2. OBJECTIVES:
- Define the problem of non-communicable diseases
(NCDs);
- Recognize the risk factors underlying most common
NCDs;
- Discuss the epidemiology of some NCDs;
- Identify the prevention and control measures of
some chronic diseases
3. DEFINITION:
A non-communicable disease (NCD) is a
medical condition or disease that is non-
infectious or non-transmissible. NCDs can
refer to lifestyle-related diseases or chronic
diseases which last for long periods of time and
progress slowly.
5. Worldwide; NCDs are currently the leading
causes of death, disability and disease burden,
except in sub-Saharan Africa.
The WHO and the World Bank project that,
while the major NCDs in 2001 accounted for
nearly 60 percent of all deaths, this toll will rise
to 73 percent by 2020.
6. IN EGYPT,
NCDs are currently the leading cause of death. In
2014, NCDs were estimated to account for 84% of
all deaths in Egypt;
cardiovascular diseases account for most deaths
followed by cancer,
chronic respiratory diseases
and diabetes.
8. Epidemiology of NCDs:
discusses their Distribution, Dynamics and
Determinants as it occurs in groups of persons OR the
entire population.
I- Distribution: by place, time, person
_
By place: Epidemiology of the NCDs differs across countries.
This is due to the variability in the prevalence of the different
risk factors among them, as well, the extent of quality
utilized health services particularly the PHC services.
9. By time: Epidemiology of NCDs is
changing all the time. Some countries
succeeded in improving the pattern of
some NCDs e.g. reduction in the incidence
of coronary heart diseases through
extensive anti-smoking programs.
However, other NCDs could emerge at
any time with new risk factors
10. By person: All age groups, both
sexes with NCDs' risk factors, can
potentially be affected. However,
NCDs are more common among the
elderly.
11. II- DYNAMICS: NCDS ARE OF INCREASING
PREVALENCE. FACTORS INCLUDE:
1- The epidemiological transition: In 1900ies, it
resulted in a major shift in leading causes of premature
death and disability around the globe: from infections and
malnutrition (our traditional enemies, due to sanitary
environment, immunizations , antibiotics etc.), to heart
disease, cancer, Type II diabetes, obesity.
12. 2- The demographic transition from high birth and death rates
to lower birth and death rates resulted in subsequent
increase in the proportion of the elderly populations. NCDs
are usually associated with aging.
13. 3-The nutrition transition: Large shifts have occurred in
dietary and physical activity patterns. Modern societies are
converging on sedentary life with a diet high in saturated fat,
sugar, and refined foods and low in fiber, often termed the
"Western diet.“
14. 4- The multiplicity of NCDs ' risk factors:
Unlike communicable disease, it is difficult to identify the
specific cause-effect relationship in NCDs. It is just risk
factors. This limits the opportunities to have specific
prevention measures and represents a challenging issue
to public health programs. .
15. 5- Migration of population across different
cultures: The individuals who migrate from
low-risk culture (e.g. rural areas) to high-risk
culture (e.g. urban areas) follow the life-style
of the new culture and demonstrate increased
risk for NCDs.
16. 6- International communication (through mass
media/satellites/internet), overseas travel, international
food marketing& new food technologies resulted in
sharing unhealthy lifestyles, behaviors and dietary
patterns leading to risks to NCDs.
Adolescents and youth are the mostly exposed to this.
Their exposure early in the life cycle to the risk of
NCDs will result in development of a large cohort with
health problems during adulthood and older age.
17. 7- Environmental changes:
The increase in the level of chemical, physical and biological
pollution in the air, water, food is associated with high
prevalence of NCDs
18. 8- Limited universal use of effective
NCDs' prevention strategies:
Effective prevention strategies for NCDs
do exist. In the developing countries, the
high cost is challenging.
20. III- DETERMINANTS
1- NCDs risk factors are related to the lifestyle&
behavior, environmental and genetic factors. Most
NCDs are the result of four particular behaviors;
tobacco use,
physical inactivity,
unhealthy diet, and
the harmful use of alcohol.
21. NCDs' risk factors in Egypt among the adult
population are of significant high prevalence
(Stepwise survey: (MOHP& WHO, 2011- 2012):
22. 1) 24% prevalence of smoking.
2) one of the most overweight populations in the world,
with 60% of women overweight and 40% obese
3) almost three quarters of the population not involved in
vigorous activity.
4) 17% prevalence of diabetes. •
5) 40% prevalence of hypertension.
6) Egyptians have an average daily salt intake of 9
grams, nearly double the recommended allowance.
23.
24. Role of the PHC physician in prevention
and control of NCDs:
1. Health education to improve the life style and dietary
patterns.
2. Early detection of both the risk factors and silent
cases of NCDs by screening the high-risk groups.
3. Managing the cases with guidance and counseling to
ensure compliance to treatment and healthy behavior.
4. Referral of the identified cases to specialists.
25. In the developing countries, PHC is not well
prepared for confronting the challenges caused
by the epidemics of NCDs because of its typical
policy direction _toward preventing MCH
conditions and infectious diseases._
26. CORONARY HEART DISEASE (CHD)
Definition: Is a disease in which atherosclerosis builds up
inside one or more of the heart coronary arteries that leads to
blockages. The heart becomes starved of oxygen and become at
risk of infarction.
27. MAGNITUDE OF THE PROBLEM:
Worldwide; (CHD) is a major cause of death
and disability.
declined in many developed countries due to
extensive antismoking programs- ,
but is increasing in developing countries -
including Egypt-, due to expanding risk
factors.
28. IN EGYPT
According to the latest WHO data
published in may 2014 Coronary
Heart Disease deaths reached
23.14% of total deaths.
29. Macrophages Foam cells
LD
Endothelial injury by
smoking and/ or HT
Atherosclerosis: The arteries, which start out smooth and
elastic, become narrow and rigid, restricting blood flow to
the heart
30. RISK FACTORS FOR CHD:
NON MODIFIABLE RISK FACTORS:
Age: CHD increases with age (after 45 years) with the
progressive atherosclerosis.
Sex:. Before menopause: women are at lower risk for CHD
than men (the male to female ratio for CHD is about 10:1).
This could be attributed to the protective effect of
estrogen against atherosclerosis. After menopause: The
risk of CHD increases among women
Genetic factors :(NB: Familial tendency is due to the
common dietary and lifestyle pattern among the family.)
31. MODIFIABLE RISK FACTORS:
Unhealthy Diet with increased saturated animal fat,
cholesterol and refined carbohydrates is associated
with increased CHD risk.
Physical inactivity and sedentary life increase the risk
for CHD by operating through the other risk factors:
obesity, hypertension, dyslipidemia and diabetes.
Cigarette smoking.
Harmful use of alcohol.
32. 5- Stress& tension:
• Emotional status of
anger,
fear, anxiety
and depression
• Type A personality
(A personality characterized by aggressiveness,
competitive drive, preoccupation with deadlines and
time urgency) is at risk for CHD.
33. II- DISEASE CONDITIONS AS RISK FACTORS FOR
CHD:
1- Dyslipidemia:
High LDL cholesterol
(atherogenic effect) and triglycerides
Low HDL cholesterol (protective
against CHD)
2- Hypertension
3- Diabetes mellitus
4- Over weight and obesity
34. METABOLIC SYNDROME
It is a disorder of energy utilization and storage that
increases the risk of development of cardiovascular disease,
particularly heart failure, and type 2 diabetes. It is
diagnosed by a co-occurrence of three out of five of the
following abnormalities:
1- Abdominal (central) obesity,
2- Elevated blood pressure,
3- Elevated fasting plasma glucose,
4- Low HDL
5- High serum triglycerides
37. _I- Primordial and primary prevention:_
1- Preventing the occurrence of risk
factors………..
Since many risk factors for CHD start now during
childhood like overweight and physical inactivity,
parents and families together with public health
programs should emphasize that following a healthy
lifestyle can help all including children prevent or
control many CHD risk factors.
38. FIVE MAIN DIRECTIONS ARE RECOMMENDED:
• Maintain a healthy weight,
• Follow a healthy diet,
• Do physical activity regularly,
• Don't smoke or use alcohol
harmfully, and
• Mange stress properly.
39. NB: DIETS RICH IN THE NEXT FOODS ARE KNOWN
TO BE PROTECTIVE AGAINST CHD:
-Omega-3 fatty acids (a
polyunsaturated fat), found in
fish oils, and fatty fish
especially from salmon acts to
lower the levels of cholesterol
and LDL
in the blood.
- dietary fibers
40. 2- DEALING WITH CHD RISK
FACTORS:
IF ONE OR MORE OF THE CHD RISK
FACTORS ARE ALREADY PRESENT;
Life style modifications
should be adopted
41. II- SECONDARY PREVENTION:_
Aims at early CHD detection in the pre-clinical stage for
subsequent proper management. Opportunities for
health appraisal include:
Comprehensive medical examination e.g.
periodic follow up of elderly , and family medicine
program,
Curative services: For cases consulting the
physician
42. Screening tests done on periodic medical checkup for
the at-risk groups.
Examples of CHD screening:
Measuring blood pressure for hypertension.
Measuring risk factors; LDL, HDL, serum triglycerides,
fasting plasma glucose
43. IF PROVEN TO ALREADY HAVE CHD :
Healthy lifestyle can help control CHD risk factors
and prevent CHD from worsening,
If lifestyle changes aren't enough, a treatment plan
for lowering the major metabolic risk factors, heart
attack, and other heart problems should be initialed
44. III- TERTIARY PREVENTION/
REHABILITATION SERVICES:
Rehabilitation is physical, vocational, economic and
psychological/ social. This is to have a socially
acceptable independent disabled person that is useful
for himself and community.
46. DEFINITION:
long term medical condition in which the blood pressure in the
arteries is persistently elevated. High blood pressure usually
does not cause symptoms. Long term high blood pressure,
however, is a major risk factor for of cerebral, cardiac, and
renal events.
Next box summarizes the categories of hypertension for adults
18 years old and above
47. Category Systolic Diastolic
Normal < 120 and <80
Prehypertension 120-139 or 80-89
High Blood Pressure/Hypertension
Stage 1 Hypertension 140-159 or 90-99
Stage 2 Hypertension > 160 or >100
Types of Hypertension:
Essential hypertension (also called
primary hypertension or
idiopathic hypertension)
Secondary hypertension
It is the most common type of
hypertension, affecting 90- 95% of
hypertensive patients.
It is by definition has no
identifiable cause.
It is hypertension due to an
identifiable cause .e.g.
Cushing's syndrome ,
Hyperthyroidism ,
Renal artery stenosis.,
48. RISK FACTORS FOR ESSENTIAL HYPERTENSION:
Non modifiable risk factors:
► Age: The risk of hypertension increases with age.
Essential hypertension usually occurs among
population of the age group 25-55 years. Secondary
hypertension could occur at any age.
► Sex: Men show a higher average BP in young and
middle age. This is reversed in postmenopausal
period.
► Genetic factors: Hypertension runs in families.
49. MODIFIABLE RISK FACTORS:
1- Unhealthy diet
• Sodium Sensitivity and Salt Intake:
People who are sodium sensitive retain sodium in case
of common salt intake with subsequent fluid retention
and increase in the blood pressure.
• Low Potassium Intake: Potassium is a mineral that
helps balance the amount of sodium in cells. Low
consumption of diet rich in potassium could result in
sodium accumulation in the cells.
50. • Dietary fibers:
Inversely related to CHD and hypertension, as it reduces
total and LDL cholesterol.
2- Tobacco Smoking:
• Chemicals in tobacco cause damage to the intima of the
arteries and facilitate atherosclerosis.
• Nicotine causes constriction of the blood vessels and
increases the burden on the heart to pump blood to the
constricted arteries.
51. 3- Physical inactivity: Sedentary life increases the
burden on the heart muscle to pump blood to arteries.
Inactivity leads to obesity and its risk for hypertension.
4- Harmful use of alcohol: Chronic excess alcohol
consumption is associated with hypertension.
52. II- DISEASE CONDITIONS AS RISK FACTORS FOR
ESSENTIAL HT:
► Obesity:
With the increase in the body mass, the volume of blood
needed to supply oxygen and nutrients to the tissues
increases. The increase in the blood volume creates
more pressure on the arterial walls.
► Diabetes
► Dyslipedemia
54. USE SPHYGMOMANOMETER FOR HYPERTENSION
SCREENING
To get accurate measurement for the blood pressure the
following are the guides:
4- Individuals should not drink coffee or smoke cigarettes
30 minutes before measuring the blood pressure,
4- Evacuation of the urinary bladder prior to blood
pressure measurement is essential. Full bladder could have
effect in false increase in the blood pressure reading.
55. -I- The individual should sit for five minutes with
his/her back supported and the feet flat on the ground.
The arm should rest on a table at the level of the heart.
-I- The arm should be well-exposed (short sleeve).
4- Two readings should be taken at least 5 minutes
apart and the average result represents the current
blood pressure measurement.
For screening purposes in the community-based
epidemiological cross sectional studies, the above
standards could be used.
56. Cancer
Definition: Cancer is the name given to a collection of related diseases; more than 100 different and distinctive diseases. In all types of
cancer, some of the body's cells begin to divide without stopping and spread to one or many parts of the body.
Magnitude of the problem:
There were an estimated 14.1 million cancer cases around the world in 2012. This number is expected to increase to 24 million by 2035.
The specific types of cancer vary from place to another. The top three worldwide cancers were lung cancer, breast cancer (women only)
and Colorectal cancer respectively. Cancer is a serious disease, and one of the major cause s of mortality worldwide.
Current situation in Egypt: According to The National Cancer Registry Program, the 2014 published data revealed that the
commonest sites were; liver (23.8%), breast (15.4%), and bladder (6.9%) (both sexes). By 2050, a 3-fold increase in incident cancer
relative to 2013 was estimated.
57. A
Factors contribute to cancer death: 90- 95%
(The remaining 5—10% are due to inherited genetics.)
Tobacco use (25-30%) Infections
(15-20%)
Diet and obesity (30-35%)
Radiation
(both
ionizing and non -ioniz in g (up to
10%),
Other factors include: stress, lack of physical activity and environmental pollutants (air, food, water).
Risk Factors for Cancer
Non modifiable risk factors:
• Age: Population over 40 years of age are at-risk for cancer.
• Sex:. Males are more susceptible to cancer due to environmental, occupational and smoking risk factors
• Genetic factors: Hereditary cancer contribute to less than 3-10% of cancers. Known cancers include breast , ovarian and colorectal
cancers.
Modifiable risk factors:
I- Lifestyle factors:
1- Tobacco use (including cigarette, cigars, pipe , water pipe and secondhand smoke. As well, tobacco chewing and snuffing):
Tobacco smoking is a risk factor of cancer of lung, larynx, head, neck, stomach, bladder, kidney, esophagus and pancreas. Tobacco
smoke contains over fifty known carcinogens, including nitrosamines and polycyclic aromatic hydrocarbons.
Cancer due to smoking is more among males than females. However, with increase in female use of tobacco, those types of cancer
attributed to tobacco have shown increase among females.
2. Dietary Factors:
For other dietary risk and protective factor for cancer, refer to Nutrition Chapter NB1: Obesity increases the risk of
endometrial cancer, postmenopausal breast cancer, kidney cancer, gall bladder and colon cancer.
NB2: Harmful use of alcohol increases the risk of liver and digestive tract cancers
12
58. 2- Infections:
Chronic infections (especially with viruses), present cancer risk factors with a proportion ranges from a high of 25% in
Africa to less than 10%
in the developed world.
Infection Associated cancer
Hepatitis B and C viruses Hepatocellular carcinoma
Human Papilloma Virus Cancer cervix
Herpes virus type 2 Cancer cervix
Kaposi's sarcoma herpesvirus
Kaposi's sarcoma and primary effusion lymphomas
Epstein Barr virus
Lymphoma and nasopharyngeal carcinoma
Helicobacter pylori Gastric carcinoma
Schistosoma haematobium Cancer bladder
liver flukes and Clonorchis sinensis Cholangiocarcinoma (bile duct cancer)
Radiation exposure, both ionizing radiation (from medical imaging , radiotherapy
and radon gas) and non-ionizing ultraviolet radiation (mostly from sunlight) is found to be a risk factor for
■ Up to 10% of invasive cancers like leukemia, lung, and thyroid cancers
■ The majority of non-invasive non-melanoma skin cancers are caused by non-ionizing ultraviolet radiation (UVB) , which are
the most common forms of cancer in the world.
4- Environmental pollutants (air, food, water):
• Exposure to chemicals at the work place: as mesothelioma (pleural cancer) can come from inhaling asbestos fibers, or leukemia
from exposure to benzene.
• Aflatoxin B1, a frequent food contaminant, causes liver cancer
5- Medications and hormones
• Use of immunosuppressive agents in the organ-transplanted patients could result in non-Hodgkin's lymphoma.
• Estrogen replacement therapy given to menopausal women that has been used for many years all over the world is now forbidden
due to its risk for cancer breast and endometrial cancer.
6- Reproductive Health Factors
3-Radiation:
59. ■ Early onset of menstruation, late onset of menopause, later age at first pregnancy, and never having given birth have been
associated with an increase in breast and ovarian cancer risk.
■ Ever breast feeding is protecting against cancer breast
■ Multiparty is a risk factor for endometrial cancer
Prevention of cancer:_
_I- Primordial and Primary Prevention_
Between 70% and 90% of common cancers are due to controllable lifestyle and environmental factors. So, cancer is generally preventable.
Specific measures:
• The hepatitis B vaccine prevents infection with hepatitis B virus and thus decreases the risk of liver cancer.
• Human papillomavirus vaccine decrease the risk of developing cervical cancer
General measures:
1- Health education programs:
a- Abstinence from all types of tobacco use
b- Avoid excess weight/obesity and alcohol consumption: Encourage vegetables, fruit, whole grains and fish on the expense of processed
and red meat (beef, pork, lamb), animal fats and refined carbohydrates. c- Adopt regular suitable physical activity d- Avoid exposure to
other risk factors like:
■ sexually transmitted infections and Schistosomiasis
■ excessive unprotected skin exposure to sun
2- Anti-smoking program especially to be directed to adolescents and youth.
3- Environmental sanitation:
• Air sanitation: For indoor air, a main effort is to reduce exposure to radon and second hand smoke. Poor outdoor air quality due to
traffics can be successfully improved through regulations.
• Food sanitation: Proper storage of cereals and nuts to prevent fungal contamination, control of food additives which are added to
give taste, color, odor and preserve food.
4- Occupational health program measures:
■ Safe work environment, health education to workers, monitoring of the workplace and supervision of the workers.
■ Prevention and control of the exposure to ionizing radiation, UV rays, asbestos dust etc.
5- Precautions in the medical settings:
60. • Fulfill the standards to prevent exposure to overdose of irradiation.
• Infection control to prevent blood borne viral infections (VHB, VHC, HIV).
• Sales and use of medications especially hormones should be restricted to medical prescription and follow up.
6- Management programs for cancer provoking medical conditions
- Children' growth monitoring to early manage childhood overweight/obesity.
- Management of risky infections as:
V Helicobacter pylori by specific antibiotics.
V Schistosomiasis
- Proper management of precancerous lesions like Actinic Keratosis, breast cysts and papillomata, peptic ulcer, tongue ulcers,
leukoplakia etc.)
_II. Secondary Prevention /Control Services:_
Aims at early detection for subsequent proper management. Opportunities for health appraisal include:
• Comprehensive medical examination e.g. pre-employment, and family medicine program
• Curative services: For cases consulting the physician
• Screening tests done on periodic medical checkup for the at-risk groups
Examples for cancer screening:
► Cytological examination for exfoliating cancer cells: Papaniculae smear -Pap Smear- (cervical swab) for early detection of cancer
cervix and sputum examination for detection of cancer lung).
► Mammography: To screen above 40 women who are at-risk for cancer breast (NB: Breast self-examination is no longer relied upon).
► Serum examination: A rising titer for alpha fetoprotein is used for screening of asymptomatic cases of hepatocellular carcinoma.
III- Tertiary Prevention/ Rehabilitation Services Same as in the CHD (vise supra).
Diabetes Mellitus
Definition: Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin
secretion, insulin action, or both.
Magnitude of the problem:
The growing diabetes pandemic poses an enormous public health challenge for almost every country across the globe. In 2014, more
than 380 million people were living with diabetes worldwide, This number is expected to increase to 592 million by 2035- 90% of these
people will have Type 2 diabetes.
Situation in Egypt: Diabetes mellitus is a growing clinical and public health problem in Egypt due to expanding risk factors. The
prevalence of diabetes found to be 17.2%
61. among those aged 15- 65 years- based on the fasting blood sugar measured during the Egypt stepwise survey, MOHP& WHO,
2011-2012.
Types of Diabetes
*of all diagnosed cases of diabetes
Diabetes Type I: is a genetic autoimmune disorder that end by insulin-producing P-cells destruction. This may be triggered by
Some viral infections (e.g. mumps, patients with congenital rubella syndrome, Coxsackievirus B, cytomegalovirus) and/ or
environmental factors (like early drinking of cow's milk or exposure to certain toxins e.g. Rodenticides)
62. Risk factors for Diabetes Type II
Obesity Family History
Alone or part of the
metabolic syndrome
Older
age:
Above 45 year
old
Sedentary lifestyle
Nutritional habits: excess animal fats and refined
carbohydrates
Excess Smoking/ alcohol
Unhealthy life style Tension /stress
NB1: Except for the "age", all risk factors of diabetes type II are modifiable NB2: Family history of diabetes (mostly due to
sharing unhealthy feeding and
lifestyle habits)
NB1: Diabetes Mellitus s is one of the "Silent" diseases. Often symptoms are not severe, or may be absent, and consequently
hyperglycaemia sufficient to cause pathological and functional changes may be present for a long time before the diagnosis is
made.
NB2: The chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction and failure of different organs,
especially the eyes, kidneys, nerves, heart and blood vessels.
Prevention of diabetes:_
I- Primary Prevention of Diabetes Type I:_
S Mass MMR immunization (to prevent the risk of mumps and rubella in diabetes)
S Encourage breast feeding
S Advice to avoid consanguineous marriage (control genetic risk factors)
S Premarital/ Pre-conception counseling (control genetic risk factors)
II- Primordial and Primary Prevention of Diabetes Type II:_
Diabetes type II can be generally delayed or prevented. It was proved that the incidence of diabetes can be decreased by ~
80% by controlling the lifestyle factors.
63. 1- Health education programs about:
a-Avoid excess weight/obesity through
► Proper diet: Encourage vegetables, fruit, whole grains and fish on the expense of animal fats and refined carbohydrates,
► Regular suitable physical activity
b- Avoid smoking and harmful use of alcohol c- Manage stress properly
2- Precautions in the medical settings:
Sales and use of diabetes induced medications should be restricted to medical prescription and follow up e.g. steroids, antidepressants,
and anti-rejection drugs.
III- Secondary Prevention of Diabetes Type I and II:_
Aims at early detection for subsequent proper management. Opportunities for health appraisal include:
• Comprehensive medical examination e.g. premarital, antenatal and preemployment programs
• Curative services : for cases consulting the physician
• Screening tests done on periodic medical checkup for the at-risk groups
Simple screening tests include testing blood for glucose level. The screening test could identify cases in the pre-clinical stage (pre-
diabetics) and undiagnosed diabetes (accidentally discovered diabetes). see next box for the diagnostic criteria for diabetes.
Screening Tests and Diagnosis of Diabetes Mellitus
Lab Test Diagnosis
Normoglycemic
Impaired Glucose Tolerance
(prediabetes)
Diabetes
(Clinical
Diabetes)
Fasting plasma glucose
(FPG) < 110 mg/dl
>110 and <126 mg/dl
>126 mg/dl
2-hours PostGlucose Load
< 140 mg/dl >140 and <200 mg/dl >200 mg/dl
■ The FPG test is the best screening test for its ease of administration, convenience, acceptability to patients, and lower
cost
■ Fasting is defined as no consumption of food or beverage other than
water for at least 8 h before testing._
64. r *Hb A 1 c
below 8%
Diabetes control and the 5 follow up goals
**
Blood pressure less
than 140/90
LDL levels less than 100
mg/ dL
1 aspirin/ day as
recommer ded
*Hemoglobin A1c (HbA1c): A minor component of hemoglobin to which glucose is bound. The test’s results give an idea of your
average blood glucose levels for the preceding two to three months. The test can help determine if you have diabetes or pre- diabetes.
The higher the glucose concentration in blood, the higher the level of HbA1c.
IV- Tertiary Prevention /Rehabilitation services of Diabetes Type I and II:
Same as in the CHD (vise supra).
References
1. International Diabetes Federation, 2014: Available at:
http://www.idf.org/membership/mena/egypt Accessed 14th july, 2015.
2. Institute for Health Metrics and Evaluation, 2014: Global Burden of Disease Profile:
Egypt. Available
at:http://www.healthdata.org/sites/default/files/files/country_profiles/GBD/ihme_gbd _country_report_egypt.pdf Accessed 2nd
March, 2014.
3. World Health Organization. Non-communicable diseases (NCD) country profiles 2014.
http://www.who.int/nmh/countries/egy_en.pdf. Accessed January 21, 2015.
4. WHO-country office, 2014: Tobacco Control in Egypt. Personal interview with WHO-country office technical officer.
5- The 2011/12 Stepwise survey, conducted by the Ministry of Health and Population (MOHP), Egypt, in collaboration with WHO
Ministry of Health & population
6. World Health Organization 2013. Global Plan of Action for the Prevention and Control of Non-communicable diseases 2013- 2020.
7. Cancer Incidence in Egypt: Results of the National Population-Based Cancer Registry Program: Amal S. Ibrahim, Hussein M.
Khaled, Nabiel NH Mikhail, Hoda Baraka,4 and Hossam Kamel2 Journal of Cancer Epidemiology Volume 2014 (2014), Article ID
437971, 18 pages
http://dx.doi.org/10.1155/2014/437971. . Accessed june. 11, 2015
8. World Health Organization. Non-communicable diseases (NCD) country profiles 2014.
http://www.who.int/nmh/countries/egy_en.pdf. Accessed July 27, 2015.
