Unsafe injection practices and injection drug use have been linked to multiple HIV outbreaks in Pakistan since 2003; however, few studies have systematically analyzed the causes of these outbreaks. ...We conducted a systematic review of published English-language literature indexed in bibliographic databases and search engines and a focused gray literature review to collate and analyze all reported HIV outbreaks in Pakistan during 2000–2019. Of 774 unique publications reviewed, we identified 25 eligible publications describing 7 outbreaks. More than half occurred during 2016–2019. The primary sources of transmission were iatrogenic transmission, affecting children, persons with chronic medical conditions, and the general population (4 outbreaks); injection drug use (2 outbreaks); and a combination of both (1 outbreak). In the absence of robust HIV testing and surveillance in Pakistan, timely and detailed outbreak reporting is important to understand the epidemiology of HIV in the country.
From April to June 2019, a total of 909 new HIV infections were identified in Larkana, Pakistan; 86% was children younger than 15 years. To identify the possible transmission links in this outbreak, ...a case-control study was conducted in June 2019.
For cases, we selected a systematic random sample of 100 HIV-positive children from the screening list. We chose 2 age-matched and sex-matched controls from the neighborhood of each HIV-positive case. All selected children were tested using the World Health Organization-approved rapid diagnosis test algorithm. We interviewed the parents of each selected child about previous exposures to parenteral treatment and compared exposures of case and control children using conditional logistic regression.
The ages of the selected children ranged from 1 month to 10 years. More than 90% of both HIV+ and HIV- children had received outpatient health care from MBBS-qualified private physicians. Eighty-three percent of HIV+ children versus 46% of HIV- children had received health care from one private physician adjusted odds ratio (aOR) = 29, 95% confidence interval (95% CI): 10 to 79. Intravenous infusions during the last outpatient visit were reported by 29% of case versus 7% of controls (aOR 57, 95% CI: 2.9 to >1000), whereas no case children and 17% of control children had received only intramuscular injections (aOR 0, 95% CI: 0 to 41). Among cases, 94% had been given infusions through a drip set compared with 85% of control children (aOR = 7.7, 95% CI: 2.3 to 26). Infusions had been administered with reused IV drip sets in 70% of cases compared with 8% of controls (aOR = 197, 95% CI: 16 to 2400).
Private physicians reusing intravenous drip sets to treat outpatients seen in private practice were responsible for this HIV epidemic. Mapping and regulation of private practitioners were suggested.
In recent years Pakistan has faced frequent measles outbreaks killing hundreds of children despite the availability of vaccine for decades. This study was undertaken to determine the persistence of ...maternal transferred measles antibody levels in infants before measles vaccination with relation to their feeding practices.
A cross sectional study was conducted at district Islamabad over 1 year between 1st October 2013 to 30th Sept. 2016. Any infant less than 9 months of age, not suffering from an acute or debilitating illness and not vaccinated was enrolled in the study. After taking written informed consent from parents / guardians, information was collected on a pretested questionnaire. About 3 cc venous blood was taken to quantify any measles IgG antibodies. Data was analyzed by using Epi Info 7.2 version.
Three hundred eighty-four infants were enrolled and were divided into three age groups, 1-90, 91-180 and 181-270 days age groups. Mean age of infants was 4.4 months ±3.2 SD. Male to female ratio was 1.2:1. A level of maternal measles IgG antibodies ≥12 U/ml was taken as protective. Of total 384 infants, 91(24%) had protective measles antibody titters (> 12 U/ml). and 65 (73%) of them were on breast milk. Highest antibody levels were found in 1-90 days age group. Analysis showed that 181-270 days aged infants had 3.1875 more odds of having unprotected/ low levels of antibodies against measles than children aged less than 180 days. Age group < 180 days found to be statistically significant with protective IgG levels (OR: 3.1875, P value: < 0.000063).
Measles protective antibodies were found in infants < 180 days age group. Breast feeding provides early protection against measles. Levels drop down to low levels immediately after birth and then after 06 months. It is, therefore, recommended that measles vaccination should be considered for administration at 6 months or even earlier if measles immunity is desired.
Hyderabad, Pakistan, was the first city to witness an outbreak of extensively drug resistant (XDR) typhoid fever. The outbreak strain is resistant to ampicillin, chloramphenicol, ...trimethoprim-sulfamethoxazole, fluoroquinolones, and third-generation cephalosporin, thus greatly limiting treatment options. However, despite over 5000 documented cases, information on mortality and morbidity has been limited.
To address the existing knowledge gap, this study aimed to assess the morbidity and mortality associated with XDR and non-XDR Salmonella serovar Typhi infections in Pakistan.
We reviewed the medical records of culture-confirmed typhoid cases in 5 hospitals in Hyderabad from October 1, 2016, to September 30, 2018. We recorded data on age, gender, onset of fever, physical examination, serological and microbiological test results, treatment before and during hospitalization, duration of hospitalization, complications, and deaths.
A total of 1452 culture-confirmed typhoid cases, including 947 (66%) XDR typhoid cases and 505 (34%) non-XDR typhoid cases, were identified. Overall, ≥1 complications were reported in 360 (38%) patients with XDR typhoid and 89 (18%) patients with non-XDR typhoid (P<.001). Ileal perforation was the most commonly reported complication in both patients with XDR typhoid (n=210, 23%) and patients with non-XDR typhoid (n=71, 14%) (P<.001). Overall, mortality was documented among 17 (1.8%) patients with XDR S Typhi infections and 3 (0.6%) patients with non-XDR S Typhi infections (P=.06).
As this first XDR typhoid outbreak continues to spread, the increased duration of illness before hospitalization and increased rate of complications have important implications for clinical care and medical costs and heighten the importance of prevention and control measures.
In humanitarian emergencies, traditional disease surveillance systems either do not exist to begin with or come under stress due to a huge influx of internal or external migrants. However, cramped ...camps with an unreliable supply of safe water and weak sanitation systems are the ideal setting for major disease outbreaks of all kinds. The Early Warning, Alert and Response Network (EWARN) has been supported by the WHO since the late 1990s to ensure health system capacity to identify and control risks early before they become major epidemics. These systems have been proven to be an excellent asset in reducing morbidity and mortality in humanitarian crises around the world. However, there is also a global challenge of transitioning them back to a regular or national monitoring system in their respective countries. This article is the result of in-country consultations arranged by the Eastern Mediterranean office of the World Health Organization. In these consultations, the unique local conditions and limitations of different countries were discussed to identify a way forward for transitioning these emergency disease surveillance systems into regular systems. After these discussions, different options were presented which could be further modified according to local needs. As there has not been any documented evidence of a successful transition of any emergency surveillance system, it is difficult to discuss or determine the gold standard for transition. As with any public health program being practiced in the field, local decision-making with some broad guidelines will be the best approach available. This article provides these guidelines and practical steps which could be further modified according to country needs.
Countries in the World Health Organization (WHO) Eastern Mediterranean Region (EMR) are predisposed to highly contagious, severe and fatal, emerging infectious diseases (EIDs), and re-emerging ...infectious diseases (RIDs). This paper reviews the epidemiological situation of EIDs and RIDs of global concern in the EMR between 2001 and 2018.
To do a narrative review, a complete list of studies in the field was we prepared following a systematic search approach. Studies that were purposively reviewed were identified to summarize the epidemiological situation of each targeted disease. A comprehensive search of all published studies on EIDs and RIDs between 2001 and 2018 was carried out through search engines including Medline, Web of Science, Scopus, Google Scholar, and ScienceDirect.
Leishmaniasis, hepatitis A virus (HAV) and hepatitis E virus (HEV) are reported from all countries in the region. Chikungunya, Crimean Congo hemorrhagic fever (CCHF), dengue fever, and H5N1 have been increasing in number, frequency, and expanding in their geographic distribution. Middle East respiratory syndrome (MERS), which was reported in this region in 2012 is still a public health concern. There are challenges to control cholera, diphtheria, leishmaniasis, measles, and poliomyelitis in some of the countries. Moreover, Alkhurma hemorrhagic fever (AHF), and Rift Valley fever (RVF) are limited to some countries in the region. Also, there is little information about the real situation of the plague, Q fever, and tularemia.
EIDs and RIDs are prevalent in most countries in the region and could further spread within the region. It is crucial to improve regional capacities and capabilities in preventing and responding to disease outbreaks with adequate resources and expertise.
ABSTRACT Objective: An outbreak investigation team was deputed to assess the magnitude of disease, to evaluate risk factors and recommend control measures. Study Design: Case control study. Place and ...Duration of Study: Boy’s Training Center Karachi, from 4th Apr to 28th Apr 2017. Material and Methods: On 30th March 2017, 30 suspected cases of acute viral hepatitis were reported. Active case search carried out and hospitals record reviewed. Age and gender matched controls (1:1) taken. Case definition was “Sudden onset of jaundice PLUS presence of Hepatitis E IgM on ELISA in a resident of Boys vocational training center from 9th March to 12th May 2017”. Total 79 blood samples collected for hepatitis screening and 5 water samples collected for microbiological/physiochemical testing. Descriptive analysis was carried out, frequencies/ attack rates were determined and odds ratios were calculated at 95% confidence interval and p<0.05. Results: Total 79 cases were identified (49 active search). All male with mean age of 22 ± 4.6 years. Overall attack rate was 9% and most affected age-group was 20-29 years (AR: 11%). Significant risk factors were consumption of raw vegetables (OR: 5.39, 95% CI: 2.37-12.25) and use of tap water (OR: 2.28, 95%CI: 1.14-4.58). While hand washing (OR: 0.37, 95% I: 0.18-0.81) and use of filtered water (OR: 0.008, 95% CI: 0.002-0.029) found protective. Total 76 (96.2%) blood samples were positive for Hepatitis E IgM while 4 (80%) water samples had coliform organisms. Environmental assessment revealed rusty and broken water pipelines running parallel to sewage line. No water decontamination and overcrowding in living areas observed. Conclusion: Cross contamination between water and sewage lines was probable source of outbreak. It was recommended to replaced old pipelines, filter/decontaminate drinking water and more rooms should be constructed to avoid overcrowding.
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