The Journal of Infection in Developing Countries https://jidc.org/index.php/journal <p>A peer-reviewed open access journal, focusing on global health.</p> en-US <p>Authors who publish with this journal agree to the following terms:</p> <ol type="a"> <li class="show">Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a <a title="Creative Commons Attribution License" href="http://creativecommons.org/licenses/by/4.0/" target="_new">Creative Commons Attribution License</a> that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.</li> <li class="show">Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.</li> <li class="show">Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See <a title="The Effect of Open Access" href="http://opcit.eprints.org/oacitation-biblio.html" target="_new">The Effect of Open Access</a>).</li> </ol> info@jidc.org (JIDC Central Office) support@jidc.org (JIDC Tech Support) Wed, 31 Jul 2019 00:00:00 -0700 OJS 3.1.2.1 http://blogs.law.harvard.edu/tech/rss 60 Physicians’ knowledge, attitudes and practices towards Zika virus infection in Jordan https://jidc.org/index.php/journal/article/view/11356 <p>Introduction: Zika virus (ZIKAV) disease is a public health problem of international concern. Recent evidence has documented imported ZIKAV cases into the Middle East and the existence of ZIKAV-transmitting mosquitoes in Jordan. However, limited data exist on the role of physicians in public awareness in this regard. This study aimed to assess ZIKAV knowledge, attitudes and counseling practices (KAP) of general physicians and gynecologists in Amman, Jordan.</p> <p>Methodology: In this cross-sectional study, a structured paper-based questionnaire was completed by 119 participants during 2016-2017.</p> <p>Results: Only 4.2% of the physicians correctly addressed ZIKAV-complication questions. A misconception of considering direct contact between individuals and breastfeeding as modes of ZIKAV transmission was observed. Only one participant correctly recognized that isolation of infected or exposed persons is not recommended. Having at least five years of experience in medical practice was the only factor that was significantly associated with a high knowledge score (<em>P-</em>value=0.011). Although prevention measures are the sole method to control ZIKAV spread, only 50% of participants believed in the efficacy of such measures<strong>.</strong> Despite a quarter of participants perceiving ZIKAV as a threat to their patients, none of them have counseled a patient in this regard before. The presence of an evidence of ZIKAV in Jordan and health authorities' recommendations were the most important predictors for adoption of counseling practice.</p> <p>Conclusions: General physicians and gynecologists in Jordan had several gaps in knowledge of key aspects of ZIKAV disease, and there is a need for specific training programs of physicians and gynecologists.</p> Eman Y Abu-rish, Eman R Elayeh, Michael J Browning Copyright (c) 2019 Eman Y. Abu-rish, Eman Elayeh, Michael Browning http://creativecommons.org/licenses/by/4.0 https://jidc.org/index.php/journal/article/view/11356 Wed, 31 Jul 2019 00:00:00 -0700 Performance of a new in-house medium Carba MTL-broth for the rapid detection of carbapenemase-producing Enterobacteriaceae https://jidc.org/index.php/journal/article/view/11305 <p>Introduction: The spread of carbapenemase-producing<em> Enterobacteriaceae</em> (CPE) represents a major public health issue. Methods allowing rapid detection of carbapenemases in developing countries are therefore urgently needed. In the current study, we developed a new in-house medium for the rapid detection of CPE isolates, especially OXA-48 producers.</p> <p>Methodology: A panel of 144 clinical strains previously characterized was tested on in-house Carba MTL-broth medium using four different concentrations of ertapenem (0.5 to 2 mg/L), and compared to chromID® OXA-48 and chromID® CARBA (BioMérieux) media.</p> <p>Results: Comparative evaluation of the Carba MTL-broth with chromID® OXA-48 and chromID® CARBA showed that chromID® OXA-48 and Carba MTL-broth had the highest sensitivity for detection of OXA-48 producers (93.9% and 100%, respectively) comparatively to chromID® CARBA (21.2%). The chromID® OXA-48 had the highest specificity (100%), as compared to the Carba MTL-broth (65.5%) and chromID® CARBA (84.4%) for the detection of OXA-48 producers.</p> <p>Conclusions: The in-house Carba MTL-broth developed in this study is sensitive, inexpensive, an easy-to-use phenotypic method for the detection of OXA-48-producing enterobacteria. Given the burden of pan-drug resistance, its implementation in the microbiology laboratory of developing countries could be a useful tool for rapid detection of these bacteria.</p> Assia Mairi, Abdelaziz Touati, Alix Pantel, Catherine Dunyach-Remy, Albert Sotto, Christophe De Champs, Jean-Philippe Lavigne Copyright (c) 2019 Assia Mairi, Abdelaziz Touati, Alix Pantel, Catherine Dunyach-Remy, Albert Sotto, Christophe De Champs, Jean-Philippe Lavigne http://creativecommons.org/licenses/by/4.0 https://jidc.org/index.php/journal/article/view/11305 Wed, 31 Jul 2019 00:00:00 -0700 Multidrug-resistant Gram-negative bacilli sepsis from a neonatal intensive care unit: a case-case-control study https://jidc.org/index.php/journal/article/view/10402 <p>Introduction: To identify the risks and outcomes for multidrug-resistant Gram-negative bacilli (MDRGNB) sepsis in neonates.</p> <p>Methodology: This was a retrospective case-case-control study between 1991 and 2016. The control group was selected from the same source records of all neonates with clinical or suspected sepsis but not culture-proven.</p> <p>Results: The numbers of patients in the MDRGNB sepsis, non-MDRGNB sepsis, and control groups were 157, 88, and 218, respectively. MDRGNB sepsis was significantly associated with outborn infants [adjusted odds ratio (aOR) 2.08; p = 0.003] and infants who had a neurologic sequela (aOR 11.58; p = 0.04), lower gestational age (p = 0.03) or previous aminoglycoside use (aOR 2.43; p &lt; 0.001) compared with the control group. Non-MDRGNB sepsis was associated with outborn infants (aOR 2.63; p &lt; 0.001), and infants who had neurologic sequelae (aOR 48.25; p = 0.001) and previous cephalosporin use (aOR 6.28; p &lt; 0.001) or cefoperazone plus sulbactam use (aOR 6.48; p = 0.02) compared with the control group. Case fatality (OR 3.63; p &lt; 0.001) and septic shock (OR 12.81; p &lt; 0.001) rates, length of stay (p &lt; 0.001), and daily hospital costs (p = 0.01) were higher in the MDRGNB sepsis group than in the control group.</p> <p>Conclusions: Smaller preterm neonate with previous aminoglycoside use had a higher MDRGNB than non-MDRGNB sepsis compared with the control group. Intervention to reduce MDRGNB sepsis in the NICU is cost-effective.</p> Anucha Thatrimontrichai, Nutchana Premprat, Waricha Janjindamai, Supaporn Dissaneevate, Gunlawadee Maneenil Copyright (c) 2019 Anucha Thatrimontrichai, Nutchana Premprat, Waricha Janjindamai, Supaporn Dissaneevate, Gunlawadee Maneenil http://creativecommons.org/licenses/by/4.0 https://jidc.org/index.php/journal/article/view/10402 Wed, 31 Jul 2019 00:00:00 -0700 Non-tuberculous mycobacteria profiles and their anti-mycobacterial resistance at a major medical center in Lebanon https://jidc.org/index.php/journal/article/view/11028 <p>Introduction: Infection with non-tuberculosis mycobacteria (NTM) has been on the rise globally causing a wide spectrum of respiratory and extrapulmonary infections in humans. Studies on these pathogens from the Middle-East including Lebanon are scarce.</p> <p>Methodology: This retrospective study addresses the approach used for investigation, speciation and antimicrobial resistance (AMR) profiles of recovered NTM isolates from respiratory sources at a major tertiary care center in Lebanon during two periods (2003-2007 and 2013-2017). Processing of specimens, culture and differentiation of recovered NTM isolates from <em>Mycobacterium tuberculosis</em> were done in-house according to standard procedures. Upon request, speciation and AMR testing were performed using molecular and broth dilution methods, respectively, at Mayo Medical Laboratories (Rochester, Minnesota, USA).</p> <p>Results: Among 108 NTM analyzed isolates, 8 species were revealed during the two periods: <em>M</em>. <em>simiae</em> (51%<em> vs </em>61%), <em>M</em>. <em>avium </em>complex (MAC) (6 % <em>vs</em> 12%) <em>M</em>. <em>fortuitum</em> (12% <em>vs</em> 5%), <em>M</em>. <em>gordonae</em> (6% <em>vs</em> 5%), <em>M</em>. <em>abscessus</em> (6% <em>vs </em>7%), <em>M</em>. <em>immunogenum</em> (12% <em>vs</em> 0%), <em>M</em>. <em>szulgai</em> (4% <em>vs</em> 0%) and <em>M</em>. <em>peregrinum</em> (0% <em>vs</em> 2%). <em>M</em>. <em>simiae</em> isolates showed high susceptibility (93%-96%) to amikacin and clarithromycin, but high resistance to rifampin, ethambutol, ciprofloxacin, rifabutin, linezolid, trimethoprim/sulfamethoxazole and moxifloxacin. MAC isolates were only susceptible to clarithromycin (86%). <em>M</em>. <em>abscessus</em> isolates were uniformly susceptible to amikacin (100%).</p> <p>Conclusion: The revelaed different NTM species, with predominance of <em>M.simiae </em>and various AMR profiles provide a current epidemiologic database and help guiding the selection of appropriate empirical therapy once the clinical relevance is established.</p> George F Araj, Omar Z Baba, Lina Y Itani, Aline Z Avedissian, Ghena M Sobh Copyright (c) 2019 George Farah Araj, Omar Z Baba, Lina Y Itani, Aline Z Avedissian, Ghena M Sobh http://creativecommons.org/licenses/by/4.0 https://jidc.org/index.php/journal/article/view/11028 Wed, 31 Jul 2019 00:00:00 -0700 Predominance of Central Asian strain (ST 26) in Mycobacterium tuberculosis isolates from Balochistan by spoligotyping https://jidc.org/index.php/journal/article/view/10803 <p>Introduction: Tuberculosis is a chronic debilitating infectious disease causing a severe challenge to public health, especially in developing countries. The aim of this study was to examine genetic diversity in <em>Mycobacterium tuberculosis</em> strains circulating in the Balochistan region of Pakistan.</p> <p>Methodology: One hundred isolates collected from patients visiting the Fatima Jinnah TB Hospital in Quetta were subjected to genotype analysis by spoligotyping.</p> <p>Results: Three main genotypes were identified: Central Asian Strain 1 (CAS1) (n = 89), East African Indian (EAI) strain (n = 7) and Latin American Mediterranean (LAM) strain (n = 3). The CAS1 clade (ST 26) had high genetic diversity represented by seven different spoligopatterns, of which one had major predominace (n = 75).</p> <p>Conclusions: This is the first insight into the genotype of <em>M. tuberculosis</em> strains in the Balochistan region that might serve as a base line study for control of tuberculosis in the community.</p> Muhammad Shafee, Ferhat Abbas, Zunera Tanveer, Andrew Whitelaw, Lemese Ah Tow, Muhammad Ashraf, Irshad Ahmad, Simon G Patching, Abdul Jabbar, Ali Akbar, Mohammad Zahid Mustafa Copyright (c) 2019 Muhammad Shafee, Ferhat Abbas, Andrew Whitelaw, Lemese Ah Tow, Muhammad Ashraf, Irshad Ahmad, Simon G. Patching, Abdul Jabbar, Ali Akbar, Mohammad Zahid Mustafa https://creativecommons.org/licenses/by/4.0 https://jidc.org/index.php/journal/article/view/10803 Wed, 31 Jul 2019 00:00:00 -0700 Biocide susceptibilities and biofilm-forming capacities of Acinetobacter baumannii clinical isolates from Malaysia https://jidc.org/index.php/journal/article/view/11455 <p>Introduction. <em>Acinetobacter baumannii </em>is a Gram-negative nosocomial pathogen that has the capacity to develop resistance to all classes of antimicrobial compounds. However, very little is known regarding its susceptibility to biocides (antiseptics and disinfectants) and capacity to form biofilms, particularly for Malaysian isolates.</p> <p>Aim. To determine the susceptibility of <em>A. baumannii </em>isolates to commonly-used biocides, investigate their biofilm-forming capacities and the prevalence of biocide resistance and biofilm-associated genes.</p> <p>Methodology. The minimum inhibitory concentration (MIC) values of 100 <em>A. baumannii</em> hospital isolates from Terengganu, Malaysia, towards the biocides benzalkonium chloride (BZK), benzethonium chloride (BZT) and chlorhexidine digluconate (CLX), were determined by broth microdilution. The isolates were also examined for their ability to form biofilms in 96-well microplates. The prevalence of biocide resistance genes <em>qacA</em>, <em>qacE</em> and <em>qac</em><em>D</em><em>E1</em> and the biofilm-associated genes <em>bap</em> and <em>abaI</em> were determined by polymerase chain reaction (PCR).</p> <p>Results. Majority of the <em>A. baumannii</em> isolates (43%) showed higher MIC values (&gt; 50 µg/mL) for CLX than for BZK (5% for MIC &gt; 50 µg/mL) and BZT (9% for MIC &gt; 50 µg/mL). The <em>qac</em><em>D</em><em>E1</em> gene was predominant (63%) followed by <em>qacE</em> (28%) whereas no isolate was found harbouring <em>qacA</em>. All isolates were positive for the <em>bap</em> and <em>abaI</em> genes although the biofilm-forming capacity varied among the isolates.</p> <p>Conclusion. The Terengganu <em>A. baumannii</em> isolates showed higher prevalence of <em>qac</em><em>D</em><em>E1</em> compared to <em>qacE</em> although no correlation was found with the biocides’ MIC values. No correlation was also observed between the isolates’ biofilm-forming capacity and the MIC values for the biocides.</p> Muhammad Harith Nor A'shimi, Ahmed Ghazi Alattraqchi, Farahiyah Mohd Rani, Nor Iza A Rahman, Salwani Ismail, Fatimah Haslina Abdullah, Norlela Othman, David W Cleary, Stuart C Clarke, Chew Chieng Yeo Copyright (c) 2019 Ahmed Ghazi Alattraqchi, Nor Iza A. Rahman, Salwani Ismail, Stuart C. Clarke, Chew Chieng Yeo https://creativecommons.org/licenses/by/4.0 https://jidc.org/index.php/journal/article/view/11455 Wed, 31 Jul 2019 00:00:00 -0700 The Antibiotic sensitivity of Stenotrophomonas maltophilia in a 5-year period and investigation of clonal outbreak with PFGE https://jidc.org/index.php/journal/article/view/11171 <p>Introduction:<em> Stenotrophomonas maltophilia, </em>which is able to form a biofilm, has mostly been related to catheters when it is the agent in hospital infections; these infections generally present as bacteremia and pneumonia, which may progress with complications and result in death.</p> <p>Methodology: The study included 153 <em>S. maltophilia</em> strains isolated from clinical samples sent to our hospital laboratory between 1 January 2014 and 30 June 2018. The bacteria were identified and their antibiotic sensitivity was determined using the VITEK-2 automated system. PFGE (Pulsed Field Gel Electrophoresis): The strains isolated from 34 patient clinical samples and from 1 patient bedcover were taken for PFGE examination.</p> <p>Results: The TMP/SXT and levofloxacin sensitivity of 153 <em>S. maltophilia</em> strains was examined. TMP/SXT resistance was determined to be 39% and levofloxacin resistance at 5%. Among 35 <em>S. maltophilia</em> strains, seven genotypes were identified using the PFGE method. While three strains showed a specific genotype profile, the other 32 were determined to consist of four clusters. The cluster rate was therefore 91.4% (32/35).</p> <p>Conclusions: There was a clonal relationship between the vast majority of the 35 <em>S. maltophilia</em> isolates, which suggests that there was a cross-contamination problem in the hospital. One strain (#4) was identified by dendrogram analysis showed a high rate of similarity to the other strains and was determined to be the common source of the cross-contamination.</p> Ahmet Çalışkan, Ayşegül Çopur Çicek, Nebahat Aydogan Ejder, Alper Karagöz, Özlem Kirişci, Selçuk Kılıç Copyright (c) 2019 AHMET ÇALIŞKAN, Ayşegül Çopur Çicek, Nebahat Aydogan Ejder, Alper Karagöz, Özlem Kirişci, Selçuk Kılıç https://creativecommons.org/licenses/by/4.0 https://jidc.org/index.php/journal/article/view/11171 Wed, 31 Jul 2019 00:00:00 -0700 A simple STAR Element Repetitive-PCR (SER-PCR) typing method for the rapid characterization of Staphylococcus aureus https://jidc.org/index.php/journal/article/view/11404 <p>Introduction: <em>Staphylococcus aureus</em> repeat (STAR) elements are abundant repeat sequences that are highly variable in numbers and locations within the genome of<em> S. aureus</em>. The evolutionary variation of these repeats occurs rapidly over time and may correlate with their evolutionary lineage. Therefore, the aim of this study is to analyze STAR elements to develop a simple PCR-based typing technique that can be used routinely in clinical laboratories.</p> <p>Methodology: The genomes of 10 reference strains of <em>S. aureus</em> were analyzed to identify the number and location of STAR elements. One pair of PCR primers was designed to target the variable region of these elements. The designed primers were first evaluated against 13 well-known reference strains of <em>S. aureus</em> and eventually evaluated against 40 well-characterized clinical isolates.</p> <p>Results: STAR element repetitive-PCR (SER-PCR) showed good typeability with acceptable discriminatory power against the reference and clinical strains. The new method clearly differentiated between community-associated methicillin-resistant <em>S. aureus</em> (CA-MRSA) and hospital-associated (HA-MRSA) strains. Phylogenetic analysis of the SER-PCR patterns and multilocus sequence typing (MLST) data showed good correlation between the two methods.</p> <p>Conclusions: This study provides a simple genotyping method for <em>S. aureus</em> based on the variation of the amplicon size of a single set of primers and rapidly extracted DNA. The method is rapid with acceptable discriminatory power and does not require a sophisticated apparatus or special expertise. The results suggest that SER-PCR could be routinely useful in any clinical microbiology laboratory, particularly in developing countries.</p> Ibrahim A Al-Zahrani Copyright (c) 2019 Ibrahim Ali Al-Zahrani http://creativecommons.org/licenses/by/4.0 https://jidc.org/index.php/journal/article/view/11404 Wed, 31 Jul 2019 00:00:00 -0700 A prospective pharmacovigilance study in the infectious diseases unit of a tertiary care hospital https://jidc.org/index.php/journal/article/view/11503 <p>Introduction: The frequency, causality, severity, preventability and risk factors of ADRs (adverse drug reactions) in infectious disease units are not well defined in the literature. Thus, the aim of this study was to determine the characteristics of the ADRs encountered in an infectious disease unit of a tertiary teaching hospital.</p> <p>Methodology: The patients who were admitted to the infectious disease unit of a tertiary teaching hospital longer than 24 hours between January and December of 2016 were followed prospectively. Patients were observed and questioned for any sign of ADRs. The proportion of ADRs and patient characteristics were investigated. Causality was evaluated by the Naranjo algorithm, severity was determined using the Hartwig classification, and preventability was assessed using the Schumock and Thornton scale.</p> <p>Results: 210 patients were admitted to the unit during the study period, of whom 44 patients (20.9%) experienced 51 ADRs. 5.9% of ADRs were found to be serious according to the Hartwig severity classification. In addition, 88.1% of ADRs were not preventable. The most frequently detected ADR was skin and subcutaneous tissue reactions (33.3%), and systemic antimicrobials were the most common type of drugs that caused an ADR. Prolonged hospitalization (p &lt; 0.001) and usage of an increased number of drugs (p &lt; 0.001) were found to be significant risk factors for ADR development.</p> <p>Conclusions: Prolonged hospital stay and polypharmacy are significant risk factors that increase the incidence of ADRs in infectious disease units. The likelihood of unavoidable ADRs should arouse the attention of clinicians when prescribing antimicrobials.</p> Berna Karaismailoglu, Nese Saltoglu, Ilker Inanc Balkan, Bilgul Mete, Fehmi Tabak, Recep Ozturk Copyright (c) 2019 Berna Karaismailoglu, Nese Saltoglu, Ilker Inanc Balkan, Bilgul Mete, Fehmi Tabak, Recep Ozturk http://creativecommons.org/licenses/by/4.0 https://jidc.org/index.php/journal/article/view/11503 Wed, 31 Jul 2019 00:00:00 -0700 Awareness, knowledge, and practice for hepatitis B infection in Southeast Asia: a cross-sectional study https://jidc.org/index.php/journal/article/view/10479 <p>Introduction: The prevalence of hepatitis B virus (HBV) infection in Southeast Asia is high. Awareness and early detection are essential for timely prevention and treatment.</p> <p>Methodology: We examined the awareness of, knowledge about, practices and views on treatment for HBV infection in Southeast Asia. A cross-sectional survey was conducted from December 2016 to February 2017 among individuals from six nations in Southeast Asia—Myanmar, Thailand, Vietnam, Cambodia, the Philippines, and Singapore. The study population comprised healthcare and non-healthcare personnel.</p> <p>Results: In total, 799 healthcare personnel and 1079 non-healthcare personnel completed an online survey. The prevalence of the awareness of their own HBV infection status and risk of this regionally endemic infection was 85.6% (684/799) among healthcare personnel and 54.0% (583/1079) among non-healthcare personnel. Similarly, 85.9% of healthcare personnel and 45.5% of non-healthcare personnel had good knowledge about disease transmission, complications, and the need for treatment, and 76.6% of healthcare personnel and 39.8% of non-healthcare personnel followed good HBV infection-prevention practices. Overall, 90.6% found the idea of treatment acceptable. Awareness had a significant impact on both knowledge and practice scores among both healthcare personnel and non-healthcare personnel (p &lt; 0.01) but without statistically significant differences in treatment acceptance between the two groups (p = 0.61).</p> <p>Conclusions: Awareness of HBV infection was relatively low among non-healthcare personnel in Southeast Asian populations. The provision of additional hepatitis B awareness campaigns is crucial to eliminating viral hepatitis in the region.</p> Kyi Pyar Soe, Wirichada Pan-ngum, Apichart Nontprasert, Chatporn Kittitrakul, Navuddh Oam, Vo Duy Thong, Pisit Tangkijvanich, Wattana Leowattana, Kittiyod Poovorawan Copyright (c) 2019 Kyi Pyar Soe, Wirichada Pan-ngum, Apichart Nontprasert, Chatporn Kittitrakul, Navuddh Oam, Vo Duy Thong, Pisit Tangkijvanich, Wattana Leowattana, Kittiyod Poovorawan http://creativecommons.org/licenses/by/4.0 https://jidc.org/index.php/journal/article/view/10479 Wed, 31 Jul 2019 00:00:00 -0700 Adenovirus 36 and its effect on vitamin D levels in obese and overweight patients https://jidc.org/index.php/journal/article/view/11285 <p>Introduction: The aim of this study was to investigate the prevalence of Adenovirus-36 (Ad-36) in overweight and obese patients and the effects of this virus on some metabolic parameters.</p> <p>Methodology: The study included 236 female patients with body mass index (BMI) ≥ 25. The patients were separated into 2 groups as overweight (BMI: 25-29.99) and obese (BMI ≥ 30). To quantitatively determine the antibody (Ab) specific to adenovirus type 36 in the serum samples, the enzyme-immunoassay (EIA) method was used (AdV36-Ab, ELISA Kit, MyBioSource). <em>Laboratory</em>parameters were compared between patients who are Ad-36 Ab positive and negative.</p> <p>Results: Of the total 236 patients, 82 (34.7%) were determined as Ad-36 positive and 154 (65.3%) were negative. Ad-36 Ab positivity was statistically significantly higher in the obese group (p = 0.018). The HOMA-IR index, triglyceride, total cholesterol, high-density lipoprotein, and low-density lipoprotein were found to be the same in both groups with no statistically significant differences(p &gt; 0.05). Vitamin D levels were significantly higher in BMI ≥ 30 Ad-36 Ab positive group than negative group (p &lt; 0.05).</p> <p>Conclusion: The frequency ofAd-36 Ab positivity was significantly higher in the obese group than in the overweight group. These results can be considered to shed a different perspective from previous reports in literature as only overweight and obese females were included. To the best of our knowledge, this study is the first to have shown that Ad-36 has the effect of elevating the Vitamin D levels.</p> Elçin Kal Çakmaklıoğulları, Nurhayat Özkan Sevencan Copyright (c) 2019 Elçin Kal Çakmaklıoğulları, Nurhayat Özkan Sevencan https://creativecommons.org/licenses/by/4.0 https://jidc.org/index.php/journal/article/view/11285 Wed, 31 Jul 2019 00:00:00 -0700