Early child health in Lahore, Pakistan: XII. Milestones

Psychomotor development was assessed in 1476 infants from four different levels of urbanization in and around Lahore, Pakistan. Development was assessed monthly at birth to 24 months of age by using a set of 10 milestones selected from the Denver Developmental Screening Test and the Developmental Screening Inventory. The psychomotor development of children in the upper middle (Um) class was consistent with reference population groups in Europe and North America, hence this group was used as control. There was significant delay in the psychomotor development of infants belonging to the poorer areas compared to the Um class. There was no sex difference in the development of the milestones in any study area, except for girls in the Um class who were earlier for about one month than boys in talking. Infants in the poorer areas were, on average about 3 months, delayed in their walking and fine motor activity (building a tower of 3 cubes) in comparison with the Um class. Observed disturbance in psychomotor development at an early age may affect the abilities and achievements in later life.     

Prevalence of Thalassemia Traits and Iron Deficiency Anemia in Sindh,Pakistan

Among microcytic hypochromic anemias, the most common disorders are iron deficiency anemia and co-pathological conditions such as α- or β-thalassemia (α- or β-thal) traits. The aim of the present study was to determine the frequency and prevalence of iron deficiency anemia and α- or β-thal traits based on clinical laboratory data across different ethnic groups in five districts of Sindh Province, Pakistan. The present retrospective study analyzed 3 years (2012–2015) of encoded and unlinked clinical laboratory data, and identified 3030 microcytic hypochromic anemia cases. The data contained complete blood counts (CBCs) with smear morphology examinations, serum ferritin levels, and hemoglobin (Hb) electrophoreses. After reviewing the data, 994 confirmed subjects (iron deficiency anemia and α- and β-thal traits) were then selected for the present study. The prevalence of α- and β-thal traits was highest in Badin district (35.27%), while the prevalence of iron deficiency anemia was highest in Larkana district (30.73%). According to the ethnic-wise distribution, higher numbers of α- and β-thal trait cases were seen in the Sindhi ethnic group [375 (64.21%) and 283 (69.02%), respectively] than in the other ethnic groups. In addition, a higher distribution of β-thal trait cases was observed in the Sindhi ethnic group [n?=?327 (56%)] in α- and β-thal cases overall. Findings from the present study strongly suggested that screening is important not only for β-thal trait but also other traits as well. However, careful monitoring of CBC parameters, including red blood cell (RBC) indices and morphology, along with clinical findings are essential to diagnose carrier cases, especially in high prevalence areas.     

Hepatitis B virus genotypes, subgenotypes, precore, and basal core promoter mutations in the two largest provinces of Pakistan

Background and Aim:  Hepatitis B virus (HBV) genotyping has been done in most countries, but unfortunately, in Pakistan, HBV genotypic distribution is still unclear. The aim of the present study was to determine the prevalent genotype and subgenotype in the two most populated provinces in Pakistan: Punjab and Sind.
Methods:  In total, 236 HBV DNA-positive samples were selected for genotyping by polymerase chain reaction–restriction fragment length polymorphism (RFLP). The RFLP results were further confirmed with whole genome and partial genome sequencing.
Results:  Genotype D was detected as the most prevalent (93.22%) genotype in all eight cities of both provinces; genotype C was present in 5.93% and genotype A was present in 0.85% of the samples. The D1 subtype was present in 84%, and D2 was present in 8% of 25 whole genome-sequenced samples. The C2 subtype was detected in 58.33% of S gene-sequenced samples, while D1 was detected in the remaining 41.67% of 24 samples sequenced for the S gene. Subtype D1 is the most dominant in D, while C2 is dominant in genotype C. Eight- and 15-bp deletion mutations were also detected in genotype D samples. Other precore and basal core promoter (BCP) mutations included T1915 (100%), A1679 (86.96%), T1762 (39.13%), and A1764 (30.43%), which were also detected in the genotype D samples.
Conclusion:  Genotype D subtype D1 is the most prevalent HBV strain in Pakistan with 8-bp deletion mutants the most common in HBV carriers.     

Dengue outbreak in Karachi, Pakistan, 2006: experience at a tertiary care center

This is the first report of the largest epidemic of dengue hemorrhagic fever (DHF) virus infection (2006) with IgM-confirmed cases from Karachi, Pakistan. Medical records of 172 IgM-positive patients were reviewed retrospectively for demographic, clinical and laboratory data. Patients were categorized into dengue fever (DF) and DHF according to the WHO severity grading scale. The mean+/-SD age of the patients was 25.9+/-12.8 years, 55.8% were males and the hemoconcentration was recorded in a small number of patients [10 (7.0%)]. Male gender [odds ratio (OR)=14.7, P=0.003), positive history of vomiting (OR=4.3, P=0.047), thrombocytopenia at presentation (OR=225.2, P<0.001) and monocytosis (OR=5.8, P=0.030) were independently associated with DHF, but not with DF. Five cases (2.9%) had a fatal outcome, with a male-to-female ratio of 1:4. Three were from a pediatric group (<15 years). Pulmonary hemorrhages, disseminated intravascular coagulation and cerebral edema preceded death in these patients. The results have highlighted significant findings, such as adult susceptibility to DHF, pronounced abdominal symptoms and lack of hemoconcentration at time of presentation in the study population. These findings may play an important role in the case definitions of future studies from this part of the world.     

Human papillomavirus in tonsillectomy specimen from China and Pakistan — Prevalence and genotype distribution

Background

The expected corresponding increase in tonsillar human papillomavirus (HPV) infection associated with increasing incidence of oropharyngeal squamous cell carcinoma (OPSCC) substantiate the evaluation of normal tonsillar tissue in different population. The epidemiology of HPV in tonsillar tissue varies geographically. This study evaluated samples from two countries to determine the prevalence in respective samples.

Prevalence and risk factors for intrafamilial transmission of hepatitis C virus in Karachi,Pakistan

Household contacts of hepatitis C virus (HCV)-positive patients are considered at increased risk of HCV infection. This cross-sectional study during April through June 1999 assessed the prevalence and risk behaviours associated with HCV seropositivity among the household contacts of HCV seropositive thalassaemic children in Karachi, Pakistan. Among the 341 household contacts of 86 thalassaemic HCV seropositive children who were tested, 70 (20.5%) were positive for anti-HCV antibodies. The stratified analysis showed that HCV seroprevalence among the contacts did not differ significantly by the gender of the index patient and the type of relationship of contact with the index patient. However, HCV seroprevalences among the fathers and mothers of male index patients was substantially higher compared to those of female index patients. HCV RNA was recovered and genotyped from nine index patients and corresponding nine HCV-seropositive household contacts. HCV genotype 3a and 3b were found in 89% (8/9) and 11% (1/9) of the pairs, respectively. The final multivariable conditional logistic regression model revealed that after adjusting for the effect of ethnicity and past hospital admission history, the HCV-seropositive household contacts were more likely than HCV seronegative household contacts to have been bitten by the carrier [adjusted matched odds ratio (mOR)=2.6, 95% CI 1.3–5.2] or have shared a toothbrush with the carrier (adjusted mOR=8.2; 95% CI 1.56–43.5). Control efforts should focus on the risk behaviours.     

Impact of human mobility on the emergence of dengue epidemics in Pakistan

The recent emergence of dengue viruses into new susceptible human populations throughout Asia and the Middle East, driven in part by human travel on both local and global scales, represents a significant global health risk, particularly in areas with changing climatic suitability for the mosquito vector. In Pakistan, dengue has been endemic for decades in the southern port city of Karachi, but large epidemics in the northeast have emerged only since 2011. Pakistan is therefore representative of many countries on the verge of countrywide endemic dengue transmission, where prevention, surveillance, and preparedness are key priorities in previously dengue-free regions. We analyze spatially explicit dengue case data from a large outbreak in Pakistan in 2013 and compare the dynamics of the epidemic to an epidemiological model of dengue virus transmission based on climate and mobility data from ∼40 million mobile phone subscribers. We find that mobile phone-based mobility estimates predict the geographic spread and timing of epidemics in both recently epidemic and emerging locations. We combine transmission suitability maps with estimates of seasonal dengue virus importation to generate fine-scale dynamic risk maps with direct application to dengue containment and epidemic preparedness.Dengue is the most rapidly spreading mosquito-borne disease worldwide (1, 2). Half the global population now lives in at-risk regions for dengue virus transmission, due to the wide distribution of the mosquito vector, Aedes aegypti, which thrives in peri-urban areas and transmits the virus between humans (3). Dengue virus can cause acute febrile illness and carries the risk of severe disease, hospitalization, and shock syndrome, especially in clinical settings with little experience treating dengue patients. There is currently no specific therapeutic protocol for, or vaccine against, infection (1). Current control measures focus on vector control, although these measures are often logistically difficult and have shown varying efficacy in controlling epidemics (4). In the absence of effective prevention and treatment, public health system preparedness remains the single most important tool for minimizing morbidity and mortality as dengue epidemics spread beyond endemic areas (5, 6).The introduction of dengue into new populations is mediated by travel of infected individuals to areas that can support transmission, because mosquito vectors move only short distances during their lifespans (3, 7–12). International travel to endemic countries has resulted in imported cases and outbreaks in Europe and the Americas (2, 8, 10, 13). Local variation in transmission, within a single city for example, is also driven by mobility patterns of individuals on short timescales (7). Forecasting methods are needed to spatially target interventions and epidemic preparedness measures that reflect both the changing temporal risks of importation and environmental suitability that go beyond solely climate-based methods (14).Dengue has long been endemic in most Southeast Asian countries (1), but has more recently emerged in parts of the Middle East and South Asia, including Pakistan (15, 16). In Pakistan, the transmission of dengue viruses was largely confined to the southern city of Karachi until 2011 when a large dengue epidemic with over 20,000 cases occurred in the northeastern city of Lahore (16), causing significant morbidity and mortality. In 2013, a second large epidemic occurred in northeastern Pakistan in Punjab and Khyber-Pakhtunkhwa (KP) provinces, establishing the region as an emerging focus of seasonal dengue epidemics. It has been hypothesized that the recent geographic expansion of A. aegypti mosquito vectors, changing environmental suitability, and human importation of dengue from endemic regions all contributed to the emergence of dengue in northern areas (17). Pakistan is therefore representative of many countries that are on the verge of countrywide endemic dengue transmission and are struggling to contain its emergence into previously dengue-free regions.Measuring changing risks of importation events that spark epidemics has been extremely challenging on the refined temporal and spatial scales necessary to inform local policies (18). Being able to predict when to prepare surveillance systems and health facilities for dengue outbreaks could dramatically reduce the morbidity and mortality associated with epidemics and would allow policy makers to pinpoint regions that are particularly vulnerable to imported cases, for vector control. Mobile phone data offer direct measures of human aggregation and movement and represent a unique source of information on the human determinants of the geographic expansion of emerging epidemic diseases like dengue. Here, we conduct a retrospective epidemiological analysis of large dengue outbreaks in Pakistan in 2013, to examine the predictive ability of an epidemiological model that integrates human mobility from the largest mobile phone dataset analyzed to date with climate information. We show that within-country human mobility predicts emerging epidemics in Pakistan, and epidemiological models incorporating this type of data can predict the spatial extent and timing of outbreaks, providing a new approach to forecasting.     

The challenge of spinal cord injury care in the developing world

Great strides have been made in reducing morbidity and mortality following spinal cord injury (SCI), and improving long-term health and community participation; however, this progress has not been uniform across the globe. This review highlights differences in global epidemiology of SCI and the ongoing challenges in meeting the needs of individuals with SCI in the developing world, including post-disaster. Significant disparities persist, with life expectancies of 2 years or less not uncommon for persons living with paraplegia in many developing countries. The international community has an important role in improving access to appropriate care following SCI worldwide.