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P R E - M A R I T A L

P R E - M A R I T A L. COUNSELING AND TESTS. Marwah Hassounah MPH-HCOM, MBBS Community Medicine Unit Faculty Family and Community Medicine Department- King Saud University Reproductive System Block- 2 nd year Medical Students April 4th, 2018 11-12 p.m. 1.

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P R E - M A R I T A L

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  1. PRE-MARITAL COUNSELING ANDTESTS Marwah Hassounah MPH-HCOM,MBBS Community Medicine UnitFaculty Family and Community Medicine Department- King SaudUniversity Reproductive System Block- 2nd year MedicalStudents April 4th,2018 11-12p.m. 1

  2. Bytheend ofthislecturethestudentshouldbeableto: RecognizetheSaudiHealthyMarriageprogram Recalltheprogram’sareasofpre-maritalcounseling ListdiseasesincludedintheSaudipre-maritalscreening program Identifythefateoftestedindividuals(case,carrier,clear) Recognizeculturalconsiderationsforpre-maritalcounselingin SaudiArabia LearningObjectives 2

  3. The SaudiScene BriefontheSaudipre-maritalscreeningprogram Pre-maritalcounselinganditsapplicationinKSA The program’sobjectives Overviewvideo Culturalconsiderations 3 minutes in-class stretchingbreak Scenarioapplicationforfatesoftestedcouples Infectious diseasescenarios Inherited blooddisorders Closingremarks LectureOutline 3

  4. Thescene • ThemiddleEastisoneoftheregionsknownforhighratesofsicklecell • disease andbeta-thalassemia.(1) • In the 80s Saudi Arabia was hyper-endemic with Hep B Virus.(2) • In Saudi Arabia, Hepatitis C persists as a problem in hemodialysis patientsandIVdrugusers.InKKUH,HepCprevalencewas0.58%in 1996 and decreased to 0.08% in 2006.(2) • Fromtheyear2000to2009,therewere2,956reportedSaudicasesof • HIV. A rate of 1.5 cases per100,000 Saudis. Markedregionalvariationsintheprevalenceofsicklecelldiseaseandb-thalassemiainSaudiArabia:Findingsformthepre-maritalscreeningandgeenticcounselingprogram.JournalofEpidemiology andGlobalHealth.December2011.ZiadA.MemishMohamadY.Saeedi. EpidemiologyofviralHepatitisinSaudiArabia:AreWeOfftheHook?.SaudiJournalofGastroenterology.Nov-Dec2012. AymanAbdo,FaisalM.Sanai,FalehZ.Al-Faleh. HIVCaseNotificationRatesintheKingdomofSaudiArabiaoverthePastDecade(2000-2009).PLoSONE.Sep2012.MohammedA.A.I.Mazroaetal 4

  5. 5

  6. Healthy MarriageProgram • Program started in 2004. It includedtests for hemoglobinopathies: • sickle cell andthalassemia.(1) • In2008theMOHaddedtotheprogramtestingforHIV,HepB, HepC.(2) • In 2013, the program changed its name from pre-marital screening جاوزلا لبقام صحف to healthy marriage programجمانرب يحصلا جاوزلا, and started electronic integration.(3) AlsaeedES,FarhatGN,AssiriAM,MemishZ,AhmedEM,SaeediMY,Al-DossaryMF,BashawriH.DistributionofhemoglobinopathydisordersinSaudiArabiabasedondatafromthepremaritalscreeningandgeneticcounseling program,2011–2015.JournalofEpidemiologyandGlobalHealth. 2017Dec15. AlswaidiFM,O'BrienSS.IsthereaneedtoincludeHIV,HBVandHCVvirusesintheSaudipremaritalscreeningprogrammeonthebasisoftheirprevalenceandtransmissionriskfactors?.JournalofEpidemiology&Community Health. 2009 Jan1:jech-2009. MOHreleaseshealthymarriageprograminsteadofpre-maritalscreening[onlinenewsarticle].Akhbar24.URL:https://akhbaar24.argaam.com/article/detail/143471.Published:July25th,2013.Accessed: April3rd, 2018. 6

  7. Centers • ListofMOHcentersaccreditedtogivethehealthymarriage certificate: • https://www.moh.gov.sa/en/HealthAwareness/Beforemarriage/Pa ges/002.aspx • Thereareothersinnon-MOHinstitutes.Ex:PCC1hereinKKUHfor • KSUstaff Healthy Marriage Programcnt’ 7

  8. The SaudiScene BriefontheSaudipre-maritalscreeningprogram Pre-maritalcounselinganditsapplicationinKSA The program’sobjectives Overviewvideo Culturalconsiderations 3 minutes in-class stretchingbreak Scenarioapplicationforfatesoftestedcouples Infectious diseasescenarios Inherited blooddisorders Closingremarks LectureOutline 8

  9. Pre-maritalcounseling Pre-marital: beforemarriage Counseling: “professional guidance of the individual by utilizing psychologicalmethods……” (1) Definition of Counseling [online webpage]. Merriam- Webster Dictionary. URL: https://www.merriam-webster.com/dictionary/counseling. Accesed: April 2nd, 2018. 9

  10. Pre-marital Counseling inKSA • TheSaudipre-maritalscreeningprogram,testsforgeneticblood disorders(hemoglobinopathies)and infectious diseases. Then according to theresults, it provides counseling on: • The odds of transferring this disease to their prospectivemarriage partner • The odds of transferring this disease to their futurechildren • Solutionsandhowtomoveforward Premarital Screening [online webpage]. Ministry of Health. URL: https://www.moh.gov.sa/en/HealthAwareness/Beforemarriage/Pages/default.aspx. Last Update: July 1st, 2017. Accessed: April 2nd,2018. 10

  11. The program’sobjectives AnatomieHIV-Virusillustrationbywww.medicalgraphics.de,distributedundercreativecommonsCCBY-ND3.0.URL:http://www.medicalgraphics.de/en/free- pictures/erkrankungen/hiv-virus-offen.html. Accessed: April 2nd, 2018 EmojiimagebyEbrahim,distributedundertheCreativeCommonsAttribution-ShareAlike4.0Internationallicense.URL: https://commons.wikimedia.org/wiki/File:Emojione_1F613.svg. Accessed: April 2nd,2018

  12. The program’sobjectives Tomakeiteasierforpeoplewhowanttomake the test toask for it Toraiseawarenessabouttheconceptofa comprehensive healthymarriage Premarital Screening [online webpage]. Ministry of Health. URL: https://www.moh.gov.sa/en/HealthAwareness/Beforemarriage/Pages/default.aspx. Last Update: July 1st, 2017. Accessed: April 2nd,2018.

  13. Certificate of healthymarriage The certificate is issued afterthe test results have beendoneandcounselinghasbeenperformed inthecounselingclinicforcasesthatmandateit. Examples of such cases: Having Hep C, hemoglobinopathywithchanceofhaving diseasedchildren

  14. Culturalconsiderations • Consanguineous marriage (56% in 1995, 57.7% in 2007 inKSA)* • Respectthecouple’sdecisions.Thetestismandatorybutthe • results are notmandatory. • Family and tribalpressure • Tabooofcertaindiseases/stigma • Privacy andconfidentiality El-HazmiMA,Al-SwailemAR,WarsyAS,Al-SwailemAM, SulaimaniR,Al-MeshariAA.ConsanguinityamongtheSaudiArabianpopulation.Journalofmedicalgenetics.1995Aug1;32(8):623-6. El-MouzanMI,Al-SalloumAA,Al-Herbish AS,QurachiMM,Al-OmarAA.RegionalvariationsintheprevalenceofconsanguinityinSaudiArabia.SaudiMedicalJournal. 2007;28(12):1881-4. 15

  15. The SaudiScene BriefontheSaudipre-maritalscreeningprogram Pre-maritalcounselinganditsapplicationinKSA The program’sobjectives Overviewvideo Culturalconsiderations 3 minutes in-class stretchingbreak Scenarioapplicationforfatesoftestedcouples Infectious diseasescenarios Inherited blooddisorders Closingremarks LectureOutline

  16. The SaudiScene BriefontheSaudipre-maritalscreeningprogram Pre-maritalcounselinganditsapplicationinKSA The program’sobjectives Overviewvideo Culturalconsiderations 3 minutes in-class stretchingbreak Scenarioapplicationforfatesoftestedcouples Infectious diseasescenarios Inherited blooddisorders Closingremarks LectureOutline

  17. Scenario#1 MohammedandFatimapresentedtotheprimarycareclinicfor pre-maritalscreening.You performed the following blood tests: complete blood count, sickle cell test, hemoglobin electrophoresis,andvirologytestsforHIV,HepC,andHepB.Both were clear from anyabnormalities. 1. Is counseling required in thissituation?

  18. Scenario#2 Amal and Tareq performed pre-marital screening tests and it was foundthat TareqisaHepBcarrier.Repeattheteststoconfirm.To issue them a health marriage certificate it is mandatory that they gotothecounselingclinic. what will you counsel themabout? Transmission to wife- HepB vaccine Transmission to future children – HepB vaccine Solutions:refertospecialtyclinicasneeded.

  19. WhatifitwasHepCorHIV? • Repeat the tests toconfirm. • Counseling is mandatory aswell. • Transmissiontowife-novaccines,healtheducation • Transmission to futurechildren • Solutions:refertospecialtyclinicasneeded.(antiviraltherapy) • Themarriage • HepC:ifdecidedtoproceed,signthattheyreceivedcounseling • andtheyaregoingaheadwiththemarriagedespitecounseling • HIV:MedicalrecordgoestoMOI.Onlyallowedtomarryfromother HIV affectedindividuals.

  20. The SaudiScene BriefontheSaudipre-maritalscreeningprogram Pre-maritalcounselinganditsapplicationinKSA The program’sobjectives Overviewvideo Culturalconsiderations 3 minutes in-class stretchingbreak Scenarioapplicationforfatesoftestedcouples Infectious diseasescenarios Inherited blooddisorders Closingremarks LectureOutline

  21. Scenario#3 • Ali, from the Eastern region, presented to your clinic for pre- marital screening as he intends to marry his cousin. His prospective wife did the test and was clear from any abnormalities.Ali’s hemoglobin electrophoresis shows Hb A: 60 • % , HbSS:40% ,HbF:2%,meaningheisacarrierofsicklecell trait. • What would you tell them aboutthe • odds of inheritance for their futurechildren?

  22. Scenario #3cnt’ Inheritance of Sickle Cell Anemia [ online webpage]. Sickle Cell Society. URL: http://www.sicklecellsociety.org/resources/inheritance-of-sickle-cell-anaemia/. Published: July 13th, 2014. Accessed: April 3rd,2018

  23. Counseling: • Transmission to futurechildren? • Solutions/alternatives? • Findanotherpartnerformarriagewhodoesn’t havesicklecelltraitoranemia • Certificateofhealthymarriagewillbegiven aftertheygotothecounselingclinic. WhatifAli’sfiancéSarawasalsoa sickle cell traitcarrier? Inheritance of Sickle Cell Anemia [ online webpage]. Sickle Cell Society. URL: http://www.sicklecellsociety.org/resources/inheritance-of-sickle-cell-anaemia/. Published: July 13th, 2014. Accessed: April 3rd,2018

  24. Oddsoftransmissiontofuturechildren? • Isanappointmentatthecounselingclinic mandatory to issue thecertificate? WhatifAlihadsicklecellanemia and Sara wasclear? Image by NigeriaGalleria. Used without permission. [online webpage]. URL: https://www.nigeriagalleria.com/Community-Health/Sickle-Cell.html. Accessed:April 3rd, 2018. 26

  25. Counseling: • Oddsoftransmissiontofuturechildren? • Alternatives/solutions? • Findanotherpartnerformarriagewho doesn’thavesicklecelltraitoranemia • Certificateofhealthymarriagewillbegiven aftertheygotothecounselingclinic. WhatifAliisacarrierandSarahas sickle cellanemia? 27 Imagefrommarkgadogbe.Wordpresswithoutpermission.LoveandSickleCell[onlineblogpost].URL:https://markgadogbe.wordpress.com/tag/heartbreak/.Posted:May4th,2015. AccessedApril 3rd,2018.

  26. Imagefrommarkgadogbe.Wordpresswithoutpermission.LoveandSickleCell[onlineblogpost].URL:https://markgadogbe.wordpress.com/tag/heartbreak/.Imagefrommarkgadogbe.Wordpresswithoutpermission.LoveandSickleCell[onlineblogpost].URL:https://markgadogbe.wordpress.com/tag/heartbreak/. Posted:May 4th, 2015. Accessed April 3rd,2018. 28

  27. Image by NigeriaGalleria. Used without permission. [online webpage]. URL: https://www.nigeriagalleria.com/Community-Health/Sickle-Cell.html. Accessed: April3rd, 2018. 29

  28. The SaudiScene BriefontheSaudipre-maritalscreeningprogram Pre-maritalcounselinganditsapplicationinKSA The program’sobjectives Overviewvideo Culturalconsiderations 3 minutes in-class stretchingbreak Scenarioapplicationforfatesoftestedcouples Infectious diseasescenarios Inherited blooddisorders Closingremarks LectureOutline

  29. Bytheend ofthislecturethestudentshouldbeableto: RecognizetheSaudiHealthyMarriageprogram Recalltheprogram’sareasofpre-maritalcounseling ListdiseasesincludedintheSaudipre-maritalscreening program Identifythefateoftestedindividuals(case,carrier,clear) Recognizeculturalconsiderationsforpre-maritalcounselingin SaudiArabia LearningObjectives

  30. THANKYOU Marwah.m.i.h@gmail.com

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