Franklin White

Ethnic subgroup differences in hypertension in Pakistan

Objective Cardiovascular risks are globally elevated in South Asians, but this masks important ethnic subgroup differences in risk factors, such as hypertension, which have not been fully explored. We conducted this study to explore the variations in hypertension within ethnic subgroups among South Asians. Design Cross-sectional survey [National Health Survey of Pakistan (NHSP) (1990–1994)]. Setting Population based. Participants A total of 9442 individuals aged 15 years or over. Methods Data on sociodemographic and clinical variables were collected. Distinct ethnic subgroups – Muhajir, Punjabi, Sindhi, Pashtun and Baluchi – were defined by mother tongue. Main outcome measure Hypertension defined as systolic blood pressure ⩾ 140 mmHg or diastolic blood pressure ⩾ 90 mmHg, or currently receiving antihypertensive therapy. Results The age-standardized prevalence of hypertension was highest among Baluchis (25.3% in men and 41.4% in women), then Pashtuns (23.7% in men and 28.4% in women), Muhajirs (24.1% in men and 24.6% in women), and lowest among Punjabis (17.3% in men and 16.4% in women) and Sindhis (19.0% in men and 9.9% in women) (P = 0.001). While hypertension was more prevalent in urban (22.7%) versus rural dwellers (18.1%) [odds ratio (OR) 1.34; 95% confidence interval (CI), 1.20, 1.49], this difference was no longer significant after adjusting for body mass and waist circumference (OR 1.03; 95% CI, 0.91, 1.16). However, ethnic differences persisted after adjusting for major sociodemographic, dietary and clinical risk factors (unadjusted OR for Baluchi versus Sindhi, 2.92; 95% CI, 2.20–3.89; adjusted OR, 2.71; 95% CI, 1.97–3.75). Conclusions A threefold difference in prevalence of hypertension exists between people of South Asian descent, which, unlike the urban/rural difference, cannot be accounted for by measured risk factors. Further study would provide valuable etiological and therapeutic clues.

Risk factors for non-fatal myocardial infarction in young South Asian adults

Objective: To determine the risk factors for premature myocardial infarction among young South Asians. Design and setting: Case–control study in a hospital admitting unselected patients with non-fatal acute myocardial infarction. Methods and subjects: Risk factor assessment was done in 193 subjects aged 15–45 years with a first acute myocardial infarct, and in 193 age, sex, and neighbourhood matched population based controls. Results: The mean (SD) age of the subjects was 39 (4.9) years and 326 (84.5%) were male. Current smoking (odds ratio (OR) 3.82, 95% confidence interval (CI) 1.47 to 9.94), use of ghee (hydrogenated vegetable oil) in cooking (OR 3.91, 95% CI 1.52 to 10.03), raised fasting blood glucose (OR 3.32, 95% CI 1.21 to 8.62), raised serum cholesterol (OR 1.67, 95% CI 1.14 to 2.45 for each 1.0 mmol/l increase), low income (OR 5.05, 95% CI 1.71 to 14.96), paternal history of cardiovascular disease (OR 4.84, 95% CI 1.42 to 16.53), and parental consanguinity (OR 3.80, 95% CI 1.13 to 1.75) were all independent risk factors for acute myocardial infarction in young adults. Formal education versus no education had an independently protective effect on acute myocardial infarction (OR 0.04, 95% CI 0.01 to 0.35). Conclusions: Tobacco use, ghee intake, raised fasting glucose, high cholesterol, paternal history of cardiovascular disease, low income, and low level of education are associated with premature acute myocardial infarction in South Asians. The association of parental consanguinity with acute myocardial infarction is reported for the first time and deserves further study.

Ethnic differences and determinants of diabetes and central obesity among South Asians of Pakistan.

Aims  To study the within ethnic subgroup variations in diabetes and central obesity among South Asians.

Evaluation of a water, sanitation, and hygiene education intervention on diarrhoea in northern Pakistan

OBJECTIVE Inadequate water and sanitation services adversely affect the health and socioeconomic development of communities. The Water and Sanitation Extension Programme (WASEP) project, undertaken in selected villages in northern Pakistan between 1997 and 2001, was designed to deliver an integrated package of activities to improve potable water supply at village and household levels, sanitation facilities and their use, and awareness and practices about hygiene behaviour. METHODS A case-control study was conducted during July-September 2001 to evaluate whether, after selected confounders were controlled for, children aged <6 years with diarrhoea were more or less likely to reside in villages that participated in the project than in villages that did not participate. Descriptive and logistic regression analyses were performed. FINDINGS Children not living in WASEP villages had a 33% higher adjusted odds ratio for having diarrhoea than children living in WASEP villages (adjusted odds ratio, 1.331; P<0.049). Boys had 25% lower odds of having diarrhoea than girls (adjusted odds ratio, 0.748; P<0.049). A 2.6% decrease was found in the odds of diarrhoea for every yearly increase in the mothers age (adjusted odds ratio, 0.974; P<0.044) and a 1.4% decrease for every monthly increase in the childs age (adjusted odds ratio, 0.986; P<0.001). CONCLUSIONS The findings in this study may help refine the approach to future water, sanitation, and hygiene initiatives in northern Pakistan. The integrated approach taken by WASEP, which incorporates engineering solutions with appropriate education to maximize facility usage and improve hygiene practices, is a useful example of how desired health benefits can be obtained from projects of this type.

Una intervención para mejorar el control de la diabetes en Chile

Objetivos. Investigaciones anteriores han demostrado que el control de la glucemia mejora los desenlaces a corto y largo plazo de los pacientes con diabetes de tipo 1 y 2. El objetivo de este estudio consistio en investigar en un pais en desarrollo la eficacia de una intervencion que incluyo la educacion del paciente, la automonitorizacion de la glucemia y la determinacion de la hemoglobina glucosilada (HbA1c). Metodos. Los pacientes fueron agrupados en tres categorias, teniendo en cuenta caracteristicas clinicas tales como la duracion de la diabetes, su tratamiento y los antecedentes de hospitalizacion. Los que cumplieron los criterios de inclusion y exclusion fueron asignados aleatoriamente a un grupo que recibio la intervencion educativa (210 pacientes) o a un grupo de control que recibio la asistencia habitual (206 pacientes). El grupo de intervencion recibio la informacion educativa necesaria para la automonitorizacion de la glucemia y para la autoevaluacion de las conductas positivas y negativas relacionadas con el control metabolico de la enfermedad. Resultados. Los dos grupos eran similares con respecto a la edad (media de 52,3 y 50,5 anos) y a la proporcion de pacientes con diabetes de tipo 1 (13,8% y 16,0%). Inicialmente no habia diferencias entre las concentraciones medias de HbA1c de los dos grupos (8,9 ± 0,1 y 8,9 ± 1,4%). Cincuenta pacientes (un 14,8% del grupo de intervencion y un 9,2% del grupo de control) abandonaron el estudio de forma prematura. En el grupo de intervencion, el cumplimiento de las recomendaciones dieteticas aumento del 57,5% al principio del estudio al 82,5% al final del mismo, lo cual representa un cambio porcentual del 43,5% (P < 0,001); en el grupo de control el cambio registrado no fue significativo. Aunque los pacientes con concentraciones iniciales elevadas de HbA1c estaban subrepresentados en este estudio, la concentracion media de HbA1c disminuyo significativamente en el grupo de intervencion (-0,4 ± 1,1%; P = 0,001), pero no en el grupo de control (-0,1 ± 0,1%). Conclusiones. En un pais en desarrollo, la educacion diabetologica del paciente consiguio mejorar el control metabolico, hecho atribuible principalmente a su impacto positivo sobre la dieta.

High incidence of childhood pneumonia at high altitudes in Pakistan: a longitudinal cohort study

OBJECTIVE To determine the incidence of pneumonia and severe pneumonia among children living at high altitudes in Pakistan. METHODS A longitudinal cohort study was conducted in which 99 female government health workers in Punial and Ishkoman valleys (Ghizer district, Northern Areas of Pakistan) enrolled children at home, conducted home visits every 2 weeks and actively referred sick children to 15 health centres. Health centre staff used Integrated Management of Childhood Illness criteria to screen all sick children aged 2-35 months and identify those with pneumonia or severe pneumonia. FINDINGS Community health workers enrolled 5204 eligible children at home and followed them over a 14-month period, ending on 31 December 2002. Health centre staff identified 1397 cases of pneumonia and 377 of severe pneumonia in enrolled children aged 2-35 months. Among children reported with pneumonia, 28% had multiple episodes. Incidence rates per 100 child-years of observation were 29.9 for pneumonia and 8.1 for severe pneumonia. Factors associated with a high incidence of pneumonia were younger age, male gender and living at high altitude. CONCLUSION Pneumonia incidence rates in the Northern Areas of Pakistan are much higher than rates reported at lower altitudes in the country and are similar to those in high-altitude settings in other developing countries. More studies are needed to determine the causes of pneumonia in these high-mountain communities. However, early introduction of the vaccines that are known to prevent pneumonia should be considered.

De la evidencia al desempeño: cómo fijar prioridades y tomar buenas decisiones

En esta epoca de respeto por la ciencia medica y por la responsabilidad gerencial, las organizaciones de salud deben rendir cuentas por sus acciones con creciente frecuencia. La epoca en que se determinaban las prioridades y se tomaban las decisiones sobre bases politicas o acatando el consejo intuitivo de asesores respetados y bien intencionados ha dado paso gradualmente a una era que valora la demostracion de efectividad y eficiencia. Las decisiones relativas a las prioridades y a los programas deben basarse firmemente en conocimientos comprobados y someterse a evaluacion continua. Esta transicion requiere promover el pensamiento critico en todos los ambitos. Surge entonces la siguiente pregunta: ?Como podemos promover el razonamiento critico en los servicios de salud para fijar prioridades, adoptar decisiones acertadas y poner en practica iniciativas efectivas? En otras palabras, ?como podemos pasar de la evidencia al desempeno? Una pregunta aun mas basica es ?por que debemos fijar prioridades?

Elevated Blood Lead Levels among Children Living in a Fishing Community, Karachi, Pakistan

Lead is a widespread environmental contaminant worldwide and is associated with adverse outcomes in children, including impaired neurobehavioral development and learning difficulties. A cross-sectional survey of 53 young children was conducted in a fishing village on an island adjacent to Karachi, Pakistan. Whole blood from each individual was tested for lead levels. Also tested were samples of cooked food, house dust, and drinking water from 36 households. Laboratory determinations were made by the Pakistan Council for Scientific and Industrial Research with quality control by the United States Centers for Disease Control and Prevention. Fifty-two subjects (98%) had blood lead levels above 10 μg/dl (mean 21.60 μg/dl), an internationally recognized threshold for potential neurotoxicity. The mean concentration was 3.90 μg/g in cooked food, 4.02 μg/l in drinking water, and 91.30 μg/g in house dust. These findings indicate possible major health concerns and suggest significant environmental contamination in this community as well as the need to identify locally relevant early childhood exposures.

Elevated blood lead levels in Karachi children.

Editor – The recent review of environmental lead exposure (1) is timely for Karachi, where we have just completed a survey of blood lead levels in children. Our objectives were to compare current levels with those from a study done a decade ago and to assess the contribution of sources that may be amenable to intervention. The design entailed a geographically stratified urban sample of 400 children in the age range 3–5 years from randomly selected households, selecting the eldest child in the age range from each household. Laboratory determinations were made by the Pakistan Council for Scientific and Industrial Research, with quality control provided by the United States Centers for Disease Control and Prevention (CDC). While detailed statistical analyses are still under way, we wish to share the results regarding the actual levels found, in view of their public health importance. Of the 400 children in the study, 322 (80.5%) had blood lead levels >10 mg/dl, 75 (18.8%) had levels >20 to 30 mg/dl, while 9 (2.3%) were found to have levels >30 mg/dl. The mean blood lead level was 15.6 mg/dl in contrast to 38.2 mg/dl (range 21.3–52.2) previously reported from a study of children at two Karachi schools located in a high traffic density area of the city (2). Our studywas designed to bemore representative of young children. These findings indicate that themajority of children in Karachi are likely to suffer some degree of intellectual damage as a result of environmental lead exposure, while some may suffer additional harm such as impairment of haeme synthesis and biochemical disturbances. While the levels are lower than previously reported, the high proportion of children with levels >10 mg/dl is cause for public health concern. The problemof lead in petrol has been recognized in Pakistan for several years, but action is needed. We will report our findings regarding other sources of elevated lead levels in due course. n Franklin White, Professor and Chair Department of Community Health Sciences (email: franklin.white@aku.edu)

Trends in lead content of petrol in Pakistan

Editor – We appreciate the comments of P.J. Landrigan concerning our article on the factors associated with elevated blood concentrations in children in Karachi, Pakistan (1, 2). In his editorial, however, he commented that the decline in the use of leaded petrol in Pakistan had resulted in declines in childrens blood lead levels. Mean blood lead concentrations in schoolchildren had been reported to be 38mg/dl in 1989 (3) as compared to the 15.6mg/dl we reported in children aged 36–60 months in 2000 (2). We believe the difference between these findings was largely due to differences in sample collection and analysis, especially as our study demonstrated that children who lived in areas with high levels of traffic congestion in urban Karachi had higher blood lead concentrations than those who lived in an adjacent rural community. To investigate further the role of decreased production of leaded petrol we surveyed all refineries in Pakistan to find out exactly when the lead content of petrol was decreased between 1989 and 2000. There are four refineries in Pakistan currently producing petrol: Pakistan Refinery Limited (PRL), National Refinery Limited (NRL), Attock Refinery Limited (ARL) and Pak-Arab Refinery Limited (PARCO). Previously two grades of petrol were marketed — regular containing 0.42g/l lead and high octane containing 0.84g/l lead. PRL reported that it decreased the lead content of Regular to 0.34g/l and high octane to 0.42g/l lead in 1997–98 and since July 2001 only produces lead-free petrol (personal communication, Irfan Mirza, Head of Economy and Scheduling, 22 November 2002). NRL reduced the lead content of Regular to 0.35g/l in November 2000, and has also been producing lead-free petrol since July 2001 (personal communication, Shaikh Zaheeruddin, Operations & Training, 20 November 2002). ARL produced regular containing 0.42g/l lead until 1999, following which it produced regular and a mixture containing 0.35g/l lead and methyl tertiary butyl ether (MTBE). In July 2002, they phased out lead as well as MTBE from petrol PARCO started production in Pakistan in September 2000 with petrol containing a bare minimum of lead and from July 2001 moved to production of lead-free petrol (personal communication , Shahid Hak, Managing Director, 26 November 2002). These changes were in response to a Government of Pakistan directive in 2001. Currently, the permissible limit of lead in petrol is 0.02 g/l and all refineries are meeting that standard We conclude therefore, that since lead in petrol was lowered by only …