Risk Factors of Crimean-Congo Haemorrhagic Fever in Sindh Province, Pakistan.

OBJECTIVES: In Sindh Province, Pakistan, confirmed Crimean-Congo haemorrhagic fever (CCHF) increased from zero in 2008 to 16 in 2015-2016. To counter this increase, in 2016, we initiated structured CCHF surveillance to improve estimates of risk factors for CCHF in Sindh and to identify potential interventions. METHODS: Beginning in 2016, all referral hospitals in Sindh reported all CCHF cases to surveillance agents. We used laboratory-confirmed cases from CCHF surveillance from 2016 to 2020 to compute incidence rates and in a case-control study to quantify risk factors for CCHF. RESULTS: For the 5 years, CCHF incidence was 4.2 per million for the Sindh capital, Karachi, (68 cases) and 0.4 per million elsewhere. Each year, the onset of new cases peaked during the 13 days during and after the 3-day Eid-al-Adha festival, when Muslims sacrificed livestock, accounting for 38% of cases. In Karachi, livestock for Eid were purchased at a seasonal livestock market that concentrated up to 700,000 livestock. CCHF cases were most common (44%) among the general population that had visited livestock markets (odds ratio = 102). CONCLUSIONS: Urban CCHF in Sindh province is associated with the general public's exposure to livestock markets in addition to high-risk occupations.

An Epidemic of Pediatric HIV From Reuse of Infusion Equipment in Pakistan.

BACKGROUND: From April to June 2019, a total of 909 new HIV infections were identified in Larkana, Pakistan; 86% was children younger than 15 years. To identify the possible transmission links in this outbreak, a case-control study was conducted in June 2019. METHODS: For cases, we selected a systematic random sample of 100 HIV-positive children from the screening list. We chose 2 age-matched and sex-matched controls from the neighborhood of each HIV-positive case. All selected children were tested using the World Health Organization-approved rapid diagnosis test algorithm. We interviewed the parents of each selected child about previous exposures to parenteral treatment and compared exposures of case and control children using conditional logistic regression. RESULTS: The ages of the selected children ranged from 1 month to 10 years. More than 90% of both HIV+ and HIV- children had received outpatient health care from MBBS-qualified private physicians. Eighty-three percent of HIV+ children versus 46% of HIV- children had received health care from one private physician [adjusted odds ratio (aOR) = 29, 95% confidence interval (95% CI): 10 to 79]. Intravenous infusions during the last outpatient visit were reported by 29% of case versus 7% of controls (aOR 57, 95% CI: 2.9 to >1000), whereas no case children and 17% of control children had received only intramuscular injections (aOR 0, 95% CI: 0 to 41). Among cases, 94% had been given infusions through a drip set compared with 85% of control children (aOR = 7.7, 95% CI: 2.3 to 26). Infusions had been administered with reused IV drip sets in 70% of cases compared with 8% of controls (aOR = 197, 95% CI: 16 to 2400). DISCUSSION: Private physicians reusing intravenous drip sets to treat outpatients seen in private practice were responsible for this HIV epidemic. Mapping and regulation of private practitioners were suggested.

The Relationship of Drug Therapy to Aplastic Anemia in Pakistan: A Hospital-Based Case Control Study.

INTRODUCTION: Drug-induced aplastic anemia has long been a menacing outcome of modern pharmacotherapy. The incidence of idiosyncratic, drug-induced aplastic anemia varies depending on the genetic susceptibility and the associated drug. Only scarce studies have explained the epidemiology and actual incidence of this reaction. PURPOSE: The aim of the study was to establish the association between drugs and aplastic anemia. METHODS: A case-control study was conducted with 191 cases and 696 controls at a tertiary hospital for blood diseases in Karachi-Pakistan. Cases were patients of aplastic anemia diagnosed through bone marrow biopsy. The controls did not have either AA or chronic diseases. Each case was paired with four sex and age group match controls. Cases and controls were compared with respect to the drugs used. Univariate and multivariate analysis were performed in order to delineate the association. RESULTS: Median age of the study-participants was 27 years (04-69 years). The majority 84 (44%) were from age group 16 to 30 years. The male-to-female ratio was 2:1. Among study participants, various drugs were significantly associated with aplastic anemia. Treatment of epilepsy with carbamazepine showed a positive association (OR=2.7, 95% C.I, 1.0-6.8). An increased risk of aplastic anemia was noted with exposure to thiazide (OR=3.1, 95% C.I, 1.3-7.4) and mebendazole (OR=3.7, 95% C.I, 1.5-9.2). However, risks were not increased with chloramphenicol, trimethoprim/sulfamethoxazole, benzodiazepines, antihistamines, oral contraceptives, and herbal medicine. CONCLUSION: This large-scale case-control study provide association of aplastic anemia with exposure to carbamazepine, thiazides and mebendazole in population of Pakistan. Patients should be monitored with complete blood indices for early detection of drug toxicity.

Emergence of a febrile illness of unknown causes among the population and visitors of Upper Egypt.

This is a fictional case study for training that encourages participants to interact and apply theory into practice. A febrile illness of unknown cause that occurred in Upper Egypt in 2002 was chosen for the events. The location of Aswan was selected to define the climate, topography, and location with the characteristics that support the events. Data obtained from applied research work in Egypt was included. The case study deals with the incidence of severe cases of fever of unknown origin accompanied by neurological and intestinal symptoms, as well as a high percentage of deaths. Most of the symptoms appear in people with direct contact with farm animals especially equines and birds, or those who were near waterways, either tourism workers or tourists. Most of the infected cases or deaths have accumulated in Aswan and some in the neighbouring governorates. This case study focusses on the steps taken during an outbreak investigation, and deals with investigative challenges as well as concepts of biosafety and biosecurity.

Outbreak investigation of an unknown gastrointestinal illness in District Victoria, Country Mala, 2016.

This case study is based on an outbreak investigation conducted by multisectoral team from animal and public health offices in Kaktong (a remote village in Zhemgang District Bhutan) during July-September 2010. This outbreak caused by ingestion of infected cow meat which had died after a brief illness (bleeding of unclotted blood from nostrils). The owner of the affected cow had opened the carcass and dressed the meat, which he shared or sold within the village for human consumption. It simulates an epidemiological investigation including active and passive case finding, descriptive and analytical epidemiology, laboratory confirmation, risk communication with implementation of control measures. This case study is designed for the training of front-line public health professional, basic, intermediate and advanced level field epidemiology trainees. The case study will build the capacity of the trainees regarding investigating illnesses caused by animal-human interface.

Morbidity and Mortality Associated with Typhoid Fever Among Hospitalized Patients in Hyderabad District, Pakistan, 2017-2018: Retrospective Record Review.

BACKGROUND: Hyderabad, Pakistan, was the first city to witness an outbreak of extensively drug resistant (XDR) typhoid fever. The outbreak strain is resistant to ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, fluoroquinolones, and third-generation cephalosporin, thus greatly limiting treatment options. However, despite over 5000 documented cases, information on mortality and morbidity has been limited. OBJECTIVE: To address the existing knowledge gap, this study aimed to assess the morbidity and mortality associated with XDR and non-XDR Salmonella serovar Typhi infections in Pakistan. METHODS: We reviewed the medical records of culture-confirmed typhoid cases in 5 hospitals in Hyderabad from October 1, 2016, to September 30, 2018. We recorded data on age, gender, onset of fever, physical examination, serological and microbiological test results, treatment before and during hospitalization, duration of hospitalization, complications, and deaths. RESULTS: A total of 1452 culture-confirmed typhoid cases, including 947 (66%) XDR typhoid cases and 505 (34%) non-XDR typhoid cases, were identified. Overall, ≥1 complications were reported in 360 (38%) patients with XDR typhoid and 89 (18%) patients with non-XDR typhoid (P<.001). Ileal perforation was the most commonly reported complication in both patients with XDR typhoid (n=210, 23%) and patients with non-XDR typhoid (n=71, 14%) (P<.001). Overall, mortality was documented among 17 (1.8%) patients with XDR S Typhi infections and 3 (0.6%) patients with non-XDR S Typhi infections (P=.06). CONCLUSIONS: As this first XDR typhoid outbreak continues to spread, the increased duration of illness before hospitalization and increased rate of complications have important implications for clinical care and medical costs and heighten the importance of prevention and control measures.

Risk Factors of Extensively Drug Resistant Typhoid Fever Among Children in Karachi: Case-Control Study.

BACKGROUND: Extensively drug resistant typhoid fever (XDR-TF) has been responsible for an ongoing outbreak in Pakistan, which began in November 2016. OBJECTIVE: This study aimed to determine the risk factors associated with XDR-TF. METHODS: This age- and sex-matched case-control study was conducted during May-October 2018 in Karachi. All patients with XDR-TF were identified from the laboratory-based surveillance system data. Cases included patients aged <15 years living in Karachi with culture-positive Salmonella enterica serovar Typhi with resistance to chloramphenicol, ampicillin, trimethoprim/sulfamethoxazole, fluoroquinolones, and third-generation cephalosporins. Age- and sex-matched controls included children free from the symptoms of TF, aged under 15 years, and residing in Karachi. All controls were recruited from among those who attended outpatient clinics. RESULTS: A total of 75 cases and 75 controls were included in this study. On univariate analysis, the odds of having XDR-TF were 13-fold higher among participants who used piped municipal water than among those who did not (odds ratio [OR] 12.6, 95% CI 4.1-38.6). The use of bore water was significantly associated with XDR-TF (OR 5.1, 95% CI 1.4-19.0). Cases were more likely to report eating French fries with sauce (OR 13.5, 95% CI 3.9-47.0) and poppadum (OR 3.4, 95% CI 1.7-6.7) from street vendors than controls. Boiling water at home was negatively associated with XDR-TF (OR 0.3, 95% CI 0.2-0.7). On multivariate analysis, 2 factors were independently associated with XDR-TF. Using piped municipal water (OR 10.3, 95% CI 3.4-30.4) and eating French fries with sauce from street vendors (OR 8.8, 95% CI 2.1-36.2) were significantly associated with an increased odds of XDR-TF. CONCLUSIONS: Community water supply and street food eating habits were implicated in the spread of the superbug S typhi outbreak, which continues to grow in Karachi. Therefore, it is recommended to improve the community water supply to meet recommended standards and to develop a policy to improve the safety of street food. In addition, health authorities are required to conduct mass vaccination for TF among high-risk groups.

An Investigation of Selected Socio-Demographic Factors with Aplastic Anemia in Pakistan: A Case-Control Study.

INTRODUCTION: In Pakistan, the incidence rate of aplastic anemia is 3.5 cases/million. The associated risk factors are exposure to pesticides, chemicals, and some drugs. The link between aplastic anemia and socio-demographic factors is debatable. PURPOSE: We conducted this study to investigate the role of socio-economic and -demographic factors with aplastic anemia. METHODOLOGY: A total of 191 lab-confirmed incident cases of aplastic anemia were identified from the tertiary hospital of Karachi-Pakistan in between 2015 and 2018. Age and gender-matched 694 controls were randomly selected from the same institute admitted or visited for other non-neoplastic conditions. Socio-demographic and exposure information was gathered using a data collection form. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were computed for selected socio-demographic factors. RESULTS: Among socio-demographic factors, significant associations of aplastic anemia risk emerged for illiteracy (aOR: 2.3; 1.5; 3.5) occupation (any type) (aOR: 2.1; 1.7; 2.5), living in rural environments (aOR: 2.9; 1.9; 4.2). The odds of aplastic anemia increased with the age group 31-50 years (aOR: 1.8; 1.7; 3.5) and >50 years (aOR: 2.5; 2.1; 4.2). We observed no association of income with the risk of aplastic anemia. CONCLUSION: This study highlights the importance of socio-demographic factors as a risk factor for the development of aplastic anemia in the population of Pakistan. In order to reduce disease incidence, health education program and use of personal protective equipment and organization of screening camps in high-risk population is warranted.