A pediatric HIV outbreak in Pakistan.

Background: Following reports of an outbreak of HIV infection among children in Larkana District, Pakistan, an international team investigated the extent and cause of the outbreak between April and June 2019. Aims: To investigate the incidence of HIV among children in Larkana District, Pakistan and describe the distribution of cases by time, place and person. Methods: Self-referred persons were tested for HIV using the national testing protocol. Local epidemiology of HIV was reviewed to generate hypotheses. An infection prevention and control (IPC) team conducted site visits and reviewed IPC practices. Results: Between 25 April and 27 June 2019, a total of 30 191 persons were tested for HIV in Larkana District, and 876 of them tested positive. Of those who tested positive, 719 (82%) were children aged <15 years. Traditional skin piercing procedures and transmission from high-risk populations to children were ruled out during the investigation. Informative interviews with parents or guardians of a convenience sample of 211 children aged <15 years showed that 99% of children had an injection or infusion for medical treatment within the past 12 months. Our investigation identified lack of HIV prevalence data for the general population including tuberculosis patients and those who attended antenatal care services. Conclusions: Investigations indicate that unsafe healthcare practices in formal and informal healthcare settings as the most likely cause of the 2019 outbreak of HIV infection in Larkana, Pakistan. Measures should be taken to improve IPC practices at the facility level, especially in pediatric and antenatal care clinics.

A systematic review on the bioremediation of metal contaminated soils using biochar and slag: current status and future outlook.

Heavy metals contaminated soils are posing severe threats to food safety worldwide. Heavy metals absorbed by plant roots from contaminated soils lead to severe plant development issues and a reduction in crop yield and growth. The global population is growing, and the demand for food is increasing. Therefore, it is critical to identify soil remediation strategies that are efficient, economical, and environment friendly. The use of biochar and slag as passivators represents a promising approach among various physicochemical and biological strategies due to their efficiency, cost-effectiveness, and low environmental impact. These passivators employ diverse mechanisms to reduce the bioavailability of metals in contaminated soils, thereby improving crop growth and productivity. Although studies have shown the effectiveness of different passivators, further research is needed globally as this field is still in its early stages. This review sheds light on the innovative utilization of biochar and slag as sustainable strategies for heavy metal remediation, emphasizing their novelty and potential for practical applications. Based on the findings, research gaps have been identified and future research directions proposed to enable the full potential of passivators to be utilized effectively and efficiently under controlled and field conditions.

Aquaculture sediments amended with biochar improved soil health and plant growth in a degraded soil.

Sustainable and safe management of aquaculture sediments is of great concern. Biochar (BC) and fishpond sediments (FPS) are rich in organic carbon and nutrients and thus can be used as soil amendments; however, it is not fully explored how the biochar amended fishpond sediments can affect soil properties/fertility and modulate plant physiological and biochemical changes, particularly under contamination stress. Therefore, a comprehensive investigation was carried out to explore the effects of FPS and BC-treated FPS (BFPS) on soil and on spinach (Spinacia oleracea L.) grown in chromium (Cr) contaminated soils. Addition of FPS and BFPS to soil caused an increase in nutrients content and reduced Cr levels in soil, which consequently resulted in a significant increase in plant biomass, chlorophyll pigments, and photosynthesis, over the control treatment. The most beneficial effect was observed with the BFPS applied at 35 %, which further increased the antioxidant enzymes (by 2.75-fold, at minimum), soluble sugars by 24.9 %, and upregulated the gene expression activities. However, the same treatment significantly decreased proline content by 74.9 %, Malondialdehyde by 65.6 %, H2O2 by 65.1 %, and Cr concentration in spinach root and shoot tissues. Moreover, the average daily intake analysis showed that BFPS (at 35 %) could effectively reduce human health risks associated with Cr consumption of leafy vegetables. In conclusion, these findings are necessary to provide guidelines for the reutilization of aquaculture sediments as an organic fertilizer and a soil amendment for polluted soils. However, more future field studies are necessary to provide guidelines and codes on aquaculture sediments reutilization as organic fertilizer and soil amendment for polluted soils, aiming for a more sustainable food system in China and globally, with extended benefits to the ecosystem and human.

Adsorption of Pb(II) from wastewater using a red mud modified rice-straw biochar: Influencing factors and reusability.

Efficient environmental remediation of toxic chemicals using effective sorbents has received considerable attention recently. For the present study, the synthesis of a red mud/biochar (RM/BC) composite was performed from rice straw with the aim of achieving Pb(II) removal from wastewater. Characterization was performed by using X-ray diffraction (XRD), Fourier transform infrared spectroscopy (FTIR), energy dispersive spectroscopy (EDS), Zeta potential analysis, elemental mapping, scanning electron microscopy (SEM), and transmission electron microscopy (TEM). Results showed that RM/BC had higher specific surface area (SBET = 75.37 m2 g-1) than raw biochar (SBET = 35.38 m2 g-1). The Pb(II) removal capacity (qe) of RM/BC was 426.84 mg g-1 at pH 5.0, and the adsorption data well fitted pseudo second order kinetics (R2 = 0.93 and R2 = 0.98), as well as the Langmuir isotherm model (R2 = 0.97 and R2 = 0.98) for both BC and RM/BC. Pb(II) removal was slightly hindered with the increasing strength of co-existing cations (Na+, Cu2+, Fe3+, Ni2+, Cd2+). The increase in temperatures (298 K, 308 K, 318 K) favored Pb(II) removal by RM/BC. Thermodynamic study indicated that Pb(II) adsorption onto BC and RM/BC was spontaneous and primarily governed by chemisorption and surface complexation. A regeneration study revealed the high reusability (>90%) and acceptable stability of RM/BC even after five successive cycles. These findings indicate that RM/BC evidenced special combined characteristics of red mud and biochar, hence its use for Pb removal from wastewater offers a green and environmentally sustainable approach fitting the "waste treating waste" concept.

The Adsorption Potential of Cr from Water by ZnO Nanoparticles Synthesized by Azolla pinnata.

Aqueous solutions containing toxic elements (TEs) (such as hexavalent chromium (Cr (VI)) can be toxic to humans even at trace levels. Thus, removing TEs from the aqueous environment is essential for the protection of biodiversity, hydrosphere ecosystems, and humans. For plant fabrication of zinc oxide nanoparticles (PF-ZnONPs), Azolla pinnata plants were used, and X-ray diffraction (XRD), energy dispersive spectroscopy (EDS), SEM, and FTIR techniques were used for the identification of PF-ZnONPs and ZnONPs, which were used to remove Cr (VI) from aqueous solution. A number of adsorption parameters were studied, including pH, dose, concentration of metal ions, and contact time. The removal efficiency of PF-ZnONPs for Cr (VI) has been found to be 96% at a time (60 min), 69.02% at pH 4, and 70.43% at a dose (10 mg·L-1). It was found that the pseudo-second-order model best described the adsorption of Cr (VI) onto PF-ZnONPs, indicating a fast initial adsorption via diffusion. The experimental data were also highly consistent with the Langmuir isotherm model calculations.

Zinc oxide nanoparticles improved chlorophyll contents, physical parameters, and wheat yield under salt stress.

Nanotechnology has a wide range of applications. Nanotechnology refers to the particle in nanoscale used to improve agricultural productivity and to encounter the unsolved problems conventionally. Nanostructured formulation through mechanisms, such as targeted delivery or slow/controlled release mechanisms as well as conditional release, could release their active ingredients in response to the environmental conditions and biological demands more precisely. Nanotechnology has a great potential for achieving sustainable agriculture, especially in developing countries. Salinity is among the major abiotic stresses which limits the yield and quality of global crops. Zinc (Zn) is a vital micronutrient that is mandatory for the ideal growth of plants and has proved to reduce the hazardous effects of salt stress. To counter the salinity problem, a pot experiment was conducted at wire house of the Institute of Soil and Environmental Sciences (ISES), University of Agriculture, Faisalabad, Pakistan, to observe the effects of zinc oxide (ZnO) nanoparticles (NPs) on wheat variety "Gemmieza" imported from Egypt under salt stress. Notably, 10 dS m-1 salinity was developed artificially, and different doses of Zn conventional fertilizer and ZnO NPs were applied to potted wheat. ZnO NPs (0.12 g pot-1) significantly increased the physical parameters of wheat compared to control under salt stress. Application of ZnO NPs (0.12 g pot-1) significantly increased chlorophyll A and B contents by 24.6 and 10%, plant height at vegetative and maturity stages by 34.6 and 37.4%, shoot and spike lengths by 30.7 and 27.6%, root fresh and dry weights by 74.5 and 63.1%, and wheat grain yield by 42.2%, respectively. ZnO NPs performed better compared to Zn conventional fertilizer under salt stress and could be used in place of Zn conventional fertilizer in salt-affected soils for attaining better crop production.

Could Emergency Diseases Surveillance Systems Be Transitioned to Routine Surveillance Systems? A Proposed Transition Strategy for Early Warning, Alert, and Response Network.

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.

Risk Factors of Dengue Fever in Urban Areas of Rawalpindi District in Pakistan During 2017: A Case Control Study.

BACKGROUND: During August 2017, increased numbers of suspected dengue fever cases were reported in the hospitals of Rawalpindi district. A case control study was conducted to determine the risk factors among urban areas, dengue serotype, and recommend preventive measures. OBJECTIVE: The objective of the investigation was to determine the risk factors among urban areas, dengue serotype, and recommend preventive measures. METHODS: A case was defined as having acute febrile illness with one or more of the following symptoms: retro-orbital pain, headache, rash, myalgia, arthralgia, and hemorrhage. The cases were residents of Rawalpindi and were confirmed for dengue fever from August 30, 2017, to October 30, 2017. All NS1 confirmed cases from urban areas of Rawalpindi were recruited from tertiary care hospitals. Age- and sex-matched controls were selected from the same community with a 1:1 ratio. Frequency, univariate, and multivariate analyses were performed at 95% CI with P<.05 considered statistically significant. RESULTS: Totally 373 cases were recruited. The mean age was 36 (SD 2.9) years (range 10-69 years), and 280 cases (75%) were male. The most affected age group was 21-30 years (n=151, attack rate [AR] 40%), followed by 31-40 years (n=66, AR 23%). Further, 2 deaths were reported (case fatality rate of 0.53%). The most frequent signs or symptoms were fever (n=373, 100%), myalgia and headache (n=320, 86%), and retro-orbital pain (n=272, 73%). Serotype identification was carried out in 322 cases, and DEN-2 was the dominant serotype (n=126, 34%). Contact with a confirmed dengue case (odds ratio [OR] 4.27; 95% CI 3.14-5.81; P<.001), stored water in open containers at home (OR 2.04; 95% CI 1.53-2.73; P<.001), and travel to a dengue outbreak area (OR 2.88; 95% CI 2.12-3.92; P<.001) were the main reasons for the outbreak, whereas use of mosquito repellents (OR 0.12; 95% CI 0.09-0.18; P<.001) and regular water supply at home (OR 0.03; 95% CI 0.02-0.04; P<.001) showed protective effects. The geographical distribution of cases was limited to densely populated areas and all the 5 randomly collected water samples tested positive for dengue larvae. CONCLUSIONS: Stored water in containers inside houses and subsequent mosquito breeding were the most probable causes of this outbreak. Based on the study findings, undertaking activities to improve the use of mosquito repellents and removing sources of breeding (uncovered water stored indoors) are some recommendations for preventing dengue outbreaks.

Emerging and Re-emerging Infectious Diseases in the WHO Eastern Mediterranean Region, 2001-2018.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

An Epidemic of Pediatric HIV From Reuse of Infusion Equipment in Pakistan.

BACKGROUND: 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. METHODS: 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. RESULTS: 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). DISCUSSION: 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.

Morbidity and Mortality Associated with Typhoid Fever Among Hospitalized Patients in Hyderabad District, Pakistan, 2017-2018: Retrospective Record Review.

BACKGROUND: 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. OBJECTIVE: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.

Outbreak investigation of Candida auris at a tertiary care hospital in Karachi, Pakistan.

BACKGROUND: From September 2014, a tertiary care hospital in Karachi, Pakistan, started diagnosing 3-5 cases/month of a yeast locally identified as Saccharomyces spp. resistant to fluconazole. US Centers for Disease Control and Prevention identified the isolates as Candida auris. The Pakistan Field Epidemiology and Laboratory Training Program (FELTP) and the hospital investigated the outbreak from April 2015 to January 2016. OBJECTIVE: The aim of the outbreak investigation was to determine the risk factors and to inform measures to limit the spread of the organism in the hospital. METHODS: Medical records, nursing schedules and infection control practices were reviewed. Sixty-two age- and sex-matched hospital controls from the same wards were identified. RESULTS: Thirty cases (17 males) were identified (mean age = 51.6 years, age range = 2-91 years), case fatality was 53%. Multivariate logistic regression showed that a history of surgery within 90 days of diagnosis, admission to the emergency department and history of chronic kidney disease were significantly associated with C. auris infection. DISCUSSION: This is the report of the outbreak investigation that triggered a global exploration of C. auris as a newly identified multidrug-resistant nosocomial organism, spreading within the hospital, especially among patients with invasive procedures. Unfortunately, we could not identify any specific source of the outbreak nor stop the transmission of the organism.

Seroprevalence of Transplacentally acquired Measles antibodies in unvaccinated infants at nine months of age and its relation to the feeding practices.

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.

Comparative efficiency of wheat straw and sugarcane bagasse biochar reduces the cadmium bioavailability to spinach and enhances the microbial activity in contaminated soil.

Biochar is considered a novel soil amendment for cadmium (Cd) stabilization in contaminated soils. A pot experiment was conducted to examine the efficiency of wheat straw and sugarcane bagasse induced biochar on Cd mobility in soil and its bioavailability to spinach in contaminated soil. Soil pH, Cd contents in plant tissues and microbial biomass were examined. Results showed that Cd was significantly decreased by 30.95% and 20.83% with wheat straw and sugarcane bagasse biochar at 2% application rate respectively, relative to the control. Similarly, Cd contents were decreased in plants shoots by 15.41 and 14.33%, while in roots by 48.3 and 35.54%, when wheat straw and sugarcane biochar were added at 2% application rate respectively. Moreover, soil microbial biomass was significantly increased with the application of all biochar types and their applications rates. Finally, wheat straw biochar at 2% application rate can be considered as an effective approach for Cd stabilization in contaminated soils.