Burden of influenza A (H1N1)pdm09 infection among tuberculosis patients: a prospective cohort study.

BACKGROUND: Influenza and tuberculosis both cause significant morbidity and mortality worldwide. Therefore, this study aimed to estimate the burden of influenza A (H1N1)pdm09 virus infection among human tuberculosis patients and the general population. METHODS: A prospective cohort study was conducted among a cohort group (TB positive patients) as exposed and a comparison group (general population) as non-exposed. A total of 304 participants were recruited in both groups and followed for a period of 12 weeks. Of the 304 concurrently enrolled individuals, 152 were TB-positive patients (cohort group) and 152 were from the general population (comparison group).To calculate the sample size, the power of study was kept at 80% for detecting a difference at 5% alpha level assuming the 25% prevalence of respiratory viruses in cohort group compared to 12.5% in general population. An oropharyngeal swab was taken from a participant with symptoms of influenza-like illness (ILI). Samples were tested by conventional reverse transcription polymerase chain reaction (RT-PCR) for the detection of influenza A (H1N1)pdm09. All statistical analyses were conducted using R software. RESULTS: A total of 95 participants developed influenza-like illness (ILI) symptoms. Among these, 64 tested positive for influenza A(H1N1)pdm09, of which 39 were from the exposed group and 25 were from the non-exposed group. During the 12-week period of follow-up, the influenza A (H1N1)pdm09 incidence rate was 20 per 1000 people. The risk of testing positive for influenza A (H1N1)pdm09 was 1.66 times higher in the exposed group compared to the non-exposed group. The cumulative incidence indicated that 25% of the TB cohort and 16% of the comparison group were at risk of getting influenza A (H1N1)pdm09 during the 12 weeks of follow-up. CONCLUSION: Participants from the TB cohort had a higher incidence of influenza A (H1N1)pdm09 than the general population suggesting that they should be prioritized for influenza vaccination.

Sentinel surveillance for influenza A viruses in Lahore District Pakistan in flu season 2015-2016.

BACKGROUND: Influenza A virus (IAV) remains an important global public health threat with limited epidemiological information available from low-and-middle-income countries. The major objective of this study was to describe the proportions, temporal and spatial distribution, and demographic and clinical characteristics of IAV positive patients with influenza like illness (ILI) and severe acute respiratory illness (SARI) in Lahore, Pakistan. METHODS: Prospective surveillance was established in a sentinel hospital from October 2015 to May 2016. All eligible outpatients and inpatients with ILI or SARI were enrolled in the study. Nasal and/or throat swabs were collected along with clinico-epidemiological data. Samples were tested by real-time RT-PCR (rRT-PCR) to identify IAV and subtype. The descriptive analysis of data was done in R software. RESULTS: Out of 311 enrolled patients, 284 (91.3%) were ILI and 27 (8.7%) were SARI cases. A distinct peak of ILI and SARI activity was observed in February. Fifty individuals (16%) were positive for IAV with peak positivity observed in December. Of 50 IAV, 15 were seasonal H3N2, 14 were H1N1pdm09 and 21 were unable to be typed. The majority of IAV positive cases (98%) presented with current or history of fever, 88% reported cough and 82% reported sore throat. The most common comorbidities in IAV positive cases were hepatitis C (4%), obesity (4%) and tuberculosis (6%). The highest incidence of patients reporting to the hospital was seen three days post symptoms onset (66/311) with 14 of these (14/66) positive for IAV. CONCLUSION: Distinct trends of ILI, SARI and IAV positive cases were observed which can be used to inform public health interventions (vaccinations, hand and respiratory hygiene) at appropriate times among high-risk groups. We suggest sampling from both ILI and SARI patients in routine surveillance as recommended by WHO.

Cutaneous Leishmaniasis in Pakistan: a neglected disease needing one health strategy.

BACKGROUND: Cutaneous Leishmaniasis (CL) is a neglected tropical disease, which mainly affects poor communities. It is one of the major vector-borne disease and endemic in Pakistan. METHODS: A case-control study to evaluate potential risk factors of human-CL was conducted in Khewra region, District Jhelum, Pakistan from January-April 2014. Case data about 90 cases registered during October 2012 to November 2013 was retrieved from Municipal Hospital. Controls were matched (1,1 ratio) on the date of registration with cases from same hospital. Both cases and controls were invited to participate and data was collected in a face-to-face interview. A prospective study of canine leishmaniasis (canine-CL) was also conducted at Civil Veterinary Hospital in the same area. Suspected dogs with skin ulceration signs were included in the study and blood samples were collected. Statistical analyses were conducted to determine association between various parameters and outcome of interest. RESULTS: The ages of cases ranged from 1 to 76 years (median = 15 years) and proved to be protective factor i.e. increase in each year in age reduced the likelihood of being infected with human-CL [Odds Ratio (OR) = 0.4, 95% Confidence Interval (CI) = 0.25-0.76]. People sleeping outsides in an open area were more likely to become a case (OR = 8.7, 95% CI = 2.90-26.37) than a control. Poor sanitary condition inside the house (OR = 3.3, 95% CI 1.03-10.56) and presence of other animals in house (livestock, poultry) (OR = 3.6, 95% CI = 1.07-12.12) also identified as risk factors of high significance. The proportion of positive dogs with canine-CL was 21.05% and was significantly associated with human-CL cases in the same area (p < 0.05). CONCLUSIONS: We concluded that adopting self-protections measures against sand-fly, and maintaining good hygiene may lower the risk of human-CL. One-Health Strategy is suggested to control leishmaniasis in human and dog population.

Risk Factors of Influenza-Associated Respiratory Illnesses Reported to a Sentinel Hospital of Lahore, Pakistan: 2015-2016.

Epidemiological data about determinants of influenza A virus (IAV) in the Pakistani population is scarce. We aimed to conduct a prospective hospital-based active surveillance study from October 2015 to May 2016 to identify potential risk factors associated with IAV infection among patients with influenza-like illness (ILI) and severe acute respiratory illness (SARI). Surveillance was conducted in Lahore General Hospital, selected as a sentinel site in Lahore District, Pakistan. Nasal/throat samples were collected along with epidemiological and clinical data from enrolled patients. Real-time reverse-transcription polymerase chain reaction (rRT-PCR) was performed to identify IAV and its subtypes (H1N1pdm09, H3N2). Data were analyzed to determine risk factors and risk markers associated with IAV infections. A total of 311 suspected ILI and SARI cases were enrolled in the study, and among these 50 were IAV-positive. Of these 50 confirmed cases of IAV, 14 were subtyped as H1N1pdm09 and 15 were H3N2; the remaining 21 were untyped. A final multivariable model identified four independent risk factors/markers for IAV infection: exposure history to ILI patients within last 7 days and gender being male were identified as risk factors of IAV infection, while use of antibiotics prior to hospital consultation and presence of fever were identified as risk markers. We concluded that adopting nonpharmaceutical interventions like hand hygiene, masks, social distancing, and where possible, avoiding identified risk factors could decrease the risk of IAV infection and may prevent imminent outbreaks of IAV in the community.

Prospective study of avian influenza H9 infection in commercial poultry farms of Punjab Province and Islamabad Capital Territory, Pakistan.

A prospective study was conducted from November 2013 to February 2014 to estimate the spatial clustering; cumulative incidence and risk factors associated with avian influenza (AI) subtype H9 infection on commercial poultry farms of Pakistan. A total of 400 farms were enrolled and followed during the study period. Among these, 109 farms submitted samples suspected for AI to the laboratory, and only 47 farms were confirmed positive by hemagglutinin inhibition (HI) test. Data was collected from these 109 farms about their demography, management, and biosecurity practices. The cumulative incidence of H9N2 was 11.75 % (95 % confidence interval (CI) 8.76-15.23). The highest number of cases (40.42 %) was reported in January. One most likely cluster (p = 0.009, radius = 4.61 km) occurred in the Kasur district. Multivariable logistic regression analyses showed that the presence of wild birds on the farms (odds ratio (OR) = 16.18; 95 % CI 3.94-66.45) was independently associated with H9N2 infection. Cleaning of cages before delivery on farm (OR = 0.16; 95 % CI = 0.06-0.47), presence of a footbath at the entrance of farm (OR = 0.24; 95 % CI 0.08-0.79), and changing of gloves (OR = 0.33; 95 % CI 0.11-0.99) were protective factors against H9N2 infection. Reducing the exposure to risk factors and adapting biosecurity measures may reduce the risk of AI H9N2 infection on commercial poultry farms in Pakistan.

Knowledge, Attitude, Practice and Barriers Associated with Influenza Vaccination among Health Care Professionals Working at Tertiary Care Hospitals in Lahore, Pakistan: A Multicenter Analytical Cross-Sectional Study.

Health Care Professionals (HCPs), including doctors, nurses, pharmacists, and paramedics, are a high-risk group for influenza infection due to their continuous exposure to patients having a known or unknown history of influenza-like illnesses. Influenza vaccination is the most effective method of primary prevention. This study was conducted to assess knowledge, attitude, practice, and barriers associated with influenza vaccination among HCPs at tertiary care hospitals in Lahore, Pakistan. A multicenter analytical cross-sectional study was conducted among HCPs. Data were collected using a structured questionnaire. All statistical analyses were conducted in R software. A total of 400 HCPs were enrolled, and among these, 67% had a high level of knowledge and 65.5% had a positive attitude towards influenza vaccination. About 51% of HCPs adopted good practices leading to influenza vaccination. Results identified major barriers for influenza vaccinations, including unfamiliarity with vaccine availability (RII = 0.760), insufficient staff for administering the vaccine (RII = 0.649), lack of proper storage (RII = 0.625), safety concerns (RII = 0.613), and cost of vaccine (RII = 0.602). More than half of the HCPs showed a high level of knowledge, a positive attitude, and good practice against influenza vaccination. Despite the positive Knowledge, Attitude, and Practice (KAP) scores and published guidelines, a very low percentage of HCPs were vaccinated against influenza. Many hindering factors were associated with influenza vaccination.

Serosurvey of Avian Influenza Viruses (H5, H7, and H9) and Associated Risk Factors in Backyard Poultry Flocks of Lahore District, Pakistan.

Rural poultry constitutes 56% of the total poultry population in Pakistan; however, epidemiological information about avian influenza viruses (AIVs) in backyard poultry flocks is lacking. A cross-sectional survey of villages of Lahore district was conducted from July 2009 to August 2009 using two-stage cluster sampling and probability proportional to size (PPS) sampling to estimate seroprevalence and its associated risk factors. A random selection of 35 clusters from 308 villages of Lahore were considered, and from each cluster, six chickens aged >2 months were selected. A total of 210 serum samples were collected and examined by the hemagglutination inhibition (HI) test for specific antibodies against AIV subtypes H5, H7, and H9. Overall weighted seroprevalence for AIVs was 65.2% (95% CI: 55.6-74.8%), and for subtype H5, H7 & H9 was 6.9% (95% CI: 10.8-23.0%), 0% (95% CI: 0-1.7%), and 62.0% (95% CI: 52.2-71.8%) respectively. However, none of the samples were positive for H7. The average flock size was 17.3 birds, and the main purpose of keeping poultry was for eggs/meat (70.6%, 95% CI: 59.7-81.4). A majority of them were reared in a semi-caged system (83%, 95% CI: 74.5-91.3). Backyard birds were received from different sources, that is, purchased from the market or received as a gift from friends or any NGO, and were 5.7 times more likely to become avian influenza (AI) seropositive than those that were not exposed to these sources (CI 95%: 2.0-716.0). Backyard birds which were received from different sources, that is, purchased from the market or received from friends or any NGO, were 5.7 times more likely to become AI seropositive compared to those that were not (CI 95%: 2.5-18.7). To reduce the risk of AIV in Pakistan, continuous surveillance of backyard poultry would be needed.

Outbreak investigation of foot and mouth disease in Nangarhar province of war-torn Afghanistan, 2014.

Afghanistan has long history of ongoing conflicts, resulting in massive destruction of the country's infrastructure. Illegal trade of livestock between Afghanistan and Pakistan boosted the spread of Foot & Mouth Disease (FMD). Current study was conducted to investigate outbreaks of FMD occurred between April-August 2014 in Nangarhar, Afghanistan. Descriptive data about suspected FMD cases were collected from the Civil Veterinary Hospital, Nangarhar to analyze spatio-temporal pattern of FMD. Case farms (n = 137) were selected from list of clinically confirmed FMD outbreaks available in the hospital. Control farms (n = 137) were enrolled from neighboring premises of case farms. The epidemic curve showed that the virus is continuously circulating among susceptible population. The mean age of the oldest lesion was 2.8 days. Foot & Mouth Disease was more likely to occur in female animals compared to male animals (p < 0.001). Farmers having no ability to clinically recognize FMD (OR 5.8, 95% CI 1.4-23.8); previously having any FMD case in herd (OR 11.8, 95% CI 3.0-45.8), farms where animals leave shed during day (OR 15.4, 95% CI 5.6-42.0), and farms, where neighboring farmers used to visit the premises (OR 3.5, 95% CI 1.2-9.9) were identified as risk factors. Current findings may be used to create awareness of concerned veterinary health authorities about FMD control.

Incidence of Animal-Bite Injuries Registered in Public Hospitals of Post-Conflict Swat District, Pakistan in 2014.

The Swat district, a conflict-hit territory due to Taliban militancy, had a damaged local health infrastructure. Animal-bite injuries leading to rabies is one of the major health concerns in developing countries, especially within conflict zones. The current prospective epidemiological study was conducted to estimate the cumulative incidence of animal-bite injuries, to summarize characteristics of bite victims and biting animals, and to collect information about post-exposure prophylaxis (PEP) practices in Swat district, Pakistan, during 2014. A questionnaire was designed to collect data about the sociodemography of the patients, bite incident situation (provoked or unprovoked), injury pattern, animal type, PEP, and vaccination. Descriptive analyses were conducted using bar graphs, frequency tables, and chi-square tests were used to determine associations. The cumulative incidence of animal-bite injuries was 39 per 100,000 people during the study period (May-August 2014). The majority of incidents were reported from rural regions (77.7%) and were males (76.6%) younger than 10 years (37.3%). Dogs were the most frequent biting animal (86.8%) followed by rats (4.7%). About 77.7% patients washed their wound before arrival at hospital. After an eclipse phase of 10 days, 44 (10.1%) animals developed sign of rabies. The current study has highlighted a topic of interest for health, education, veterinary, and local government policy makers regarding prevention of animal bites, benefits of PEP, vaccination of human and domestic animals, control of stray dogs, and eradication of rabies in developing countries with damaged healthcare structures.

Avian influenza at animal-human interface: One-health challenge in live poultry retail stalls of Chakwal, Pakistan.

BACKGROUND: Live poultry retail stalls (LPRSs) are believed to be the source of human infection with avian influenza viruses (AIVs); however, little is known about epidemiology of these viruses in LPRSs of Pakistan. OBJECTIVES: The current study was conducted to estimate the virological and serological prevalence of AIVs in humans and poultry and associated risk factors among seropositive butchers. METHODS: A field survey of LPRSs of Chakwal District was conducted between December 2015 and March 2016. In total, 322 samples (sera = 161 and throat swab = 161) from butchers and 130 pooled oropharyngeal swabs and 100 sera from birds were collected. Baseline sera (n = 100) from general population were also tested. Data were collected by structured questionnaires. Sera were tested by hemagglutination inhibition (HI) test further confirmed by micro-neutralization test (MN). Swabs were processed by real-time RT-PCR. Logistic regression analyses were conducted to identify risk factors. RESULTS: In butchers, 15.5% sera were positive for antibodies against H9 virus using a cutoff of ≥40 in HI titer; 6% sera from general population were positive for H9. Seroprevalence in poultry was 89%, and only 2.30% swabs were positive for H9. Presence of another LPRS nearby and the number of cages in the stall were risk factors (OR > 1) for H9 seroprevalence in butchers. CONCLUSIONS: This study provides evidence of co-circulation of H9 virus in poultry and exposure of butchers in the LPRSs, which poses a continued threat to public health. We suggest regular surveillance of AIVs in occupationally exposed butchers and birds in LPRSs.

Genome Sequences of an H9N2 Avian Influenza Virus Strain Found in Pakistan in 2017.

In 2017, we isolated an H9N2 avian influenza virus in Pakistan. Genetic analysis showed that the A/chicken/Kasoor/SI36/2017(H9N2) isolate belongs to the G1 lineage. In addition, this isolate possesses mammalian host-specific mutations which could possibly favor interspecies transmission, suggesting that Pakistani H9N2 viruses are still potentially infectious for mammals.

Dengue Epidemic in Postconflict Swat District, Khyber Pakhtunkhwa, Pakistan, 2013.

AbstractSwat, a lush green valley of 1.3 million persons, remained under militant insurgency from 2007 to 2009, which damaged the health infrastructure. An outbreak of dengue fever (DF) was declared in the valley in 2013. To investigate this outbreak, we established active surveillance of national hospitals and private clinics, reviewed available clinical and laboratory records, and conducted entomological survey. From August to November 2013, 16,000 suspected patients with acute febrile illness were presented to health facilities. Among those, 9,036 were confirmed positive for DF by clinical manifestation and presence of nonstructural protein 1-soluble antigen. Of 9,036 patients, majority were men and aged 21-40. The epidemic peaked in September 2013 (N = 6,487). The attack rate was 7.18/1,000 populations. Among the confirmed case-patients, 36 deaths were reported, and proportion of mortality was 0.4%. Each year, increase in age was significantly associated with risk of complication due to DF leading to death (P < 0.001).

Comparative efficacy of diminazene diaceturate and diminazene aceturate for the treatment of babesiosis in horses.

The present work was conducted to study the comparative efficacy of two anti-protozoan (babesicidal) drugs on the recovery and health of horses. A total of 80 horses, showing typical clinical symptoms of the disease, were selected for this study; the presence of babesiosis was confirmed through blood smear examination. These animals were divided into two groups i.e. A and B. Horses of Group A, were treated with diminazene diaceturate, while horses of Group B were treated with diminazene aceturate. Efficacy of the drugs was determined by the reversal of clinical signs and a negative blood smear examination. The efficacy of diminazene diaceturate was demonstrated to be 80% while diminazene aceturate was found to have 90% efficacy against babesiosis.