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.

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.

Risk Factors Associated with a Dengue Fever Outbreak in Islamabad, Pakistan: Case-Control Study.

BACKGROUND: On October 23, 2016, 79 dengue fever cases were reported from the Union Council Tarlai to Federal Disease Surveillance and Response Unit Islamabad. A team was established to investigate the suspected dengue outbreak. OBJECTIVE: The aim of this study was to determine the extent of the outbreak and identify the possible risk factors. METHODS: Active case finding was performed through a house-to-house survey. A case was defined as an acute onset of fever ≥38℃ in a resident of Tarlai from October 2 to November 11, 2016, with a positive dengue virus (nonstructural protein, NS-1) test and any of the two of following signs and symptoms: retroorbital/ocular pain, headache, rash, myalgia, arthralgia, and hemorrhagic manifestations. A structured questionnaire was used to collect data. Age- and sex-matched controls (1:1) were identified from residents in the same area as cases. Blood samples were taken and sent to the National Institute of Health for genotype identification. RESULTS: During the active case search, 145 cases of dengue fever were identified by surveying 928 houses from October 23 to November 11, 2016. The attack rate (AR) was 17.0/10,000. The mean age was 34.4 (SD 14.4) years. More than half of the cases were male (80/145, 55.2%). Among all cases, 29% belonged to the 25-34 years age group and the highest AR was found in the 35-44 years age group (35.6/10,000), followed by the 55-64 years age group (35.5/10,000). All five blood samples tested positive for NS-1 (genotype DENV-2). The most frequent presenting signs/symptoms were fever and headache (both 100%). Stagnant water around houses (odds ratio [OR] 4.86, 95% CI 2.94-8.01; P<.001), presence of flower pots in the home (OR 2.73, 95% CI 1.67-4.45; P<.001), and open water containers (OR 2.24, 95% CI 1.36-3.60; P<.001) showed higher odds among cases. Conversely, use of bed nets (OR 0.44, 95% CI 0.25-0.77; P=.003), insecticidal spray (OR 0.33, 95% CI 0.22-0.55; P<.001), door screens (OR 0.27, 95% CI 0.15-0.46; P<.001), mosquito coil/mat (OR 0.26, 95% CI 0.16-0.44; P<.001), and cleanliness of the house (OR 0.12, 95% CI 0.05-0.26; P<.001) showed significant protective effects. CONCLUSIONS: Stagnant water acting as breeding grounds for vectors was identified as the probable cause of spread of the dengue outbreak. Establishment of surveillance and an early reporting system along with use of protective measures against the vector are strongly recommended.

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.

Risk Factors of Extensively Drug Resistant Typhoid Fever Among Children in Karachi: Case-Control Study.

BACKGROUND: Extensively drug resistant typhoid fever (XDR-TF) has been responsible for an ongoing outbreak in Pakistan, which began in November 2016. OBJECTIVE: This study aimed to determine the risk factors associated with XDR-TF. METHODS: This age- and sex-matched case-control study was conducted during May-October 2018 in Karachi. All patients with XDR-TF were identified from the laboratory-based surveillance system data. Cases included patients aged <15 years living in Karachi with culture-positive Salmonella enterica serovar Typhi with resistance to chloramphenicol, ampicillin, trimethoprim/sulfamethoxazole, fluoroquinolones, and third-generation cephalosporins. Age- and sex-matched controls included children free from the symptoms of TF, aged under 15 years, and residing in Karachi. All controls were recruited from among those who attended outpatient clinics. RESULTS: A total of 75 cases and 75 controls were included in this study. On univariate analysis, the odds of having XDR-TF were 13-fold higher among participants who used piped municipal water than among those who did not (odds ratio [OR] 12.6, 95% CI 4.1-38.6). The use of bore water was significantly associated with XDR-TF (OR 5.1, 95% CI 1.4-19.0). Cases were more likely to report eating French fries with sauce (OR 13.5, 95% CI 3.9-47.0) and poppadum (OR 3.4, 95% CI 1.7-6.7) from street vendors than controls. Boiling water at home was negatively associated with XDR-TF (OR 0.3, 95% CI 0.2-0.7). On multivariate analysis, 2 factors were independently associated with XDR-TF. Using piped municipal water (OR 10.3, 95% CI 3.4-30.4) and eating French fries with sauce from street vendors (OR 8.8, 95% CI 2.1-36.2) were significantly associated with an increased odds of XDR-TF. CONCLUSIONS: Community water supply and street food eating habits were implicated in the spread of the superbug S typhi outbreak, which continues to grow in Karachi. Therefore, it is recommended to improve the community water supply to meet recommended standards and to develop a policy to improve the safety of street food. In addition, health authorities are required to conduct mass vaccination for TF among high-risk groups.

Rising HIV seroconversion rates & associated risks among employees of organization 'X': A case control study, Pakistan, 2017.

BACKGROUND AND OBJECTIVES: In 2004 Pakistan escalated from 'low-prevalence' to 'concentrated' phase of HIV epidemic. Despite global decline in HIV incidence since 1997, rate of HIV infections in Pakistan is persistently rising since 1990. Available literature focusses on key populations or localized outbreaks limited by short study duration and regional applicability of results. We studied HIV seroconversion trends over a period of 8 years in a geographically diverse population and evaluated associated risk factors. METHODS: A desk review of HIV surveillance data from 2010 to 2017 was carried out at Armed Forces Institute of Pathology. A case was defined as any adult employed in organization 'X', initially screened for HIV but later seroconverted on ELISA and western blot. Case-control study was conducted on cases diagnosed in 2017. Age and sex matched controls were identified from same population sub-group. Structured telephonic interviews were conducted and statistical analysis done at 5% margin of error. RESULTS: The annual HIV diagnosis rate remained relatively stable till 2015 (< 40 /100,000/yr) after which it rose sharply to 60/100,000/yr in 2016 .Upward trend continued in 2017 to reach 125/100,000/yr (>200% increase from baseline). Acquisition of HIV was significantly associated with commercial sex activities (OR=9; 95% CI: 1.25-395). CONCLUSION: HIV seroconversion rates among employees of organization X have increased significantly in the past two years. Unlike HIV outbreaks previously reported from Pakistan, sexual route seems to be the predominant mode of transmission. Focus is mandated on prevention of sexual transmission of HIV at national level as well for all vulnerable populations.

Knowledge, Awareness, and Health-Seeking Behaviour regarding Tuberculosis in a Rural District of Khyber Pakhtunkhwa, Pakistan.

BACKGROUND: Pakistan is a country with one of the highest burden of tuberculosis (TB) in the world, and therefore, it is imperative to revisit the design of behaviour change interventions in the program. This study was designed to understand and assess the knowledge, awareness, perceptions, and health-seeking behaviour of general and specifically TB-affected population and to determine the presence and level of stigma and discrimination toward TB patients. METHODS: A mixed-method study was conducted in district Haripur of the Khyber Pakhtunkhwa province, comprising a household survey, whereby 526 individuals were interviewed, and five focus group discussions with various subgroups including TB patients and health workers and authorities. Study sought an ethical approval, and data of all respondents was kept confidential. RESULTS: Quantitative results show that women were more knowledgeable on symptomatology and spread of TB, and with rising education, awareness on TB improves. The majority of our respondents had the understanding that it is a curable disease, yet some would avoid TB patients. Most of the respondents (both men and women) knew that one must go to a government facility for treatment. Only one-third would speak to doctor first, if they suspect TB-like symptoms. Television was a popular source of information on TB. Qualitative results captured people's perceptions that TB was related with poverty and was still considered a stigma in the community; hence, patients afflicted feared disclosing the disease. CONCLUSION: With contextual understanding of communities' knowledge, attitudes, health-seeking behaviour, and care-seeking patterns, it can be concluded that there is a need to increase the awareness about TB symptoms, mode of transmission, prevention, diagnosis and treatment, and destigmatization of the disease through health education.

The Role of the Global Health Development/Eastern Mediterranean Public Health Network and the Eastern Mediterranean Field Epidemiology Training Programs in Preparedness for COVID-19.

The World Health Organization (WHO) declared the current COVID-19 a public health emergency of international concern on January 30, 2020. Countries in the Eastern Mediterranean Region (EMR) have a high vulnerability and variable capacity to respond to outbreaks. Many of these countries addressed the need for increasing capacity in the areas of surveillance and rapid response to public health threats. Moreover, countries addressed the need for communication strategies that direct the public to actions for self- and community protection. This viewpoint article aims to highlight the contribution of the Global Health Development (GHD)/Eastern Mediterranean Public Health Network (EMPHNET) and the EMR's Field Epidemiology Training Program (FETPs) to prepare for and respond to the current COVID-19 threat. GHD/EMPHNET has the scientific expertise to contribute to elevating the level of country alert and preparedness in the EMR and to provide technical support through health promotion, training and training materials, guidelines, coordination, and communication. The FETPs are currently actively participating in surveillance and screening at the ports of entry, development of communication materials and guidelines, and sharing information to health professionals and the public. However, some countries remain ill-equipped, have poor diagnostic capacity, and are in need of further capacity development in response to public health threats. It is essential that GHD/EMPHNET and FETPs continue building the capacity to respond to COVID-19 and intensify support for preparedness and response to public health emergencies.

Fractional-Dose Inactivated Poliovirus Vaccine Campaign - Sindh Province, Pakistan, 2016.

Following the declaration of eradication of wild poliovirus (WPV) type 2 in September 2015, trivalent oral poliovirus vaccine (tOPV) was withdrawn globally to reduce the risk for type 2 vaccine-derived poliovirus (VDPV2) transmission; all countries implemented a synchronized switch to bivalent OPV (type 1 and 3) in April 2016 (1,2). Any isolation of VDPV2 after the switch is to be treated as a potential public health emergency and might indicate the need for supplementary immunization activities (3,4). On August 9, 2016, VDPV2 was isolated from a sewage sample taken from an environmental surveillance site in Hyderabad, Sindh province, Pakistan. Possible vaccination activities in response to VDPV2 isolation include the use of injectable inactivated polio vaccine (IPV), which poses no risk for vaccine-derived poliovirus transmission. Fractional-dose, intradermal IPV (fIPV), one fifth of the standard intramuscular dose, has been developed to more efficiently manage limited IPV supplies. fIPV has been shown in some studies to be noninferior to full-dose IPV (5,6) and was used successfully in response to a similar detection of a single VDPV2 isolate from sewage in India (7). Injectable fIPV was used for response activities in Hyderabad and three neighboring districts. This report describes the findings of an assessment of preparatory activities and subsequent implementation of the fIPV campaign. Despite achieving high coverage (>80%), several operational challenges were noted. The lessons learned from this campaign could help to guide the planning and implementation of future fIPV vaccination activities.

Disease surveillance system: a mandatory conduit for effective control of infectious diseases in Pakistan.

In Pakistan, absence of a nationwide surveillance mechanism and strategy is the main reason for the failure in effectively controlling communicable diseases. The seasonal outbreaks of various infectious diseases every year call for an integrated surveillance system on a national level for planning effective preventive strategies. Opportunity to adopt a tested and tried model exists at this time in terms of the "Disease Early Warning System" set up by World Health Organization in conflict-affected districts. Replicating this system in other districts is both practical and feasible as technical support is readily available through the World Health Organization. Such a system once put in place has potential to not only decrease morbidity and mortality through early detection and prompt control of outbreaks but also to facilitate effective financial, human resource, and materials management at the district level. This would be a step toward a more responsive health system at the local level.