Impact of hepatitis B birth dose on immune response in Pakistani children: an open-label, non-inferiority randomized controlled trial, implications for achieving SDG target.

BACKGROUND: Despite presence of hyperendemic areas, the national immunisation schedule in Pakistan does not include a hepatitis B birth dose, placing newborns at an additional risk of acquiring hepatitis B. This study aimed to assess the impact of adding hepatitis B birth dose in existing national vaccination schedule. METHODS: An open label, randomised controlled non-inferiority trial enrolled 296 healthy near-term mothers to intervention and control groups. Newborns in the intervention group received a hepatitis B birth dose along with routine immunisation vaccines, while control group newborns received vaccinations under the national schedule. Seroprotection was measured and compared at birth and 8 weeks after administering the third dose of pentavalent vaccine. The risk ratio of seroprotection was computed and compared with the delta value set at 5%. RESULTS: The study found that 95.8% of infants in the intervention group achieved seroprotection, which was significantly higher than the control group's 58.7%. The difference in risk ratio of seroprotection was 1.62 (CI95: 1.37-1.93), with the upper limit of the CI below the delta margin, confirming non-inferiority. The time interval between birth and the first hepatitis B immunisation shot was a predictor of seroprotection, with an odds ratio of 1.79 (CI95: 1.01-2.9). CONCLUSION: Our study indicates that adding a hepatitis B birth dose to the immunisation schedule in Pakistan is non-inferior to the existing one. This can also contribute towards Pakistan's achievement of the SDG target of reducing hepatitis B surface antigen seroprevalence in children under 5 years of age. TRIAL REGISTRATION NUMBER: NCT04870021.

Provincial differences in levels, trends, and determinants of childhood immunization in Pakistan.

BACKGROUND: Efforts to improve immunization rates are urgently needed in Pakistan but national statistics mask important local differences in immunization levels and determinants. AIM: In this study we aimed to determine how similar or different are recent trends and levels of immunization coverage in Pakistan's 4 main provinces [Punjab, Sindh, Khyber Pakhtunkhwa (KPK) and Balochistan], and what factors are associated with complete childhood immunization in each province. METHOD: We analysed data from the 2006-07 and 2012-13 Pakistan Demographic and Health Surveys. Trends in immunization coverage among children aged 12-23 months were calculated for each province. Bivariate and multivariate analyses were conducted to identify factors associated with complete immunization. RESULTS: The proportion of children completely immunized had risen significantly in Punjab but had fallen significantly in Balochistan. Complete coverage ranged from 16.4% in Balochistan to 65.8% in Punjab (2012-13). Tetanus toxoid injection during pregnancy was a significant predictor of complete immunization everywhere. Other predictors in specific provinces were: urban residence in Balochistan, wealth in Sindh and KPK, mother's education in Punjab and KPK, and distance to the facility in Punjab. CONCLUSIONS: Although some strategies to increase immunization coverage are relevant nationwide, programme managers need to seek solutions specific to provincial trends and predictors. This analysis demonstrates that viewing childhood immunization in Pakistan through a provincial lens can help achieve a deeper understanding of the challenges and potential strategies to boost coverage.

Risk factors for bloodborne viral hepatitis in healthcare workers of Pakistan: a population based case-control study.

OBJECTIVES: A high prevalence of viral hepatitis B and C was found among healthcare workers during a province-wide screening in Sindh Province, Pakistan. A follow-up study was undertaken to identify risk factors for this high prevalence in healthcare workers. DESIGN: Population based case-control design. SETTING: Public sector healthcare facilities in a rural district of Pakistan. PARTICIPANTS: Healthcare workers who were screened for hepatitis B surface antigen (HBsAg) and hepatitis C virus (HCV) antibodies. 178 healthcare workers employed at the public sector clinics and hospitals of the district were approached, of which 14 refused to participate. Cases had detectable serum antibodies against HCV and the presence of HBsAg. Healthcare workers non-reactive to HCV antibodies and with no HBsAg were controls. These were matched in a ratio of 1:1. OUTCOME MEASURE: Detectable serum HBsAg and HCV antibody titer were taken as outcome. OR for various exposures was calculated; those with p<0.25 were entered in a multivariate logistic regression model to find out significant predictors. RESULTS: Needle stick injury (OR=6; CI95 1.4 to 23), recapping the needle (OR=5.7; CI95 1.1 to 28), wound care at accident and emergency of a hospital (OR=5.5; CI95 1 to 28), female gender (OR=3.4; CI95 1 to 12) and more than 10 years of formal education (OR=0.25; CI95 0.07 to 0.8) were associated with hepatitis C. Hepatitis B was found to be associated with trying to bend or break a needle after use (OR=4.9; CI95 1 to 24). CONCLUSIONS: Healthcare workers in Pakistan are at additional risk of exposure to bloodborne pathogens. Bi-dimensional risk factors present at individual and broader health systems levels are responsible. Occupational safety, health trainings and redesigning of the curriculum for allied health professionals are required.

The health workforce crisis in Pakistan: a critical review and the way forward.

Today, the developing world suffers due to the health "workforce crisis." The World Health Report 2006 uses this term to study the current scenario in the developing countries. Human resource planning is a critical activity within the broader sectoral planning, especially when it comes to the health sector. Pakistan faces an acute shortage of different cadres of healthcare workers, which is bound to escalate further because of the high population growth rate, inequitable distribution and out-migration of the healthcare workforce. In the wake of ongoing reforms in the health sector of Pakistan, it is suggested that for the strengthening of health systems, there ought to be a serious thought process involved for developing a human resource plan for the health sector that responds to the needs of the population and the disease burden. A national strategy is imperative to retain, train and incentivize the health workforce.

Hepatitis B vaccination coverage in medical students at a medical college of Mirpurkhas.

OBJECTIVES: To estimate the coverage of Hepatitis B vaccine in medical students enrolled in a private Medical College. METHODS: This cross sectional study was done at Muhammad Medical College Mirpurkhas. It has a total of 375 medical students from first year to final year. All students were interviewed using a pre-structured urdu translated questionnaire to find out the vaccination status of these students and the reasons for not getting vaccinated. RESULTS: A total of 395 medical students were approached to participate in the study but only 375 (95%) students (M=214, F=159) gave response. Out of the total 375 students, 214 (57%) were vaccinated against Hepatitis B. Amongst this group 188 (87.8%) had completed their vaccination schedule of 03 doses and 26 (13%) were partially vaccinated. Vaccination uptake was higher (55.6%) in males as compared to females (44.3%). Reasons of not vaccination were lack of motivation ( 29.2%), no need felt (24.8%), (3) never thought of vaccination (21.7%), fear of injection (10.5%) and lack of belief in vaccination (8.07%). Only 130 (60.7%) students were screened before taking the vaccine. The self reported seropositivity of Hepatitis B Surface Antigen in medical students was 3.7%. CONCLUSIONS: Despite the availability and accessability of a cost effective Hepatitis B vaccine since mid 80's, the vaccination coverage among medical students is low. Health education needs to be improved in all medical students especially in the private sector.

Seropositivity of hepatitis C in prison inmates of Pakistan--a cross sectional study in prisons of Sindh.

OBJECTIVE: To assess the proportion of seropositivity of Hepatitis C amongst the prison inmates in the jails of Sindh. METHODS: A cross sectional HCV seroprevalence survey was done at 14 out of 19 prisons in the Sindh province from November 2008 to January 2009. A team of Pathologist, phlebotomist and laboratory technician took the blood sample of the inmates inside the correctional facility; the blood was centrifuged at the spot and brought back to the pathology laboratory on same day in cold chain i.e. a temperature-controlled supply chain. Serum was analyzed on 3rd generation ELISA for HCV antibodies. Standard ethical considerations were properly followed. RESULTS: Atotal of 9508 prison inmates were approached. Refusal rate was 20%. Remaining, 7539 prisoners were screened at 14 out of 19 jails in Sindh. HCV antibody positive were 965 making the proportion of seropositivity 12.8% (95% C.I. 8.92% - 12.92%). Higher seropositivity in the jails of northern Sindh jails was identified. CONCLUSIONS: Hepatitis C prevalence in the prison population of Sindh is higher than the national prevalence of 4.9% amongst general population. However it is lower than that reported from correctional facilities of developed countries. Hepatitis prevention and control activities in the correctional facilities of Pakistan need to be institutionalized (JPMA 60:476; 2010).