Spinal muscular atrophy genetic epidemiology and the case for premarital genomic screening in Arab populations.

BACKGROUND: Spinal muscular atrophy (SMA) is a fatal autosomal recessive disorder for which several treatment options, including a gene therapy, have become available. SMA incidence has not been well-characterized in most Arab countries where rates of consanguinity are high. Understanding SMA disease epidemiology has important implications for screening, prevention, and treatment in those populations. METHODS: We perform SMA diagnostic testing in a clinical multi-national patient cohort (N = 171) referred for hypotonia and/or muscle weakness. In addition, we carry out genetic newborn screening for SMA on 1502 healthy Emirati newborns to estimate the carrier frequency and incidence of the disease in the United Arab Emirates. RESULTS: Patients referred for SMA genetic testing are mostly Arabs (82%) representing 18 countries. The overall diagnostic yield is 33.9%, which is higher (>50%) for certain nationalities. Most patients (71%) has two SMN2 copies and earlier disease onset. For the first time, we estimate SMA carrier frequency (1.3%) and incidence of the disease (1 in 7122 live births) in the United Arab Emirates. Using birth and marriage rates in two Arab populations (United Arab Emirates and Saudi Arabia), as well as disease incidence in both countries, we show that, besides preventing new cases, premarital genetic screening could potentially result in around $8 to $324 million annual cost savings, respectively, relative to postnatal treatment. CONCLUSIONS: The SMA carrier frequency and incidence we document suggests high potential benefit for universal implementation of premarital genomic screening for a wide range of recessive disorders in Arab populations.

The occurrence of spinal muscular atrophy, a fatal genetic nerve and muscle disease, has been poorly studied in most Arab countries. Individuals who carry a single mutated gene copy (carriers) may be more likely to marry other carriers in regions where marriage rates amongst relatives, who share similar genetics, are high. Here we report the results of a newborn testing program for this disease in 1502 Emiratis and calculate the presence of carriers (1/79) and occurrence of disease (1/7122) in this population. Using this new information along with the annual birth and marriage rates in the United Arab Emirates and Saudi Arabia, we make the case that premarital genomic screening (carrier testing) is the best way to prevent this and other similarly inherited disorders in the Arab population.

Temporal trends of hemoglobin among pregnant women: The Mutaba'ah study.

BACKGROUND: Low hemoglobin (Hb) level is a leading cause of many adverse pregnancy outcomes. Patterns of changes in Hb levels during pregnancy are not well understood. AIM: This study estimated Hb levels, described its changing patterns across gestational trimesters, and identified factors associated with these changes among pregnant women. MATERIALS AND METHODS: Data from the ongoing maternal and child health cohort study-The Mutaba'ah Study, was used (N = 1,120). KML machine learning algorithm was applied to identify three distinct cluster trajectories of Hb levels between the first and the third trimesters. Descriptive statistics were used to profile the study participants. Multinomial multivariable logistic regression was employed to identify factors associated with change patterns in Hb levels. RESULTS: The three identified clusters-A, B and C-had, respectively, median Hb levels (g/L) of 123, 118, and 104 in the first trimester and 119, 100, and 108 in the third trimester. Cluster 'A' maintained average normal Hb levels in both trimesters. Cluster 'B', on average, experienced a decrease in Hb levels below the normal range during the third trimester. Cluster 'C' showed increased Hb levels in the third trimester but remained, on average, below the normal range in both trimesters. Pregnant women with higher gravida, diabetes mellitus (type 1 or 2), nulliparity or lower level of education were more likely to be in cluster 'B' than the normal cluster 'A'. Pregnant women who reported using iron supplements before pregnancy or those with low levels of education. were more likely to be in cluster 'C' than the normal cluster 'A'. CONCLUSION: The majority of pregnant women experienced low Hb levels during pregnancy. Changes in Hb levels during pregnancy were associated with parity, gravida, use of iron before pregnancy, and the presence of diabetes mellitus (type 1 or 2).

Rare case of chemotherapy-refractory metastatic vaginal squamous cell carcinoma with complete response to concurrent pembrolizumab and radiotherapy- case report and literature review.

Primary vaginal cancer is a rare malignancy with a lack of international guidelines and supporting clinical trial evidence to guide decision making. Historical results have shown poor outcomes with chemotherapy for stage IVB vaginal squamous cell carcinoma (SCC). The evolving role of checkpoint inhibitors in rare gynaecological cancers prompted us to investigate the role of pembrolizumab in this setting. The efficacy of pembrolizumab in vaginal SCC has never been investigated in any clinical trial. There is established data to support the use of concurrent chemoradiotherapy in gynaecological cancers, however, the data for concurrent use of immunotherapy and radiotherapy is still lacking but is the subject of several clinical trials. We herein present the first reported case of chemotherapy refractory vaginal SCC with complete response to pembrolizumab and concurrent pelvic radiotherapy. We also present wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) as a rare but new immune related adverse event.

Impact of Recurrent Miscarriage on Maternal Outcomes in Subsequent Pregnancy: The Mutaba'ah Study.

PURPOSE: To estimate the prevalence of recurrent miscarriage (RM) and investigate the association between RM and adverse maternal outcomes in subsequent pregnancies. PARTICIPANTS AND METHODS: This is an interim analysis of a prospective study of 1737 pregnant women with gravidity of two or more prior to the current pregnancy. These women joined the Mutaba'ah Study between May 2017 and April 2019 and were followed up until they delivered. Hospital medical records were used to extract data on past pregnancy history and the progress and outcomes of the current pregnancy, such as gestational diabetes, preeclampsia, mode of delivery, preterm delivery, and complications at birth. RESULTS: Amongst pregnant women with at least two previous pregnancies (n=1737), there were 234 (13.5%) women with a history of two or more consecutive miscarriages. Women with RM were slightly older, more parous, and more likely to have had previous infertility treatment (all p-values <0.05). Women with a history of RM had independently significant increased odds of cesarean section (adjusted odds ratio (aOR) 1.81, 95% CI 1.24-2.65) and preterm (<37 weeks, aOR: 2.52, 95% CI 1.56-4.08) or very preterm delivery (<32 weeks, aOR: 7.02 95% CI 2.41-20.46) in subsequent pregnancies than women who did not have a history of RM. CONCLUSION: Women with a history of RM were twice as likely to undergo cesarean section and seven times more likely to deliver prior to 32 weeks of gestation than women without a history of RM. The study findings support the need for early pregnancy monitoring or assessment units to ensure better follow-up and customized care for at-risk pregnant women with a history of RM.

Mutaba'ah-Mother and Child Health Study: protocol for a prospective cohort study investigating the maternal and early life determinants of infant, child, adolescent and maternal health in the United Arab Emirates.

INTRODUCTION: Early life exposures, particularly environmental and parental lifestyle factors, have a major influence on children's health and development. Due to increasing interest in the early life developmental origins of diseases, many birth cohorts have been established. These studies constitute a repository of data which researchers use over many years to investigate emerging research questions. However, no such databank or cohort study is available in the United Arab Emirates (UAE). This project aims to establish a prospective mother and child cohort study in Al Ain (Abu Dhabi, UAE) to investigate the maternal and early life determinants of infant, child, adolescent and maternal health of the Emirati population. METHODS AND ANALYSIS: During the period 2017-2021, this study aims to recruit 10 000 pregnancies at approximately 12 weeks of gestation from hospitals and clinics in Al Ain city. For each mother/newborn pair, an initial dataset will be collected including anthropometric, physiological and biochemical measurements, medical interventions, circumstances of pregnancy, delivery details and neonatal and perinatal growth and health using a combination of questionnaires, interviews and medical record extractions. Baseline data will act as the starting point from which the children will be followed up and re-surveyed at intervals throughout their life course until the age of 16 years, to explore how familial, socioeconomic and lifestyle factors interact with genetic and environmental factors to influence health outcomes and achievements later in life. ETHICS AND DISSEMINATION: Ethical approval has been granted by the United Arab Emirates University Human Research Ethics Committee and the ethical committees of the participating institutions. Results will be widely disseminated via peer-reviewed manuscripts, conference presentations, media outlets and reports to relevant authorities.

Severe acute maternal morbidity in a high-income developing multiethnic country.

With declining maternal mortality, the study of severe acute maternal morbidity (SAMM) provides an opportunity to measure the quality of maternal care and to identify ways to improve it. The objective was to study the epidemiology of severe acute maternal morbidity in a high income, rapidly developing, multiethnic country in the Middle East, and to determine the role of ethnicity in maternal morbidity. We included all births occurring in maternal units with more than 500 births a year over a 6 year period in Abu Dhabi emirate, the largest province of the United Arab Emirates. Data on SAMM was collected retrospectively for the first 3 years and prospectively for the later 3 years. A clinical criteria based approach was used to define SAMM. Over the 6 year period there were 122,705 deliveries, and a total of 926 cases of SAMM were identified. The SAMM to births ratio was 7.5/1,000 deliveries. The leading cause of maternal morbidity was hypertensive disorders (59.5 %) followed by hemorrhage (39.6 %). There were clear ethnic differences. Preeclampsia was significantly higher in women from the Indian sub-continent and hemorrhage was more prevalent in UAE women. We have shown that it is possible to use a clinical criteria based approach to study the epidemiology of SAMM. The leading contributors to SAMM were hypertensive disorders and hemorrhage with clear ethnic links supporting earlier reports of a complex interaction between ethnicity, socioeconomic status and maternal health.

Ovarian salvage in bilaterally complicated severe ovarian hyperstimulation syndrome.

OBJECTIVE: To report the management of 2 cases of severe ovarian hyperstimulation syndrome (OHSS) bilaterally complicated by rupture and late subsequent torsion. DESIGN: Two case reports. SETTING: Obstetrics and Gynecology department of a hospital. PATIENT(S): Case 1: Severe OHSS complicated by massive intraperitoneal hemorrhage and bilateral extensive ovarian rents and rupture at multiple sites. Case 2: Twin IVF pregnancy and late severe OHSS complicated further by subsequent bilateral torsion. INTERVENTION(S): Case 1: Diagnosed by clinical, hematologic, and ultrasound findings. Resuscitation, laparotomy, and meticulous ovarian repair with suture, glue, and hemostat affected bilateral ovarian conservation. Case 2: Diagnosed clinically and confirmed by color Doppler. Left salpingoopherectomy was performed because of a devitalized left ovary; 3 days later laparoscopic right ovarian detorsion and aspiration was possible as early Doppler diagnosis was made. MAIN OUTCOME MEASURE(S): Case 1: ovarian conservation. Case 2: ovarian conservation and continuation of pregnancy. RESULT(S): Case 1: Recovery and normal serum FSH and E(2) 2 months postsurgery. Case 2: Continuation of pregnancy and the remaining ovary was healthy at abdominal delivery. CONCLUSION(S): Two cases of bilaterally complicated severe OHSS in which the patients' safety and bilateral ovarian integrity were at jeopardy. The cases are presented to define the importance of awareness, early diagnosis, and intervention, as well as the use of various methods and techniques to affect preservation of ovarian integrity and reserve.

Confidential enquiries into maternal mortality in the United Arab Emirates: a feasibility study.

AIM: Routine confidential enquiry into maternal deaths is not yet part of the United Arab Emirates health care system. A confidential enquiry into maternal deaths was undertaken to test the feasibility of this approach and to identify the causes and preventability of maternal deaths. MATERIAL & METHODS: Data on all maternal deaths over a six year period from 1998 to 2003 were abstracted and reviewed by a panel of experts to assign the cause if in doubt, and to determine whether the deaths were preventable. RESULTS: Over the six year period, 26 deaths were identified with 122,075 births and the maternal mortality ratio was 21.2/100,000 live births. The mean maternal age at death was 32.3 years and two-thirds of the deaths occurred during the postpartum period. The leading causes of death were thromboembolic events, hemorrhage and infection. After reviewing the clinical data the expert panel concluded that one third of the deaths were avoidable. CONCLUSION: This first ever confidential enquiry has shown that it is feasible to adopt this approach in the United Arab Emirates and the causes identified would be of help in prioritizing clinical guidelines development and training programs aimed at professionals, which will ultimately lead to safer motherhood for women.

Cervical cancer prevention in the human papilloma virus vaccine era.

Globally, cervical cancer is second only to breast cancer as the leading cause of cancer in women, with a global prevalence of 2.3 million. It is the third most common cause of female cancer-related mortality worldwide, and 82% of new cervical cancer cases occur in developing countries. As stated by WHO, "without screening programs, cervical cancer is detected too late and leads to death in almost all cases." However, even in Europe, the United States, and Canada, where most women have access to routine screening, approximately 30,000 women die each year. Infection with oncogenic types of HPV 16 and 18 is the most significant risk/causative factor in cervical cancer etiology, and worldwide HPV positivity in cervical carcinoma has been documented to be 99.7%. In 2006 Merck's quadrivalent vaccine was approved by FDA. It targets four HPV types (6, 11, 16, and 18) that are involved in cervical cancer, high and low grade squamous intraepithelial lesions, and anogenital warts. Results from combined Phase II/III studies show that the efficacy of vaccine was 95-100% against LGSIL and HGSIL related to HPV 16 and 18 and vaccine use led to a 99% reduction in the incidence of genital warts (related to HPV 6 and 11). Due to morbidity associated with infection with HPV types 6, 11, 16, and 18, a prophylactic quadrivalent HPV vaccine targeting these four HPV types is expected to substantially reduce the burden of HPV-related disease.

Expression of insulin-like growth factor-1 receptors, Wilm's tumor-1 protein, c-kit and p16 in primary fallopian tube carcinoma in diabetic patients.

BACKGROUND: Primary fallopian tube carcinoma (PFTC) represents less than 1% of all gynecological malignancies and its association with diabetes mellitus is seldom reported. CASES: We report three cases of PFTC presented primarily as advanced ovarian cancer while the primary site totally silent. Two of them were diabetics and showed expression of insulin-like growth factor receptors, Wilm's tumor protein-1, c-kit and P16. In all these cases there was neither clinical nor perioperative suspicion of PFTC and the first clinical diagnosis was ovarian carcinoma which was supported by positive cytology for ascitic fluid and raised serum level of CA125. The diagnosis was only established after histopathologic examination of serial sections of the whole fallopian tube since we were able to demonstrate the continuity between the invasive and the in situ components of PFTC in the lining epithelial layer of the fallopian tube. CONCLUSION: The presence of malignant cells in the female pelvic organs without a mass should raise the possibility of primary fallopian tube carcinoma. Pre-operative diagnosis of PFTC is seldom made and most of the time the diagnosis is made after histopathological examination as in our cases. Diabetes mellitus can be a risk factor in the development of PFTC.

Unusual presentation of cervical cancer as advanced ovarian cancer.

BACKGROUND: Ovarian metastases from cervical cancers are uncommon. In most cases, the primary site of cervix is known before the occurrence of metastasis. We report a case of cervical adenocarcinoma presenting primarily as advanced ovarian cancer with the primary site totally silent. CASE REPORT: A 47-year old multiparous patient presented to her local hospital with vague abdominal pain for 2 months. Initial investigations with abdominal ultrasound and computerized tomography scan suggested right ovarian dermoid cyst. Her CA125 was 12 micro/ml (0-35). Right salpingo-oophorectomy was performed with the histologic diagnosis of dermoid cyst. Follow-up after 5 months showed a higher level of serum CA 125 (1,594 micro/ml) and a negative cervical smear. Exploratory laparotomy was done with the intent to progress to total abdominal hysterectomy, left salpingo-oophorectomy and omentectomy with staging. Surprisingly, the histologic features of the specimen obtained at laparotomy were consistent with a moderately differentiated cervical adenocarcinoma with metastases to corpus uterus, ovaries, left fallopian tube, omentum and pleural cavity. The final stage was stage IV cervical cancer. Following this, the patient was referred to medical oncologist for chemotherapy. CONCLUSION: Cervical carcinoma should be suspected in any patient presented with bilateral ovarian tumors and positive ascitic fluid cytology. Negative cervical smears do not exclude the possibility of primary cervical carcinoma.

Low-grade endometrial stromal sarcoma with sex cord-like differentiation metastatic to the thoracic spines.

We report a case of monostotic low-grade stromal sarcoma (ESS) with sex cord-like elements metastatic to the thoracic spines, which to the best of our knowledge has not previously been documented. A 48-year-old female who had undergone total abdominal hysterectomy for low-grade endometrial stromal sarcoma 7 years previously presented with insidious onset of severe back pain of 2 months' duration. Magnetic resonance image (MRI) showed involvement of the eleventh and twelfth thoracic vertebral bodies. Decompression at the level of T10-12 was performed. Histologically, the laminae of thoracic vertebrae 11 and 12 were replaced by sheets of ovoid cells with plump nuclei intermixed with anastomosing trabeculae, cords and small nests, reminiscent of a sex-cord stromal tumor pattern. The tumor cells showed diffuse nuclear immunostaining for estrogen receptors (ER) and progesterone receptors (PR), as well as membranous immunostaining for CD10. The immunostaining for smooth muscle actin was focal and sparse. These findings confirmed the diagnosis of metastatic low-grade ESS with sex cord-like differentiation. Low-grade ESS with sex cord-like differentiation is an uncommon tumor which rarely metastasizes to the bone, and use of a panel of ER, PR, CD10, actin, cytokeratin and inhibin immunostains is essential to establish the diagnosis.

Colposcopy services in the United Arab Emirates.

BACKGROUND: United Arab Emirates (UAE) is a young country with a population of 3 million, an abundant oil wealth, and a high standard of living. There is no organized cervical screening program, but the authorities are planning to introduce one soon. OBJECTIVE: To study the availability and quality of colposcopy services. METHODS: A questionnaire survey of all gynecologists in the major government and private hospitals in the country. RESULTS: Twenty government hospitals offer obstetrics and gynecology services, 11 governments and 4 private hospitals have colposcopy services. Of the 52 specialists performing colposcopy, 8 had adequate training, 3 had formal recognition, and 3 had long-term experience. The number of cases seen per doctor varies from 10 to 100 a year, with a mean and median of 28 and 15, respectively. Three units had the required basic colposcopy equipment for diagnosis and treatment. Only 1 unit performs audit. CONCLUSIONS: Colposcopy service is widely available in many hospitals in the United Arab Emirates, but substantial variation exists in clinical standards and needs more organization and standardization.

Cervical smear abnormalities in the United Arab Emirates: a pilot study in the Arabian Gulf.

OBJECTIVE: To gather epidemiologic data on cervical abnormalities and make recommendations pertaining to a national cervical screening policy in the United Arab Emirates (UAE). STUDY DESIGN: A cross-sectional survey of patients and physicians in the UAE with regard to cervical cytology was carried out. Knowledge, attitudes and practices (KAP) of a group of female primary care physicians on cervical cytology were assessed by a self-administered questionnaire. Pap smears and Chlamydia testing were offered to women attending selected primary care centers and secondary health care facilities. RESULTS: Results of Chlamydia prevalence and KAP were published elsewhere; this report addresses the cytologic aspects of this study. There were 2,013 smears collected from primary health centers and 2,042 from secondary care. The overall rate of cervical screening among women in this survey was 85.5% in primary care and 77% in secondary care. The proportion of unsatisfactory smears was < 5%. The prevalence of cervical abnormalities according to the Bethesda System 2001 was 3.6%. There were 9 (primary care) and 21 (secondary care) cases of low grade squamous intraepithelial lesion (LSILs), for a prevalence of 0.77%. There were 4 primary care and 17 secondary care cases of high grade squamous intraepithelial lesion (HSIL), for a prevalence of 0.54%. The combined prevalence for LSIL and HSIL is 1.32%. There were 3 cases of glandular abnormalities. The atypical squamous cells of undetermined significance/SIL ratio was 1.71. No cases of squamous cell carcinoma were detected. No tissue follow-up information is available. The prevalence of cervical abnormalities is low in the UAE. We first recommend the institution of a more organized approach to opportunistic screening in the UAE with appropriate clinical follow-up rather than the immediate launch of a cervical mass screening program.

Is there a correlation between vaginal chlamydia infection and cervical smear abnormalities? A community-based study in the Al-Ain district, United Arab Emirates.

AIM: The purpose of this study was to determine the correlation between vaginal chlamydia infection and cervical abnormalities. The data on the prevalence of chlamydia infection and cervical abnormalities have been presented elsewhere and in this article we provide the results of a correlation analysis. METHODS: In this cross-sectional, community-based survey, women attending primary and secondary care in the Al-Ain medical district, United Arab Emirates, were offered cervical screening using the Papanicolaou smear, and chlamydia testing. A total of 793 women underwent cervical screening and 728 were tested for chlamydia. A commercially available kit was used to determine the prevalence of chlamydia. The correlation between cervical abnormalities and chlamydia infection was tested using the chi-squared test or Fisher's exact test, as appropriate. RESULTS: The prevalence of abnormal smears was 1.51% (95% confidence interval [CI], 0.66-2.4). Twelve subjects had abnormal smears, including smears showing atypical squamous cells of undetermined significance. The prevalence of chlamydia infection in this population was 2.5% (95% CI, 1.2-3.3). Statistical analysis showed no association (chi2 0.6, P = 0.4) between the prevalence of chlamydia infection and cervical abnormalities. CONCLUSION: Although there have been earlier reports of an association between vaginal chlamydia and cervical abnormalities, our study does not provide evidence to support this association.

Cultural and ethnic barriers in conducting research. Factors influencing menarche in the United Arab Emirates.

OBJECTIVE: The objective of this cross sectional survey was to study the feasibility of conducting research on issues related to physical and sexual maturation in a predominantly Islamic society and to identify the factors influencing menarche in this multi ethnic community. METHODS: This study was conducted in Al-Ain, United Arab Emirates (UAE) between January 1999 through to February 1999. Fifteen female secondary schools located in different geographical regions in Al-Ain were chosen in consultation with the District Education Department. All girls aged 12-16-years were selected. Information regarding whether they had attained menarche including month and the year, age at menarche and the factors influencing it such as height and weight, diet, physical activity were gathered. Univariate and multiple linear regressions were used in analysis. RESULTS: Of the 1500 questionnaires distributed, 1416 questionnaires were returned but only 890 had the required information and were used in the analysis. Ninety-three (10.4%) had not attained menarche and as expected these girls were younger (p<0.0001) than those who had attained menarche. Mean age at menarche was 12.68 (SD 1.27) years. In the univariate analysis UAE nationality, vegetarians (p=0.001), higher income group (p=0.008), low body weight (p=0.009) and a diagnosis of anemia (p<0.05) in the year before menarche were all positively associated with the age at menarche. Only anemia achieved borderline significance (p=0.056) in multivariate analysis and no other variables were significant. CONCLUSION: This study highlights the difficulties of conducting research on issues considered to be sensitive by the community and provide data on factors influencing menarche in a multi ethnic community.

A study of knowledge, attitude, and practice of cervical screening among female primary care physicians in the United Arab Emirates.

Cancer is the third leading cause of death In the United Arab Emirates (UAE), which is situated in the Arabian Gulf. A national programme for cervical cancer screening is likely to be implemented in the future. In this study, we assessed the knowledge, attitude, and practice of UAE female primary care physicians of cervical screening through a self-administered questionnaire. Of the 98 physicians who participated in the study only 40% reported ever having performed a Pap smear. In the study, we identified various training needs, and a training programme on cervical screening currently is being developed based on the results of this study.

Prevalence of Chlamydia trachomatis infection among women in a Middle Eastern community.

BACKGROUND: Common vaginal infections that manifest in women are usually easily diagnosed. However, Chlamydia infection is often asymptomatic, leading to infertility before it is detected. If it occurs in pregnancy, it could lead to significant neonatal morbidity. It may also play a role with other viral infections for e.g. Human Papilloma Virus in the development of cervical cancer. The objective of this study was to determine the prevalence of Chlamydia infection in women undergoing screening for cervical abnormalities as a part of a research project in primary and secondary care institutions in the United Arab Emirates. METHODS: In this cross sectional study married women attending primary and secondary care participating in a large nationwide cervical abnormalities screening survey were offered Chlamydia testing using a commercially available test kit. This kit uses a rapid immunoassay for the direct detection of Chlamydia trachomatis antigen in endocervical swab specimens. As this study was performed in a traditional Islamic country, unmarried women were excluded from testing, as the management of any positive cases would create legal and social problems. All married women consenting to take part in the study were included irrespective of age. RESULTS: Of 1039 women approached over a period of eight months 919 (88.5%) agreed to participate. The number of women in the 16 to 19 years was small (0.01%) and 30% were aged over 40 years. The prevalence of Chlamydia infection in this study was 2.6% (95% confidence interval 1.2-3.3%), which was marginally higher in women screened in secondary care (p = 0.05). CONCLUSION: This is one of the few reports on the prevalence of Chlamydia infection in women from the Middle East. Due to cultural and social constraints this study excluded a large proportion of women aged less than 19 years of age. Hence no direct comparisons on prevalence could be made with studies from the West, which all included younger women at high risk of Chlamydia. However this study emphasizes the importance of cultural factors while interpreting results of studies from different cultures and communities.