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CHAPTER 15
EPIDEMIOLOGY OF The Egyptian National Hypertension Project (NHP) Data presented in this chapter were collected during the Egyptian NHP. The Egyptian NHP is the first nation wide field survey conducted in an Arab or developing country to examine the prevalence of hypertension, its rates of awareness, treatment and control in the general population. It also provided data about the prevalence of hypertensive complications and other cardiovascular risk factors. The Survey was conducted in 21 sampling locations in six Egyptian governorates representing all Egyptian geographic regions and socioeconomic groups. It followed rigorous quality control measures that ensured the validity and accuracy of collected data. The NHP was carried out at a number of stages. Preparatory Stage During the preparatory stage which lasted for ten months, the data collection staff and senior investigators team were recruited. An education course and manual of operations were developed. The sample size and areas of surveys were selected based upon the information from the Egyptian Central Agency for Public Mobilization and Statistics and according to the most recent national census. Data collection forms were prepared and the staff were trained and certified. A number of pilot studies were carried in Cairo and El-Fayoum governorates in order to test the logistics and responses to survey questionnaires. A biochemical and echocardiographic laboratories were established at Cairo Univer-sity Hospital.
This stage took two years and included two phases. In phase I the data collection staff which were newly graduated medical doctors visited the households, questionnaire forms were filled, collecting information about housing conditions, level of education, socioeconomic status, family size, medical history and anthropometric measurements. Phase I was a hypertension prevalence survey conducted in six of Egypt’s 26 governorates. Each governorate represented a distinct region of the country. Cairo (urban capital), Bani Sweif (Northern Upper Egypt), Aswan (Southern Upper Egypt), Sharkia (Delta), Port Said (Coastal) and El-Wadi El-Gedid (Frontirs). Four blood pressure measurements were obtained from each participant according to a standardized protocol. Based upon the average of these four measurements, the BP status of each participant was classified according to a criteria established by the Fifth Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC V). Hypertension was defined as an average systolic BP ³ 140 mmHg, and/or diastolic BP ³ 90 mmHg, and/or self-reported treatment with antihypertensive medications. For estimation of the overall prevalence of hypertension, the prevalence estimated for each of the regional samples were weighted according to the age, sex and urban-rural population distributions of the total population for the region they represented using the data from the most recent Egyptian census. In the second phase of the field operations, all hypertensives identified in phase I with gender matched normotensive controls were re-examined in special centers established in main hospitals in the areas surveyed. During phase II, detailed clinical and laboratory examination were performed which included optic fundus examination, electrocardio gram, echocardio gram and skin colour spectropho tometric measure- ments. Blood and urine samples were collected for detailed biochemical studies. The objectives of phase II of the survey were to define the prevalence of hypertensive complications, hypertension and other cardiovascular risk factors.
Response Rate and Demographic Characteristics The sample frame consisted of 3600 households in which there were 7915 adult residents. The overall response rate by households was 93.9% and for individuals 85.1%. The mean age of the survey participants was 45.6 years, the age range was 25 to 95 years. More than 50% of the participants were in the age range between 25 and 44 years. Elderly individuals aged greater than 65 years constituted 11.6% of the sample. A majority of the survey participants were women. Housing Conditions 21% of the participants were living in mud-brick houses, no running water in 27.7% and no electricity in 2.4% of houses. 73% of the participants lived in an urban area. Marital Status 76.4% of participants were married, 8.7% were widows and 1.3% divorced. Education, Socioeconomic Level and Employment Illiteracy rate was presented in 40.9% of the total sample, more in women (53.6%), than men (24.3%). University graduates constituted 14.9% of the sample. In the sample 39.7% of individuals were classified as poor and 10.3% as rich. Employment: Approximately half (50.9%), of participants were homemakers, students or retirees who were not employed outside of the home. Of the remainders, 18% were engaged in manual labour, 16.6% in office work, and 13.9% in a profession.
Prevalence of Hypertension The weighted national estimate of the prevalence of hypertension among Egyptians was 26.3%. Hypertension prevalence increased progressively with age, with the exception of the oldest age group (³ 75 years). In the youngest age group (25-34 years), hypertension was present in 7.8% of the population, whereas the prevalence rate was 59.4% in the 65-74 age group. Hypertension appeared to be slightly more common in Egyptian women (26.9%) than men (25.7%). However, the difference in prevalence between men and women changed with age and type of BP elevation (systolic versus diastolic). In the youngest age groups (25 to 44 years) systolic hypertension was more common in men than in women, but the reverse was true in the older age groups. Diastolic hypertension was constantly more common in men than women. The prevalence of hypertension varied in different regions in Egypt. The highest prevalence rate was present in greater Cairo area (31.0%), while the lowest rate was in the frontier and oasis regions (19.9%). Four regions (Cairo, Coastal, Northern Upper Egypt and Southern Upper Egypt), had an estimated prevalence in excess of 25%. Classification of BP according to JNC V indicates that 58.3% of all Egyptians ³ 25 years of age had a normal BP; 17.5% had a high normal BP; and 14.7% had Stage I, 6.2% Stage II, 2.6% Stage III and 0.7% Stage IV hypertension. Hypertension severity varied by region, with the highest prevalence of Stage III and Stage IV hypertension noted in Northern (4.9%) and Southern (4.3%) Upper Egypt. Hypertension was more prevalent in the higher socioeconomic groups (rich) than in the poor (37.4% versus 28.9%, unweighted estimate). Hypertension Awareness, Treatment and Control Slightly more than one third (37.5%) of all Egyptians were aware that Epidemiology of Hypertension in Egyptians they had high BP. Rates of awareness increased steadily with progressively higher stages of hypertension. Awareness also varied by region, the highest rates of awareness were noted in the Coastal Region and Cairo (56.5% and 56.0%, respectively), the lowest rates were found in Northern Upper Egypt (20.3%). Women were more aware of their diagnosis than men (46.3% versus 28.0%). The estimated percentage of hypertensive individuals receiving pharmacological treatment in Egypt was 23.9%. The percentage of participants being treated with antihypertensive medications varied by region with the rate being the highest in the Coastal Region and Cairo (43.3% and 40.4%, respectively), and lowest in Northern Upper Egypt (10.8%). The estimated percentage of hypertensive individuals whose BPs were under control (systolic BP < 140 mmHg and diastolic BP < 90 mmHg) was 8%. The best control rates were noted in the Coastal Region and Cairo (15.9% and 14.9%, respectively), and the lowest control rates were observed in Northern and Southern Upper Egypt (0.9% and 2.8%, respectively). Control rates were higher in women than men (10.9% and 4.8%, respectively). Implications of NHP Data The extremely high prevalence of hypertension coupled with the disturbingly low prevalence of awareness, treatment and control has important implications for public health officials and health policy decision makers in Egypt. Because cardiovascular diseases, such as stroke, acute myocardial infarction and sudden death often strike without prior warning, efforts directed towards the treatment and prevention of hypertensives as well as other atherosclerotic risk factors should be an important component of cardiovascular disease prevention strategies. The public health community must also be alerted to the emergence of hypertension as an important health problem in Egypt. Education for health-care providers at all stages of professional training will be especially important. The Egyp- Epidemiology of Hypertension in Egyptianstian Hypertension Society is taking a leading role in the coordination and facilitation of hypertension research and teaching initiatives in Egypt. The high prevalence of hypertension mandates both a population-based strategy, to reduce BP and prevent this condition, and a complementary high-risk strategy, to treat those people with established hypertension. Efforts include use of the mass media to educate the general population, instruct in medical schools to educate students, and encourage pharmaceutical companies to support research and education initiatives. ÑÞã ÇáÅíÏÇÚ 15986 / 2001
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