public health - Health Services Academy

Vol. 3, No. 2 June 2013

Health Services Academy H E ALT

H

CADEM S E RV I C E S A

Y

PAKISTAN JOURNAL OF

PUBLIC HEALTH ISSN: 2225-0891 E-ISSN: 2226-7018

Pak J Public Health

3

Pakistan Journal of Public Health, 2013 (June)

Vol. 3 No. 2 (June) 2013

Perceptions about measles among mothers living in rural area: A cross-sectional study at Larkana, Sindh Hussain S, Kumar R, Ali M, Khan EA, Ahmed J, Khan SA, Hussain S.

2

Gaps Analysis in Knowledge, Practices & Control Responses to Combat Cutaneous Leishmaniasis in Bagh AJ&K Akbar J, Rathor HR, Hassan SA, Bilal H, Khan IA, Idrees M

6

Susceptibility of Salmonella enterica serotype typhi, to the usual line of antimicrobial treatment in Rawalpindi Abdullah MA, Zahid A, Sattar NY

14

World Health Organization diabetic care guidelines: knowledge and practices of general practitioners in private Clinics of Rawalpindi, Pakistan Durrani HM, Kumar R, Durrani SM, Anwar-ul-Haq

19

Bioactivity of botanicals against Aedes aegypti Linnaeus and Anopheles stephensi Liston Larvae Inam-llah H, Rathor HR, Bilal H, Hassan SA and Khan IA, Faridi TA

23

Morbidity Patterns in Pakistan: Evidence from Pakistan Panel Household Survey 2010 Bari I, Abbas N

28

Socioeconomic and demographic dynamics of Birth Interval in Pakistan Abbas N, Shaikh I, Bari I

35

Short Communication A Spot Survey to Investigate an Outbreak of Cutaneous Leishmaniasis at Afghan Refugee Camp at Khairabad Village in KPK. Rathor HR, Hassan SA, Bilal H, Khan IA, Fridi TA.

40

Prof. Dr. Hamayun Rashid Rathor,

University of Health Sciences, Lahore

Dr Shahzad Ali Khan, Dr Inayat Thawar Health Services Academy, Islamabad Dr Ejaz Ahmed Khan, Dr Samina Naeem, Health Services Academy Islamabad Dr Katrina Aminah Ronis, Health Services Academy Islamabad

Cairo

Dr Michael Mecdonald, World Health Organization, Geneva Prof. Dr. William K. Reisen, University of California, USA

Mr Imtinan Akram Khan, Health Services Academy, Islamabad

Asma Sana Health Services Academy, Islamabad Dr Saima Iqbal Paracha Health Services Academy, Islamabad





Correspondence to Prof. Dr. Hamayun Rashid Rathor Executive Editor Pakistan Journal of Public Health Health Services Academy Prime Minister National Health Complex Park Road, Chak Shahzad Islamabad, 44000, Pakistan E-mail: [email protected] Ph: +92-51-9255590-94, Ext 104,106 Fax: +92-51-9255591


Pak J Public Health Vol. 3, No. 2, 2013 We are pleased to present the volume 3, second issue of the Pakistan Journal of public Health. This journal is gaining its popularity due to the fact that it provides unique and equal opportunity to young as well as experienced medical and biomedical research workers in Pakistan, to share their research outcomes with national and international researchers. An innovative feature of this journal is that it responds to the burning issues of public health. In this issue the original articles present ideas that can form basis for public health planning and policy, especially aimed at more vulnerable groups of the community and the diseases that have assumed epidemic form in the country. One paper draws attention to paying extra attention to female section of community because females of age 10 and above, especially 60 and above show higher level of morbidity compared to males. Another paper deals with the subject of measles that assumed epidemic form this year. It draws signicant links to mother's level of education to appropriate vaccination of children against measles. Diabetes mellitus is growing in Pakistan at an alarming rate. An article deals with the ability of General practitioners to deal appropriately with the Diabetes cases. In view of the prevailing epidemics of dengue and leishmaniasis, papers have been included, in this issue, on recent indigenous research in the eld of Medical Entomology and Disease Vector Control. A short communication on quick investigation of leishmaniasis outbreak presents in-depth analysis of factors responsible for the outbreak and provides comprehensive solutions for present and possible future outbreaks. We wish to thank our contributors and readers for their overwhelming response and support to PJPH and as reported earlier, the Pakistan Journal of Public Health has obtained the indexation in WHO EMRO database of Scientic journals (IMEMR), Index Copernicus and EMBASE, it is in progress with Thomas Reuters, Pakistan Medical and Dental council and Higher Education Commission of Pakistan. We wish to acknowledge our gratitude, for the members of editorial board and reviewers for ensuring the quality of publications and national and international members of Advisory Board for support and advice for continued improvement of the Journal.

Prof. Dr. Hamayun Rashid Rathor June 2013. Islamabad


Pak J Public Health Vol. 3, No. 2, 2013

Perceptions about measles among mothers living in rural area: A cross-sectional study at Larkana, Sindh Shahid Hussain1, Ramesh Kumar2, Mansoor Ali1, Ejaz Ahmed Khan2, Jamil Ahmed2, Shahzad Ali Khan2, 1 Sadat Hussain 1 2 Alumni Health Services Academy Islamabad Pakistan, Faculty of Public Health, Health Services Academy Islamabad Pakistan. (Correspondence to Kumar R:[email protected]) Introduction: Measles is still a public health problem in Pakistan. Despite disease prevention initiatives taken by the government, the disease is on the increase in rural and remote areas of the country. About 21,000 children die annually due to measles, which is about 58 children dying daily due to this infection. 63% coverage by vaccination has been reported in Pakistan, which is below the overall global coverage. This disease is endemic in the country and is considered to be a major cause of childhood morbidity & mortality. Methods: A cross-sectional study design with mixed methodological approach was conducted at rural union council of district Larkana. Total 106 mothers were selected for the study by adapting the multistage sampling technique. A semistructured questionnaire was adapted and focus Group Discussions were carried out with mothers residing outside the study site. Results: Study revealed that all the parents somehow had knowledge about vaccination, 85% of the mothers realized measles vaccination to be benecial, but only 14% had got their children immunized, 41% of the mothers in area of study did not vaccinate their children because of the fear of bad effects of vaccines. There was signicant relationship between the literacy of mothers and their knowledge about the total doses recommended for measles (p value 0.06). Conclusion: The study revealed that knowledge, attitude and practices of mothers about measles are related to their economic status and better socio-cultural factors, which is signicantly related with mother's level of education. (Pak J Public Health 2013; 3(2): 2-5) Keywords: Measles, Practices, Knowledge of mothers, children and vaccination.

Introduction Pakistan has been reported as highly endemic country for measles infections due to the low coverage by measles vaccine (1).Globally, 139,300 deaths, 380 deaths per day or 15 deaths every single hour resulting from measles have been reported in year 2010. Most of the cases occur in Low & Middle Income Countries (LMICs) settings. However, the vaccination resulted in a 74% drop in number of measles cases during the past. About 85% of the world's children received single dose of measles vaccine before reaching their 1st year of life (2). In 2012 the number of measles cases decreased through better organized supplementary immunization campaigns and better Expanded Program on Immunization (EPI) (3). Approximately 2.1 million Pakistani people have been affected by measles, consequently; about 21,000 children die every year. It is endemic in the country and is considered to be a major cause of childhood morbidity & mortality. In Pakistan, as per the EPI schedule, immunization against measles is recommended at 9 months of age, which can be the reason for increased mortality rate amongst infants who are younger than 9

months, because they had not received the vaccine (4). The economic, social, and health burden of measles infection is huge. Measles, a communicable disease, affects children & transmit as droplets from the nose, throat or mouth of the infected person. Measles vaccine is believed to be the most cost effective public health intervention. Vaccinating a child signicantly reduces costs of treating diseases, thus providing a healthy childhood and reducing poverty and suffering. Recently, the immunization coverage rates have improved sufciently in the developed countries, thereby conferring herd immunity, whereas most of the developing countries are still struggling with faltering rates (5). In Pakistan, the reported EPI coverage is still far below the herd immunity threshold (6). Reasons underlying poor coverage have been studied by researchers globally and besides other factors, knowledge and beliefs of parents have been documented to affect immunization coverage (7). Therefore it is a challenge for immunization service providers, to offer parents balanced and comprehensive information about the risks as well as the benets of vaccination during the counseling sessions. The 2


current study was proposed to decrease morbidity and mortality in children by early identication of causative factors of measles and by improving knowledge, attitude and practices of target population.

Methods A Cross sectional study was conducted from September to December 2012. A mixed methodology by including both qualitative and quantitative approaches was adapted to collect the data from mothers having at least one under ve-child living at rural areas of Taulka Ratudero District Larkana. A semi-structured questionnaire and eld guide were developed and translated into local language and used for data collection. Female data collectors were hired and trained before data collection process. Householders were considered eligible to participate if they have at least one under-ve child lived there and those mothers who had any mental disability were excluded. Following identication of such a household, the mother of the eligible child was interviewed after obtaining the written consent. Sample sizes were calculated by using the proportional formula. Multistage sampling technique was used in which at initial stage, convenient sampling technique was used for the selection of one Union Council out of 11 at Taluka Ratodero. Afterwards, sub units/sub clusters containing 4 to 5 Lady Health Workers (LHWs) serving areas which were adjacent to each other were demarked within the selected Union Council. Further to it, out of all sub units/sub clusters one sub unit/sub cluster was selected randomly. After that list of households with eligible mothers were collected from concerned Lady Health Worker (LHWs) and entered into SPSS. Finally, 106 eligible households were selected randomly through SPSS. Further, in case of nonresponse/refusals than already accounted 10%, next household were to be selected to compensate sample size. Quantitative survey was the major part of study, for which a semi-structured questionnaire was utilized to collect information on basic demographic characteristics, socio-economic status, parental education, reproductive history, immunization status of the child (coverage status was veried by checking EPI card or verbal inquiry) and mothers' knowledge, attitude and practices about measles and it's vaccination. For the qualitative part of this study to explore KAP of mothers about measles, Focus Group Discussions (FGDs) were carried out with mothers residing outside the study site. A total of 3 FGDs were conducted, however the respondents refused to have been audio recorded hence the written notes were taken. Quantitative data was entered in SPSS version 17 and descriptive analysis was carried out. Summary statistics for continuous

variables and frequencies and proportions for categorical variables were used. Data is presented in tables and graphs. Chi square test was used to for associations between knowledge about measles and other variables. For FGDs, all of the summarized notes were read and translated in one sitting to look for trends and comments that elicited emotional response or phrased negatively were noted. Finally the report was made by keeping in mind that the results generated would reect the purpose. All the analysis was done manually. Institutional ethical considerations were taken from Health Services Academy Islamabad, Pakistan.

Results Demographic information shows that, only 36% had some formal education whereas 64% of mothers were completely uneducated. For those who were educated there were drop outs at every level from primary, high school to college and university; 15 percent had primary while only 8 percent reached college/university level. Compared to their spouses, almost 18% of fathers had sought their Primary education and 41% of them never went to any school. Majority of mothers 92% were house wives where as 38% of their husbands were farmers followed by other 18% who were Government employees. Information about household characteristics was asked in relation to type of construction, number of rooms and number of persons sharing one room, type of facility and source of drinking water. Information revealed that almost half of the houses were made up of cement (50%). Majority of the houses had toilet 77% while very few 19% were using open area for defecation. Result shows that all of the parents somehow had knowledge about government's EPI programme, 85% of the mothers realized measles vaccination to be benecial, but only 14% had got their children immunized. 41% of the mothers in area of study did not vaccinate their children because of the fear of bad effects of vaccines. This trend was further followed by fever, staff attitude and long waiting hours at the facility (37% each) being the main hindering factors to keep mothers away from vaccinating their children. According to ndings of this study majority of studied mothers agreed that measles was a vaccine preventable disease, but nearly half of them (43%) did not know even about the total doses of measles vaccine. More so 6% said that 2nd dose was never required. 82% of the under-ve children of mothers were partially immunized. Literacy rate in mothers was very low; almost 64% of the mothers were illiterate and only 8% of the mothers from 4 villages attained the highest level of college. This highlights 3


the female restriction to home due to cultural barriers and non-availability of separate schools for girls. Majority, 92% of the mothers were house wives. Agriculture is the main earning source on which villagers depend for most of their income. Most of the mothers were engaged in agricultural activities with their men. Fathers education was also low, 41% were reported as illiterate. Only 18% of the fathers were government employees. More than half (61%) of the families had joint family system and 50% had cemented houses. Table 1 shows that perception about measles as a vaccine preventable disease highly statistically signicantly different with respect to their knowledge about the doses of measles vaccine (p value 0.05

Monthly household income had strong association with the perception of mothers about measles (p value 88%) had no specied staff to respond neglected tropical diseases (NTDs). The majority of available staff (80%) had inadequate knowledge about treatment and transmission mechanism of cutaneous Leishmaniasis. Majority of respondents (70%) were neither reporting nor notifying CL cases. Knowledge about rst and second line responses were signicant (70% know what to do). Conclusion: Socio-demographic situation of primary health care system favor the existence of human reservoir for further transmission of cutaneous Leishmaniasis. There is a huge gap in indigenous and technical knowledge and practices regarding detection and treatment of cases at health sector. (Pak J Public Health 2013; 3(2): 6-13) Key words: Sand y, Cutaneous Leishmaniasis, healthcare provider, knowledge, tropical disease

Introduction Tropical diseases are infectious diseases that are found predominantly in the tropics, where ecological and socioeconomic conditions facilitate their propagation. Climatic, social and economic factors create environmental conditions that facilitate transmission, and the lack of resources prevents affected populations from obtaining effective prevention and care (1). Dengue and Leishmaniasis are serious diseases that the World Health Organization (WHO) characterizes as lacking effective control measures. They are transmitted by insect vectors and can result in epidemic outbreaks. For dengue neither a specic treatment nor a vaccine is available, although good supportive treatment of dengue patient can drastically reduce mortality. Prevention of dengue through vector mosquito control is the only best available strategic option. For Leishmaniasis, treatment relies largely on drugs based on Antimony. Sustained control of the insect vectors of dengue and Leishmaniasis may not be easy because their high reproductive potential that allows quick recovery of vector populations after intervention wherever adequate breeding conditions exist (2), however, with motivated community participation, vector breeding can be prevented and controlled. Moreover, community education and mobilization can also prevent vector-man contact and reduce disease

transmission. Leishmaniasis is an emerging and resurging tropical disease with an ability to adapt to changing environments. It is caused by a protozoan “Leshmania” and transmitted through the bite of the female sand ies “Phlebotomus” (3). It is amongst the 15 most neglected disease of the world (4). Old world cutaneous Leishmaniasis, known as oriental sore , is an ancient disease dated back to 650 BC. Arab physicians, including Avicenna described details of oriental sore in 10th century. Texts from the 15th and 16th centuries mentioned the risk run by seasonal agricultural workers who returned from the Andes with skin ulcers (5,6). The disease has four main forms, depending on the parasite species and the cellular immune system of the patient. Clinical symptoms of different parasites are variable; they include: (a) visceral leishmaniasis, characterized by weight loss, irregular bouts of fever, anemia, enlargement of spleen and liver etc. (b) Mucocutaneous leishmaniasis, leading to partial or total destruction of mucous membrane of nose, mouth and throat and (C.) Cutaneous leishmaniasis, producing ulcer on exposed parts of the body, scarring and on occasion serious disability (7,8). The transmission of the disease may be zoonotic or anthroponotic and even from human to animals 6


transmission is possible (9). In many geographic areas only infected animals (such as rodents or dogs) along with sand ies maintain the disease cycle, called Zoonotic Cutaneous Leishmaniasis (ZCL). However, in some parts of the world, infected people generally maintain the cycle; this type is known as Anthroponotic Cutaneous Leishmaniasis (ACL) (10). In Asia, Africa, Europe and South America, the transmission mainly occurs in rain forests, desert areas, rural, peri urban, sylvatic and domestic habitat areas. The zoonotic visceral and cutaneous leishmaniasis is caused by L. infantum while sporadic anthroponotic cutaneous leishmaniasis caused by L. tropica (11). It is estimated that 12 million cases of Leishmaniasis exist worldwide and 2 million new cases are occurring annually. The geographical distribution of Leishmaniasis is restricted to tropical and temperate regions (12). It is prevalent in four continents and endemic in 88 countries (22 in the New World and 66 in the Old World). Among these, 16 are developed countries and 72 are developing countries; 13 of them are among the least developed countries. More than 90% of the CL cases occur in countries like Brazil, India, Sudan, Afghanistan, Iran, Saudi Arabia and Syrian Arab Republic. CL is now estimated to affect 15,000-20,000 people in Pakistan yearly (13). Several factors had been analyzed to determine the transmission of Leishmaniasis include; biological, environmental, geopolitical, socio-economic, cultural and behavioral factors as illustrated in gure 1.

Geo-political factors Wars and Disasters resulting migration and displacement Non immune human population moves in areas where the disease and the vector are present

Socio economic Factors Poor Socio economic systems Construction of houses with mud walls and earthen oors Unscreend rooms Urbanization

The present survey was limited to determination of gaps in knowledge and control responses of healthcare providers which fall under the socio-economic, cultural and behavioral factors. In the view of increased numbers of cases and unavailability of drugs and treatment facilities this study was planned and conducted to assess the potential gaps in knowledge and control responses regarding transmission of CL. Both clinical and public health interventions depend on the capacity of a given country's health system to deliver, noting that some interventions are more demanding than others in terms of infrastructure and human resources. In addition, decisions about which interventions should be given priority will depend on assessments of the local burden of disease, local health infrastructure and other social factors as well as on costeffectiveness analysis (14). Research capacity continues to limit the successful implementation of those interventions most needed to improve health in resource-constrained environments. The number of people trained to carry out the surveillance and the laboratory and operational research that are so essential to the successful implementation of cost-effective interventions remains woefully inadequate (15). An estimated 72% of patients are unable to access medical treatment, mainly because a very few hospitals in country are providing free treatment and these are specic to hard access. Most government hospitals do not have any drugs and skilled staff for Leishmaniasis treatment (16).

Behavioral Factor Occupation Daily activity Sleeping habit Use of mosquito net Increased exposure to disease vector

Biological Factor Hosts; Humans, Animals Vector; Phlebotomine Sand Flies Agent; Leshmania species Reservoirs; Canine, Rodents & man Availability of blood meal

Outbreaks of Coctancous Leishmaniasis Transmitted by Sand y

GAPS in Knowledge & Practices Inadequate Knowledge and practice of community about transmission of Leishmaniasis & sand y role Inadequate responses to CL at healthcare provider level Lack of community involvement in control strategies

Environmental Factors Favorable Humidity & temp. Livestock kept close to human dwellings Debris of organic materials & animal dung Deforestation & Vegetation near house

Figure 1: Conceptual framework of Risks factors determining Transmission of Leishmaniasis

7


Methods The study was carried out in rural areas of Bagh, Azad Kashmir: having 3 sub divisions, 19 union councils and 106 villages. Bagh has a hilly topography with mountainous altitudes, dened snowlines, thick forests with diverse ora and fauna and streams and Nallahas. It lies between 73º ― 75º and 33º― 36º longitudes and latitudes, respectively. Altitude varies from 3000 feet to 10,000 feet from sea level. Climate is temperate with average temperature range 2.6oC to 43.2oC, average annual precipitation is 1500 mm. The total population is 0.386 million and 770 sq.km area. Population density 501 person /sq km, household size 7 people per house and growth rate is 2.00% (AJ&K Planning & Development 2012). Health sector provides primary and secondary level healthcare. The district health department comprises: 1 DHQ hospital, 1 THQ-Hospital, 6 RHCs, 17 BHUs and 11 CDs (DHIS Bagh 2012) A cross-sectional quantitative KAP survey was conducted, where, structured and semi structured interviews were carried out to assess the level of knowledge and control responses to combat resurgence, emergence and outbreaks of Leishmaniasis. The questionnaire had designed to analyze strengths, weaknesses, opportunities to combat Leishmaniasis in the existing primary healthcare system. The questionnaire used for collection of data on general and study variables includes three main parts; sociodemographics of health units (number of staff, skilled staff to respond NTDs, availability of anti Leishmaniasis drugs, availability of insecticides and availability of IEC material regarding CL) knowledge about disease, vector and reservoirs and knowledge about treatment and control responses of CL cases. Healthcare providers were selected from BHUs, RHCs and DHQ- Hospital. In-charges of the health units were approached for responses. At least one healthcare provider from each health unit preferably in-charge was selected for interview. Moreover the district health authorities were also approached to assess their actions and plans about Leishmaniasis control. Calculations and statistical analysis The data was collected and recorded carefully to make the degree of scientic rigor required for the survey. Data analysis was followed the objectives, hypothesis and analysis plan. SPSS 20 package used to analyze the data. The analysis expressed as condence intervals (CI) and p-values. 95 % CI and 0.05 p value were used as signicance levels for results

Results Stafng Only 6 RHCs (14%) health facilities were strengthen with more than 15 healthcare providers. While 8 BHUs have (18.6%) 11-15, 5 BHUs (11.6%) with 6-10 and 24 BHUs (55.8) with 2-5 staff members respectively. The status of technical staff regarding vector borne disease control and management were investigated and it was found that most of the health units (>88%) were lacking any designated healthcare provider to monitor and respond VBDs, whereas 1 (2.3%) health facility had 1 while 2 (9.3%) with 4 designated persons to responds VBDs. These are malaria supervoisers. There was no medical entomologist, neither epidemiologist but only 01 microbiologist in the whole District. Drugs and insecticides The availability of anti Leishmaniasis dugs was scarce. Only 1 facility responded positively while 42(97%) had no such drugs. Only 11 (25.6%) have stock sometimes in the year while 29 (67.4%) had no availability and 3(7%) never ever had. Notication and Reporting system 13 (30.2%) health facilities notifying cases of CL, 24 (55.8%) not notifying while 6(14%) did not know about the mechanism of CL cases notication (Table: 1). Knowledge level of Healthcare providers Types of Leishmaniasis: Majority of the respondents (22; 51.2%) were unaware about the types of Leishmaniasis. However, 15 (34.9%) have sound knowledge about various types of Leishmaniasis. Treatment of CL The treatment protocol of CL was known to 18.6% while more than 80 did not knowing the standard treatment protocol. Anti-Leishmaniasis Drugs More than 60% respondents were unaware of the drugs used to treat CL cases. Medicines: 25.6% knew that an injection is used to treat CL cases. While 11.6 % knew that there are some tablets used to treat CL cases. Mode of Disease Transmission 19 out of 43 (44.2%) respondents knew about the mode of transmission while about 55% were unaware of the transmission mechanism of CL. The respondents had improper knowledge; weather it is a vector borne disease or otherwise. Only 44% knew it as VBD while 19 % were unaware that it is a vector bone disease. Name of Vector: Only 34% PHC workers were familiar that sand y is the vector of CL while more than 75% were unaware about the name of the insect either it is sand y or any else insect. Case conrmation more than 23 % did not responded properly. 72% responded that laboratory method could be 8


Table 1: Characteristics of Health Facilities Items

Category

No. of Respondents (n=43)

%

a- Manager

4

9.3

b- Planner

1

2.3

c- Clinician

38

88.4

a- 2 to 5

24

55.8

b- 6 to 10

5

11.6

c- 11 to15

8

18.6

d- >15

6

14

a- No (0)

38

88.4

b- 1

1

2.3

c- 2

4

9.3

4- # of Epidemiologists in Health Facilities

a- No

43

100

5- # of Med. entomologists in Health Facilities

a- No

43

100

6- # of microbiologists in Health Facilities

a- No

42

97.7

b- 1

1

2.3

a- No

42

97.7

b- WHO Supply

1

2.3

a- Yes

11

25.6

b- No

29

67.4

c- Don't know

3

7

a- Yes

13

30.2

b- No

24

55.8

c- Don't know

6

14

a- No

16

37.2

b- Don't Know

4

9.3

c- Health Technician d- Doctor

10

23.3

2

4.7

e- CDC Worker

11

25.6

a- No

28

65.1

b- CDC Worker

4

9.3

c- Doctor

3

7

d- Health Technician e- Media

7

16.3

1

2.3

1- Role &Responsibility of Respondent

2- # of staff in Health Facilities

3- # of CDC ofcials in Health Facilities

7- Availability of anti Leishmaniasis drug 8- Availability of Insecticide

9- Reporting/Notifying CL Cases

10- Who is planning CDC activities

11- Who is reporting /Notifying cases

9


used to conrm CL cases. More than 4% responded that symptoms are used to conrm the CL cases. Trend of Disease 44% said there is no particular trend while 27 % have knowledge that there are certain localities where disease occurs and 7% told that the disease is related to some occupations (farmers, wood cutters). Knowledge and perceptions about control Responses for Leishmaniasis Cases When respondents were asked about the responses upon the report of CL case; different answers were recorded. The rst line actions were not known to 30.2% while 70% were responding to the cases. 68% respondents were referring CL cases to higher facility. Only 2.3 % of respondents were treating the cases of CL at the facility. 68% not practicing and 30% did not know about treatment protocol (Table: 2). Only 2% prescribing Glucantime as the standard treatment regime while more than 98% did not knew about these injections. Majority (70%) of responds knowing about second line actions while 24 % did not knew about second line actions. More than 60% respondents were thinking health education while 16% thinking vector control by different means in the areas where CL cases reported. Discussion This study was an empirical analysis of strengths, weaknesses and opportunities in the available primary healthcare system to responding the cases of CL in the health facilities and interventions at high risk areas in community. The available resources, knowledge and perceptions regarding strategies and control responses of healthcare providers to combat Leishmaniasis are again supporting our Hypothesis. The availability of skilled staff is alarming majority of health facilities (> 50%) had only 2-5 persons while more than 80% of PHC facilities had not a single person to deal with NTDs. There was neither entomologist nor epidemiologist in whole District department. These ndings are differing from the similar studies conducted in Eastern African countries regarding gap analysis to combat CL, where designated ofcials has disease specic duties (17). The knowledge about the vector and types of Leishmaniasis was greater (40% and 35% respectively) than the knowledge about the treatment (18%) and name of anti-Leishmaniasis drugs (38%). The difference was due to unavailability anti Leishmaniasis drugs in the facilities. However the insecticide available at 25% health facilities indicates some existence of control activities. These answers were different from the study of Kumar and Singh 2011. In the referred study, level of knowledge in India,

Bangladesh and Nepal were even higher (18). This difference could be due to existence of effective VL control program and more strong communication and skilled staff availability. The reporting mechanism and notifying the CL cases was very weak only 20% were notifying CL cases while 80% have no such practices. This is an indication of under reporting and under estimation of disease burden in the study area. This situation did not full the WHO criteria of notifying cases of NTDs (Global strategic IVM framework 2008-15) to combat NTDs (19). The knowledge about rst line actions at health facilities to respond CL cases were referring patients to higher consultation level (67%) and only 2% knowing and giving treatment (where, WHO supporting medicines supply). These perceptions and practices are due to absence of medicines and improper skills of healthcare providers in dealing with CL cases (DHO Bagh report 2012). These actions are not matching the ndings of Zijlstra et al. 2001 to combat disease. It has been described that patients are potential reservoirs and if not responded properly they are playing vital role in transmission, especially anthroponotic transmission. It had been described that existing cases of Leishmaniasis are thought to increase transmission of the disease, when untreated .Skilled human resources could effectively control and manage the CL by prompt responses. These responses would be; surveillance of CL, treatment of CL cases, health education and vector control measures (20). However, the knowledge and perceptions about second line actions were satisfactory more than 70% knew that either health education are vector control while 23% are not considering any sort of intervention. These interventions have been supported in a similar study in Iran. It seems that the best way in prevention and reducing the related problems of the cutaneous Leishmaniasis, considering high prices for treatments and scarcity of medicaments with acceptable safety and efcacy, is to implement a suitable health education course that leads to enhanced people's knowledge resulting in early diagnosis, effective treatment and acceptable follow up. Based on the results of this study it had been recommended to prepare and organize a suitable health educational course to be used not only for health volunteers, but also for ordinary people as well, to get better understanding of the cause, main routes of spread and prevention of the disease, that in turn leads to a considerable decline in prevalence of the CL (21). 10


Table 2: Knowledge and perceptions of Health care Provider regarding control Responses to combat Cutaneous Leishmaniasis Variables 1- First line actions at PHC unit

2- Practicing the Treatment of CL Cases

3- Prescribing the injections for CL cases 4- Second line actions of Respondent

5- Types of methods used/advised

The results of existing system and strategies are different from the Special Programme for Research and Training in Tropical Diseases (TDR), that dene, best public health drugs, vaccines and health promotion tools will be unsuccessful when the health policies and systems are not responsive to the epidemiological realities and the social needs of the population (22). In terms of vector borne diseases, WHO has developed new strategies for prevention and controls that emphasis 'integrated vector management' as an approach that reinforces links between health and environment. Moreover European Union (EU) also intervening for VBDs control. By 2013, European Centre for Disease Prevention and Control (ECDC) had made signicant contributions to the scientic knowledge of communicable diseases and their health consequences. To enhance the knowledge of the health, economic, and social impact of communicable diseases in the EU this includes all surveillance-related strategies (23).

Responses a- No Action b- Treatment c- Referring a- Yes b- No c- Don't Know a- No b- Glucantime a- Don't Know b- Health Education c- Vector Control d- No Action a- No b- Don't Know c- Environment Management d- Chemical Control

No. of Respondents (n=43) % 13 30.2 1 2.3 29 67.4 1 2.3 29 67.4 13 42 1 5 26 7 5 21 13 8

30.2 97.6 2.3 11.6 60.5 16.3 11.6 48.8 30.2 18.6

1

2.3

Conclusion There is a huge gap in indigenous knowledge and practices regarding detection and treatment of cases at health sector. Lack of surveillance of cases and poor understanding the risk factors could become a disaster. The reporting mechanism further conrming the underreporting of CL cases and the situation regarding disease burden might be worse than the known. There are certain strengths at health care providers' level. They had certain aptitude, to respond at community level as health education and vector control mechanisms. It seems that the best way in prevention and reducing the related problems of the cutaneous Leishmaniasis, considering high prices for treatments and scarcity of medicaments with acceptable safety and efcacy, is to implement a suitable health education course that leads to enhanced people's knowledge resulting in early diagnosis, effective treatment and acceptable follow up. These gaps demand special attention in certain 11


areas under integrated disease management strategy; which could bring the remarkable change without any big investments. Strengthening local health systems to ensure long-term sustainability, it is therefore a need to strengthen health care systems, including their capacity for diagnosis, treatment, case management and surveillance. It will be important however, that details on the various pathological forms of Leishmaniasis, the age, sex and geographic origin of the patient are maintained when data are collected and collated through the prevailing reporting system. If collation of surveillance data at national level is currently not possible, efforts should be made to at least improve reporting and data analysis in the known highly endemic areas. Maintaining awareness of the situation in these locations will allow a faster response when needed. As part of the process, epidemic thresholds will need to be agreed upon to differentiate seasonal increases in case loads from actual outbreaks. Capacity Building for effective delivery of NTD control relies on appropriately trained staff. There is a need to provide support, technical guidance and training to relevant health personnel especially in the light of global and national strategic frame work of IVM in this regard.

6.

7. 8.

9.

10.

11.

12.

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Remme JH., Feenstra P, Lever PR , Médici A, Morel C, Noma M, et al. Tropical Diseases Targeted for Elimination: Chagas Disease, Lymphatic Filariasis, Onchocerciasis, and Leprosy. 2nd ed. Disease Control Priorities in Developing Countries. chapter-2. Cattand P, Desjeux P, Guzman MG, Jannin J, Kroeger A , Medici A, Philip, Musgrove, Nathan MB, Shaw A, Schoeld CJ. Tropical Diseases Lacking Adequate Control Measures: Dengue, Leishmaniasis,and African Trypanosomiasis. Onchocerciasis, and Leprosy. 2nd ed. Disease Control Priorities in Developing Countries. Chapter-23. David C, Penny M. Habitat analysis of North American sand ies near veterans returning from Leshmania endemic war zones. 2008. International Journal of Health. Geographics 7: 65 Bari A. Chronology of cutaneous Leishmaniasis: An overview of the history of the disease. Journal of Pakistan Association of Dermatologists. 2006; 16: 24-27. Sharma U, Singh S. Insect vectors of Leshmania: distribution, physiology and their control. J Vector Borne Dis. 2008; 45(4): 255-72.

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Gouveia C, Oliveira RM, Zwetsch A, Motta-Silva D, Carvalho BM, Santana AF, et al. Integrated Tools for American Cutaneous Leishmaniasis Surveillance and Control: Intervention in an Endemic Area in Rio de Janeiro, RJ, Brazil. Interdisciplinary Perspectives on Infectious Diseases. Volume 2012, Article ID 568312,9 pages doi:10.1155/2012/568312 Manan M, Nadeem S. Visceral Leishmaniasis. Haematology Updates 2010. Manan, MU, Yousaf M, Idrees M, Ghufran SB. Focus of Visceral Leishmaniasis in District Abbottabad. J Ayub Med Coll. Abbottabad. 2000; 12(2), 17-8. Brooker S, Mohammed N, Adil K. Leishmaniasis in refugee and local Pakistani populations. Emerg Infect Dis. 2004; 10: 1681–84. Bari UA, Rizwan Y, Tariq B, Amer E. Mucocutaneous leishmaniasis in Central Punjab and Azad Kashmir regions of Pakistan, J Pak Asso Dermatol. 2012; 22(3):191-196 Hewitt S. Anthroponotic cutaneous leishmaniasis in Kabul, Afghanistan: vertical distribution of cases in apartment blocks. Transaction of the Royal Society of Tropical Medicine and Hygiene. 1998; 92: 273-274. Reithinger R, Jean-Claude D, Hechmi L, Claude P, Bruce A, Simon B, Cutaneous leishmaniasis. Lancet Infect Dis. 2007; 7:581–96. Rowland M, Munir A, Durrani N, Noyes H, Reyburn H. An outbreak of cutaneous leishmaniasis in an Afghan refugee settlement in north-west Pakistan. Trans R Soc Trop Med Hyg. 1999; 93(2):133-6 Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al. Disease Control Priorities in Developing Countries 2nd ed. Bloom BR, Michaud CM, La Montagne JR, Simonsen L. Priorities for Global Research and Development of Interventions. Disease Control Priorities in Developing Countries. 2nd ed. chapter-4 Almeida MC, VilhenaV, Barral A, Barral-Netto M. Leshmania infection: Analysis of its rst steps. A review. Mem Inst Oswaldo Crust. 2003; 98: 861–70. Malaria Consortium; Leishmaniasis control in eastern Africa: Past and present efforts and future needs. Situation and gap analysis. November 2010. Kumar N, Siddiquil NA. How do health care providers deal with kala-azar in the Indian Subcontinent. 2011; 349-355 World Health Organization (WHO) Global plan to combat neglected tropical diseases. 2008-2015 Zijlstra EE, Musa AM, Khalil EAG. El Hassan IM, El 12


Hassan AM. Post-Kala-azar dermal Leishmaniasis. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2001; 95: 7-58 21. Tafti MHD, Moghadam MHB. A survey on effect of health education on health volunteer performance and knowledge in prevention of cutaneous leishmaniasis in Yazd. Journal of Pakistan Association of Dermatologists. 2011; 21: 27-32 22. Blas E. Health policy research is essential but difcult. TDR news No. 60 October 1999 (Published by the UNDP/WORLD BANK/WHO Special Programme for Research and Training in Tropical Diseases (TDR) 23. ECDC Corporate; Strategies for disease-specic programmes 2010–2013 (Stockholm, July 2010 © European Centre for Disease Prevention and Control, 2010)

13



Susceptibility of Salmonella enterica serotype typhi, to the usual line of antimicrobial treatment in Rawalpindi 1

2

Muhammad Ahmed Abdullah , Adnan Zahid , Nargis Yousaf Sattar

3

1

Department of Community and Family Medicine, Shifa College of Medicine (STMU), Islamabad, 3 Department of Medicine, District Headquarters Teaching Hospital, Rawalpindi, Department of Basic Health Sciences, Shifa College of Medicine (STMU), Islamabad. (Correspondence to Abdullah MA: [email protected]) 2

Introduction: Enteric Fever is a global public health problem, with annual death rates of around 600,000. The bacterial infection with serious implications largely affects poor populations in the developing world. Modern medicine has developed an effective arsenal against most infectious diseases during the last century, however the casual use of antimicrobial agents in many developing countries, has rendered them useless. The present study purports to look into the issue of antimicrobial resistance against S. typhi. Methods: This study is a Cross-sectional study conducted in a total of 150 consenting participants presenting at DHQ teaching hospital Rawalpindi, over a period of 6 months (November 2012 to May 2013), through non-random consecutive sampling technique. Blood cultures were taken from the 96 participants who had tested positive for S. typhi infection. The results of these blood culture reports have been discussed with a special focus on the various anti-microbial drugs being currently used. Results: Out of the 150 study participants 62.5% were men and the remaining were women, mean age of the respondents was almost 33 years, approximately 40% were uneducated and around half were from urban Rawalpindi. The rst line agents including Ampicillin, Chloramphenicol and Co-trimoxazole showed resistance in more than 75% of cases, while strikingly Flouroquinolones including Ciprooxacin, Levooxacin and Ooxacin showed around 80-90% resistance. All the organisms were sensitive to Ceftriaxone and Cexime. Conclusion: Anti-microbial resistance is a global health issue with regards to many infectious diseases. Enteric fever has been treated with various remedial strategies over the years ranging from spiritual healing and water from various shrines to antibiotics and surgical correction of complications. Owing to various reasons including the prescribing practices of our physicians, this ticking time bomb of antimicrobial resistance is inuencing the lives of many people. Robust regulatory strategies and educational interventions are the need of the day, but the most important thing in this regard is the motivation and good intent of the people responsible for treating and preventing infectious diseases. (Pak J Public Health 2013; 3(2): 14-18) Key Words: S. typhi, Antimicrobial drugs, Resistance, Rawalpindi

Introduction With an estimated global burden of over 27 million cases and 200,000 deaths annually, typhoid fever causes substantial morbidity and mortality throughout the developing world. Salmonella enterica subsp. Enterica serovar typhi (S. Typhi) and Salmonella enterica subsp. Enterica serovar paratyphi (S. paratyphi) are the causative agents of typhoid fever (1). The true burden of typhoid fever in developing countries is difcult to estimate. According to recent estimates, more than 22 million new cases occur each year round the world while 90% of the sufferers are from the South-east Asia. Reported deaths from typhoid fever accounts to around 2,16,000 per year (2). Asia, with 274 cases per 100,000 persons has the highest incidence

of typhoid fever cases worldwide, especially in Southeast Asian countries and on the Indian subcontinent, followed by sub-Saharan Africa and Latin America with 50 cases per 100,000 persons (3). Typhoid fever is among the water borne infections characteristic of environment with poor sanitation and hygiene. The causative agent Salmonella enteric serovar typhi is pathogenic both to man and animals with associable inammatory reaction in the intestinal tract. Like other enteric pathogens, S. enteric serovar typhi is transmitted through food or water that has been contaminated with faeces from acutely infected person's persistent excretors (that is constant stooling or diarrhea) or from chronic asymptomatic carriers (4). In a recent study conducted in India it was found out that the frequency of 14


S. typhi infection was 75.3% in Chandigarh India, clearly pointing out towards the high occurrence of the disease in the region (5). The emergence of drug-resistant strains in recent years, especially multidrug-resistant (MDR) Salmonella typhi (resistant to ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole), has been of major concern (6). For more than 40 years since its discovery, chloramphanicol was the drug of choice for the treatment of typhoid. However, the emergence in the late 1980s of multidrug-resistant (MDR) serovar typhi (isolates resistant to ampicillin, chloramphenicol, and cotrimoxazole) in outbreaks reported in the Indian subcontinent (7), Arabian Gulf, the Philippines, and South Africa has led to the use of the uoroquinolones as alternative drugs. In a recent study conducted in Egypt it was seen that 43% patients with Typhoid fever had MDR typhoid (8). According to statistics from a systematic review of data based on the population of Northern India the following sensitivity patterns were seen for various anti-microbial agents; 65.3 % to Ampicillin, 93.8% to ciprooxacin, 95.5% to ceftriaxone and 50% to chloramphenicol (9). Given the considerable morbidity associated with MDR typhoid in children, and increased mortality with delay in treatment (10), it is essential that appropriate antibiotic therapy be instituted promptly. Oral quinolones have provided an effective oral form of therapy for MDR typhoid in adults but are still not licensed for widespread pediatric use. Where the generic use of quinolones has become widespread, there are also recent disturbing reports of emerging quinolone resistance (11). Broad-spectrum cephalosporins have thus remained an important therapeutic alternative for the therapy of MDR typhoid in children, with excellent primary cure rates (12). Typhoid being an important public health issue poses new problems in terms of resistance to usual available treatments. The present study purports to look at the current sensitivity pattern of most commonly prescribed drugs for treatment of S. typhi infection and the prevalence of MDR typhoid fever. As the sensitivity pattern keeps on changing with time, currently most drugs are prescribed without obtaining a culture and sensitivity report. Based on the results of our study, recommendations about the empirical antimicrobial prescription will be made which will promote appropriate treatment of these infections, while utilizing a judicious approach for prescribing antimicrobial agents.

Methods The current study is a Cross-sectional study. Information

was collected from patients attending the Outpatient unit of the Department of Medicine and their blood samples were collected for culture sensitivity. This was done in order to see the trends of resistance to the usual line of antimicrobial treatment being employed at the DHQ teaching hospital, Rawalpindi in specic and health care settings in Pakistan in general. The intent of this research is to generate and disseminate evidence in a local perspective with much broader long term implications. We purport to identify the issue of antimicrobial resistance as a major public health concern for the developing world, and generate an academic debate and put forth an idea for further research. For this purpose a total of 150 patients were selected attending the Out Patient Department of DHQ Teaching Hospital Rawalpindi, with the suspicion of having Typhoid Fever, after obtaining written informed consent. The diagnosis was conrmed by Typhidot test, as a result of which 96 people were declared of being infected with S. typhi. Blood samples from these 96 patients were sent for Culture and Sensitivity. The organisms isolated from the blood of these individuals were tested for sensitivity and resistance against relevant antimicrobial agents (Ampicillin, Chloremphanicol, Nalidixic Acid, Ciporoxacin, Levooxacin, Ooxacin, Cexime, Ceftriaxone). The results have been presented in the form of descriptive statistics. Ethical approval was taken from the IRB of DHQ Teaching Hospital Rawalpindi. Technical approval was also granted by the Research wing of the College of Physicians and Surgeons of Pakistan. Written informed consent was taken from all the participants, and the purpose, process, risks and benets of the study were clearly explained to them. Keeping in mind the concept of patient condentiality all participant information was coded using ID numbers rather than names. No but besides the research team had access to the information. Treatment was facilitated for the participants, although the resource and time constraints did create hurdles in this regard.

Results A cross-sectional study was conducted, where patients coming in at the DHQ teaching hospital; suspected of having Enteric Fever, were enrolled after obtaining written informed consent. Blood samples were drawn and sent for a Culture and Sensitivity report. The purpose behind this exercise was simple; To nd out the resistance/sensitivity status of the commonly prescribed antimicrobial drugs, with a special focus on ciprooxacin. Out of our 150 respondents 62.5% (94) were male while the remaining 37.5% were females. More than a 15


quarter females became a part of this study giving our modest sample selection technique a natural stratication. The mean age of the respondents was 32.98 years with a standard deviation of +10.4 years. The age distribution of the respondents is given in the table 1 Table 1: Table showing age distribution of the respondents

Table 3: Sensitivity and Resistance patterns of the drugs Antimicrobial Agent

Sensitivity Resistance

Ampicillin

26

70

Co-trimoxazole

21

75

Chloramphenicol

37

59

Frequency

Percentage (%)

Ciprooxacin

06

90

18 – 28

60

39.6

Ooxacin

11

85

29-38

42

28.1

Levooxacin

17

79

39-48

40

27.1

Cexime

96

00

49 and above

8

5.2

Ceftriaxone

96

00

Total

150

100

Age distribution (years)

DHQ teaching hospital Rawalpindi, serves a very large and unclearly dened population. The clientele of this hospital comes from diverse landscapes and surroundings ranging from the old city of Rawalpindi to the hill tops of Azad Kashmir. Our patients belong to different ethnicities and localities. Because we serve such versatile and widely dispersed population base, our practice of medicine demands constant evidence generation in order to iteratively improve the performance standards. Based on the operational denition participants selected for this study were suspected of having Typhoid fever when two or more of the symptoms given in Table 2 were present. All of these symptoms do not essentially occur simultaneously; neither do they occur in mutual exclusion, keeping this in mind the following table gives the frequency of various symptoms seen in our participants. The Sensitivity and Resistance patterns of the various drugs of common use have been given in table 3. Table 2: Signs and symptoms Symptoms/signs

Frequency Percentage % 150

100

74

48.9

Constipation

53

35.4

Diarrhea Relative bradycardia

87

58.3

81

54.2

Rash(Rose spots)

10

7.3

Splenomegaly/Hepatomegaly

36

24

Abdominal pain/tenderness

99

66.7

Vomiting/nausea

109

73.8

Fever Headache/Neurological symptoms

The interesting fact to view in these simple details are the return of the Chloremphanicol, Co-trimoxazole and Ampicillin sensitive strains, while the high prevalence of strains resistant to Flouroquinolones is also a matter of great concern. These statistics would gather even more strength if they are gleaned simultaneously with a study on the prescription patterns of our physicians. However it is quite clear that the drugs most commonly prescribed by physicians in Public Health care delivery settings have almost completely lost their efcacy. Discussion The ndings of the present study are basically a repetition of the evidence previously generated by international scientic literature. What we believe we have done is that we have generated simple yet pertinent local evidence that will be very helpful in the operational and strategic planning in terms of clinical practice. Typhoid fever is a global public health issue with a disease burden of 27 million cases and 200,000 deaths annually (13). Our clinical practice in public sector hospitals of a developing country with questionable trends in terms of evidence based medicine often poses the conundrum of treating people on the basis of intuition, due to limited resources. This style of medical practice turns out to be cost-effective in the short run, but the way it inuences the micro-organisms that we are ghting against and the arsenal of antimicrobial drugs, is disastrous. Antimicrobial resistance is a major public health problem in both S. typhi and S. paratyphi, and timely treatment with appropriate antimicrobial agents is important for reducing the mortality associated with enteric fever (14). Resistance to the traditional rst-line antimicrobial agents; ampicillin, chloramphenicol, and trimethoprimsulfamethoxazole denes multidrug resistance (MDR) in S. enterica. The MDR phenotype has been shown to be 16


widespread among S. typhi for many years (15) and is present, although at lower rates, among S. paratyphi (16). Surveillance studies demonstrate considerable geographic variation in the proportion of S. typhi isolates that are MDR in the same region, with sites in India, Pakistan, and Vietnam having higher rates of MDR isolates than sites in China and Indonesia (17). Furthermore, longitudinal studies at the same site showed marked changes in the proportion of S. typhi and S. paratyphi. A with MDR over time, including reductions in the proportion of isolates with MDR (18). Our study has shown the same results that most participants were resistant to the above mentioned rst line agents, but did not show 100% resistance patterns. There were a large proportion of individuals who showed resistance to all rst line agents (Multi-drug resistance). Another important aspect to consider is that around 40% study participants had organisms sensitive to Chloramphenicol, this statistic is pointing towards the probable re-emergence of the Chloramphenicol sensitive strain of S. typhi in our catchment population. The wide distribution and high prevalence of MDR among Salmonella species has led touoroquinolones assuming a primary role in the therapy forinvasive salmonellosis. Some investigators have noted increases in the prevalence of S. typhi and S. paratyphi strains susceptible to traditional rst-line antimicrobials coinciding with a switch to uoroquinolones for the management of enteric fever (19). However, the widespread use of uoroquinolones has also been associated with decreased susceptibility and documented resistance to this class of drugs (20). Our study has also shown high resistance to three ourquinolones (Ciprooxacin, Ooxacin and Levooxacin). This is a very alarming trend as this is the most commonly used group of anti-microbial agents used in our setting against S. typhi. This not only raises questions regarding the changing microbial patterns in our surroundings but also about the prescription practices of our physicians. There is a lack of evidence based practice in our settings and these trends of intuition based medicine are already having repercussions. As uoroquinoloneuse continues to expand and as decreased ciprooxacin susceptibility and uoroquinolone resistance drives the use of third-generation cephalosporins and other agents for the management of enteric fever, new patterns of antimicrobial resistance can be anticipated. Literature and recent evidence is also pointing towards the

use of Gatioxacin a recent member of the ouroquinolone group, to which most strains of S. typhi are still sensitive. This drug is not in common use in our setting. Cephalosporins are now the available options (Ceftriaxone, Cexime) in our region but the threat of resistance looms over our heads due to their non-judicious and unchecked use in the present and future.

Conclusion Although no data regarding prescription practices was gathered during the course of this study, yet one can say with experience that the anti-microbial agent prescribing practices in our settings are awed and have a lot of room for improvement. Over the years many useful drugs have lost their potency due to the development of resistance by various microorganisms, owing to their non-evidence based used. Most rst line agents against S. typhi have shown the development of resistance, but the most alarming aspect is the almost complete resistance of S. typhi to Quinolones. These drugs were considered to be a fool proof remedy against typhoid fever, yet over time due to a multitude of factors and inuences they are now of limited and in some cases of no use. The study concluded following recommendations on various levels to curb this threat of anti-microbial agent resistance.

Policy Level Recommendations Evidence based policies Policy development in accordance with International and regional guidelines Greater role of motivated technocrats in policy formulation Stricter law enforcement and policy implementation Neutral policy observers and technical audits Periodic reviews of health policy with room for regular changes and improvements

Health Systems Level Recommendations Greater role of infection control committees Community awareness campaigns regarding safe and judicious use of antimicrobial drugs Stricter laws regarding over the counter sale of antimicrobial agents Improved availability of resources in terms of diagnostic and treatment facilities Regulations for private practice of Medicine Central data base development CME (Continuing Medical Education) for all medical practitioners Development of local and regional guidelines 17


Operational recommendations Use of Culture/Sensitivity instead of non-specic tests before initiating antimicrobial therapy Use of evidence based practice of medicine (International / Local guideline) Avoidance of empirical anti-microbial therapy IEC (Information, Education, Communication) material should be made freely available in hospitals and health care settings Use of hospital records data for generating local evidence Regular academic sessions for experience sharing

References Kaashif AA, Khan LH, Roshan B, Bhutta ZA. Factors associated with typhoid relapse in the era of multiple drug resistant strains. J Infect Dev Ctries. 2011; 5(10): 727-731. 2. Rahman AKMM, Ahmed M, Begum RS, Hossain MZ, Hoque SA, Matin A. Typhoid fever in children : An update. J Dhaka Med Coll. 2010; 19(2) : 135-143. 3. Rajiv K, Nomeeta G, Shalin S. Multi-drug resistant typhoid fever. Ind. J. Ped. 2007; 74(1): 39-42. 4. Jawetz M, Adelberg S. Medical microbiology, 25th edition. Prentice Hall International Inc. 2007. pp. 307314. 5. Gupta V, Kaur J, Chander J. An increase in enteric fever cases due to Salmonella paratyphi A in & around Chandigarh. Indian J Med Res. 2009; 129: 95-98. 6. Hammad OM, Hifnaway T, Omran D, Tantawi MA, Gigis NI. Ceftriaxone versus Chloramphenicol for Treatment of Acute Typhoid Fever. Life Science Journal, 2011; 8(2): 100-106. 7. Dimitrov T, Udo EE, Albaksami O, Kilani AA, Shehab el-DM. Ciprooxacin treatment failure in a case of typhoid fever caused by Salmonella enterica serotype paratyphi A with reduced susceptibility to ciprooxacin. J Med Microbiol.2007; 56 (pt. 2): 277279. 8. Zaki SA, Karande S. Multidrug-resistant typhoid fever: a review. J Infect Dev Ctries 2011; 28(5): 324-337. 9. Kariuki S. Antimicrobial Resistance in Enteric Pathogens in Developing Countries. Springer, New York; 2010, pp 177-197 10. Kumar R, Gupta N, Shalini N. Multidrug-resistant typhoid fever. Indian J Pediatr. 2007; 74(1): 39-42 11. Keddy KH, Smith AM, Sooka A, Ismail H, Oliver S. Fluoroquinolone-Resistant Typhoid, South Africa.

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18



World Health Organization diabetic care guidelines: knowledge and practices of general practitioners in private Clinics of Rawalpindi, Pakistan 1

2

3

4

Hameed Mumtaz Durrani ,Ramesh Kumar , Salma Mumtaz Durrani , Anwar-ul-Haq 1

Department of Public Health & Community Medicine, AJK Medical College, Muzaffarabad, Azad Jammu & Kashmir.2 Department of Health System and Policy, Health Services 3 4 Academy Islamabad-Pakistan. Alumni Rawalpindi Medical College, Rawalpindi, Pakistan. Alumni Health Services Academy Islamabad, Pakistan. (Correspondence to Kumar R: [email protected])

Introduction: Diabetes mellitus is growing at an alarming rate all over the world particularly in Pakistan.In 1995, Pakistan had an estimated 4 million diabetics and was eighth in the world in terms of prevalence. It is projected that by 2025, Pakistan willmove to the fourth highest prevalence with 15 million diabetics. General practitioners (GPs) constitute the back bone of any health care system and providing healthcare services to the community.The World Health Organization (WHO)has a standard of care guideline for people with diabetes which is consideredto be the 'Gold Standard'.This study assesses the Knowledge, Attitude and Practice of GPs theWHO guidelines for the management and care of diabetes mellitus in Rawalpindi city. Methods: In the study, a total of 100 medical doctors registered with Pakistan Medical and Dental Council (PM&DC) were included in the study from four towns of Rawalpindi city for interview through semi-structured questionnaires for their knowledge and practices regarding diabetics as per WHO guidelines. Data was analyzed by Statistical Package for Social Sciences (SPSS) version 17. Results: The mean age of the GPs was 43.3 years ± 5.44 (SD), mean duration of clinical practice amongst the GPs was 14.73years ± 5.48 (SD). The average daily practicing time for the GPs was 8.1 hours ± 2.1 (SD) with an average of 48 patients per GP per day. Twenty one per cent (21%) of the patients had diabetes. Most 85% of the GPs had Knowledge regarding the complication of Diabetes Mellitus (DM) and 78% had Knowledge about sign and symptoms of DM. Conclusion: Study concluded that the knowledge of GPs regarding DM was good but they were not following the WHO guidelines for treatment of DM. (Pak J Public Health 2013; 3(2): 19-22. Keywords: Diabetes Mellitus, Knowledge, General Practitioners and diabetic care

Introduction The prevalence of diabetes mellitus worldwide has increased dramatically during the past few decades. Diabetes is now one of the most common noncommunicable diseases globally. The incidence of diabetes is on the incline possibly due to afuence in certain sections of our community bringing about major changes in our eating habits and life style (1). The prevalence of diabetes for all age-groups worldwide was estimated to be 2.8% in 2000 and 4.4% in 2030 (2). In the United States, almost 8 percent of the adult population and 19 percent of the population older than the age of 65 years have diabetes (3). As a developing country, Pakistan faces many health challenges amongst which the increasing incidence & prevalence of DM is one of the most important issues to be resolved on priority basis. The prevalence of Diabetes in Pakistan is high and 12% of people above 25 years of age

suffer from the condition and 10% have impaired glucose tolerance (IGT) (4). The major risk factors identied are age, positive family history and obesity especially central obesity (5).Diabetes care centers are limited in number and are mostly concentrated in urban areas and especially in the big cities. Rawalpindi is one of the most populated cities of Pakistan. According to an estimate, there is one doctor for every 1600 patients (6).General practitioners (GPs) constitute the back bone of any health care system and they are one of the main health care providers in most countries and therefore treat the majority of patients at a primary level. A survey of GPs working in both rural and urban areas of Pakistan showed the average time spent with a person with diabetes was 8.5 minutes (7).GPs are serving a great number of populations and it was concluded in one study that GPs in Pakistan under-diagnose and under-educate patients with diabetes (8). This study was designed to explore and ascertain 19


Methods A cross sectional study was conducted by interviewing 100 general practitioners (GPs) registered with Pakistan Medical and Dental council (PMDC) practicing in Rawalpindi city from April to June 2009.The sample size was calculated by using the proportional formula (add ref). A multistage sampling technique was adopted according to the proportion of GP to population ratio (1: 1600). Initially the GPs were identied in each area through a list of GPs (with the identication numberobtained from an international pharmaceutical company)and then a simple random approach wasustilised toselect the study participants from all areas.Those GPs who had postgraduation in any medical eld and working as specialist were excluded from the study. There was no refusal reported during the data collection process. All the data collectors were trained by the Principal Investigator before the data collection. The knowledge of GPs was assessed by adapting the World Health Organization (WHO) guidelines on DM questionnaire after taking the written consent from Gps (9). Data was analyzed by Statistical Package for Social Sciences (SPSS) version 17. Institutional ethical approval was taken from ethical committee of Health Services Academy Pakistan.

Results The survey was carried on 100 private practicing general practitioners of Rawalpindi city. Table-1 shows the gender representations in the study from all four areas. The mean age of the GPs was 43.3 years ± 5.44 (SD) and range of 31 (28 – 59). Mean duration of clinical practice amongst these GPs were 14.73years ± 5.48 (SD).The average daily clinical practicing time of GPs was 8.1 hours ± 2.1 (SD) with an average of 48 patients seen daily. Of the 48 patients 10 (21%) had diabetes. From the 84 male GPs 19 (22.6%) were government employees and also having their own private clinics.. Over three quarters of the GPs 65 (77.4%) were only practicing at their private clinic.

Table 1: Gender distribution and areas of the study population. Areas and Gender of the Respondents Gender Group Total

Rawal Pothohar Rawalpindi Chaklala Town Town Cantt Cantt

Male

84

35

26

17

07

Female 16

05

06

04

01

Total

40

31

21

08

100

Figure 1 show that the majority 85% of the GPs had knowledge regarding complications of DM management and 78% had knowledge about the signs and symptoms during the diagnosis of DM. As far as treatment of diabetes mellitus is concerned 61% GPs were practicing the WHO guidelines. Few 17% of the Gps could write acceptable investigations for laboratory diagnosis of diabetes mellitus as per WHO guidelines. Above one thirds 40% of the GPs were found to provide the patient education related to life style modication and care of DM. 90 80 70

Percentage (%)

whether GPs are following the WHO guidelines for diabetes management and to what extent This is unique in terms that previous studies have assessed the knowledge and practice regarding diabetes among diabetic patients only and not among the GPs. Due to rapid increase in incidence of diabetes in Pakistan, it is required to identify the deciencies in the management of diabetes mellitus and consequently help in improving the diabetes diagnosis & management skills of the general practitioners. Finally, the study will help in formulating strategies to combat the disease in future.

60 50 40

85

78

30

61

20

40

10

17

0

Knowledge on signs and symptoms

Knowledge on laboratory Diagnosis

Knowledge about Treatment

Knowledge about complications

Knowledge on Patient’s education on DM

Figure 1: Knowledge of GPs regarding Diabetes Mellitus as per WHO guidelines Table 2 reveals that 80% of the guidelines had been followed by 22 GPs, 60% by 33, 40% and 20% by 17 GPs each. However, 5 out of the totals were not following at all. Only 6 GPs (5 males and 1 female) were found following WHO guidelines completely. Table 2: Proportion of WHO guidelines followed by the number GPs Percentage of WHO Guidelines

Number of GPs(N=100)

0% of Guidelines

5

20% of Guidelines

17

40% of Guidelines

17

60% of Guidelines

33

80% of Guidelines

22

100% of Guidelines

6

20


Source of knowledge update Regarding knowledge update about diabetes mellitus, all of the GPs were found to be interested in updating their knowledge.Just over half (54%) found updated information through pharmaceutical literature, 21% through the internet and 25% through medical journals. Only 15% of the GPs attended refresher courses (g.2).

Pharmaceutical Literature 54%

Medical Journals 25%

Internet 21%

laboratory diagnosis of diabetes. In this study, it was found that one thirds of the GPs were educating their patients about DM during their patient management. Study supported our ndings and concluded that the general practitioners fail to educate the patient about diabetes mellitus (13). Conclusions Study concluded that the knowledge of GPs regarding DM was good but they were not following the WHO guidelines for treatment of DM. This low proportion of the GPs leads much to be desired, as overall understanding of the GPs regarding this condition is very less. Overall the GPswere not diagnosing the DM patients and also not giving the health education to the patients of DM as per WHO guidelines. References 1.

Figure 2: Sources of Knowledge in GPs regarding DM This study reveals that an evenly distributed GP's clinics in the study area comprising both male and female doctors. Although having a mean age of 43 years, most of the GPs gave maximum time both to their practice and patient, with daily average consultation of 48 patients out of which 10 were diabetics. In this study, knowledge of the GPs about Diabetes Mellitus was assessed by asking them questions related to Signs, Symptoms, Laboratory Diagnosis, Treatment, Complications and education of the patient about diabetes according to WHO guidelines. It is interesting to know that a good proportion of the general practitioners have the knowledge of Signs, Symptoms and Complications of the disease. A similar study was conducted among GPs in Pakistan, where they found that the mean duration of clinical practice was 13.5 years with an average consultation of 58 patients/day and GPs have good knowledge (10). Most of the GPs rarely follow any international guidelines for managing their diabetic patients. In a study conducted on family physicians of Pakistan, it has explored and identied the need for improvement in their practices for treating and educating diabetics. There are many sources to update their knowledge but now a day many GPs get updated by the pharmaceutical literature (11). Studies also supported our ndings that GPs in Pakistan under-diagnose and undertreat the patients due to their poor knowledge on guidelines provided for different diseases (12). It is interesting to observe that the vast majority of the study participants (GPs) did not haveadequate knowledge regarding

2.

3.

4.

5. 6.

7.

8.

Sarah W, Gojka R, Anders G, Richard S, and Hilary K. Global Prevalence of Diabetes DiabetesCare. 2004; 27(5):1047-1053. Wild S, Roglic G, Green A, Sicree R, King H. Global Prevalence of Diabetes. Diabetes Care. 2004; 27(5): 1047-1053. Harris MI, Flegal KM, Cowie CC, et al. Prevalence of diabetes, impaired fasting glucose, andimpaired glucose tolerance in U.S. adults. Diabetes Care. 1998; 21:518-524. Shera AS, Raque G, Khwaja IA, etal. Pakistan National Diabetes Survey: prevalence of glucose intolerance and associated factors in Shikarpur, Sindh Province. Diabetic Medicine.1995; 12: 1116-1121. Shera AS, Jawad F, Maqsood A. Prevalence of diabetes in Pakistan. Diabetes Res Clin Pract CRCP: Patient Doctor ratio in Rawalpindi and Islamabad [online] 18 Jan 2002 [cited 2009 March 29].Available from: URL: http:// www. Patient doctor ratio in Rawalpindi and Islamabad. Shera AS, Jawad F, Basit A. Diabetes related Knowledge, Attitude and Practices of Family Physicians in Pakistan. J. Pak Med Assoc. 2002; 52: 465-470. Shahpurwala MM, Sani N, Shah S, Shuja F, Shahid K, Tariq H, et al. General medical practitioners in Pakistan fail to educate patients adequately about complications of diabetes.Practical Diabetes International. 2006; 23: 57- 61. [electronic] [cited 2008 Jan02]. Available from: URL: http://: www. Wiley Inter Science Journal Abstract.htm 21


9.

10.

11.

12.

13.

World Health Organization 2006. Guidelines for the prevention, management and care of diabetes mellitus. EMRO Technical Publication Series 32. Shera AS, Jawad F, Basit A. Diabetes related knowledge, attitude and practices of familyphysicians in Pakistan. J Med Assoc. 2002; 52(10): 465-470. Shera AS, Jawad F, Basit A. Diabetes related knowledge, attitude and practices of family physicians in Pakistan. J Pak Med Assoc. 2002; 52: 465-470. Tazeen H. J, Saleem J, Fahim H. J, Mohammad I, Raza O, Sarwar O, Andrew S, Nish C, General Practitioners' Approach to Hypertension in Urban Pakistan ; American Heart Association. 2005;111: 1278-1283. Shahpurwala MM, Sani N, Shah S, Shuja F, Shahid K, Tariq H, et al. General medical practitioners in Pakistan fail to educate patients adequately about complications of diabetes.Practical Diabetes International 2006; 23: 57-61. [electronic] [cited 2013 Sep 15]. Available from: URL: http://: www. Wiley Inter Science Journal Abstract htm.

22



Bioactivity of botanicals against Aedes aegypti Linnaeus and Anopheles stephensi Liston Larvae 1

1

1

1

1

Haz Inam-llah , Hamayun Rashid Rathor , Hazrat Bilal , Soaib Ali Hassan and Imtinan Akram Khan , 1 Tallat Anwar Faridi 1 Department of Medical Entomology and Disease vector Control, Health Service Academy, Islamabad. (Correspondence to Bilal H: [email protected]) Background: Globally plants have been reported to contain certain compounds which have insecticidal properties, especially on the larval stages of mosquitoes. Method: Some of the locally grown plants such as Olea vera (Olive), Linum usitatissimum (Linseed), Piper nigrum (Black pepper), Syzygium aromaticum (Clove) and Calotropis procera (Aak), were selected and evaluated for their larvicidal activity against dengue vector Aedes aegypti and malaria vector Anopheles stephensi mosquitoes in Pakistan. The extracts were evaluated according to WHO guidelines for larvae of mosquitoes. Results: Among the ve plant extracts, linseed had the lowest LC50(2.32%) after 24 hours of exposure while after 48 hours it had 2.32 % LC50 value against Aedes aegypti. Again linseed had the lowest LC50 value (1.1 % and 0.07 %) after 24 hours and 48 hours of exposure against Anopheles stephensi. In terms of % age mortality when population was exposed to series of concentrations (2%-10%), linseed gave high % mortality against both the tested mosquitoes' species larvae. Conclusion: The result revealed that all the 5 plant species have some larvicidal effect but linseed had great potential against both tested mosquito species. Further small scale eld trials with the extracts of the most promising ones (linseed) shall be conducted to determine operational feasibility. (Pak J Public Health; 3(2): 23-27. Key words: Mosquitoes, Plant extracts, Larvicide

Introduction Malaria, dengue, lariasis, yellow fever and Japanese encephalitis are the most important diseases spread by mosquitoes (1). Globally it is estimated that every year 243 million cases and approximately 8, 63, 000 deaths were occurred due to malaria in 2008 (2), while in EMRO region there were 5.7 million suspected cases and only one million cases were conrmed malaria cases parasitologically, 17% cases were contributed by Pakistan (3)and according to an estimate by WHO, 50 million cases of dengue occurred every year (4). In Pakistan there were an estimated 4.5 million suspected malaria cases and 59, 284 conrmed cases of malaria in 2008 (4) and in 2010, suspected cases of malaria were 3, 00000 due to ood (5). Similarly dengue epidemic in 2011 is being observed in Pakistanwith more then 22, 778 conrmed cases with 353 deaths (6). Worldwide mosquito control depends on the application of synthetic insecticides as a part of Integrated Vector Control (IVM) Programmes (7) but due to the toxic effects and resistance to synthetic insecticides, are some problems in controlling mosquitoes therefore it is necessary to develop safe alternative insecticides which required minimum care (8). Plant extracts may be the best alternative sources

of mosquito control agents as they contain bioactive compounds that are biodegradable into non-toxic products and potentially suitable for use in control of mosquito larvae. In fact, many researchers have reported on the effectiveness of plant extracts or essential oils against mosquito larvae (9). Recent studies stimulated the investigation of insecticidal properties of botanicals and concluded that they are environmentally safe, degradable and target specic (10). Muthukrishnan and Puspalatha (11) evaluated the larvicidal effects of extracts from Calophyllum inophyllum (Clusiaceae), Rhinacanthus nasutus (Acanthaceae), Solanum suratense (Solanaceae) and Samadera indica (Simaroubaceae), Myriophyllum spicatum (Haloragaceae) against Culex quinquefasciatus, Aedes aegypti and Anopheles stephensi. A number of other researchers which have used plant products for the mosquito control like scientists reported the petroleum ether extracts of Rhinacanthus nasutus, Trigonostemon reidioides,Derris elliptica, Stemona tuberose, Homalomena aromatica, Acorus calamus, Piper nigrum, Artemisia annua, Sonchus oleraceus, Chenopodium album, Solanum xanthocarpum and Argemone mexicana (12-16). In the view of increased interest in development of plant based insecticides as an alternative to synthetic 23


insecticide, this study was planned and conducted to assess the larvicidal potential of the medicinal plant against the two medically important vectors Aedes aegypti and Anopheles stephensi.

Methods Collection of Plants Seeds of olive (Olea vera L.Burm. f.), linseed (Linum usitatissimum L.), black pepper (Piper nigrum L.), clove (Syzygium aromaticum L. Merrill & Perry syn.) and aak leaves (Calotropis procera Aiton) were collected from Rawalpindi (33° 40' N, 40º 30' E) and Islamabad ( 33° 42' N, 73º 10' E). Extraction of oil The seeds and leaves were washed, then dried and later grounded in an electric grinder (Anex Germany). The grounded material was placed in thimble and kept in extraction tube of Soxhelt apparatus with extractor ID 38mm, extractor volume 85ml and ask volume 250ml for the extraction of oil by steam distillation method using ether as solvent (250 ml/20 g sample). The cycle time for one sample was 4–5 h. Solvent was evaporated at room temperature, leaving oil which was then collected (17). Preparation of Solution Stock solution was prepared by adding 1 ml of oil from each plant in 99ml of acetone and considered as 1% stock solution from which series of concentrations (%) were prepared (18). Collection and Rearing of Mosquitoes The immature Anopheles stephensi were collected from different areas of Islamabad and Rawalpindi by dipping with a standard 375ml dipper while adults were collected by mouth aspirator and CDC sweeper from cattle sheds and

Aedes aegypti were collected from tire shops with standard pipette. Larvae and adults were reared for mass population in the insectary of the Department of Medical Entomology and Disease Vector Control at Health Services Academy, Islamabad. The rst instar larvae were fed with fat free milk powder while other instars larvae were fed with chicken liver powder at 27±2 0C and 75±5% humidity. Adults were reared in steel cages by providing 10% sucrose solution while female mosquitoes werealso fed on the blood of albino rats (19). Larvicidal Bioassay The extracted oils were used in four different concentrations (2%, 4%, 6% and 8%) with three replicates for each treatment; each replicate containing 200ml of the oil solution in 250ml Pyrex glass beakers. A batch of fteen3rd instar larvae of the Aedes aegypti and Anopheles stephensi were exposed in each beaker containing oil solution (20], while control was treated with acetone only. Mortality of larvae was counted after 24 and 48 hours. The experiment was conducted under lab conditions at 27± 20C and 75± 5% relative humidity. Statistical Analysis Abbot's formula was used for corrected mortality and the data so obtained was analyzed by probit analysis (21) by using MANITAB-15 software for dose mortality regression line and %age mortality graphs were prepared by using Microsoft Origin software. Results The results of plant oils against Aedes aegypti after 24 hours (Table: 1.) revealed that linseed exhibited the lowest LC50 (5.78%) followed by aak and clove oil (7.59% and 9.71%) respectively. Black pepper and clove oil had the

Table 1: Larvicidal activity of plant extracts against 3rd instar larvae of Aedes aegypti. Botanical name

Time

LC 50*

**LFL

***ULF

Slope±S.E

X2

Reg. equation

Olive (Olea vera)

24 48

18.0 6.05

10.3 5.1

214.9 7.65

0.73±0.24 1.16±0.21

0.93 0.81

Y=0.73X -2.13 Y=1.16X -2.10

Linseed (Linum usitatissimum)

24 48

5.78 2.32

4.58 0.79

8.21 3.31

0.82±0.19 0.59±0.18

2.56 2.01

Y=0.82X -1.45 Y=0.59X -0.50

Black Pepper (Piper nigera)

24 48

17.9 14.1

11.0 8.2

153.4 298.21

1.10±0.36 0.54±0.20

6.9 5.89

Y=1.10X -3.19 Y=0.54X -1.43

Clove (Syzygium aromaticum)

24 48

9.71 6.31

7.92 4.99

15.17 9.4

1.52±0.34 0.82±0.19

2.29 8.73

Y=1.52X -3.46 Y=0.82X -1.52

Aak (Calotropis procera)

24 48

7.59 4.3

5.92 2.23

12.71 7.58

0.85±0.21 0.47±0.18

12 2.57

Y=0.85X -1.74 Y=0.47X -0.68

*LC50 i.e., lethal concentration (%age) to kill 50% population of the subjected organism **LFL = Lower ducial Limit ***UFL = Upper ducial Limit

24


highest LC50 value (18% and 17.9%) respectively. In terms of %age mortality linseed and aak oils gave 43% and 34% mortality respectively, followed by clove, olive and black pepper gave mortality less than 20% as shown in g # 1. While after 48 hours (Table # 1.) linseed had the lowest LC50(2.32%) followed by aak and olive (4.3 % and 6.05%) respectively. Black pepper and clove oil had the highest LC50 value (14.1% and 6.31%) respectively. In terms of %age mortality linseed and aak oils gave 65% and 51% mortality respectively, followed by clove, olive and black pepper gave mortality less than 40% as shown in g # 1. The results of plant oils against Anopheles stephensi after 24 hrs (Table # 2.) showed that linseed had the lowest LC50 value (1.1%) followed by aak and olive (2.18% and 3.62%) respectively. Black pepper and clove oil had the highest LC50 value (14.32% and 3.72%) respectively. In terms of %age mortality linseed and aak oils gave 80% and 70% mortality respectively, followed by olive, black pepper and clove gave almost 50% mortality as shown in g # 2. While after 48 hrs (Table: 2) linseed had the lowest LC50 value (0.07%) followed by aak and olive oil (1.3% and 1.57%). Clove and black pepper oil had the highest LC50 value (6.23% and 1.78%) respectively. In terms of %age mortality linseed and aak oils gave 94% and 78% mortality respectively, followed by olive, black pepper and clove gave almost 70% mortality as shown in gure: 2.

70

24 Hours 48 Hours

65 60 55 50 45 40 35 30 25 20 15 10 5 Piper Nigera

Linum Syzygium Calotropis aromaticum Procera usitatissium

Olea Vera

Plant Species

Fig 1: % age mortality of plant extracts against 3rd instar larvae of Aedes aegypti. independently contribute to the generation of larvicidal activities of mosquito (24). The results of ve different plant species oils are presented in Tables 1 and 2 obtained were satisfactory and establish the efcacy. Mortality increases with increase in dose of plant oil and at higher dose it gave almost complete mortality without any pupal or adult emergence. While in control, mortality was less than 5% after 48 h. Many variations in reaction to oil toxicity between the two tested mosquito species appeared. The LC50 values were low and % age mortality of oils were very high in the case of Anopheles stephensi compared to Aedes aegypti, these variations are not abnormal. Minijas and Sarda, however, showed that crude extracts containing saponin from fruit pods of Swartzia madagascariensis produced higher mortality in the larvae of Anopheles gambiae than in the

Discussion Due to the development of resistance to synthetic insecticide (22), residue problems in the environment and toxic effect on humans and non-target organism, investigators now direct their attentions towards the development of new plant based insecticide. Various compounds, including phenolics, terpenoids, and alkaloids, exist in plants (23) and may jointly or

Table 2: Larvicidal activity of plant extracts against 3rd instar larvae of Anopheles stephensi. Slope±S.E

X2

Reg. equation

4.47 2.57

0.90±0.19 0.54±0.19

3.54 1.94

Y=0.90X -1.16 Y=0.56X -0.24

0.08 0.02

1.95 0.10

0.62±0.20 0.38±0.28

8.1 3.75

Y=0.62X -0.05 Y=0.38X+1

3.72 1.78

2.14 0.91

5.22 2.42

0.58±0.18 0.94±0.21

1.93 3.76

Y=0.58X -0.76 Y=0.94X -0.54

24 48

14.32 6.23

7.81 3.94

4595.4 65.61

0.45±0.19 0.41±0.18

2.83 2.35

Y=0.45X -1.22 Y=0.41X -0.76

24 48

2.18 1.3

1.08 0.15

2.95 2.19

0.77±0.19 0.60±0.19

4.01 4.39

Y=0.77X -0.60 Y=0.60X -0.16

Botanical name

Time

LC 50*

LFL

Olive (Olea vera)

24 48

3.62 1.57

2.71 0.16

Linseed (Linum usitatissimum)

24 48

1.1 0.07

Black Pepper (Piper nigera)

24 48

Clove (Syzygium aromaticum) Aak (Calotropis procera)

ULF

*LC50 i.e., lethal concentration (%age) to kill 50% population of the subjected organism

25


70

other plant extracts should be investigated for the control of mosquitoes under eld conditions.

24 Hours 48 Hours

65 60 55

References

50

1.

45 40 35 30

2.

25 20 15 10

3.

5 Piper Nigera

Linum Syzygium Calotropis aromaticum Procera usitatissium

Olea Vera

Plant Species

Fig 2: % age mortality of plant extracts against 3rd instar larvae of Anopheles stephensi. larvae of A. aegypti, and no mortality was induced in the larvae of Culex quinquefasciatus (25). While our study is not t with the study of Novak that anophelines were less sensitive than aedines when assayed to plant extracts (26). According to our ndings black pepper had some potential but not so much as linseed does as describe by Nath 2006, the effectiveness of black pepper against Aedes albopictus and Culex quinquefasciatus (27).There was less effectiveness of black pepper when compared with other tested plant extracts against the adults of Aedes aegypti (28). Similar studies have been reported that plant extracts can be highly toxic to mosquitoes like Sarita et al. (2010) traced out larvicidal potential of three species of peppercorns against larvae of Ae. aegypti. These extracts were effective in terms of LC50 and larvae shows abnormal behavior after its application. In another study, the oil of menthe, sativa and Melissa against the larvae of Culex pipens and its constituent piperiten one oxide was the highly active with LC50 value (29, 30). Patrícia 2010, reported the 94 plant extracts against Ae. aegypti as larivicide and six plant species (Coccoloba mollis, Guettarda grazielae, Merremia aegyptia, Rourea doniana, Spermacoce verticillata and Triplaris americana) shows 100 % mortality and shown good results against medically important mosquitoes (31).

4. 5.

6. 7.

8.

9.

10.

11.

12.

Conclusion

13.

Our results indicated that out of the 5 plants linseed oil has good larvicidal potential against both species but more effective against larvae of An. Stephensi then Ae. aegypti in terms of Lc50 and % age mortality as shown in tables and graphs. So we suggest that Linseed extracts as well as

14.

Rozendaal JA. Vector Control - Methods for Use by Individuals and Communities. Geneva. 1997. World Health Organization. World Health Organization. Dengue and dengue haemorrhagic fever. Geneva. 2009. (Fact sheet N°117). World Health Organization. World Malaria Report. Geneva, 2010, pp 54. World Health Organization. World Malaria Report. Geneva, 2009. (ISBN 978 92 4 156390 1). Anonymous (Pakistan Malaria Cases. http://www.defence.pk/forums/current-events-socialissues/76348-u-n-says-300-000-pakitan-malariacases-html, accessed 29 October 2010). Anonymous, Weekly epidemiological report. 2011; 2(45): 1-6. Becker N, Dusan P, Marija Z, Clive B, Minoo M, Christine D, et al. Mosquito and their Control, 2nd edition. Published by Springer.2010. (ISBN 978-3540-92873-7). Pp: 442, 443. Mittal PK, Subbarao SK. Prospects of using herbal products in the control of mosquito vector. ICMR Bulletin. 2003; 33:1–10. Rahuman AA, Geetha G, Venkatesan P, Kannappan G. Isolation and identication of mosquito larvicidal compound from Abutilon indicum (Linn.) Sweet. Parasitol Res. 2008; 102(5):981– 988. Govindarajan M, Jebanesan A, Pushpanathan T. Larvicidal and ovicidal activity of Cassia stula Linn. Leaf extract against larial and malarial vector mosquitoes. Parasitol Res. 2008;102: 289–292. Muthukrishnan J, Puspalatha E. Effects of plant extracts on fecundity and fertility of mosquitoes. J Applied Entomol, 2001; 125:31–35 Komalamisra N, Yuwadee T, Yupha R, Chamnarn A. Screening for larvicidal activity in some Thai plants against four mosquito vector species. Southeast Asian J Trop Med Public Health. 2005; 36(6):1412–1422. Siddiqui BS, Gulzar T, Mahmood A, Begum S, Khan B, Afshan F. New insecticidal amides from petroleum ether extract of dried Piper nigrum L. whole fruits. Chemical Pharmaceutical Bulletin. 2004; 52 (11):1349–1352. Sharma P, Mohan L, Srivastava CN. Phytoextract26


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induced developmental deformities in malaria vector. Biores Technol. 2006; 97(14):1599–1604. Mohan L, Sharma P, Srivastava CN. Evaluation of Solanum xanthocarpum extracts as mosquito larvicides. J Environ Biol. 2005; 26(2):399–401. Sakthivadivel M, Thilagavathy D. Larvicidal and chemosterilant activity of the acetone fraction of petroleum ether extract from Argemone mexicana L seed. Biores Technol. 2003; 89 (2):213–216. Vogel AI. Text Book of Practical organic Chemistry. The English language Book Society and Longman, 1978 London. Akram W, Haz AAK, Faisal H, Hazrat B, Yeon KK, Jong-Jin. Potential of citrus seed extracts against dengue Fever mosquito, Aedes albopictus (skuse) (Culicidae: Diptera). Pak J Botany. 2010; 42(4): 33433348 World Health Organization. Manual on practical Entomology in Malaria, part II. Methods and Techniques. Geneva. 1975 Pp: 165-172. World Health Organization. Guidelines for Laboratory and Field testing of Mosquito larvicides. Geneva 2005 (WHO/CDS/WHOPES/GCDPP/2005.13). Capinera JL. Encyclopedia of Entomology. Published by Springer. 2008 (ISBN: 978-1-4020-6242-1). Pp: 2. Khan HAA, Waseem A, Khurram S, Shaalan EA. First report of eld evolved resistance to agrochemicals in dengue mosquito, Aedes albopictus (Diptera: Culicidae), from Pakistan. Parasites & Vectors. 2011; 4:146-156. Kim SI, Shin OK, Song C, Cho KY Ahn YJ. Insecticidal activities of aromatic plant extracts against four agricultural insects. AgricChemBiotechnol. 2001;44:23-26. Hostettmann K Potterat O. Strategy for the isolation and analysis of antifungal, molluscicidal, and larvicidal agents from tropical plants. In Phytochemicals for Pest Control, Hedin, P. A., Hollingworth, R. M., Masler, E. P.,Miyamoto, J. and Thompson, D. G. (eds.), 1997. ACS Symp. Ser. No. 658, pp. 14-26, Am. Chem. Soc., Washington D.C., USA. Minijas J, Sarda RK. Laboratory observations on the toxicity of Swartzia madagascariensis (Leguminosae) extract to mosquito larvae. Trans R Soc Trop Med Hyg. 1986; 80:460–461 Novak D. Nonchemical approaches to mosquito control in Czechoslavakia. In: Laird M, Miles JW (eds) Integrated mosquito control methodologies, vol 2. 1985. Academic, San Diego, pp 185–196

27. Nath DR, Bhuyan M, Goswami S. Botanicals as Mosquito Larvicides. Defense Sci J. 2006; 56(4):507511 28. Chaiyasit D, Wej C, Eumporn R, Udom C, Prasong C, Atchariya J, Pongsri T, Doungrat R, Benjawan P. Essential oils as potential adulticides against two populations of Aedes aegypti, the laboratory and natural eld strains, in Chiang Mai province, northern Thailand. Parasitol Res. 2006; 99:715–721 29. Sarita K, Radhika W, Naim W. Larvicidal potential of ethanolic extracts of dried fruits of three species of peppercorns against different instars of an Indian strain of dengue fever mosquito, Aedes aegypti L. (Diptera: Culicidae). Parasitol Res. 2010; 107:901–907. 30. George K, Danae P, Elias K, Antonios M, Olga T. Chemical composition and larvicidal evaluation of Mentha, Salvia and Melissa essential oils against the West Nile virus mosquito Culex pipiens. Parasitol Res.2010; 107: 327–335. 31. Patrícia V, Jesu C, Ferreira Jr, Fabyanne S, Moura GS, Lima FM, et al. Larvicidal activity of 94 extracts from ten plant species of northeastern of Brazil against Aedes aegypti L. (Diptera: Culicidae). Parasitol Res. 2010; 107:403–407.

27


Review


Morbidity Patterns in Pakistan: Evidence from Pakistan Panel Household Survey 2010 1

Imran Bari , Nayyar Abbas

2

1

MAARK Pharmaceuticals (Pvt) Ltd, 2Alumni Pakistan Institute of Development economics, Islamabad (Correspondence to Bari I: [email protected]) Introduction: With recent information available on the disease status of population the current study explores the morbidity patterns among different subgroups of population and observes what type of diseases are common among children, adults and of the older ages in Pakistan. Methods: Data source for analyses in this study is taken from Pakistan Panel household survey. This survey was conducted in year 2010 with a sample size of 4142 households, 1342 in urban and 2800 rural. The current study uses the sample of population reported ill to be around 8177 in all age groups. Results: High proportion (27%) reported ill with almost 30% females and 25% males respectively. Age group 60+ is the most prevalent in disease with high level of morbidity among females ranging from ages 10 and above. Most commonly reported disease was fever and majority was reported in the younger age groups. The older segment of the population reported degenerative diseases like diabetes, heart problems and renal/kidney problems. Conclusions: Diseases were found to be more prevalent among the age groups of 0-4, 30-59 and 60+, indicating high levels of morbidity and especially among females. High incidence of illness were reported by males in the younger age groups of 0-4 and 5-9.These are the only ages where males have shown high morbidity rates than their females counter parts thus reecting the poor health status of females overall. (Pak J Public Health; 3(2): 28-34. Key Words: Health, Morbidity Patterns, and Pakistan

Introduction Health is undoubtedly a basic requirement and an important factor of human life. Good health reects reduced morbidity levels as well as decreasing the burden of diseases in a population. Improved health status has positive implications for the social and economic well being of a population. It is a well-established fact that an enhanced health not only reduces the mortality, morbidity, fertility levels but also adds to increased productivity, as fewer workdays are lost due to illness, thus having an economic uplift (1).In order to achieve efcient and productive human resource it is of central importance to invest in health (2). Pakistan has a fast growing population and has the highest rates of fertility, infant, child and maternal mortality when compared with its neighboring countries. This is not to deny the fact that over the years, Pakistan has shown considerable improvement in some of the health indicators but on a whole, it still lags far behind the desired levels (3). In terms of the total burden of disease, (BOD) Pakistan is almost in the middle of epidemiological transition having a double burden of disease (having both communicable and non-communicable diseases) (4). Almost 40% of the total burden of disease accounts for the

communicable/ infectious diseases mostly affecting the children, including respiratory diseases, diarrheal diseases, tuberculosis, malaria and childhood cluster (measles, pertussis and polio). Another 12% is due to reproductive health problems and certain nutritional deciencies. The remaining major bulk of 40% is of the noncommunicable/degenerative diseases common in old age population, including cardio-vascular diseases, diabetes, cancers and other non-communicable diseases (2, 5).

Methods Data source for analyses in this study was taken from Pakistan Panel household survey. Pakistan Institute of Development Economics conducted this survey in year 2010 with a sample size of 4142 households, 1342 in urban and 2800 rural. Two separate questionnaires were used male and female, the section of health was included in female section for the detailed information on disease status and related behavior of each member (children and adults) in the household. The logic for asking from females about the health status of the household members was that, it is generally the female member of the house who attends to the sick, as they have a less participation in work outside the home. The current study used the sample of population 28


reported ill to be around 8177 in all age groups. The data analysis on research is based on bivariate analysis using percentages for analysis and assessment of the disease prevalence and patterns by sex/age. These percentages gave a detailed and useful view into each issue, which is being examined in the study. SPSS was used for this research where frequencies cross tabulation and graphs were run.

Table 1: Percentage of Population Reported ill by Sex and Age Group Age Groups

Male

Female

Both Sexes

0-4

35.5

32.1

33.8

5-9

22.7

19.2

21.0

10-19

15.1

16.8

15.9

Results

20-29

15.6

26.6

20.6

About 27.6% of the population reported to be ill during the past 12 months preceding the survey (results from PPHS, 2010). For males, this proportion is about 25% and for females 30.6%. This signies that the morbidity rates of 276 per 1000 population, 250 for males and 306 for females. These ndings and estimates seem to be a bit higher as these percentages include injuries and disabilities as well. When compared with other similar morbidity surveys, the morbidity rates are higher, the reason lies in the reference period as only two weeks prior to survey were taken for reporting illness and PSES 2001 did not collect data on injuries and disabilities. A useful view of illness can be made by observing age/sex patterns.

30-59

29.2

43.2

36.1

60+

58.4

60.0

59.1

All

24.9

30.5

27.6

Total (N)

15488

14230

29718

Patterns of Disease/Injuries by Age and Sex: A broad view of Morbidity by age group is given in the gure 1, a U-shaped morbidity pattern was be observed among the different age groups with illness highest in the older 70

Morbidity Pattern

Percentages

60 50 40 30 20 10 0 0-4

5-9

10-19

20-29

30-39

40-49

50-59

60+

Age Groups

Source: Original data of Pakistan Panel Household Survey 2010.

Figure 1: Morbidity by Age Groups

A view of illness by age and sex are given in the table 1. The age differentials show that the illness is highest among the age group of 60+ that is almost 59% then age group of 30-59 and age group of 0-4 in descending order for percentage of illness. Pakistan like many developing countries has shown high incidence of morbidity and mortality among children between ages 0-4 and the aged population (1), almost similar results can be observed with the exception of the morbidity rates of age group 30-59 (36%). The reasons


can be the type of diseases explored in this survey as many diseases are of old ages (types of diseases discussed in the next section of the paper) and the inclusion of injuries as they also may be endured by population in older ages. It can be observed in table 4 that the percentages of females reported ill are higher than males in the ages from 10 above reective of the poor health status of females. This can also be due to higher rates of reproductive health problems, post-menopausal health issues faced by females in these ages. Other sources have identied similar scenario, as reproductive health issues (6) attribute out of the total burden of diseases in Pakistan is 12%. Maternal issues are relatively common in Pakistan and disease among 20-59 age groups because of high number of childbirths that could lead to under nourishment, in turn increasing the morbidity rates in these ages. The biological advantage of females over males is reected in the table-1 especially among children < 10 years of age, as fewer females were reported ill as compared to male children. The reporting biases cannot be ruled out particularly the gender preference values in Pakistan as male sick child is immediately identied resulting in higher reporting of male children (1,7). In Pakistan and other countries of South East Asian region women suffering from illnesses are less frequently reported for treatment than men are (8). Research suggests that in older ages males are more venerable to degenerative diseases thus increasing the morbidity rates (1). Major illness and their Patterns The percentage distribution of population reported ill by the type of diseases among different age groups for both females and males are given in the table 2. Larger portion 29


of population suffered from fever (40%) followed by the group of unspecied diseases (others), which account for 20%. As signicant proportion reported to be ill with fever this can be due to respondent's perception of fever as disease with diagnosing as a specic type of disease that has symptoms of fever. Almost 10% of the population reported to be suffering from heart diseases including the problems of blood pressure. It may be observed that fever is more common among the younger age groups; these results are expected considering a situation in Pakistan where there is high morbidity and mortality in children. The population reported ill by the unspecied diseases needs to be further probed as information on these diseases would give important insight into disease patterns and types. Furthermore, Table 2 does not show major differentials in illness status between males and females expect for fever (higher for males), heart problems and reproductive health problems (affecting females more). As expected with other types of illnesses heart problems, cataract, diabetes and renal/kidney problem are the diseases of old age and similar results are shown in the table5. Heart diseases and diabetes account for almost 11% of the total burden of diseases in Pakistan (6), further women in Pakistan have a greater burden of heart diseases than men (9). Interestingly in this data, almost similar results are displayed as 11.2% females have heart diseases compared to 9% in males. Tuberculosis is another important disease as 2% of the population reported to have TB, in context of developing countries especially in the South East Asian region TB accounts for 3.5% of total Disability Adjusted Life Years or DALY's lost (10). Information of permanent disabilities and their percentage distribution is given in the table 3. The nature and severity of disease can be assessed by the duration of illness (number of days ill with disease) table 4 shows the percentage distribution of reported ill by duration of illness. Almost 54% of the population reported to be ill for more than 15 days. This indicates that about half of population has serious illnesses of longer duration, while the rest remain ill for shorter periods. One reason can be due to the diseases as most of them are non-communicable, degenerative diseases and tend to affect the population for longer periods. Fever is the only disease among other illness groups where almost 60% of population had that disease for less than 7 days. As majority of the diseases affected the ill

Table 3: Percentage Distribution of Population Reported ill by Disability Percentage

N 11

Deaf

5.7 2.6

Mute

5.2

10

Loss of limb

8.9

17

Lame

10.0

19

Paralysis

20.0

38

Mental

20.5

39

Other

26.8

51

Total

100

190

Disability

Blind

5


population for longer periods, it would be worthwhile to examine these illnesses in detail, especially for younger segment of the population. Table 5 reports the percentage distribution of diseases affecting the population for 90 and more days (chronic illnesses) by age groups. The age groups of 30-59 has the major bulk of disease (43%) followed by the age group of 60+ with higher proportions reporting with diabetes, heart problems, reproductive health problems and intestinal problems. Reproductive health problems tend to affect the ill population for long periods especially in the age groups 2029 and 30-59 with 30% and 54 % respectively. Furthermore fever majorly affects the age group of 0-4 and 30-59 indicating that it may be caused by chronic or long duration diseases, calling for a further probe into the matter. The intensity and severity of these diseases can also be assessed by the episode of the diseases. Table 6 details into the number of episode of each disease; almost 69% of all diseases had only one episode during the 12 months preceding the survey. As said earlier the diseases studied in the current study are mainly of old age affecting the patient permanently and usually have one episode that is why most of the diseases have one episode. Two and more episode was reported by relatively small proportion of population, among the group of four and more episodes fever has the largest percentage (13%). The denition of illness, questions on illness and respondent's perception of illness and the reference periods can vary from one survey to another, so comparing the results of these surveys has its limitations. Keeping in view of limited population based morbidity data these comparisons were made in the current study.

30


Table 2: Percentage Distribution of Disease by Age and Sex Age Groups Sex

0–4

5–9

10 – 19

20 – 29

30 – 59

60+

All Ages

3.5 2.3 2.9

2.2 2.8 2.4

2.9 2.0 2.5

2.5 3.0 2.8

3.7 3.1 3.4

7.5 4.9 6.5

4.3 3.4 3.9

1.5 1.3 1.4

2.9 2.1 2.5

3.1 2.8 3.0

2.4 1.7 2.1

1.5 1.3 1.4

2.7 2.3 2.5

2.5 2.8 2.6

1.8 1.9 1.8

40.8 37.9 39.4

25.1 23.6 24.4

15.3 12.1 14.2

40.0 39.4 39.7

6.4 6.6 6.5

15.0 17.0 16.2

22.5 27.3 24.2

9.1 11.2 10.2

2.0 0.8 1.4

1.3 1.3 1.3

1.3 1.1 1.2

1.2 1.0 1.1

1.3 0.6 0.9

2.7 3.0 2.8

1.1 0.8 1.0

8.3 12.2 10.2

4.2 6.5 5.5

0.5 0.7 0.5

2.7 4.7 3.7

4.9 6.6 5.7

5.1 6.4 5.8

2.3 2.3 2.3

3.7 4.6 4.2

0.1 -

0.1 0.1 0.1

0.1 0.2 0.1

0.4 0.2 0.3

4.4 4.5 4.5

5.4 4.6 5.0

4.6 4.6 4.6

3.7 3.5 3.6

0.1 0.5 0.3

4.2 5.5 5.3

15.1 9.8 9.0

3.2 3.1 3.1

21.9 19.6 20.8

22.7 22.8 22.9

23.6 22.6 23.2

20.1 20.7 20.4

1.3 1.2 1.2

2.5 2.5 2.5

1.8 1.6 1.7

Injury Male Female Both Sexes

1.3 1.2 1.2

2.9 2.6 2.7

3.8 2.8 1.7 1.8 2.8 2.3 Respiratory Problem

Male Female Both Sexes

5.5 3.6 4.5

4.0 4.6 4.3

2.3 2.7 2.5


1.3 1.3 1.3

2.4 0.8 1.6

2.1 1.3 1.7


0.3 1.0 0.6

0.8 1.7 1.2

1.1 1.8 1.5


66.6 67.5 67.0

68.7 71.6 70.1

58.0 54.0 56.0


0.6 0.6 0.6

0.5 0.5


0.6 0.6 0.6

1.0 0.2 0.6


0.3 0.1

0.8 0.5 0.6


-

-


2.5 1.5 2.0

2.4 1.1 1.8

3.7 4.5 4.1


2.0 0.3 1.2

0.5 0.2

0.1 0.8 0.5


0.5 0.3 0.4

1.3 0.5 0.9

3.3 4.2 3.8


-

-

0.5 0.1 0.3


16.9 20.4 18.7

11.8 14.1 12.9

16.7 19.2 17.9


0.8 1.0 0.9

2.4 1.7 2.0

TB

Intestinal Problem

Fever

Heart problem/BP 2.5 1.7 2.1 Mental illness 0.5 1.3 0.9

Cataract / other sight problem 0.6 0.6 0.6

0.3 1.0 0.6

Reproductive health problem 1.5 3.0 2.2 Jaundice / hepatitis

Measles

Renal / Kidney Problem

Diabetes

Others

Permanent Disability 2.5 2.3 2.4

1.8 2.2 2.0


31


Table 4: Percentage Distribution of Disease by Days of illness LESS THAN 7 DAYS

8-14 DAYS

15 DAYS+

TOTAL

N

Injury

15.1

14.2

70.5

100

204

Respiratory problem

19.2

10.4

70.

100

318

TB

6.5

1.1

92.2

100

161

Intestinal problem

11.5

11.5

76.9

100

154

Fever

59.5

20.8

19.5

100

3239

Heart problem/BP

12.5

3.4

83.9

100

833

Mental illness

3.3

2.2

94.3

100

91

Cataract / other sight problem

23.4

1.2

75.3

100

83

Reproductive health problem

16.5

6.7

76.6

100

312

Jaundice / hepatitis

8.1

4.9

86.8

100

344

Measles

28.0

16.0

56.0

100

25

Renal / Kidney problem

11.6

5.9

82.3

100

300

Diabetes

8.8

1.9

89.1

100

255

Others

21.7

7.6

70.6

100

1668

Permanent Disability

7.2

2.2

90.6

100

190

Total

33.0

12.1

54.8

100

8177

DISEASES


Table 5: Percentage Distribution of Disease byDays ( DISEASES

90) of Illness (Chronic Diseases) AGE GROUP 20-29 30-59

0-4

5-9

10-19

60+

Total

Injury

3.7

5.0

15.1

15.1

Respiratory problem

10.3

4.9

8.1

TB

8.3

4.8

Intestinal problem

4.2

Fever

(N)

36.7

24.0

100

79

10.3

32.2

33.8

100

183

13.9

10.4

39.8

22.3

100

143

2.1

8.4

10.5

48.4

26.3

100

95

26.2

9.3

17.2

14.7

22.6

9.7

100

278

Heart problem/BP

1.0

0.3

2.7

7.0

52.0

36.7

100

655

Mental illness

8.6

6.1

9.8

16.0

40.7

18.5

100

81


1.9

-

7.6

11.5

21.1

57.6

100

52


-

-

11.2

29.4

53.9

4.3

100

139


6.1

1.9

15.4

18.5

47.4

8.4

100

259

Measles

14.2

14.2

14.2

-

28.5

28.5

100

7


1.9

2.8

10.0

14.8

48.3

22.0

100

209

Diabetes

-

-

1.7

1.7

54.6

41.7

100

225

Others

8.2

4.7

11.1

13.6

40.9

21.1

100

922


7.2

11.2

19.2

17.6

23.2

21.6

100

125

All

6.7

3.6

9.8

12.5

42.7

24.4

100

3252


32


Table 6: Percentage Distribution of Population Reported ill by Number of Episodes of Each Disease Type DISEASES

1 - Episode 2 - Episodes

3 - Episodes

4 - Episodes

Total

N

Injury

82.8

5.3

4.4

7.3

100

204

Respiratory problem

75.1

7.2

4.7

12.8

100

318

TB

87.5

3.1

0.6

8.6

100

161

Intestinal problem

74.6

9.7

3.8

11.6

100

154

Fever

48.4

22.3

16.0

13.1

100

3239

Heart problem/BP

86.6

2.6

2.4

8.2

100

833

Mental illness

84.6

1.0

3.2

10.9

100

91


81.9

6.0

7.2

4.8

100

83


80.1

6.4

5.1

8.3

100

312


88.3

6.1

0.5

4.9

100

344

Measles

82.0

0

12.0

16.0

100

25


82.3

4.3

5.6

7.3

100

300

Diabetes

90.1

1.9

1.1

6.6

100

255

Others

78.0

5.0

5.6

11.2

100

1668


82.8

2.8

4.2

10.0

100

190

Total

68.46

11.7

8.8

10.9

100

8177


Conclusions Based on the data from Pakistan Panel Household Survey 2010, this study explored the incidence of disease among population by age and sex. Almost 27 percent of the population reported ill 2010 prior to survey and this percentage is higher for females around 30 percent with males exhibiting about 25 percent. Disease seems to be more prevalent among the age group of 60+, indicating high levels of morbidity and especially among females. High incidence of illness were reported by males in the younger age groups of 0-4 and 59.These are the only ages where males have shown high morbidity rates than their females counterparts reecting the poor health status of females. Most commonly reported disease was fever and majority was reported in the younger age groups. As expected, older segment of population suffered from degenerative diseases like diabetes, heart problems and renal/kidney problems. Almost 55% of Surveyed population reported that they fell ill for 15 days and more.43% of the ill population reported to be still suffering from illness/diseases, that are almost 13% of the total survey population indicating a signicant percentage of burden of diseases. Health is a neglected sector in Pakistan comprises of underfunded public health sector, which are

concentrated in urban centers, and an expensive private health sector, making it out of reach for many. Poverty coupled with illiteracy, weak health system, poor standards of sanitation, cultural and social beliefs has lead high incidence of morbidity among population thus making Pakistan one of countries with double burden of disease. Improvement in the morbidity and health status of Pakistan can be made by promotion of both preventive and curative health services. Focusing these interventions to the sub groups of population having high levels of morbidity the much-needed improvement in health status can be achieved. References 1.

2.

3. 4. 5.

Mehmood N, Ali M.The Disease Pattern and Utilization of Health Care Service in Pakistan. The Pakistan Development Review. 2002;41(2):745–757 Akram M, Jehangir F. Health Care Services and Government Spending in Pakistan. PIDE Working Papers. 2007. Pakistan Economic survey 2009-10 World Population Data Sheet, Population Reference Bureau. Washington, DC. 2010 World Bank. Pakistan Poverty Assessment, Poverty in Pakistan: vulnerabilities, social gaps, and rural 33


dynamics. Poverty Reduction and Economic Management Sector Unit South Asia Region 2002. 6. Pakistan Economic survey2007 -08 7. Ali M. Gender and Health Care Utilization in Pakistan. T h e P a k i s t a n D e v e l o p m e n t R e v i e w. 2 0 0 0 ; 33(4):759–771. 8. Shaikh BT, Hatcher J.Health seeking behavior and health services utilization trends. National Health Survey of Pakistan: what needs to be done? J Pak Med Assoc. 2007; 57(8): 34-40. 9. Pakistan Medical Research Council National Health Survey of Pakistan—Health Prole of the People of Pakistan. Islamabad: Pakistan Medical Research Council 1998 10. Murray CJ. The Global Burden of Disease 2000 project: aims, methods and data sources. Harvard Burden of disease unit National Institute on aging grant.2001.

34


Review


Socioeconomic and demographic dynamics of Birth Interval in Pakistan 1

2

Nayyar Abbas , Irum Shaikh , Imran Bari 1

3 2

Pakistan Institute of Development Economics, Waseela-e-Sehat, Benazir Income Support Program, 3 MAARK Pharmaceuticals Pvt. Ltd. (Correspondence to Abbas N [email protected]) Introduction: There are many socio-economic and demographic variables such as (education level of parents, age at marriage, present age of women, parity of women, age differences between spouses, family income, son preference, gender relations, family planning education, infant mortality, sex of the previous child, survival status of previous child) which plays a momentous role in birth spacing. Methods: For this study the Pakistan Demographic and Health Survey 2006-2007 to nd the relationship of these factors with birth interval. This study uses simple median of months of succeeding (subsequent) birth intervals for analyses and assessment of birth spacing practices. Results: We have found that in younger women interval between births are longer than older women, also women with secondary and higher education and those belong to urban areas tend to space birth more widely. Employed couple get interval for rst birth between 27-31 mean months. While if the couple is unemployed then interval going to decrease between 27-29 months. There is no signicant difference between the employed and unemployed women. In this data the interesting point is to be noted that non-user of more and contraceptives has longer interval then users. Conclusions: The study found that socio-economic and demographic variables on birth interval are showing almost same results on all birth order seven by using median (month intervals),do not show any signicant results. This could be because of data limitations as data in Pakistan Demographic and Health Survey (PDHS) is collected birth-to-birthand not pregnancy-to-pregnancy so they do not take into account if there were any wastage of pregnancy or miscarriages. (Pak J Public Health 2013; 3(2): 35-39

Introduction Birth and pregnancy histories and marriage have been used by researchers to study fertility behavior of women. Birth history analysis undoubtedly provides useful information about reproduction and family formation. Fertility depends not only on the decisions of couples but also on many socioeconomic, demographic and healthrelated as well as tradition-related factors (1).These factors have also effects on child spacing. Thus birth intervals experienced by women may reveal some insights about their reproduction patterns. Thegap (in months) between two consecutive births is birth interval. A detailed analysis of the sequence of steps in the childbearing process could provide a more comprehensive picture of the dynamics of birth intervals (2).Pakistan with its fast growing population, high rates of fertility, low age at marriage and contraceptive use, less female education and employment, has poor socio-economic and demographic indicators compared to its neighboring countries. Over the years, Pakistan has not shown any considerable increase in birth spacing according to different surveys, contrary to the trend found in the neighboring countries (3).

Methods The data source for this study is the Pakistan Demographic

and Health Survey, (PDHS) 2006-2007, which was conducted by the National Institute of Population Sciences (NIPS). PDHS (2006-07) is the largest household based survey ever conducted in Pakistan. 972 sample points were visited across Pakistan and data were collected from a nationally representative sample of over 95000 households. There were 10023 ever married women in this s u r v e y. T h e s e w o m e n w e r e a s k e d a b o u t t h e i r demographic, health and social status. The main objectives of the survey were to provide state level estimates on fertility, family planning practices, infant and child mortality, reproductive health and child health, nutrition of women and children, and quality of health and family welfare services. For this study the section on female birth history that has the detailed information on fertility status and related behavior of each female. From female's birth history the detail information about the fertility related pattern of females in PDHS. There are various ways of measuring birth intervals: inter-pregnancy intervals, interbirths, and birth-to-conception intervals. In PDHS can be obtained, birth interval is calculated by duration between two births. The type of interval used depends on the issue being studied. Inter-birth intervals, or the duration between 35


two succeeding births, using the data from the birth history was calculated. This study uses median of months of succeeding (subsequent) birth interval for analysis and assessment of birth spacing practices. The present paper gives median birth intervals to have an insight into fertility behavior of women in Pakistan. Median is preferred over mean because medians are less sensitive to extreme scores and are probably a better indicator. Median is the middle with 50% of values above and 50% below it. When the data is not symmetrical, this is the form of 'average' that gives a better idea of any general tendency in the data. Means are the arithmetic average and are often used with larger sample sizes. The mean depends on the actual values in a data set, but the median is dependent only on the relative position of the values. Changing one data value does not affect the median, unless the data value is moved across the middle of the data set. But every change in a data value affects the mean. Thus, the mean is affected by a few extremely large or extremely small values outside the range of the rest of the data, but the median is not.

Results The dynamics of fertility performance can be understood better in term of birth spacing than by the other conventional indicators. Many economic, social and demographic factors are deeply related with birth interval. Table-1 shows some socio demographic variables which are consider to be related to birth intervals. As the discussed in table-1, age at marriage has negative impact on the birth intervals. If a women get married in younger ages then they have long intervals, but if she gets married at older age, like thirty or thirty ve, then she tend to complete her family quickly (4). In Pakistan, majority of women do not have rst birth until their twentieth birthday (PDHS, 1990-91) (5)and same is the case according to (PDHS, 2006-07). The birth of child before the age 15 is uncommon. There are many reasons of it like age at marriage in increasing over the time due to increase in education attainment among males and females, marriage of both sexes should not be under 18 is restricted by law (4). Parental educational status has positive impact on birth intervals, with higher the levels of education longer the interval (6). Province and type of residence can also affect birth intervals as the different ethnic groups in Pakistan have different intervals. Intervals for the birth by the wealth status generally show that rich women have longer intervals than poor women but the results in this study show reverse outcomes. Employment statuses of the parents

have negative impact on the intervals because employed parents have longer intervals than unemployed parents. Sex of the last child and last child's survival status can also affect the next child intervals and this study shows presence of sex preference. Table 1, shows Median intervals between births for the 1st parity to 8th parity. Females are giving 21 median month's interval at 1st and 24 median month's interval at 2nd birth. There is no difference in median months interval has observed in remaining birth orders. As the age at marriage increases the median interval decreases as aged women have short intervals, this can be because they are approaching the end of their reproductive span. Results show that for all age groups (10-30+) median interval shows some variation only at rst order births and there is a decreasing trend in median intervals between births by increasing in the age at marriage. For all other births almost the same results for all age groups are found little with a variation seen in the last age group (30+). For the educational attainment of the mother was notice that illiterate women have 22 median months while at the graduate level it is 15 months for the rst order child in all age groups. Highly educated women have long intervals for the succeeding births, for second and third births 24 and 28 median interval respectively, while the uneducated women giving 25 median intervals at the rest of all the birth (7). In the provincial difference, the median interval is longer in the Baluchistan, which is 24 months than the Punjab 20, Sindh 22 and KPK that is 20 median intervals for the rst birth. It was noticed in the province the median birth interval for the succeeding births are increasing in provinces. Median interval between the births is showing almost same trend in next all birth orders. By looking the urban rural differential, urban women have shorter intervals 19 than rural 22 for the rst birth. At the wealth index, the poor women have longer interval 23 than the rich 19 as rst birth but then almost same median interval in other all births. There is no signicant difference between the employed and unemployed women, as they show almost same interval among all births. In the blood relation with the husband is concern the women who have no relation with their husband tend to have shorter interval with those who had any blood relation with her husband only at rst birth.

Conclusion This study has presented the association of socio economic and demographic factors of birth intervals / spacing in Pakistan. It is mainly concerned with 36


Table 1: Median Interval between succeeding births with Socio-Economic and Demographic Variables Background Characteristics Age At Marriage

Birth Order 1

2

3

4

5

6

7

8

10 – 14

28

25

25

25

24.5

24

25

25

15 – 24

20

24

25

25

25

25

25

26

25 – 29

18

24

26

26

25

24

28

27

30+

16

22

27

25

36

29.5

39

24

No Education

22

24

25

24

25

25

25

25

Primary

20

24

24

25

25

25

25

27

Secondary

17

24

26

26

26

25

26

29

Graduate and Higher

15

24

28

31

29

25

24

21

No Education

22

24

25

24

25

24

25

25

Primary

22

24

24

24

25

25

25

25

Secondary

20

24

25

25

26

25

26

27

Graduate and Higher

17

24

27

27

25

25

23

23

Punjab

20

24

25

25

25

25

25

25

Sindh

22

24

25

25

24

24

24

25

KPK

20

24

26

24

26

25

26

26

Baluchistan

24

25

26

26

25

25

26

25

Urban

19

23

25

24

25

25

25

26

Rural

22

24

25

25

25

25

25

25

Poor

23

25

25

25

25

25

25

25

Middle

22

23

25

25

25

25

26

25

Rich

19

24

25

25

26

25

25

26

Employed

22

24

25

25

25

24

24

25

Unemployed

21

24

25

25

25

25

25

26

Mothers Education

Husbands Education

Region

Type of Residence

Wealth Index

Mother's Occupation

37


Husband's Occupation Employed

21

24

25

25

25

25

25

25

Unemployed

21

23

24

22.5

26

25

25

25

Yes

19

23

25

24

25

25

25

25

No

22

24

25

25

25

25

25

26

Yes

-

19

19

18

19

18

19

19

No

-

24

26

25

26

25

25

26

Male

-

24

25

25

25

25

25

25

Female

-

24

25

24

25

25

25

26

No Relation

20

24

25

25

25

25

26

26

Blood Relation

21

25

25

25

25

25

25

26

Other

22

23

24

25

25

25

24

23

Total

21

24

25

25

25

25

25

25

Contraceptive use

Child Last Child alive

Sex of Last Child

Blood Relation with Husband

Source: Calculated from Pakistan Demographic and Health Survey (PDHS 2006-07)

determining the relation of socioeconomic and demographic factors on birth interval dynamics. It was found that in younger women interval between births are longer than older women, also women with secondary and higher education and those belong to urban areas tend to space birth more widely. Employed couple get interval for rst birth between 27-31 mean months. While if the couple is unemployed then interval going to decrease between 2729 months. There is no signicant difference between the employed and unemployed women. In this data the interesting point is to be noted that non user of more and contraceptives has longer interval then users. In the provincial difference, the mean interval is longer in the Baluchistan than the Punjab, Sindh and KPK. In the data it was noticed that if the rst-born was a boy; women delay the pregnancy for their 2nd birth, because they might be wanting invest more on boy. As we proceed from the third to the seventh birth all the important factors, residence, occupation, region and

contraception, do not show any signicant impact on the birth intervals. From the above result it can be concluded that, education and age at marriage are more signicant indicators of birth intervals, because as the age at marriage increase women want to conceive quicker than most marriages at younger ages. Educational attainment also impact on birth spacing, as the increase in educational status wider leads to birth spaces. We have found insignicant results because of data limitations. Difference in found only at rst birth in mean and median month's interval among all females. The PDHS has very useful information about fertility related behavior of woman for throughout her reproductive span; still it has some limitation, which is a barrier to fully analyze the topic under study. For example data about pregnancy is not available, making analysis of inter-pregnancy interval impossible. The results about birth spacing do not include intervals probably due to miscarriages or the wastage of pregnancies having place 38


between two births. That is why probably in Baluchistan, where miscarriages have the highest rate in Pakistan, shows long interval between births compared to other province. Similar confounding results are found for the wealth index, son preferences, education attainment and age at marriage when analyzed for birth intervals. References 1.

2.

3.

4.

5. 6. 7.

Alasdair D. Population Dynamics and Birth Spacing in Oman. International Journal of Middle East Studies1999, 5(1): pp136-40. Pebley A, Millman S. “Birth spacing and child survival” International Family Planning Perspective. 1986; 12(3): 71-79. Fertility in Pakistan, A Review of ndings from the Pakistan Fertility Survey: 1984. Sathar Z Birth spacing in Pakistan. Journal of Biosocial Science Pakistan Institute of Development Economics Islamabad1988; 20(2): 175-194. Demographic and Health Survey (PDHS 1990-91). Suwar J. Socio-cultural dynamics of birth intervals in Nepal. Nepalese studies. 1996;28(1): 1-33. Jungho K. Women's Education and Fertility, an Analysis of the Relationship between Education and Birth Spacing in Indonesia”Economic Development and Cultural Change University of Chicago Press.2010; 58(4): 739-774.

39


Short Communication


A Spot Survey to Investigate an Outbreak of Cutaneous Leishmaniasis at Afghan Refugee Camp at Khairabad Village in KPK. -1

1

1

1

Hamayun Rashid Rathor , Soaib Ali Hassan , Hazrat Bilal , Imtinan Akram Khan , 1 Tallat Anwar Fridi . 1

Department of Medical Entomology and Disease Vector Control (MEDVC) Health Services Academy Islamabad (Correspondence to Hassan SA: [email protected]) Summary Leishmaniasis is caused by infection of protozoan parasite belongs to genus Leishmania. The protozoa transmitted to human by the bite of infected sand ies of genus phlebotomus in old world. Leishmaniasis is group of diseases the most common form and wide spread in world is CL causing morbidity (leaving scar after healing) in number of people. In Pakistan a number of out breaks of CL have been reported from all the provinces including AJK. However, most recently an outbreak of CL was reported from Khairabad village of district Nowshahera, KPK. All suspected patients visiting Frontier Primary Health Care (FPHC) of Khairabad were conrmed trough laboratory test and then registered for treatment with Sodium Stibogluconate injections provided by United Nation High Commissioner for Refugees (UNHCR). A total of 593 patients were registered out of which the percentage of male was 42.32% and 57.67% were female patients. Most the patients were secondary infected which shows that there is lack of knowledge about disease. So, beside treatment of cases, community should be educated about the vectors, transmission and symptoms of disease. Also there is an urgent need to conduct research for seasonal distribution of vector species in the area and to establish insecticide susceptibility / resistance status of vector species of sand ies, which will help in strategic planning for the control of sand ies and ultimately the disease burden will reduce. (Pak J Public Health 2013, 3(2): 40-41 Keys words: Cutaneous Leishmaniasis, Outbreak, Sand ies

Outbreak Report Leishmaniasis is caused by infection of protozoan parasite belongs to genus Leishmania. The protozoa transmitted to human by the bite of infected sand ies of genus Phlebotomus in old world. (1) Leishmaniasis is group of diseases the most common form and wide spread in world is CL causing morbidity (leaving scar after healing) in number of people. Worldwide 1.5 million of CL cases occur annually (2,3). In Pakistan a number of out breaks of CL have been reported from all the provinces including AJK. However, most recently an upsurge of CL was reported from Khairabad village of district Nowshahera, KPK. A spot survey of the reported area was conducted by MEDVCHSA team, in December, 2012, to investigate the outbreak. The village is situated on river side at the border of Punjab and KPK province. The patients who visited Frontier Primary Health Care (FPHC) at Khairabad Nowshahera, KPK during 2012 were recorded. Discussions were made with medical and paramedical staff of the FPHC. All suspected patients visiting the (FPHC) of Khairabad were conrmed trough laboratory test and then registered for treatment with Sodium Stibogluconate injections provided by United Nation High Commissioner for Refugees (UNHCR). During the survey it

was observed that a total of 593 patients were registered out of which the percentage of male was 42.32% and 57.67% were female patients. The age wise distribution of cases in each month for both male and female patients is shown in table 1. The lower prevalence of disease in males is might be because of traveling for jobs outside the endemic area. The higher prevalence of CL in females is because they spend most of their times in and around the houses and working in the animals sheds as shown by another study in 2009. (4) It was observed that the majority of community members lacked knowledge about the disease symptoms and awareness on how to prevent infective bites by the vector sand ies, therefore, treatment was started very late and because of long incubation period and slow process of healing the patients are acting as a main amplifying host in further spread of disease. The above explains why most the patients had secondary infections beside treatment of cases. Conclusions It can be concluded that the inux of infected Afghan refugees, lack of preventive measures and delayed treatment of primary infections resulted in outbreak of CL at Khairabad. In all situations, treatment of infected cases 40


Table 1: Month wise distribution and total numbers of CL in Khariabad Village (Nowshahera, KPK) < 5 yeas

5-14 yeas

>15 yeas

Months

M

F

M

F

M

F

Total

January

6

7

14

13

6

19

65

February

11

7

18

23

11

28

98

March

6

2

12

19

14

23

76

April

8

12

18

19

12

28

97

May

10

6

12

10

3

18

59

June

0

1

5

3

6

8

23

July

1

2

1

3

3

4

14

August

0

0

0

0

4

0

4

September

1

4

4

4

3

6

22

October

2

0

8

1

4

8

23

November

3

6

9

11

9

17

55

December

6

6

9

14

12

10

57

Total

54

53

110

120

87

169

593

remains primary need, However, the disease can only be prevented by mean of vector control activities constituting, operationalizing sustained sand y control through Integrated vector management (IVM). Personal protection measure especially during the dusk to dawn periods; using insecticide treated bed nets and clothing (5) and minimizing skin exposure to infective bites of vector sand ies by applying insect repellents (6). In addition, most importantly the community should be educated about the vectors, transmission and symptoms of disease. Also there is an urgent need to conduct research for seasonal distribution of vector species in the area and to establish insecticide susceptibility / resistance status of vector species of sand ies, which will help in strategic planning for the control of sand ies and ultimately the existing and future outbreaks.

References 1.

2.

3.

4.

5. 6.

Shakila A, Bilqees FM, Salim A, Mionuddin. Geographical Distribution of Cutaneous Leishmaniasis and sandies in Pakistan. Acta Parasitologica Turcica. 2006; 30(1): 1-6. World Health Organization. Report of the fth consultative meeting on leishmaniasis/ HIV coinfection. Addis Ababa, Ethiopia. 20-22, March 2007. World Health Organization. Sixtieth World Health Assembly. Resolution and decision Annexes. Geneva. 14-23 May, 2007. Ullah S, Jan AH, Wazir SM, Ali N. Prevalence of cutaneous leishmaniasis in Lower Dir District (N.W.F.P), Pakistan. Journal of Pakistan Association of Dermatologists. 2009; 19: 212-215. Herwaldt BL. Leishmanaisis. Lancet. 1999; 354: 1191-9. Desjeux P. Leishmanaisi: Public health aspects and control. Clin Dermatol. 1996; 14: 417-23.

41

Vol. 3 No. 2 (June) 2013

Perceptions about measles among mothers living in rural area: A cross-sectional study at Larkana, Sindh Hussain S, Kumar R, Ali M, Khan EA, Ahmed J, Khan SA, Hussain S.

2

Gaps Analysis in Knowledge, Practices & Control Responses to Combat Cutaneous Leishmaniasis in Bagh AJ&K Akbar J, Rathor HR, Hassan SA, Bilal H, Khan IA, Idrees M

6

Susceptibility of Salmonella enterica serotype typhi, to the usual line of antimicrobial treatment in Rawalpindi Abdullah MA, Zahid A, Sattar NY

14

World Health Organization diabetic care guidelines: knowledge and practices of general practitioners in private Clinics of Rawalpindi, Pakistan Durrani HM, Kumar R, Durrani SM, Anwar-ul-Haq

19

Bioactivity of botanicals against Aedes aegypti Linnaeus and Anopheles stephensi Liston Larvae Inam-llah H, Rathor HR, Bilal H, Hassan SA and Khan IA, Faridi TA

23

Morbidity Patterns in Pakistan: Evidence from Pakistan Panel Household Survey 2010 Bari I, Abbas N

28

Socioeconomic and demographic dynamics of Birth Interval in Pakistan Abbas N, Shaikh I, Bari I

35

Short Communication A Spot Survey to Investigate an Outbreak of Cutaneous Leishmaniasis at Afghan Refugee Camp at Khairabad Village in KPK. Rathor HR, Hassan SA, Bilal H, Khan IA, Fridi TA.

40