HIV seroprevalence surveys in Pakistan. HIV Seroprevalence Study Group of Pakistan.
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Female↗
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Abstracts of the 9th Annual Cancer Conference of the Pakistan Society of Clinical Oncology. 20-22 December 2002, Karachi, Pakistan.
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Animals↗
Abstracts of the Pakistan Society of Clinical Oncology 10th Annual Cancer Conference. 19-21 December 2003, Peshawar, Pakistan.
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Humans↗
Comparative epidemiology of epilepsy in Pakistan and Turkey: population-based studies using identical protocols.
PURPOSE: To determine comparative prevalence rates, demographics, phenomenology, seizure classification, presumptive etiology, treatment status, and selected socioanthropological aspects of epilepsy in Pakistan and Turkey. METHODS: A population-based, cross-cultural comparative study of epilepsy was designed with identical protocols to be performed simultaneously in Pakistan and Turkey. The essential feature of the design was an unselected population, with reference to their previous medical contact, and use of standardized International Community-Based Epilepsy Research Group (ICBERG) protocols to assess cross-cultural differences. RESULTS: In all, 24,130 persons in Pakistan and 11,497 persons in Turkey (both urban and rural, of all ages and both sexes) were studied. The crude prevalence rate of epilepsy was 9.98 in 1,000 in Pakistan and 7.0 in 1,000 in Turkey (14.8 in 1,000 in rural and 7.4 in 1,000 in urban areas of Pakistan; 8.8 in 1,000 in rural and 4.5 in 1,000 in urban areas of Turkey). In both countries, epilepsy was twice as prevalent in rural areas than in urban areas. Mean age of onset of epilepsy was 13.3 years in Pakistan and 12.9 years in Turkey. Overall frequency of seizure types was similar in both countries, with no urban/rural differences. The frequency distribution in Pakistan and Turkey, respectively, was as follows; generalized tonic-clonic, 80.5 and 65.4%; simple partial, 5 and 7.4%; complex partial, 5 and 12.3%; generalized absence, 0.8 and 4.9%; tonic and atonic, 5.8 and 3.7% each; and myoclonic, 5.8 and 1.2%. A putative cause for the epilepsy could be attributed in 38.4% of cases in Pakistan and 35.7% of cases in Turkey. Only 3% of patients in Pakistan, but 71% of patients in Turkey, believed that their illness was due to supernatural causes. The treatment status was very poor. In Pakistan, 27.5% of people with epilepsy in urban areas and 1.9% of people with epilepsy in rural areas were receiving antiepileptic drugs (AEDs) at the time of the survey. In, Turkey 30% of patients were receiving AEDs (marginally higher in rural areas). CONCLUSIONS: The prevalence of epilepsy is slightly higher in Pakistan than in Turkey; some marginal differences in age and sex distribution, are not statistically significant. The results are comparable to those in Ecuador, where the same epidemiologic protocol was used.
Adolescent↗
Pakistan embarks on new campaign to reduce fertility.
There was both international and domestic significance in a plea for population stabilization issued by Pakistan's Prime Minister Nawaz Sharif in his address at the recent Earth Summit conference in Rio de Janeiro. Speaking as both a national leader and chairman of the Group of 77, a coalition of developing countries, Sharif said that to eradicate the abject poverty under which more than a billion people in the world live today "developing countries must assume their full responsibility in limiting population growth to manageable levels." Those words may seem odd coming from the leader of a country that has been indifferent about population problems for the past 2 decades. Until Prime Minister Sharif made a public commitment to a population program last July, the last leader of Pakistan to take such action was the late President Ayub Khan in 1969. With an annual 3.1% growth rate, Pakistan's population of 122 million is projected to double in only 23 years. The average Pakistani woman has 6.1 children in her reproductive lifetime. Reduction of population growth was an issue in the October 1990 election campaign. After his Islamic Democratic Alliance won, the government named Syeda Abida Hussain, a prominent and popular politician, to the cabinet post of Minister of Family Welfare. Hussain, who is now Pakistan's Ambassador to the US, recalls that many experts felt that starting a population program would be "an impossible undertaking, "that" attitudes were not conducive to family planning and government would never support it." In a speech on World Population Day in Rio, organized by the Population Institute, she said she soon found that "the problems were managerial, not attitudinal." She maintained that the relatively low acceptance of contraception among the people of Pakistan, Bangladesh and India is not because of religion or ideology "but because they are too poor to have access to birth control." Shortly after Hussain was names Minister of Family Welfare, she travelled throughout Pakistan to promote a small family norm. Under the new government program, family planning services would be provided along with maternal and child health services. Meanwhile, in an address before a national population conference, Prime Minister Sharif made a strong emotional appeal for a slowdown in population growth. He directed all government ministries and departments to provide all possible support. A recent study in Pakistan showed that the lack of service delivery outlets, rather than lack of awareness of family planning, was the reason behind the weak response to earlier programs. The study further indicated that 60% of married women either do not want more children or want to delay their next birth, but only 20% have access to family planning services. 90% said their desired family size was 4 children, yet they were having 7. The shortage of family planning services is especially acute in rural areas. While 54% of the country's 35 million urban residents have access to services, only 5% of rural people do. In the past, population programs in Pakistan have been handicapped by bureaucratic red tape, inefficiency and corruption. But with the Prime Minister solidly supporting lower population growth as a key to the success of his economic initiatives, top managers of the program are optimistic that this time it will work. "Bringing down the population growth rate in Pakistan is not the world's responsibility, "says Ambassador Syeda Abida Hussain. "It is Pakistan's."
Asia↗
Karachi Cancer Registry Data--implications for the National Cancer Control Program of Pakistan.
Cancer registries play a major role in providing the data to justify establishment, implementation and monitoring of cancer control programs, therefore stability in cancer registration is of pivotal importance. An erroneous assessment of the cancer burden can have long-term negative implications for the limited health resources of a country. Thus, registries starting simultaneously with cancer control programs clearly cannot be adequate for the purpose. The Karachi Cancer Registry (KCR) is the first population-based registry of Pakistan, with 9 years proven data stability (1995-2003) for Karachi South (KS), a location with a population distribution similar to that for the country in general as regards age, gender, and religion. It also has the distinction of being the only district in the country with representation of all ethnic and socio-economic groups of the country. The primary recommended strategy for the 'National Cancer Control Program' (NCCP), Pakistan based on the assessment of eight common cancers in Karachi and the WHO estimates would be identical. A curb on the epidemic levels of tobacco and areca nut use would reduce malignancies in males by 43.7% and in females by 17.8%. WHO estimates put these figures at 45% and 18.5% for males and females respectively. Primary prevention in the form of diet control, checks on preservatives, dyes, and pesticides; protection from occupational hazards, control of biological agents and solar UV protection would help control of another half of the malignancies. Resource restrictions put high technology methods beyond the scope of Pakistan today. Early detection of cancers of accessible sites, though not an urgent requirement, would be warranted for oral, cervical and breast cancer, after sufficient capacity building, initially in the high-risk groups. In females, this could help target 47.6% (approximately half) of the malignancies and in men 13% of the total. Establishment of equitable pain control and a palliative care network throughout the country is an urgent and essential measure as more than 70% of cancer patients report with very advanced stages of malignancy. The estimated annual incident cancer cases for Pakistan, year 2000 on the basis of KCR data were 138,343 for males and 135,054 for females; approximately twice the number cited by WHO for the same year. The argument that higher KCR estimates reflect an urban catchment population may be justified, the urban: rural ratio being 2:1 in Pakistan. Evidence-based strategies, however,support the counter argument, that the rising incidence of cancer in Pakistan is primarily attributable to risk factors equally prevalent in the rural and urban areas viz. increasing tobacco use, low socio-economic conditions, dietary deficiencies and prevalence of oncogenic viruses. Pakistan has a significant cancer burden and rising trends of risk factors - it is a country in dire need of a Cancer Control Program. KCR data along with WHO estimates can form the initial framework of a NCCP in Pakistan; the lack of a national cancer registration should not deter initiatives. Benefits of an immediate, prompt and targeted implementation established today will be realized after 20-30 years. Otherwise the country should be prepared to face epidemic proportions of the disease in the next decade or two. Prerequisite 'qualification criteria' or 'sincerity of intent test' for NCCP funding by international donors should be legislation against tobacco and areca nuts in Pakistan and stringent evaluative criteria.
Adolescent↗
HIV/AIDS in Pakistan: the context and magnitude of an emerging threat.
STUDY OBJECTIVE: The objectives of this review were to: (1) assess the nature and comprehensiveness of information regarding HIV/AIDS in Pakistan; (2) to evaluate the extent of HIV/AIDS in Pakistan by epidemiological estimates; (3) to indicate the implications of the results for health policy in Pakistan and other regions at a similar stage in the epidemic. DESIGN: A structured review of published, unpublished, and government literature was undertaken to collate all available information and present a descriptive epidemiological profile of HIV/AIDS in the country. SETTING: Pakistan, a developing country in the South Asian region. National and regional information and analysis are presented in so far as the data allowed. Sample sizes varied from 1.35 million people screened at the national level to smaller studies of fewer than 100 screened. RESULTS: Data pertaining to HIV/AIDS in Pakistan showed the best national estimates of HIV prevalence as 64 per 100,000 (0.064%). Within patients with sexually transmitted diseases the seroprevalence was as high as 6100 per 100,000 (6.1%); in men with extramarital contacts, 5400 per 100,000 (5.4%) and was as low as zero in some studied populations as well. The average age of onset was reported as 30 years. It is estimated that if all incident cases of AIDS were to die, there would be at least 5000 deaths annually attributable to HIV/AIDS. CONCLUSION: Coupled with the extremely low awareness of HIV/AIDS in Pakistan, as well as growing number of cases, the AIDS epidemic is poised to take a hold in Pakistan. The presence of additional risk factors such as unscreened blood, and low condom use rates make the situation fertile for AIDS to become a major public health issue. Pakistan's health policy must be proactive in tackling this emerging health threat.
Acquired Immunodeficiency Syndrome↗
Health-related millennium development goals: policy challenges for Pakistan.
OBJECTIVES: There are two objectives: (a) to clearly articulate the Millennium Development Goals (MDGs) adopted by the United Nations in 2000 and their implications for developing countries like Pakistan; and (b) to critically review the challenges faced by Pakistan in achieving the health-related MDGs. METHODS: A critical review of secondary data and information generated primarily by multilateral agencies and United Nations organizations. RESULTS: The MDGs represent a global consensus on the broad goals of development to be achieved by 2015. Of the eight Millennium Development Goals, three are specifically health related--reducing infant (under-5) and maternal mortality; and combating HIV/AIDS, tuberculosis, malaria and other significant communicable diseases. According to various studies, many developing countries will not achieve the MDGs without concerted efforts and commitment of additional resources. Like many other developing countries, Pakistan is also faced with an enormous challenge in reaching the Millennium Development Goals and targets set by the United Nations. For Pakistan, perhaps the most challenging MDG is that of reducing "by three-quarters the maternal mortality ratio." Maternal mortality is so intertwined with other "social" factors--including the status of women--that a comprehensive holistic approach is required. CONCLUSION: In order to achieve the MDGs, Pakistan would require a fundamental shift in its policy and strategic directions. Along with allocation of significant additional resources for health, it needs to review and reprioritize the use of existing resources, focusing more on primary health care. Pakistan must also adopt a holistic integrated approach that views health, education, and other social sector development as intrinsically interrelated and interwoven. Without such an integrated approach, achieving the health-related MDGs is likely to remain illusive for Pakistan. There is a critical need to foster a healthy debate on the health-related Millennium Development Goals in Pakistan so as to inform and, hopefully influence, public policy.
Developing Countries↗
The determinants of infant mortality in Pakistan.
This study examines factors associated with infant survival in Pakistan. It uses data from the Pakistan Integrated Household Survey 1991, a nationally representative sample survey of the Government of Pakistan, funded by the World Bank. The infant mortality rate was still very high in Pakistan until the early 1990s, at 100 deaths per 1000 live births. The study shows that there is no evidence of a secular decline in infant mortality during the 1980s. Large differentials in infant survival by socio-economic factors and access to water and sanitation indicate that social and gender inequities are the underlying cause of the stagnation of infant mortality in Pakistan. Economic and social policies of earlier decades have resulted in tremendous disparities in wealth and access to resources in Pakistan. The low social, economic and legal status of women is intimately tied to the well-being of their children. Health interventions in Pakistan should be designed to reach the most under-served: women and children. Systematic evaluations of health interventions will be necessary to make informed decisions about health investments in the future.
Adolescent↗
Molecular detection and sequence analysis of a new hepatitis E virus isolate from Pakistan.
Sporadic and epidemic acute viral hepatitis E in many developing countries is caused by hepatitis E virus (HEV). The HEV genome has been classified into three major genotypes. However, extensive diversity has been noted among HEV isolates from patients with acute hepatitis in China and Taiwan. Some reports indicated that multiple genotypes of HEV could cocirculate in the same area; even distinct genotypes of HEV could exist in the same patient. Pakistan is a highly endemic area for hepatitis E. So far only two Pakistan HEV isolates Sar-55 (87-Pakistan-A) and Abb-2B (88-Pakistan-2B) have been characterized, and the nucleotide sequences of these two HEV isolates show only 90% homology. In this study, a third HEV isolate from Pakistan (87-Pakistan-B) is reported. The sequences of a 438-bp fragment from ORF-2 and a 259-bp fragment from the ORF-1-3 region of this new HEV isolate were obtained and sequenced. The sequence analysis showed that this new HEV isolate was very closely related to the Sar-55 but different from the Abb-2B HEV isolate. These results indicated that the Sar-55 (87-Pakistan-A) genotype is the main endemic HEV strain in the Sargodha area. These data will be useful for HEV epidemiological studies, diagnosis and vaccine development.
Base Sequence↗
A review of rotavirus diarrhea in Pakistan: how much do we know?
INTRODUCTION: Rotavirus diarrhea has a worldwide distribution, infecting almost all children by the age of 3-5 years. EPIDEMIOLOGY: A comparable etiological 2-year survey carried out by the W.H.O Diarrheal Disease control (CDD) Program in 1991, in a multicenter study in 5 developing countries including Pakistan revealed that Rotavirus was found to be the most frequently detected pathogen in diarrheal episodes, during the first year of life, with the highest incidence (20%) occurring among 6-11 months old. Two other studies done in Pakistan, in under five children done in Lahore (between 1985 and 1991) and Rawalpindi (between May 1983 and April 1984) showed that Rotavirus was the second most common Diarrhea causing enteric pathogen following E.Coli TRANSMISSION: Rotaviruses are shed in high concentrations 2 days before and as many as 10 days after onset of symptoms in immunocompetent hosts, thus being an important source of viral transmission. CLINICAL COURSE: A multicenter study in 5 developing countries including Pakistan conducted by WHO CDD program revealed that only 1.8 % of cases presented with severe dehydration and these were mostly due to Rotavirus, V. Cholerae and ETEC13. DIAGNOSTIC TESTS: A study conducted in local hospitals in Pakistan during the period of October 1985-April 1986 compared the different diagnostic modalities for the detection of rotavirus in the faeces of children with acute diarrhea. The study all methods detected Rotavirus to varying degrees but ELISA was found to be the most sensitive method with 72.4% stools being positive. PREVENTIVE STRATEGIES: A study was conducted in Lahore (Pakistan) among 72 infants 6 weeks old in 1991 to assess safety and efficacy of RRV vaccine. It was found that of all infants given RRV with OPV, 50% had a two to four-fold rise in neutralization titers against rotavirus. RRV was found to be safe and not associated with adverse reactions in the 6 weeks old infants. CONCLUSION: With regards to Pakistan, there is a great need for defining rotavirus associated disease burden and strain prevalence. We also need to conduct Rotavirus vaccine trials to assess its efficacy and safety in our setting.
Child, Preschool↗
The urban bias in health facilities in Pakistan.
In this paper we examine the urban bias in the health facilities in Pakistan. Although urban areas in Pakistan contain less than 30% of the population, the health facilities are grossly over-represented here. We have argued that the evolution of the health sector has taken place under the broader dynamics of the economy and society in Pakistan. Opting for a capitalist path of growth, with its inherent class contradictions, the health sector has grown in response to the needs of the bourgeois (predominantly urban) classes. The two factors which we feel are responsible for this urban bias are the type of medical education in Pakistan, and the role of the Government. The pattern of medical education is one which is a replica of the developed countries resulting in a demand for the 'latest' and the 'best' in medical care. The result is an urban-biased, hospital-oriented, curative-care model. The Government of Pakistan has also enhanced this urban-bias by investing heavily in urban-centred health facilities, often at the expense of the larger rural population. We have argued that it is the class structure under capitalism which gives rise to an urban bias. Policies are made by the ruling class, and allocations within and outside the health sector are made not on need, but on political expediency and on the ability to pay. To alter this maldistribution of resources, it is the class structure in Pakistan which will have to be attacked.
Curriculum↗
A comparison of the prevalence of rheumatoid arthritis and other rheumatic diseases amongst Pakistanis living in England and Pakistan.
The impact of environmental factors on the causation of rheumatoid arthritis (RA) is thought to be considerable. We explored this by comparing the prevalence of RA amongst Pakistanis living in England, where it is relatively high amongst ethnic English, and in Pakistan. The frequency of other rheumatic diseases was also compared. Information on 2056 adult Pakistanis in England and 4232 in Pakistan was obtained by house-to-house surveys using identical protocols. Positive respondents were examined by the same two clinicians in both countries. Rheumatic complaints increased with age and were more common in females in both communities. The standardized morbidity ratio (SMR) (95% CI) of RA in England was 2.1 (1.1-3.1) compared with Pakistan, a difference that was entirely attributable to females. The SMR (95% CI) for women was 3.0 (0.4-5.6) and for men 0.86 (-0.84 to 2.56). In Pakistan, there was a trend to more reporting of some but not all rheumatic complaints amongst the affluent segment of the population. This was increasingly apparent amongst those resident in England and the possibility of an impact of easier ascertainment amongst the more educated cannot be discounted. Low back pain was significantly more common in England. Furthermore, the colder climate was frequently invoked as a cause of more symptoms in England. Thus, several factors may have influenced the observation that RA is more common amongst Pakistanis in England compared with Pakistan. An environmental factor cannot be excluded. However, the frequency of non-specific musculoskeletal pain was similar. The regions of Pakistan from which the two populations were derived were also different and immunogenetic heterogeneity might also have contributed to the difference in RA prevalence.
Adolescent↗
Seroprevalence of the antibody to hepatitis C in select groups in the Punjab region of Pakistan.
GOALS: Hepatitis C is on the rise in clinics in Pakistan. To estimate the occurrence of hepatitis C in the region and to create awareness about the disease in the general public, two studies were conducted in Punjab, Pakistan. Before this, no such effort has been made in Pakistan. BACKGROUND: Two studies were held in Lahore and Gujranwala of Punjab, Pakistan. These studies were advertised throughout the city, and people who participated were screened for anti-hepatitis C virus (anti-HCV)-positive serology at a concession rate and were surveyed through a questionnaire. In Lahore, there were 488 participants (mean age, 28 years; male-to-female ratio, 1.4 to 1). In Gujranwala, there were 1,922 participants (mean age, 27 years; male-to-female ratio, 1.5 to 1). The patients' blood was tested using an immuno-chromatography to identify the antibody to hepatitis C using Instatest HCV, with very high sensitivity. RESULTS: In Lahore, the occurrence of anti-HCV-positive serology was 15.9%. In Gujranwala, the occurrence of anti-HCV-positive serology was 23.8%. In Lahore, the occurrence was 1.2% in participants 20 years of age and younger and was 23.5% in those who were more than 20 years of age. In Gujranwala, the occurrence of anti-HCV-positive serology was 5.4% in participants 20 years of age and younger and was 34% in those who were more than 20 years of age. CONCLUSION: It can be seen that in those younger than 20 years of age, the occurrence of hepatitis C is almost at par with the rest of the world (0.5-2%). However, those more than 20 years of age had a very high occurrence, as high as 50% in certain age groups. The time-frame of contraction of the HCV for those individuals more than 20 years of age (approximately 20 to 35 years ago) corresponds with that of the smallpox eradication program conducted in Pakistan from 1964 to 1982. This may indicate the likelihood of a relationship between the high rate of hepatitis C and the administration of the smallpox vaccine in Pakistan.
Adult↗
Determining the optimal concentration of fluoride in drinking water in Pakistan.
OBJECTIVES: This study was designed to determine the optimal concentrations of fluoride for drinking water in Pakistan. Clinical dental examination of 1020 school children aged 12 years was carried out in 19 cities of Pakistan. Correlation between concentrations of water fluoride, caries and fluorosis was investigated by analyzing the data on fluoride concentrations in drinking water in the sampled population for which the caries and the fluorosis levels were also measured. METHODS: The optimal level of fluoride in drinking water is universally calculated by applying the equation of Galagan and Vermillion, which permits the calculation of water intake as a function of temperature. The annual mean maximum temperatures (AMMT) recorded during the last 5 years were collected from the meteorological centres of the 28 divisional headquarter stations. The average AMMT of Pakistan is 29 degrees C at which the optimal fluoride in drinking water of Pakistan was calculated to be 0.7 ppm. As drinking habits differ in various parts of the world, determination of optimal concentration of fluoride for drinking water in Pakistan was performed using a modified Galagan and Vermillion equation, which applies a correction factor of 0.56 to the equation. The optimal fluoride in drinking water in Pakistan using this modified equation was determined to be 0.39 ppm. RESULTS: Observation of the correlation showed that a fluoride concentration of 0.35 ppm in drinking water was associated with maximum reduction in dental caries and a 10% prevalence of fluorosis. CONCLUSIONS: Determining the most appropriate concentrations of fluoride in drinking water is crucial for communities. It is imperative that each country calculates its own optimal level of fluoride in drinking water based on the dose-response relationship of fluoride in drinking water with the levels of caries and fluorosis. Climatic conditions, dietary habits of the population and other possible fluoride exposures need to be considered in formulating these recommendations.
Cariostatic Agents↗
HIV-infected workers deported from the Gulf States: impact on Southern Pakistan.
HIV prevalence is still very low in Pakistan, but its south Asian location and subgroups with recognized lifestyle risk factors suggest that Pakistan will experience expanded diffusion of HIV. We report the frequency of HIV infections identified by the AIDS Control Programme on the Sindh province of Pakistan. Most HIV-positive cases currently reported to the Sindh AIDS Control Programme are found among Pakistani workers deported from the Gulf States and among foreigners. The 58 returned workers with HIV represent 61 to 86% of reported cases in any given year during the 1996-1998 period. Five wives of returning workers have been identified with HIV. Expatriate workers in the Gulf States are tested for HIV routinely, unlike other subgroups in Pakistan. Considering the risk of HIV/AIDS due to regular introduction of HIV from returned workers, and the limited awareness surrounding sexual health and HIV/STD transmission issues in Pakistan, intervention programmes targeted at overseas workers need to be implemented to control the expansion of the HIV epidemic in Pakistan.
Acquired Immunodeficiency Syndrome↗
HIV-infected workers deported from the Gulf States: impact on Southern Pakistan.
HIV prevalence is still very low in Pakistan, but its south Asian location and subgroups with recognized lifestyle risk factors suggest that Pakistan will experience expanded diffusion of HIV. We report the frequency of HIV infections identified by the AIDS Control Programme in the Sindh province of Pakistan. Most HIV positive cases currently reported to the Sindh AIDS Control Programme are found among Pakistani workers deported from the Gulf States and among foreigners. The 58 returned workers with HIV represent 61 to 86% of reported cases in any given year during the 1996-1998 period. Five wives of returning workers have been identified with HIV. Expatriate workers in the Gulf States are tested for HIV routinely, unlike other subgroups in Pakistan. Considering the risk of HIV/AIDS due to regular introduction of HIV from returned workers, and the limited awareness surrounding sexual health and HIV/STD transmission issues in Pakistan, intervention programmes targeted at overseas workers need to be implemented to control the expansion of the HIV epidemic in Pakistan (Int J STD AIDS 1999;10:812-14).
Journal Article↗
Malaria in Afghan refugees in Pakistan.
Prevalence of malaria in Afghan refugees in Pakistan is higher than in the local population. Malaria control officials in Pakistan hypothesized that Afghan refugees have brought a heavy load of malaria infections with them from Afghanistan, causing a serious setback to the malaria control programme in Pakistan. The purpose of this study was to test this hypothesis, because it is important regarding the selection of appropriate strategy for malaria control. The proposed hypothesis is rejected because of the following evidence against it: (i) a comparison of age-specific parasite rates of malaria in Afghan refugees and a nearby local population at Karachi indicated that Afghan refugees were susceptible to malaria even in later age-groups, while infections in the local population were limited to younger age-groups; (ii) a comparison of epidemiological trends of malaria in Afghan refugees and the local population in the North-West Frontier Province from 1979 to 1986 demonstrated that the rate of increase in the prevalence of malaria over the years was much higher in Afghan refugees than in the local population, a manifestation of low herd immunity in Afghan refugees. The most plausible alternate hypothesis is that Afghan refugees, being more susceptible, were at high risk of malaria infection in Pakistan rather than that they brought a high infection load with them from Afghanistan. Therefore, malaria control in Afghan refugee camps in Pakistan should be primarily based on preventive, rather than curative, measures.
Adolescent↗