Prevalence of latent tuberculosis infection in healthcare workers in tertiary care hospitals of Pakistan.

OBJECTIVE: To determine the prevalence of latent tuberculosis infection (LTBI) in healthcare workers in tertiary care hospitals of Rawalpindi, using interferon gamma release assay. METHODS: It was a cross-sectional study. The samples were collected from pulmonology and microbiology departments of three hospitals; i) Military Hospital, Rawalpindi, ii) Fauji Foundation Hospital, Rawalpindi and iii) Pakistan Institute of Medical Sciences, Islamabad. The study was completed in one year from January 2017 to January 2018. Fifty-five asymptomatic healthcare workers of both genders between the ages of 18-50 years with a working tenure of at least one year in concerned departments were included and those with active tuberculosis were excluded from the study. Whole blood from subjects was collected and plasma was checked for interferon gamma value by IGRA (Interferon gamma release assay). RESULTS: In this study of total 55 healthcare workers a high prevalence 22 (40.0%) of latent tuberculosis was found. When LTBI distribution was analyzed within occupational categories, the most frequently affected were sanitary workers 3 (100.0%), nurses 5 (50.0%), doctors 6 (43%) and nursing assistants 2 (40%). CONCLUSION: The prevalence of LTBI in healthcare workers is alarmingly high in our local healthcare settings.

Effectiveness of a mobile health intervention on infant and young child feeding among children ≤ 24 months of age in rural Islamabad over six months duration.

Background: Childhood development is highly influenced by feeding practices at the infancy and young age of children. Unfortunately, according to the National Nutrition Survey (2011), the prevalence of exclusive breastfeeding in Pakistan was 21% at four months, and 13% at six months of age with 51.3% of mothers initiating semisolid foods to their children at the recommended 6-8 months of age. The latest Pakistan Demographic & Health Survey (PDHS 2018) however; indicates that only 48% of infants are exclusively breastfed which has been improved from 38% as reported in the past five years but still more improvement is anticipated. Methods: A quasi-experimental study design was employed for this post-intervention survey assessing effectiveness of mobile health (mhealth) regarding infant & young child feeding (IYCF) among pregnant and lactating mothers in Tarlai, Islamabad from May to June 2018. A total of 135 mothers who were earlier included in the intervention phase were recruited after obtaining verbal & written consent. The data was entered in EpiData (3.1) and analyzed in SPSS version 21. Results: The mean age of these pregnant and lactating mothers was 30.5 years ± 4.5 SD with the majority of mothers in the age group of 25 to 29 years. After the intervention, the overall knowledge of mothers regarding IYCF nutrition was raised to 69.6% among 94 mothers as compared to 74 (54.8%). Overall attitude regarding IYCF was found to be positive among 86 (63.7%) of the mothers, whereas 88 (65.2%) of the mothers had good IYCF related practices. Conclusion: Our post-intervention survey signifies the effectiveness of mhealth in raising knowledge, attitude, and practices of mothers regarding IYCF in rural Islamabad. However, implementation of mhealth in masses requires future research specifically to address the cost-effectiveness of such interventions in maternal & child health programmes.

Epidemiology of Transfusion Transmitted Infection among Patients with ß-Thalassaemia Major in Pakistan.

Introduction. Transfusion Transmitted Infections (TTIs) continue to be a major risk in transfusions in many parts of the world. The transfusion-dependent ß-thalassaemia patients are particularly at risk of acquiring TTIs. The current study was undertaken to estimate the prevalence of TTIs in transfusion-dependent ß-thalassaemia patients. Material and Methods. A cross-sectional study of 1253 multitransfused thalassaemia major patients was conducted in five different centres of Islamabad, Rawalpindi, and Karachi. The study subjects were screened for HIV, HCV, and HBV. The screening was performed at two centres: Department of Pathology, Shaheed Zulfiqar Ali Bhutto (SZAB) Medical University, and Blood Transfusion Services, Jinnah Postgraduate Medical Centre, from July to December 2015. The confirmatory screening was performed by Chemiluminescent Immunoassay (CLIA). Results. Out of the 1253 multiple transfused patients, 317 (25.3%) were infected with TTIs. HCV was positive in 273 cases (21.7%), HBV in 38 cases (3.0%), and HIV in 6 cases (0.5%). Conclusion. HCV was the leading TTI in multitransfused thalassaemia major patients in the study. Presence of HIV in thalassaemia patients is a recent disturbing development in Pakistan. Improved regulation of blood banks including use of internationally or nationally evaluated kits will bring down the incidence of TTIs in transfusion-dependent ß-thalassaemia patients. More stringent behavioral and serological pretransfusion screening of blood for TTIs must be implemented in blood banks.

Effect Of Internal Mammary Artery Harvesting With And Without Pleurotomy On Respiratory Complications In Patients Undergoing Coronary Artery Bypass Grafting.

BACKGROUND: Respiratory problems are one of the major issues faced by cardiovascular surgeons, which increase morbidity and mortality among patients undergoing coronary artery bypass grafting (CABG). It is possible to harvest the left internal mammary artery (LIMA) without opening the left pleura; however this cannot be reliably achieved in all cases due to intimate anatomical relationship. This study was designed to evaluate the effect of internal mammary artery harvesting with and without pleurotomy on respiratory complications in patients undergoing coronary artery bypass grafting. METHODS: In this observational study 90 patients who underwent coronary artery bypass surgery were included by review of records. Patients were stratified into two groups according to surgical procedures, i.e., Internal Mammary artery harvesting with pleurotomy; (WP Group) (n=45) and with extra pleural harvesting technique; (EP Group) (n=45). Inclusion criteria were elective coronary artery bypass grafting, age over 18 years, willingness to be randomly assigned, provision of informed consent. Exclusion criteria were chronic obstructive pulmonary disease (COPD) or skeletal abnormalities that caused pulmonary restriction. Only the first 30 days postoperative outcome was studied. Data was analysed using SPSS version 21. RESULTS: The demographic characteristics in terms of age and gender were comparable in study groups. The preoperative clinical presentation and medical history were also found similar. The hospital stay was significantly longer in WP Group than EP Group patients (7.2 vs 6.1 days, p<0.005). Moreover, post-operative morbidity was more prevalent in WP group 10 (22.2%) than EP Group 3 (66%) (p<0.03). In WP Group more respiratory complications were observed; 2 (4.4%) patients had dry cough and atelectasis, 1 (2.2%) patient experienced pleural effusion, 3 (6.6%) had bronchospasm while 1 (2.2%) patient each had sternal dehiscence and bleeding, however, these did not differ significantly among study groups. CONCLUSIONS: Respiratory complications were more frequent in patients undergoing Internal Mammary artery harvesting with pleurotomy compared to those managed extra pleural harvesting.

Measuring coverage in MNCH: a prospective validation study in Pakistan and Bangladesh on measuring correct treatment of childhood pneumonia.

BACKGROUND: Antibiotic treatment for pneumonia as measured by Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) is a key indicator for tracking progress in achieving Millennium Development Goal 4. Concerns about the validity of this indicator led us to perform an evaluation in urban and rural settings in Pakistan and Bangladesh. METHODS AND FINDINGS: Caregivers of 950 children under 5 y with pneumonia and 980 with "no pneumonia" were identified in urban and rural settings and allocated for DHS/MICS questions 2 or 4 wk later. Study physicians assigned a diagnosis of pneumonia as reference standard; the predictive ability of DHS/MICS questions and additional measurement tools to identify pneumonia versus non-pneumonia cases was evaluated. Results at both sites showed suboptimal discriminative power, with no difference between 2- or 4-wk recall. Individual patterns of sensitivity and specificity varied substantially across study sites (sensitivity 66.9% and 45.5%, and specificity 68.8% and 69.5%, for DHS in Pakistan and Bangladesh, respectively). Prescribed antibiotics for pneumonia were correctly recalled by about two-thirds of caregivers using DHS questions, increasing to 72% and 82% in Pakistan and Bangladesh, respectively, using a drug chart and detailed enquiry. CONCLUSIONS: Monitoring antibiotic treatment of pneumonia is essential for national and global programs. Current (DHS/MICS questions) and proposed new (video and pneumonia score) methods of identifying pneumonia based on maternal recall discriminate poorly between pneumonia and children with cough. Furthermore, these methods have a low yield to identify children who have true pneumonia. Reported antibiotic treatment rates among these children are therefore not a valid proxy indicator of pneumonia treatment rates. These results have important implications for program monitoring and suggest that data in its current format from DHS/MICS surveys should not be used for the purpose of monitoring antibiotic treatment rates in children with pneumonia at the present time.

Clinical presentation, risk factors and outcome of stroke at a district level teaching hospital.

BACKGROUND: Stroke is a fatal clinical syndrome with mortality rate ranging up to 25%. Hypertension, smoking and diabetes mellitus are common preventable risk factors which are associated with serious outcome. Objective of this study was to determine the clinical presentation, risk factors and outcome of stroke. METHODS: A cross-sectional study was conducted in the Medical Wards of DHQ Teaching Hospital, Mirpur Azad Kashmir from March 2010 to January 2011. A questionnaire was prepared in accordance with the objectives of the study. Frequency of risk factors in patients with stroke were studied. Different clinical features were also noted and response to the given treatment was checked in the form of mortality and recovery. Frequencies and percentages were calculated using SPSS-12. RESULTS: Two hundred patients with stroke were selected. Of the total, 136 (68%) had hypertension, 55 (27.5%) were smokers, 53 (26.5%) had diabetes and 25 (12.5%) patients had ischemic heart disease. One hundred and two (51%) patients presented with headache, 99 (49.5%) developed hemiplegia and 94 (47%) had loss of consciousness. CT brain showed infarction in 144 (72%) patients while 56 (28%) had haemorrhage. Observed mortality in this study was 18 (9%) while 182 (91%) patients were discharged after treatment. CONCLUSION: Hypertension, smoking and diabetes mellitus are major modifiable risk factors for stroke. Headache, hemiplegia and loss of consciousness are major clinical features. Ischemic stroke is much common compared to hemorrhagic stroke. With proper care stroke is manageable satisfactorily.

Determinants of suboptimal breast-feeding practices in Pakistan.

OBJECTIVE: Exclusive breast-feeding is estimated to reduce infant mortality in low-income countries by up to 13 %. The aim of the present study was to determine the risk factors associated with suboptimal breast-feeding practices in Pakistan. DESIGN: A cross-sectional study using data extracted from the multistage cluster sample survey of the Pakistan Demographic and Health Survey 2006-2007. SETTING: A nationally representative sample of households. SUBJECTS: Last-born alive children aged 0-23 months (total weighted sample size 3103). RESULTS: The prevalences of timely initiation of breast-feeding, bottle-feeding in children aged 0-23 months, exclusive breast-feeding and predominant breast-feeding in infants aged 0-5 months were 27·3 %, 32·1 %, 37·1 % and 18·7 %, respectively. Multivariate analysis indicated that working mothers (OR = 1·48, 95 % CI 1·16, 1·87; P = 0·001) and mothers who delivered by Caesarean section (OR = 1·95, 95 % CI 1·30, 2·90; P = 0·001) had significantly higher odds for no timely initiation of breast-feeding. Mothers from North West Frontier Province were significantly less likely (OR = 0·37, 95 % CI 0·23, 0·59; P < 0·001) not to breast-feed their babies exclusively. Mothers delivered by traditional birth attendants had significantly higher odds to predominantly breast-feed their babies (OR = 1·96, 95 % CI 1·18, 3·24; P = 0·009). The odds of being bottle-fed was significantly higher in infants whose mothers had four or more antenatal clinic visits (OR = 1·93, 95 % CI 1·46, 2·55; P < 0·001) and belonged to the richest wealth quintile (OR = 2·41, 95 % CI 1·62, 3·58; P < 0·001). CONCLUSIONS: The majority of Pakistani mothers have suboptimal breast-feeding practices. To gain the full benefits of breast-feeding for child health and nutrition, there is an urgent need to develop interventions to improve the rates of exclusive breast-feeding.

Determinants of inappropriate timing of introducing solid, semi-solid or soft food to infants in Pakistan: secondary data analysis of Demographic and Health Survey 2006-2007.

Inappropriate timing of introducing complementary food deprives the infant of optimum nutrition, leading to undernutrition, and increased mortality and morbidity. The aim of this analysis was to identify determinants of inappropriate timing of introduction of solid, semi-solid and soft foods in Pakistan. Data on 941 infants 3.00 to 8.99 months were obtained from the Pakistan Demographic and Health Survey 2006-2007. The prevalence of introduction of foods among infants aged 3.00-5.99 months and 6.00-8.99 months was examined against a set of individual, household and community level variables using univariate analysis. Adjusted odds ratio (AOR) for early introduction in age 3.00-5.99 months and non-introduction in 6.00-8.99 months of age were calculated using backward stepwise logistic regression models. The prevalence of early introduction of complementary foods among 3.00- to 5.99-month-old and timely introduction among 6.00- to 8.99-month-old infants were 10.6% and 39.2%, respectively. Multivariate analyses revealed that mothers who had four or more antenatal clinic visits (AOR=2.68) and who lived in the provinces of Sindh (AOR=2.89) and Baluchistan (AOR=6.75) were more likely to introduce complementary foods early. Mothers from middle-level households (AOR=7.82), poorer households (AOR=4.84) and poorest households (AOR=5.72) were significantly more likely to delay introduction of complementary foods. In conclusion more than half (60.8%) of Pakistani infants do not receive complementary foods at recommended time. Public health interventions to improve the timing of introduction of complementary food are needed at national level with special focus on high risk groups.

Comparison of oral amoxicillin with placebo for the treatment of world health organization-defined nonsevere pneumonia in children aged 2-59 months: a multicenter, double-blind, randomized, placebo-controlled trial in pakistan.

BACKGROUND: world Health Organization (WHO) acute respiratory illness case management guidelines classify children with fast breathing as having pneumonia and recommend treatment with an antibiotic. There is concern that many of these children may not have pneumonia and are receiving antibiotics unnecessarily. This could increase antibiotic resistance in the community. The aim was to compare the clinical outcome at 72 h in children with WHO-defined nonsevere pneumonia when treated with amoxicillin, compared with placebo. METHODS: we performed a double-blind, randomized, equivalence trial in 4 tertiary hospitals in Pakistan. Nine hundred children aged 2-59 months with WHO defined nonsevere pneumonia were randomized to receive either 3 days of oral amoxicillin (45mg/kg/day) or placebo; 873 children completed the study. All children were followed up on days 3, 5, and 14. The primary outcome was therapy failure defined a priori at 72 h. RESULTS: in per-protocol analysis at day 3, 31 (7.2%) of the 431 children in the amoxicillin arm and 37 (8.3%) of the 442 in placebo group had therapy failure. This difference was not statistically significant (odds ratio [OR], .85; 95%CI, .50-1.43; P = .60). The multivariate analysis identified history of difficult breathing (OR, 2.86; 95% CI, 1.29-7.23; P = .027) and temperature >37.5°C 100°F at presentation (OR, 1.99; 95% CI, 1.37-2.90; P = .0001) as risk factors for treatment failure by day 5. CONCLUSION: clinical outcome in children aged 2-59 months with WHO-defined nonsevere pneumonia is not different when treated with an antibiotic or placebo. Similar trials are needed in countries with a high burden of pneumonia to rationalize the use of antibiotics in these communities.

Presentation of congestive cardiac failure in children with ventricular septal defect.

BACKGROUND: While there is much data on cardiac problems of adults, there is a limited statistical data available to evaluate the magnitude of the cardiac problems in children in Pakistan. Many of these children present with recurrent chest infections and congestive cardiac failure (CCF), and are managed by general practitioners. A careful search for underlying cardiac problems and awareness about the presentation of CCF and its magnitude will definitely decrease the morbidity and mortality of these children. The objective of this study was to see the frequency and clinical presentation of CCF in children with Ventricular Septal Defect (VSD). METHODS: Forty-nine patients met the preset criteria during the study period of 6 months. A detailed history and physical examination with special emphasis on symptoms and signs was sought and the findings were noted in a questionnaire. Data was analysed using SPSS-11. Frequencies and percentages were calculated for all categorical variables. RESULTS: CCF in VSD was found more in males, with a male to female ratio of 1.45:1. Majority (63.1%) of the patients presented in infancy. The common symptoms at presentation were dyspnoea (98%), cough (83.7%), and feeding difficulty (9.6%). Other important symptoms were fever, fatigue, failure to thrive, sweating and wheezing. The common physical signs in order of frequency were murmur 98%, tachypnoea 91.8%, tachycardia 89.8%, hepatomegally 89.9% and crackles in chest 85.7%. Other presenting signs were displaced apex beat 57%, oedema 28.6% and chest deformity 20.4%. Regarding the type of VSD, perimembranous was the commonest 61.2% as confirmed by echocardiography. CONCLUSION: This study was done on a smaller scale in hospitalised children. The exact studies regarding CCF in paediatric patients are scarce. There is a need to design more studies in children with CCF. Early recognition of signs and symptoms of CCF on paediatric patients with VSD and awareness at primary health care level can prevent the delay in the diagnosis and early referrals by GPs to hospital setup will definitely reduce the morbidity and mortality.

Comparison of standard versus double dose of amoxicillin in the treatment of non-severe pneumonia in children aged 2-59 months: a multi-centre, double blind, randomised controlled trial in Pakistan.

INTRODUCTION: WHO pneumonia case management guidelines recommend oral amoxicillin as first line treatment for non-severe pneumonia. Increasing treatment failure rates have been reported over a period of time, which could possibly be due to increasing minimum inhibitory concentrations of Streptococcus pneumoniae and Haemophilus influenzae for amoxicillin. Microbiological data show that this resistance can be overcome by increasing amoxicillin dosage. Based on this data, we examined whether we can improve the clinical outcome in non-severe pneumonia by doubling the dose of amoxicillin. METHODS: A double blind randomised controlled trial was conducted in the outpatient departments of four large hospitals in Pakistan. Children aged 2-59 months with non-severe pneumonia were randomised to receive either standard (45 mg/kg/day) or double dose (90 mg/kg/day) oral amoxicillin for 3 days and then followed up for 14 days. Final outcome was treatment failure by day 5. RESULTS: From September 2003 to June 2004, 876 children completed the study. 437 were randomised to standard and 439 to double dose oral amoxicillin. 20 (4.5%) children in the standard and 25 (5.7%) in the double dose group had therapy failure by day 5. Including the relapses, by day 14 there were 26 (5.9%) cumulative therapy failures with standard and 35 (7.9%) with double dose amoxicillin. These differences were not statistically significant (p = 0.55 and p = 0.29, respectively). CONCLUSION: Clinical outcome in children aged 2-59 months with non-severe pneumonia is the same with standard and double dose oral amoxicillin. Non-severe pneumonia can be treated effectively and safely with a 3 day course of a standard dose.