 9.22% had been reported from Golestan, 4% from Mazandaran, and 2.6% from Gilan. Furthermore, animal rabies cases had occurred mostly in Gonbadekavoos, Bandar Torkaman, Gorgan and Kolaleh in the Golestan Province Behshahr, Neka and Chalus in the Mazandaran Province and Masal, Fuman and Rezvanshahr in the Gilan Province. The most important disease vector (91.3%) for both human and animal rabies was the dog. A total of 41 human deaths due to rabies had been reported during the period, 2 being from Mazandaran.

Conclusion: The results show that a more effective disease control and surveillance system is essential and can help improve planning for service provision in the health care centers.

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Background and Aim: Thalassemia, a heterogeneous disease, is one of the most common single-gene diseases worldwide. The aim of this study was to find associations between hematological indices and severity of beta-globin gene mutations in beta-thalassemia carriers.
Materials and Methods: In this cross-sectional study, 30 beta-goblin gene mutations (b+ and b○) in 1206 unrelated beta-thalassemia carriers were investigated. In addition, their hematological indices, including CBC and electrophoresis results, were determined. The association between genetic findings and hematological parameters (mean corpuscular volume (MCV) and mean hematocrit corpuscular hematocrit (MCH)) were determined using the SPSS software, the statistical test being the t-test.
Results: The results indicated that b+-thalassemia carriers had higher MCV and MCH means than b○-thalassemia carriers. These findings would certainly have practical implications in public health.
Conclusion: The results show a significant correlation between two hematological indices and certain types of mutations in beta-thalassemia carriers.

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Background and Aim: Coronary artery disease (CAD) and its complications at a low age are more serious and more progressive than at higher age. Because of this difference in the natural history of the disease as a function of age, this study was conducted to compare CAD risk factors between two age groups, namely people below and above 45 years old.

Materials and Methods: Two groups of 200 hospitalized CAD patients each, one below, and one above, 45 years old were selected by simple random sampling between 2005 and 2007. Two groups were similar with regard to dates and duration of hospitalization. The following data were collected from the patients' hospital files and analyzed using SPSS/Win: age, sex and marital status area of residence a history of smoking, diabetes, and hypertension a family history of early-onset cardiovascular disease (CVD) weight and height and lipid profile. The logistic regression test was used to compare the variables between the two groups.

Results: The following variables were found to be positively associated with CAD in the under-45 year group: smoking history (OR=2.54 p=0.009), a history of early-onset CVD (OR=3.15 p=0.009), low high- density lipoprotein cholesterol (HDLc) (OR=5.53 p<0.001), and high blood cholesterol (OR=3.96 p<0.006).

Conclusion: The most important coronary heart disease risk factors at a lower age are smoking, a history of early-onset CVD, low blood HDLc, and high total blood cholesterol.

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Data missing, which occurs for different reasons, is an unavoidable problem in epidemiological studies. It is quite widespread and, therefore, it is considered as a challenge in research design and data analysis by many methodologists. Complete case analysis is often used in studies with missing data however, this approach may result in inaccurate estimates and inferences due to bias associated with missing data. It is possible to obtain more accurate results through data repairing methods. Ordinary, simple strategies, such as single imputation methods, have drawbacks and limitations in practice. It has, however, been demonstrated that using modern imputation techniques can, despite their complexity, reduce bias dramatically in many situations, if used appropriately and properly. In this review, application of multiple imputations, as a novel technique for handling missing data in health and epidemiological research, is briefly discussed

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Background and Aim: Malaria threatens more than half of the world's population in about 100 countries. During the period 1921-1951 malaria was one of the most important public health issues in Iran, no other disease causing as much financial loss and mortality as malaria did. The objective of this study was to investigate malaria epidemiology in Iran during the period 1940- 2006 (65 years), in the hope that the infotmation and experience will be used in the future.

Materials and Methods: This study included a review of the available literature on the suject, as well as a study of health systems, existing records, and analysis of data and information on malaria in Iran. Data were colected from three main sources: national or international electronic sources (26 sources) non-electronic sources, including theses, journal articles, and various documents and reports, as well as data obtained from the national malaria surveillance system (a total of 180) and interviews with five informed and expert individuals. In addition, national documents prepared by the Center for Disease Control, Ministry of Health and Medical Education, during the previuos 6 months were made available to, and used by, the research team.

Results: The findings show that, despite several annual fluctuations, the trend of incidence of the disease during the 65-year period, from 1940 to 2006, was a downward trend. The incidence declined from 250-333 per 1000 people in the early 1940's to 0.22 per 1000 people in 2006.

Conclusion: The changes in incidence of malaria show that elimination of malaria is a possible and feasible goal. The experiences achieved in controlling this disease can be utilized for controlling other diseases as well.

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Background and Aim: The time needed to achieve a wanted pregnancy is referred to as time to pregnancy (TTP). Due to differences in lifestyles and geographical locations in different countries, factors affecting TTP may be different in various countries. This study was conducted in 2011 to determine factors affecting time to TTP in Kermanshah, Iran.
Materials and methods: In this case-control study 174 women with TTP>12 months (cases) and 587 women with TTP<=12 months (controls) were selected. The tool for collecting data was a questionnaire. The SPSS-16 software was used for data analysis, a p-value <0.05 being considered as statistically significant.
]Results: Multivariate analysis showed that factors decreasing TPP statistically significantly were women's education level (≥high school diploma OR=0.854, CI 95%=0.741-0.984), frequency of intercourse in a week (OR=0.728, CI95%=0.631-0.839), blood group A compared to O (OR=0.639, CI95%=0.405-1.01), and non-exposure to smoking (OR=0.606, CI95%=0.380-0.965). On the other hand, factors increasing TPP were a woman's irregular menstrual cycle (OR=3.701, CI95%=2.127-6.441), lack of physical activity (OR=1.920, CI95%=1.263-2.918) and a body mass index (BMI) higher than 25 (OR=2.221, CI 95%=1.489-3.312).
Conclusion: According to the results of this study, a high BMI and lack of exercise increase, while factors such as frequency of intercourse decrease the length of TTP. Couples seeking medical intervention for pregnancy often disregard factors associated with TTP. It is recommended that care-providers support these couples, promote their awareness, and give them suitable advice.

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Background and Aim: Nowadays, prioritizing problems and distribution of resources is determined according to the basic needs of the individuals in the population. Based on the study done by researchers in Tehran University of Medical Sciences School of Public Health in Golhesar Village, Tehran, taking action about "drug abuse" was ranked by the community as the first priority. Therefore, the present study aimed to estimate the size of the population of drug abusers using the network expansion method.

Materials and Methods: This cross-sectional study was conducted on a purposive sample of 320 persons 15-65 years old. The study included two parts: 1. estimation of the social network based on 32 population subgroups using the frequency of network expansion approach; 2. estimation of the size of the hidden population. The relevant correction coefficients were used for adjusting errors usually observed in this method.                                                                                                                                                    Results: The mean of the social network was 160.79±16.68) 95% CIs: 128.78-194.30.(The frequencies of cigarette smoking, hookah smoking, alcohol consumption, opium use, meth use, crack use, heroin use, injecting drugs and ecstasy were 103.43, 88.25, 96.9, 76.46, 69.37, 30.03, 20.48, 7.36, and 4.23 per 1000; respectively. The percentage of drug abusers was higher among men.

Conclusion: As compared to results of previous reports, the size of drug abuser population in Golhesar Village is currently higher. In order to solve this problem an appropriate action plan should be implemented by the planners and policy-makers in partnership with community members.

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Background and Aim: Diabetes mellitus is one of the most prevalent and important health problems in the world.Considering the high prevalence of metabolic syndrome in diabetic patients and the potential effects of its components on HbA1C in these patients, the present study was conducted to determine the effect of metabolic syndrome components on HbA1C in type-2 diabetic patients.
Materials and Methods: This retrospective cohort study was conducted on 157 diabetic patients regularly referring to the Diabetes Control Center in Qazvin City during 2014, where complete data about theirmetabolic syndrome components, as well as HbA1C levels were available. The data were analyzed using multiple linear regression (α=0.05 for statistical significance).
Results: Based on the regression model, the effects of age, HDL-C and fasting blood glucose on HbA1C were statistically significant; the effects of other variables were nonsignificant. The R²value for the variables entered for prediction of HbA1C was found to be 0.45 (R² = 45%).
Conclusion: Considering the significant relationship between some components of the metabolic syndrome such as HDL-C and fasting blood glucose on HbA1C in diabetic patients, it is essential to design and implement programs to reduce the level of HbA1C in these patients.