1. Screening System for Hypertension and Diabetes at Primary Care Level

2. Hypertension and diabetes are considered the major contributors, whether individually or by interacting collectively, to the occurrence of the main chronic non communicable diseases such as cardiovascular diseases, cerebrovascular diseases, renal disease, and retinopathy.
They may also reflect the presence of other behavioral risk factors such as physical inactivity or unhealthy diet.

3. There are million peoples with diabetes mellitus in the world, and the number of diagnosed cases is increasing yearly. It is predicted to grow to more .
Diabetes is frequently not diagnosed until complications appear, and approximately one-third of all people with diabetes may be undiagnosed.
Chronic hyperglycemia is associated with long-term dysfunction, damage, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels.

4. Hypertension may occur in as many as millions
Hypertension may occur in as many as millions. Similarly, about one third of people with high blood pressure are unaware of their condition.
High blood pressure is a major contributor for heart diseases and cerebrovascular diseases even modest elevation in blood pressure is associated with an increase in morbidity.

5. In Iraq the estimated prevalence of diabetes is around 9%, and of hypertension is around 30% among adult population. Specific population subgroups are at higher risk than others, probably due to the associated risk factors.
Therefore, such diseases can be considered the top candidates for identification and early management as part of control of major chronic non-communicable diseases. This can be accomplished through screening of target population.

6. Indications for screening:
Both hypertension and diabetes meet the essential criteria required for screening including:
- The diseases represent important health problems that impose significant burden on population.
- The natural history of the diseases is understood.
- There is a recognizable preclinical (asymptomatic) stage during which the disease can be diagnosed.
- Tests are available that can detect undiagnosed conditions in the preclinical stage.

7. For screening to be effective, certain points should be taken into consideration:
- Facilities and resources are available to treat newly detected cases
- Screening should be a systematic ongoing process, and not merely a single one time effort.
- The cost of case finding and treatment are balanced in relationship to health expenditures as a whole.

8. Screening testing:
There is a major distinction between diagnostic testing and screening. Screening test is only applied to asymptomatic persons, to identify individuals who are likely to have the disease. Patients presenting with symptoms or complications need to receive a diagnostic testing. This does not constitute screening.
Separate diagnostic tests using standard criteria are required after positive screening tests to establish a definitive diagnosis.

9. Optimal screening methods and cut off points
Hypertension:
- Sphygmomanometer is usually used for screening. The test is highly accurate when performed correctly.
- Intra-arterial catheters are the most accurate devices for measuring blood pressure, but they are not appropriate for screening because of their invasiveness, technical limitations, and cost.
High blood pressure (HBP) is defined as systolic pressure of 140 mm Hg or more and /or diastolic pressure of 90 mmHg or more.

10. Diabetes:
- Fasting plasma glucose (FPG), is the best screening test for diabetes.
- Oral glucose tolerance test (OGTT) is also a suitable test; however, the FPG test is preferred in clinical settings because it is easier and faster to perform, more convenient and acceptable to patients, and less expensive.
Hyperglycemia is defined as the fasting plasma level of 126 mg/dl or more (equal to or more than 7 mmol/L).

11. Linkage with other activities
For screening to be effective, the screened persons should receive appropriate care according to the test results.
Hypertension should not be diagnosed on the basis of a single measurement; elevated readings should be confirmed on more than one reading at each of three separate visits.
An FPG 126 mg/dl (7.0 mmol/l) is an indication for retesting, which should be repeated on a different day to confirm a diagnosis. If the FPG is <126 mg/dl (<7.0 mmol/l) and there is a high suspicion for diabetes, an OGTT should be performed.
If necessary, plasma glucose testing may be performed on individuals who have taken food or drink shortly before testing. Such tests are referred to as

12. casual plasma glucose measurements and are given without regard to time of last meal. A casual plasma glucose level 200 mg/dl (11.1 mmol/l) with symptoms of diabetes is considered diagnostic of diabetes. A confirmatory FPG test or OGTT should be completed on a different day if the clinical condition of the patient permits.
It is important to consider that certain drugs, including glucocorticoids and nicotinic acid, may produce hyperglycemia.

13. Selection criteria:
It is recommended that any adult attending the PHC centers should be screened for hypertension and diabetes according to the following selection criteria:
- Any patient with an age equal to or more than 25 years should be screened for hypertension. Normotensives should receive blood pressure measurements at least once every two years.
- Any patient with an age equal to or more than 45 years should be screened for diabetes every 3 years. This does not address screening for gestational diabetes mellitus (GDM).

14. The rationale for this interval is that the test will be repeated before substantial time elapses, and there is little likelihood of an individual with a false negative result to develop any of the complications to a significant degree within this period
Persons with abnormal readings require more frequent measurements. The frequency of checkup should be based on the state of the individual.

15. Thank you