Betel Quid Chewing in Dagon (East) Township

Transcription

1 Betel Quid Chewing in Dagon (East) Township Ko Ko Zaw 1, Mya Ohnmar 1, Moh Moh Hlaing 1, Swe Swe Win 2, Maung Maung Than Htike 3, Phyu Phyu Aye 4, Mg Mg Myint 1, Sein Shwe 2 & Moe Thida Htwe 2 1 Department of Medical Research (Lower Myanmar), 2 University of Dental Medicine (Yangon), 3 International Health Division, Ministry of Health, 4 Department of Health Introduction 600 million people (10% of the world s population) chew betel quid worldwide. (A review of human carcinogens Part E. Lancet Oncol 2009;10: ) Betel quid chewing has been common in Southeast Asia and Asia Pacific Region including Myanmar for a long time. Prevalence of betel quid chewing varies from 5% in Karachi, Pakistan through 49% in Sarawak, Indonesia up to 80% in parts of India 1

2 Introduction (contd.) Betel quid use - multiple impacts on health. Areca nut forms nitrosamines in the saliva of chewers which induces oral pre-neoplastic disorders with a high propensity to progress to cancer. Areca nut, with/without added tobacco, is a cause of oral cancer pharyngeal cancer & esophageal cancers (IARC. Betel-quid and areca-nut chewing and some areca-nut derived nitrosamines ) Introduction (contd.) Areca nut with added tobacco cause pancreatic tumours, too. (IARC. A review of human carcinogens. 2012) There is also limited evidence that areca nut causes liver cancer. (A review of human carcinogens Part E. Lancet Oncol 2009;10: ) 2

3 Introduction (contd.) Recent epidemiological studies show that betel quid use is associated with a higher risk of: obesity, metabolic syndromes, cardiovascular disease, type 2 diabetes chronic kidney disease, low birth weight and cirrhosis of the liver. (Chien-Hung Lee et al. Intercountry prevalences and practices of betel-quid use in south, southeast and eastern Asia regions and associated oral preneoplastic disorders.int J Cancer, 2011 Oct 1;129(7): ) Introduction (contd.) In Myanmar, prevalence of smoking is getting lower (22% in 2009) but that of smokeless tobacco use, mostly in betel quid, is still high in Myanmar (30%). The majority of these smokeless tobacco users used it in a form of betel quid. In Myanmar, oral cancer, a serious consequence of betel chewing, stood at the 6 th among male caners and 10 th among female cancers, contributing 3.5% of the whole body cancers, according to cancer registries of Yangon and Mandalay General Hospitals. 3

4 Introduction (contd.) Community-based surveys on betel chewing and oral health were scare and outdated in Myanmar and updateted epidemiological information on these issues is needed. So this study tried to help fill this information gap to some extent. Objectives The study aims to assess betel quid chewing practice and its relation to oral pre-cancerous lesions in adult population in Dagon (East) township. The study has the following specific objectives: To determine the prevalence of betel quid chewing in adult population of Dagon (East) township. To describe the characteristics of betel quid chewing practice To assess its relation to oral pre-cancerous lesions 4

5 Methodology Study Design: cross-sectional design Study Place: Dagon (East) township, Yangon Region Study Population: persons aged 18 and above of both sexes Excluded - very ill persons and mentally ill persons. Methodology (contd.) Sample Size Determination Using the formula for one sample proportion with the following assumptions: Alpha error is set at 5%, so, z statistics is 1.96; P was conservatively estimated at 50% ( the exact prevalence of betel quid chewing in Myanmar is unknown) Margin of error (e) is 5%; Rate of refusal to participate is10%. Required sample size was 428 persons. 5

6 Methodology (contd.) Sampling procedure Four hundred and twenty two households were selected from Ward 133: one hundred and twenty two households were selected from Sit-Pin village. One eligible person was selected from each selected household. Methodology (contd.) Data collection Data collection was done in April, By using a pretested structured questionnaire, 11 trained interviewers from DMR(Lower Myanmar) collected from the respondents the following data on: socioeconomic characteristics betel quid chewing practice alcohol drinking smoking 6

7 Methodology (contd.) Data collection Photos showing field data collection Methodology (contd.) Data collection 5 oral examination teams comprising 13 dental surgeons and 8 dental house surgeons from University of Dental Medicine (Yangon) made oral examination on every respondent. Toluidine blue staining and oral brush biopsy were done on the respondents with visible oral lesions. When these oral lesions were positive by Toluidine blue stain and/or oral brush biopsy, these were regarded as potentially malignant. 7

8 Methodology (contd.) Data collection Photos showing oral examination Methodology (contd.) Data collection Photo showing Toluidine blue staining Photo showing oral brush biopsy specimen 8

9 Methodology (contd.) Data management and analysis Prevalence of betel quid chewing was calculated by age and sex. Characteristics of betel quid chewing practice were described for men and women and both sexes. Prevalence of oral potentially malignant disorders was determined by major health risk behaviours. Multiple logistic regression was performed to determine the independent effect of health risk behaviours on oral pre-cancers, controlling for possible confounders. Methodology (contd.) Ethical considerations The proposal was approved for ethical clearance by the Ethical Review Committee of the Department of Medical Research (Lower Myanmar). Informed consent was obtained from the respondents for interview and oral examination. 9

10 Results 542 persons aged 18 and above participated in the survey. Age and sex distribution of the respondents Age Male Female Total [5.17%] 31 [5.72%] 59 [10.89%] [16.97%] 128 [23.62%] 220 [40.59%] [14.39%] 125 [23.06%] 203 [37.45%] [4.24%] 37 [6.83%] 60 [11.09%] Total 221 [40.77%] 321 [59.23%] 542 [100%] 10

11 Prevalence of current betel quid chewing among the respondents by sex and age Sex and age Pop. Chewers of b etel quid without tobacco with tobacco total Male [3.2%] 153 [69.2%] 160 [72.4%] [95%CI= 1.2 to 6.4% ] [95%CI=62.7 to75.2%] [95%CI=66 to 78.2%] [7.1%] 19 [67.9%] 21 [75%] [1.1%] 74 [80.4%] 75 [81.5%] [5.1%] 49 [62.8%] 53 [68.0%] [0%] 11 [47.8%] 11 [ 48.8%] Female [11.5%] 87 [27.1%] 124 [38.6%] [95%CI=8.2 to 15.5%] [95%CI= 22.3 to 32.3% ] [95%CI= 33.3 to 4.2% ] [6.5%] 2 [6.5%] 4 [12.9%] [10.2%] 38 [29.7%] 51 [39.8%] [13.6 %] 41 [32.8%] 58 [46.4%] [13.5%] 6 [16.2%] 11 [29.7%] Total [8.1%] 240 [44.3%] 284 [52.4%] [95%CI= 6 to10.7% ] [95%CI= 40 to 48.6% ] [95%CI= 48 to 56.7% ] [6.8%] 21 [35.6%] 25 [42.4%] y ears [6.4%] 112 [10.9%] 126 [57.3%] [10.3%] 90 [44.3%] 111 [54.7%] [8.3%] 17 [28.3%] 22 [36.7%] Prevalence of current betel quid chewing among the respondents by sex and age Sex and age Pop. Chewers of b etel quid without tobacco with tobacco total Male [3.2%] 153 [69.2%] 160 [72.4%] [95%CI= 1.2 to 6.4% ] [95%CI=62.7 to75.2%] [95%CI=66 to 78.2%] [7.1%] 19 [67.9%] 21 [75%] [1.1%] 74 [80.4%] 75 [81.5%] [5.1%] 49 [62.8%] 53 [68.0%] [0%] 11 [47.8%] 11 [ 48.8%] Female [11.5%] 87 [27.1%] 124 [38.6%] [95%CI=8.2 to 15.5%] [95%CI= 22.3 to 32.3% ] [95%CI= 33.3 to 4.2% ] [6.5%] 2 [6.5%] 4 [12.9%] [10.2%] 38 [29.7%] 51 [39.8%] [13.6 %] 41 [32.8%] 58 [46.4%] [13.5%] 6 [16.2%] 11 [29.7%] Total [8.1%] 240 [44.3%] 284 [52.4%] [95%CI= 6 to10.7% ] [95%CI= 40 to 48.6% ] [95%CI= 48 to 56.7% ] [6.8%] 21 [35.6%] 25 [42.4%] y ears [6.4%] 112 [10.9%] 126 [57.3%] [10.3%] 90 [44.3%] 111 [54.7%] [8.3%] 17 [28.3%] 22 [36.7%] Overall prevalence = 52.4% 11

12 Current betel chewers 7/15/2014 Prevalence of current betel quid chewing by sex 80.0% 70.0% 72.4% 60.0% 50.0% 40.0% 38.6% 30.0% 20.0% 10.0% 0.0% Male (n=221) Female (n=321) Prevalence of current betel quid chewing by age 75.0% 81.5% 68.0% 48.8% 39.8% 46.4% 29.7% 12.9% Male (n=28) (n=92) (n=78) 65+ (n=23) Female (n=31) (n=128) (n=128) 65+ (n=37) 12

13 Prevalence of current betel quid chewing by age 75.0% 81.5% 68.0% 48.8% 39.8% 46.4% 29.7% 12.9% Male (n=28) (n=92) (n=78) 65+ (n=23) Female (n=31) (n=128) (n=128) 65+ (n=37) Addition of tobacco to betel quid Among 284 current chewers, 240 (85%) added tobacco to betel quid. 13

14 Kinds of tobacco consumed with betel quids among chewers of betel quid with tobacco (n=240) * 62.9% *Multiple responses 30.8% 19.6% 15.4% 7.5% 7.1% 4.2% 3.3% 2.1% Photo showing some kinds of tobacco added to betel quids 14

15 Boxplot showing age at which betel quid chew started Oldest age 61 Median age 25 Earliest age 10 (N=284, the respondents who currently chewed betel quids) Boxplot showing duration of betel quid chewing Longest duration 75 Median duration 10 Shortest duration 0 year (N=284, the respondents who currently chewed betel quids) 15

16 Boxplot showing number of betel quids chewed per day Highest number 100 quids Median number Lowest number 8 quids 1 quid (N=284, the respondents who currently chewed betel quids) Ways of dealing with betel quid juice among the respondents who currently chewed betel quids Both swallow and spit out (8.5%) Swallow (2.8%) Spit out (88.7%) (N=284, the respondents who currently chewed betel quids) 16

17 Ways of discarding betel quid among the respondents who currently chewed betel quids Way of discarding used betel quid* Male (n=160) Female (n=124) Total (n=284) - Spit out onto the ground/building corner 116 [72.5%] 78 [63.9%] 194 [68.8%] - Spit out to plastic bags or other containers 41 [25.6%] 46 [37.7%] 87 [30.9%] -Spit out to dustbin/dump 16 [10.0%] 3 [2.5%] 19 [6.7%] *Multiple responses Reasons for chewing betel quid among the respondents who currently chewed betel quids* (N=284) 35.1% 34.4% *Multiple responses 14.5% 9.9% 9.6% 5.0% To ease an sour sensation in the mouth Addiction to chewing betel quids To be alert To be concentrated To make breaths sweet To quit smoking 17

18 Prevalence of oral potentially malignant lesions Out of 542 persons, 25 persons (4.6%) turned out to have visible oral lesions (ulcer or patch) which tested positive for Toludine blue staining and/or oral brush biopsy (95%CI=3.0 to 6.7). These oral lesions were regarded as potentially malignant (precancerous). Prevalence and unadjusted risk of oral precancer by three major lifestyles Pop. Oral potentially malignant lesions Number Percent [95% CI] Crude Odds Ratio Betel quid chewing habit Non-chewers (Ref. group) [0 to 2.1] 1 Chewers without tobacco [0.06 to 12] 6 [2 to 17] Chewers with tobacco [6.2 to 14] 27 [12 to 62] Smoking habit Non-smoker (Ref. group) [2.7 to 7.2] 1 Smoker [2.0 to 9.0] 1.02 [0.4 to 2.6] Alcohol drinking habit Non-drinker (Ref. group) [2.2 to 6.0] 1 Drinker [3.9 to 16.6] 2.5 [1.1 to 5.7] 18

19 Prevalence and unadjusted risk of oral potentially malignant lesions by betel quid chewing Pop. Oral potentially malignant lesions Betel quid chewing habit Number Percent [95% CI] Crude Odds Ratio [95% CI] Non-chewers (Ref. group) [0 to 2.1] 1 Chewers without tobacco [0.06 to 12] 6 [2 to 17] Chewers with tobacco [6.2 to 14] 27 [12 to 62] Prevalence of oral precancer rose from 0.5% in nonchewers through 2.3% in chewers without tobacco to 9.6% in chewers with tobacco. Prevalence and unadjusted risk of oral potentially malignant lesions by betel quid chewing Pop. Oral potentially malignant lesions Betel quid chewing habit Number Percent [95% CI] Crude Odds Ratio [95% CI] Non-chewers (Ref. group) [0 to 2.1] 1 Chewers without tobacco [0.06 to 12] 6 [2 to 17] Chewers with tobacco [6.2 to 14] 27 [12 to 62] Betel chewers were 6 times more likely to have oral precancer than non-chewers. The risk increased to 27 times with addition of smokeless tobacco to betel quid, compared to nonchewers.. 19

20 Prevalence and unadjusted risk of oral potentially malignant lesions by smoking Pop. Oral potentially malignant lesions Smoking habit Number Percent [95% CI] Crude Odds Ratio [95% CI] Non-smoker (Ref. group) [2.7 to 7.2] 1 Current smoker [2.0 to 9.0] 1.02 [0.4 to 2.6] The prevalence of oral precancer was similar between non-smokers and smokers. Unadjusted ORs were similar too. Prevalence and unadjusted risk of oral potentially malignant lesions by alcohol drinking Pop. Oral potentially malignant lesions Alcohol drinking habit Number Percent [95% CI] Crude Odds Ratio [95% CI] Non-drinker (Ref. group) [2.2 to 6.0] 1 Drinker [3.9 to 16.6] 2.5 [1.1 to 5.7] CI=Confidence interval Drinkers were 2.5 times more likely to have oral precancer than non-drinkers. 20

21 Odds ratios of oral precancer from multiple logistic regression according to demographic and major lifestyles characteristics Multiple logistic regression was performed to determine the independent effect of demographic and life style factors on oral pre-cancer. Initially, 5 variables (age, sex, betel chewing, smoking and alcohol drinking,, all of which were defined as categorical, were included in the model. In the final model, only 4 variables (age, sex, betel chewing and alcohol drinking) remained: smoking was omitted because it was multicollinear with alcohol drinking. Odds ratios of oral potentially malignant lesions from multiple logistic regression according to four demographic and major lifestyles characteristics Variable Adjusted Odds Ratio 95% Confidence Interval Age <=40 (Ref. group) to to 5.7 Sex Female (Ref. group) 1.0 Male to 1.7 Betel quid chewing habit Non-chewers (Ref. group) 1.0 Chewers without tobacco 5.7* 1.4 to 22.9 Chewers with tobacco 28.6* 9.8 to 83.6 Alcohol drinking habit Non-drinker (Ref. group) 1.0 Drinker to 4.0 *Significant at 0.05 level 21

22 Odds ratios of oral potentially malignant lesions from multiple logistic regression according to four demographic and major lifestyles characteristics Variable Adjusted Odds Ratio 95% Confidence Interval Age <=40 (Ref. group) to to 5.7 Sex Female (Ref. group) 1.0 Male to 1.7 Betel quid chewing habit Non-chewers (Ref. group) 1.0 Chewers without tobacco 5.7* 1.4 to 22.9 Chewers with tobacco 28.6* 9.8 to 83.6 Alcohol drinking habit Non-drinker (Ref. group) 1.0 Drinker to 4.0 *Significant at 0.05 level Betel chewing is significantly associated with risk of oral pre-cancer. Chewers of betel quid alone has 6-fold increase and chewers of betel quid with tobacco 29-fold increase in risk of oral precancer, compared to non-chewers. Odds ratios of oral potentially malignant lesions from multiple logistic regression according to four demographic and major lifestyles characteristics Variable Adjusted Odds Ratio 95% Confidence Interval Age <=40 (Ref. group) to to 5.7 Sex Female (Ref. group) 1.0 Male to 1.7 Betel quid chewing habit Non-chewers (Ref. group) 1.0 Chewers without tobacco 5.7* 1.4 to 22.9 Chewers with tobacco 28.6* 9.8 to 83.6 Alcohol drinking habit Non-drinker (Ref. group) 1.0 Drinker to 4.0 *Significant at 0.05 level Old age, female sex and alcohol drinking were also associated with increased risk of oral pre-cancer but their relationship was not significant. 22

23 Discussion Half of this population were currently chewing betel quids. This prevalence of betel chewing is quite high given the global estimate of 10-20% and regional estimates of 20%-40% in India, Pakistan and Nepal over the last two decades. Discussion(contd.) In the current study, 85% of the betel quid chewers added tobacco, comparable to levels for Dhaka, Bangladesh (85.2%) (Rahman et al.). Current betel quid chewing in men was highest (81%) in the most productive age group (24-44 ). Betel quid chewers mostly started betel chewing practice around 25 of age, chewed 8 betel quids per day for 10 or more. 23

24 Discussion(contd.) 4.6% of study population had oral precancer as determined by rapid screening tests (Toludine blue staining and oral brush biopsy). Prevalence of oral precancer in current chewers of betel quid without tobacco (2.3%) increased to nearly 10% with addition of smokeless tobacco to betel quid. This finding provides additional evidence for formulating policy on control of smokeless tobacco use in Myanmar. Discussion(contd.) Multiple logistic regression indicated that older age, betel chewing, especially with tobacco and consumption of alcohol were associated with risk of oral pre-cancer. These findings are consistent with the internationally established risk factors for oral pre-cancer. 24

25 Conclusion Betel quid chewing was found to be a common habit in both men and women of the study population Because betel quid chewing have serious health consequences, an anti-betel quid chewing programme is warranted for current chewers. Health risks of betel quid chewing should be emphasized in the health education to the public and especially betel chewers. Regular oral examination of betel quid chewers may help prevent avoidable oral cancers in the future. Conclusion As the habit is rooted in Myanmar tradition and culture, anthropological studies are indicated for designing appropriate educational campaigns. 25

26 Utilization of research findings The findings were provided to the tobacco control program of Department of Health for future programming and policy formulation. The persons who tested positive for Toluidine blue stain and oral brush biopsy were referred to University of Dental Medicine for further investigation, regular follow-up and necessary treatment. Acknowledgements We wish to thank all respondents who gave up their time to be interviewed and examined and who welcomed interviewers into their homes. We thank local health staff from Urban Health Center in Ward 133 and from Sitpin RHC, Dagon (East) Township. We would also like to appreciate the commitment and professionalism of the interviewers from Department of Medical Research (Lower Myanmar) and oral examination teams from University of Dental Medicine (Yangon). 26

27 References IARC Monographs Program. A review of human carcinogens Part E. Lancet Oncol 2009;10: Gupta PC, Ray CS. Epidemiology of betel quid usage. Ann Acad Med Singapore 2004; 33:31 6. Gupta PC, Warnakulasuriya S. Global epidemiology of areca nut usage. Addict Biol 2002;7: Ministry of Information. Myanmar Encyclopaedia. CD-ROM; Myanmar IARC. Tobacco habits other than smoking; betel quid and areca-nut chewing and some related nitrosamines. IARC Monograph on the Evaluation of Carcinogenic Risk of Chemicals to Humans, Vol 37. Lyon: International Agency for Research on Cancer; IARC. Betel-quid and areca-nut chewing and some areca-nut derived nitrosamines. IARC Monograph on the Evaluation of Carcinogenic Risk of Chemicals to Humans, Vol 58. Lyon: International Agency for Research on Cancer; References (contd.) IARC. A review of human carcinogens. IARC Monograph on the Evaluation of Carcinogenic Risk of Chemicals to Humans, Vol 100. Lyon: International Agency for Research on Cancer; Chien-Hung Lee1, Albert Min-Shan Ko, Saman Warnakulasuriya. Intercountry prevalences and practices of betel-quid use in south, southeast and eastern Asia regions and associated oral preneoplastic disorders: An international collaborative study by Asian betel-quid consortium of south and east asia. Int J Cancer Oct 1;129(7): World Health Organization. Non-communicable Disease Risk Factor Survey Myanmar New Delhi : WHO Regional Office for South-East Asia; Mazahir S, Malik R, Maqsood M, Merchant KA, Malik F, Majeed A, et al. Sociodemographic correlates of betel, areca and smokeless tobacco use as a high risk behaviour for head and neck cancers in a squatter settlement of Karachi, Pakistan. Subst Abuse Treat Prev Policy. 2006; 26:

28 References Rahman M, Rahman M, Flora MS, Akter SFU, Hossain S, Mascie-Taylor CGN. Behavioural risk factors of non-communicable diseases in Bangladesh. Dhaka: National Institute of Preventive and Social Medicine, Meerjady S F, Christopher GN M-T, Mahmudur R. Betel quid chewing and its risk factors in Bangladeshi adults. WHO South-East Asia Journal of Public Health 2012;1(2): Thank you for the kind attention! 28