Fixation of pfcrt chloroquine resistance alleles in Plasmodium falciparum clinical isolates collected from unrest tribal agencies of Pakistan / Fixação de alelos de resistência à cloroquina pfcrt em isolados clínicos de Plasmodium falciparum coletados de agitações de agências tribais do Paquistão

Plasmodium falciparum resistance to Chloroquine (CQ) is a significant cause of mortality and morbidity worldwide. There is a paucity of documented data on the prevalence of CQ-resistant mutant haplotypes of Pfcrt and Pfmdr1 genes from malaria-endemic war effected Federally Administered Tribal Areas of Pakistan. The objective of this study was to investigate the prevalence of P. falciparum CQ-resistance in this area. Clinical isolates were collected between May 2017 and May 2018 from North Waziristan and South Waziristan agencies of Federally Administrated Trial Area. Subsequently, Giemsa-stained blood smears were examined to detect Plasmodium falciparum. Extraction of malarial DNA was done from microscopy positive P. falciparum samples, and P. falciparum infections were confirmed by nested PCR (targeting Plasmodium small subunit ribosomal ribonucleic acid (ssrRNA) genes). All PCR confirmed P. falciparum samples were sequenced by pyrosequencing to find out mutation in Pfcrt gene at codon K76T and in pfmdr1 at codons N86Y, Y184F, N1042D, and D1246Y. Out of 121 microscopies positive P. falciparum cases, 109 samples were positive for P. falciparum by nested PCR. Pfcrt K76T mutation was found in 96% of isolates, Pfmdr1 N86Y mutation was observed in 20%, and 11% harboured Y184F mutation. All samples were wild type for Pfmdr1 codon N1042D and D1246Y. In the FATA, Pakistan, the frequency of resistant allele 76T remained high despite the removal of CQ. However, current findings of the study suggest complete fixation of P. falciparum CQ‑resistant genotype in the study area.

A resistência do Plasmodium falciparum à cloroquina (CQ) é uma causa significativa de mortalidade e morbidade em todo o mundo. Há uma escassez de dados documentados sobre a prevalência de haplótipos mutantes CQ-resistentes dos genes Pfcrt e Pfmdr1 da guerra endêmica da malária em áreas tribais administradas pelo governo federal do Paquistão. O objetivo deste estudo foi investigar a prevalência de resistência a CQ de P. falciparum nesta área. Isolados clínicos foram coletados entre maio de 2017 e maio de 2018 nas agências do Waziristão do Norte e do Waziristão do Sul da Área de Ensaio Administrada Federalmente. Posteriormente, esfregaços de sangue corados com Giemsa foram examinados para detectar Plasmodium falciparum. A extração do DNA da malária foi feita a partir de amostras de P. falciparum positivas para microscopia, e as infecções por P. falciparum foram confirmadas por nested PCR (visando genes de ácido ribonucleico ribossômico de subunidade pequena de Plasmodium (ssrRNA)). Todas as amostras de P. falciparum confirmadas por PCR foram sequenciadas por pirosequenciamento para descobrir a mutação no gene Pfcrt no códon K76T e em pfmdr1 nos códons N86Y, Y184F, N1042D e D1246Y. De 121 microscopias de casos positivos de P. falciparum, 109 amostras foram positivas para P. falciparum por nested PCR. A mutação Pfcrt K76T foi encontrada em 96% dos isolados, a mutação Pfmdr1 N86Y foi observada em 20% e 11% abrigou a mutação Y184F. Todas as amostras eram do tipo selvagem para o códon N1042D e D1246Y de Pfmdr1. No FATA, Paquistão, a frequência do alelo resistente 76T permaneceu alta apesar da remoção de CQ. No entanto, as descobertas atuais do estudo sugerem a fixação completa do genótipo resistente a CQ de P. falciparum na área de estudo.

Fixation of pfcrt chloroquine resistance alleles in Plasmodium falciparum clinical isolates collected from unrest tribal agencies of Pakistan

Abstract Plasmodium falciparum resistance to Chloroquine (CQ) is a significant cause of mortality and morbidity worldwide. There is a paucity of documented data on the prevalence of CQ-resistant mutant haplotypes of Pfcrt and Pfmdr1 genes from malaria-endemic war effected Federally Administered Tribal Areas of Pakistan. The objective of this study was to investigate the prevalence of P. falciparum CQ-resistance in this area. Clinical isolates were collected between May 2017 and May 2018 from North Waziristan and South Waziristan agencies of Federally Administrated Trial Area. Subsequently, Giemsa-stained blood smears were examined to detect Plasmodium falciparum. Extraction of malarial DNA was done from microscopy positive P. falciparum samples, and P. falciparum infections were confirmed by nested PCR (targeting Plasmodium small subunit ribosomal ribonucleic acid (ssrRNA) genes). All PCR confirmed P. falciparum samples were sequenced by pyrosequencing to find out mutation in Pfcrt gene at codon K76T and in pfmdr1 at codons N86Y, Y184F, N1042D, and D1246Y. Out of 121 microscopies positive P. falciparum cases, 109 samples were positive for P. falciparum by nested PCR. Pfcrt K76T mutation was found in 96% of isolates, Pfmdr1 N86Y mutation was observed in 20%, and 11% harboured Y184F mutation. All samples were wild type for Pfmdr1 codon N1042D and D1246Y. In the FATA, Pakistan, the frequency of resistant allele 76T remained high despite the removal of CQ. However, current findings of the study suggest complete fixation of P. falciparum CQ-resistant genotype in the study area.

Resumo A resistência do Plasmodium falciparum à cloroquina (CQ) é uma causa significativa de mortalidade e morbidade em todo o mundo. Há uma escassez de dados documentados sobre a prevalência de haplótipos mutantes CQ-resistentes dos genes Pfcrt e Pfmdr1 da guerra endêmica da malária em áreas tribais administradas pelo governo federal do Paquistão. O objetivo deste estudo foi investigar a prevalência de resistência a CQ de P. falciparum nesta área. Isolados clínicos foram coletados entre maio de 2017 e maio de 2018 nas agências do Waziristão do Norte e do Waziristão do Sul da Área de Ensaio Administrada Federalmente. Posteriormente, esfregaços de sangue corados com Giemsa foram examinados para detectar Plasmodium falciparum. A extração do DNA da malária foi feita a partir de amostras de P. falciparum positivas para microscopia, e as infecções por P. falciparum foram confirmadas por nested PCR (visando genes de ácido ribonucleico ribossômico de subunidade pequena de Plasmodium (ssrRNA)). Todas as amostras de P. falciparum confirmadas por PCR foram sequenciadas por pirosequenciamento para descobrir a mutação no gene Pfcrt no códon K76T e em pfmdr1 nos códons N86Y, Y184F, N1042D e D1246Y. De 121 microscopias de casos positivos de P. falciparum, 109 amostras foram positivas para P. falciparum por nested PCR. A mutação Pfcrt K76T foi encontrada em 96% dos isolados, a mutação Pfmdr1 N86Y foi observada em 20% e 11% abrigou a mutação Y184F. Todas as amostras eram do tipo selvagem para o códon N1042D e D1246Y de Pfmdr1. No FATA, Paquistão, a frequência do alelo resistente 76T permaneceu alta apesar da remoção de CQ. No entanto, as descobertas atuais do estudo sugerem a fixação completa do genótipo resistente a CQ de P. falciparum na área de estudo.

Fixation of pfcrt chloroquine resistance alleles in Plasmodium falciparum clinical isolates collected from unrest tribal agencies of Pakistan / Fixação de alelos de resistência à cloroquina pfcrt em isolados clínicos de Plasmodium falciparum coletados de agitações de agências tribais do Paquistão

Abstract Plasmodium falciparum resistance to Chloroquine (CQ) is a significant cause of mortality and morbidity worldwide. There is a paucity of documented data on the prevalence of CQ-resistant mutant haplotypes of Pfcrt and Pfmdr1 genes from malaria-endemic war effected Federally Administered Tribal Areas of Pakistan. The objective of this study was to investigate the prevalence of P. falciparum CQ-resistance in this area. Clinical isolates were collected between May 2017 and May 2018 from North Waziristan and South Waziristan agencies of Federally Administrated Trial Area. Subsequently, Giemsa-stained blood smears were examined to detect Plasmodium falciparum. Extraction of malarial DNA was done from microscopy positive P. falciparum samples, and P. falciparum infections were confirmed by nested PCR (targeting Plasmodium small subunit ribosomal ribonucleic acid (ssrRNA) genes). All PCR confirmed P. falciparum samples were sequenced by pyrosequencing to find out mutation in Pfcrt gene at codon K76T and in pfmdr1 at codons N86Y, Y184F, N1042D, and D1246Y. Out of 121 microscopies positive P. falciparum cases, 109 samples were positive for P. falciparum by nested PCR. Pfcrt K76T mutation was found in 96% of isolates, Pfmdr1 N86Y mutation was observed in 20%, and 11% harboured Y184F mutation. All samples were wild type for Pfmdr1 codon N1042D and D1246Y. In the FATA, Pakistan, the frequency of resistant allele 76T remained high despite the removal of CQ. However, current findings of the study suggest complete fixation of P. falciparum CQ-resistant genotype in the study area.

Resumo A resistência do Plasmodium falciparum à cloroquina (CQ) é uma causa significativa de mortalidade e morbidade em todo o mundo. Há uma escassez de dados documentados sobre a prevalência de haplótipos mutantes CQ-resistentes dos genes Pfcrt e Pfmdr1 da guerra endêmica da malária em áreas tribais administradas pelo governo federal do Paquistão. O objetivo deste estudo foi investigar a prevalência de resistência a CQ de P. falciparum nesta área. Isolados clínicos foram coletados entre maio de 2017 e maio de 2018 nas agências do Waziristão do Norte e do Waziristão do Sul da Área de Ensaio Administrada Federalmente. Posteriormente, esfregaços de sangue corados com Giemsa foram examinados para detectar Plasmodium falciparum. A extração do DNA da malária foi feita a partir de amostras de P. falciparum positivas para microscopia, e as infecções por P. falciparum foram confirmadas por nested PCR (visando genes de ácido ribonucleico ribossômico de subunidade pequena de Plasmodium (ssrRNA)). Todas as amostras de P. falciparum confirmadas por PCR foram sequenciadas por pirosequenciamento para descobrir a mutação no gene Pfcrt no códon K76T e em pfmdr1 nos códons N86Y, Y184F, N1042D e D1246Y. De 121 microscopias de casos positivos de P. falciparum, 109 amostras foram positivas para P. falciparum por nested PCR. A mutação Pfcrt K76T foi encontrada em 96% dos isolados, a mutação Pfmdr1 N86Y foi observada em 20% e 11% abrigou a mutação Y184F. Todas as amostras eram do tipo selvagem para o códon N1042D e D1246Y de Pfmdr1. No FATA, Paquistão, a frequência do alelo resistente 76T permaneceu alta apesar da remoção de CQ. No entanto, as descobertas atuais do estudo sugerem a fixação completa do genótipo resistente a CQ de P. falciparum na área de estudo.

Community- vs. hospital-based management of multidrug-resistant TB in Pakistan.

BACKGROUND Multidrug-resistant TB (MDR-TB) treatment takes 18-24 months and is complex, costly and isolating. We provide trial evidence on the WHO Pakistan recommendation for community-based care rather than hospital-based care.METHODS Two-arm, parallel-group, superiority trial was conducted in three programmatic management of drug-resistant TB hospitals in Punjab and Sindh Provinces, Pakistan. We enrolled 425 patients with MDR-TB aged >15 years through block randomisation in community-based care (1-week hospitalisation) or hospital-based care (2 months hospitalisation). Primary outcome was treatment success.RESULTS Among 425 patients with MDR-TB, 217 were allocated to community-based care and 208 to hospital-based care. Baseline characteristics were similar between the community and hospitalised arms, as well as in selected sites. Treatment success was 74.2% (161/217) under community-based care and 67.8% (141/208) under hospital-based care, giving a covariate-adjusted risk difference (community vs. hospital model) of 0.06 (95% CI -0.02 to 0.15; P = 0.144).CONCLUSIONS We found no clear evidence that community-based care was more or less effective than hospital-based care model. Given the other substantial advantages of community-based care over hospital based (e.g., more patient-friendly and accessible, with lower treatment costs), this supports the adoption of the community-based care model, as recommended by the WHO.

EVALUATION OF SOME BIOCHEMICAL MARKERS AND THE ANTIBODY RESPONSE TO HEPATITIS B VACCINE IN HEMODIALYSIS PATIENTS.

OBJECTIVE: The aim: The goal of this study was to assess the immune response to the HB vaccine (the level of anti-HBs titer), as well as the prevalence of serum creatinine, urea, CRP, and serum albumin levels, and the relationship between these and immune response to the vaccine. PATIENTS AND METHODS: Materials and methods: 127 patients with chronic renal disease on hemodialysis (HD) were compared to 40 healthy people in Iraqi dialysis center, Baghdad. Antibodies to the hepatitis B core antigen (anti-HBc) were detected using the ARCHITECT SYSTEM and the Anti-HBs titer, HBs Ag, Anti-HCV determined by ELISA. RESULTS: Results: When compared to the poor and non-responder groups, the mean value of anti-HBs titer increased considerably in the good responder group. The good responder and control groups, on the other hand, showed no significant changes. The anti-HBs titer was found to have the strongest negative correlation with serum creatinine, blood urea, and C-reactive protein levels. There was a considerable positive connection between anti-HBs titer and albumin levels. CONCLUSION: Conclusions: The responses of HD patients to the HB vaccine revealed the significant negative relation between serum creatinine, blood urea levels, and CRP, as well as a significant positive correlation between serum albumin.

EVALUATION OF SEROLOGICAL SCREENING AND PCR-AMPLIFICATION OF HEPATITIS B VIRUS DNA AMONG IRAQI BLOOD DONORS.

OBJECTIVE: The aim: Infection with the hepatitis B virus (HBV) caused by blood transfusion is a big problem throughout the world. The aim of study is to determine the faster and more accurate methods for detection of hepatitis B infections by serological screening and PCR- amplification. PATIENTS AND METHODS: Materials and methods: A total of 140528 donors were tested for HBsAg and total anti-HBc from January to October 2021 in Iraq's National Blood Transfusion Center; however, only 100 samples with HBsAg (-) and anti-HBc (+) were collected and tested for HBV DNA using quantitative real-time PCR. RESULTS: Results: From 2015 to 2021, the percentage of HBsAg positive donors was 0.33 percent in 2015, 0.32 percent in 2016, 0.30 percent in 2017, 0.28 percent in 2018, 0.23 percent in 2019, 0.22 percent in 2020, and 0.27 percent in 2021. Between January and October of 2021, the overall anti-HBc rate among the (140528) donors was 4.42 percent. According to our findings, only 7% of blood samples from NBTC donors with HBsAg (-) anti-HBc (+) were positive for HBV DNA. The results showed no significant change in HBs Ag (+) and total anti-HBc rates among blood donors between 2015 and 2021. CONCLUSION: Conclusions: HBV infection could be transmitted from a blood donor with OBI. PCR (RT PCR) is substantially more sensitive and effective. Despite this the use of an anti-HBc test for blood donors could be seen as a second choice to control HBV from spreading during blood transfusions.

Fixation of pfcrt chloroquine resistance alleles in Plasmodium falciparum clinical isolates collected from unrest tribal agencies of Pakistan.

Plasmodium falciparum resistance to Chloroquine (CQ) is a significant cause of mortality and morbidity worldwide. There is a paucity of documented data on the prevalence of CQ-resistant mutant haplotypes of Pfcrt and Pfmdr1 genes from malaria-endemic war effected Federally Administered Tribal Areas of Pakistan. The objective of this study was to investigate the prevalence of P. falciparum CQ-resistance in this area. Clinical isolates were collected between May 2017 and May 2018 from North Waziristan and South Waziristan agencies of Federally Administrated Trial Area. Subsequently, Giemsa-stained blood smears were examined to detect Plasmodium falciparum. Extraction of malarial DNA was done from microscopy positive P. falciparum samples, and P. falciparum infections were confirmed by nested PCR (targeting Plasmodium small subunit ribosomal ribonucleic acid (ssrRNA) genes). All PCR confirmed P. falciparum samples were sequenced by pyrosequencing to find out mutation in Pfcrt gene at codon K76T and in pfmdr1 at codons N86Y, Y184F, N1042D, and D1246Y. Out of 121 microscopies positive P. falciparum cases, 109 samples were positive for P. falciparum by nested PCR. Pfcrt K76T mutation was found in 96% of isolates, Pfmdr1 N86Y mutation was observed in 20%, and 11% harboured Y184F mutation. All samples were wild type for Pfmdr1 codon N1042D and D1246Y. In the FATA, Pakistan, the frequency of resistant allele 76T remained high despite the removal of CQ. However, current findings of the study suggest complete fixation of P. falciparum CQ-resistant genotype in the study area.

The therapeutic potential of convalescent plasma therapy on treating critically-ill COVID-19 patients residing in respiratory care units in hospitals in Baghdad, Iraq.

The current COVID-19 pandemic needs unconventional therapies to tackle the resulted high morbidity and mortality. Convalescent plasma is one of the therapeutic approaches that might be of benefit. Forty nine early-stage critically-ill COVID-19 patients residing in Respiratory Care Units (RCU) of three hospitals in Baghdad, Iraq, were included: 21 received convalescent plasma while 28, namely control group, did not receive it. Recovery or death, length of stay in hospital, and improvement in the clinical course of the disease were monitored clinically along with laboratory monitoring through SARS-CoV-2 RNA detection via PCR, and SARS-CoV-2 IgG and IgM serological monitoring. Patients who received convalescent plasma showed reduced duration of infection in about 4 days and showed less death rate [1/21 versus 8/28 in control group]. In addition, all the patients who were given convalescent plasma showed high levels of SARS-CoV-2 IgG and IgM three days after plasma transfusion. Plasma from donors with high levels of SARS-CoV-2 IgG and donors with positive SRAS-CoV-2 IgM showed better therapeutic results than other donors. Convalescent plasma therapy is an effective therapy if donors with high level of SARS-Cov2 antibodies are selected and if recipients are at their early stage of critical illness, being no more than three days in RCUs.

The therapeutic effectiveness of Convalescent plasma therapy on treating COVID-19 patients residing in respiratory care units in hospitals in Baghdad, Iraq

ObjectivesThe current COVID-19 pandemic needs unconventional therapies to tackle the resulted high morbidity and mortality. Convalescent plasma is one of the therapeutic approaches that might be of benefit. MethodsForty nine early-stage critically-ill COVID-19 patients residing in RCU of three hospitals in Baghdad, Iraq were included, 21 received convalescent plasma while 28 did not receive, namely control group. Recovery or death, length of stay in hospital, and improvement in the clinical course of the disease were monitored clinically along with laboratory monitoring through SARS-CoV-2 RNA detection via PCR, and SARS-CoV-2 IgG and IgM serological monitoring. ResultsPatients received convalescent plasma showed reduced duration of infection in about 4 days, and showed less death rate, 1/21 versus 8/28 in control group. In, addition, all of the patients received convalescent plasma showed high levels of SARS-CoV-2 IgG and IgM 3 days after plasma transfusion. Plasma from donors with high levels of SARS-CoV-2 IgG and donors with positive SRAS-CoV-2 IgM showed better therapeutic results than other donors. ConclusionsConvalescent plasma therapy is an effective mode of therapy if donors with high level of SARS-Cov2 antibodies are selected and if recipients were at their early stage of critical illness, being no more than 3 days in RCU.

Evaluation of sagittal condylar guidance angles using computerized pantographic tracings, protrusive interocclusal records, and 3D-CBCT imaging techniques for oral rehabilitation.

OBJECTIVE: The goal of registering the condylar guidance is to recreate the patient's occlusion as exactly as possible on the articulator, and is therefore essential for successful prosthodontic rehabilitation. Clinical, radiographic, and pantographic methods are used to determine sagittal condylar guidance angles (SCGAs). These methods generate different angles in the same patients. The present study is the first disquisition to evaluate and correlate SCGAs determined by the use of pantographic tracing (PT), protrusive records (PR), and radiographic (CBCT) techniques. MATERIALS AND METHODS: The condylar guidance was measured using PT, PR, and CBCT imaging techniques in 23 nonpatient participants aged between 18 and 30 years irrespective of sex. PT was recorded using Cadiax® Compact system, a computerized recorder of SCGAs. PR was obtained using polyvinyl siloxane bite registration material, transferred to a semiadjustable articulator (Denar Mark II, Whip Mix Corp., USA) using facebow transfer (Denar Mark II, Whip Mix Corp., USA) and CR records, to determine SCGAs. Images of the mid-facial region were obtained using CBCT scan for 3D reconstruction. The angle formed between Frankfort horizontal plane (FHP) and a line extending from the most supero-anterior point on the glenoid fossa to the most convex point on the apex of articular eminence (AE) was measured to obtain SCGAs. RESULTS: The mean left and right SCGAs were as follows: PT (34.42° and 33.93°, respectively), PR (32.14° and 31.82°), and CBCT (38.96° and 38.12°). The Pearson coefficients for the correlations with PT and PR on the left and right sides were 0.899 and 0.907, respectively, while it was 0.911 and 0.934, and 0.842 and 0.874 from PT and CBCT, and PR and CBCT, respectively. CONCLUSION: Strong correlations were found between SCGAs obtained using PT, PR, and CBCT techniques.

Role of oral vaccines as an edible tool to prevent infectious diseases.

Plants have been as medicinal mediators for centuries. Recent trends in agro-biotechnology however, improved the therapeutic roles of plants to a significant level and introduced plant-based oral vaccine which can arouse an immune response in consumer. Although conventional vaccines against infectious diseases have been administrated for years the discovery of plant-based oral vaccines can potentially replace them completely in the future. The probable limitations in conventional vaccines are found to be overcome by plant-based oral vaccines. Humans and animals will no longer be dependent upon local or systemic administration of vaccines but they will just receive the vaccines as a routine food. For the purpose, gene of interest is introduced into plant through transformation, and expression of specific antigen is obtained in plant products which are then consumed by humans or animals. Therefore, plants can serve as bioreactors or bio-factories for production of edible vaccines. A detailed overview about edible vaccines, methods for edible vaccine production, candidate bioreactors and future perspectives of edible vaccines has been summarized in current article. The future of vaccination seems to be present within plant-based vaccination system. Keywords: vaccine; edible vaccine; infectious diseases; antigen; edible crops; oral immunization.

Community-based integrated approach to changing women's family planning behaviour in Pakistan, 2014-2016.

Setting: Karachi, Pakistan. Objective: To assess the effectiveness of a community-based integrated approach in changing women's behaviour regarding contraceptive use. Design: The Sukh Initiative is a multipronged approach with door-to-door services using community health workers to provide quality family planning/reproductive health services at both public and private facilities and a 24/7 family planning helpline service that provides youth skill-based education. Methods: Retrospective pre- and post-intervention data using samples of 5140 and 3810 women, respectively. Results: The contraceptive prevalence rate increased by 10.7%, from 42.3% at baseline to 53.0% mid-intervention, with an increase in use of modern contraceptive methods of 9.2%. A significant association was found between door-to-door counselling and the use of contraceptive methods (OR 3.4, 95%CL 2.9-4.1) and access to public and private facilities for modern contraceptives (OR 2.4, 95%CL 2.0-3.0). However, support group meetings and 24/7 helpline use did not show any association with use of contraceptive method. Conclusion: The study helped to increase access to and choice of family planning services through a community-based approach that successfully reduced unmet needs and improved continuity in contraceptive use.

Contexte : Des enquêtes avant et après intervention ont été réalisées à Karachi, Pakistan.Objectif : Evaluer l'efficacité d'une approche intégrée à base communautaire afin de modifier le comportement des femmes en matière d'utilisation de la contraception.Schéma : La Sukh Initiative est une approche multiple avec des services de porte-à-porte par des travailleurs de santé communautaire, la fourniture de services de qualité en matière de planification familiale/santé reproductive, à la fois dans des structures publiques et privées, offrant une disponibilité 24/7 d'une assistance téléphonique en planification familiale et engager les jeunes pour les guider grâce à une éducation basée sur les compétences de vie.Méthodes : On a utilisé les données rétrospectives des enquêtes avant et après l'intervention, avec un échantillon de respectivement 5141 et 3861 femmes.Résultats : Le taux de prévalence contraceptive a augmenté de 10,7% par rapport au taux initial (42,3% contre 53,0% à mi-parcours), avec une augmentation du taux d'utilisation des méthodes contraceptifs modernes de 9,2%. Des associations significatives ont été constatées entre le conseil en porte-à-porte et l'utilisation de méthodes contraceptives (OR 3,4 ; niveau de confiance à 95% 2,9­4,1), et l'accès aux structures publiques et privées pour des contraceptifs modernes (OR 2,4 ; niveau de confiance à 95% 2,0­3,0). Les réunions de groupes de soutien et l'assistance téléphonique 24/7 n'ont cependant pas mis en évidence d'association avec l'utilisation d'une méthode contraceptive.Conclusion : L'étude actuelle a contribué à augmenter l'accès aux services de planification familiale et le choix des méthodes grâce à une approche à base communautaire qui a réduit avec succès les besoins non satisfaits et amélioré la continuité de l'utilisation de contraceptifs.

Marco de Referencia: En Karachi, Paquistán, se llevaron a cabo encuestas antes y después de una intervención.Objetivo: Evaluar la eficacia de una estrategia comunitaria integrada, encaminada a modificar el comportamiento de las mujeres con respecto a la utilización de los anticonceptivos.Diseño: La iniciativa Sukh consiste en un enfoque en varios frentes, que comporta servicios puerta a puerta a cargo de agentes de salud comunitarios, provisión de servicios de planificación familiar y salud reproductiva de gran calidad en establecimientos del sector público y el sector privado, con asistencia telefónica permanente en materia de planificación familiar y búsqueda de la participación de los jóvenes en tutorías de preparación para la vida activa.Método: Se realizó un análisis retrospectivo de los datos de una encuesta anterior a la intervención realizada a 5141 mujeres y de 3861 mujeres en una encuesta posterior a la misma.Resultados: La tasa de prevalencia de utilización de anticonceptivos aumentó hasta un 10,7% con respecto al valor inicial (42,3% contra 53,0% en mitad del período), con un aumento de 9,2% del recurso a los métodos modernos de anticoncepción. Se observó una asociación significativa del asesoramiento puerta a puerta con el uso de métodos anticonceptivos (OR 3,4; nivel de confianza a 95% 2,9­4,1) y el recurso a los servicios de establecimientos públicos y privados para la utilización de métodos anticonceptivos modernos (OR 2,4; nivel de confianza a 95% 2,0­3,0). Sin embargo, las reuniones en grupos de apoyo y la asistencia telefónica permanente no exhibieron ninguna correlación.Conclusión: Según el estudio realizado, se aumentó el acceso a los servicios de planificación familiar y la decisión de acudir a ellos, gracias a una estrategia comunitaria que logró reducir las necesidades insatisfechas y reforzar la continuidad de la utilización de los anticonceptivos.

Did diabetes mellitus affect treatment outcome in drug-resistant tuberculosis patients in Pakistan from 2010 to 2014?

Settings: All hospitals managing drug-resistant tuberculosis (DR-TB) according to national guidelines in Pakistan. Objectives: To assess the effect of diabetes mellitus (DM) and factors associated with unfavourable outcomes in DR-TB. Methods: A cross-sectional study based on a retrospective record review of patients enrolled on DR-TB treatment from 2010 to 2014 in Pakistan. DR-TB data reported to Pakistan's National TB Control Programme on a monthly basis were used for the study. Result: Among 5811 patients enrolled on second-line drugs, 8.8% had DM. Overall, 68.9% had favourable outcomes. No association was found between DM and DR-TB treatment outcomes (risk ratio 0.90, 95%CI 0.74-1.05). Unfavourable outcomes were more frequent among DR-TB patients with human immunodeficiency virus (HIV) co-infection (OR 11.58, 95%CI 2.20-60.72), extensively drug-resistant TB patients (OR 5.36, 95%CI 1.00-28.72), patients with exposure to both first-line and second-line anti-tuberculosis drugs (OR 2.45, 95%CI 1.21-4.97) and those with a previous history of treatment in the private sector (OR 1.53, 95%CI 1.16-2.02). Conclusion: Although there were limitations to correctly measuring DM and its management, DM appears not to be a risk factor for unfavourable outcomes in DR-TB patients in our study. DR-TB and HIV co-infection, second-line drug resistance and history of treatment in the private sector were nevertheless more frequently associated with adverse outcomes.

Contexte : Tous les hôpitaux prenant en charge la tuberculose pharmacorésistante (TB-DR) selon les directives nationales du Pakistan.Objectif : Evaluer l'effet du diabète (DM) et les facteurs associés à un résultat défavorable du traitement de la TB-DR.Méthode : Etude transversale basée sur une revue rétrospective de dossiers de patients enrôlés dans un traitement de TB-DR de 2010 à 2014 au Pakistan. Les registres de TB-DR envoyés au programme national de lutte contre la TB chaque mois ont été utilisés pour l'étude.Résultats : Parmi 5811 patients enrôlés dans un traitement par médicaments de deuxième ligne, 8,8% avaient un DM. Dans l'ensemble, 68,9% ont eu des résultats favorables. Il n'a pas été trouvé d'association entre le DM et le résultat du traitement de la TB-DR (ratio de risque 0,90 ; IC95% 0,74­1,05). Les facteurs associés à des résultats défavorables sont la coinfection par TB-DR et le virus de l'immunodéficience humaine (VIH) (OR 11,58 ; IC95% 2,20­60,72), la TB ultrarésistante (OR 5,36 ; IC95% 1,00­28,72), l'exposition à la fois aux médicaments de première ligne et de deuxième ligne (OR 2,45 ; IC95% 1,21­4,97) et des antécédents de traitement dans le secteur privé (OR 1,53 ; IC95% 1,16­2,02).Conclusion : Dans notre étude, avec ses limites en termes de mesures correctes du DM et de sa prise en charge, le DM ne semble pas être un facteur de risque de résultat défavorable pour les patients TB-DR. Par contre, la coinfection TB-DR et VIH, la résistance aux médicaments de deuxième ligne et les antécédents de traitement dans le secteur privé ont été associés à des résultats médiocres.

Marco de referencia: Todos los hospitales que suministran tratamiento contra la tuberculosis farmacorresistente (TB-DR) en el marco de las directrices nacionales de Pakistán.Objetivo: Evaluar el efecto de la diabetes (DM) sobre el desenlace de la TB-DR y los factores que se asocian con los desenlaces desfavorables.Método: Un estudio transversal realizado a partir del examen retrospectivo de las historias clínicas de los pacientes que iniciaron tratamiento por TB-DR del 2010 al 2014 en el Pakistán.Métodos: En el presente estudio se consultaron los registros de los casos de TB-DR que se notifican mensualmente al Programa Nacional de control de la Tuberculosis.Resultados: De los 5811 pacientes que iniciaron tratamiento con medicamentos de segunda línea, el 8,8% sufría DM. En general, el 68,9% de los casos alcanzó desenlaces favorables. No se observó ninguna asociación entre la presencia de DM y el desenlace terapéutico de la TB-DR (riesgo relativo 0,90; IC95% 0,74­1,05). Los factores que se asociaron con desenlaces desfavorables fueron la coinfección por el virus de la inmunodeficiencia humana (VIH) y la TB-DR (OR 11,58; IC95% 2,20­60,72), la TB ultrarresistente (OR 5,36; IC95% 1,00­28,72), la exposición a los dos tipos de fármacos, de primera y de segunda línea (OR 2,45; IC95% 1,21­4,97) y el antecedente de tratamiento antituberculoso en el sector privado (OR 1,53; IC95% 1,16­2,02).Conclusión: Según los resultados del presente estudio, pese a algunas limitaciones en la evaluación correcta de la DM y su tratamiento, no pareciera que la presencia de DM fuese un factor de riesgo de resultados desfavorables del tratamiento de pacientes con TB-DR. Sin embargo, la coinfección por el VIH y la TB-DR, la resistencia a fármacos de segunda línea y el antecedente de tratamiento antituberculoso en el sector privado se asociaron con desenlaces desfavorables.

Pre-treatment loss to follow-up among smear-positive TB patients in tertiary hospitals, Quetta, Pakistan.

Setting: Three public sector tertiary care hospitals in Quetta, Balochistan, Pakistan, with anecdotal evidence of gaps between the diagnosis and treatment of patients with tuberculosis (TB). Objectives: To assess the proportion of pre-treatment loss to follow-up (LTFU), defined as no documented evidence of treatment initiation or referral in TB registers, among smear-positive pulmonary TB patients diagnosed in 2015, and the associated sociodemographic factors. Design: A retrospective cohort study involving the review of laboratory and TB registers. Results: Of 1110 smear-positive TB patients diagnosed (58% female, median age 40 years, 5% from outside the province or the country), 235 (21.2%) were lost to follow-up before starting treatment. Pre-treatment LTFU was higher among males; in patients residing far away, in rural areas, outside the province or the country; and in those without a mobile phone number. Conclusion: About one fifth of the smear-positive TB patients were lost to follow-up before starting treatment. Strengthening the referral and feedback mechanisms and using information technology to improve the tracing of patients is urgently required. Further qualitative research is needed to understand the reasons for pre-treatment LTFU from the patient's perspective.

Contexte : Trois hôpitaux publics tertiaires à Quetta, Baloutchistan, Pakistan, avec des preuves empiriques d'un fossé entre le diagnostic et le traitement des patients tuberculeux (TB).Objectif : Evaluer la proportion de patients perdus de vue avant le traitement (pas de preuve documentée de mise en route du traitement ou de référence dans les registres TB) parmi les patients atteints de TB pulmonaire à frottis positif diagnostiqués en 2015, et identifier les facteurs sociodémographiques associés.Schéma : Etude rétrospective de cohorte impliquant une revue des registres de laboratoire et de TB.Résultats : Sur 1110 patients TB à frottis positif diagnostiqués (58% de femmes, d'âge médian 40 ans, 5% venant de l'extérieur de la province ou du pays), 235 (21,2%) ont été perdus de vue avant de démarrer le traitement. Cette perte de vue avant le traitement a été plus élevée parmi les hommes ; parmi les patients résidant loin, en zone rurale, hors de la province ou du pays ; et parmi ceux ne possédant pas de téléphone portable.Conclusion : Environ un cinquième des patients TB à frottis positif ont été perdus de vue avant la mise en route du traitement. Il est nécessaire de manière urgente de renforcer les mécanismes de référence et de retro-information et d'avoir une meilleure traçabilité des patients grâce aux techniques d'information. Une autre recherche qualitative est requise afin de comprendre les raisons de cette perte de vue avant le traitement selon la perspective des patients.

Marco de referencia: Tres hospitales de atención terciaria del sector público de Quetta, en la provincia de Balochistán del Pakistán, donde existen datos anecdóticos de un desfase entre el diagnóstico y el tratamiento de los pacientes con tuberculosis (TB).Objetivos: Evaluar la proporción de pérdidas durante el seguimiento antes de comenzar el tratamiento (falta de documentación de la iniciación del tratamiento o la remisión a otros centros en los registros de TB) de los pacientes con TB pulmonar y baciloscopia positiva diagnosticados en el 2015 y analizar los factores socioeconómicos determinantes.Métodos: Un estudio retrospectivo de cohortes a partir del examen de los registros de laboratorio y los registros de TB.Resultados: De los 1110 pacientes con baciloscopia positiva diagnosticados (58% de sexo femenino, mediana de la edad 40 años y 5% procedente de otra provincia o país), 235 (21,2%) se perdieron durante el seguimiento antes de iniciar el tratamiento. Estas pérdidas fueron mayores en los pacientes de sexo masculino; los pacientes que residían en zonas rurales remotas, fuera de la provincia o del país; y en las personas que no contaban con un número de teléfono celular.Conclusión: Cerca de un quinto de los pacientes con diagnóstico de TB y baciloscopia positiva se perdió durante el seguimiento antes de comenzar el tratamiento. Es urgente fortalecer el mecanismo de remisiones y de retroinformación de los resultados y mejorar la localización de los pacientes haciendo uso de la tecnología de la información. Se precisan nuevas investigaciones cualitativas que favorezcan la comprensión de las razones de esta pérdida durante el seguimiento desde la perspectiva de los pacientes.

Infection control in hospitals managing drug-resistant tuberculosis in Pakistan: how are we doing?

Setting: Ten hospitals managing drug-resistant tuberculosis (TB) in Pakistan. Objective: To assess the implementation of TB infection control (IC) practices and reasons for non-adherence to guidelines. Design: This was a descriptive study conducted between April and October 2016 with three components: 1) non-participant observation of service delivery areas (SDAs) (n = 82) in hospitals (n = 10) using structured checklists; 2) exit interviews with 100 patients (10 per hospital); and 3) interviews with 100 health-care workers (HCWs, 10/hospital). Results: Of the 82 SDAs, posters were displayed in 34 (41%), mechanical ventilation was implemented in 79% and functional ultraviolet germicidal irradiation (UVGI) was available in only 26%. Patient interviews showed 50-65% adherence to triage and use of personal protective measures. Key reasons for non-adherence were lack of adequate supplies, discomfort using N-95 masks, a lack of knowledge or training, perceived non-cooperation by patients, poor maintenance of mechanical ventilators and UVGI due to unstable electricity supply, a lack of clarity in roles (no-one designated in charge) and staff shortages and subsequent workloads. Adherence to natural ventilation usage was poor for reasons related to climate and privacy. Conclusion: Implementation of TBIC measures in hospitals was suboptimal. Urgent measures need to be put in place, including retraining of HCWs, addressing weaknesses in mask and poster supplies and constant supervision and monitoring.

Contexte : Dix hôpitaux prenant en charge la tuberculose (TB) pharmacorésistante au Pakistan.Objectif : Evaluer la mise en œuvre des pratiques de lutte contre l'infection TB (CITB) et les raisons de la non-adhésion aux directives.Schéma : Étude descriptive réalisée entre avril et octobre 2016 avec trois composants : 1) observation non participative des zones de prestations de service (SDA) (n = 82) dans des hôpitaux (n = 10) grâce à des checklists structurées ; 2) entretiens de sortie avec 100 patients (10 par hôpital) ; 3) entretiens avec 100 prestataires de soins de santé (HCW, 10 par hôpital).Résultats : Parmi 82 SDA, des affiches ont été déployées dans 34 (41%) d'entre elles, une ventilation mécanique a été mise en œuvre dans 79% et un système fonctionnel d'irradiation par ultraviolets germicides (UVGI) a été disponible dans seulement 26%. Les entretiens avec les patients ont mis en évidence 50­65% d'adhérence au triage et à l'utilisation de mesures de protection personnelles. Les raisons majeures de la non-adhésion ont été le manque de fournitures appropriées, l'inconfort d'utilisation des masques N-95, le manque de connaissance ou de formation, la perception d'une non-coopération par les patients, la maintenance médiocre des ventilateurs mécaniques et de l'UVGI à cause de l'instabilité de l'alimentation électrique et le manque de clarification des responsabilités (aucune personne désignée responsable), et la pénurie de personnel avec surcharge de travail du personnel présent. L'adhésion à la ventilation naturelle a été médiocre en raison du climat et pour des problèmes de confidentialité.Conclusion : La mise en œuvre de mesures de CITB dans les hôpitaux a été sous-optimale. Des mesures urgentes sont requises, notamment la formation continue des HCW, la lutte contre les problèmes de fourniture de masques et d'affiches et une supervision et un suivi constants.

Marco de referencia: Diez hospitales que se ocupan del tratamiento de la tuberculosis (TB) multirresistente en el Pakistán.Objetivo: Evaluar la aplicación de las prácticas de control de la infección TB (CITB) y determinar las razones del incumplimiento de las normas.Método: De abril a octubre del 2016 se realizó un estudio descriptivo que comportó los siguientes elementos: 1) personas no vinculadas evaluaron las zonas de prestación de servicios (n = 82) en los hospitales (n = 10), con listas de verificación estructuradas; 2) se realizaron entrevistas de salida a 100 pacientes (10 por cada hospital) y 3) entrevistas a 100 profesionales de salud (HCW; 10 por cada hospital).Resultados: De las 82 zonas de prestación de servicios evaluadas, en 34 había afiches expuestos (41%), el 79% contaba con sistemas de ventilación mecánica y solo en el 26% existía un dispositivo funcional de radiación ultravioleta germicida (UVGI). Las entrevistas a los pacientes revelaron un cumplimiento de 50% a 65% con la selección de los pacientes y las medidas de protección personal. Las principales explicaciones del incumplimiento fueron la insuficiencia de suministros, la incomodidad de utilización de las mascarillas N-95, la carencia de conocimientos o capacitación adecuada, la percepción de una falta de cooperación por parte de los pacientes, un mantenimiento deficiente de los ventiladores mecánicos y los dispositivos de UVGI debido a la inestabilidad del suministro eléctrico y la poca claridad con respecto a las funciones (falta de designación de una persona encargada), la escasez de personal y la consecuente sobrecarga de trabajo. El cumplimiento de las normas de ventilación natural era deficiente por causa de las condiciones climáticas y aspectos relacionados con el respeto de la intimidad.Conclusión: La aplicación de las medidas de CITB en los hospitales es deficiente. Se precisa de manera urgente instaurar medidas como la actualización de la formación de los HCW, la corrección de las deficiencias en el abastecimiento de mascarillas y afiches y la práctica constante de la supervisión y la vigilancia.

Can the number of patients with presumptive tuberculosis lost in the general health services in Pakistan be reduced?

The frequency of patients with presumptive tuberculosis (TB) who are not investigated by sputum smear microscopy is unknown in Pakistan. Using a simple intervention comparing patient and laboratory registers, patients with presumptive TB were identified in two districts from July to December 2013, a list of missing patients was prepared and the patients traced. The intervention significantly reduced the number of patients with presumptive TB lost, from 8.5% before the intervention to 6.9% after. A systematic comparison of out-patient and laboratory registers, followed by tracing missing persons, can reduce the proportion of patients with presumptive TB lost before diagnosis.

Investigation of presumptive tuberculosis cases by private health providers: lessons learnt from a survey in Pakistan.

Pakistan's National Tuberculosis Control Programme (NTP) is missing data on many tuberculosis (TB) cases who visit private providers. A survey on the incidence and under-reporting of TB in Pakistan provided a database for exploring the investigation and referral of presumptive TB cases by private health providers. The survey showed that private health providers requested both sputum smear and X-ray for diagnostic investigations. Of 2161 presumptive TB cases referred, 1189 (55%) were sent for investigations to a district NTP TB centre, of whom only 314 (26.4%) were registered. This indicates an urgent need to strengthen the link between private health providers and NTP to enhance TB notification.

Le Programme national de lutte contre la tuberculose (PNT) du Pakistan manque de nombreux cas de tuberculose (TB) soignés par des prestataires de soins privés. Une enquête sur l'incidence et la sous-déclaration de la TB au Pakistan a fourni une base de données afin d'explorer les investigations réalisées en cas de présomption de TB et leur référence par les prestataires de soins privés. L'enquête a montré que les prestataires privés demandaient à la fois un frottis de crachats et une radiographie pour le diagnostic. Sur 2161 cas suspects de TB référés, 1189 (55%) ont été envoyés pour investigations à un centre anti-tuberculeux de district (PNT), parmi lesquels seulement 314 (26,4%) ont été enregistrés. Ceci met en évidence le besoin urgent de renforcer les liens entre les prestataires privés et les PNT afin d'améliorer la déclaration de la TB.

En el Programa Nacional contra la Tuberculosis (PNT) del Pakistán se están pasando por alto muchos casos de tuberculosis (TB) que acuden a los profesionales del sector privado. A partir de una encuesta sobre la incidencia de TB y la tasa de subnotificación en el país, se examinó la investigación de los casos y la remisión de las personas con presunción diagnóstica de TB por parte de los profesionales del sector privado. Se puso en evidencia que en el sector privado, los profesionales investigan la TB mediante la solicitud de la baciloscopia del esputo y además la radiografía de tórax. De los 2161 casos referidos por presunción diagnóstica, 1189 (55%) se remitieron para estudio al centro distrital PNT de TB y de ellos solo se registraron 314 (26,4%). Estos resultados indican la urgencia que existe de fortalecer los vínculos entre los profesionales del sector privado y el PNT, con el fin de mejorar la notificación de los casos de TB.