Risk factors associated with influenza A (H1N1)pdm09: a nested case control study of TB patients with ILI in Lahore District, Pakistan.

BACKGROUND: Co-morbidity with respiratory viruses including influenza A, cause varying degree of morbidity especially in TB patients compared to general population. This study estimates the risk factors associated with influenza A (H1N1)pdm09 in TB patients with ILI. METHODS: A cohort of tuberculosis (TB) patients who were admitted to and enrolled in a TB Directly Observed Therapy Program (DOTs) in tertiary care hospitals of Lahore (Mayo Hospital and Infectious Disease Hospital) were followed for 12 weeks. At the start of study period, to record influenza-like illness (ILI), a symptom card was provided to all the participants. Every participant was contacted once a week, in person. When the symptoms were reported by the participant, a throat swab was taken for the detection of influenza A (H1N1)pdm09. A nested case control study was conducted and TB patients with ILI diagnosed with influenza A (H1N1)pdm09 by conventional RT-PCR were selected as cases, while those who tested negative by conventional RT-PCR were enrolled as controls. All cases and controls in the study were interviewed face-to-face in the local language. Epidemiological data about potential risk factors were collected on a predesigned questionnaire. Logistic analysis was conducted to identify associated risk factors in TB patients with ILI. RESULTS: From the main cohort of TB patients (n = 152) who were followed during the study period, 59 (39%) developed ILI symptoms; of them, 39 tested positive for influenza A (H1N1)pdm09, while 20 were detected negative for influenza A (H1N1)pdm09. In univariable analysis, four factors were identified as risk factors (p < 0.05). The final multivariable model identified one risk factor (sharing of towels, P = 0.008)) and one protective factor (wearing a face mask, p = < 0.001)) for influenza A (H1N1)pdm09 infection. CONCLUSION: The current study identified the risk factors of influenza A (H1N1)pdm09 infection among TB patients with ILI.

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.

Burden and factors associated with occupational tuberculosis infection among high-risk workers in Lahore District, Pakistan.

INTRODUCTION: The main objective of the study was to estimate the burden of occupational tuberculosis infection in high-risk occupational workers and to identify risk factors associated with the prevalence of Mycobacterium tuberculosis complex (MTBC). METHODOLOGY: An analytical cross-sectional study was conducted among high-risk occupational workers including veterinarians, abattoir workers, animal handlers, livestock farmers, and microbiology laboratory workers. Sputum samples were collected from 100 participants and polymerase chain reaction (PCR) tests were done to diagnose tuberculosis (TB) infection. Data on potential risk factors was collected in a pre-designed questionnaire. The MTBC prevalence ratio was estimated. Logistic regression analysis was conducted to identify risk factors and the crude odds ratio (OR) was calculated. RESULTS: Among the 100 enrolled high risk occupational workers, the prevalence of MTBC was 46% (95% CI: 35.98-56.25). Living in a joint family (OR 3.85, 95% CI: 1.58-9.37), and use of unpasteurized milk (OR 3.42, 95% CI: 1.4-8.39), were significantly associated with MTBC infection. CONCLUSIONS: Tuberculosis is a significant health burden in high-risk occupational groups, especially animal handlers and laboratory workers, in Lahore, Pakistan. The study also emphasized the need for formal work-related training, and enhanced zoonotic TB awareness among occupational workers.

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.

Prevalence and molecular characterization of typhoidal and non-typhoidal Salmonella isolated from meat and environmental samples of retail shops of Lahore Punjab, Pakistan.

Non-typhoidal Salmonellae are important foodborne bacterial pathogens that can cause bacteremia, gastroenteritis, and subsequent infection. The aim of the study was to determine the prevalence of Salmonella in the live bird market and retail shops of Lahore (Pakistan). A total of 720 samples of chicken meat, chopping board, cages, hands, and transportation vans were collected. Salmonella was recovered from 103 (14.36%) samples. The highest prevalence (33.33%) was found in transportation van samples followed by chicken meat samples (17.26%). In the towns of Lahore, the highest prevalence was found in Samanabad Town (19%) followed by Data Ganj Bakhsh Town (17%) with the lowest in Gulberg Town (6.9%). Salmonella Typhimurium was most common (35.92%) followed by S. Enteritidis (25.24%), S. Dublin (14.56%), S. Gallinarum biovar Gallinarum (8.74%), and untyped Salmonella species (15.53%). This was the first baseline study of the prevalence of non-typhoidal Salmonella at the live bird market and retail shops of Lahore. Implementation of appropriate control measures is required at both the human side and poultry food production chain to reduce the burden and transmission of the zoonotic Salmonellae.

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.