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Human immunodeficiency virus-associated disorders in Pakistan.

We have documented evidence of the human immunodeficiency virus (HIV) infection in four individuals including a blood donor and three members of a family (husband, wife, and a child) in Karachi, Pakistan. Our data indicate that HIV has been transmitted to the wife of the seropositive male, a drug abuser, in the recent past and that she has passed the virus to her newborn child perinatally/transplacentally. The two seropositive males (blood donor and drug abuser) were diagnosed clinically as having persistent generalized lymphadenopathy, an AIDS-related condition (ARC), and the child presented with developmental disorders and neurologic manifestations. This is the first report of AIDS/ARC cases from Pakistan that can be directly related to HIV infection and its heterosexual transmission.

AIDS-Related Complex↗

Dietary risk factors associated with acute and persistent diarrhea in children in Karachi, Pakistan.

Feeding practices may have an important impact on diarrheal diseases in developing countries. This study evaluated feeding practices in three groups of male children aged 6-36 mo: 100 with persistent diarrhea (PD), 79 with acute diarrhea (AD), and 86 in a comparison group (CG). The children came from comparably poor socioeconomic settings in Karachi, Pakistan, except that the literacy rates were higher in mothers of the CG (P = 0.0001). Although greater than 95% of all infants were breast-fed, delayed initiation of breast-feeding was more common in the diarrhea groups. Children with diarrhea were also more likely to receive supplemental milk (PD = 92%, AD = 87%) than were children in the CG (69%, P less than 0.05). Feedings were not withheld during diarrhea but changes were made in the nature of foods given. These results indicate that several feeding practices may be important risk factors for diarrhea in Pakistan.

Acute Disease↗

Evaluation of blood bank practices in Karachi, Pakistan, and the government's response.

BACKGROUND: National legislation in Pakistan regulating blood banks has been introduced several times, but has never been passed. To support provincial-level efforts to develop legislation we conducted a study to evaluate blood-banking practices in Karachi, Pakistan, to identify areas that could be improved. METHODS: Thirty-seven blood banks were randomly selected from a list of 87 Karachi blood banks. The research team interviewed blood bank personnel, inspected available facilities and equipment, and observed blood collection using structured questionnaires and observation forms. RESULTS: Of the 37 selected facilities, 25 were operational and 24 agreed to participate. Twelve (50%) of the facilities reported regularly utilizing paid blood donors, while only six (25%) activity recruited volunteer donors. During observation only 8% of facilities asked donors about injecting drug use, and none asked donors any questions about high-risk sexual behaviour. While 95% of blood banks had appropriate equipment and reagents to screen for hepatitis B, only 55% could screen for HIV and 23% for hepatitis C. Twenty-nine percent of the facilities were storing blood products outside the WHO recommended temperature limits. IMPLICATIONS: Practices at most Karachi blood banks fell well below WHO standards. Findings from this study were instrumental in developing and passing legislation to regulate blood transfusion throughout Sindh Province, and suggest a method for improving blood transfusion practices in other developing countries.

Blood Banks↗

The determinants of reproductive health service provision by general practitioners in Pakistan.

OBJECTIVE: The aim of this cross-sectional study was to identify the factors that influence the provision of reproductive health services by General Practitioners (GPs) working in the province of Sind, Pakistan. METHODS AND PARTICIPANTS: One hundred and ninety-eight GPs were selected as the study participants by a multistage, randomized stratified, proportionate sampling procedure. Data were collected using a self-completed questionnaire, which was validated for content validity by an expert review panel and for face validity by a pilot test administered to doctors from developing countries. Data collection took place between November 2000 and February 2001. RESULTS: Eighty-six percent of GPs (171/198) responded to the questionnaire. Of those, only 25% reported providing reproductive health services in their clinics. The major determinants of reproductive health service provision were found to be the urban location of the GP clinic, being a female GP, postgraduate training in reproductive health and a good knowledge of reproductive health. CONCLUSIONS: The findings of this study suggest that the provision of reproductive health services in Sind could be improved by increasing the involvement of female GPs. This can be achieved by encouraging more female GPs into the specialty, with the use of incentives if necessary, and providing adequate postgraduate training to improve their reproductive health knowledge and skills. The results of this study have broadened understanding of the factors that influence GPs in their provision of reproductive health services, and will contribute significantly to research on reproductive health in Pakistan.

Adult↗

Increasing contraceptive use in rural Pakistan: an evaluation of the Lady Health Worker Programme.

Past efforts to promote family planning in Pakistan have been disappointing, but between 1990-91 and 2000-01 contraceptive use has more than doubled. This rise has coincided with a concerted effort on the part of the Pakistani government to increase access to contraceptive services, particularly in rural areas. The Lady Health Worker Programme (LHWP), initiated under the Ministry of Health in the early 1990s, aimed at integrating family planning into the doorstep provision of primary health care. This paper presents findings from the first national evaluation of this Programme. Data are analyzed from a random sample survey of 4277 women living in households served by the LHWP and those living in control areas. Logistic regression analysis was performed to determine the effect of the Programme on the uptake of modern reversible contraceptive methods, controlling for other independent variables. The data provide strong evidence that the LHWP has succeeded in increasing modern contraceptive use among rural women. Women served by Lady Health Workers are significantly more likely to use a modern reversible method than women in communities not served by the Programme (OR=1.50, 95% CI=1.04-2.16, p=0.031), even after controlling for various household and individual characteristics. The model of providing doorstep services through community-based female workers should remain central to achieving universal access to safe family planning methods by the end of the decade--the long-term objective of Pakistan's most recent population policy adopted in 2002.

Adolescent↗

Injection use in two districts of Pakistan: implications for disease prevention.

OBJECTIVE: To estimate the annual number of injections per person in Sindh province of Pakistan and to describe their distribution with regard to prescribers, settings, and safety. DESIGN: A population-based cross-sectional study in July-September 2001. SETTING: Lyari, an urban town in Karachi district; and Digri, a rural subdistrict in Mirpur Khas district. STUDY PARTICIPANTS: We selected a population-based cluster sample of 1150 individuals aged > or =3 months. We interviewed one person per household for the number of encounters they had with health care providers, number and types of injections received, safety circumstances, and cost of injections during the past 3 months. Main outcome measure. The number of injections per person per year. RESULTS: After adjusting for age and sex, 68% of participants had received at least one injection in the previous 3 months (13.6 injections/person/year). The majority of the respondents received injections at the clinics of qualified general practitioners (n = 571, 67%) by dispensers (644, 76%). Most of the injections (n = 3446, 96%) were for curative purposes. A freshly opened syringe was used for only 454 (53%) of the injections. The average fee for receiving an injection was Rs. 51 (US$ 0.8). CONCLUSION: Injections are overused in Pakistan's Sindh province and the ratios of injection per capita that we found are among the highest ever reported. INTERVENTIONS: are needed to substantially reduce injection prescription among private health care providers who prescribe most of the injections received by the population.

Adolescent↗

Yellowfever mosquito (Diptera:Culicidae) introduced into Landi Kotal, Pakistan, by tire importation.

Although the recent distribution of yellowfever mosquito, Aedes aegypti (L.), in Pakistan has been restricted to the port city of Karachi, adult and immature mosquitoes breeding in imported tires in warehouses at Landi Kotal (North-West Frontier Province) were identified as Ae. aegypti. The patterns of tire trade and the current disjunct distribution of Ae. aegypti indicated that the introduction into Landi Kotal may have been either from Karachi or India. Thermal fog application of pirimiphos-methyl and residual spray of malathion during 1993 reduced abundance in October-November. Living larvae or adults were not found during January 1994, apparently because of cold weather. However, Ae. aegypti reappeared during May-June 1994, most probably from eggs that overwintered. Population increased during late August when another round of spray using the same insecticides and fenthion as an additional larvicide again reduced abundance. Although this mosquito apparently has not spread into neighboring areas, its survival at Landi Kotal through all seasons despite control measures indicates its potential of becoming established in other areas of Pakistan.

Aedes↗

Daily iron supplementation is more effective than twice weekly iron supplementation in pregnant women in Pakistan in a randomized double-blind clinical trial.

In the context of limited effectiveness of iron supplementation programs, intermittent iron supplementation is currently under debate as a possible alternative strategy that may enhance the effectiveness of operational programs. This field-based trial assessed the outcome of twice weekly iron supplementation compared to daily in Pakistan. A double-blind, randomized, clinical trial was conducted in Northern Pakistan. Anemic pregnant women (n = 191) were assigned to receive daily (200 mg ferrous sulfate) or twice weekly (2 x 200 mg ferrous sulfate) iron supplementation. Hemoglobin was measured at baseline and at 4-wk intervals for up to 12 wk. Serum ferritin was measured at baseline and 8 or 12 wk. Analysis was by intention to treat. The two groups did not differ in age, parity, sociodemographic characteristics, hemoglobin or serum ferritin concentrations at baseline. Women who received iron daily had a greater rise in hemoglobin compared with women who received iron twice weekly (17.8 +/- 1.8 vs. 3.8 +/- 1.2 g/L, P < 0.001). The serum ferritin concentrations increased by 17.7 +/- 3.9 microgram/L (P < 0.001) in the daily supplemented group and did not change in the twice weekly group. Daily iron supplementation remained superior to twice weekly supplementation after controlling initial hemoglobin Z-scores and duration of treatment. The body mass index (BMI) modified the effect of daily versus twice weekly iron supplementation. For every unit increase in BMI, the difference between the two treatment groups was reduced by 0.0014 (final hemoglobin Z-score; P = 0.027). We recommend continuation of daily iron supplementation as opposed to intermittent iron supplementation in pregnant women in developing countries.

Adult↗

Prevalence and awareness of risk factors and behaviours of coronary heart disease in an urban population of Karachi, the largest city of Pakistan: a community survey.

OBJECTIVES: To estimate the prevalence and awareness of risk factors and risk behaviours of coronary heart disease (CHD) in the lower middle class residing in urban localities of Karachi, a mega city of Pakistan. METHODS: The design consisted of a cross-sectional community based survey in the lower middle class urban localities of Karimabad, Garden and Kharardar in Karachi, Pakistan. One thousand four hundred adults (18 years and above) registered with the Aga Khan Development Network (AKDN) participated in the survey. Life style, self-reported risk variables, blood pressure and anthropometric measurements were recorded. RESULTS: Prevalence of hypertension, high cholesterol and diabetes were 38.5, 10.7 and 9.1 per cent, respectively. 52.2 per cent of the sample was overweight or obese; 64.8 per cent never exercised; 11.9 per cent had two or more major risk factors of CHD. CONCLUSION: The communities studied showed a very high prevalence of hypertension, obesity and a sedentary life style. Despite a high literacy rate, awareness regarding CHD risk factors was low. This underlines the need for measures to increase awareness regarding CHD and its risk factors and a healthy lifestyle in the developing countries.

Adolescent↗

Health seeking behaviour and health service utilization in Pakistan: challenging the policy makers.

There is a growing literature on health seeking behaviours and the determinants of health services utilization especially in the context of developing countries. However, very few focused studies have been seen in Pakistan in this regard. This paper presents an extensive literature review of the situation in developing countries and relates the similar factors responsible for shaping up of a health seeking behaviour and health service utilization in Pakistan. The factors determining the health behaviours may be seen in various contexts: physical, socio-economic, cultural and political. Therefore, the utilization of a health care system, public or private, formal or non-formal, may depend on socio-demographic factors, social structures, level of education, cultural beliefs and practices, gender discrimination, status of women, economic and political systems environmental conditions, and the disease pattern and health care system itself. Policy makers need to understand the drivers of health seeking behaviour of the population in an increasingly pluralistic health care system. Also a more concerted effort is required for designing behavioural health promotion campaigns through inter-sectoral collaboration focusing more on disadvantaged segments of the population.

Cultural Characteristics↗

Corticosteroid use and abuse by medical practitioners for arthritis and related disorders in Pakistan.

A total of 256 consecutive patients attending our out-patient clinic in Islamabad, Pakistan, with complaints of pain in or around the joints were evaluated for use of corticosteroids prescribed by medical practitioners they had seen earlier. The appropriateness of such prescriptions and their consequent effects were assessed. Of the 256 patients, 110 (i.e. 42.5%) were identified as steroid users; some of them were suffering from conditions known to be unresponsive to this form of therapy. One hundred and one of the 256 patients had rheumatoid arthritis and 67% of these had been using steroids, mostly in an irrational manner. The general practitioners and consultants (all non-rheumatologists) were responsible for the majority of steroid prescriptions. Steroid side-effects were observed in 42/110 (38.2%) cases. This prevalent practice in Pakistan is a reflection of the state of affairs in developing countries, and indicates a need for improvement and better regulation of health care in such countries.

Adrenal Cortex Hormones↗

Measurements of activity concentrations of naturally occurring radionuclides in soil samples from Punjab province of Pakistan and assessment of radiological hazards.

The natural level of radioactivity in soil is one of the major causes of external gamma rays exposure. It was considered imperative to measure gamma-ray activity concentrations due to naturally occurring, potentially hazardous radionuclides from 232Th, 226Ra and 40K in soil samples from Punjab, the most populated province of Pakistan. The activity concentrations were measured in soil samples collected from all 34 district headquarters of Punjab province using a P-type coaxial high purity germanium (HPGe)-based gamma-ray spectrometer having a relative efficiency of 60%. The mean activity concentrations for 232Th, 226Ra and 40K were found to be 41 +/- 8, 35 +/- 7 and 615 +/- 143 Bq kg(-1), respectively in soil samples from all 34 district headquarters of Punjab. The mean values of radium equivalent index (Ra(eq)) and total annual external gamma radiation dose were found to be 141 +/- 27 Bq kg(-1)and 0.38 mSv, respectively. Since these estimated radiological impact assessment factors are lower than the recommended values there seems to be no potential radiological health hazard associated with the soils from the district headquarters in the Punjab province of Pakistan. Geological studies show that most of the soils in Punjab have developed on the extensive fluviatile deposits of five rivers and a stable ratio of natural activity concentrations is observed in soil samples of the areas under study.

Air Pollution, Radioactive↗

Activity Concentration of 137Cs in soil samples from Punjab province (Pakistan) and estimation of gamma-ray dose rate for external exposure.

Punjab is one of the most populated provinces of Pakistan having 34 districts. There is always a need to have baseline background level information about 137Cs and the corresponding gamma-ray doses to the population. In this respect, soil samples were collected to a depth of 30-50 cm from all 34 district headquarters of the Punjab province of Pakistan and 137Cs activity concentrations were measured. 137Cs activity concentration was found to be in the range from 1.1 +/- 1.0 to 5.3 +/- 2.5 Bq kg(-1). The average value of estimated external gamma-ray dose rate from all 34 districts of Punjab province was computed to be 0.18 +/- 0.07 nSv h(-1) from 137Cs in soil samples. The measured 137Cs activity concentration range was compared with the reported ranges in the literature from some of the other locations in the world. Results obtained in this study show that 137Cs concentration is of a lower level in the investigated area. The average value of estimated external effective dose rate is found far below the dose rate limit of 1.0 mSv y(-1) for members of the general public recommended by the International Commission on Radiological Protection (ICRP) as well as the external gamma radiation dose of 0.48 mSv y(-1) received per head from the natural sources of radiation assessed by UNSCEAR (2000). It is concluded that 137Cs soil contamination does not pose radiation hazards to the population in the investigated areas.

Body Burden↗

Radiological impact on the workers, members of the public, and environment from the partial decommissioning of Pakistan Research Reactor-I and its associated radioactive residues.

The Pakistan Research Reactor-I (PARR-I) is a swimming pool type research reactor originally designed and built for a thermal power of 5 MW using High Enriched Uranium (HEU) fuel. In 1990-1991 the reactor was redesigned, partially decommissioned and recommissioned to operate with Low Enriched Uranium (LEU) fuel at a thermal power of 10 MW. An essential requirement, construction and commissioning of a wet spent fuel storage bay and fabrication of an irradiated fuel transfer cask were completed before actual dismantling of the reactor core. During the partial decommissioning operations, radioactive waste generated included 600 m3 low-level liquid radioactive waste and 14 m3 of solid radioactive waste with an average specific activity of 4.52 Bq ml(-1) and 2.22 kBq g(-1), respectively. External radiation doses of the workers were determined using TLD (NG 6,7) and direct reading dosimeters. The maximum individual external radiation dose received by any worker during this practice was 5 mSv, which was 25% of the annual dose limit of 20 mSv. Detection and measurement of internal contamination was carried out using bioassay techniques. During the whole operation, not a single case of internal contamination was detected. The ambient radiation levels around waste seepage pits are periodically monitored using TLD (G-2 cards) and G. M. radiation survey meters. Underground migration of radioactivity is checked by analyzing seepage water samples taken from boreholes that have been dug at different locations in the vicinity of the radioactive residues. The monitoring around disposal sites containing radioactive residues has been continued during the last 9 y and will be continued in the future. So far, no rise in the environmental gamma radiation dose level and migration of underground radionuclides has been found in the vicinity of these disposal sites. Working personal during the decommissioning of PARR-I have been found to be radiologically safe. Adherence to the ALARA principle, sound decommissioning and proper radioactive waste disposal procedures helped to protect the working personnel, members of the public, and the environment from the harmful effects of the ionizing radiations present due to the partial decommissioning of the research reactor and its radioactive residues. Experience gained during this work, along with the current international procedures, will be helpful for full restoration of the environment from radioactive residues likely to be generated in the future from any other practices in Pakistan.

Body Burden↗

Multiple infection, recombination and genome relationships among begomovirus isolates found in cotton and other plants in Pakistan.

Begomoviruses occur in many plant species in Pakistan and are associated with an epidemic of cotton leaf curl disease that has developed since 1985. PCR analysis with primer pairs specific for each of four already sequenced types of DNA-A of cotton leaf curl virus (CLCuV-PK types a, 26, 72b and 804a), or for okra yellow vein mosaic virus (OYVMV), indicated that many individual naturally infected plants of cotton and other malvaceous species contained two or three begomovirus sequences. Similarly, sequence differences among overlapping fragments of begomovirus DNA-A, amplified from individual naturally infected plants, indicated much multiple infection in malvaceous and non-malvaceous species. Some cotton plants contained DNA-A sequences typical of begomoviruses from non-malvaceous species, and some non-malvaceous plants contained sequences typical of CLCuV-PK. Some DNA-A sequences were chimaeric; they each included elements typical of different types of CLCuV-PK, or of different malvaceous and/or non-malvaceous begomoviruses. Often an apparent recombination site occurred at the origin of replication. No complete CLCuV-PK DNA-A sequence was found in malvaceous or non-malvaceous species collected in Pakistan outside the area of the cotton leaf curl epidemic but chimaeric sequences, including a part that was typical of CLCuV-PK DNA-A, did occur there. We suggest that recombination among such pre-existing sequences was crucial for the emergence of CLCuV-PK. Recombination, following multiple infection, could also explain the network of relationships among many of the begomoviruses found in the Indian subcontinent, and their evolutionary divergence, as a group, from begomoviruses causing similar diseases in other geographical regions.

Base Sequence↗

Mothers' mental health and infant growth: a case-control study from Rawalpindi, Pakistan.

BACKGROUND: Epidemiological studies in Pakistan show high rates of depression in women, while rates of malnutrition in children are also high. This study aimed to determine whether poor maternal mental health is associated with an increased risk of infant undernutrition. METHODS: Clinic-based case-control study. A total of 172 consecutive infants and their mothers attending for 9-month measles immunization were recruited over a 3-month period. Eighty-two undernourished infants [weight for age below the National Centre for Health Statistics (NCHS)/World Health Organization (WHO) third centile] were matched to 90 controls (weight for age above 10th centile), and their mothers interviewed for mental distress using the Self-Reporting Questionnaire (WHO SRQ-20, a psychiatric screening instrument). Infants' exposure to maternal distress (score > or = 10 on SRQ-20) and other potential risk or protective biological, social, socio-economic and family factors were measured. RESULTS: Mental distress determined by WHO SRQ-20 was associated with increased risk of undernutrition in infants (odds ratio 3.91, 95% confidence interval 1.95-7.86). This association remained significant after controlling for birthweight and social factors. CONCLUSION: Exposure to maternal mental distress is associated with undernutrition in 9-month infants in urban Pakistan. These mothers may represent a group whose children are at higher risk of ill health, and potentially be a specific target for advice on infant care. Early recognition and treatment of mental health problems in mothers may help reduce morbidity and mortality rates in children.

Case-Control Studies↗

Effect of month of vaccine administration on antibody responses in The Gambia and Pakistan.

OBJECTIVE: To explore the relationship between calendar month of administration and antibody (Ab) response to vaccination in subjects from The Gambia and Pakistan, two countries with distinct patterns of seasonality. METHODS: Three cohorts were investigated: Responses to rabies and pneumococcal vaccine were assessed in 472 children (mean age 8 years, males 53%) from rural Gambia. Responses to tetanus, diphtheria and hepatitis B (HBsAg) were investigated in 138 infants also from The Gambia (birth to 52 weeks of age, males 54%). Responses to rabies and Vi typhoid vaccines were assessed in 257 adults from Lahore, Pakistan (mean age 29.4 years, males 57%). RESULTS: In Gambian children, significant associations were observed between month of vaccination and Ab response for the pneumococcal and rabies vaccines. As no consistent pattern by month was observed between the responses, it is assumed that different immunomodulatory stimuli or mechanisms were involved. In Pakistani adults, a significant pattern by month of vaccination was observed with both rabies and typhoid vaccine. No monthly influences were observed in the infant study to the tetanus, diphtheria or the HbsAg vaccines. CONCLUSIONS: Antibody responses to certain specific vaccines are influenced by month of administration. Further research is required to elucidate the precise mechanisms explaining these observations, but a co-stimulatory effect of seasonally variable environmental antigens is a likely cause. Future studies of Ab response to vaccination in countries with a seasonally dependent environment should consider month of vaccination when interpreting study findings.

Adult↗

Estimates of intraclass correlation coefficient and design effect for surveys and cluster randomized trials on injection use in Pakistan and developing countries.

BACKGROUND: To assess injection practices and to test interventions aimed at reducing unsafe injections in developing countries, cluster surveys and cluster randomized trials are needed. The design of cluster-based studies requires estimates of intraclass correlation coefficients that have to be obtained from previous studies. This study presents such estimates. METHODS: Data were derived from a cross-sectional study of injection use and health seeking in Pakistan that used 34 clusters to select 1150 study subjects aged > or =3 months. We analysed variance to separate its components. RESULTS: Most of intraclass correlation coefficients were in the range of 0.01-0.05. For proportion of injections received during last 3 months, mean number of injections received and health seeking during the past 3 months the intraclass correlation coefficients were 0.02, 0.04 and 0.02, respectively. CONCLUSION: These estimates can be useful in designing cluster surveys and cluster randomized trials for injection safety in Pakistan and other developing countries.

Adolescent↗