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20
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e
l
a
t
e
d
t
o
j
u
v
e
n
i
l
e
i
d
i
o
p
a
t
h
i
c
a
r
t
h
r
i
t
i
s
,
i
a
t
r
o
g
e
n
i
c
(
p
r
e
v
i
o
u
s
i
n
t
r
a
o
c
u
l
a
r
s
u
r
g
e
r
y
,
s
t
e
r
o
i
d
t
r
e
a
t
m
e
n
t
,
o
r
r
a
d
i
a
t
i
o
n
e
x
p
o
s
u
r
e
)
,
c
r
a
n
i
o
f
a
c
i
a
l
s
y
n
d
r
o
m
e
s
(
H
a
l
l
e
r
m
a
n
n
-
S
t
r
e
i
f
f
,
R
u
b
i
n
s
t
e
i
n
-
T
a
y
b
i
,
S
m
i
t
h
-
L
e
m
l
i
-
O
p
i
t
z
,
a
n
d
o
t
h
e
r
s
)
,
r
e
n
a
l
s
y
n
d
r
o
m
e
s
(
A
l
p
o
r
t
s
y
n
d
r
o
m
e
a
n
d
L
o
w
e
s
y
n
d
r
o
m
e
)
,
a
n
d
o
c
u
l
a
r
a
n
o
m
a
l
i
e
s
(
p
e
r
s
i
s
t
e
n
t
f
o
e
t
a
l
v
a
s
c
u
l
a
r
i
z
a
t
i
o
n
,
p
o
s
t
e
r
i
o
r
l
e
n
t
i
c
o
n
u
s
o
r
l
e
n
t
i
g
l
o
b
u
s
p
o
s
t
e
r
i
o
r
s
e
g
m
e
n
t
t
u
m
o
r
,
r
e
t
i
n
a
l
d
e
t
a
c
h
m
e
n
t
(
r
e
g
a
r
d
l
e
s
s
o
f
c
a
u
s
e
)
,
o
r
c
o
l
o
b
o
m
a
)
.
I
n
a
d
d
i
t
i
o
n
,
t
h
e
i
d
i
o
p
a
t
h
i
c
n
a
t
u
r
e
’
s
c
a
u
s
e
s
[
5
]
,
[
9
]
.
C
h
ild
r
en
with
c
atar
ac
ts
,
o
r
o
p
ac
if
icatio
n
o
f
th
e
c
r
y
s
tallin
e
len
s
,
r
e
q
u
ir
e
to
b
e
s
p
ec
ialized
,
h
i
g
h
-
q
u
ality
tr
ea
tm
e
n
t
to
m
in
im
ize
th
e
d
am
a
g
e
th
at
co
u
ld
r
esu
lt
i
n
lo
s
s
o
f
v
is
io
n
.
Ad
u
lts
h
av
e
f
u
lly
d
e
v
elo
p
ed
ey
es
an
d
e
y
esig
h
t,
an
d
o
n
ce
ca
tar
ac
t
is
r
em
o
v
e
d
,
m
o
s
t
ca
s
es
o
f
tr
ea
tm
en
t
ar
e
s
u
cc
ess
f
u
l.
I
n
ch
ild
r
en
,
th
e
ey
e
an
d
b
r
ain
ar
e
s
till
d
ev
elo
p
in
g
u
n
ti
l
th
e
ag
e
o
f
8
o
r
1
0
,
s
o
ca
tar
ac
ts
ca
n
ca
u
s
e
ir
r
ev
er
s
ib
le
ef
f
ec
ts
o
n
th
e
ch
ild
'
s
v
is
io
n
as we
ll a
s
p
er
m
an
en
t p
r
o
b
lem
s
with
th
e
b
r
ai
n
-
ey
e
c
o
n
n
ec
tio
n
[
1
1
]
.
T
h
e
m
a
j
o
r
i
t
y
o
f
p
e
d
i
a
t
r
i
c
c
a
t
ar
a
c
t
s
a
r
e
d
i
f
f
i
c
u
lt
f
o
r
a
n
y
o
n
e
c
l
o
s
e
t
o
t
h
e
c
h
i
l
d
t
o
d
e
t
e
c
t
,
wh
i
c
h
m
i
g
h
t
p
o
s
t
p
o
n
e
d
i
a
g
n
o
s
i
s
.
F
u
r
t
h
e
r
m
o
r
e
,
l
i
n
k
e
d
t
o
l
a
t
e
p
r
e
s
e
n
t
a
t
i
o
n
i
n
c
l
u
d
e
s
o
c
i
o
d
e
m
o
g
r
a
p
h
i
c
,
c
u
l
t
u
r
a
l
,
a
n
d
h
e
a
l
t
h
s
y
s
te
m
i
s
s
u
es
[
1
2
]
.
I
n
t
h
i
s
r
e
g
ar
d
,
c
h
i
l
d
r
e
n
f
r
o
m
l
o
w
-
i
n
c
o
m
e
f
a
m
i
l
i
es
a
n
d
b
a
c
k
g
r
o
u
n
d
s
a
p
p
e
a
r
t
o
b
e
m
o
r
e
l
i
k
e
ly
t
o
e
n
c
o
u
n
t
e
r
o
b
s
t
a
c
le
s
w
h
e
n
t
r
y
i
n
g
t
o
a
c
c
e
s
s
c
a
r
e
a
n
d
t
o
s
t
ic
k
w
i
t
h
t
h
e
i
r
t
r
e
a
t
m
e
n
t
p
l
a
n
f
r
o
m
a
n
e
a
r
l
y
a
g
e
[
1
3
]
.
E
ar
ly
d
iag
n
o
s
is
,
ex
ce
llen
t
s
u
r
g
ical
in
ter
v
e
n
tio
n
,
a
n
d
p
o
s
to
p
er
ativ
e
r
eh
ab
ilit
atio
n
a
r
e
th
e
m
o
s
t
r
elev
an
t
m
an
ag
e
m
en
t
p
r
o
ce
s
s
es
f
o
r
s
tab
ilizin
g
ca
s
es.
I
n
o
r
d
er
to
o
f
f
er
ter
tiar
y
lev
el
o
p
h
th
alm
o
lo
g
ical
ca
r
e,
ch
ild
ca
tar
ac
t
tr
ea
tm
en
t
clin
ics
s
h
o
u
ld
h
av
e
a
well
-
estab
li
s
h
ed
s
p
ec
ialis
t
team
o
f
clin
ician
s
with
ex
p
er
ien
ce
,
o
p
to
m
etr
is
ts
,
an
d
o
r
t
h
o
p
tis
ts
[
1
4
]
.
W
h
en
m
u
ltip
le
p
iece
s
o
f
in
f
o
r
m
atio
n
an
d
s
y
m
p
t
o
m
s
in
d
icatin
g
th
e
d
ev
elo
p
m
e
n
t
an
in
f
an
tile
ca
tar
ac
t
ar
e
f
o
u
n
d
,
th
e
d
iag
n
o
s
is
i
s
m
o
r
e
lik
ely
to
b
e
ac
cu
r
ate.
Gen
er
ally
,
leu
k
o
co
r
ia,
s
tr
ab
is
m
u
s
,
ab
e
r
r
a
n
t
ey
e
m
o
v
em
e
n
ts
,
p
o
o
r
v
is
io
n
o
r
d
elay
ed
v
is
u
al
m
iles
to
n
es
ar
e
th
e
aty
p
ical
is
s
u
es
th
at
p
ar
en
ts
f
in
d
m
o
s
t
o
f
ten
in
th
ei
r
ch
ild
r
e
n
[
1
5
]
.
T
h
er
ef
o
r
e
,
f
u
r
th
er
in
f
o
r
m
atio
n
m
u
s
t
b
e
co
llected
,
co
v
er
in
g
th
e
ag
e
at
wh
ich
s
y
m
p
to
m
s
f
ir
s
t
ap
p
ea
r
,
h
o
w
l
o
n
g
th
ey
last
,
p
r
en
atal,
p
er
in
atal,
an
d
p
o
s
tn
atal
h
is
to
r
y
,
d
is
o
r
d
e
r
s
lin
k
ed
to
ca
t
ar
ac
ts
,
f
am
ily
h
is
to
r
y
o
f
ca
tar
ac
ts
,
an
d
co
n
s
an
g
u
i
n
ity
[
1
5
]
.
I
n
d
ee
d
,
s
u
r
g
er
y
a
n
d
p
o
s
to
p
er
ativ
e
ca
r
e
a
r
e
n
o
t
th
e
o
n
ly
tr
ea
tm
en
t
f
o
r
th
is
ty
p
e
o
f
ca
s
e.
T
r
ea
tm
e
n
t
o
f
am
b
ly
o
p
ia
an
d
r
ef
r
ac
tiv
e
co
r
r
ec
tio
n
is
eq
u
ally
cr
u
cial,
a
n
d
m
ay
co
n
tin
u
e
f
o
r
m
o
n
th
s
o
r
ev
en
y
ea
r
s
af
ter
ca
tar
ac
t
r
em
o
v
al.
Mo
r
o
cc
o
h
as
r
ec
ei
v
ed
litt
le
r
e
s
ea
r
ch
o
n
ch
ild
h
o
o
d
ca
tar
ac
ts
o
v
er
th
e
p
ast
f
ew
d
ec
a
d
es,
m
ak
in
g
t
h
e
ef
f
o
r
ts
o
f
h
ea
lth
p
o
licies
less
ef
f
ec
tiv
e.
T
o
th
is
en
d
,
we
c
o
n
d
u
cte
d
a
s
tu
d
y
in
th
e
Ma
r
r
ak
ec
h
-
Saf
i
r
eg
i
o
n
(
ce
n
tr
al
Mo
r
o
cc
o
)
s
p
ec
if
ically
f
o
c
u
s
in
g
o
n
in
f
a
n
tile
ca
tar
ac
ts
,
as
a
r
esp
o
n
s
e
to
th
e
h
ig
h
r
ate
o
f
th
ese
p
ath
o
lo
g
ies
f
o
u
n
d
in
th
e
s
tu
d
y
b
y
So
u
k
ain
a
et
a
l.
[
8
]
.
T
h
is
a
llo
wed
u
s
to
f
u
r
th
er
a
n
aly
ze
t
h
e
ep
id
em
io
l
o
g
ical,
p
ath
o
lo
g
ical,
a
n
d
s
o
cio
d
em
o
g
r
ap
h
ic
d
ata
co
n
tr
ib
u
tin
g
to
th
e
o
n
s
et
o
f
th
is
ey
e
d
is
ea
s
e
in
ch
ild
r
en
.
T
h
is
s
tu
d
y
allo
wed
f
o
r
th
e
an
aly
s
is
o
f
s
p
atio
tem
p
o
r
al
tr
en
d
s
an
d
n
o
tab
le
m
o
v
em
en
ts
o
f
in
cr
ea
s
e,
d
ec
r
ea
s
e,
o
r
co
n
s
tan
cy
o
f
c
h
ild
h
o
o
d
c
atar
ac
ts
o
v
e
r
t
h
e
p
ast
5
y
ea
r
s
.
T
h
e
p
u
r
p
o
s
e
o
f
th
is
s
tu
d
y
is
to
ass
ess
th
e
ep
id
e
m
io
lo
g
ical
ch
ar
ac
ter
is
tics
an
d
s
p
atio
tem
p
o
r
al
d
is
tr
ib
u
tio
n
f
ea
tu
r
es
o
f
in
f
an
tile
ca
tar
ac
t
in
ch
ild
r
en
r
esid
in
g
in
th
e
Ma
r
r
ak
ec
h
-
Saf
i
r
eg
io
n
o
f
Mo
r
o
cc
o
.
2.
M
E
T
H
O
D
2
.
1
.
P
o
pu
la
t
io
n a
nd
s
t
ud
y
a
re
a
T
h
i
s
r
e
t
r
o
s
p
e
c
ti
v
e
s
t
u
d
y
t
o
o
k
p
l
a
c
e
i
n
t
h
e
o
p
h
t
h
a
l
m
o
l
o
g
y
d
e
p
a
r
t
m
e
n
t
o
f
t
h
e
E
r
r
az
i
h
o
s
p
i
t
a
l
a
t
t
a
c
h
e
d
t
o
t
h
e
M
o
h
a
m
m
e
d
V
I
U
n
i
v
e
r
s
i
t
y
H
o
s
p
i
t
a
l
C
e
n
t
r
e
(
U
HC
)
i
n
Ma
r
r
a
k
e
c
h
.
T
h
e
c
e
n
t
e
r
s
e
r
v
e
s
t
h
e
e
n
t
i
r
e
M
a
r
r
a
k
e
c
h
-
S
a
f
i
r
e
g
i
o
n
,
w
h
i
c
h
i
s
l
o
c
a
t
e
d
in
c
e
n
t
r
a
l
M
o
r
o
c
c
o
,
a
s
s
h
o
w
n
in
F
i
g
u
r
e
1
.
T
h
is
r
e
g
i
o
n
c
o
m
p
r
i
s
e
s
s
e
v
e
n
p
r
o
v
i
n
c
e
s
a
n
d
o
n
e
p
r
e
f
e
c
t
u
r
e
(
r
e
g
i
o
n
a
l
c
ap
i
t
a
l
)
,
c
o
v
e
r
i
n
g
a
n
a
r
e
a
o
f
4
1
,
4
0
4
k
m
²
(
i
.
e
.
,
6
%
o
f
t
h
e
M
o
r
o
c
ca
n
t
e
r
r
i
t
o
r
y
)
[
8
]
.
2
.
2
.
I
ns
t
rum
ent
s
T
h
e
d
ata
was
co
llected
u
s
in
g
a
p
r
e
-
estab
lis
h
ed
q
u
esti
o
n
n
air
e
b
ased
o
n
th
e
W
HO
s
tan
d
ar
d
ized
q
u
esti
o
n
n
air
e
n
am
ed
W
HO
/PB
L
ey
e
ex
am
in
atio
n
r
ec
o
r
d
f
o
r
ch
ild
r
e
n
with
b
li
n
d
n
ess
an
d
lo
w
v
is
io
n
[
1
6
]
,
[
1
7
]
.
Ou
r
a
d
ap
ted
q
u
esti
o
n
n
air
e
co
n
s
is
ted
o
f
a
s
ec
tio
n
o
n
th
e
p
atien
t'
s
s
o
cio
d
em
o
g
r
ap
h
ic
d
ata,
as
well
as
th
e
ag
e
o
f
o
n
s
et
o
f
th
e
p
r
o
b
le
m
an
d
th
e
v
a
r
iab
les
o
f
co
n
s
an
g
u
in
ity
an
d
f
am
ily
h
is
to
r
y
.
A
s
ec
o
n
d
s
ec
tio
n
o
n
th
e
ass
ess
m
en
t
o
f
v
is
u
al
ac
u
ity
,
wh
er
e
we
h
av
e
in
co
r
p
o
r
ated
a
m
etr
ic
f
o
r
th
e
g
r
o
u
p
o
f
s
ig
h
ted
p
eo
p
le.
Nex
t,
b
ased
o
n
th
e
t
y
p
e
o
f
ca
tar
ac
t
an
d
its
later
ality
at
th
is
p
o
in
t,
th
e
e
y
e
ex
am
in
atio
n
p
r
ec
is
ely
p
in
p
o
in
ts
t
h
e
lesi
o
n
'
s
lo
ca
tio
n
.
T
h
e
p
atien
t'
s
etio
lo
g
y
f
o
r
th
is
p
ath
o
lo
g
y
is
t
h
en
d
is
cu
s
s
ed
.
I
n
o
r
d
er
to
d
o
a
s
p
atio
tem
p
o
r
al
an
aly
s
is
,
we
in
clu
d
ed
th
e
v
ar
iab
le
o
f
th
e
y
ea
r
o
f
ch
ild
ca
r
e
in
o
u
r
q
u
esti
o
n
n
air
e.
2
.
3
.
Da
t
a
c
o
llect
io
n a
nd
a
na
ly
s
is
Data
co
llectio
n
was
ca
r
r
ied
o
u
t
b
etwe
en
Ma
r
ch
2
5
,
2
0
2
4
,
an
d
Ap
r
il
2
6
,
2
0
2
4
,
in
th
e
o
p
h
t
h
alm
o
lo
g
y
d
ep
ar
tm
en
t.
W
e
ad
o
p
ted
an
e
x
h
au
s
tiv
e
m
eth
o
d
d
u
e
to
a
lim
ited
n
u
m
b
er
o
f
ca
s
es.
T
h
e
d
at
a
wer
e
co
llected
b
y
co
n
s
u
ltin
g
th
e
m
ed
ical
f
iles
o
f
ch
ild
r
en
with
ca
tar
ac
ts
wh
o
u
n
d
er
wen
t
an
o
p
er
atio
n
f
o
r
t
h
is
r
ea
s
o
n
b
etwe
en
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
P
ed
ia
tr
ic
ca
ta
r
a
cts:
E
p
id
emio
lo
g
ica
l,
etio
lo
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ic
a
l
,
a
n
d
clin
ic
a
l p
r
o
files
in
Mo
r
o
cc
o
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(
S
o
u
ka
in
a
Lo
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lid
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)
1153
th
e
y
ea
r
2
0
1
9
an
d
th
e
y
ea
r
2
0
2
3
.
All
ch
ild
r
en
u
n
d
e
r
1
5
y
ea
r
s
o
f
ag
e
wh
o
h
ad
u
n
d
e
r
g
o
n
e
tr
ea
tm
en
t
at
th
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Mo
h
am
m
ed
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HUC
liv
in
g
in
th
e
Ma
r
r
ak
ec
h
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Saf
i
r
e
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io
n
wer
e
in
clu
d
ed
i
n
th
e
s
tu
d
y
.
All
ch
ild
r
en
liv
in
g
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u
ts
id
e
th
e
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tu
d
y
r
eg
io
n
o
r
o
v
er
th
e
ag
e
o
f
1
5
wer
e
ex
clu
d
e
d
f
r
o
m
th
e
s
tu
d
y
to
m
in
im
ize
co
n
f
o
u
n
d
in
g
f
ac
to
r
s
in
th
e
p
r
esen
t
s
tu
d
y
.
T
h
e
s
am
p
le
co
n
s
is
ts
o
f
3
0
9
ch
ild
r
en
o
f
wh
o
m
we
h
av
e
r
ec
r
u
ited
all
th
e
ch
ild
r
en
m
ee
tin
g
th
e
in
clu
s
io
n
cr
iter
ia
an
d
wh
o
u
n
d
er
wen
t
ca
tar
ac
t
r
em
o
v
al
s
u
r
g
er
y
o
v
er
a
5
-
y
ea
r
p
er
io
d
,
b
etwe
en
th
e
y
ea
r
s
2
0
1
9
a
n
d
2
0
2
3
s
o
th
at
a
s
p
ati
o
tem
p
o
r
al
-
tr
e
n
d
an
al
y
s
is
co
u
ld
b
e
p
er
f
o
r
m
e
d
.
So
cio
d
em
o
g
r
ap
h
ic
ch
ar
ac
ter
is
tics
s
u
ch
as
g
en
d
er
,
ag
e,
a
n
d
o
r
i
g
in
,
as
well
as
ep
id
em
io
lo
g
ical
an
d
clin
ical
ch
ar
ac
ter
is
tics
s
u
ch
as
ag
e
o
r
y
ea
r
o
f
ca
tar
ac
t
o
n
s
et,
ty
p
e
o
f
ca
tar
ac
t,
co
n
s
an
g
u
in
ity
i
n
p
a
r
en
ts
,
f
a
m
ily
h
is
to
r
y
,
v
is
u
al
ac
u
ity
(
V
A)
,
ey
e
af
f
ec
ted
b
y
o
p
ac
if
icatio
n
,
an
d
ca
u
s
es,
wer
e
an
aly
ze
d
s
tatis
tica
lly
b
y
u
s
i
n
g
SP
SS
1
6
.
0
s
o
f
twar
e.
T
h
e
a
s
s
o
ciatio
n
b
etwe
en
ca
tar
ac
t
ty
p
es
an
d
s
o
cio
d
em
o
g
r
ap
h
ic
an
d
p
ath
o
l
o
g
ical
v
ar
i
ab
les
was
an
aly
s
ed
u
s
in
g
th
e
C
h
i
-
s
q
u
ar
e
(
χ²)
test
.
T
h
e
s
ig
n
if
ican
ce
lev
el
o
f
test
s
was p
<0
.
0
5
.
2
.
4
.
E
t
hica
l c
o
ns
idera
t
io
ns
T
h
e
s
t
u
d
y
w
a
s
c
a
r
r
ie
d
o
u
t
w
i
th
r
e
s
p
e
c
t
f
o
r
c
o
n
f
i
d
e
n
t
i
a
l
it
y
a
n
d
a
n
o
n
y
m
i
t
y
a
n
d
a
d
h
e
r
e
d
t
o
t
h
e
t
e
n
e
t
s
o
f
t
h
e
D
e
c
la
r
a
t
i
o
n
o
f
H
el
s
i
n
k
i
.
Au
t
h
o
r
i
z
a
t
i
o
n
f
o
r
d
a
t
a
c
o
ll
e
c
ti
o
n
w
a
s
o
b
t
ai
n
e
d
f
r
o
m
t
h
e
c
e
n
t
r
a
l
a
d
m
i
n
is
t
r
a
ti
o
n
o
f
t
h
e
M
o
h
a
m
m
e
d
V
I
U
n
i
v
e
r
s
i
t
y
H
o
s
p
i
t
al
c
e
n
t
e
r
(
N
°
:
7
8
3
8
)
a
n
d
w
a
s
g
r
a
n
t
e
d
b
y
t
h
e
d
i
r
ec
t
o
r
o
f
th
e
E
r
r
a
z
i
h
o
s
p
i
t
al
.
Fig
u
r
e
1
.
R
eg
io
n
al
an
d
l
o
ca
l
Ma
r
r
ak
ec
h
-
Saf
i
r
eg
io
n
m
ap
3.
RE
SU
L
T
S AN
D
D
I
SCU
SS
I
O
N
3
.
1
.
Resul
t
s
Acc
o
r
d
in
g
to
t
h
e
s
tu
d
y
’
s
d
ata,
3
0
9
ch
ild
r
en
wer
e
th
e
to
tal
o
f
ca
s
es
wh
o
u
n
d
er
wen
t
ca
tar
a
ct
r
em
o
v
al
s
u
r
g
er
y
o
v
e
r
a
5
-
y
ea
r
p
er
io
d
,
b
etwe
en
th
e
y
ea
r
s
2
0
1
9
a
n
d
2
0
2
3
as
s
h
o
wn
in
T
a
b
le
1
.
T
h
e
av
er
ag
e
a
g
e
was 6
.
8
y
ea
r
s
,
an
d
th
e
m
o
s
t
co
m
m
o
n
a
g
e
g
r
o
u
p
was 0
-
3
y
ea
r
s
(
2
8
.
5
%),
f
o
llo
wed
b
y
4
-
7
y
ea
r
s
(
2
8
.
2
%).
B
o
y
s
m
ad
e
u
p
6
4
.
7
%
o
f
th
e
to
tal,
an
d
th
e
s
ex
r
atio
was
1
.
8
3
.
C
h
ild
r
en
f
r
o
m
u
r
b
a
n
ar
ea
s
r
ep
r
esen
t
5
2
.
4
%
o
f
th
e
t
o
tal.
Mo
r
e
th
an
h
alf
o
f
th
e
ch
ild
r
en
with
ca
tar
ac
ts
wer
e
f
r
o
m
th
e
Ma
r
r
a
k
ec
h
p
r
ef
ec
tu
r
e
(
5
4
%),
f
o
llo
w
ed
b
y
th
e
p
r
o
v
i
n
ce
o
f
E
lk
alaa
d
es
Sra
g
h
n
a
(
1
6
.
2
%)
an
d
E
lh
ao
u
z
(
9
.
7
%),
with
th
e
p
r
o
v
i
n
ce
o
f
Saf
i
c
o
m
in
g
in
last
(
2
.
6
%)
as
s
h
o
wn
in
T
ab
le
1
.
Fo
r
th
e
y
ea
r
s
2
0
1
9
,
2
0
2
2
,
a
n
d
2
0
2
3
,
th
e
f
r
eq
u
en
cy
o
f
c
h
ild
r
en
u
n
d
e
r
g
o
in
g
ca
tar
ac
t
r
em
o
v
al
as
o
b
s
er
v
ed
in
th
is
s
tu
d
y
is
co
m
p
ar
ativ
ely
s
tab
le
as
s
h
o
wn
in
T
ab
le
2
.
Nev
er
t
h
eless
,
in
2
0
2
0
,
th
er
e
wer
e
a
v
er
y
lo
w
n
u
m
b
er
o
f
4
4
ch
ild
r
en
,
a
n
d
in
2
0
2
1
th
er
e
wer
e
8
1
ca
s
es
—
th
e
m
ajo
r
ity
.
I
n
all
5
y
ea
r
s
,
th
e
s
p
atio
tem
p
o
r
al
d
is
tr
ib
u
tio
n
also
i
n
d
icate
d
a
p
r
ed
o
m
in
a
n
ce
o
f
p
atien
ts
f
r
o
m
Ma
r
r
ak
ec
h
.
E
lk
alaa
d
es
Sra
g
h
n
a
ex
p
er
ien
ce
d
th
e
s
am
e
s
itu
atio
n
in
2
0
1
9
,
2
0
2
1
,
2
0
2
2
,
an
d
2
0
2
3
.
T
h
e
r
e
was
a
d
is
ce
r
n
ib
le
d
ec
r
ea
s
e
in
Saf
i
ca
s
es
d
u
r
in
g
2
0
1
9
,
2
0
2
0
,
an
d
2
0
2
3
,
as we
ll a
s
in
C
h
ich
ao
u
a
an
d
R
h
am
n
a
in
2
0
2
1
an
d
2
0
2
2
,
r
esp
ec
tiv
ely
as sh
o
wn
in
Fig
u
r
e
2
.
T
h
e
p
e
r
ce
n
tag
e
o
f
ca
s
es
v
ar
i
es
b
ased
o
n
th
e
r
esid
en
ce
’
s
lo
ca
tio
n
an
d
t
h
e
y
ea
r
o
f
f
ir
s
t
m
ed
ical
co
n
s
u
ltatio
n
.
T
h
e
r
ate
o
f
ca
s
es
was
h
ig
h
in
u
r
b
an
ar
ea
s
in
2
0
1
9
a
n
d
2
0
2
1
,
a
n
d
it
was
h
ig
h
in
r
u
r
al
ar
ea
s
in
2
0
2
2
a
n
d
2
0
2
3
as
s
h
o
wn
in
Fig
u
r
e
3
.
Mo
r
e
th
an
h
alf
o
f
c
h
ild
r
en
ar
e
b
o
r
n
with
ca
tar
ac
t
s
(
5
3
.
1
%
o
f
ca
s
es),
f
o
llo
wed
b
y
th
e
4
-
7
ag
e
g
r
o
u
p
(
1
5
.
9
%),
wh
ile
o
n
ly
6
.
8
%
o
f
ch
ild
r
en
d
e
v
elo
p
ca
tar
ac
ts
in
th
e
m
o
n
th
s
af
ter
b
ir
th
u
n
til
th
ey
ar
e
3
y
ea
r
s
o
l
d
as
s
h
o
wn
in
T
ab
le
3
.
Six
ch
ild
r
en
o
u
t
o
f
1
0
(
5
7
.
6
%)
h
ad
co
n
g
en
ital
ca
tar
ac
ts
,
wh
ile
4
1
.
1
%
h
ad
ca
tar
ac
ts
as
a
r
esu
lt
o
f
o
cu
lar
tr
au
m
a.
Fo
u
r
ch
ild
r
en
(
1
.
3
%
o
f
all
ca
s
es)
h
ad
d
ev
elo
p
m
en
tal
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
14
,
No
.
3
,
Sep
tem
b
er
20
25
:
1
1
5
1
-
1
1
5
9
1154
ca
tar
ac
ts
o
f
wh
ich
th
r
ee
h
ad
co
r
tico
s
ter
o
id
ca
tar
ac
ts
an
d
o
n
e
h
ad
u
v
eitic
ca
tar
ac
ts
.
I
n
co
n
tr
ast
to
4
8
.
5
%
f
o
r
u
n
ilater
al
ca
tar
ac
ts
,
a
later
alit
y
an
aly
s
is
s
h
o
wed
a
r
ate
o
f
5
1
.
5
%
f
o
r
b
ilater
al
ca
tar
ac
ts
.
I
t
i
s
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.
2
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I
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th
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r
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tu
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ch
ild
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tar
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ts
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wen
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r
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all
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atic
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ly
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ical
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ates
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ig
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ates
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r
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n
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ates f
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v
ir
o
n
m
en
ts
.
Of
all
ch
ild
r
en
,
h
alf
(
5
3
.
1
%)
h
ad
ca
tar
ac
ts
at
b
ir
th
,
f
o
llo
w
ed
b
y
t
h
e
4
to
7
ag
e
g
r
o
u
p
(
1
5
.
9
%).
A
n
u
m
b
er
o
f
in
d
icato
r
s
,
in
clu
d
in
g
v
is
io
n
im
p
air
m
e
n
t,
wh
ich
m
ay
s
er
v
e
as
a
s
tar
tin
g
p
o
in
t
f
o
r
a
co
n
s
u
ltatio
n
an
d
d
iag
n
o
s
is
to
id
en
tify
th
e
u
n
d
er
ly
in
g
o
cu
lar
an
o
m
aly
,
m
ay
p
la
y
a
r
o
le
in
t
h
e
d
is
co
v
er
y
o
f
ca
t
ar
ac
ts
in
ch
ild
r
en
.
T
h
ese
s
tatis
tics
also
r
ef
lect
th
e
f
ac
t
th
at
m
o
s
t
c
o
n
g
e
n
ital
ca
tar
ac
t
ca
s
es
h
av
e
an
ea
r
ly
b
eg
in
n
in
g
.
I
n
co
n
tr
ast,
th
e
co
r
r
elatio
n
s
tu
d
y
s
h
o
wed
t
h
at
o
cu
lar
tr
au
m
a
f
r
eq
u
en
tly
h
ap
p
en
s
in
ea
r
ly
i
n
f
an
cy
,
with
3
4
.
6
%
o
f
ch
ild
r
en
in
th
e
4
–
7
ag
e
g
r
o
u
p
an
d
3
1
.
5
% in
th
e
8
–
1
1
ag
e
g
r
o
u
p
r
e
p
o
r
tin
g
h
av
in
g
ex
p
er
ien
ce
d
t
h
is
tr
au
m
a.
I
n
d
ee
d
,
t
h
e
ty
p
e
o
f
p
ath
o
lo
g
y
an
d
its
ag
e
o
f
o
n
s
et
ar
e
s
tr
o
n
g
ly
co
r
r
elate
d
,
w
h
ich
was
r
ep
o
r
ted
as
a
s
ig
n
if
ican
t
ass
o
ciatio
n
(p
-
v
alu
e
=
0
.
0
0
0
)
.
W
ith
a
p
r
e
v
alen
ce
o
f
5
7
.
6
%,
c
o
n
g
e
n
ital
ca
tar
ac
ts
p
r
ed
o
m
in
ate
d
in
th
is
r
eg
ar
d
,
f
o
llo
we
d
b
y
ca
tar
ac
ts
th
at
o
cc
u
r
r
ed
as
a
r
esu
lt
o
f
o
cu
lar
tr
au
m
a
(
4
1
.
1
%).
I
n
o
n
e
in
f
a
n
t
in
o
u
r
in
v
esti
g
atio
n
,
u
v
eitic
ca
tar
ac
t
d
ev
elo
p
m
e
n
t w
as r
ig
id
ly
d
e
v
e
lo
p
ed
f
r
o
m
b
i
r
th
.
C
h
ild
r
en
i
n
t
h
e
s
ec
o
n
d
an
d
th
ir
d
ag
e
g
r
o
u
p
s
o
f
ca
tar
ac
t
o
n
s
et
f
r
o
m
th
e
ag
e
o
f
f
o
u
r
h
a
d
d
ev
elo
p
m
en
tal
ca
tar
ac
t.
B
ec
au
s
e
co
n
tin
u
o
u
s
u
s
e
o
f
co
r
tico
s
ter
o
id
s
—
wh
eth
er
th
r
o
u
g
h
s
elf
-
m
ed
icatio
n
o
r
a
p
r
escr
ip
tio
n
d
r
u
g
f
r
eq
u
e
n
tly
u
s
ed
to
t
r
ea
t
in
f
lam
m
atio
n
s
—
ca
u
s
es
co
r
tis
o
n
e
ca
tar
ac
t.
Acc
o
r
d
i
n
g
to
Kr
am
er
&
T
o
m
k
i
n
s
-
Netz
er
[
2
3
]
,
th
e
r
is
k
was
0
.
0
1
/EY
(
9
5
%
co
n
f
id
en
ce
in
t
er
v
al,
0
.
0
0
5
-
0
.
0
3
/EY
)
f
o
r
s
u
b
jects
r
ec
eiv
in
g
3
d
r
o
p
s
p
er
d
ay
,
s
u
g
g
esti
n
g
th
at
co
r
tico
s
ter
o
id
d
o
s
ag
es
m
ay
al
s
o
h
av
e
an
im
p
ac
t
o
n
th
e
s
tar
t
o
f
ca
tar
ac
ts
.
C
o
m
p
ar
ab
ly
,
th
e
r
ate
o
f
in
f
an
tile
co
n
g
en
ital
ca
tar
ac
ts
was
4
0
.
8
%
in
Yao
u
n
d
é
[
3
]
,
with
tr
au
m
atic
ca
tar
ac
ts
co
m
in
g
in
s
ec
o
n
d
at
2
7
.
6
%.
T
h
e
s
am
e
r
esu
lts
wer
e
n
o
ted
in
Gh
an
a,
wh
e
r
e
th
e
r
ate
o
f
c
o
n
g
e
n
ital
ca
tar
ac
ts
was
3
9
.
5
%,
f
o
llo
wed
b
y
tr
au
m
atic
ca
tar
ac
t
(
3
3
.
1
%)
[
2
2
]
.
T
h
e
r
ef
o
r
e,
th
e
least
im
p
ac
ted
b
y
tr
a
u
m
atic
ca
tar
ac
t
wer
e
o
ld
er
ch
ild
r
en
(
2
–
1
2
y
ea
r
s
,
OR
=
1
2
.
5
9
,
p
<0
.
0
0
1
;
>
1
2
y
e
ar
s
,
OR
=
7
.
5
7
,
p
=
0
.
0
0
4
)
,
as
well
as
f
em
ale
ch
ild
r
en
(
OR
=
0
.
5
8
,
p
=
0
.
0
3
8
)
[
2
2
]
.
As
th
e
liter
atu
r
e
in
d
icate
s
,
co
n
g
e
n
ital
d
is
ea
s
es
m
ay
n
o
t
ap
p
ea
r
f
r
o
m
b
ir
th
[
2
4
]
.
Fo
r
th
e
f
o
u
r
r
em
ain
i
n
g
ag
e
g
r
o
u
p
s
in
o
r
d
er
o
f
r
an
k
in
g
,
a
m
in
o
r
ity
o
f
ch
ild
r
e
n
(
4
.
5
%,
2
.
2
%,
1
.
7
%,
an
d
2
.
2
%,
r
esp
ec
tiv
ely
)
ex
h
ib
itin
g
s
y
m
p
to
m
s
o
f
co
n
g
e
n
ital c
atar
ac
t in
th
e
y
ea
r
s
af
ter
b
ir
th
wer
e
d
etec
ted
in
o
u
r
s
tu
d
y
.
W
ith
5
1
.
5
%
o
f
c
h
ild
r
en
d
is
co
v
er
ed
to
h
av
e
b
ilater
al
ca
tar
ac
ts
an
d
4
8
.
5
%
to
h
av
e
u
n
ilater
a
l
ca
tar
ac
ts
,
later
ality
d
id
n
o
t
ap
p
ea
r
to
b
e
a
s
ig
n
if
ican
t
f
ac
to
r
.
I
n
o
u
r
s
tu
d
y
,
tr
au
m
atic
ca
tar
ac
t
was
s
tr
o
n
g
ly
ass
o
ciate
d
with
a
h
ig
h
r
ate
o
f
u
n
ilater
alis
m
.
Gh
an
a
[
2
2
]
lik
ewise
ex
h
i
b
ited
r
ates
o
f
later
ality
th
at
wer
e
co
m
p
ar
ativ
el
y
id
en
tical
(
5
1
.
7
%
f
o
r
u
n
ilater
al
ca
tar
ac
t
an
d
4
7
.
5
%
f
o
r
b
ilater
al
ca
tar
ac
t)
.
I
n
a
s
im
ilar
v
e
in
,
th
er
e
f
o
u
n
d
n
o
v
ar
iatio
n
in
later
ality
am
o
n
g
B
r
az
ilian
in
f
an
ts
ag
es
0
to
1
[
1
8
]
.
Dif
f
er
e
n
tly
f
r
o
m
o
u
r
r
esu
lts
an
d
th
o
s
e
o
f
Gh
an
a,
an
d
B
r
az
il,
Ko
r
ea
[
1
9
]
r
ep
o
r
ted
a
u
n
ilater
al
ca
tar
ac
t
r
ate
th
at
was
ex
ce
s
s
iv
ely
h
ig
h
er
th
an
th
e
b
ilater
al
ca
tar
ac
t r
ate
(
8
2
% a
n
d
1
8
%,
r
esp
ec
tiv
ely
)
.
A
s
ig
n
if
ican
t
p
er
ce
n
tag
e
o
f
th
e
ch
ild
r
e
n
d
ia
g
n
o
s
ed
h
a
d
b
lin
d
n
ess
(
v
is
u
al
ac
u
ity
less
th
an
3
/6
0
t
o
n
o
lig
h
t
p
er
ce
p
tio
n
)
in
b
o
th
ey
e
s
(
2
8
.
5
%
f
o
r
th
e
lef
t
e
y
e
a
n
d
3
2
.
4
%
f
o
r
th
e
r
ig
h
t
ey
e)
.
No
r
m
al
v
is
io
n
was
m
ea
s
u
r
ed
in
2
3
.
6
%
o
f
lef
t
ey
e
s
an
d
2
0
.
4
%
o
f
r
ig
h
t
ey
es.
I
n
co
n
tr
ast,
3
6
.
6
%
o
f
ch
il
d
r
en
wer
e
u
n
a
b
le
to
h
av
e
th
eir
v
is
u
al
ac
u
ity
m
ea
s
u
r
e
d
d
u
e
to
th
eir
y
o
u
n
g
ag
e
.
Ocu
lar
tr
au
m
a
was
th
e
m
o
s
t
co
m
m
o
n
ty
p
e
o
f
ca
tar
ac
t
to
ca
u
s
e
b
lin
d
n
ess
in
th
e
af
f
ec
ted
ey
e,
an
d
th
e
co
n
g
en
ital f
o
r
m
o
f
ca
tar
ac
t c
au
s
ed
b
lin
d
n
ess
in
m
o
s
t c
ases
.
An
aly
zin
g
th
e
r
is
k
f
ac
to
r
s
lin
k
ed
to
ca
tar
ac
ts
was
cr
u
cial.
T
h
e
m
ajo
r
ity
o
f
p
atien
ts
,
esp
ec
ially
th
o
s
e
with
co
n
g
en
ital
ca
tar
ac
ts
,
h
ad
an
u
n
k
n
o
wn
o
r
u
n
d
etec
ted
ca
u
s
e
(
4
2
.
7
%).
T
h
e
p
r
e
d
o
m
in
a
n
ce
o
f
p
o
s
tn
atal
an
d
in
f
an
tile
f
ac
to
r
s
(
4
2
.
4
%),
s
u
g
g
ests
th
at
tr
au
m
atic
ca
tar
ac
ts
,
wh
ich
d
am
a
g
e
th
e
le
n
s
,
ar
e
c
o
m
m
o
n
a
n
d
a
r
e
o
f
te
n
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
P
ed
ia
tr
ic
ca
ta
r
a
cts:
E
p
id
emio
lo
g
ica
l,
etio
lo
g
ic
a
l
,
a
n
d
clin
ic
a
l p
r
o
files
in
Mo
r
o
cc
o
…
(
S
o
u
ka
in
a
Lo
u
lid
i
)
1157
ca
u
s
ed
b
y
s
h
ar
p
o
b
jects
o
r
h
ea
t
o
r
ch
em
ical
b
u
r
n
s
.
T
r
au
m
atic
ca
tar
ac
t
in
ch
ild
r
e
n
was
clo
s
ely
lin
k
ed
to
en
v
ir
o
n
m
en
tal
f
ac
to
r
s
,
n
o
tab
ly
p
lay
an
d
h
o
u
s
eh
o
ld
m
is
h
ap
s
.
Acc
o
r
d
in
g
to
Gü
n
ay
d
ın
an
d
Or
al'
s
s
tu
d
y
[
2
5
]
,
wh
ich
was
co
n
d
u
cted
in
an
I
s
tan
b
u
l
o
p
h
th
alm
o
lo
g
y
r
ef
e
r
r
al
ce
n
ter
in
2
0
2
2
,
ch
ild
r
en
'
s
tr
au
m
atic
ca
tar
ac
ts
ar
e
p
r
i
m
ar
ily
ca
u
s
ed
b
y
s
h
ar
p
item
s
.
O
n
e
s
tak
eh
o
ld
er
to
b
e
e
x
am
in
ed
in
th
e
c
u
r
r
e
n
t
r
esear
ch
was
th
e
h
er
ed
itar
y
f
ac
t
o
r
.
T
h
e
f
in
d
in
g
s
s
h
o
wed
th
at
th
is
f
ac
to
r
co
n
tr
ib
u
ted
t
o
1
3
.
3
%
o
f
ch
ild
r
en
s
u
f
f
er
in
g
f
r
o
m
ca
tar
ac
ts
,
an
d
th
at
th
is
n
u
m
b
er
o
n
ly
in
clu
d
e
d
ch
ild
r
e
n
wh
o
h
ad
co
n
g
en
ital
ca
tar
ac
ts
.
I
n
2
0
2
3
[
2
6
]
,
a
n
o
th
er
s
tu
d
y
ca
r
r
ied
o
u
t
o
n
T
u
r
k
is
h
f
am
ilies
with
co
n
g
en
ital
ca
tar
a
cts
r
ev
ea
led
th
at
5
8
%
o
f
f
am
i
lies
h
ad
au
to
s
o
m
al
d
o
m
in
an
t
tr
an
s
m
is
s
io
n
an
d
4
2
%
h
a
d
au
t
o
s
o
m
al
r
ec
es
s
iv
e
tr
an
s
m
is
s
io
n
.
T
h
ese
r
e
s
u
lts
h
ig
h
lig
h
t
th
e
im
p
o
r
tan
ce
o
f
in
v
esti
g
atio
n
an
d
s
u
r
v
ey
s
co
n
d
u
cted
f
o
r
th
e
b
en
ef
it
o
f
f
am
ilies
wh
o
s
e
m
em
b
er
s
h
av
e
co
n
g
en
ital
ca
tar
ac
ts
in
o
r
d
er
t
o
g
u
ar
an
tee
ea
r
ly
tr
ea
tm
e
n
t
f
o
r
ca
s
es
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at
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tewo
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th
y
th
at
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.
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in
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ce
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a
f
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er
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h
o
h
a
d
b
ee
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af
f
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tar
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e
also
in
v
esti
g
ate
th
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o
tio
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o
f
co
n
s
an
g
u
in
ity
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o
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g
th
e
p
ar
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ts
o
f
ch
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r
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af
f
ec
ted
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y
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tar
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ec
au
s
e
th
e
etio
lo
g
y
o
f
th
is
o
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lar
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at
h
o
lo
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etic.
I
n
co
n
tr
ast
to
th
e
8
8
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3
%
o
f
c
h
ild
r
en
wh
o
h
a
d
n
o
co
n
s
an
g
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in
ity
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etwe
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eir
p
ar
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ts
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th
e
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o
f
p
a
r
en
tal
co
n
s
an
g
u
in
ity
am
o
n
g
th
ese
c
h
ild
r
en
was
1
1
.
7
%.
T
h
is
v
ar
iab
le
also
p
er
tain
ed
to
th
e
co
n
g
en
ital
f
o
r
m
,
with
th
e
ex
ce
p
tio
n
o
f
two
k
id
s
wh
o
h
ad
tr
au
m
atic
ca
tar
ac
ts
,
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o
s
e
co
n
s
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g
u
i
n
ity
h
ad
n
o
b
ea
r
in
g
o
n
th
e
ac
cid
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tal
ty
p
e.
L
ik
ewise,
in
f
an
tile
ca
tar
ac
ts
ar
e
o
n
e
o
f
th
e
h
er
e
d
itar
y
p
ath
o
lo
g
ies,
ac
co
r
d
in
g
to
a
s
tu
d
y
o
n
th
e
ep
i
d
em
io
lo
g
y
o
f
b
lin
d
n
ess
a
n
d
v
is
u
al
im
p
air
m
en
t
in
in
f
an
ts
co
n
d
u
cted
in
th
e
s
am
e
r
eg
io
n
[
8
]
.
I
n
th
is
r
eg
ar
d
,
ch
i
ld
r
en
with
ey
e
p
r
o
b
lem
s
th
at
m
ay
h
av
e
a
g
en
etic
o
r
ig
in
ar
e
m
o
r
e
lik
ely
to
b
e
c
o
n
s
an
g
u
in
e
o
u
s
[
2
7
]
.
T
h
u
s
,
in
co
n
s
an
g
u
in
e
o
u
s
p
o
p
u
latio
n
s
,
au
to
s
o
m
al
r
ec
ess
iv
e
co
n
g
en
ital
ca
tar
ac
ts
a
r
e
h
i
g
h
l
y
co
m
m
o
n
[
2
8
]
.
J
o
m
aa
et
a
l.
[
2
9
]
also
f
o
u
n
d
th
at
in
c
h
ild
r
en
with
c
o
n
g
e
n
ital
ca
tar
ac
t,
co
n
s
an
g
u
in
ity
is
p
r
esen
t
in
8
5
.
7
1
%,
an
d
f
am
ily
h
is
to
r
y
was
d
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ted
in
2
3
.
8
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Ou
r
s
tu
d
y
p
r
esen
ted
f
am
ily
h
is
to
r
y
v
er
y
m
in
im
al
ly
(
6
.
8
%).
Ho
wev
er
,
it
h
as
r
ea
ch
ed
2
0
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in
Ken
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a
[
3
0
]
.
T
h
e
v
ar
iab
les
o
f
co
n
s
an
g
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in
ity
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d
f
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to
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r
d
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p
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ip
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if
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4
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[
1
6
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