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Introduction
http://dx.doi.org/10.1053/j.semnuclmed.2016.01.005
0001-2998/& 2016 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
265
D. Paez et al.
266
Table 1 Selected Demographic Data and Projections Per Country, Excluding Palestine
Country
Total Population
in 2014, in
Millions1
Projected Total
Population in
2040, in
Millions2
Surface
Area, km21
Population
Median Age in
2013, y4
World Bank
Income
Group1
Bahrain
Cyprus
Egypt
Iran
Iraq
Israel
Jordan
Kuwait
Lebanon
Oman
Qatar
Saudi Arabia
Syria
Turkey
UAE
Yemen
TOTAL
1.344
1.153
83.387
78.470
34.278
8.215
6.607
3.479
4.510
3.926
2.268
29.369
23.300
75.837
9.446
24.969
390.558
1.760
1.351
113.001
96.772
59.614
11.280
8.997
5.610
4.662
5.007
2.912
38.193
35.486
91.778
14.064
38.769
529.256
760
9.250
1.001.450
1.745.150
435.240
22.070
89.320
17.820
10.450
309.500
11.610
2.149.690
185.180
783.560
83.600
527.970
30.1
35.2
25.2
28.5
19.7
30.1
23.4
29.2
29.8
26.3
31.7
27.5
22.4
29.4
30
19.1
High
High
Lower middle
Upper middle
Upper middle
High
Upper middle
High
Upper middle
High
High
High
Lower middle
Upper middle
High
Lower middle
Demographic Data
Egypt is the most populous country with about 83 million
people in 2014, followed by Iran with roughly 79 million
inhabitants and Turkey with an approximate population of
76 million people. The population of Cyprus is the smallest, comprising 1.15 million people, followed by Bahrain
with 1.34 million.1 The total population of the region is
395 million people, and is projected to increase by 140
million people in the next 25 years, reaching 529 million.2
Saudi Arabia encompasses the largest territory in the
region, whereas Iran and Egypt take the second and third
place, respectively.1 The median age of the population was
set at between 19.1 years in Yemen and 35.2 years in
Cyprus.3 Great economic disparities exist between the
countries. Table 1 demonstrates some demographic characteristics of the Middle Eastern countries.
Health Indicators
Table 2 shows the wide range of life expectancy at birth. The
average of 75 years as well as life expectancy in most of the
countries individually was higher than the world average of 71
years. Adult mortality rate was lowest in Kuwait (52 per 1000
population), and highest in Yemen (232 per 1000 population).3 Cardiovascular diseases (CVDs), cancers, diabetes, and
chronic respiratory diseases as main non-communicable diseases (NCDs) are associated with a probability of premature
death varying between 9% in Cyprus and Israel and 25% in
Egypt.4
Risk factors for NCDs (Table 3) are present in a large
percentage of population in the region. Obesity represents a big
challenge and affects as much as 50% of all adult women and
42% of the total adult population in Kuwait (2008). In
Lebanon, one-third of all adult men and 29% of the countrys
adult population suffer from raised blood pressure (2008).4 An
estimated 17% of Egypts adult population was diagnosed with
elevated fasting blood glucose.3 The NCDs account for a great
portion of total mortality in the region and are responsible for
267
Table 2 Life Expectancy at Birth, Adult Mortality Rate and Premature NCDs-Associated Mortality Per Country, Excluding Palestine
Country
Bahrain
Cyprus
Egypt
Iran
Iraq
Israel
Jordan
Kuwait
Lebanon
Oman
Qatar
Saudi Arabia
Syria
Turkey
UAE
Yemen
77
80
71
74
69
82
74
74
80
77
79
76
75
75
77
63
64
56
156
119
153
56
114
52
59
100
67
80
95
109
76
232
13
9
25
17
24
9
20
12
12
18
14
17
19
18
19
23
more than half of all deaths in all the countries except Yemen
(39%) and Syria (46%), reaching levels as high as 86% in
Turkey and 90% in Cyprus. Specically, CVDs make up the
biggest part of the NCDs related death burden in all countries,
with Turkey and Lebanon carrying the largest burden, where
CVDs are the cause of death in 47% of all cases; except in Israel,
where cancer kills more people than CVDs. Rates of diabetesassociated mortality vary between 1% in Syria and Egypt and
as high as 13% in Bahrain.4
With already high prevalence of NCDs and the associated
mortality, as well as because negative health trends such as ever
growing obesity rates threaten to worsen the situation and
overburden the healthcare systems in the future, identifying
appropriate management strategies is of utmost importance. As
NM plays a crucial role in the diagnosis, risk stratication and
management of most NCDs, its practice in the region should
Available Technology
There is great heterogeneity as to the availability of technical
capacities in the region with some countries having state-ofthe-art technology including cyclotrons and PET/CT. According to data provided to the International Atomic Energy
Agency (IAEA) in 2015 by NM professionals in the region,
the total number of gamma cameras available is 910 including
107 SPECT/CT systems with Turkey, Iran, Israel, and Saudi
Arabia having 310/12, 200/8, 63/26, and 49/34 SPECT/
SPECT-CT systems, respectively (Table 4). The ratio of gamma
cameras per million population ranges between 0.1 in Iraq and
Table 3 Specic and Total NCDs-Associated Proportional Mortality Per Country in 2014 in Percentages4, Excluding Palestine
Country
Cardiovascular
Diseases
Cancers
Diabetes
Chronic Respiratory
Diseases
Other NCDs
Total
Bahrain
Cyprus
Egypt
Iran
Iraq
Israel
Jordan
Kuwait
Lebanon
Oman
Qatar
Saudi
Arabia
Syria
Turkey
UAE
Yemen
26
38
46
46
33
26
35
41
47
33
24
46
13
24
14
13
10
27
15
14
22
10
18
10
13
7
1
2
4
6
7
4
4
10
9
5
6
5
4
4
3
5
3
2
4
2
1
3
20
16
19
11
12
22
16
12
8
13
17
14
78
90
85
76
62
86
76
73
85
68
69
78
28
47
30
21
10
22
13
5
1
2
3
2
2
8
3
3
5
7
16
8
46
86
65
39
D. Paez et al.
268
Table 4 List of Available Infrastructure in the Region, Data Obtained From Nuclear Medicine Professionals
Number of Centers and Available Equipment in the Middle East
Country
Bahrain
3
Cyprus
6
Egypt
58
Iran
155
Iraq
6
Israel
40
Jordan
14
Kuwait
12
Lebanon
27
Oman
2
Palestine
1
Qatar
2
Syria
4
Saudi Arabia 41
Turkey
240
UAE
13
Yemen
4
TOTAL
628
3
9
65
200
5
63
13
30
27
3
1
3
2
49
310
15
5
803
1
2
9
8
0
26
0
6
1
2
0
1
2
34
12
3
0
107
PET/CT Per
Million
People
Cyclotrons
3.0
9.5
0.9
2.6
0.1
10.8
2.0
10.3
6.2
1.3
0.2
1.8
0.2
2.8
4.2
1.9
0.2
0.7
0.9
0.2
0.04
0
1.1
0.9
1.7
2.2
0.5
0
0.4
0.1
0.4
1.6
0.4
0
1
0
3
4
0
4
2
2
2
1
0
1
1
6
16
3
0
46
1
1*
15
3
0
9
6
6
10
2
0
1
2
13
122
4
0
194
*This PET/CT is installed at the Near East University Nicosia, North Cyprus and due to absence of information on the remaining infrastructure of this
center, it is not included in the overall statistical analysis.
Radiopharmacists or Radiochemists
Albeit the scarce number of radiopharmacists or radiochemists
in the region, the NM specialty has grown in the last 2 decades.
In total, there are approximately 173 professionals with
training in these disciplines (Table 5), in most of the cases
obtained abroad. However, with growing research and development infrastructure in some countries the need for training
scholars with highest academic degrees has been brought
about, and in certain countries for example, Iran and Turkey
academic training programs in radiopharmacy or radiochemistry already exist at PhD level. To fulll the need for
sustainable services at hospital radiopharmacy facilities,
degrees at technician level in radiopharmacy or radiochemistry
or onsite training for individuals who have obtained basic
science degrees have been established in many countries.
Medical Physicists
According to the denition of the IAEAs International Basic
Safety Standards,5 a medical physicist working in a clinical
environment is: a health professional, with specialist education and training in the concepts and techniques of applying
physics in medicine, and competent to practice independently
in one or more of the subelds (specialties) of medical physics.
In the eld of NM their role is pivotal, they usually participate
in several tasks,6 such as the establishment of institutional
radiation protection programs, quality control of NM instruments, and optimization of NM clinical procedures, including
acquisition and processing protocols. Moreover, because of the
increasing number of cases of radionuclide therapy in different
clinical centers in the region, personalized clinical dosimetry in
medical practice has strengthened their roles. According to the
269
Table 5 List of Available Human Resources in Nuclear Medicine in the Region, Data Obtained From Nuclear Medicine Professionals
Country
Radiopharmacists/
Radiochemists
Medical
Physicists
Technologists
Nuclear Medicine
Physicians
Bahrain
Cyprus
Egypt
Iran
Iraq
Israel
Jordan
Kuwait
Lebanon
Oman
Palestine
Qatar
Saudi Arabia
Syria
Turkey
UAE
Yemen
TOTAL
2
0
12
23
5
5
5
10
4
0
0
3
25
5
70
2
2
173
2
7
32
123
21
7
20
10
7
14
0
3
60
25
250
2
3
586
5
10
95
400
10
85
34
150
50
17
1
13
172
10
850
45
6
1953
5
7
105
200
11
75
29
50
15
9
1
5
79
10
535
15
6
1157
Technologists
Like in other parts of the world, the shortage of technologists is
a common problem in the region. The total number of
technologists approximates to 1953 (Table 5), and the availability per camera (including SPECT and PET scanners) varies
between 0.9 in Israel and 3.6 in Kuwait (Fig.). The high ratio in
Kuwait is partly due to the fact that technologists in the country
do not provide support only to NM procedures, but rather to
all diagnostic imaging modalities. Training programs for
technologists in NM are available in the form of a Bachelors
degree in Egypt, Iran, Jordan, Kuwait, and Turkey and Masters
in Science degree in Israel, whereas other countries mostly rely
on onsite training. In most cases, the training is not focused on
NM only but covers other areas of radiation medicine such as
D. Paez et al.
123
Tl
201
111
InInOctereos- DTPA
can
111
Inoxine
111
IDatscan
81
Rb-81m- 67Ga
Kr
citrate
generator
123
I-NaI
123
Bahrain
Cyprus
Egypt
Iran
Iraq
Israel
Jordan
Kuwait
Lebanon
Oman
Palestine
Qatar
Saudi
Arabia
Syria
Turkey
UAE
Yemen
131
99
Mo-99mTc
generator
Country
Table 6 List of Available Diagnostic Tracers in the Region, Data Obtained From Nuclear Medicine Professionals
131
IMIBG
IMIBG
18
F-FDG
18
F-NaF
13
N-NH3
68
Ge-68G- 11Ca
radiotragenerator cers
68
/ Garadiotracers
82
Sr-82Rb
generator
270
271
Table 7 List of Available Therapeutic Agents in the Region, Data Obtained From Nuclear Medicine Professionals
Country
131
Bahrain
Cyprus
Egypt
Iran
Iraq
Israel
Jordan
Kuwait
Lebanon
Oman
Palestine
Qatar
Saudi Arabia
Syria
Turkey
UAE
Yemen
131
I-MIBG
32
90
153
89
Sm-EDTMP
Discussion
The average number of gamma cameras including SPECT/CT
systems per million people in the region is 2.3, with a range of
0.1 in Iraq to 10.3 in Kuwait and 10.8 in Israel. This is lower
than the average ratio in Latin America of 2.6,10 Europe 5.57,
Canada 20.35,11 and USA 47.2.12
The availability of PET/CT in the region is one scanner per
2.04 million people, and relative to the population, Lebanon
(2.2) followed by Kuwait (1.7) have the highest number of
scanners per million people. Recommendations provided in
literature that takes into account global, nonspecic data,
suggests that the number of scanners should be 1.0-1.5 per
million inhabitants.13 In a well-developed context, expectations are that this gure would rise to 2.0-2.5 scanners per
million population.14 It becomes increasingly evident that
there is room for growth and development in the region to
install more PET/CT scanners and keep up with the support
needed to address the high incidence of NCDs.
Sr
177
188
Lu
Re
Alpha Emitters
Conclusion
Countries in the Middle East have witnessed an important
growth of NM in the past decades. Although there are
profound differences in the region regarding the availability
D. Paez et al.
272
of human as well as technical capacities, it is also evident that
the practice of this medical specialty has seen an overall
advancement. This is reected in the general availability of
current NM diagnostic and therapeutic procedures, as well as
the ever growing number of technologies installed. However,
there is a shortage of well-structured training at academic
institutions in the region, and there is a need to establish and
expand training programs for all disciplines involved in the
specialty. Furthermore, we note that PET/CT is still not
available in some countries of the region. Also, there is a need
for further raising of awareness of the usefulness of clinical
applications of NM techniques. Addressing these limiting
factors, along with strengthening intraregional and international cooperation, would enable further growth and upscaling
of NM in the Middle East, which is of utmost importance in the
wake of the growing incidence of NCDs in the region.
Disclaimer
The depiction and use of boundaries, geographic names, and
related data shown on maps and included in lists, tables,
documents, and databases on this article are not warranted to
be error free nor do they necessarily imply ofcial endorsement
or acceptance by the United Nations.
Acknowledgments
The authors would like to thank all colleagues at the NM
centers in the region for sharing the information in the
preparation of this publication.
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