Afia Zafar

Tuberculosis comorbidity with communicable and non-communicable diseases: integrating health services and control efforts

Recent data for the global burden of disease reflect major demographic and lifestyle changes, leading to a rise in non-communicable diseases. Most countries with high levels of tuberculosis face a large comorbidity burden from both non-communicable and communicable diseases. Traditional disease-specific approaches typically fail to recognise common features and potential synergies in integration of care, management, and control of non-communicable and communicable diseases. In resource-limited countries, the need to tackle a broader range of overlapping comorbid diseases is growing. Tuberculosis and HIV/AIDS persist as global emergencies. The lethal interaction between tuberculosis and HIV coinfection in adults, children, and pregnant women in sub-Saharan Africa exemplifies the need for well integrated approaches to disease management and control. Furthermore, links between diabetes mellitus, smoking, alcoholism, chronic lung diseases, cancer, immunosuppressive treatment, malnutrition, and tuberculosis are well recognised. Here, we focus on interactions, synergies, and challenges of integration of tuberculosis care with management strategies for non-communicable and communicable diseases without eroding the functionality of existing national programmes for tuberculosis. The need for sustained and increased funding for these initiatives is greater than ever and requires increased political and funder commitment.

Dengue virus serotype 3, Karachi, Pakistan.

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Encephalitis and myelitis associated with dengue viral infection clinical and neuroimaging features.

OBJECTIVES The objective of this study was to identify clinical and neuroimaging features and outcome of patients with encephalitis and myelitis associated with dengue viral infection. PATIENTS AND METHODS We retrospectively reviewed 225 cases of dengue viral infection. The diagnosis of dengue was confirmed by serology (presence of IgM antibodies). RESULTS Six patients (3%) had evidence of neurological infection (encephalitis: 5 patients; encephalomyelitis: 1 patient). Age range was 18-35 years (Mean 27 years). Five patients (83%) were women. All patients (100%) had drowsiness, five patients (83%) had fever, four patients (67%) presented with seizures and one patient presented with paraparesis (16%). All patients had elevated CSF cell count (range 25-102; mean 61) with predominant lymphocytes. Five patients (83%) had abnormal CT or MRI scan. Cerebral edema was present in three patients. Other findings included low density signals in right temporal and occipital lobe (1 patient), bi temporal hyperintensities and meningeal enhancement (1 patient), Frontal and subcortical hyperintense lesion (1 patient) and hyperintense lesion on T2 in Pons and cervical and thoracic spinal cord (1 patient). EEG was done in four patients and showed generalized slowing (2 patients), bi temporal spikes (1 patient) and burst suppression pattern (1 patient). Two patients (32%) died and one patient was discharged in bedridden state. CONCLUSION The involvement of brain and spinal cord is uncommon in dengue viral infection. Most patient present with seizures. Neuroimaging features are diverse. Prognosis is poor in patients presenting with encephalitis or myelitis.

Primary Amebic Meningoencephalitis Caused by Naegleria fowleri, Karachi, Pakistan

We report 13 cases of Naegleria fowleri primary amebic meningoencephalitis in persons in Karachi, Pakistan, who had no history of aquatic activities. Infection likely occurred through ablution with tap water. An increase in primary amebic meningoencephalitis cases may be attributed to rising temperatures, reduced levels of chlorine in potable water, or deteriorating water distribution systems.

Impact of infection control activities on the rate of needle stick injuries at a tertiary care hospital of Pakistan over a period of six years: an observational study

BackgroundAccidental exposure to blood and body fluids is frequent among health care workers. They are at high risk of nosocomial transmission of blood borne pathogens due to injuries caused by used sharps. We are reporting impact of surveillance and educational program on the rate of needle stick injuries among health care workers at a tertiary care hospital in Pakistan.MethodsAt Aga Khan University Hospital sharp injuries are reported to infection control office. To reduce these incidents a quality improvement project was inducted in the year 2005. Health care workers were educated; surveillance data from 2002 to 2007 was analyzed and compared with various risk factors.ResultsDuring study period 1382 incidents were reported. Junior doctors sustained highest number of injuries (n = 394; 28.5%) followed by registered nurses (n = 283; 20.4%). Highest number of incidents was reported during blood collection (19%). An increasing trend was observed in the pre intervention years (2002–04). However noticeable fall was noted in the post intervention period that is in year 2006 and 2007. Major decline was noted among nurses (from 13 to 5 NSI/100 FTE/year). By relating and comparing the rates with various activities directly linked with the use of syringes a significant reduction in incidents were found including; hospital admissions (p-value 0.01), surgeries and procedures performed (p = 0.01), specimens collected in the laboratory (p = 0.001) and patients visits in clinics (p = 0.01).ConclusionWe report significant reduction in needle stick injuries especially during post intervention study period. This is being achieved by constant emphasis on improving awareness by regular educational sessions, implemented as a quality improvement project.

Metallo-β-lactamase-producing clinical isolates of Acinetobacter species and Pseudomonas aeruginosa from intensive care unit patients of a tertiary care hospital

Prompt detection of metallo-beta-lactamase (MBL) producing isolates is necessary to prevent their dissemination. Frequency of MBLs producing strains among multidrug resistant (MDR) Acinetobacter species and Pseudomonas aeruginosa was evaluated in critical care patients using imipenem-EDTA disk method. One hundred MDR Acinetobacter spp. and 42 Pseudomonas aeruginosa were checked for MBL production, from January to June 2001. MBL was produced by 96.6 % of imipenem-resistant Acinetobacter isolates, whereas 100% imipenem-resistant Pseudomonas aeroginosa isolates were MBL producers. Carbapenem resistance in MDR Acinetobacter spp. and Pseudomonas aeruginosa isolates in this study was due to MBLs. This calls for strict infection control measures to prevent further dissemination.

Frequency of isolation of various subtypes and antimicrobial resistance of Shigella from urban slums of Karachi, Pakistan

OBJECTIVES Shigellosis remains a major public health problem in developing countries. Antimicrobial resistance has complicated the empirical treatment. Knowledge of serotypes is crucial in vaccine development, as cross-protection between various serotypes is limited. Therefore we conducted a prospective study to determine the frequency of isolation of Shigella serotypes and antimicrobial resistance. METHODS Stool samples from 8155 individuals, collected through a surveillance study conducted in four slums of Karachi from January 2002 to March 2004, were cultured. RESULTS Shigella was isolated in 394 (4.8%) of 8155 patients presenting with diarrhea. Two hundred and forty-two (62%) isolates were Shigella flexneri, 72 (18%) were Shigella sonnei, 43 (11%) were Shigella boydii, and 37 (9%) were Shigella dysenteriae. Thirteen S. flexneri serotypes were identified, of which the most frequent were 2a (38), 6 (37), and 1b (25), followed by 2b (23). Only 22 (5.6%) Shigella isolates were found to be pan-susceptible. Large proportions of isolates were resistant to co-trimoxazole (89% S. flexneri, 81% S. dysenteriae, 80% S. sonnei, and 56% S. boydii) and ampicillin (87% S. flexneri, 68% S. dysenteriae, 35% S. boydii, and 4% S. sonnei). CONCLUSIONS Concurrent circulation of multiple strains with high resistance is worrying and mandates surveillance at the national level to facilitate the control of shigellosis.

Enhanced disease surveillance through private health care sector cooperation in Karachi, Pakistan: experience from a vaccine trial

INTRODUCTION In research projects such as vaccine trials, accurate and complete surveillance of all outcomes of interest is critical. In less developed countries where the private sector is the major health-care provider, the private sector must be included in surveillance systems in order to capture all disease of interest. This, however, poses enormous challenges in practice. The process and outcome of recruiting private practice clinics for surveillance in a vaccine trial are described. METHODS The project started in January 2002 in two urban squatter settlements of Karachi, Pakistan. At the suggestion of private practitioners, a phlebotomy team was formed to provide support for disease surveillance. Children who had a reported history of fever for more than three days were enrolled for a diagnosis. RESULTS Between May 2003 and April 2004, 5540 children younger than 16 years with fever for three days or more were enrolled in the study. Of the children, 1312 (24%) were seen first by private practitioners; the remainder presented directly to study centres. In total, 5329 blood samples were obtained for microbiology. The annual incidence of Salmonella typhi diagnosed by blood culture was 407 (95% confidence interval (95% CI), 368-448) per 100 000/year and for Salmonella paratyphi A was 198 (95% CI, 171-227) per 100 000/year. Without the contribution of private practitioners, the rates would have been 240 per 100 000/year (95% CI, 211-271) for S. typhi and 114 (95% CI, 94-136) per 100 000/year for S. paratyphi A. CONCLUSION The private sector plays a major health-care role in Pakistan. Our experience from a surveillance and burden estimation study in Pakistan indicates that this objective is possible to achieve but requires considerable effort and confidence building. Nonetheless, it is essential to include private health care providers when attempting to accurately estimate the burden of disease in such settings.

Nosocomial Buffalopoxvirus Infection, Karachi, Pakistan

During 5 months in 2004–2005, buffalopoxvirus infection, confirmed by virus isolation and limited nucleic acid sequencing, spread between 5 burns units in Karachi, Pakistan. The outbreak was related to movement of patients between units. Control measures reduced transmission, but sporadic cases continued due to the admission of new patients with community-acquired infections.

Increase in isolation of extended spectrum beta lactamase producing multidrug resistant non typhoidal Salmonellae in Pakistan

BackgroundIncreasing resistance to quinolones and ceftriaxone in non typhoidal Salmonellae is a global concern. Resistance to quinolone and 3rd generation cephalosporin amongst non typhoidal Salmonellae (NTS) from Pakistan has been reported in this study.MethodsRetrospective analysis of laboratory data was conducted (1990-2006). NTS were isolated and identified from clinical samples using standard microbiological techniques. Antimicrobial susceptibility testing was performed by Kirby Bauer. Extended spectrum beta lactamase production (ESBL) was detected using combined disc method. Ciprofloxacin sensitivity was detected by nalidixic acid screening method. Minimum inhibitory concentration (MIC) of ciprofloxacin was determined by agar dilution method. Statistical analysis was performed using SPSS version 13.ResultsAnalysis of 1967 NTS isolates showed a significant increase in ciprofloxacin resistance from 23% in 2002 to 50.5% in 2006, with increased mean MIC values from 0.6 to 1.3 ug/mL. Ceftriaxone resistant NTS also increased and ESBL production was seen in 98.7% isolates. These isolates exhibited high resistance against amoxicillin clavulanic acid (57%), gentamicin (69%), amikacin (44%) and piperacillin tazobactam (30%). No resistance to carbapenem was seen. Ceftriaxone resistance was significantly higher in children <1 year, in invasive isolates and in Salmonella Typhimurium.ConclusionsIncrease in quinolone and ceftriaxone NTS is a serious threat to public health requiring continuous surveillance and use of appropriate screening tests for laboratory detection.