Erum Khan

Demographic and Clinical Features of Dengue Fever in Pakistan from 2003–2007: A Retrospective Cross-Sectional Study

Background Demographic features of dengue fever have changed tremendously in Pakistan over the past two decades. Small scale studies from all over the country have reported different aspects of individual outbreaks during this time. However, there is scarcity of data looking at the overall trend of dengue virus infection in the country. In this study, we examined annual trends, seasonality, and clinical features of dengue fever in the Pakistani population. Methods Demographic information and dengue IgM status of all patients tested for dengue IgM antibody at Aga Khan University Hospital from January 2003 to December 2007 were analyzed to look for trends of IgM-positive cases in Pakistan. In addition, clinical and biochemical parameters were abstracted retrospectively from medical records of all patients hospitalized with IgM-proven dengue fever between January 2006 and December 2007. These patients were categorized into dengue fever and dengue hemorrhagic fever according to the WHO severity grading scale. Results Out of a total of 15040 patients (63.2% male and 36.8% female), 3952 (26.3%) tested positive for dengue IgM antibody. 209 IgM proven dengue patients were hospitalized during the study period. During 2003, IgM positive cases were seen only during the months of July-December. In contrast, such cases were detected throughout the year from the 2004–2007. The median age of IgM positive patients decreased every year from 32.0 years in 2003 to 24.0 years in 2007 (p<0.001). Among hospitalized patients, nausea was the most common presenting feature found in 124/209 (59.3%) patients. Children presented with a higher median body temperature than adults (pu200a=u200a0.010). In addition, neutropenia was seen more commonly in children while raised serum ALT levels were seen more commonly in adults (both pu200a=u200a0.006). While a low total white cell count was more common in patients with dengue fever as compared to Dengue Hemorrhagic Fever (pu200a=u200a0.020), neutropenia (pu200a=u200a0.019), monocytosis (pu200a=u200a0.001) and raised serum ALT level (pu200a=u200a0.005) were observed more commonly in the latter group. Conclusions Dengue virus is now endemic in Pakistan, circulating throughout the year with a peak incidence in the post monsoon period. Median age of dengue patients has decreased and younger patients may be more susceptible. Total and differential leukocyte counts may help identify patients at risk of hemorrhage.

A three-year review of antimicrobial resistance of Salmonella enterica serovars Typhi and Paratyphi A in Pakistan

INTRODUCTIONnEnteric fever is among the most common bacteraemic illnesses in South Asia. Multidrug resistance as well as fluoroquinolone resistance has severely limited therapeutic options in high disease burden countries such as Pakistan. This review was conducted to determine the frequency of drug-resistant Salmonella enterica serovar Typhi (S.Typhi) and Salmonella enterica serovar Paratyphi A (S. Paratyphi A) between 2009 and 2011.nnnMETHODOLOGYnThis study was a review of laboratory data. The antibiotic susceptibility of typhoidal Salmonellae isolated from blood cultures submitted to the Aga Khan University Hospitals laboratory from all over Pakistan between January 2009 and December 2011 were reviewed.nnnRESULTSnThe sensitivity data of 4,323 positive isolates of S. Typhi and S. Paratyphi A isolated during the three-year period were reviewed. The majority of isolates were S. Typhi (59.6%).Over three years, the incidence of multidrug-resistant (MDR) S.Typhi remained high, ranging from 64.8%-66.0%, while MDR S. Paratyphi A decreased from 4.2% to 0.6%. Fluoroquinolone resistance increased for S. Typhi from 84.7% to 91.7%. Cefixime- and ceftriaxone-resistant S. Typhi were isolated in two children.nnnCONCLUSIONSnOur results show high rates of multidrug and fluoroquinolone resistance among S. Typhi and S. Paratyphi. The occurrence of two cases of ceftriaxone resistance is alarming.

Prevalent genotypes of meticillin-resistant Staphylococcus aureus: report from Pakistan

Meticillin-resistant Staphylococcus aureus (MRSA) is a major nosocomial pathogen in Pakistan and is emerging in the community. This is one of the first reports of the prevalent genotypes of MRSA in both hospital and community settings in Pakistan. Isolates collected in 2006-2007 were characterized by PFGE, staphylococcal cassette chromosome mec (SCCmec) typing and multilocus sequence typing (MLST). PFGE identified nine pulsotypes, the majority of isolates belonging to pulsotypes A (n=70) and B (n=38), which were predominant among hospital-onset MRSA (HO-MRSA) and community-onset MRSA (CO-MRSA) isolates, respectively. Among the HO-MRSA isolates, variants of SCCmec type III were prevalent, whilst SCCmec type IV or variants were predominant in the CO-MRSA isolates. MLST identified two principal sequence types, ST8 and ST239. An association was observed between ST8, PFGE pulsotype B and SCCmec type IV in the CO-MRSA (ST8-MRSA-IV). Similarly, ST239, PFGE pulsotype A and SCCmec type III were associated with HO-MRSA (ST239-MRSA-III). Therefore, the prevalent genotypes circulating in Pakistan at the time of study were ST8-MRSA-IV and ST239-MRSA-III in the community and hospital settings, respectively. A set of HO-MRSA isolates collected in 1997 were characterized by PFGE and SCCmec typing for comparison. The isolates belonged to two PFGE pulsotypes (A, n=28; B, n=11) and contained just two SCCmec types. These results suggest that an increase in genetic diversity occurred over the period 1997-2007 as a result of either microevolution or the importation of strains from surrounding areas.

In vitro Activity of Tigecycline and Other Tetracyclines against Carbapenem-Resistant Acinetobacter Species: Report from a Tertiary Care Centre in Karachi, Pakistan

Background: The Aga Khan University Hospital is a tertiary care centre in Karachi, Pakistan, where tigecycline has not been used previously. We report findings of a pre-use in vitro study to evaluate sensitivity of nosocomial Acinetobacter spp. Tigecycline minimum inhibitory concentration (MIC) was correlated with that of other tetracyclines to assess their predictive potential. Methods:Acinetobacter spp. were collected from hospitalized inpatients admitted to Aga Khan University Hospital from April to November 2007. Tigecycline, tetracycline, doxycycline, and minocycline MICs were determined by E-test. Results: One hundred isolates of Acinetobacter spp. were tested. Ninety-eight percent of Acinetobacter spp. were carbapenem-resistant. Tigecycline MIC50 and MIC90 were 1.5 and 2.0 µg/ml, respectively. Unavailability of standard breakpoints hindered categorization of these values. Minocycline was highly active, with MIC90 of 2.0 µg/ml. Conclusions: Tigecycline breakpoints for Acinetobacter spp. should be established to prevent injudicious use of this antibiotic based on misleading in vitro results. The therapeutic potential of minocycline needs more in-depth study.

Pulmonary nocardiosis: a comparative analysis of Nocardia asteroides and non-asteroides species.

Our study compares the risk factors, clinical presentations and outcomes of pulmonary infections caused by Nocardia asteroides and non-asteroides species. We performed a retrospective cohort study comparing pulmonary infections by both species in patients presenting to a tertiary care hospital in Karachi, Pakistan. Forty-one patients were identified with pulmonary nocardiosis, with 58.5% belonging to the N. asteroids complex. The most common clinical findings were fever and a cough for both groups, with lobar infiltrates being the most common finding on chest radiographs. In vitro testing showed a sensitivity of all species to trimethoprim-sulfamethoxazole (TMP-SMZ), aminoglycosides, ceftriaxone and imipenem. The majority of the patients were treated with TMP-SMZ in combination with other drugs. The results of our study suggest that there is no significant difference in the risk factors, presentations and outcomes of pulmonary infections by N. asteroides and non-asteroides species. Immunocompromised patients are more likely to have unfavorable outcomes.

Survey of Biorisk Management in Clinical Laboratories in Karachi, Pakistan

This study was designed to survey the existing Biosafety and Biosecurity levels of the clinical laboratories in order to assess the controls in place to keep the laboratory workers, and the surrounding community, safe from an outbreak of infectious diseases in Karachi, Pakistan. The survey also helped to evaluate the present level of Biorisk management practiced in these clinical laboratories. Karachi was selected as the site of this survey because it is the hub of commercial activities in the region and has a population of about 25 million. Place and Duration: This study encompassed a period of 8 months (January 2011 to August 2011) and covered laboratories in the 18 towns of Karachi, Pakistan. To begin the study, a survey questionnaire was developed with the help of Sandia National Laboratory (Albuquerque, New Mexico, USA). Results of the survey were disseminated to the relevant target audience and increased the level of information on these topics as well as ways to implement Biorisk management in accordance with CWA 15793-2008 (European Committee for Standardization, 2008). The results were also conveyed to the stakeholders (top management, laboratory management, laboratory managers, laboratory technologists, laboratory technicians, etc.). This study reflects the current level of Biosafety practices in clinical laboratories in Karachi, Pakistan, where major gaps were identified in all the critical areas of Biosafety and Biosecurity, including risk assessment, standard microbiological practices, primary barriers/personal protective equipment, and laboratory design/secondary barriers, and select agent protocols. The gaps included the following: Biosecurity is not at all defined or understood. There is no protocol/guidance for reporting laboratory acquired infections (LAIs). There is no framework for registering these laboratories before commissioning. Limited or no training for Biosafety/Biosecurity is available on a continual basis. No regulatory body oversees Biorisk/Biosecurity activities or lab registration. This study revealed that the degree of negligence regarding these requirements for clinical laboratories is very serious and work on an emergency basis is required to introduce, implement, and furnish Biosafety and Biosecurity guidelines. Training and literature in both English and the local Urdu language need to be developed and distributed. However, other extraordinary measures are also required because the majority of laboratories working at BSL-2 have no biosafety cabinets (BSCs), resulting in microbiological work being done on the open bench. The main purposes of this study were (1) to develop a culture in which Biosafety and Biosecurity practices become routine in these laboratories; and (2) to commission a National Regulatory Body to define/dictate these guidelines and to ensure that new laboratories are registered before they are commissioned. In addition, this regulatory body will address the immediate registration of those laboratories already working.

Readiness for antimicrobial resistance (AMR) surveillance in Pakistan; a model for laboratory strengthening

BackgroundLimited capacity of laboratories for antimicrobial susceptibility testing (AST) presents a critical diagnostic bottleneck in resource limited countries. This paper aims to identify such gaps and to explore whether laboratory networks could contribute towards improving AST in low resource settings.MethodsA self-assessment tool to assess antimicrobial susceptibility testing capacity was administered as a pre-workshop activity to participants from 30 microbiology laboratories in 3 cities in Pakistan. Data from public and private laboratories was analyzed and capacity of each scored in percentage terms. Laboratories from Karachi were invited to join a support network. A cohort of five laboratories that consented were provided additional training and updates sessions over a period of 15xa0months. Impact of training activities in these laboratories was evaluated using a point scoring (0-11) tool.ResultsResults of self-assessment component identified a number of areas that required strengthening (scores of ≤60%). These included; readiness for AMR surveillance; 38 and 46%, quality assurance; 49 and 55%, and detection of specific organisms; 56 and 60% for public and private laboratories respectively. No significant difference was detected in AST capacity between public and private laboratories [ANOVA; pu2009>u20090.05]. Scoring tool used to assess impact of training within the longitudinal cohort showed an increase from a baseline of 1-5.5 (August 2015) to improved post training scores of 7-11 (October 2016) for the 5 laboratories included. Moreover, statistical analysis using paired t-Test Analysis, assuming unequal variance, indicated that the increase in scored noted represents a statistically significant improvement in the components evaluated [pu2009<u20090.05].ConclusionStrengthening of laboratory capacity for AMR surveillance is important. Our data shows that close mentoring and support can help enhance capacity for antimicrobial sensitivity testing in resource limited settings. Our study further presents a model wherein laboratory networks can be successfully established and used towards improving diagnostic capacity in such settings.

Survey of biosafety & biosecurity level in biomedical laboratories in Karachi

Methods: This pilot study design was single-group pre–post non-experimental. The intervention was a combination of lectures and self-study format. Intensive classes held eight times in total which was a two-hour lecture once a week. The intervention content including the concept of health literacy, health promotion programs, self-care, etc. The self-study content was arranged according to the students’ needs and teaching content. Conveying learning requirements, reference materials through public mailbox. Students can also consult the teacher through public mail, telephone, etc., to solve the health problems encountered. Intervention evaluation consisted of basic health literacy survey and the homework of open questions. The survey content includes the health knowledge and ideas, healthy lifestyle and healthy behaviors and skills. The preliminary experiments showed the internal consistency of the questionnaire was 0.91. 17 open-questions were designed which involving health status, lifestyle, etc. Students select one of the questions to answer.M care is vital for our life and health, but the waste generated from medical activities represents a real problem of living nature and human world. Improper management of waste generated in health care facilities causes a direct health impact on the community, the health care workers and on the environment. Every day, relatively large amount of potentially infectious and hazardous waste are generated in the health care hospitals and facilities around the world. Indiscriminate disposal of BMW or hospital waste and exposure to such waste possess serious threat to environment and to human health that requires specific treatment and management prior to its final disposal. The present review articles deals with the basic issues as definition, categories, problems relating to biomedical waste and procedure of handling and disposal method of Biomedical Waste Management. It also intends to create awareness amongst the personnel involved in health care unit.C generally go through developmental stages ranges from sensor motor to formal operation, and each of these stages is associated with its own task to negotiate within the context of family, socio-environmental and psychological backgrounds. Early viewpoints recognized that both biological and environmental factors influence human development, conversely, biological extremist argued that biology is destiny, and that development was predetermined by genetic factors, these genetic or biological process led to the natural maturation. Today, there are variations that are based on how both biological and environmental factors interact to produce and determine different children and their behaviors. In both Freud’s and Erickson’ child development stages, emphasis is given to the effects of social environment on the individual’s development and behavior as a product of a particular environment. Handling children with disruptive behaviors requires a deep understanding of the evolution of the children’s biological basis of behavior, socio-environmental and family factors. Firstly, the paper identifies causative factors of disruptive behavior in children, secondly, it examines the correlation between children’s disruptive behavior in classroom, and academic performance. Finally, it called for teachers’ professional and psychological understanding of various teaching methods in classroom.Background: Smoking-related deaths are projected to rise to 10 million a year by 2020s, 70% of these in the poorer countries. Lung cancer, one of the few malignancies for which the main cause is definitely known and that can be prevented, is on the increase, especially in developing countries that have been targeted by tobacco companies. Tobacco smoking is the most important confounding factors contributing in the lung pathology. It is therefore essential to know the prevalence of smoking in the community of former mineworkers.T in Saudi Arabia represent one of the largest occupational groups among the employed women. According to the World Health Organization each year over 1.4 million women worldwide are diagnosed with breast cancer. In the present study we explored the relation between health promotion lifestyle and female’s cancer screening practice. A total of 374 female teachers mean aged 32.7+9.2 completed the study survey, which includes the Health Promotion Lifestyle Profile (HPLP) scale, demographic data and breast cancer screening behavior. Only 28.6% of the teachers know how they do the breast self examination (BSE) and do it monthly, 71.4% don’t know how they do BSE. Obesity and overweight were more prevalent among teachers who do not do BSE (27.6%-36.2%: respectively) than BSE group. The mean total HPLP were statistically different between groups (P=0.041) and for HPLP subscales, health responsibility, nutrition, and stress management (p<0.05), no significant differences were observed for physical activity, spiritual growth, and interpersonal relations. A significant correlation was established between the BSE and the overall Health Promoting Lifestyle Profile (r-0.16, p<.05) and the nutrition subscale (r=0.18, p<.05). This study demonstrated correlation between health promoting lifestyle and breast cancer screening behavior in occupational group, making an important contribution to understanding the factors influencing female’s health behavior.Aim: The aim of this research study has been to examine occupational stress, coping strategies with stressors and relevant factors in textile workers. Method: It is a descriptive and cross sectional design. The research samples were consisting of 668 textile workers. Data was collected by using worker’s Assessment Form, the Brief Job Stress Questionnaire (BJSQ) and the Brief Scales for Coping Profiles (BSCP). The BJSQ and BSCP have been adapted to the Turkish. Results: More than 53% of the workers were women. The mean age of all subjects was 33, 2±9.9 years. The mean working hours per week was 62±5.9. The score of the BJSQ was 113, 9±20.3 (median: 112), and its subscales; physical symptoms’ score was 15.3±12.9 (median: 14), psychological symptoms was 24.8±7.3 (median: 24) and job stress was 54.2±9.24 (median: 53). The scores above the median indicates the job stress and its’ effects on health. The scores of the BSCP was 53.8±8.3 (median: 54), and scores from its subscale which was higher than median was from “changing mood” 12.6±2.37 (median: 8). The scores above the median indicates the unsuccessful coping methods. It was found significant an association between the workers’ gender and physical symptoms (p 0.05). It was found negative correlation between job stress’ level and the workers’ sleep quality and also general working performance. Conclusion: The job stress’s level of the workers was found high and the coping profiles were found insufficient. Ultimately, these findings can be used as guidelines for the prevention of health problems in textile workers.B aerosols are generally characterized as biological particles suspended in the air. Mechanical, Physical and seasonal factors affect the concentration of bio aerosols released from composting plants and thus, the exposure of workers. The morphological and biochemical differences between different microorganisms may affect their potential to be aerosolized, although this phenomenon has not been well described. From this perspective, differential aerosolization of certain pathogenic microbes found in compost deserves to be studied in order to better understand the factors involved in occupational exposure. The goal of this study was to explore, using next generation sequencing, the preferential aerosolization of microorganisms in different composting plants and see if the compost microbial population and diversity differs from that of bio aerosols. Results suggest that Bacteroidetes, Firmicutes, Proteobacteria and Actinobacteria constituted the major phyla of bacteria found in bio aerosols released from compost. There is an obvious link between microorganisms found in the air and in compost samples. However, some phyla seem enriched in the air when compared to their proportion in compost whereas; others are preferentially kept in the compost, suggesting anon-random aerosolization process. Using MiSeq Illumina sequencing technology, this study suggests the preferential aerosolization of Actinobacteria and more specifically genera like Saccharopolyspora, Mycobacterium and for some Proteobacteria such as Legionella. Some phyla are also under represented in aerosols and do not seem to be easily aerosolized such as Pseudomonas sp. Exposure to preferentially aerosolized pathogenic bio aerosols may be a potential source of occupational risk and evaluation of the sources microbial content (compost) is not a good proxy of workers’ exposure to bio aerosols.