Integrating a Community-Based Health Information System with a Patient-Centered Medical Home to improve care of patients with hypertension: a longitudinal observational study protocol.

BACKGROUND: The primary healthcare system in Pakistan focuses on providing episodic, disease-based care. Health care for low-middle income communities is largely through a fee-for-service model that ignores preventive and health-promotive services. The growing burden of cardiovascular illnesses requires restructuring of the primary health care system allowing a community-to-clinic model of care to improve patient- and community-level health indicators. METHODS: We propose a model that integrates a Patient-Centered Medical Home (PCMH) with a Community-Based Health Information System (CBHIS) using hypertension (HTN) as an example. This protocol describes the integration and evaluation of the PCMH-CBHIS infrastructure through a population-based, observational, longitudinal study in a low-middle income, urban community in Pakistan. Participants are being enrolled in CBHIS and will be followed longitudinally over two years for HTN outcomes. A mixed-methods approach is adopted to evaluate the process of integrating PCMH with CBHIS. This involves building partnerships with the community through formal and informal meetings, focus group discussions, and a household health assessment survey (HAS). Community members identified with HTN are linked to PCMH for disease management. A customized electronic medical record system links community-level data with patient-level data to track changes in disease burden. The RE-AIM evaluation framework will be used to monitor community and individual-level metrics to guide implementation assessment, the potential for generalization, and the effectiveness of the PCMH in improving HTN-related health outcomes. Ethical clearance has been obtained from the Ethics Review Committee at Aga Khan University (2022-6723-20985). DISCUSSION: This study will evaluate the value of restructuring the primary care health system by ensuring systematic community engagement and measurement of health indicators at the patient- and community-level. While HTN is being used as a prototype to generate evidence for the effectiveness of this model, findings from this initiative will be leveraged towards strengthening the management of other acute and chronic conditions in primary care settings. If effective, the model can be used in Pakistan and other LMICs and resource-limited settings.

Hepatitis C prevalence and elimination planning in Pakistan, a bottom-up approach accounting for provincial variation.

In Pakistan, substantial changes to hepatitis C virus (HCV) programming and treatment have occurred since the 2008 nationwide serosurvey estimated a 4.8% anti-HCV prevalence. In the absence of an updated national study, this analysis uses provincial data to estimate a national prevalence and the interventions needed to achieve elimination. Using a Delphi process, epidemiologic HCV data for the four provinces of Pakistan (accounting for 97% of the population) were reviewed with 21 subject-matter experts in Pakistan. Province-level estimates were inputted into a mathematical model to estimate the national HCV disease burden in the absence of intervention (Base), and if the World Health Organization (WHO) elimination targets are achieved by 2030 (80% reduction in new infections, 90% diagnosis coverage, 80% treatment coverage, and 65% reduction in mortality: WHO Elimination). An estimated 9,746,000 (7,573,000-10,006,000) Pakistanis were living with viraemic HCV as of January 1, 2021; a viraemic prevalence of 4.3% (3.3-4.4). WHO Elimination would require an annual average of 18.8 million screens, 1.1 million treatments, and 46,700 new infections prevented anually between 2022 and 2030. Elimination would reduce total infections by 7,045,000, save 152,000 lives and prevent 104,000 incident cases of hepatocellular carcinoma from 2015 to 2030. Blood surveys, programmatic data, and expert panel input uncovered more HCV infections and lower treatment numbers in the provinces than estimated using national extrapolations, demonstrating the benefits of a bottom-up approach. Screening and treatment must increase 20 times and 5 times, respectively, to curb the HCV epidemic in Pakistan and achieve elimination by 2030.

Visual symptoms with Sofosbuvir in hepatitis C treatment - a case report from Pakistan.

Hepatitis C virus infection is one of the main causes of chronic liver disease worldwide. The highly efficacious direct-acting antiviral (DAA) drugs licensed for therapy have revolutionised the treatment and are reported to have few side effects. Sofosbuvir is a pan-genotypic DAA that acts by inhibition of the hepatitis C NS5B polymerase. It has shown high efficacy in combination with several other drugs with low toxicity, a high resistance barrier, and minimal drug interactions with other hepatitis C DAA drugs. We describe a first of its kind case from Pakistan with visual disturbances caused by Sofosbuvir. A temporal relationship was observed between the treatment initiation and the onset of visual disturbances. The aim of this case report is to draw attention to the unanticipated side effects of this relatively new class of drug that have not been reported previously.

Proactive Teleconsultation for Coronavirus Disease 2019 Cases Identified Through the Community-Testing Initiative in Karachi, Pakistan: A Low-Cost Value-Added Service to Support a Pandemic Response in a Resource-Limited Setting.

Introduction: Coronavirus disease 2019 (COVID-19) struck Pakistan with a magnitude that required micro- and macro-level adjustments at national and provincial levels. Access to medical consultation became a challenge; hospitals were flooded with cases beyond their capacity and transport was halted due to lockdown. Global Health Directorate of The Indus Health Network supported the provincial government by rolling out several walk-in community-based testing initiatives across Karachi. Results were conveyed to the patients through each district government. With a disproportionate rise in cases, an increasing delay in reporting results was observed. Methods: To help the district government bridge this gap, two physicians were engaged to convey timely results to patients who tested positive, through a helpline. Subsequently, proactive teleconsultation was initiated. We present a retrospective review of data collected during teleconsultation for COVID-19 cases identified through community-based testing between April 5 and June 10, 2020. Results: A total of 4,279 tests were conducted, revealing a 28% positivity rate (1,196 cases). Out of these, 752 (62.9%) baseline positive patients were contactable. Most patients identified either a close contact (46.8%) or a household contact (30.1%) as the source of infection. 41.8% patients were asymptomatic, 52.9% had mild to moderate illness, and 1.1% needed referral to the emergency department. 82.7% patients reported no comorbidities. Conclusion: The rapid surge of cases could not be handled by a small team and an institutional strategy of integration into an existing call center service was adopted. We share our insights to help develop evidence-based policies to effectively tackle current or future threats in similar settings.

Predictive factors for acquiring HCV infection in the population residing in high endemic, resource-limited settings.

BACKGROUND: In a country like Pakistan, a high prevalence of HCV persists due to a lack of awareness among the masses and the absence of adequate medical facilities in less privileged areas. Therefore, this study aimed to develop a risk-based screening tool based on the identification of predictive factors for HCV in the adult population in Karachi, Pakistan, which can later be validated for implementation. METHODOLOGY: A case-control study design was adopted and data was collected through an interview-based questionnaire from among 284 patients visiting the Family Medicine Department at The Indus Hospital, Karachi on whom the anti-HCV antibody test was conducted. Received data was then entered and analyzed using Statistical Package for the Social Sciences (SPSS) version 21.0. RESULT: Analysis indicated that in the entire cohort, marital status, employment status, history of being operated on in the past, family history of HCV infection, and body piercing were the factors significantly associated with positive HCV antibody. Results thus achieved show that the anti-HCV-positive rate was higher in ever married, employed, having had surgery, and family history of HCV infection (aOR: 2.42, 3.5, 2.04 and 2.5, P = 0.043, 0.002, 0.011 and 0.005, respectively). CONCLUSIONS: It is concluded that future research may be conducted enrolling the heterogeneous population to further probe the HCV burden and incidence in our society to initiate educational purposes. This goal can be achieved through commercial advertisements and free public lectures for disease prevention and better health awareness among the masses and the curers.

Relationship of FIB-4 index with transient elastography in chronic hepatitis C patients having APRI ≥ 0.5 - ≤2 in a resource-limited setting in Pakistan.

OBJECTIVE: We aimed to study the extent of liver fibrosis in chronic hepatitis C patients with indeterminate APRI score of ≥ 0.5 - ≤2 (between higher and lower cut off value) and correlate it to transient elastography (TE) and FIB 4 index. METHOD: A cross-sectional study, 80 patients with CHC mono infection, APRI score ≥ 0.5 - ≤2 were interviewed from the cohort visiting the CHC program clinic at a tertiary care hospital in Karachi, Pakistan. Data were analyzed using STATA 14.0 and R 3.5.2 and SPSS 24.0 software according to their capabilities. RESULT: Of 80 patients, 50 (62.5%) were females and 30 (37.5%) were males with mean (±SD) ages of 41.73 (±11.5) years and 41.16 (±9.24) years respectively. The FIB 4 value among indeterminate APRI was reported as 1.47 (IQR 1.05-2.43). TE categories was reported: F0-F1 (n = 29; 36%), F1-F2 (n = 10; 12.5%), F2 (n = 9; 11.2%) F3 (n = 13; 16.2%), F3-F4 (n = 1; 1.2%) F4 (n = 18; 22.5%). FIB4 had a moderate positive correlation with TE while a weak positive correlation was found between APRI and TE (0.488, P < 0.0001 and 0.289, P < 0.001, respectively). TE was taken as a gold standard and compared with FIB4. The model constructed reported FIB4 as a good prediction for liver fibrosis with diagnostic accuracy 72%. CONCLUSION: The combination of two serum markers proves to be a low-cost noninvasive testing strategy for CHC patients having an indeterminate APRI score. By being readily accessible both biochemical scores can simplify liver assessment in lower middle-income countries (LMIC) and help family physicians to take appropriate decisions about treatment initiation with minimum delays.

Adolescent lifestyle and behaviour: a survey from a developing country.

INTRODUCTION: Adolescents form two-thirds of our population. This is a unique group of people with special needs. Our survey aims to identify the lifestyle and behavioral patterns in this group of people and subsequently come up with issues that warrant special attention. METHODS: A survey was performed in various schools of Karachi. Data collection was done via a face-to-face interview based on a structured, pre-tested questionnaire. Participants included all willing persons between 12-19 years of age. RESULTS: Most adolescents with lifestyle issues fell in the age group of 16-18 years. Females were more depressed than males and had more sleep problems. Substance abuse and other addictions were documented more in males. Watching television or listening to music was stated as the most common late night activity (61.8%) and therefore was also referred to as the contributory factor for less than eight hours of sleep each day. (58.9%) of the respondents are getting less than eight hours of sleep daily. (41.5%) of the respondents who felt depressed sought treatment for it. Quite a few of them were also indulged in substance abuse and other addictions. Only (16.8%) of the respondents opined that physical activity is essential for health. Thirty-five adolescents out of all the respondents were smoking cigarettes currently, whereas 7% of the respondents chewed paan (areca nut). Peer pressure was the most common reason (37.1%) to start smoking. CONCLUSION: Adolescents need to be treated as a distinct segment of our population and it is important to realize and address their health and lifestyle problems. Inadequate sleep, depression and smoking were the leading unhealthy behaviours among the respondents. Families can play an important role to help these adolescents live a healthier life. Further research studies should be carried out to highlight issues of concern and their possible solutions in this population.