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During August 2017, increased numbers of suspected dengue fever cases were reported in the hospitals of Rawalpindi district. A case control study was conducted to determine the risk factors among urban areas, dengue serotype, and recommend preventive measures. The objective of the investigation was to determine the risk factors among urban areas, dengue serotype, and recommend preventive measures. A case was defined as having acute febrile illness with one or more of the following symptoms: retro-orbital pain, headache, rash, myalgia, arthralgia, and hemorrhage. The cases were residents of Rawalpindi and were confirmed for dengue fever from August 30, 2017, to October 30, 2017. All NS1 confirmed cases from urban areas of Rawalpindi were recruited from tertiary care hospitals. Age- and sex-matched controls were selected from the same community with a 1:1 ratio. Frequency, univariate, and multivariate analyses were performed at 95% CI with P<.05 considered statistically significant. Totally 373 cases were recruited. The mean age was 36 (SD 2.9) years (range 10-69 years), and 280 cases (75%) were male. The most affected age group was 21-30 years (n=151, attack rate [AR] 40%), followed by 31-40 years (n=66, AR 23%). Further, 2 deaths were reported (case fatality rate of 0.53%). The most frequent signs or symptoms were fever (n=373, 100%), myalgia and headache (n=320, 86%), and retro-orbital pain (n=272, 73%). Serotype identification was carried out in 322 cases, and DEN-2 was the dominant serotype (n=126, 34%). Contact with a confirmed dengue case (odds ratio [OR] 4.27; 95% CI 3.14-5.81; P<.001), stored water in open containers at home (OR 2.04; 95% CI 1.53-2.73; P<.001), and travel to a dengue outbreak area (OR 2.88; 95% CI 2.12-3.92; P<.001) were the main reasons for the outbreak, whereas use of mosquito repellents (OR 0.12; 95% CI 0.09-0.18; P<.001) and regular water supply at home (OR 0.03; 95% CI 0.02-0.04; P<.001) showed protective effects. The geographical distribution of cases was limited to densely populated areas and all the 5 randomly collected water samples tested positive for dengue larvae. Stored water in containers inside houses and subsequent mosquito breeding were the most probable causes of this outbreak. Based on the study findings, undertaking activities to improve the use of mosquito repellents and removing sources of breeding (uncovered water stored indoors) are some recommendations for preventing dengue outbreaks.

On October 23, 2016, 79 dengue fever cases were reported from the Union Council Tarlai to Federal Disease Surveillance and Response Unit Islamabad. A team was established to investigate the suspected dengue outbreak. The aim of this study was to determine the extent of the outbreak and identify the possible risk factors. Active case finding was performed through a house-to-house survey. A case was defined as an acute onset of fever ≥38℃ in a resident of Tarlai from October 2 to November 11, 2016, with a positive dengue virus (nonstructural protein, NS-1) test and any of the two of following signs and symptoms: retroorbital/ocular pain, headache, rash, myalgia, arthralgia, and hemorrhagic manifestations. A structured questionnaire was used to collect data. Age- and sex-matched controls (1:1) were identified from residents in the same area as cases. Blood samples were taken and sent to the National Institute of Health for genotype identification. During the active case search, 145 cases of dengue fever were identified by surveying 928 houses from October 23 to November 11, 2016. The attack rate (AR) was 17.0/10,000. The mean age was 34.4 (SD 14.4) years. More than half of the cases were male (80/145, 55.2%). Among all cases, 29% belonged to the 25-34 years age group and the highest AR was found in the 35-44 years age group (35.6/10,000), followed by the 55-64 years age group (35.5/10,000). All five blood samples tested positive for NS-1 (genotype DENV-2). The most frequent presenting signs/symptoms were fever and headache (both 100%). Stagnant water around houses (odds ratio [OR] 4.86, 95% CI 2.94-8.01; P<.001), presence of flower pots in the home (OR 2.73, 95% CI 1.67-4.45; P<.001), and open water containers (OR 2.24, 95% CI 1.36-3.60; P<.001) showed higher odds among cases. Conversely, use of bed nets (OR 0.44, 95% CI 0.25-0.77; P=.003), insecticidal spray (OR 0.33, 95% CI 0.22-0.55; P<.001), door screens (OR 0.27, 95% CI 0.15-0.46; P<.001), mosquito coil/mat (OR 0.26, 95% CI 0.16-0.44; P<.001), and cleanliness of the house (OR 0.12, 95% CI 0.05-0.26; P<.001) showed significant protective effects. Stagnant water acting as breeding grounds for vectors was identified as the probable cause of spread of the dengue outbreak. Establishment of surveillance and an early reporting system along with use of protective measures against the vector are strongly recommended.

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

Background: Event Based Surveillance (EBS) is the organized and rapid captures of information about events that are a potential risk to public health. Information can be about events related to occurrence of disease in humans or a potential exposure to a risk e.g. contaminated food,-chemicals or radio nuclear events. In Pakistan it is a recent phenomenon and is a compliment to Indicator Based Surveillance (IBS) which is traditionally going on in public sector health care facilities. Literature on effectiveness and contribution of EBS is scarce. Methodology: A cross sectional study was conducted based on retrospective record review of events reporting in Pakistan. For this purpose, Disease Surveillance and Response Units (DSRU) were identified and descriptive analysis of their reporting per epidemiological week was done. Results: Public sector health facilities were found the most frequent 75% (n=88) in reported events. Vector borne diseases 49% (n=58) were the most frequently reported event. In 85% (n=101) of events, WHO and/or CDC standard case definitions were used followed by operational cases definition 10% (n=12). System was found operational in all provinces and regions and was linked to laboratory based surveillance in all DSRUs. Median delay was found high in Vaccine Preventable Diseases (Measles and Diphtheria), eight days (range: 0-10 days) and Vector borne diseases (Dengue, Chikungunya and CL) six days (range: 0-8 days). Among all, 90% (n=105) response activities were establishment and/ or strengthening of surveillance system by training of local staff. All investigations were linked with public health laboratory investigation except for food/water borne outbreak 3% (n=4), where no laboratory confirmation of causative organism was found. Conclusion: Event based surveillance (EBS) should be strengthened as a compliment of IBS and its network should be expanded to regional and district levels. Frequent trainings of health care providers at health facilities and informal sources like media should be done to gather credible and timely information of events’ time place and persons involved. However, monitoring and evaluation should be integral part to improve event recording and hence targeted response.

Background: Event Based Surveillance (EBS) is the organized and rapid captures of information about events that are a potential risk to public health. Information can be about events related to occurrence of disease in humans or a potential exposure to a risk e.g. contaminated food,-chemicals or radio nuclear events. In Pakistan it is a recent phenomenon and is a compliment to Indicator Based Surveillance (IBS) which is traditionally going on in public sector health care facilities. Literature on effectiveness and contribution of EBS is scarce. Methodology: A cross sectional study was conducted based on retrospective record review of events reporting in Pakistan. For this purpose, Disease Surveillance and Response Units (DSRU) were identified and descriptive analysis of their reporting per epidemiological week was done. Results: Public sector health facilities were found the most frequent 75% (n=88) in reported events. Vector borne diseases 49% (n=58) were the most frequently reported event. In 85% (n=101) of events, WHO and/or CDC standard case definitions were used followed by operational cases definition 10% (n=12). System was found operational in all provinces and regions and was linked to laboratory based surveillance in all DSRUs. Median delay was found high in Vaccine Preventable Diseases (Measles and Diphtheria), eight days (range: 0-10 days) and Vector borne diseases (Dengue, Chikungunya and CL) six days (range: 0-8 days). Among all, 90% (n=105) response activities were establishment and/ or strengthening of surveillance system by training of local staff. All investigations were linked with public health laboratory investigation except for food/water borne outbreak 3% (n=4), where no laboratory confirmation of causative organism was found. Conclusion: Event based surveillance (EBS) should be strengthened as a compliment of IBS and its network should be expanded to regional and district levels. Frequent trainings of health care providers at health facilities and informal sources like media should be done to gather credible and timely information of events’ time place and persons involved. However, monitoring and evaluation should be integral part to improve event recording and hence targeted response.

Background: Event Based Surveillance (EBS) is the organized and rapid captures of information about events that are a potential risk to public health. Information can be about events related to occurrence of disease in humans or a potential exposure to a risk e.g. contaminated food,-chemicals or radio nuclear events. In Pakistan it is a recent phenomenon and is a compliment to Indicator Based Surveillance (IBS) which is traditionally going on in public sector health care facilities. Literature on effectiveness and contribution of EBS is scarce. Methodology: A cross sectional study was conducted based on retrospective record review of events reporting in Pakistan. For this purpose, Disease Surveillance and Response Units (DSRU) were identified and descriptive analysis of their reporting per epidemiological week was done. Results: Public sector health facilities were found the most frequent 75% (n=88) in reported events. Vector borne diseases 49% (n=58) were the most frequently reported event. In 85% (n=101) of events, WHO and/or CDC standard case definitions were used followed by operational cases definition 10% (n=12). System was found operational in all provinces and regions and was linked to laboratory based surveillance in all DSRUs. Median delay was found high in Vaccine Preventable Diseases (Measles and Diphtheria), eight days (range: 0-10 days) and Vector borne diseases (Dengue, Chikungunya and CL) six days (range: 0-8 days). Among all, 90% (n=105) response activities were establishment and/or strengthening of surveillance system by training of local staff. All investigations were linked with public health laboratory investigation except for food/water borne outbreak 3% (n=4), where no laboratory confirmation of causative organism was found. Conclusion: Event based surveillance (EBS) should be strengthened as a compliment of IBS and its network should be expanded to regional and district levels. Frequent trainings of health care providers at health facilities and informal sources like media should be done to gather credible and timely information of events' time place and persons involved. However, monitoring and evaluation should be integral part to improve event recording and hence targeted response.

Background Pakistan has one of the highest burdens of Hepatitis C virus (HCV) infection globally. To achieve the World Health Organization’s goals for HCV elimination, there is a need for substantial scale-up in testing, treatment, and a reduction in new infections. Data on the population impact of scaling up treatment is not available in Pakistan, nor is there reliable data on the incidence of infection/reinfection. This project will fill this gap by providing important empirical data on the incidence of infection (primary and reinfection) in Pakistan. Then, by using this data in epidemic models, the study will determine whether response rates achieved with affordable therapies (sofosbuvir plus daclatasvir) will be sufficient to eliminate HCV in Pakistan. Methods This prospective multi-centre cohort study will screen 25,000 individuals for HCV antibody (Ab) and RNA (if Ab-positive) at various centers in Pakistan- Karachi (Sindh) and Punjab, providing estimates of the disease prevalence. HCV positive patients will be treated with sofosbuvir and daclatasvir for 12-weeks, (extended to 24-weeks in those with cirrhosis) and the proportion responding to this first-line treatment estimated. Patients who test HCV Ab negative will be recalled 12 months later to test for new HCV infections, providing estimates of the incidence rate. Patients diagnosed with HCV (~ 4,000) will be treated and tested for Sustained Virological Response (SVR). Questionnaires to assess risk factors, productivity, health care usage and quality of life will be completed at both the initial screening and at 12-month follow-up, allowing mathematical modelling and economic analysis to assess the current treatment strategies. Viral resistance will be analysed and patients who have successfully completed treatment will be retested 12 months later to estimate the rate of re-infection. Conclusion The HepFREEPak study will provide evidence on the efficacy of available and widely used treatment options in Pakistan. It will also provide data on the incidence rate of primary infections and re-infections. Data on incidence risk factors will allow us to model and incorporate heterogeneity of risk and how that affects screening and treatment strategies. These data will identify any gaps in current test-and-treat programs to achieve HCV elimination in Pakistan. Study registration This study was registered on clinicaltrials.gov (NCT04943588) on June 29, 2021.

PurposeChild malnutrition is a grave concern for Pakistan, as the country has one of the highest incidences of child stunting in the developing world. The present study examines the relative significance of parents' education on a child's nutritional status in Pakistan.Design/methodology/approachFor analysis, the study has used data from Phase 7 of the Pakistan Demographic and Health Survey (PDHS) (2017–2018). Since the dependent variable ranges from 0 to 1 (1 indicates not a stunted child, while 0 represents a stunted child), binary logistic regressions are used for the analysis.FindingsThe results show that mothers' and fathers' education positively contributes to a child's nutrition. However, mothers' education is considered more significant, especially in the long run. The mother's education categories are positive and significant in the long run, while only their higher education is positive and significant for the father's. Moreover, the magnitude of the effect also shows that the probability of stunting is less if the mothers are educated. The long-run coefficient for mothers' higher education is 0.752, while that of fathers' higher education is only 0.232.Originality/valueThe present study compares the importance of mothers' and fathers' education in child nutrition and concludes that the role of the mother is more crucial for child upbringing. There are rarely any studies that focus on the role of fathers' education in child nutrition and compare whose role, mothers' or fathers,' is more important for child well-being.Peer reviewThe peer review history for this article is available at: https://publons.com/publon/10.1108/IJSE-06-2023-0483

Over 9 million new active tuberculosis (TB) cases emerge each year from an enormous pool of 2 billion individuals latently infected with Mycobacterium tuberculosis (M. tb.) worldwide. About 3 million new TB cases per year are unaccounted for, and 1.5 million die. TB, however, is generally curable if diagnosed correctly and in a timely manner. The current diagnostic methods for TB, including state-of-the-art molecular tests, have failed in delivering the capacity needed in endemic countries to curtail this ongoing pandemic. Efficient, cost effective and scalable diagnostic approaches are critically needed. We report a multiplex TB serology panel using microbead suspension array containing a combination of 11 M.tb. antigens that demonstrated overall sensitivity of 91% in serum/plasma samples from TB patients confirmed by culture. Group wise sensitivities for sputum smear positive and negative patients were 95%, and 88%, respectively. Specificity of the test was 96% in untreated COPD patients and 91% in general healthy population. The sensitivity of this test is superior to that of the frontline sputum smear test with a comparable specificity (30-70%, and 93-99%, respectively). The multiplex serology test can be performed with scalability from 1 to 360 patients per day, and is amenable to automation for higher (1000s per day) throughput, thus enabling a scalable clinical work flow model for TB endemic countries. Taken together, the above results suggest that well defined antibody profiles in blood, analyzed by an appropriate technology platform, offer a valuable approach to TB diagnostics in endemic countries.

Introduction Discharge summaries (DS) allow continued patient care after being discharged from the hospital. Only a few quality improvement projects (QIPs) focused on assessing and improving the quality and completeness of DS at tertiary care hospitals have been undertaken in Pakistan. This QIP aimed to evaluate and enhance the quality and completeness of DS at a tertiary care hospital in Pakistan to facilitate seamless healthcare transitions. Methods A QIP was conducted in the medical unit of a tertiary care hospital in Rawalpindi, Pakistan. The DS were assessed using the e-discharge summary self-assessment checklist devised by the Royal College of Physicians (RCP). This QIP was done by the plan, do, study, act (PDSA) cycle. The PDSA cycle comprised two audit cycles and an intervention in between them. The first audit cycle (AC) was conducted on 150 DS. Its duration was from March 2023 to June 2023. An educational workshop was conducted before the re-audit cycle (RAC) to address deficiencies and reinforce the implementation of the guidelines provided by the RCP. The RAC was conducted from June 2023 to August 2023. 100 DS were studied and analyzed to assess for improvement in the completeness of DS. Frequencies and percentages were calculated in each audit cycle. The Chi-squared test was applied to compare the statistical difference between the results of both audit cycles. Results A total of 150 DS were analyzed in the first AC and 100 DS in the RAC. The results of the first AC show that the details of any allergies were recorded only in 3% of the DS; this percentage significantly improved to 51% after the RAC (p-value <0.05). Relevant past medical history was included in 52% and 88% of the DS during the first AC and RAC, respectively (p-value <0.05). Secondary diagnoses were written in 54% and 71% of the DS during the first AC and RAC, respectively (p-value <0.05). Details of relevant investigations were included in 60% and 88% of the DS during the first AC and RAC, respectively (p-value <0.05). The post-discharge management plan was written in 90% and 98% of the DS during the first AC and RAC, respectively (p-value <0.05). The follow-up plan was written clearly in 65% and 93% of the DS during the first AC and RAC, respectively (p-value <0.05).  Conclusion The DS was found to be incomplete after analyzing the results of the first AC. The details related to allergies, medications, operations, and procedures were found to be missing in the majority of the cases. No mention of the patient's concerns or expectations was made in the DS. The results of the RAC showed improvement in the level of completeness of DS. The majority of the weak points observed after the first AC seemed to have improved after the RAC, which shows that intervention proved to be quite effective in improving the completeness and quality of DS. The RAC showed significant improvement in the completeness of the details relating to investigations, allergies, past medical history, secondary diagnoses, and the post-discharge follow-up plan. QIP must be routinely carried out to assess and improve the completeness and quality of DS at hospitals.