Rehabilitation of P.E.M. children.

OBJECTIVE: The High Density Diet (HDD) tested in this study is a diet prepared with indigenous food items and is therefore inexpensive. METHODS: Malnourished patients were inducted in three groups. Group A was given only high density diet (HDD) for 7 days and then given routine diet plus HDD for the next 7 days. Group B was given routine diet plus HDD for 14 days. Group C was given only routine diet for 14 days and was the control group. RESULTS: The results were best when HDD was used as a supplement to routine diet (group B). The average weight gain in gm/kg/day for this group was 6, while that for the control group was 2.1. Group A had a weight gain of 4.8 gm/kg/day. Similarly the average caloric intake for the controls was very low throughout the 2-week period, while group B had the best intake, which rose steadily from day one and reached 1200 calories on day 14. Children in group A had a maximum intake of 800 calories in the first week and in the second week this rose up to 1200, equaling that of group B. No case of vomiting, abdominal pain and cramps were reported. CONCLUSION: The High Density Diet is hence, low in cost, easy to prepare at home by mothers and effective in bringing about rapid weight gain in malnourished children.

PediaSure in the treatment of severe malnutrition in Pakistani children.

OBJECTIVES: We used "PediaSure" a high-density supplemental high caloric feed, for the purpose of nutrition therapy of malnourished children during the initial 2 weeks of rehabilitation. METHODOLOGY: Thirty-one severely malnourished children between the ages of 1-5 years of age completed the study. After management of acute medical complications, they were started on "Pediasure" as their source of calories, for 2 weeks. Their weight gain clinical tolerance, stool output were monitored, as were hematological and biochemical parameters. RESULTS: The study revealed a significant increase in caloric intake (p < 0.01) at the end of 2 weeks. There was also a significant improvement in weight gain of these children, averaging to 7.5 gm/kg/day. The Z score weight for age improved as well, (p = < 0.01) over the 2 week period. The biochemical parameters registered an increase in their serum potassium levels, but no untoward chemical imbalance was noted. Tolerance for PediSure was very high, only one child was excluded from the study due to limited intake. None of the children developed diarrhea. CONCLUSION: We conclude that "PediaSure" can be used effectively in the initial stage of nutrition rehabilitation of severely malnourished children.

Community growth monitoring.

BACKGROUND: For a decade the effectiveness of growth charts has been questioned. Along with the purpose of assessing the growth patterns of children, growth charts were considered to be an educational tool. With low levels of literacy in developing countries, and consequently a minimum understanding of growth charts by mothers, they have had limited effectiveness, The practice is also time-consuming and resource intensive. OBJECTIVE: In wake of the importance of monitoring the growth of children, yet keeping in mind the ineffectiveness of growth charts, a novel method of monitoring the growth of children has been demonstrated in this article. SETTING: Urban squatter settlement covering a population of 10,000 people of low-income families. METHODS: Secondary school educated females were trained to give primary health care to their neighboring families and they were paid by a 'Health Insurance' system devised locally. As part of the PHC program a novel method of growth monitoring was tried in the form of "Community Growth Monitoring". CONCLUSION: Community Growth Monitoring requires less time and is effective in measuring the growth of children of a community as a whole, rather than the individual child. This is demonstrated as a process indicator of nutrition counseling, used as an intervention in the community.

Seroepidemiology of varicella-zoster in Pakistan.

The availability of safe and effective vaccines has renewed interest in the epidemiology of varicella worldwide. To date published data on the epidemiology of varicella in Pakistan is very scarce. Therefore, we conducted a study to determine the age-specific seroprevalence rate of varicella-zoster virus (VZV) antibodies in Pakistan. Between December 1997 and March 1998, 1,509 healthy volunteers aged between 1 month and 30 years were recruited from the Islamabad, Karachi, Lahore and Rawalpindi areas. Demographic information, socioeconomic status and past medical history were obtained by questionnaire. Serum samples were assayed for IgG antibodies against VZV by enzyme-linked immunosorbent assay. Overall 41.8% (600/1,435) of those tested were found to be seropositive for VZV antibodies. No difference was found in results obtained from the different cities. A higher seroprevalence was observed among women (45.2%) compared to men (39.6%). Seroprevalence rates increased with age and were 28.4% in those aged 0-5 years, 41.5% in the 6-10 year age group, 42.5% in the 11-15 year age group, 46.7% in the 16-20 year age group and 53.6% in those aged 21-30 years. Socioeconomic status was not a significant risk factor for VZV seropositivity. This is the first report of the seroepidemiology of VZV in Pakistan. The results indicate that seroprevalence of VZV increases with age in the Pakistani population studied. As in other tropical countries, there is greater susceptibility to varicella among the adolescent and young adult population. The results of this study suggest that these at-risk groups should be included in vaccination programs aimed at reducing the public health impact of varicella.

Dengue virus infection among children with undifferentiated fever in Karachi.

Sera were collected from a total of 122 children, comprising 117 cases with undifferentiated fever and 5 cases with dengue hemorrhagic fever (DHF), during June to September 1994 in Karachi, Pakistan. Sera were tested by the IgM-capture ELISA using dengue type 1 (D1), dengue type 2 (D2), West Nile (WN), and Japanese encephalitis (JE) viral antigens. Among 92 single sera from undifferentiated fever cases, IgM antibodies were detected in 5 cases by D1, 8 cases by D2, and 5 cases by WN antigens, respectively. Corresponding number of positives among 25 paired sera from undifferentiated fever cases were 3 by D1, 6 by D2, and 1 by WN antigen. Four out of 5 DHF cases possessed anti-D1 as well as anti-D2 IgM antibodies. Only a single DHF case was positive for anti-WN IgM antibodies. Anti-JE IgM antibodies were not detected in any of the tested serum specimens. Clinical manifestations of undifferentiated fever patients were generally non specific, but the percentage of children with anemia, hepatomegaly and splenomegaly was higher in patients possessing anti-dengue IgM antibodies than those without. Among the groups with anti-dengue IgM antibodies, those possessing only anti-D2 but not anti-D1 IgM antibodies showed higher percentages with cough, edema, and splenomegaly. The results indicated that up to 26% of the undifferentiated fever cases were caused by dengue virus infection in Karachi, Pakistan.

Impact of health education on mothers' knowledge of preventive health practices.

A prospective community-based intervention study was conducted in a slum area of Karachi, Pakistan, with the objective of evaluating the impact of health education on the knowledge of mothers. One hundred and fifty households were studied in the intervention and the same in the non-intervention group. The post intervention knowledge scores of the mothers showed a significant difference of P < 0.05. Nearly 50.7% mothers in the intervention group knew of at least four diseases against which vaccination is given as compared to the non-intervention group (P < 0.05). Similarly, mothers in the intervention group were more aware about the advantages of breast feeding, signs of dehydration, measures for prevention of measles and tuberculosis as compared to the non-intervention group (P < 0.05). Finally, a comparison was made between the pre- and post-intervention scores between the two groups. The score in the non-intervention group changed from 11.5 to 16.1 (P > 0.05) as compared to the intervention group in which it changed from 10.2 to 32.2 (P < 0.05).

PIP: A prospective community-based intervention study was conducted in a slum area of Karachi, Pakistan, with the objective of evaluating the impact of health education on the knowledge of mothers. 150 households were studied in the intervention as well as the nonintervention group. The post-intervention knowledge scores of the mothers showed a significant difference (P 0.05). Nearly 50.7% of mothers in the intervention group knew of at least four diseases against which vaccination is given as compared to the nonintervention group (P 0.05). Similarly, mothers in the intervention group were more aware about the advantages of breast feeding, signs of dehydration, measures for prevention of measles and tuberculosis as compared to the nonintervention group (P 0.05). Finally, a comparison was made between the pre- and post-intervention scores between the two groups. The score in the nonintervention group changed from 11.5 to 16.1 (P 0.05) as compared to the intervention group, in which it changed from 10.2 to 32.2 (P 0.05).

Effect of intervention on promotion of exclusive breast feeding.

A community-based intervention study was conducted in a Katchi Abadi (slum area) of Karachi with the objective of improving optimal breast feeding practices, including promotion of exclusive breast feeding and giving of colostrum to newborns. Sixty-seven mothers were registered in the intervention group and 53 in the control group. Health education to promote exclusive breast feeding was provided in the form of flip-charts, videos and photographs. Sixty-six percent mothers in the control group gave prelacteals as compared to 31% in the intervention group (P < .0001). Colostrum was given by 97% mothers in the intervention group and 3% in the control group. Majority (94%) of intervention group mothers continued exclusive breast feeding till four months of age against 7% in the control group. It was concluded that health education programmes in the antenatal period as well as after birth can promote exclusive breast feeding practices.

An experiment in primary health care in Karachi, Pakistan.

PIP: The Health Education and Literacy Project (HELP) set up a primary health care (PHC) project in the urban slum of Naleem Colony in Karachi, Pakistan, in 1992. The project integrated preventive health, literacy, sanitation, and income generation. Its focus was the community health worker (CHW). Its motto was self-sustainability. A rotating fund allowed the community to contribute towards maintaining the CHW. A community grass-roots organization had administrative control of the project. Researchers had conducted a baseline survey and one year later a knowledge, attitude, and practices survey of 150 households that had received health education and of 150 other households that did not receive health education. The two groups were located in geographically distinct areas. At follow-up, the intervention group consistently was more likely to have good hygienic health practices than the control group (garbage covered, garbage disposal in the garbage drum, washing hands before feeding, and wash hands and child after defecation; p 0.05). Mothers in the intervention group were significantly more likely to know about the vaccinations children needed than those in the control group (for all vaccinations, 76% vs. 21%; p 0.0001). They were also more likely to know how to make oral rehydration solution (ORS) at home than their counterparts (65% vs. 15%). Among intervention mothers, 27% of their children had had diarrhea and 92% of the mothers had used ORS during an episode of diarrhea. The knowledge of correct dietary sources of protein among the intervention group improved significantly between baseline and follow-up (23% vs. 55%; p 0.05), while it did not for the controls (23% vs. 30%; p 0.05). These findings suggest that the project was on the right track towards overall community development by providing health education, sanitation, literacy, and income generation services to the people of the squatter settlement.^ieng

Enteric viral infections in pre-school children in Karachi, Pakistan.

A prospective study was conducted in Karachi, Pakistan on the virology of enteropathogens excreted by children with acute gastroenteritis and the results were compared with a control group of healthy children. Rotavirus and Adenovirus detection was done using ELISA techniques, while enterovirus isolation was done by virus culture. In 1990, 12.3% children with acute watery diarrhoea excreted rotavirus, as compared to 24.4% children in 1991. None of the healthy children excreted adenovirus 40 and 41. Preliminary results of 1992 revealed that rotavirus was seen in 13% of children with acute watery diarrhoea and adenovirus in 10% of children. Enteroviruses were isolated in the same frequency in all three groups i.e. children with acute watery diarrhoea, children with poliomyelitis and healthy children. Non-polio enteroviruses were excreted in 50-52% in all the 3 groups. The rate of enterovirus excretion is much higher than seen in other developed countries and is the same in children with diarrhoea and healthy children.

Hepatitis A, B and C seroprevalence in Pakistan.

A cross sectional study was conducted to determine the seroprevalence of Hepatitis A, B, and C virus in healthy Pakistani children. HAV IgG antibody was assayed in 258 subjects and it was found that 94% children by 5 years of age had HAV IgG-antibody. The overall seroprevalence of HAV IgG antibody was 55.8% and IgM 5.3%. HBVsAb levels assayed in 236 healthy children showed a seroprevalence of 2.97%. Similarly, HCV antibody seroprevalence was found to be a low 0.44% in healthy children. HAV is a major cause of Hepatitis, as compared to HBV and HCV which are of low endemicity.

Detection of west Nile and Japanese encephalitis viral genome sequences in cerebrospinal fluid from acute encephalitis cases in Karachi, Pakistan.

Reverse transcriptase-polymerase chain reaction (RT-PCR) on 24 cerebrospinal fluid (CSF) specimens collected between February and August 1992 detected genome sequence of West Nile (WN) virus in 8 specimens and Japanese encephalitis (JE) virus in a single specimen. The results, combined with the data by IgM-ELISA on CSF indicated that a significant proportion of acute encephalitis cases in Karachi, Pakistan, were caused by WN virus infection, while JE virus caused a small fraction.

Intrathecal immune response and virus-specific immunoglobulin M antibodies in laboratory diagnosis of acute poliomyelitis.

The intrathecal immune response in 114 patients with clinically diagnosed acute poliomyelitis was studied by measuring poliovirus-specific immunoglobulin M (IgM) antibodies in cerebrospinal fluid (CSF) by a mu-capture immunoassay and by assessing the ratio between levels of poliovirus-neutralizing antibodies in serum and CSF. Fecal specimens were used for attempts to isolate the causative agents. Eighty-five percent of CSF specimens collected during the first 15 days of disease contained virus-specific IgM antibodies. Forty-five of 48 tested children (94%) also showed virus-specific IgM responses in their sera. Later on, the antibody levels decreased, and positive results after 30 days of onset of paralytic symptoms were rare. If the presence of poliovirus-specific IgM antibodies in the CSF was considered diagnostic, more cases were confirmed by this test than by virus isolation. A relative increase in poliovirus-neutralizing antibodies in the CSF was observed in about one-third of the cases; in all but three cases the increase was observed together with the presence of virus-specific IgM antibodies. A systemic virus-specific response can be seen and poliovirus can be isolated from a subclinically infected individual suffering from a concomitant poliomyelitis-like disease, while positive results by the two methods demonstrating an intrathecal immune response are likely to indicate a true causal relationship between infection and disease. Demonstration of poliovirus-specific IgM antibodies in the CSF thus appears to be a sensitive and specific method for laboratory confirmation of clinically diagnosed poliomyelitis.

Nerve conduction studies and its importance in diagnosis of acute poliomyelitis.

Motor nerve conduction velocities was performed on 50 subjects in the pediatric age group. Thirty two patients with acute poliomyelitis and 18 controls. The MNCV was studied in the median nerve in the upper limb and the posterior tibial in the lower limb. The motor nerve conduction velocity in polio patients matched well with the controls, as well as within the accepted standards for normal. The MNCV of the median nerve ranged from 41.8 +/- 2.76 m/sec in under 1 year to 44 +/- 2.1 m/sec in 3-8 years, in polio patients, while the range in controls varied from 37 to 53 m/sec. Similarly, for the posterior tibial nerve, in polio patients the value of MNCV varied from 38.7 +/- 4.9 m/sec to 42.5 +/- 3.1 m/sec. In the controls, also the MNCV ranged from 38.5 +/- 6.3 m/sec to 48.4 +/- 3.42 m/sec. Thus, no delay on the motor nerve conduction velocity was seen. Poliomyelitis is a major problem in developing countries like Pakistan and India, where serological diagnosis is a luxury. The determination of motor nerve conduction velocity provides a quick and easy method of distinguishing poliomyelitis from other motor nerve disorders esp. Guillain Barre syndrome.

A model for health intervention.

A Primary Health Care Programme was initiated in a squatter settlement of Karachi with the aim of increasing the awareness regarding the importance of hygiene, immunization, oral rehydration (ORS), nutrition, and so on. A minimum of four resource personnel were able to reach 700 individuals by means of a 'snow-balling' effect. Primary Health Care Workers from the area were required to provide health education to mothers in the Community. A post-intervention survey revealed health education (intervention) was successful in modifying the approach of home-management of diarrhoea, fever and respiratory tract infections. Literacy also influenced home-management of diarrhoea and fever. Thus, health education not only changed the awareness and knowledge of the Community, but also successfully altered health practices which is reflected in reduced incidence of these diseases.

Growth parameters of Pakistani children.

A longitudinal study to determine anthropometric measurements was done in 1100 Pakistani children. They were selectively chosen from a high socioeconomic back-ground to eliminate factors of malnutrition and poor environmental sanitation. Measurements were compared with NCHS standards. Results indicate weight and length curves of the study group duplicating NCHS standards at all centiles. However the OFC measurements show a slight deviation whereby both the 50th and 90th centile are above NCHS standards. These results emphasise that differences between South Asian and Western standards of growth which are usually cited, are due to malnutrition, repeated infections etc. Once these biases are removed, South Asian children grow as well as their Western counterparts.