Muazzam Nasrullah

Unintentional falls mortality among elderly in the United States: Time for action

Fall injury is a leading cause of death and disability among older adults. The objective of this study is to identify the groups among the ≥ 65 population by age, gender, race, ethnicity and state of residence which are most vulnerable to unintentional fall mortality and report the trends in falls mortality in the United States. Using mortality data from the Centers for Disease Control and Prevention, the age specific and age-adjusted fall mortality rates were calculated by gender, age, race, ethnicity and state of residence for a five year period (2003-2007). Annual percentage changes in rates were calculated and linear regression using natural logged rates were used for time-trend analysis. There were 79,386 fall fatalities (rate: 40.77 per 100,000 population) reported. The annual mortality rate varied from a low of 36.76 in 2003 to a high of 44.89 in 2007 with a 22.14% increase (p=0.002 for time-related trend) during 2003-2007. The rates among whites were higher compared to blacks (43.04 vs. 18.83; p=0.01). While comparing falls mortality rate for race by gender, white males had the highest mortality rate followed by white females. The rate was as low as 20.19 for Alabama and as high as 97.63 for New Mexico. The relative attribution of falls mortality among all unintentional injury mortality increased with age (23.19% for 65-69 years and 53.53% for 85+ years), and the proportion of falls mortality was significantly higher among females than males (46.9% vs. 40.7%: p<0.001) and among whites than blacks (45.3% vs. 24.7%: p<0.001). The burden of fall related mortality is very high and the rate is on the rise; however, the burden and trend varied by gender, age, race and ethnicity and also by state of residence. Strategies will be more effective in reducing fall-related mortality when high risk population groups are targeted.

Child Marriage and Its Associations With Controlling Behaviors and Spousal Violence Against Adolescent and Young Women in Pakistan

PURPOSE Child marriage (before 18 years) is widely prevalent in Pakistan, and disproportionately affects young girls in rural, low-income, and poorly educated households. Our study aims to determine the associations between child marriage and controlling behaviors (CB) and spousal violence by husbands against adolescent and young women in Pakistan beyond those attributed to social vulnerabilities. METHODS We analyzed data from the Pakistan Demographic and Health Survey, 2012-2013, of currently married women aged 15-24 years who had participated in the domestic violence module (n = 589, 22.5% [589/2,615] of the subsample aged 15-24 years) to identify differences in CB and spousal violence experiences between early (<18 years) and adult (≥18 years) ages at marriage. Associations between child marriage and CB and spousal violence by husband were assessed by calculating adjusted odds ratios (AOR) using logistic regression models after controlling for demographics, social equity indicators (education, wealth index, and rural residence), spousal age gap, and husbands education. RESULTS Overall, 47.8% of currently married women aged 15-24 years in Pakistan were married before the age of 18 years. About one third of women aged 15-24 years in Pakistan reported experiencing CB (31.8%) and spousal violence (31.1%) by their husbands. Compared with adult marriage, child marriage was significantly associated with CB (AOR = 1.50; 95% confidence interval [CI], 1.042-2.157), any form of spousal violence (physical or emotional) (AOR = 2.03; 95% CI, 1.392-2.969), emotional violence (AOR = 1.86; 95% CI, 1.254-2.767), and physical violence (AOR = 2.44; 95% CI, 1.582-3.760), including severe physical violence (AOR = 2.57; 95% CI, 1.122-5.872). CONCLUSIONS Effective interventions are needed to prevent child marriages and raise awareness about their negative consequences, with special reference to spousal violence.

Newspaper reports: a source of surveillance for burns among women in Pakistan

BACKGROUND Our study attempts to describe the demographics, characteristics of victims and perpetrators, and circumstances leading to burn events among females in Pakistan. METHODS Human Rights Commission of Pakistan (HRCP) systematically collected data on burns among women using newspaper reports from January 2004 till December 2005. We analyzed the aggregated data and estimated burn rates. RESULTS A total of 222 burn events were reported from 2004 to 2005; complete data were not available for all variables. Adults (>or=18 years) constituted 74% (91/123) of cases with 95% (121/127) being married. Most burns were caused by bursting of stoves (34%; 64/189) or victims set-on fire (33%; n = 63/189). Burns using acids accounted for 13% (25/189). Husbands (52%; 51/98) and in-laws (23%; 23/98) were the perpetrators in known burn events. Burns were classified as accidental in half of cases (51%; 97/189) and related to domestic issues in a quarter (25%; 47/189). There were 49% of (92/189) burns that were reported as intentional. The mean annual rate of burns among women (15-64 years of age) was found to be 33 per 100,000. CONCLUSION Newspaper reports are good source of surveillance when information is otherwise limited. Majority of burns (51%) were classified as accidental while 49% were reported as intentional, though there is a limitation in the accuracy of reported accidental events. There is a dire need for systematic data collection and devising preventive strategies for this important public health problem that remains largely neglected in Pakistan.

Incidence of burns and factors associated with their hospitalisation in Rawalpindi, Pakistan

BACKGROUND The burden of burns is largely underreported due to the lack of a surveillance system in Pakistan. The aim of our study was to determine the incidence of burns and factors associated with their hospitalisation in the city of Rawalpindi, Pakistan. METHODS A prospective observational study from July 2007 to June 2008 was conducted. All the burn-related injury patients presenting to emergency departments (EDs) of the three public teaching hospitals in Rawalpindi city were included. A standard World Health Organization questionnaire was used to record the information about injury victims. RESULTS A total of 1498 burned patients presented to EDs. Females accounted for 40% of the patients. The majority of patients were ≤ 46 years. Most of the burns occurred at home (79.2%). The overall incidence of burn-related injuries per 100,000 inhabitants was 76.3 for emergency visits, 17.0 for hospitalisation and 0.3 for ED deaths. Female patients (adjusted odds ratio (aOR)=1.49, 95% confidence interval (95% CI)=1.09, 2.06), intentional burns (aOR=5.25, 95% CI=2.17-12.74) and injuries at work (aOR=3.81, 95% CI=2.40, 6.07) and in a market area (aOR=2.25, 95% CI=1.36-3.74) were more likely to result in hospitalisation. CONCLUSION Rawalpindi city has a significant burden of burns. These results showed that investigating further factors leading to burns at home and work could be useful for future safety education campaigns. Moreover, continuous surveillance is warranted to decrease burns in Pakistan.

Health Hazards, Injury Problems, and Workplace Conditions of Carpet-Weaving Children in Three Districts of Punjab, Pakistan

Abstract Carpet weaving among children is common in rural Pakistan, but little information is available on the health effects of this work. A total of 628 carpet-weaving children and 292 non-working children from 10 rural villages were evaluated with questionnaires and physical exams. Fifty-five home-based and 30 shed-based worksites in these villages were assessed. Girls comprised the majority of working (73%) and non-working (69%) children; the mean age for both boys and girls was 10 years. The mean number of hours worked daily was 7.2 for males and 6.8 for females. Dust exposure in homes was generally higher than in sheds. Working children had significantly greater odds of joint pain (OR = 2.8), dry cough (OR = 2.5), cuts/bruises (OR = 22.1), Phalens sign (OR = 17.2), and neck/shoulder abnormalities (OR = 14.2). Symptoms and signs of acute and repetitive injury and respiratory symptoms were more common among carpet-weaving children than their non-working peers.

Girl-child marriage and its association with morbidity and mortality of children under 5 years of age in a nationally-representative sample of Pakistan.

OBJECTIVE To determine the relationship between child marriage (before age 18 years) and morbidity and mortality of children under 5 years of age in Pakistan beyond those attributed to social vulnerabilities. STUDY DESIGN Nationally-representative cross-sectional observational survey data from Pakistan Demographic and Health Survey, 2006-2007 was limited to children from the past 5 years, reported by ever-married women aged 15-24 years (n = 2630 births of n = 2138 mothers) to identify differences in infectious diseases in past 2 weeks (diarrhea, acute respiratory infection [ARI], ARI with fever), under 5 years of age and infant mortality, and low birth weight by early (<18) vs adult (≥ 18) age at marriage. Associations between child marriage and mortality and morbidity of children under 5 years of age were assessed by calculating adjusted OR using logistic regression models after controlling for maternal and child demographics. RESULTS Majority (74.5%) of births were from mothers aged <18 years. Marriage before age 18 years increased the likelihood of recent diarrhea among children born to young mothers (adjusted OR = 1.59; 95% CI: 1.18-2.14). Even though maternal child marriage was associated with infant mortality and mortality of children under 5 years of age in unadjusted models, association was lost in the adjusted models. We did not find a relation between girl-child marriage and low birth weight infants, and ARI. CONCLUSIONS Girl-child marriage increases the likelihood of recent diarrhea among children born to young mothers. Further qualitative and prospective quantitative studies are needed to understand the factors that may drive child morbidity and mortality among those married as children vs adults in Pakistan.

Differences in Poisoning Mortality in the United States, 2003–2007: Epidemiology of Poisoning Deaths Classified as Unintentional, Suicide or Homicide

Introduction Poisoning, specifically unintentional poisoning, is a major public health problem in the United States (U.S.). Published literature that presents epidemiology of all forms of poisoning mortalities (i.e., unintentional, suicide, homicide) together is limited. This report presents data and summarizes the evidence on poisoning mortality by demographic and geographic characteristics to describe the burden of poisoning mortality and the differences among sub-populations in the U.S. for a 5-year period. Methods Using mortality data from the Center for Disease Control and Preventions Web-based Injury Statistics Query and Reporting System, we presented the age-specific and age-adjusted unintentional and intentional (suicide, homicide) poisoning mortality rates by sex, age, race, and state of residence for the most recent years (2003–2007) of available data. Annual percentage changes in deaths and rates were calculated, and linear regression using natural log were used for time-trend analysis. Results There were 121,367 (rate=8.18 per 100,000) unintentional poisoning deaths. Overall, the unintentional poisoning mortality rate increased by 46.9%, from 6.7 per 100,000 in 2003 to 9.8 per100.000 in 2007, with the highest mortality rate among those aged 40–59 (rate=15.36), males (rate=11.02) and whites (rate=8.68). New Mexico (rate=18.2) had the highest rate. Unintentional poisoning mortality rate increased significantly among both sexes, and all racial groups except blacks (p<0.05 time-related trend for rate). Among a total of 29,469 (rate=1.97) suicidal poisoning deaths, the rate increased by 9.9%, from 1.9 per 100,000 in 2003 to 2.1 per 100,000 in 2007, with the highest rate among those aged 40–59 (rate=3.92), males (rate=2.20) and whites (rate=2.24). Nevada (rate=3.9) had the highest rate. Mortality rate increased significantly among females and whites only (p<0.05 time-related trend for rate). There were 463 (rate=0.03) homicidal poisoning deaths and the rate remained the same during 2003–2007. The highest rates were among aged 0–19 (rate=0.05), males (rate=0.04) and blacks (rate=0.06). Conclusion Prevention efforts for poisoning mortalities, especially unintentional poisoning, should be developed, implemented and strengthened. Differences exist in poisoning mortality by age, sex, location, and these findings underscore the urgency of addressing this public health burden as this epidemic continues to grow in the U.S.

Concentrated HIV Epidemic in Pakistan: An Opportunity to Prevent Generalized Epidemic

Globally, Human immunodeficiency virus infection / Acquired immunodeficiency syndrome (HIV/AIDS) is a major public health problem. According to World Health Organization (WHO), in 2008, there were 33.4 million people living with HIV, 2.7 million were newly diagnosed with HIV, and 2 million died globally due to AIDS.[1] Pakistan, a low-income country has a population of 190 million with 35% of its population below the age of 15 years, and 60% within the age of 15-64 years.[2] According to estimates from 2000, the mean age at first marriage for males was 26.3 years and 22.1 years for females.[3] Pakistan, even though has low burden of HIV/AIDS, with an estimated 85,000 people or 0.1 percent of the adult population living with HIV, the HIV/AIDS epidemic has begun in the country [Figure 1].[4] The epidemic is still “concentrated” in injection drug users (IDUs) and male sex workers (MSWs) including transgender, often called as “Hijras”.[5] According to the March-July 2004 sexually transmitted infections (STI) survey of high risk groups, 23% of 402 IDUs and 4% of 409 men who have sex with men were HIV-positive.[6] However, the volume of unprotected sexual acts and poor infection control strategies are high in the country that may lead this epidemic to general population.[7] Pakistan established National AIDS Control Program (NACP) in 1986-87 with an initial focus on laboratory diagnosis of suspected HIV cases.[8] However, with increasing burden of HIV/AIDS, the programs focus shifted towards HIV prevention and control interventions in the community. The development of National Strategic Framework-one in 2001, the Government of Pakistan with support from the World Bank, launched an enhanced response in the form of Enhanced HIV and AIDS Control Program (EHACP).[8] In 2004, with the support of Canadian International Development Agency (CIDA), a five year HIV/AIDS Surveillance Project (HASP) was launched. HASP was a capacity building project involving the NACP, provincial AIDS control programs, and other stakeholders including NGOs, research institutes and laboratories to develop a sustainable second generation surveillance system for HIV/AIDS in the country.[8] Figure 1 Evolution of HIV epidemics in Pakistan.[4] NACP: The National AIDS Control Program of Pakistan (Ministry of Health). ANC Study: The Antenatal Clinic Study (2001). EACP: The Enhanced AIDS Control Program of Pakistan. HASP: The HIV/AIDS Surveillance Project.RT/STI ... IDUs, MSWs including transgenders were found to be high-risk groups in Pakistan[4,9] with similar findings by HASP[10] and NACP.[8] The sexual transmission of HIV beyond “core groups,” a proportion of persons who are frequently infected with and transmit the disease, depend upon the members of core groups who have sexual intercourse with members of the general population-so-called “bridge populations”.[11] The prevalence of HIV among general population and female sex workers (FSWs) in Pakistan is still quite low, which is less than 1% and <0.01% respectively.[8] However, according to recent report, the infection has started spreading among FSWs.[10] Bridge populations such as wives of IDUs, clients of sex workers, truck or bus drivers, and migrant workers have high potential to spread this epidemic among general population.[4] Male IDUs often avoid disclosures of their drug use to their wives. Majority of their wives do not know their drug-using activities till they are married, making them generally more helpless to protect them. It has been estimated through recent study in seven cities of Pakistan, the mean number of clients per FSWs varied substantially between cities, ranging from 7.6 per month in Hyderabad to 62.0 per month in Sukkur.[12] Also, the use of condom is low among clients of MSWs; it has been found that greater anal-sex clients, and sex workers reporting 30 or more clients are negatively associated with condom use.[13] Similarly, one quarter of married truck drivers are found to be engaged in commercial or non-commercial extramarital sex, and rarely use condom during sexual act.[4] A large majority of Pakistanis are working abroad[4] especially poor manual workers,[14] and many of them remain away from their homes and families for years.[14] It has been estimated that over half (55%) of single migrant men had sexual experience and 36% of married migrant men reported premarital sex, with a very few individuals wearing condom during sex.[14] There is already growing evidence from several countries in East Africa about declining HIV prevalence.[15] Lessons from these countries need to be learnt by Pakistan before the spread of this concentrated HIV epidemic in Pakistan to general population. Behavioral change in decreasing sexual encounters with commercial sex, increase use of condom, intensive HIV testing policy with intensive counseling and follow-up of HIV-positive persons, tracing of sexual partners, increasing education, decline in multiple sexual partners, delay in age at first sex, and a reduction in casual sex are some of the strategies that have shown a promising future to decrease HIV epidemic, worldwide.[16,17] Further, good communications and health service infrastructure, control of sexually transmitted infections, social marketing of condoms, voluntary counseling and HIV testing services, television and radio serial dramas on HIV awareness, and among younger women, delayed age at first birth have also proved successful in decreasing HIV epidemic in other countries.[16–18] The effectiveness of these measures needs to be tested, and those that will be found effective should be implemented in settings like Pakistan. No doubt, through HASP and NACP in Pakistan, progress has been made in drawing attention to the high risk groups for HIV and bridging groups, but these groups have a potential to spread this epidemic to general population. There are still inadequate HIV preventive measures in Pakistan, mainly because of low healthcare budget,[7] and lack evaluation of measures when placed, for their effectiveness. There is less evidence available on the role of spouses/non-commercial partners of sex workers and IDUs, clients of sex workers and other bridging groups in epidemic progression in Pakistan. There is non-existence of national reporting system to enumerate repatriated workers who acquire HIV while abroad, especially the Middle East where mandatory HIV testing is conducted at recruitment, and those who acquire HIV are deported back to Pakistan. There are dearth of studies to understand the risk profiles and networks of migrant men, and those who receive their medications through injections from non-formal medical care providers in the country. HIV is still considered a social stigma not only among general population but also healthcare workers.[7] This stigma hinders HIV positive individuals to disclose their HIV status, making not only their social networks at risk for HIV but also making them unable to receive healthcare from healthcare providers. In addition, it makes difficult for general public to take up voluntary counseling and to get tested. The HIV epidemic in Pakistan is still “concentrated;” this window should be taken as an opportunity to prevent this epidemic to spread to general public by continuous surveillance and implementing evidence-based HIV preventive measures in the country.

The association of intimate partner violence with unintended pregnancy and pregnancy loss in Pakistan

To determine if intimate partner violence (IPV) was associated with unintended pregnancy and pregnancy loss among married women in Pakistan.

Diagnostic Imaging in Disasters: A Bibliometric Analysis

OBJECTIVE To investigate the role of diagnostic imaging in the clinical diagnosis, treatment, and follow-up management of patients in response to disasters. METHODS A MEDLINE (OVID) search of original research articles identified 177 articles on this topic published since 2000. A bibliometric analysis was conducted on the top 100 articles ranked by average yearly citation. RESULTS The most frequently studied disaster categories were disease outbreak (55 articles), armed conflict (23 articles), terrorist incident (10 articles), and earthquake (7 articles). The most studied disasters were the H1N1 influenza outbreak in 2009 (28 articles), Severe Acute Respiratory Syndrome outbreak in 2003 (24 articles), War in Afghanistan, 2001-2014 (8 articles), Iraq War, 2003-2011 (6 articles), and the Sichuan earthquake (China) in 2008 (6 articles). Among the first authors, 59 were primarily affiliated with Radiology. The United States of America produced the most articles (25 articles), followed by the Peoples Republic of China (24 articles). Eighty-one studies were retrospective, with 19 studies being prospective. Computed tomography was the most investigated modality (52.8%), followed by conventional radiography (33.3%) and ultrasound (9.7%). CONCLUSIONS Our study identifies intellectual milestones in the utility of diagnostic imaging in response to various disasters, and could help guide future research in developing disaster management plans. (Disaster Med Public Health Preparedness. 2018;12:265-277).