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Reduced bacteria concentrations in wastewater is a key indicator of the efficacy of water resource recovery facilities (WRRFs). However, monitoring the presence of bacterial concentrations in real time at each stage of the WRRF is challenging as it requires taking and processing water samples offline. Although few studies have been proposed to predict bacterial concentrations using data-driven models, generalizing these models to unseen data from different WRRFs remains challenging. This paper proposes a calibration approach based on neural networks to adapt the optimal models across various WRRFs in Saudi Arabia for bacterial estimation at the influent and effluent stages. The calibration relies on the out-of-distribution (OOD) framework of the physiochemical water parameters (e.g., pH, COD, TDS, turbidity, conductivity) with a design threshold chosen based on the data distribution of the received unseen samples. We propose a calibration framework that continues updating the trained neural network model for accurate bacterial concentration estimation upon receiving new samples. We tested the effectiveness of the proposed calibration scheme on four WRRF datasets in Saudi Arabia, comparing the results with before and after calibration without the OOD. Before calibration model was based on a traditional and optimal neural network approach, typically considered the conventional method for building neural networks. After calibration without OOD, the model continued retraining without explicitly checking for OOD condition. The results showed that the proposed calibration framework of the selected baseline WRRF with the OOD scheme improved [Formula: see text] and [Formula: see text] of the worst-case influent bacteria concentration before calibration and after calibration without OOD, respectively. Similarly, the worst-case effluent bacteria concentration estimation was enhanced by [Formula: see text] before calibration and [Formula: see text] after calibration without the OOD. Our findings highlight the importance of integrating the calibration framework with neural network approaches to achieve model generalization., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Objective: Cladribine tablets are the first short-course oral treatment approved for high disease activity relapsing-remitting multiple sclerosis (HDA-RRMS) across various countries. This analysis assessed the cost-effectiveness of introducing cladribine tablets as a treatment option for patients with high disease activity compared with other HDA-RRMS therapies in the Kingdom of Saudi Arabia (KSA)., Methods: The cost-effectiveness model was adapted from the KSA payer's perspective. Data for the model's adaptation were retrieved from the literature and validated by key opinion leaders. The comparators considered in the model were alemtuzumab, dimethyl fumarate, fingolimod, interferon beta-1a (subcutaneous and intramuscular) and beta-1b, natalizumab, and teriflunomide. A sensitivity analysis was also performed to assess the robustness of the analysis., Results: The cost-effectiveness results showed cladribine tablets as the dominant strategy (ie, less costly and more effective) versus all the comparators. The incremental cost and quality-adjusted life-years gained were largely driven by drug acquisition cost and delayed expanded disability status scale progression, respectively. Cladribine tablets showed an 81% to 100% probability of being cost-effective at a threshold of Saudi Riyal 225 326 per quality-adjusted life-years gained against different comparators., Conclusions: Cladribine tablets are a dominant treatment option for patients with HDA-RRMS from the payer perspective in the KSA., (Copyright © 2021. Published by Elsevier Inc.)

Aim: The primary aim of this qualitative inquiry is to explore the experiences of Registered Nurses working in Saudi Arabia, which was a guide to answer the question, "what are the lived experiences of Registered Nurses working in a selected government hospital in Eastern Region of Saudi Arabia towards workplace violence?", Background: Workplace violence is a social phenomenon that needs a widespread campaign to eradicate. Incidence from all over the world continues to grow in number, especially among Registered Nurses in Saudi Arabia., Methods: Descriptive phenomenology. Purposive-convenience sampling was used in selecting 21 Registered Nurses as participants for individual in-depth interviews. Data were gathered over an 11 month's period from September 2017 to August 2018. We used Colaizzi's method for analysing the data. COREQ criteria were adapted in reporting the results of the study., Results: Three themes had emerged from the experiences of the participants: "co-workers become unjust and violent"; "socio-cultural divergence towards healthcare workers"; and "violence from outside influences affecting the workplace.", (© 2020 The Authors. Nursing Open published by John Wiley & Sons Ltd.)

Objective: Pending a comprehensive study of tobacco economics in Saudi Arabia, our aim was to estimate the economic costs of tobacco consumption in Saudi Arabia over a period of 10 years (2001-2010)., Methods: Pertinent data on imported tobacco were obtained from the Saudi Customs Authority through the Central Department of Statistics and Information. Mortality was calculated using the following parameters: 1 ton of tobacco consumed causes an average of 0.65 premature deaths, and the net loss was calculated as US $47.6 million (2011 US$ prices) for every 1000 tons of tobacco consumed. This represented the net cost of premature deaths and the direct and indirect costs of morbidity., Results: Using 2011 prices, the economic loss due to tobacco was US $20.5 billion over the last 10 years, without accounting for smuggled (illegally imported) tobacco. If the smuggling rate was 10% or 25%, the economic loss would be 22.6 or 25.6 billion US$, respectively. There were 280,000 premature deaths during the same period without accounting for smuggled tobacco., Conclusions: In Saudi Arabia, short-term and long-term economic gains will result from reductions in tobacco use., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: To assess the status of complementary and alternative medicine (CAM) education in health colleges in Saudi Arabia., Methods: A cross sectional descriptive study was conducted including all medical, dentistry, pharmacy, nursing, allied medical science, and health colleges in Saudi Arabia. A semi- structured questionnaire was designed to collect information covering CAM tracks, courses and contents in the college's curricula, available postgraduates programs, continuing medical education activities, number of colleges staff members specialized or interested in CAM., Results: Out of 110 health colleges in Saudi Arabia, 90 (81.1%) participated in the survey. There is no CAM specialized track or postgraduate education in any health college. Eleven (12.2%) colleges are teaching CAM courses in their curricula. Fifteen (16.7%) colleges are teaching topics related to CAM in different study subjects. Five (5.6%) colleges conducted continuing medical education (CME) activities related to CAM. Among faculty members, there are only 16 CAM specialists working in 7 colleges and 84 interested staff members, working in 20 colleges. Colleges of pharmacy are more interested in CAM education compared to other colleges with 42.9% (6/14) of them have CAM courses in their curricula, (p=0.006). Also, they have more faculty CAM specialists (p=0.026) compared to other colleges., Conclusion: There is a low and diverse attention given to CAM in medical education in Saudi Arabia. There is a need for a national plan to review health colleges curricula to prepare health care providers for the integration of evidenced based CAM practices., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: The aim of this study was to assess the level of knowledge, attitudes, and utilization of complementary and alternative medicine (CAM) of primary health care (PHC) physicians in Riyadh, Saudi Arabia., Material and Methods: A crosssectional study including all physicians working at PHC centers in the Riyadh region, Saudi Arabia, was carried out from the beginning of April 2010 to the end of June 2010. Using a self-administered questionnaire, 1,113 physicians answered questions regarding their socio-demographic data, and knowledge, attitudes and utilization of CAM., Results: About 8% of the participants had attended a continuous medical education or a training activity. Most of them were unfamiliar with reflexology, energy healing, aromatherapy, ozone therapy, homeopathy, or chiropractic care (77.4, 71.3, 71.2, 67.2, 65.7, and 63.9%, respectively). On the other hand, most physicians felt that they could understand and feel comfortable about counseling patients about Ruqyah (spiritual healing), honey and bee products, dietary supplements, massage therapy, relaxation, herbal medicine, and cupping (40.3, 38.3, 34.9, 34.4, 25.8, 22.8, and 21.4%, respectively). More than half (51.7%) of the physicians used CAM for themselves or their family, but only 14.2% referred their patients to CAM practitioners. 85.1% of studied physicians agreed that physicians should have knowledge about CAM therapies commonly used in the region. 82.5% agreed that health authorities should have a role in regulating CAM, and 75.7% agreed that the physicians' knowledge about CAM practices leads to better patient outcome., Conclusion: There is a positive attitude regarding the concept of CAM, but there is a reluctance to refer or to initiate discussion with patients regarding CAM practices, which may be attributed to a lack of knowledge., (Copyright © 2012 S. Karger AG, Basel.)

Objective: To draw a profile, and study the media habits for cigarette smokers in Saudi Arabia using the Target Group Index survey (TGI)., Methods: A household survey using the TGI sample was conducted in March 2008 in 21 cities in Saudi Arabia. A sample of 7003 individuals aged 15 years or more, male and females, living in town and cities, were randomly selected using the multistage sampling technique. One individual per household was interviewed using a structured questionnaire covering socio-economic profile, media exposure, and cigarette consumer information. The study was conducted in Arabian Center for Tobacco Control, Riyadh, Kingdom of Saudi Arabia., Results: Cigarette smoking was 35.9% in males, and 2.3% in females. This was significantly higher in the age group 30-49 years compared with younger ages (p=0.001). Among smokers, 22.3% were heavy smokers, 69.3% were using regular flavor cigarettes, and 22.4% tried to quit smoking but failed. The most common methods of quitting smoking were; nicotine gum (18.5%), hypnosis (14%), nicotine patch (8%), and acupuncture (3%). Ninety-eight percent of the smokers watched TV daily, noticed mainly big outdoor ads, and 46% used the Internet daily. Favorite TV and radio channels, newspaper, magazine, and interesting topics for the smokers were recorded, and the main smoker profile was drawn., Conclusion: The TGI can be used to draw a smoker profile and identify different segments with the greatest opportunities to send anti-smoking messages.

In 2001, the measles immunization schedule in Saudi Arabia was changed to 2 measles, mumps and rubella vaccine doses at 12 months and at 6 years. In this follow-up study we evaluated the seroresponse to the second measles dose before school entry. We recruited 138 children randomly from primary health care centres in Qassim; 124 children completed the study. Blood samples were collected before and 1 month after giving the second measles dose, before the age of 6 years. There was a statistically significant increase in the geometric mean titre of measles antibody, from 2205 m IU/mL before vaccination to 4723 mlU/mL after (P = 0.0001). The proportion of children with positive ELISA results increased fro++ 94.2% before vaccination to 99.2% after (P = 0.02), while the proportion with protective level (> or = 200 mlU/mL) increased from 97.1% before vaccination to 99.19% after (P = 0.21). The 2-dose measles immunization schedule can produce optimum protection at school entry if high vaccination coverage is guaranteed.

The Islamic Hajj pilgrimage to Mecca, Saudi Arabia has historically been associated with outbreaks of serogroup A and W135 meningococcal disease. Prevention against meningococcal disease has principally been vaccination with meningococcal polysaccharide vaccines, either in a bivalent serogroup A/C or quadrivalent A/C/Y/W135 form. These interventions have suppressed meningococcal disease since 2002. Countries with large Muslim populations have now started to show a trend of increased serogroup B meningococcal disease, a serogroup for which there is no universal vaccine available. These trends should increase our preparedness to expect a sudden change in the etiology of meningococcal disease during the Hajj.

Objective: To evaluate the sero-response to measles component of the first measles, mumps and rubella MMR dose given at 12 months by measuring measles antibody before and one month after the vaccination., Methods: A follow-up study where, 57 children at the age of 12 months were recruited randomly from the Primary Health Care Centers in Qassim, Saudi Arabia using a multistage sampling techniques. Fieldwork was conducted from October until December 2006. Blood samples were collected to measure measles IgG antibody before, and one month after giving MMR using enzyme linked immunosorbent assay. Data were compared before and after vaccination using geometric mean titer GMT and seroconversion., Results: In the 57 infants, positivity rate increased significantly from 3.5% (2/57) pre-vaccination to 100% one month after p=0.0001, and with a sero-conversion of 96.5% (55/57). Also, GMT increased significantly from 0.014-2.172 IU/ML, after vaccination p=0.0001., Conclusion: Sero conversion and GMT are significantly high after the first MMR given at 12 months and this is supported by the surveillance data in Qassim.

Objective: To evaluate immune protection against vaccine-preventable diseases targeted by the Expanded Program of Immunization in Saudi Arabia., Methods: The study was carried out from September 2001 to February 2002. Using multistage sampling techniques, samples were collected from 5 regions of Saudi Arabia and sent for laboratory assay from the following age groups; 50 samples at 12 months, 50 at 6 years, and 100 at 17 years. Sera were assayed for diphtheria, tetanus, and pertussis. Sero neutralization was used for anti-diphtheria antibody assay, while enzyme linked immunoassay was used for anti-tetanus, anti-filament hemoagglutination (anti-FHA), and anti-pertussis titer (anti-PT) antibody assay., Results: This survey showed that 100% of children had protection levels (>/=0.01 IU/ml) against diphtheria at one year, 100% at 6 years, and 93.7% at 17 years. For tetanus, 95.9% had protection levels (>/=0.1 IU/ml) at one year, 100% at 6 years, and 98.9% at 17 years. The geometric mean titer (GMT) of anti-FHA is 22 at one year, 29 at 6 years, and 24 IU/ml at 17 years, while the GMT of anti-PT is 36 at one year, 18 at 6 years, and 11 IU/ml at 17 years., Conclusion: Children at one, 6, and 17 years are well protected against diphtheria, pertussis, and tetanus.

Objective: A serosurvey study to evaluate the proportion of children with antibodies against diseases targeted by the Expanded Program of Immunization in the Kingdom of Saudi Arabia., Methods: Using multistage sampling techniques, we collected samples and sent them for laboratory assay from the following age groups; 100 samples at 6 months, 12 months, 18 months, 6 years, 13 years, and 17 years. We conducted the study from September 2001 to February 2002. We assayed sera for measles, rubella, and mumps antibodies in the measles-mumps-rubella reference laboratory in Germany, using enzyme immunoassay and plaque neutralization (PN) as a backup test for equivocal and negative samples. We only carried out a backup test for measles samples., Results: The age group of 6 months had the highest proportion with negative measles antibodies. After adding the backup test (PN), the proportions of children with protective measles antibody were; 64% at 6 months, 87% at 12 months, 91% at 18 months, 75% at 6 years, 96% at 13 years, and 98% at 17 years. Rubella antibody positivity rates (>7 IU) were 28% at 6 months, 49% at 12 months, 97% at 18 months, 98% at 6 years, and 100% at 13 years. While positivity rates in mumps were 14% at 6 months, 29% at 12 months, 59% at 18 months, 64% at 6 years, and 75% at 13 years., Conclusion: The unexpected low proportion of children with protective level at 6 years, despite being vaccinated with 2 measle doses is an important phenomenon. This reflects the interference between the first and the second measles dose. The Ministry of Health decided to conduct a catch up campaign targeting 1st through 3rd grade primary schools, who did not catch the mass campaign conducted in 2000. Also, this supports the decision taken by the ministry to change the measles immunization schedule to MMR at 12 months and a second dose at 6 years of age.

This article describesthe tremendous efforts made in the field of measles immunization in Saudi Arabia in the past 20 years, from the control phase to the elimination phase. Mandatory measles vaccination with one-dose Schwartz vaccine was introduced in 1982 by a royal decree, a step aimed at increasing vaccine coverage. In 1991, a two-dose schedule was implemented using Edmonston-Zagreb measles vaccine, with a first dose at 6 months to protect children younger than 9 months and a second dose of MMR at 12 months of age to protect those who did not respond to the first dose. A marked reduction in the epidemic peak and a shift of infection to older age were noticed. But the same data showed that 50% of measles cases in the 1- to 4-year age group occurred in vaccinated children. In 1998, with the start of elimination phase, an MMR campaign was launched in two phases, targeting school children in 1998 (secondary schools) and in 2000 (primary and intermediate schools). Evaluation of the MMR campaign and surveillance data was reflected in the measles immunization policy by shifting the age of measles immunization to 12 months and to preschool using the two-dose MMR schedule.

Background: The high prevalence of hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) in pregnant women is considered the most important factor contributing to the higher carrier rate of HBsAg in some populations, including Saudi Arabia. Universal hepatitis B vaccination in infancy was implemented in Saudi Arabia in 1990 to avoid early acquisition of infection. At the same time, another program was launched to vaccinate all school children at school entry as a second target group. The aim of this study was to evaluate the HBsAg prevalence rate in Saudi pregnant women 12 years after launching the program and to assess regional variation, if any., Methods: In a cross-sectional study, 2664 pregnant Saudi women were recruited from the five main regions in Saudi Arabia. Blood samples were tested for HBsAg. Positive samples were tested also for HBeAg., Results: Of 2664 pregnant Saudi women, 65 were positive for HBsAg (2.46%, 95% CI=2.11%-2.69%). Four were positive for HBeAg (0.15%). The HBsAg prevalence rate was higher in Gizan (4.2%) and lower in Tabuk (1.4%) (P=-0.035). Only one case was positive for HBsAg in women under the age of 20 years (1/186), a 0.5% positivity rate in this age group compared with 2.6% in the older age group (P=-0.049 for the one-sided test). A history of surgical procedures was associated with a higher (3%), but not significantly higher rate of HBsAg positivity. No significant association was found between HBsAg positivity and a history of dental procedures or blood transfusion., Conclusion: Although the HBsAg prevalence rate among Saudi pregnant women was lower than previously published data, the full impact of the hepatitis B vaccination program in infancy and childhood will take more years to decrease the prevalence rate in pregnant women. The MOH should continue to give the first dose of hepatitis B vaccine at birth to prevent early acquisition, but in the meantime a regional policy can be adopted to deal with the high prevalence rate of HBsAg among pregnant Saudi women.

Objective: To compare the national growth monitoring data with the National Centre for Health Statistics (NCHS) growth standards, which is currently used in the Kingdom of Saudi Arabia (KSA)., Methods: A cross sectional study following World Health Organization criteria in determining sample size was adopted, whereby 24,000 children from 5 regions were selected to be the desired sample. One hundred and two Primary Health Care centers were also selected randomly from the 5 regions, from where the sample was drawn. A special questionnaire was designed for the data collection. A pilot study was carried out to test the study instruments. Weight, height and head circumference were measured by standard procedures. This data was compared with the National Centre for Health Statistics (NCHS) data., Results: The total number of children examined was 23,821, 11,913 boys and 11,908 girls, they were drawn from 102 health centers selected randomly. Comparing different percentiles for Saudi and NCHS data, there was a significant difference between the Saudi and American children., Conclusion: In order to ensure a correct follow up for our children in KSA, the national figures are more appropriate to follow than the NCHS data.

We evaluated the safety of a measles-mumps-rubella (MMR) immunization campaign for Saudi children (age range: 6-13 years) and gender differences in reporting post-MMR adverse events. After vaccinations were administered, we monitored 160 schools for 14 days and 19 hospitals in the 8 cities under study for 10 weeks. Incidence rates were: all MMR adverse events, 26.5/10,000 MMR vaccines (significantly higher in females than males); Urabe strain aseptic meningitis, 1.0/295,000; fever, 40.2/10,000 (females) and 0.9/10,000 (males); and parotitis, 5.4/10,000 (females) and 0.9/10,000 (males). Combined MMR vaccine containing the Urabe mumps strain was safe for children aged 6-13 years. Gender differences regarding reactogenicity were evident and should be considered when designing future studies.

Objective: To evaluate the measles-mumps-rubella vaccine campaign targeting primary school children in the Kingdom of Saudi Arabia during the months of January and February 2000., Methods: Pre and post measles-mumps-rubella vaccine blood samples were collected from 54 children from the first grade and 96 children from the 6th grade. Antibodies against measles, mumps and rubella were assayed using enzyme immunoassay and a backup test of plaque neutralization test. This assay was carried out at the Reference Center, Koch Institute, Berlin, Germany., Results: When the backup test results were added, 96%-98% of children had protection level against measles before the campaign. It is interesting to notice that pre-vaccination measles mean titer and positivity rate with enzyme linked immunoassay in the first grade were significantly lower than the 6th grade. One hundred percent and 96.8% were positive for rubella antibody before the campaign, in the first and 6th grades. Seventy-seven percent and 67% were positive for mumps before the campaign, in the first and 6th grade. After the measles-mumps-rubella vaccine campaign, protection rate reached 100% for the 3 antigens with a statistically significant boosting effect and increase in geometric mean of the titre., Conclusion: Measles-mumps-rubella vaccine campaign was effective in increasing protective levels and boosting antibodies against the 3 targeted diseases which can prevent epidemics in the primary schools.

This paper describes the measles immunization programme in Saudi Arabia and the change from the single-dose schedule with the Schwartz vaccine to the double-dose schedule with the Edmonston-Zagreb vaccine. The recent measles-mumps-rubella school campaign is also described.

Vaccines produced in accordance with WHO formulas, differ in concentration from those used in United States according to FDA formulas. We aimed to compare the immunogenicity of both formulas. Infants who were 6 weeks old were randomly put into 3 groups to receive 3 doses of vaccines at 6 weeks, 3 months and 5 months of age. The vaccines consisted of Haemophilus influenzae type b vaccine, diphtheria-tetanus-pertussis and oral polio vaccine. Antibody levels for polyribosylribitol phosphate (PRP), tetanus, diphtheria and poliovirus were measured 1 month after the third dose of vaccines. Although diphtheria and tetanus antigens in the FDA formula are half the concentration of the WHO formula, anti-tetanus and anti-diphtheria antibodies were significantly higher. No difference was found between groups regarding oral poliovirus vaccine.