Age and gender differences in the prevalence of chronic diseases and atherosclerotic cardiovascular disease risk scores in adults in Riyadh city, Saudi Arabia.

OBJECTIVES: To evaluate age and gender differences in the prevalence of chronic diseases and to calculate atherosclerotic cardiovascular disease (ASCVD) risk scores in adults aged 30-75 years in Riyadh city, Saudi Arabia. METHODS: This cross-sectional, interview-based study was conducted with 2997 men and women, visiting primary health care centers in Riyadh, during the years 2015 to 2016. Serum glycosylated hemoglobin and lipid levels were measured by ion-exchange high-performance liquid chromatography and fully automated analyzer using enzymatic methods, respectively. The 10-year and lifetime ASCVD risk scores were calculated using an online calculator. RESULTS: The mean age of men was 43.1 (±11.7) and women was 43.8 (± 10.9) years. Prevalence rates of diabetes mellitus, hypertension, hypercholesterolemia, and obesity in men versus women were 20.3% versus 24.8% (p=0.006), 15% versus 19.5% (p=0.003), 50.7% versus 53.4% (p=0.16), and 41.2% versus 56.7% (p<0.001), respectively. Majority of men and women with chronic diseases belonged to the age groups 30-39 and 50-59 years, respectively. High 10-year ASCVD risk was found in 32% men and 7.6% women, whereas lifetime risk was present in 67% and 51%, respectively. CONCLUSION: Women in the age group 50-59 years, with multiple risk factors are at a greater risk of developing cardiovascular diseases than men of same age. Young adults were at more risk for lifetime ASCVD, whereas the 10-year ASCVD risk increased with increasing age.

Investigation of an extensive outbreak of HIV infection among children in Sindh, Pakistan: protocol for a matched case-control study.

INTRODUCTION: In April 2019, 14 children were diagnosed with HIV infection by a private healthcare provider in Larkana district, Sindh province, Pakistan. Over the next 3 months, 930 individuals were diagnosed with HIV, >80% below 16 years, the largest ever outbreak of HIV in children in Pakistan. In this protocol paper, we describe research methods for assessing likely modes of HIV transmission in this outbreak and investigate spatial and molecular epidemiology. METHODS AND ANALYSIS: A matched case-control study will be conducted with 406 cases recruited. Cases will be children aged below 16 years registered for care at the HIV treatment centre at Shaikh Zayed Children Hospital in Larkana City. Controls will be children who are HIV-uninfected (confirmed by a rapid HIV test) matched 1:1 by age (within 1 year), sex and neighbourhood. Following written informed consent from the guardian, a structured questionnaire will be administered to collect data on sociodemographic indices and exposure to risk factors for parenteral, vertical and sexual (only among those aged above 10 years) HIV transmission. A blood sample will be collected for hepatitis B and C serology (cases and controls) and HIV lineage studies (cases only). Mothers of participants will be tested for HIV to investigate the possibility of mother-to-child transmission. Conditional logistic regression will be used to investigate the association of a priori defined risk factors with HIV infection. Phylogenetic analyses will be conducted. Global positioning system coordinates of participants' addresses will be collected to investigate concordance between the genetic and spatial epidemiology. ETHICS AND DISSEMINATION: Ethical approval was granted by the Ethics Review Committee of the Aga Khan University, Karachi. Study results will be shared with Sindh and National AIDS Control Programs, relevant governmental and non-governmental organisations, presented at national and international research conferences and published in international peer-reviewed scientific journals.

Correction: Incidence and contributing factors of glucose intolerance in Saudi postpartum women: Sub-group analysis from RAHMA study.

[This corrects the article DOI: 10.1371/journal.pone.0210024.].

Incidence and contributing factors of glucose intolerance in Saudi postpartum women: Sub-group analysis from RAHMA study.

OBJECTIVES: The objectives of this study were to determine incidence and risk factors of glucose intolerance one year after delivery in a sub-cohort of Riyadh Mother and Baby Cohort Study (RAHMA) study. METHODS: This is a follow-up study of a sub-cohort from RAHMA study from King Khalid University Hospital (KKUH). All women from RAHMA database who completed one year since delivery at KKUH were contacted by phone to participate in the study. Previously collected data from RAHMA registry for each participant were linked to this study data. Clinical data measured for each participant included current weight and height to calculate the BMI and waist circumference. Blood tests done for each participant were fasting blood glucose (FPG) and HbA1c. Based on the blood tests results, participants were classified into three groups; diabetic, pre-diabetic and normal. The incidence of diabetes and prediabetes was calculated for the whole cohort. Clinical, biochemical, and sociodemographic predictors of glucose intolerance were compared between the three groups. Risk factors with P-value less than 0.05 were tested in multivariate regression model with bootstrapping to calculate the relative risk (RR) and its 95% Bias corrected Confidence Interval (C.I.). RESULTS: From the sub-cohort, 407 women fulfilled the inclusion criteria and agreed to participate in the study. From the study participants; 250 (61.4%) women were normoglycemic, 142 (35%) women had prediabetes and 15 (3.6%) women were diabetic. Following multivariable regression analysis only history of gestational diabetes mellitus (GDM), (RR 1.74, 95% CI (1.06 to 2.84), P = 0.01), obesity (RR 1.69, 95% CI (1.01-3.11), P = 0.04) and diastolic blood pressure, (RR 1.04, 95% CI (1.01-1.09), P = 0.03) remained as predictors of postpartum glucose intolerance. CONCLUSION: The incidence of postpartum glucose intolerance (diabetes and prediabetes) is very high in Saudi women. Both GDM and obesity are strong predictors of glucose intolerance.

Sociodemographic factors associated with IgG and IgM seroprevalence for human cytomegalovirus infection in adult populations of Pakistan: a seroprevalence survey.

BACKGROUND: The seroprevalence of human cytomegalovirus (HCMV) infection ranges from 30 to 90 % in developed countries. Reliable estimates of HCMV seroprevalence are not available for Pakistan. This study determined the seroprevalence and sociodemographic factors associated with HCMV infection in adult populations of Karachi, Pakistan. METHODS: A seroprevalence survey was conducted on 1000 adults, including residents of two semi-urban communities, and visitors to a government and a private hospital. Questionnaire-based interviews were conducted. Sera were analysed for HCMV-specific IgG and IgM. Chi-square or Fisher's exact test was used for comparing sociodemographic variables against seropositivity of HCMV-IgG or IgM. Multiple logistic regression modeling was performed for IgG seroprevalence and adjusted odds ratios were computed. RESULTS: The seroprevalence of HCMV-IgG and IgM was 93.2 and 4.3 % respectively. 95.3 % of individuals who were IgM seropositive were also seropositive for IgG. Around 6 % (15/250) of women of childbearing age remained uninfected and were therefore susceptible to primary infection. HCMV-IgG seroprevalence was associated with being female (p = 0.001), increasing age (p = 0.002) and crowding index (p = 0.003) and also with lower levels of both education (p < 0.001) and income (p = 0.008). Seroprevalence also differed significantly by marital status (p = 0.008) and sampling location (p < 0.001). A logistic regression model for HCMV-IgG seroprevalence showed associations with being female (OR = 1.89; 95 % CI: 1.10-3.25), increasing age (OR = 3.95; 95 % CI: 1.79-8.71) and decreasing income (OR = 0.72; 95 % CI: 0.54-0.96). A strong association was observed between increased seroprevalence of HCMV-IgM and decreasing household size (p = 0.008). CONCLUSIONS: Seroprevalence of HCMV is very high in Pakistan, although 6 % of women of childbearing age remain at risk of primary infection. The IgM seropositivity observed in some individuals living in small household size (1-3 individuals) with persistent HCMV infection could have resulted from a recurrent HCMV infection. Future longitudinal research in pregnant women and neonates is required to study the trends in HCMV seroprevalence over time in Pakistan for the development of a potential HCMV prevention and vaccination programme.

The role of rapid testing and clinical decision in the diagnosis of human influenza A H1N1 infection.

OBJECTIVE: To evaluate the role of the rapid influenza diagnostic test (RIDT) and clinical decision in the diagnosis of H1N1. METHODS: In November 2009, 290 suspected influenza patients were examined for H1N1 during an outbreak in Riyadh, Saudi Arabia. Nasopharyngeal swabs were analyzed using Directigen EZ Flu A+B kit. Monoclonal anti-human influenza A/B and reverse transcription- polymerase chain reaction (RT-PCR) were used. Positive and negative controls were used in each run of specimens. Validity indices were calculated for RIDT and clinical diagnostic criteria. RESULTS: The sensitivity and specificity of RIDT were 40.5% (95% confidence interval [CI]: 33.0-48.5), and 94.5% (95% CI: 88.6-97.6). The sensitivity of clinical decision was 66.3% (95% CI: 58.4-73.4), and the specificity was 65.4% (95% CI: 56.3-73.4). The sensitivity of clinical decision was higher in early presenters (79.2%; 95% CI: 57.3-92.1). The RIDT sensitivity was higher in younger patients (48.4%; 95% CI: 35.7-61.3). The positive predictive value (PPV) was 90.4% (95% CI: 80.7-95.7) for RIDT, and 71.1% (95% CI: 63.1-78.0) for clinical decision. The PPV for RIDT was greater for older (94.7%; 95% CI: 80.9-99.1) and late (90.7%; 95% CI: 76.9-97.0) presenters. The adjusted odds ratio for clinical decision was significant for cough, headache, and fatigue. CONCLUSION: The RIDT can be useful in epidemics and high prevalence areas, whereas clinical decision, and RT-PCR complement the diagnosis of H1N1 in any setting.

Socio-demographic determinants of antibiotic misuse in children. A survey from the central region of Saudi Arabia.

OBJECTIVE: To investigate knowledge, beliefs, and practices associated with parental antibiotic misuse. METHODS: This cross-sectional study included parents visiting 4 malls in Riyadh, Saudi Arabia. The study took place at the College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia between June and December 2010. Self-prescription of antibiotic for a child in the past year was defined as antibiotic misuse. RESULTS: From 610 parents (60.5% mothers and 39.5% fathers), 11.6% reported self-prescription. Responding parents differed by age, education, number of children, and profession. Overall, parents responded that antibiotics are required in children with runny nose or cough or sore throat or fever (50%); to reduce symptom severity and duration (57.7%), are effective against viruses (68.6%), can be stopped on clinical improvement (28.7%), and it used by another family member can be used in children (20.1%). Determinants of misuse in a multivariable model were income, number of children, type of infection treated last year, knowledge of illness requiring antibiotic or being unsure, using antibiotics used by an other family member in children, unsure of such use, and adjusting for the type of responding parent. CONCLUSION: Parents with low income, more than 2 children, lack of knowledge, inappropriate beliefs and practices are vulnerable for misusing antibiotics in children.

Population attributable risk of unintentional childhood poisoning in Karachi Pakistan.

BACKGROUND: The percentage of unintentional childhood poisoning cases in a given population attributable to specific risk factors (i.e., the population attributable risk) which can be calculated; determination of such risk factors associated with potentially modifiable risk factors, are necessary to focus on the prevention strategies. METHODS: We calculated PARs, using 120 cases with unintentional poisoning and 360 controls in a hospital based matched case- control study. The risk factors were accessibility to hazardous chemicals and medicines due to unsafe storage, child behavior reported as hyperactive, storage of kerosene and petroleum in soft drink bottles, low socioeconomic class, less education of the mother and the history of previous poisoning. RESULTS: THE FOLLOWING ATTRIBUTED RISKS WERE OBSERVED: 12% (95% confidence interval [CI] = 8%-16%) for both chemicals and medicines stored unsafe, 19% (15%-23%) for child reported as hyperactive, 40% (38%-42%) for storage of kerosene and petroleum in soft drink bottles, 48% (42%-54%) for low socioeconomic status, 38% (32%-42%) for no formal mothers education and 5.8% (2%-10%) for history of previous poisoning. 48% of cases for overall study population which could be attributed to at least one of the six risk factors. Among girls, this proportion was 23% and 43% among boys. About half of the unintentional childhood poisoning cases in this Pakistani population could be avoided. CONCLUSION: Exposure to potentially modifiable risk indicators explained about half of the cases of unintentional poisoning among children under five years of age in this Pakistani population, indicating the theoretical scope for prevention of the disease.

Does improving maternal knowledge of vaccines impact infant immunization rates? A community-based randomized-controlled trial in Karachi, Pakistan.

BACKGROUND: In Pakistan, only 59-73% of children 12-23 months of age are fully immunized. This randomized, controlled trial was conducted to assess the impact of a low-literacy immunization promotion educational intervention for mothers living in low-income communities of Karachi on infant immunization completion rates. METHODS: Three hundred and sixty-six mother-infant pairs, with infants aged ≤ 6 weeks, were enrolled and randomized into either the intervention or control arm between August - November 2008. The intervention, administered by trained community health workers, consisted of three targeted pictorial messages regarding vaccines. The control group received general health promotion messages based on Pakistan's Lady Health Worker program curriculum. Assessment of DPT/Hepatitis B vaccine completion (3 doses) was conducted 4-months after enrollment. A Poisson regression model was used to estimate effect of the intervention. The multivariable Poisson regression model included maternal education, paternal occupation, ownership of home, cooking fuel used at home, place of residence, the child's immunization status at enrollment, and mother's perception about the impact of immunization on child's health. RESULTS: Baseline characteristics among the two groups were similar. At 4 month assessment, among 179 mother-infant pairs in the intervention group, 129 (72.1%) had received all 3 doses of DPT/Hepatitis B vaccine, whereas in the control group 92/178 (51.7%) had received all 3 doses. Multivariable analysis revealed a significant improvement of 39% (adjusted RR = 1.39; 95% CI: 1.06-1.81) in DPT-3/Hepatitis B completion rates in the intervention group. CONCLUSION: A simple educational intervention designed for low-literate populations, improved DPT-3/Hepatitis B vaccine completion rates by 39%. These findings have important implications for improving routine immunization rates in Pakistan.

Predictors of unintentional poisoning among children under 5 years of age in Karachi: a matched case-control study.

OBJECTIVE: Poisoning is the fourth leading cause of unintentional injury and a common paediatric emergency in children under 5 years of age. The objective of this study was to determine the factors associated with unintentional poisoning among children under 5 years of age presenting to emergency rooms at tertiary care hospitals in Karachi, Pakistan. SETTING: Children were recruited from the emergency rooms of the three biggest tertiary care hospitals in Karachi. DESIGN: A matched case-control study was conducted on 120 cases and 360 controls, with matching done on gender and age. Parents were interviewed using a structured questionnaire containing information on sociodemographic factors, the child's behaviour, and the storage practices of hazardous substances of caregivers in the homes. Conditional logistic regression was performed to analyse the data. RESULTS: Accessibility to hazardous chemicals and medicines due to unsafe storage (adj mOR=5.6, 95% CI 1.9 to 16.7), child's behaviour reported as usually aggressive (adj mOR=8.2, 95% CI 4.6 to 16.1), storage of kerosene oil and petrol in soft drink bottles (adj mOR=3.8, 95% CI 2.0 to 7.3), low socioeconomic status (adj mOR=9.2, 95% CI 2.8 to 30.1), low level of mother's education (adj mOR=4.2, 95% CI 1.8 to 9.6), and history of previous poisoning (adj mOR=8.6, 95% CI 1.7 to 43.5) were independently related to unintentional poisoning. CONCLUSION: The practice of storing kerosene and petroleum in soft drink bottles and the easy accessibility of chemicals and medicines are potentially modifiable. Health messages focusing on the safe storage of chemicals and medicines and the use of child resistant containers may play a key role in decreasing the burden of childhood poisoning in Karachi, Pakistan.

Genotyping and drug resistance patterns of M. tuberculosis strains in Pakistan.

BACKGROUND: The incidence of tuberculosis in Pakistan is 181/100,000 population. However, information about transmission and geographical prevalence of Mycobacterium tuberculosis strains and their evolutionary genetics as well as drug resistance remains limited. Our objective was to determine the clonal composition, evolutionary genetics and drug resistance of M. tuberculosis isolates from different regions of the country. METHODS: M. tuberculosis strains isolated (2003-2005) from specimens submitted to the laboratory through collection units nationwide were included. Drug susceptibility was performed and strains were spoligotyped. RESULTS: Of 926 M. tuberculosis strains studied, 721(78%) were grouped into 59 "shared types", while 205 (22%) were identified as "Orphan" spoligotypes. Amongst the predominant genotypes 61% were Central Asian strains (CAS ; including CAS1, CAS sub-families and Orphan Pak clusters), 4% East African-Indian (EAI), 3% Beijing, 2% poorly defined TB strains (T), 2% Haarlem and LAM (0.2). Also TbD1 analysis (M. tuberculosis specific deletion 1) confirmed that CAS1 was of "modern" origin while EAI isolates belonged to "ancestral" strain types.Prevalence of CAS1 clade was significantly higher in Punjab (P < 0.01, Pearsons Chi-square test) as compared with Sindh, North West Frontier Province and Balochistan provinces. Forty six percent of isolates were sensitive to five first line antibiotics tested, 45% were Rifampicin resistant, 50% isoniazid resistant. MDR was significantly associated with Beijing strains (P = 0.01, Pearsons Chi-square test) and EAI (P = 0.001, Pearsons Chi-square test), but not with CAS family. CONCLUSION: Our results show variation of prevalent M. tuberculosis strain with greater association of CAS1 with the Punjab province. The fact that the prevalent CAS genotype was not associated with drug resistance is encouraging. It further suggests a more effective treatment and control programme should be successful in reducing the tuberculosis burden in Pakistan.

Prenatal exposure to wood fuel smoke and low birth weight.

BACKGROUND: Maternal exposure to wood fuel smoke may lead to impaired fetal growth due to hypoxia and or oxidative stress from smoke constituents such as carbon monoxide and particulate matter. OBJECTIVES: We studied the risk of low birth weight (LBW) and reduced mean birth weight in relation to reported use of wood for cooking during the prenatal period, compared with natural gas (NG). METHODS: We studied a historical cohort of women who had a singleton live birth in the years 2000-2002, from a semirural area of Pakistan. Infant's birth weight was obtained from records, and prenatal records had data for maternal body mass index and parity. Cooking habits, daytime sleep habits, and type of fuel used during the pregnancies in 2000-2002 were ascertained by a survey done in 2004-2005. We performed multiple linear and logistic regression modeling using propensity scores to adjust for confounding variables. RESULTS: Unadjusted mean (+/- SD) birth weight was 2.78 +/- 0.45 kg in wood users, and 2.84 +/- 0.43 kg (p < 0.06) in NG users. Infants born to wood users averaged 82 g lighter than infants born to NG users when weight was adjusted for confounders (p < 0.07). The rate of LBW (< 2,500 g) was 22.7% among wood users compared with 15.0% in NG users (p < 0.01), for an adjusted relative risk of 1.64 (95% confidence interval, 1.10-2.34). The population attributable risk for LBW explained by wood use was estimated to be 24%. CONCLUSION: Cooking with wood fuel during pregnancy, a potentially modifiable exposure, was associated with LBW and marginally lower mean birth weight compared with using NG.

Characterization of Mycobacterium tuberculosis Central Asian Strain 1 using mycobacterial interspersed repetitive unit genotyping.

BACKGROUND: The Central Asian Strain 1 (CAS1) genogroup of Mycobacterium tuberculosis (MTB) is the most prevalent in Pakistan, India and Bangladesh. Mycobacterial interspersed repetitive units variable number tandem repeat (MIRU-VNTR) typing is a reliable and reproducible method for differentiation of MTB isolates. However, information of its utility in determining the diversity of CAS1 strain is limited. We performed standard 12 loci based MIRU-VNTR typing on previously spoligotyped CAS1 strains and 'unique' strains in order to evaluate its discriminatory power for these isolates. METHODS: Twelve loci based MIRU- VNTR typing was used to type 178 CAS1 and 189 'unique' MTB strains. The discriminatory index for each of the loci was calculated using the Hunter Gaston Discriminatory Index (HGDI). A subset of these strains (n = 78) were typed using IS6110 restriction fragment length polymorphism (RFLP). MIRU-VNTR profiles were studied together with their drug susceptibility patterns. RESULTS: A total of 349 MIRU patterns were obtained for the 367 strains tested. The CAS1 strains were subdivided into 160 distinct patterns; 15 clusters of 2 strains each, 1 cluster of four strains and 144 unique patterns. Using HGDI, seven MIRU loci, (numbers 26, 31, 27, 16, 10, 39, and 40) were found to be "highly discriminatory" (DI: >or=0.6), four MIRU loci (numbers 20, 24, 23, and 4) were "moderately discriminatory" (DI: 0.3-0.59), and one locus (number 2) was "poorly discriminatory" (DI< 0.3). Loci 26 and 31 were the most discriminatory for the CAS1 isolates. Amongst 'unique' strains in addition to loci 26, 31, 27, 16, 10, 39, and 40, locus 23 was highly discriminatory, while no locus was poorly discriminating. DI values for loci 4, 10 and 26 were significantly lower (P-value < .01) in CAS1 strains than in 'unique' strains. The association between CAS1 strains and MDR was not found to be significant (p value = 0.21). CONCLUSION: We propose that MIRU typing could be used to estimate the phylogenetic relatedness amongst prevalent CAS1 strains, for which MIRU loci 26, 31, 16, 10, 27, 39 and 40 were found to be the most discriminatory.