Changes in the prevalence of hepatitis B and C viral infections in Sindh province, Pakistan: Findings from two sero-surveys in 2007 and 2019.

Pakistan harbours a large burden of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection. We utilised repeat sero-surveys to assess progress achieved towards hepatitis elimination in Pakistan. Multilevel logistic regression evaluated the change in HBV infection (HBV surface antigen (HBsAg)-positive) prevalence and HCV exposure (HCV antibody (HCV-Ab)-positive) prevalence between two sero-surveys from 2007 and 2019 for Sindh province and associated risk factors. Adjusted odds ratios (aORs) were estimated and population-attributable fractions (PAF) for modifiable risk factors for HCV exposure. The 2007 and 2019 surveys included 8855 and 6672 individuals. HBsAg prevalence decreased from 2.6% (95% confidence intervals (95% CI): 2.2-2.9) in 2007 to 1.1% (95% CI: 0.8-1.3) in 2019, while HCV-Ab prevalence increased from 5.1% (95% CI: 4.6%-5.5%) to 6.2% (95% CI: 5.6%-6.8%). The age and gender-adjusted HBsAg prevalence decreased by 80% (aOR = 0.2, 95% CI: 0.1-0.4) among children and 60% (aOR = 0.4, 95% CI: 0.3-0.6) among adults over 2007-2019, while HCV-Ab prevalence decreased by 60% (aOR = 0.4, 95%CI:0.2-0.7) in children and increased by 40% (aOR = 1.4, 95% CI: 1.2-1.7) in adults. HCV-Ab prevalence was lower in adults with secondary (aOR = 0.6, 95% CI: 0.5-0.8) and higher (aOR = 0.5, 95%CI:0.3-0.8) education compared to illiterates and higher among adults reporting blood transfusion (aOR = 1.7, 95% CI: 1.2-2.4), family history of hepatitis (aOR = 2.5, 95% CI: 1.9-3.3), past year medical injection (aOR = 2.1, 95% CI: 1.6-2.7), being tattooed (aOR = 1.4, 95% CI: 1.0-1.9) and shaved by traditional barber (aOR = 1.2, 95% CI: 1.0-1.5). Modifiable risk factors accounted for 45% of HCV exposure, with medical injection(s) accounting for 38% (95%CI,25.7-48.4%). Overall HCV has increased over 2007-2019 in Sindh province, while HBV prevalence has decreased. Medical injections should be an important focus of prevention activities.

Karachi Cancer Registry (KCR): Consolidated Data of 5-years 2017-2021.

OBJECTIVE:  To collect and analyse epidemiologic data of all malignancies by age group and gender for the Karachi population to estimate the cancer incidence of 5-years (2017-2021) and identify major risk factors for setting priorities towards cancer control programs. STUDY DESIGN: Observational study. Place and Duration of the Study: Karachi Cancer Registry (KCR) Secretariat, Pakistan Health Research Council (PHRC), JPMC, Karachi, from 2017-2021. METHODOLOGY: Cancer data of seven tertiary care hospitals of Karachi submitted to KCR during the study period were analysed including age, gender, date of first contact, primary site and ICD coding. All the data was cleaned, merged, and analysed. All patients 0-14 years were classified as 'children', all aged 15-19 years were classified as 'adolescents', and those age 20-years and above as 'adults'. Age standardised incidence rates (ASIR) were determined for both genders. RESULTS: During the last five years (2017-2021), a total of 65,886 malignant cases were received. The distributions seen amongst males and females were 33,510 (51%) and 32,376 (49%), respectively with 60,145 (91.3%) tumours found in adults (≥20 years), 4844 (7.3%) in children, and 897 (1.4%) in adolescents. The three most common tumour sites were oral, liver, and colorectal in males; breast, oral and ovary in females; bone, brain and connective tissue in adolescents; and leukaemia, brain and bone in children. The overall ASIR (%) in males was 89.20 for adults, 9.19 for children, and 1.61 for adolescents. The overall ASIR (%) in females was 93.44 for adults, 5.45 for children, and 1.11 for adolescents. CONCLUSION: Oral cancer, a largely preventable cancer is the leading cancer in males while breast cancer is the leading cancer in females followed by oral cancer. In adolescents and children, the incidence closely matches most of the world. KEY WORDS: Karachi, Cancer registry, Oral cancer, Breast cancer, Age-standerdised ratio.

Response to different conventional interferons in treatment of chronic hepatitis C.

BACKGROUND: Sustained virological response to interferon therapy is a great challenge for patients of chronic Hepatitis C. Over 20 brands of interferons are available in the local market with each claiming over 80% response and a wide variation in the cost thus creating confusion for treating physicians as to which drug should be selected. METHODS: Chronic Hepatitis C patients attending outpatients department of Pakistan Medical Research Centre JPMC from January 1998-December 2010 were evaluated. Complete blood count, liver function tests, serum proteins, HCV-RNA were done in all cases before starting therapy. Side effects were also noted. RESULTS: Total of 851 cases received interferon 3 MIU three times a week for 6 months. There were 638 (75%) males and 213 (25%) females, mean age was 36.1 +/- 10.4 years. All were HCV-RNA positive prior to treatment, at the end of 6 months 666 (78.3%) became negative while 185 (21.7%) were non-responders with positive HCV RNA. End of treatment response (ETR) showed 84.7% with Bioferon (Argentina), 83.8% Hebron (Cuba), 82.2% INF (Argentina), 82.1% Ceron (China), 81% Viteron (Korea), 80.7% Leveron (Argentina), 81.5% Hepaferon, 79.1% Anferon (China), 77.4% Intron (Belgium), 75% Green alpha (Korea), 74% Roferon (Switzerland), 67.3% Uniferon (Lithuania), and 68.4% with others. Post-treatment 211 cases were lost to follow-up. In remaining 358/640 (55.9%) negative for HCV-RNA, at six months follow up, whereas 98 (15.3%) relapsed. Sustained virological response (SVR) Ceron 68.2%, Hebron 66.3%, Bioferon 65.2%, Leveron 60.5%, Intron 60.3%, Viteron 57%, Anferon 53.3%, Green alpha, Roferon, Hepaferon, and others 50%, INF 48.5% and Uniferon 41.9%. Average cost of these interferons was Rs. 6,000/month, except Hepaferon 5,000/month, Roferon 10,600/month. CONCLUSIONS: ETR ranged from 74-84.7% and SVR 41.9% to 68.2% and > 60% SVR was observed with Ceron, Hebron, Bioferon, Leveron, Intron and were cost effective.

Integration of informal medical practitioners in DOTS implementation to improve case detection rate.

OBJECTIVE: To integrate informal registered medical practitioners (IRMP) in Directly Observed Therapy Short Course (DOTS) implementation to improve case detection rate. METHODS: This interventional study was conducted in the settlement area of Malir district whereas New Karachi was taken as control, between February to November 2005. All registered healthcare providers within 5 kilometer around Tuberculosis (TB) DOTS center Malir were included. New sputum positive and sputum direct smear negative cases of pulmonary Tuberculosis above 15 years residing in the catchments area were included as target population. Informal registered medical practitioners were trained for the referral of suspected cases to the TB DOTs center where three sputum samples were taken, and X-ray chest was done to confirm if sputum direct smear (D/S) was negative. Demographic data regarding age, gender, address, case number, onset of symptoms, treatment given, response, compliance to treatment was all collected. RESULTS: Out of 64 health care providers there were a drop out of 6 leaving 58 informal registered medical practitioners (36 homeopathic/22 Hakims) who referred 54 cases, of these 16 cases were actual suspects. Two out of these 16 (12.5%) were Tuberculosis positive. One was Sputum D/S positive and the other sputum direct smear negative with X-ray chest positive. Comparison of data (Malir and New Karachi diagnostic center) showed that by incorporating homeopathic and Hakims an increase in the proportion of case identification (0.477) was significantly higher in Malir (intervention area) vs New Karachi (non-intervention area) (0.316). CONCLUSION: Integration of informal registered medical practitioners was found to be effective in DOTS implementation hence they can be incorporated in other national programmes to improve public health.

Karachi Cancer Registry (KCR): Age-Standardized Incidence Rate by Age-Group and Gender in a Mega City of Pakistan.

OBJECTIVES: To estimate the cancer incidence by age group and gender for the population of Karachi Division by analyzing the Karachi Cancer Registry data of 2017-19. SETTINGS: The population of Karachi division is 16.1 million according to national census 2017. 'Karachi Cancer Registry' which is a part of 'National Cancer Registry' is collecting data from eight major hospitals in Karachi since 2017. For outcome measures, cancer counts and the age standardized incidence rates (ASIR) per 100,000 population were computed for age groups (0-14, 15-19 and ≥20 years), in both genders and all cancer site/type. METHODS: The population denominators were based on the population of Karachi division estimated at 16.1 million in the population census, 2017. Counts and age-standardized incidence rates (ASIR) were calculated for each of the three age categories. RESULTS: From Jan 2017 till Dec 2019 a total of 33,309 malignant cases were recorded in KCR database comprising 17,490 (52.5%) females and 15,819 (47.5%) males. ASIRs in age groups 0-14, 15-19 and ≥ 20 years, among female were 11.5, 2.4 and 223.6 and in males were 17.6, 3.2 and 216.7 respectively. The commonest diagnosis in children, adolescent and adults were (1) among females: children; bone (3.12),  leukemia (2.09) brain/CNS (1.26); in adolescents: bone (0.78), brain/CNS (0.27), connective and soft tissue (0.11), in adults: breast cancer (76.07), oral cancer (16.68) and ovary (10.89) respectively, and (2) among males: children; bone (4.56),  leukemia (2.79) and brain/CNS (1.88); in adolescent; bone (1.19), brain/CNS (0.31) and leukemia (0.21) and in adults: oral cancer (42.83), liver (16.10) and bone (13.37) respectively. CONCLUSION: Oral Cancer, a largely preventable cancer is the leading cancer in Karachi adult males while in female adults Breast Cancer is the leading cancer followed by Oral Cancer. In children and adolescents Bone, Leukemia and Brain/CNS malignancies are most common.
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Treatment of HBV and HDV co-infection using lamivudine.

OBJECTIVE: To see effect of Lamivudine on sero conversion of HBeAg positive cases co infected with Delta hepatitis. METHODS: Hepatitis B positive patients with deranged liver functions for 6 months were tested for HBeAg, HBV DNA and anti-Delta virus (HDV), using ELISA. Patients were divided into 2 groups, group 1: HBeAg, HBV DNA positive (wild type) but delta negative and group 2: HBeAg, HBV DNA positive (wild type) with delta positive. Lamivudine (100 mg) was advised to both groups till sero-conversion. RESULTS: Of 124 cases in year 1999-2005, 69 were in (Group 1), and 55 were in (Group 2). Eighty percent were males in both groups. ALT normalisation occurred in 75%, 24% cases within 6 months respectively. At the start of therapy mean HBeAg was 289 +/- 189 in group 1 and 142 +/- 160 in group 2. With treatment, the values did not change much till 12 months of therapy. The fall was significantly slow in delta positive cases. At 36 months 26 (38%) cases in group 1 and 9 (16.4%) cases in group 2 sero-converted. Nine cases in each group remained non-responders while 2 in each group relapsed. CONCLUSION: Wild type of HBV/HDV co-infected cases have a 16% chance of seroconversion which negates the concept that once infected with delta virus there is not much that can be done.

Adiponectin and infarction size in subjects with and without cerebrovascular disease.

OBJECTIVE: To investigate whether hypo-adiponectinemia is present in ischemic stroke patients. METHODS: This comparative study was carried out in the Biochemistry Department, Ziauddin University, Karachi, Pakistan in 2008. In this study, plasma adiponectin concentration was measured by an enzyme-linked immunosorbent assay in subjects with and without ischemic cerebrovascular disease (CVD). RESULTS: A total of 80 subjects were studied (40 patients with CVD, and 40 without CVD as controls). The mean plasma level of adiponectin of the 40 patients with ischemic CVD was significantly lower than that of the 40 subjects without CVD (4.36+/-0.21 ug/mL versus 6.97+/-0.241 ug/mL; p=0.000). Decreasing concentrations of adiponectin were negatively correlated with infarction size in ischemic CVD patients. CONCLUSION: These data show that there are significantly lower levels of plasma adiponectin in patients with ischemic CVD. Moreover, adiponectin is negatively correlated with infarction size in these patients suggesting the possible role of adiponectin in cerebrovascular disease.

Comparison of adiponectin, leptin and blood lipid levels in normal and obese postmenopausal women.

OBJECTIVE: To determine adiponectin, leptin and blood lipid levels in normal and obese postmenopausal women and to compare them. METHODS: Eighty postmenopausal women were selected which included 40 normal controls and 40 obese women matched for age and height. Adiponectin and leptin levels were determined by ELISA. Triglycerides, cholesterol, LDL cholesterol and HDL cholesterol were determined by standard kit methods using Clinicon 4010. RESULTS: Serum adiponectin level decreased and leptin level increased significantly (P < 0.001) in obese women compared to controls. Similarly triglycerides, cholesterol and LDL cholesterol were increased significantly (P < 0.001) in obese subjects compared with controls. No significant change in HDL cholesterol was observed in both groups. Significant correlation of leptin with lipid profile was observed when both groups were combined. CONCLUSION: Serum adiponectin level decreased and leptin level increased significantly in obese women compared to controls. Significant correlation exists between leptin and lipid profile in combined group.

Morbidity pattern and utilization of a primary health care center in a low socioeconomic area of Karachi.

OBJECTIVE: To identify the morbidity pattern according to age, gender and seasonal variation using the ICD coding and the utilization of Primary Health Care (PHC) center services in a demographically defined community. METHODS: The data collected from 2001-2003 was analyzed using the International Classification of Diseases-10 (ICD-10) coding for identifying the morbidity patterns presenting at the PHC Center. The age and gender distribution of the patients and the seasonal variation of few diseases were noted. Only the residents of the area visiting the center for preventive or curative services were included. A structured performa was designed to enter the age, gender, disease and ICD codes. The faculty was trained for using the coding system. RESULTS: A total of 13,519 patients visited the PHC during three-year period. On an average, 376 patients were seen during a month with male to female ratio of 1:2. The most common diseases presented belong to the respiratory system, followed by infections or parasitic infestations and diseases of the reproductive system. The women presented for first visit of antenatal check up were 960 out of 4614 women of reproductive age group. Among the adult population, 391 (6%) presented with hypertension, 64 (1%) were Type 2 diabetics and 86 (1.3%) were asthmatics. The paediatric population analysis showed that 918 (13%) had upper respiratory infections and 1339 (19%) had diarrhoea. CONCLUSION: Problem oriented medical records from health centers, computerized in a uniform standardized way, can give extensive information about the content and burden of health problems in family practice and presumably public health.

Circulating levels of resistin, IL-6 and lipid profile in elderly patients with ischemic heart disease with and without diabetes.

BACKGROUND: The cytokines that act as inflammatory hormones show a role in coronary atherosclerotic disease. AIMS: This study aimed to measure serum resistin, IL-6 levels and lipid profile in nondiabetic controls, diabetics, and ischemic heart disease subjects with and without diabetes. Association between resistin and IL-6 was also determined. MATERIALS & METHODS: In this comparative cross-sectional study, 147 subjects were selected, aged between 40 and 70 years. Subjects were divided into four groups as mentioned above. Plasma glucose was measured using the gluco-oxidase method. Lipid profile levels were measured using standard enzymatic methods. Levels of resistin and IL-6 were determined by ELISA. RESULTS: Out of 147 patients, 36 were controls and 111 were cases. Serum resistin and IL-6 levels increased significantly in diabetics (23.4 ± 0.74 ng/ml and 73.1 ± 2.57 ng/ml, respectively) and nondiabetics with ischemic heart disease (14.1 ± 0.51 ng/ml and 66.2 ± 2.08 ng/ml, respectively) compared with diabetics and nondiabetic controls. Positive correlations were found between IL-6 and resistin, and a significant positive correlation was shown in ischemic heart disease groups (r = 0.659; p = 0.001). CONCLUSION: This study shows that the plasma resistin and IL-6 concentrations increased significantly in patients with ischemic heart disease with and without diabetes. This shows that there is a possible role of resistin and IL-6 in inflammatory processes, especially in atherosclerosis.