Iqbal Azam

Health burden of skin lesions at low arsenic exposure through groundwater in Pakistan. Is river the source

A significant proportion of groundwater in south Asia is contaminated with arsenic. Pakistan has low levels of arsenic in groundwater compared with China, Bangladesh and India. A representative multi-stage cluster survey conducted among 3874 persons > or = 15 years of age to determine the prevalence of arsenic skin lesions, its relation with arsenic levels and cumulative arsenic dose in drinking water in a rural district (population: 1.82 million) in Pakistan. Spot-urine arsenic levels were compared among individuals with and without arsenic skin lesions. In addition, the relation of age, body mass index, smoking status with arsenic skin lesions was determined. The geographical distribution of the skin lesions and arsenic-contaminated wells in the district were ascertained using global positioning system. The total arsenic, inorganic and organic forms, in water and spot-urine samples were determined by atomic absorption spectrophotometry. The prevalence of skin lesions of arsenic was estimated for complex survey design, using surveyfreq and surveylogistic options of SAS 9.1 software.The prevalence of definitive cases i.e. hyperkeratosis of both palms and soles, was 3.4 per 1000 and suspected cases i.e. any sign of arsenic skin lesions (melanosis and/or keratosis), were 13.0 per 1000 among > or = 15-year-old persons in the district. Cumulative arsenic exposure (dose) was calculated from levels of arsenic in water and duration of use of current drinking water source. Prevalence of skin lesions increases with cumulative arsenic exposure (dose) in drinking water and arsenic levels in urine. Skin lesions were 2.5-fold among individuals with BMI <18.5 kg/m2. Geographically, more arsenic-contaminated wells and skin lesions were alongside Indus River, suggests a strong link between arsenic contamination of groundwater with proximity to river.This is the first reported epidemiological and clinical evidence of arsenic skin lesions due to groundwater in Pakistan. Further investigations and focal mitigation measures for arsenic may be carried out alongside Indus River.

Polymorphisms in MTHFR, MS and CBS genes and homocysteine levels in a Pakistani population.

Background Hyperhomocysteinemia (>15 µmol/L) is highly prevalent in South Asian populations including Pakistan. In order to investigate the genetic determinants of this condition, we studied 6 polymorphisms in genes of 3 enzymes - methylenetetrahydrofolate reductase (MTHFR; C677T; A1298C), methionine synthase (MS; A2756G), cystathionine-β-synthase (CBS; T833C/844ins68, G919A) involved in homocysteine metabolism and investigated their interactions with nutritional and environmental factors in a Pakistani population. Methodology/Principal Findings In a cross-sectional survey, 872 healthy adults (355 males and 517 females; age 18–60 years) were recruited from a low-income urban population in Karachi. Fasting venous blood was obtained and assessed for plasma/serum homocysteine; folate, vitamin B12, pyridoxal phosphate and blood lead. DNA was isolated and genotyping was performed by PCR-RFLP (restriction-fragment-length- polymorphism) based assays. The average changes in homocysteine levels for MTHFR 677CT and TT genotypes were positive [β(SE β), 2.01(0.63) and 16.19(1.8) µmol/L, respectively]. Contrary to MTHFR C677T polymorphism, the average changes in plasma homocysteine levels for MS 2756AG and GG variants were negative [β(SE β), −0.56(0.58) and −0.83(0.99) µmol/L, respectively]. The average change occurring for CBS 844ins68 heterozygous genotype (ancestral/insertion) was −1.88(0.81) µmol/L. The combined effect of MTHFR C677T, MS A2756G and CBS 844ins68 genotypes for plasma homocysteine levels was additive (p value <0.001). Odds of having hyperhomocysteinemia with MTHFR 677TT genotype was 10-fold compared to MTHFR 677CC genotype [OR (95%CI); 10.17(3.6–28.67)]. Protective effect towards hyperhomocysteinemia was observed with heterozygous (ancestral/insertion) genotype of CBS 844ins68 compared to homozygous ancestral type [OR (95% CI); 0.58 (0.34–0.99)]. Individuals with MTHFR 677CT or TT genotypes were at a greater risk of hyperhomocysteinemia in folate and vitamin B12 deficiencies and high blood lead (p value <0.05) level. Conclusions Gene polymorphism (especially MTHFR C677T transition), folate and vitamin B12 deficiencies, male gender and high blood lead level appear to be contributing towards the development of hyperhomocysteinemia in a Pakistani population.

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.

Post partum anxiety and depression in peri-urban communities of Karachi, Pakistan: a quasi-experimental study

BackgroundPostpartum anxiety and depression is a major public health concern because of its adverse effects on the cognitive and social development of the infant. Globally postpartum depression has been widely investigated but as anxiety is a more prominent feature of postpartum depression we assessed the prevalence of anxiety and depression and their associated factors in post partum women.MethodsA quasi-experimental study investigating the impact of postpartum anxiety and depression on child growth and development was conducted in two peri-urban, multiethnic, communities of Karachi, a mega city of Pakistan. A house to house questionnaire based survey was done by trained field workers; 420 consenting pregnant women were identified and data for socio-demographic, home environment and family relationship variables was collected between 36 weeks of pregnancy and within 10 days of childbirth. Mothers levels of anxiety and depression were assessed after one month, two months, six months and twelve months of childbirth; this was two step process: initially an indigenous, validated screening instrument Aga Khan University Anxiety and Depression Scale was used and diagnostic confirmation was done through a psychologists interview based on DSM IV criteria. Women found to be anxious and depressed at least once out of four assessments were considered for the computation of overall prevalence of postpartum anxiety and depression as well as its risk factors. However, point prevalences of postpartum anxiety and depression were also reported at each assessment time. Two sixty seven women could be followed for one year. Data was analyzed using SPSS. Chi-square test, simple and multiple logistic regression were used to see the association of different factors.ResultsThe overall prevalence of postpartum anxiety and depression was found to be 28.8 percent. Domestic violence, difficulty in breast feeding at birth and unplanned current pregnancy were found to be significantly associated with postpartum anxiety and depression.ConclusionDomestic violence and not having the right to plan pregnancy are related to the patriarchal culture and lack of empowerment of women. The association with difficulties in breast feeding needs to be further explored in future studies

Measles susceptibility in children in Karachi, Pakistan

Measles, despite being vaccine preventable is still a major public health problem in many developing countries. We estimated the proportion of measles susceptible children in Karachi, the largest metropolitan city of Pakistan, one year after the nationwide measles supplementary immunization activity (SIA) of 2007-2008. Oral fluid specimens of 504 randomly selected children from Karachi, aged 12-59 months were collected to detect measles IgG antibodies. Measles antibodies were detected in only 55% children. The proportion of children whose families reported receiving a single or two doses of measles vaccine were 78% and 12% respectively. Only 3% of parents reported that their child received measles vaccine through the SIA. Among the reported single dose measles vaccine recipients, 58% had serologic immunity against measles while among the reported two dose measles vaccine recipients, 64% had evidence of measles immunity. Urgent strengthening of routine immunization services and high quality mass vaccination campaigns against measles are recommended to achieve measles elimination in Pakistan.

Frequency and Associated Factors for Anxiety and Depression in Pregnant Women: A Hospital-Based Cross-Sectional Study

Antepartum anxiety and/or depression is a major public health problem globally. The aim of this study was to estimate the frequency of antepartum anxiety and/or depression among pregnant women. This was a cross-sectional study conducted in a tertiary care hospital among pregnant women. A total of 165 pregnant women were interviewed by a clinical psychologist using HADS for assessing anxiety and/or depression and also collected information regarding sociodemographic, obstetric, family relationships, and home environment. Out of the total of 165 pregnant women about 70 percent of them were either anxious and/or depressed. The increasing age of women (P-value = 0.073), not having any live birth (P-value = 0.036), adverse pregnancy outcome in past including death of a child, stillbirth or abortion (P-value = 0.013), participants role in household decision making (P-value = 0.013), and domestic violence (verbal or physical abuse towards mother or children by any family member) (P-value = 0.123). Our study highlights that anxiety and/or depression is quite common among pregnant women. Therefore, there is a need to incorporate screening for anxiety and depression in the existing antenatal programs and development of strategies to provide practical support to those identified.

Randomized controlled trial of standard versus double dose cotrimoxazole for childhood pneumonia in Pakistan

OBJECTIVE Increasing concern over bacterial resistance to cotrimoxazole, which is recommended by WHO as a first-line drug for treating non-severe pneumonia, led to the suggestion that this might not be optimal therapy. However, changing to alternative antimicrobial agents, such as amoxicillin, is costly. We compared the clinical efficacy of twice-daily cotrimoxazole in standard versus double dosage for treating non-severe pneumonia in children. METHODS A randomized controlled multicentre trial was implemented in seven hospital outpatient departments and two community health programmes. A total of 1143 children aged 2-59 months with non-severe pneumonia were randomly allocated to receive 4 mg trimethoprim plus 20 mg sulfamethoxazole/kg of body weight or 8 mg trimethoprim plus 40 mg sulfamethoxazole/kg of body weight orally twice-daily for 5 days Treatment failure occurred when a child required a change of therapy, died or was lost to follow-up. Children required a change of therapy if their condition worsened (they developed chest indrawing or danger signs) or if at 48 hours after enrollment, their clinical condition was the same (defined as having a respiratory rate that was 5 breaths/minute higher or lower than at the time of enrollment). FINDINGS The results of 1134 children were analysed: 578 were assigned to the standard dose of cotrimoxazole and 556 to the double dose. Treatment failed in 112 children (19.4%) in the standard group and 118 (21.2%) in the double-dose group (relative risk 1.10; 95% confidence interval = 0.87-1.37). Using multivariate analysis we found that treatment was more likely to fail in children who were not given the medicine correctly (P = 0.001), in those younger than 12 months (P = 0.004), those who had used antibiotics previously (P = 0.002), those whose respiratory rate was > or =20 breaths/minute above the age-specific cut-off point (P = 0.006), and those from urban areas (P = 0.042). CONCLUSION Both standard and double strength cotrimoxazole were equally effective in treating non-severe pneumonia. Close follow-up of patients is essential to prevent worsening of disease. Definitions of clinical failure need to be more specific. Surveillance in both rural and urban areas is essential in the development of treatment policies that are based on clinical outcomes.

Effectiveness of counseling for anxiety and depression in mothers of children ages 0-30 months by community workers in Karachi, Pakistan: a quasi experimental study

BackgroundThe prevalence of anxiety/depression is quite high during the perinatal period but unfortunately its detection and treatment have been less than satisfactory. Moreover, many women are reluctant to take pharmacotherapy for fear of excretion of drugs into their breast milk. This study assesses the effectiveness of counseling from minimally trained community health workers in reducing anxiety/depression, the rate of recurrence and the interval preceding recurrence in women during first two and a half years after childbirth.MethodsIn a quasi-experimental study, community women from two under-privileged communities were trained in data gathering, teaching healthy child-rearing practices, basic counseling skills, and screening for anxiety/depression by using an indigenously developed questionnaire, the Aga Khan University Anxiety and Depression Scale (AKUADS). The diagnosis was further confirmed by a clinical psychologist using DSM IV criteria. After obtaining consent, 420 women were screened and 102 were identified as having anxiety/depression. Screening was carried out after 1, 2, 6, 12, 18, 24 and 30 months of a live birth. Only 62 out of 102 agreed to be counseled and received eight weekly sessions. AKUADS was re-administered at 4 weeks and 8 weeks after the beginning of counseling; this was followed by the clinical psychologists interview for confirmation of response. After recovery, screening was continued every 3 months for detection of recurrence throughout the study period. Out of the women who had declined counseling 12 agreed to retake AKUADS after 4 and 8 weeks of diagnosis. Independent samples t-test, chi-square test, Repeated Measures ANOVA and Kaplan Meier technique were used for the analysis.ResultsA significant decline in level of anxiety/depression was found in both the counseled and the non-counseled groups at 4 and 8 weeks (p-value < 0.001) but the counseled group fared better than the non-counseled for recovery, reduction in the rate of recurrence and increase in the duration before relapse.ConclusionsAs our results cannot be generalized; further studies need to be carried out, to assess the benefit of incorporating minimal counseling skills in the training of community health workers.

Comparison of estimates of under-nutrition for pre-school rural Pakistani children based on the WHO standard and the National Center for Health Statistics (NCHS) reference.

OBJECTIVE To compare estimates of under-nutrition among pre-school Pakistani children using the WHO growth standard and the National Center for Health Statistics (NCHS) reference. DESIGN Prevalence of stunting, wasting and underweight as defined by WHO and NCHS standards are calculated and compared. SETTING The data are from two cross-sectional surveys conducted in the early 1990s, the time frame for setting the baseline for the Millennium Development Goals: (i) National Health Survey of Pakistan (NHSP) assessed the health status of a nationally representative sample and (ii) Thatta Health System Research Project (THSRP) was a survey in Thatta, a rural district of Sindh Province. SUBJECTS In all, 1533 and 1051 children aged 0-35 months from national and Thatta surveys, respectively. RESULTS WHO standard gave a significantly higher prevalence of stunting for both national [36.7 (95 % CI 33.2, 40.2)] and Thatta surveys [52.9 (95 % CI 48.9, 56.9)] compared to the NCHS reference [national: 29.1 (95 % CI 25.9, 32.2) and Thatta: 44.8 (95 % CI 41.1, 48.5), respectively]. It also gave significantly higher prevalence of wasting for the Thatta survey [22.9 (95 % CI 20.3, 25.5)] compared to the NCHS reference [15.7 (95 % CI 13.5, 17.8)]. Differences due to choice of standard were pronounced during infancy and for severely wasted and severely stunted children. CONCLUSIONS Pakistan should switch to the robustly constructed and up-to-date WHO growth standard for assessing under-nutrition. New growth charts should be introduced along with training of health workers. This has implications for nutritional intervention programmes, for resetting the countrys targets for Millennium Development Goal 1 and for monitoring nutritional trends.

A multicenter matched case control study of breast cancer risk factors among women in Karachi, Pakistan.

BACKGROUND Breast cancer (BC), the most common female cancer in Pakistan, is associated with a very high mortality. However, the roles of individual risk factors for BC among Pakistani women are still controversial. To assess potential risk factors for BC, a matched case-control study was conducted in two tertiary care hospitals of Karachi, Pakistan. MATERIALS AND METHODS The study population included 297 pathologically confirmed incident cases of BC patients diagnosed between January 2009 and December 2010. 586 controls without any history of BC were matched on a hospital basis, within 5 years of patient ages. RESULTS Family history of BC (MOR=1.72; 95%CI: 1.10, 2.80 for first degree vs. none), single marital status (MOR=1.55; 95%CI: 1.10, 2.39 for single women vs. married women), older age at menopause (MOR=3.92; 95%CI: 2.52, 6.18 for menopausal women aged below 45 years, MOR=6.42; 95%CI: 3.47, 11.98 for menopausal women above 45 years of age compared with premenopausal women) conferred an increased risk of BC for women. Increasing parity decreased the risk of BC (MOR=0.90; 95%CI: 0.85, 0.97 for each live birth). Intake of Vitamin D supplements (MOR=0.30; 95%CI: 0.12, 0.81 for <3 years and MOR=0.27; 95%CI: 0.13, 0.56 for >3 years) was protective compared to non-users of Vitamin D. CONCLUSIONS This study confirmed only few of the recognized risk factors in Pakistani women. The protective effect of Vitamin D is important from public health perspective and needs to be further explored through a randomized controlled trial.