Search

Background To contribute to the World Health Organization’s End TB Strategy, the active tuberculosis (TB) case-finding approach has been proven effective. Methods A total of 66 chest camps were organised for patients in 15 selected districts in Punjab, Pakistan, in 2017. A mixed-method process evaluation was conducted in four randomly selected districts to evaluate the use of chest camps for active TB case finding to reach the maximum number of people with TB and to assess the implementation outcomes, such as effectiveness, feasibility, fidelity, and costs. Results Results indicated that 1458 attendees visited 24 chest camps in four selected districts. Among attendees, 297 presumptive cases were found and smear-tested; and 34 of the smear-tested were diagnosed as smear-positive TB patients. The prevalence of smear-positive TB patients among the chest camp participants was found to be 2.3%. The findings from interviews showed that preparation of chest camp activities, especially the involvement of community leaders, was found to be effective in achieving the desired level of attendance. The respondents found attending the chest camps for TB symptoms feasible and acceptable. The chest camp costs approximately US$280, including the pre-camp mobilisation events, whereas the cost per TB-positive patient was found to be US$197.64. Conclusions The higher number of attendees without TB symptoms, the low proportion of smear-negative case registrations; and relatively high unit cost (per patient detected) were the areas identified for further attention. The study supports the continuation of chest camp activity, with further attention required for quality and efficiency concerns.

The occurrence of Crimean-Congo haemorrhagic fever (CCHF) in humans is linked with animals living in close vicinity, and information on the incidence of CCHF at the human-animal interface is scarce. Therefore, the current study was designed to identify the high-risk groups of individuals linked with animals in the Chakwal district of Pakistan having a history of CCHF cases in humans. In subject matter, coupled with risk factor analysis, we performed a sero-based CCHF surveillance in three selected risk groups of humans including abattoir workers (n = 137), milkmen (n = 169) and animal handlers (n = 147). Sera samples and questionnaire-based data were collected from each of the participants and screened for anti-CCHFV IgG antibodies using enzyme-linked immunosorbent assay. The highest seroprevalence was observed in animal handlers (n = 14, 9.52%, 95% CI: 4.68-13.99) followed by abattoir workers (n = 9, 6.57%, 95% CI: 2.42-10.72) and milkmen (n = 3, 1.78%, 95% CI: 0.24-4.24). The risk of seropositivity was significantly associated with humans linked with tick-infested animals (OR: 11.0, 95% CI: 1.5-83.0, p = .002), old age >40 years (OR: 6.6, 95% CI: 2.7-16.0, p < .0001), illiteracy (OR: 4.3, 95% CI: 1.5-13.0, p = .004) and humans without knowledge about CCHF (OR: 7.6, 95% CI: 1.8-33.0, p = .0009). The findings of the current study highlighted the seroprevalence of CCHF in high-risk groups of humans living in a disease-endemic area of Pakistan and highlight the need for well-integrated disease surveillance in the future to better comprehend disease control interventions.

Crimean-Congo Haemorrhagic Fever (CCHF) is a deadly viral zoonotic disease, which is endemic in Pakistan. We report a case study analysis of three cases of CCHF which occurred in Chakwal, Pakistan in 2016. The disease was suspected in three patients exhibiting clinical symptoms suggestive of CCHF; two of the three patients died. The presence of CCHF was detected by seroconversion (IgG) from the surviving patient, while the antigen was detected in Hyalomma ticks originating from animals in the vicinity. This report indicates increase threat emergence of CCHF in Pakistan and highlights its zoonotic implications requiring immediate interventions under the "One-Health" concept.

Crimean-Congo Haemorrhagic Fever (CCHF) is a viral zoonotic disease. Butchers and slaughterhouse workers are considered to be high risk occupational groups for the disease. Sistan and Baluchistan province is an area in southeastern Iran which is endemic for CCHF, and the most confirmed cases of the disease are reported from this province. The aim of this study was to investigate the seroprevalence of CCHF and risk factors for seropositivity among them in Sistan and Baluchistan province in 2011.Questionnaire data and blood sample collection were carried out for each participant and the sera samples were sent to the national reference laboratory for ELISA IgG testing.In this study, the seroprevalence of CCHF among 190 butchers and slaughterhouse workers from 11 counties was 16.49%. 79% of participants were aware that they were at risk of zoonosis and 39.7% did not use any personal protective equipment during their work. Of 31 CCHF IgG positive individuals in this study, eleven individuals had a previous record of CCHF infection in 57 months prior to the study.High seroprevalence of CCHF among butchers and slaughterhouse workers and minimal use of personal protective equipment's during daily work indicates the need for training courses, for these groups to increase their knowledge, attitude and practice with respect to zoonosis.

Owing to consistent genetic mutation and recombination, various escape mutants and/or drug-resistant mutants of human immunodeficiency virus (HIV-1) are now emerging worldwide. Therefore, an understanding of the genetic characteristics of prevailing strains, particularly with regard to drug-resistance-associated substitutions, is essential for devising and implementing treatments and disease control interventions in endemic settings such as Pakistan. We processed a total of 130 plasma samples originating from HIV-treatment centers in selected districts of Punjab province, Pakistan. The samples were first screened using an HIV-1 Ag/Ab Combo test followed by amplification of the pol gene (1084 bp) from samples that were positive either for the antigen or for both the antigen and antibodies simultaneously. Screening revealed that a total of 45 samples were positive (34.62%; 95% CI: 26.99-43.13) for either antigen or both antigen and antibodies (n = 18, 40%; 95% CI: 27.02-54.55) or for antibodies alone (n = 27, 60%; 95% CI: 45.45-72.98). A largest number of positive samples was from the district of Lahore (n = 19/43, 44.18%; 95% CI: 30.44-58.9) followed by Faisalabad (n= 12/36, 33.33%; 95% CI: 20.21-49.66), Gujranwala (n = 05/23, 21.7%; 95% CI: 9.66-41.9) and Sargodha (n = 09/28, 32.1%; 95% CI: 17.93-50.66). The probability of occurrence of HIV infection was significantly associated with individuals having a history of injecting drug use (68.08%; OR = 11.15; 95% CI: 53.84-79.61, p = 0.0001). Phylogenetic analysis based on the pol gene showed that the sequences from this study clustered into three distinct clades representing recombinant form 02_AG (n = 14, 77.0%; 95% CI: 54.79-91.00), and subtypes A (n = 2, 11.1%; 95% CI: 3.1-32.8) and G (n = 2, 11.1%; 95% CI: 3.1-32.8). Although we screened 18 samples for drug-resistance-associated mutations, except for an accessory mutation (M46K) in the protease (PR) region in one subject, we found a lack of drug-resistance-associated substitutions in the PR region. On the other hand, we found two subjects (2/18) carrying a resistance-associated mutation (V106I) conferring a low level of resistance against non-nucleoside reverse transcriptase inhibitors. The present study shows that multiple subtypes of HIV-1 are present in the affected population. Continuous disease surveillance coupled with evaluation of drug resistance at higher resolution should be done in future studies.

Pakistan ranks 5th among the world's highest tuberculosis (TB) burden countries and 6th among the countries with the highest prevalence of drug-resistant TB. However, insufficient data are available on the genetic structure of M. tuberculosis strains circulating in this country. The objective of this study was to explore the genetic diversity of multidrug-resistant M. tuberculosis isolates from Punjab, Pakistan with a combination of spoligotyping and 24-loci MIRU-VNTR typing. Among a total of 127 MDR isolates studies, 53 spoligotypes were obtained, split into 14 clusters (n = 88, 69.3%, 2–29 isolates per cluster) and 39 (30.7%) unique patterns. At the phylogenetic level, the most prevalent sublineage was CAS1_DELHI (n = 53, 41.7%), mostly represented by ST 1942 (n = 29, 22.8%), followed by T1 (n = 14, 11%) and Beijing (n = 10, 7.8%). The remaining nine sublineages (CAS, MANU2, EAI5, T2, LAM10_CAM, H1, X1, H4 and CAS2) involved altogether 24 (18.9%) isolates. Twenty-six (20.5%) isolates could not be assigned to any specific clade. MIRU-VNTR typing identified 123 (96.8%), 97 (76.4%) and 65 (51.2%) unique types with a tolerance of 0, 1, and 2 locus differences between the patterns. Upon combined spoligotyping and MIRU-VNTR typing analysis, 123 (96.8%), 108 (85%), and 91 (71.7%) unique types were identified if a tolerance of 0, 1, and 2 locus differences in the MIRU-VNTR patterns was assumed, respectively. Based on the clustering results, the transmission rate for MDR-TB cases under the study was calculated at 3.2%, 15%, and 28.3%. Overall, three clades, namely CAS1_DELHI, T1, and Beijing accounted for the majority of MDR-TB cases in Pakistan. Up to a third of the cases were clustered upon combined spoligotyping and MIRU-VNTR typing, suggesting a moderate level of active transmission.

Tuberculosis (TB) is a cause of death from a single infectious agent Mycobacterium tuberculosis (MTB), leading to approximately 2.5 million deaths annually worldwide. Information regarding prevalence and pattern of drug resistance among TB patients in Pakistan remains inadequate due to the country’s limited resources. This study compared conventional diagnostic techniques with a PCRbased assay targeting IS6110 sequence. In addition, MTB drug resistant profiles against four first-line drugs (ethambutol, isoniazid, rifampin, and streptomycin) from new and retreatment cases of TB. From 101 sputum samples microscopic examination of Ziehl-Neelsen-stained smears and culturing on Lowenstein Jensen medium resulted in 96% and 100% positives, compared to 98% by PCR. Prevalence of MDR-MTB was 41.5% and 58.5% among new (n = 51) and retreatment (n = 50) cases, but 10% of the former group were sensitive to all four first-line anti-TB drugs. Thus, MDR-MTB is highly prevalent among TB patients in Punjab Province, Pakistan (where the study was conducted) and, although PCR amplification of MTB-specific IS6110 sequence was rapid, it lacked the sensitivity of the culture assay.

Surveillance is a valuable tool for understanding prevailing and previously undiagnosed infections in a geographic area. We examined 480 archived serum samples from patients with history of persistent fever (>40°C, 60-72h) who were referred to hospitals in Rawalpindi/Islamabad, Lahore, and Faisalabad districts for dengue antibody detection in 2014-15. Each sample was processed for detection of antigens and seroconversion, using real-time polymerase chain reaction and enzyme linked immunosorbent assay, respectively, against dengue haemorrhagic fever (DHF) virus serotypes 1-4, West Nile virus fever (WNVF), Crimean-Congo haemorrhagic fever (CCHF), and Chikungunya virus (CGV). The presence of antigens and antibodies to at least one of the studied viral haemorrhagic fevers (VHFs) was detected in 465 (96.8%, 95% CI: 94.9-98.1) and 442 samples (92.1%, 95% CI: 89.3-94.2), respectively. No sera were found positive to CCHF. There was a significant association between gender and positivity to at least one of the VHFs (χ2=8.12, df=1, p

Background : The co-occurrence of diabetes mellitus (DM) and tuberculosis (TB) is largely associated with high frequency of morbidity. Objective : To determine the prevalence of DM among TB patients and describe the socio-demographic and behavioral factors associated with TB-DM co-occurrence . Methods : We enrolled 500 TB patients from September, 2014 to August 2015 at four major public sector hospitals of Lahore, Pakistan. A questionnaire was used to collect information regarding associated socio-demographic and behavioral factors of the patients. We monitored the fasting blood sugar of each patient by using a semi automated clinical chemistry analyzer followed by an HbA1c level check of all hyperglycemic patients. Results : The prevalence of TB-DM co-occurrence was 14.8%. The prevalence of TB-DM was higher (62.2%) among males. The >57 year age group had the highest proportion of patients (35.1%), with co-existent TB-DM. Most were illiterate (73.0%) and unemployed (48%). Moreover, among the 74 patients positive for TB-DM had a history of smoking. Age and education level were significantly associated with DM-TB while gender, occupation and smoking were not associated. Conclusion : The study revealed a 14.8% prevalence of DM among TB patients. This was associated with several socio-demographic factors, including age, unemployment, literacy and polluted environment. Thus, poor and unhealthy lifestyles were the factors associated with DM among immunologically compromised individuals due to TB. Keywords : Tuberculosis (TB), diabetes mellitus (DM), socio-demographic and behavioral factors.

Background Drug resistant tuberculosis (DR-TB) is a major public health problem in developing countries such as Pakistan. Objective The current study was conducted to assess the frequency of drug resistant tuberculosis including multi drug resistance (MDR- TB) as well as risk factors for development of DR-TB, in Punjab, Pakistan. Methodology Drug susceptibility testing (DST) was performed, using proportion method, for 2367 culture positive Mycobacterium tuberculosis (MTB) cases that were enrolled from January 2012 to December 2013 in the province of Punjab, Pakistan, against first-line anti-tuberculosis drugs. The data was analyzed using statistical software; SPSS version 18. Results Out of 2367 isolates, 273 (11.5%) were resistant to at least one anti-TB drug, while 221 (9.3%) showed MDR- TB. Risk factors for development of MDR-TB were early age (ranges between 10–25 years) and previously treated TB patients. Conclusion DR-TB is a considerable problem in Pakistan. Major risk factors are previous history of TB treatment and younger age group. It emphasizes the need for effective TB control Program in the country.

Objective/Background: Tuberculosis (TB) is a leading cause of death worldwide, with new threats of multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB. Pakistan is the fifth highest among high-burden TB countries and the fourth highest among high-burden drug-resistant-TB countries. Pakistan is the sixth most populous country in the world, and Pakistani youth is the highest population group in Pakistan and second in the world. This study was aimed at assessing the understanding, awareness, and mindset of university students toward TB, MDR TB, and XDR TB in Lahore. Methods: A cross-sectional questionnaire-based study was performed on 1137 individuals from three major public-sector universities in Lahore, Pakistan. Information regarding their knowledge and attitude toward MDR and XDR TB was gathered using a structured questionnaire. Data collected was analyzed using SPSS version 20. Results: Male (531) and female (606) students were asked about different aspects of MDR and XDR TB. Although 80.47% students had good knowledge about simple TB, a very small fraction had awareness and appropriate knowledge about MDR/XDR-TB. Considering TB as a stigma, only 9.3% students disclosed that they had household TB contact. Only 25% students knew about XDR TB. Conclusion: Our results indicated that a small fraction of people knew the exact definition and treatment duration of MDR TB and XDR TB in our society. There is a need to increase the awareness and knowledge status of university students about MDR and XDR TB.

The health risks of wastewater use in agriculture were investigated in the city of Faisalabad, Pakistan, by means of a cross-sectional study. The study showed an increased risk of intestinal nematode infection and hookworm infection, in particular, in wastewater farmers (OR = 31.4, 95% CI 4.1-243) and their children (OR = 5.7, 95% CI 2.1-16) when compared with farming households using regular (non-wastewater) irrigation water. Textile labourers living in the same village as the wastewater farmers showed a lower risk of hookworm infection than wastewater farmers but an increased risk compared with farming households using regular irrigation water. Many urban and peri-urban farmers make a living by using untreated wastewater in the production of fresh produce for the urban market. Banning the use of untreated wastewater would deprive these farmers of their livelihood and affect food supply for the urban population. If treatment of wastewater is not a feasible option, the promotion of footwear and improved hygiene, the construction of toilets, in combination with regular anthelminthic treatment, would be suitable alternatives to safeguard the health of wastewater farmers and their children.

Background Since the first reported outbreak of dengue hemorrhagic fever in Pakistan, several mini outbreaks have erupted in the region. Dengue virus serotype 3 (DEN-3) was first documented in 2005 outbreak in Karachi. Reports show that serotype 3 is prevalent in Lahore since 2008. Serotype 2 (DEN-2) is the major circulating serotype in Pakistan as it is documented since 1994. We have conducted a detailed study of three outbreaks of dengue virus infection that occurred in years 2007, 2008 and 2009 in Lahore by using molecular techniques such as PCR and nucleotide sequencing of the C-prM gene junction of Dengue virus. Results Through the analysis of 114 serum samples collected over the period of three years (2007-2009), total 20 patients were found to be infected with dengue virus. In year 2007, four were positive for serotype 2 and one sample was positive for serotype DEN-3. In 2008, five samples had concurrent infection with serotypes DEN-2 and DEN-3 while three samples were infected only with serotype DEN-2. In year 2009, one sample had concurrent infection with serotypes DEN-2 and DEN-3 while six were positive for serotype DEN-2 only. Conclusions Our study showed that serotype DEN-2 was dominant in positive samples of dengue virus infection collected during the period of three years (2007-2009). The other serotype present was serotype DEN-3. Genotypes of serotype DEN-2 and serotype DEN-3 were subtype IV and subtype III, respectively.

Background Prompt, quality assured laboratory diagnosis is key to effective malaria case management and control, especially since the introduction of the more expensive artemisinin combination therapy (ACT). The malaria programme and its non-government partners, on the basis of WHO recommended Lot Quality Assurance methods, have developed a district level external quality assurance (EQA) system. This study was designed to assess the feasibility, under programme conditions, of an integrated district level external quality assurance and supervision approach for malaria microscopy. Design and Methods A prospective study conducted over seven months period (May-November 2007). In addition to the standard WHO EQA elements, three operational innovations were introduced, with the a district laboratory supervisor: a) onsite re-checking of slides, b) in ensuring uninterrupted availability of laboratory reagents and supplies at diagnostic centers, and c) supervision of administrative and technical components. The quantitative data for the study came from the service records/documents, whereas the qualitative data came from the key informant interviews. Results During the seven month period in four districts, a total of 8,118 slides were examined of which 209 (2.6%) were found positive for malaria parasites (slide positivity range between1.6% to 6.0%). The District Laboratory Supervisors in four districts reexamined a total of 1,770 slides (22%). The proportion of slides found discordant ranged from 0.5% to 1%. The quality of smear preparation was found acceptable in 73% slides. Conclusions A district-based EQA, based on lot quality assurance methods was implemented, using context-specific operational guidelines, tools and training modules, and other inputs from the malaria control programme and partners. This EQA and supervision approach was found to be feasible and acceptable to those involved. Further study is required on the microscopy quality and cost-effectiveness of adding external quality assurance and supervision to district malaria microscopy services.