Amna Rehana Siddiqui

Paan without tobacco: an independent risk factor for oral cancer.

Oral cancer is the second most common cancer in women and the third most common in men in Pakistan. Tobacco is smoked and chewed extensively in Pakistan. Paan is a quid of piper betel leaf that contains areca nut, lime, condiment, sweeteners, and sometimes tobacco, which is also used extensively. We did this study to clarify the independent association of paan and oral cancer. Between July 1996 and March 1998, we recruited biopsy‐proven, primary cases of oral squamous‐cell carcinoma, from 3 tertiary teaching centers in Karachi, Pakistan, and controls pair‐matched for age, gender, hospital and time of occurrence, excluding persons with a past or present history of any malignancy. There were 79 cases and 149 controls. Approximately 68% of the cases were men, 49 years old on average, the youngest being 22 years old and the eldest 80. People with oral submucous fibrosis were 19.1 times more likely to develop oral cancer than those without it, after adjusting for other risk factors. People using paan without tobacco were 9.9 times, those using paan with tobacco 8.4 times, more likely to develop oral cancer as compared with non‐users, after adjustment for other co‐variates. This study identifies an independent effect of paan without tobacco in the causation of oral cancer. Its findings may be of significance in South Asian communities where paan is used, and among health‐care providers who treat persons from South Asia. Int. J. Cancer 86:128–131, 2000.

Does improving maternal knowledge of vaccines impact infant immunization rates? A community-based randomized-controlled trial in Karachi, Pakistan

BackgroundIn Pakistan, only 59-73% of children 12-23 months of age are fully immunized. This randomized, controlled trial was conducted to assess the impact of a low-literacy immunization promotion educational intervention for mothers living in low-income communities of Karachi on infant immunization completion rates.MethodsThree hundred and sixty-six mother-infant pairs, with infants aged ≤ 6 weeks, were enrolled and randomized into either the intervention or control arm between August - November 2008. The intervention, administered by trained community health workers, consisted of three targeted pictorial messages regarding vaccines. The control group received general health promotion messages based on Pakistans Lady Health Worker program curriculum. Assessment of DPT/Hepatitis B vaccine completion (3 doses) was conducted 4-months after enrollment. A Poisson regression model was used to estimate effect of the intervention. The multivariable Poisson regression model included maternal education, paternal occupation, ownership of home, cooking fuel used at home, place of residence, the childs immunization status at enrollment, and mothers perception about the impact of immunization on childs health.ResultsBaseline characteristics among the two groups were similar. At 4 month assessment, among 179 mother-infant pairs in the intervention group, 129 (72.1%) had received all 3 doses of DPT/Hepatitis B vaccine, whereas in the control group 92/178 (51.7%) had received all 3 doses. Multivariable analysis revealed a significant improvement of 39% (adjusted RR = 1.39; 95% CI: 1.06-1.81) in DPT-3/Hepatitis B completion rates in the intervention group.ConclusionA simple educational intervention designed for low-literate populations, improved DPT-3/Hepatitis B vaccine completion rates by 39%. These findings have important implications for improving routine immunization rates in Pakistan.

Prenatal Exposure to Wood Fuel Smoke and Low Birth Weight

Background Maternal exposure to wood fuel smoke may lead to impaired fetal growth due to hypoxia and or oxidative stress from smoke constituents such as carbon monoxide and particulate matter. Objectives We studied the risk of low birth weight (LBW) and reduced mean birth weight in relation to reported use of wood for cooking during the prenatal period, compared with natural gas (NG). Methods We studied a historical cohort of women who had a singleton live birth in the years 2000–2002, from a semirural area of Pakistan. Infant’s birth weight was obtained from records, and prenatal records had data for maternal body mass index and parity. Cooking habits, daytime sleep habits, and type of fuel used during the pregnancies in 2000–2002 were ascertained by a survey done in 2004–2005. We performed multiple linear and logistic regression modeling using propensity scores to adjust for confounding variables. Results Unadjusted mean (± SD) birth weight was 2.78 ± 0.45 kg in wood users, and 2.84 ± 0.43 kg (p < 0.06) in NG users. Infants born to wood users averaged 82 g lighter than infants born to NG users when weight was adjusted for confounders (p < 0.07). The rate of LBW (< 2,500 g) was 22.7% among wood users compared with 15.0% in NG users (p < 0.01), for an adjusted relative risk of 1.64 (95% confidence interval, 1.10–2.34). The population attributable risk for LBW explained by wood use was estimated to be 24%. Conclusion Cooking with wood fuel during pregnancy, a potentially modifiable exposure, was associated with LBW and marginally lower mean birth weight compared with using NG.

Eye and respiratory symptoms among women exposed to wood smoke emitted from indoor cooking: a study from southern Pakistan

Prolonged exposure to wood smoke as cooking fuel on a daily basis has been associated with increased occurrence of respiratory and other ailments. Accumulated data from developing countries have linked acute and chronic eye and respiratory conditions to indoor air pollution exposures. The present study compared self-reported eye and respiratory symptoms among women who used wood as fuel to those who used natural gas (NG) in a semi-rural setting from southern Pakistan. During the winter season, a total of 122 wood (n = 57) and NG users (n = 65) were interviewed regarding history of acute eye and respiratory symptoms the immediate past two weeks. In addition, histories of difficulty in breathing during the past year and of ever having asthma were also ascertained. Unadjusted estimates showed that wood users reported a higher frequency than NG users of eye congestion (odds ratio (OR) = 4.2, 95 % confidence interval (CI) = 1.8-10.1), nasal congestion (OR = 2.5, 95 % CI = 1.1-5.5), throat-related symptoms (OR = 5.4, 95 % CI = 2.4-12.5), and cough (OR = 3.8, 95 % CI = 1.7-8.6). Similarly, wood users had higher odds of reporting difficulty in breathing any time during the past year (OR = 3.9, 95 % CI = 1.7-8.8) and ever having asthma (OR = 3.3, 95 % CI = 1.5-8.1) compared to NG users. Our study showed an interactive effect of age with wood use. Acute eye symptoms were more frequently reported by wood users who were younger than age 28 years (OR = 5.1, 95 % CI = 1.3-19.8) than by NG users; however, a smaller, marginally significant difference was observed in older women. A greater proportion of older wood users reported chronic respiratory symptoms, mainly cough (OR = 6.6, 95 % CI = 1.9-26.7) than NG users, but no significant difference was observed for younger women. Throat-related symptoms were associated with wood use after adjusting for the effect of body mass index (BMI) (OR = 5.9, 95 % CI = 2.6-14.2); eye and other respiratory symptoms were significantly associated with wood use only in women with a BMI of < 19.8 kg/m 2 . . This cross-sectional study demonstrated that overall eye and respiratory symptoms were significantly associated with wood use in t his setting. Future longitudinal study is needed to establish the etiological role of wood smoke in eye and respiratory ailments.

Nosocomial Outbreak of Hepatitis E Infection in Pakistan with Possible Parenteral Transmission

unacceptably high rates of treatment failure [2, 3]. In vitro data indicate that the newer fluoroquinolones are active against Listeria species but have relatively poor penetration into the CNS, and ciprofloxacin used in a murine model of listeriosis was ineffective [4]. Linezolid is active against L. monocytogenes in vitro [5], and CSF concentrations of linezolid that are adequate for treatment have been attained in a rabbit model [6]. Additional data derived from the use of linezolid in neurosurgical settings, as well as the efficacy demonstrated in the treatment of CNS listeriosis in a murine model [7, 8], prompted us to use linezolid in the patient we describe. Rifampin crosses the blood-brain barrier, penetrates cell membranes, and is also active against L. monocytogenes. In a study of isolates recovered from patients with Listeria meningitis, rifampin and TMP-SMZ were the most potent monotherapeutic drugs tested [9]. Combination treatment involving rifampin and another active antimicrobial may reduce the emergence of resistance to rifampin. Our success with the combination of linezolid and rifampin may offer a valid alternative therapy for brain abscess caused by L. monocytogenes.

Predictors of unintentional poisoning among children under 5 years of age in Karachi: a matched case-control study

Objective Poisoning is the fourth leading cause of unintentional injury and a common paediatric emergency in children under 5 years of age. The objective of this study was to determine the factors associated with unintentional poisoning among children under 5 years of age presenting to emergency rooms at tertiary care hospitals in Karachi, Pakistan. Setting Children were recruited from the emergency rooms of the three biggest tertiary care hospitals in Karachi. Design A matched case–control study was conducted on 120 cases and 360 controls, with matching done on gender and age. Parents were interviewed using a structured questionnaire containing information on sociodemographic factors, the childs behaviour, and the storage practices of hazardous substances of caregivers in the homes. Conditional logistic regression was performed to analyse the data. Results Accessibility to hazardous chemicals and medicines due to unsafe storage (adj mOR=5.6, 95% CI 1.9 to 16.7), childs behaviour reported as usually aggressive (adj mOR=8.2, 95% CI 4.6 to 16.1), storage of kerosene oil and petrol in soft drink bottles (adj mOR=3.8, 95% CI 2.0 to 7.3), low socioeconomic status (adj mOR=9.2, 95% CI 2.8 to 30.1), low level of mothers education (adj mOR=4.2, 95% CI 1.8 to 9.6), and history of previous poisoning (adj mOR=8.6, 95% CI 1.7 to 43.5) were independently related to unintentional poisoning. Conclusion The practice of storing kerosene and petroleum in soft drink bottles and the easy accessibility of chemicals and medicines are potentially modifiable. Health messages focusing on the safe storage of chemicals and medicines and the use of child resistant containers may play a key role in decreasing the burden of childhood poisoning in Karachi, Pakistan.

Prevalence of multi-drug resistant tuberculosis in Karachi, Pakistan: identification of at risk groups

Multidrug-resistant tuberculosis (MDR-TB) is a possible threat to global tuberculosis control. Despite a disease prevalence of 263/100 000 population Pakistan lacks information on prevalence of drug resistant TB. Our objective was to estimate prevalence of MDR and associated risk factors in patients with pulmonary tuberculosis in Karachi. Six hundred and forty consenting adult patients were enrolled from field clinics from July 2006 to August 2008 through passive case finding. Prevalence of MDR-TB with 95% confidence interval (CI) was calculated with Epi-Info. Logistic Regression analyses were performed for risk factors associated with MDR. Overall MDR rate was 5.0%, 95% CI: 3.3-6.6% (untreated 2.3%, treated 17.9%). Mean age was 32.5 (+/-15.6) years and there were 292 (45.6%) females and 348 (54.4%) males. Factors independently associated with MDR were: female gender (OR 3.12; 95% CI: 1.40-6.91), and prior history of incomplete treatment (OR 10.1; 95% CI: 4.71-21.64). Ethnic groups at higher risk for MDR included Sindhis (OR 4.5; 95% CI: 1.42-14.71) and Pashtoons (OR 3.6, 95% CI: 1.12-11.62). This study reports an overall MDR rate of 5.0% in our study population. It further highlights the need for MDR prevention through re-focusing Directly Observed Treatment, Short-course DOTS delivery with emphasis on women and certain high risk sub groups.

Development and validation of sunlight exposure measurement questionnaire (SEM-Q) for use in adult population residing in Pakistan

BackgroundVitamin D deficiency has been identified as a major public health problem worldwide. Sunlight is the main source of vitamin D and its measurement using dosimeters is expensive and difficult for use in population-based studies. Hence, the aim of this study was to develop and validate questionnaires to assess sunlight exposure in healthy individuals residing in Karachi, Pakistan.MethodsTwo questionnaires with seven important items for sunlight exposure assessment were developed. Fifty four healthy adults were enrolled based on their reported sunlight exposure (high = 17, moderate = 18, low = 19) from Aga Khan University, Karachi. Over four days, study participants were asked to wear a dosimeter between sunrise and sunset and report time spent and activities undertaken in the sun for questionnaire validation. Algorithm for item weightage was created as an average score based on ultraviolet B percentage received. Blood samples were obtained for serum vitamin D.ResultsThe mean time (minutes) spent in sun over 4 days (±SD) was 69.5 (±32) for low, 83.5 (±29.7) for moderate and 329 (±115) for high exposure group. The correlation between average time (minutes) spent in sun over 4 days and mean change in absorbance of UV dosimeters for 4 days was 0.60 (p < 0.01). Correlation between average score and vitamin D levels was found to be 0.36 (p = 0.01) for short term questionnaire score, 0.43 (p = 0.01) for long term questionnaire score in summers and 0.48 (p = 0.01) in winters.ConclusionsThe sunlight exposure measurement questionnaires were valid tools for use in large epidemiological studies to quantify sunlight exposure.

Tackling the health burden of air pollution in South Asia

Bhargav Krishna and colleagues call for health driven, multisectoral policy making with defined air quality targets to curb the impact of air pollution exposure in South Asia