Assessment of risk factors associated with outbreak of hepatitis A in Shakrial, Rawalpindi, Pakistan.

INTRODUCTION: Two patients with jaundice reported to the National Institute of Health (NIH), Islamabad from Shakrial, Rawalpindi in April 2017. An outbreak investigation team was formulated to assess the disease magnitude, risk factors and control measures. METHODOLOGY: A case-control study was conducted in 360 houses in May 2017. The case definition was: onset of acute jaundice with any symptom including fever, right upper-quadrant pain, loss of appetite, dark urine, nausea and vomiting among Shakrial residents from March 10 - May 19, 2017. Four age and gender matched controls were selected for each case. Blood samples were sent to the NIH for laboratory confirmation. Frequencies, attack rates (AR), odd ratios, and logistic regression were computed at 95% confidence interval and p < 0.05. RESULTS: A total of 25 cases (23 new) were identified with mean age 8 years and male to female ratio 1.5:1. Overall AR was 1.39% and the most severely affected age-group was 5-10 years (AR of 3.92%). Multivariate analysis revealed that raw vegetable consumption, lack of awareness and poor handwashing practices had significant association with disease spread. All blood samples were positive for hepatitis A, and no resident was previously vaccinated. Lack of awareness of disease spread among the community was the most probable reason for the outbreak. There were no new cases during follow up until May 30, 2017. CONCLUSIONS: Healthcare departments should implement public policies towards the management of hepatitis A in Pakistan. Health awareness sessions and vaccination for children ≤ 16 years age is recommended.

Associations of the COVID-19 pandemic with the reported incidence of important endemic infectious disease agents and syndromes in Pakistan.

BACKGROUND: Persons in Pakistan have suffered from various infectious diseases over the years, each impacted by various factors including climate change, seasonality, geopolitics, and resource availability. The COVID-19 pandemic is another complicating factor, with changes in the reported incidence of endemic infectious diseases and related syndromes under surveillance. METHODS: We assessed the monthly incidence of eight important infectious diseases/syndromes: acute upper respiratory infection (AURI), viral hepatitis, malaria, pneumonia, diarrhea, typhoid fever, measles, and neonatal tetanus (NNT), before and after the onset of the COVID-19 pandemic. Administrative health data of monthly reported cases of these diseases/syndromes from all five provinces/regions of Pakistan for a 3-year interval (March 2018-February 2021) were analyzed using an interrupted time series approach. Reported monthly incidence for each infectious disease agent or syndrome and COVID-19 were subjected to time series visualization. Spearman's rank correlation coefficient between each infectious disease/syndrome and COVID-19 was calculated and median case numbers of each disease before and after the onset of the COVID-19 pandemic were compared using a Wilcoxon signed-rank test. Subsequently, a generalized linear negative binomial regression model was developed to determine the association between reported cases of each disease and COVID-19. RESULTS: In late February 2020, concurrent with the start of COVID-19, in all provinces, there were decreases in the reported incidence of the following diseases: AURI, pneumonia, hepatitis, diarrhea, typhoid, and measles. In contrast, the incidence of COVID was negatively associated with the reported incidence of NNT only in Punjab and Sindh, but not in Khyber Pakhtunkhwa (KPK), Balochistan, or Azad Jammu & Kashmir (AJK) & Gilgit Baltistan (GB). Similarly, COVID-19 was associated with a lowered incidence of malaria in Punjab, Sindh, and AJK & GB, but not in KPK and Balochistan. CONCLUSIONS: COVID-19 was associated with a decreased reported incidence of most infectious diseases/syndromes studied in most provinces of Pakistan. However, exceptions included NNT in KPK, Balochistan and AJK & GB, and malaria in KPK and Balochistan. This general trend was attributed to a combination of resource diversion, misdiagnosis, misclassification, misinformation, and seasonal patterns of each disease.

Pain and satisfaction: the case of isolated COVID-19 patients of Pakistan.

BACKGROUND: Over 3 million people lost their lives across the globe due to the COVID-19 related pandemic. The unprecedented restrictions on mobility have imposed in the form of isolation, quarantines, and lockdowns to curb the profound effects of the pandemic and retain physical health. This study examined the relationship between various pain levels, demographic variables and patient satisfaction with COVID-19 during isolation. METHODS: The primary data in this study were collected from isolated patients during their isolation and treatment in a public hospital. We obtained information from patients with COVID-19 (N = 100) about their demographic characteristics, varying levels of pain, and satisfaction with the services provided during the isolation period. We computed the descriptive statistics to explain the profile of participants, ANOVA was used to find out the difference between various groups on patient satisfaction, and structural equation modeling was performed to examine the link between pain levels, demographic factors, and patient satisfaction. This analysis was performed with STATA and SmartPLS-3. RESULTS: The findings of this study ascertained that respondent's education (Beta, ß = 2.961, p = 0.003), assets such as possession of a house (ß = 4.563, p = 0.000), perception of income adequacy during the lockdown (=2.299, p = 0.022), and negligence in prevention (ß = 1.975, p = 0.049) significantly affects patient satisfaction during the isolation period. Moreover, satisfaction with life, physicians and medicine, income adequacy, and fear of the participants was significantly linked to the pain level (Model F-stat = 86.323, p = 0.0001). Patients who were satisfied with their treatment had significantly lower odds of having pain (OR 0.023, 95% CI [0.001-0.0452]). Patients who had enough income to meet their basic necessities were found to have significantly lower odds of having pain (OR 0.155, 95% CI [0.032-0.740]. DISCUSSION AND CONCLUSION: We conclude that a higher level of education, low income, and living in a rented house contributes significantly to the feeling of more satisfaction with the provided services. This implies that people with more affluent backgrounds are less likely to be satisfied with the provided services as low-income and living in rented house groups are more satisfied during isolation than others. The pain level is also affected by subjective factors such as fear and satisfaction which need to be considered while doing patient management. This study can be helpful in improving the delivery of public services of isolation centers by considering various characteristics and demographic factors of patients.

Use of public health emergency operations center (PH-EOC) and adaptation of incident management system (IMS) for efficient inter-sectoral coordination and collaboration for effective control of Dengue fever outbreak in Pakistan - 2019.

Public Health Emergency Operations Center (PH-EOC) and Incident Management System (IMS) provides a platform for inter-sectoral coordination, and collaboration to enhance efficiency of response activities and help in effective control of disease outbreaks. Dengue fever (DF) is an emerging serious public health threat with a potential to transform into a public health emergency. Pakistan faced a heavy outbreak of Dengue fever (DF) from August to December 2019. National Institute of Health (NIH), Islamabad activated its Public Health Emergency Operations Center (PH-EOC) with an objective to implement principles and practices of IMS for control of the outbreak. The challenges during inter-sectoral collaboration for response activities were also identified. PH-EOC was activated on 16th September 2019, and remained operational for next 81 days till 05th December 2019. Incident management structure, incident action plan (IAP), and risk communication plan was developed and executed during this phase. Daily morning and evening meetings were held during all operational days. Federal and provincial health departments, district health offices (DHO), and government/private hospitals were coordinated for collection of the data pertaining to Dengue confirmed cases and deaths. As of 05th December 2019, a total of 52,877 confirmed Dengue cases were reported from all across Pakistan with maximum cases reported from Rawalpindi and Islamabad collectively i.e. 20,988 (40%), followed by Karachi 14,768 (28%), and Peshawar 2,699 (5%), while AJK reported 1,690 (3%). A total of 92 deaths happened all across Pakistan, out of which 43 (47%) happened in Karachi, 23 (25%) in Rawalpindi, and 22 (24%) in Islamabad. The response was coordinated through NIH based PH-EOC, but was carried out by relevant federal and provincial district health offices, vector surveillance programs, dengue control programs and sanitation departments respectively. As a part of response plan, vector surveillance, larva source management, and insecticidal spraying i.e. both fogging and indoor residual spraying activities were carried out in hotspots or the areas where confirmed cases were reported. Sanitation departments daily reported the removal of additional 80-100 ton of solid waste from hotspot areas. Hospitals were coordinated for reporting of isolation of DF patients and provision of quality clinical management for admitted patients. The International Federation for Red Cross/Crescent conducted community awareness, and covered 28,800 households in affected areas of Islamabad. Conversely, the DF outbreak was controlled 02-03 weeks ahead of previous years trends. All the coordinated activities were incorporated in a daily situation report (SitRep) and this was widely distributed among all the stakeholders through emails. Additionally, the data was displayed on the dashboard in PH-EOC. The data dashboard at PH-EOC served as an information management hub that visually mapped, tracked, analyzed, and displayed clusters of DF cases and hotspots. Accordingly, SitRep substantiated as the main reporting tool to monitor response activities initiated by rapid response teams at the national and subnational level. The inter-sectoral coordinating efforts made among concerned line departments resulted in a timely response leading to effective handling of a national public health threat. The information distilled from this experience was that the early and judicious activation of PH-EOC with adaptation of IMS under decision making leadership resulted in a well-managed and prompt response executed by different departments/stakeholders, and effective control of the outbreak before its transformation into a public health event/emergency of national or international concern.

Missed takes towards a pandemic of COVID-19? A systematic literature review of Coronavirus related diseases in Pakistan.

Pakistan is also seeing the profound effect of the outbreak of COVID-19, which demands an urgent investigation of literature and further scientific investigation for cure and prevention. This study has employed the systematic approach for searching the literature from the recently compiled database of researches namely COVID-19 Open Research Dataset (CORD-19) and related diseases. The literature on Pakistan has shown the evidence of human-to-human and animal-to-human transmission of viruses, the presence of antibodies of MERS-CoV in camels, and careless attitude towards preventive measures of such respiratory diseases. There is a lot of gap in the literature regarding coronaviruses and their antibodies creating herd immunity for another coronavirus and COVID-19. In particular to Pakistan, and in general, for other developing countries, a weak health-care system coupled with the trembling economy has many implications of COVID-19 which should be carefully thought-out to combat the spread.

Passive immunization using purified IgYs against infectious bursal disease of chickens in Pakistan.

Infectious bursal disease (IBD) is an acute and highly contagious disease of young chickens caused by Birnavirus. Mortality of infected birds can be best prevented if injected with antibodies. The present study was an attempt to raise specific hyper-immune polyclonal antibodies against IBD virus in Pakistan. Commercial layers divided into four groups were injected with IBD vaccine subcutaneously according to four different treatment regimens. Eggs were collected daily and antibodies were purified from yolk with dextran sulphate. Titers of antibodies in serum and yolk were evaluated with enzyme linked immunosorbant assay and agar gel precipitation test. Antibody titers were significantly higher in yolk than serum. Eggs collected at 28 days post-vaccination had maximum antibody titers. Of treatment regimens, T3 was found to be most effective for hyperimmunization. Lyophilized antibodies stored at 4 degrees C did not lose their activity till the end of experiment. IBD virus infected birds were injected with purified antibodies which induced 92% recovery as compared to control birds. The study implicates that the purified antibodies may be useful as a therapeutic agent to cure IBD infected birds.