Pakistani physicians and the repatriation equation

In Pakistan, students who are accepted into medical school are congratulated — only half-jokingly — on three counts: that they will become doctors, that they will become certified by the American Board of Medical Specialties, and that they will soon be living in the United States

Aetiology of community-acquired neonatal sepsis in low and middle income countries

99% of the approximate 1 million annual neonatal deaths from life-threatening invasive bacterial infections occur in developing countries, at least 50% of which are from home births or community settings. Data concerning aetiology of sepsis in these settings are necessary to inform targeted therapy and devise management guidelines. This review describes and analyses the bacterial aetiology of community-acquired neonatal sepsis in developing countries

Pan-resistant Acinetobacter infection in neonates in Karachi, Pakistan.

Background: Pan-resistant Acinetobacter infection has emerged as an important nosocomial pathogen in our inPatient neonates over the past few years. Methodology: We performed a retrospective chart review during a five-year period (July 2003 - June 2008) of all neonates hospitalized in our neonatal intensive care unit (NICU) who developed Acinetobacter infection to identify mortality-associated risk factors in Acinetobacter neonatal infection. Results: During the five-year study period, 122 cultures from 78 neonates grew Acinetobacter. Source sites of positive culture were in the following descending order: blood (n = 57), trachea (n = 55), tissue/wound/body fluids (n = 4), eye (n = 4), urine (n = 1), and cerebrospinal fluid (n = 1). Twenty-four (31%) Patients had Acinetobacter isolated from more than one site. At the time of admission the mean age was 2.08 +/- 4 days and mean weight was 1.77 +/- 0.88 kg, 75% were premature. Pan-resistance (87/122, sensitive only to Polymyxin) was present in 71% of Acinetobacter isolates. Crude mortality rate of this cohort was 47%, while 70% of Patients died within four days after positive Acinetobacter culture. We identified weight of less than 1 kg on admission (p 0.06, adjusted Odds Ratio (AOR) 1.53), gestational age 28 weeks or less (p 0.011, AOR 2.88), poor perfusion (p 0.007, AOR 2.4), thrombocytopenia (p 0.01, AOR 1.6) and metabolic acidosis (p 0.01, AOR 1.67) as predictors associated with poor outcome. Conclusion: Pan-resistant Acinetobacter infection is exceedingly fatal in newborns, particularly in premature and very low-birth weight neonates. Rational antibiotic use and vigilant infection control in NICUs are key to controlling multi-drug resistant Acinetobacter infection and improving clinical outcome

Why do families of sick newborns accept hospital care? a community-based cohort study in Karachi, Pakistan

Objective: Sick young infants are at high risk of mortality in developing countries, but families often decline hospital referral. Our objective was to identify the predictors of acceptance of referral for hospital care among families of severely ill newborns and infants Karachi, Pakistan. Study Design: A cohort of 541 newborns and infants referred from home by community health workers conducting household surveillance, and diagnosed with a serious illness at local community clinics between 1 January and 31 December 2007, was followed-up within 1 month of referral to the public hospital. Result: Only 24% of families accepted hospital referral. Major reasons for refusal were financial difficulties (67%) and father/elder denying permission (65%). Religious/cultural beliefs were cited by 20% of families. Referral acceptance was higher with recognition of severity of the illness by mother (odds ratio = 12.7, 95% confidence interval = 4.6 to 35.2), family\u27s ability to speak the dominant language at hospital (odds ratio = 2.0, 95% confidence interval = 1.3-3.1), presence of grunting in the infant (odds ratio = 3.3, 95% confidence interval = 1.2-9.0) and infant temperature Conclusion: Refusal of hospital referral for sick young infants is very common. Interventions that encourage appropriate care seeking, as well as community-based management of young infant illnesses when referral is not feasible are needed to improve neonatal survival in low-income countries

A comparison of fluoroquinolones versus other antibiotics for treating enteric fever: meta-analysis

Objectives To review evidence supporting use of fluoroquinolones as first line agents over other antibiotics for treating typhoid and paratyphoid fever (enteric fever)

Validity of neonatal jaundice evaluation by primary health-care workers and physicians in Karachi, Pakistan

Objective: The Purpose of this study was to validate primary health-care workers\u27 and physicians\u27 visual assessment of neonatal hyperbilirubinemia in Karachi, Pakistan. Study Design: We compared primary health-care workers\u27 and physicians\u27 clinical identification of jaundice in infants = 15 mg per 100 ml (260 mu mol l(-1)) with 83.3% sensitivity and 50.5% specificity, neonates aged 1 to 6 days were identified with 76.2% sensitivity and 60.7% specificity. Physicians identified neonates aged 1 to 20 days with hyperbilirubimemia \u3e= 15 mg per 100 ml (260 mmol l(-1)) with 51.4% sensitivity and 90.7% specificity, and neonates aged 1 to 6 days with 50% sensitivity and 88.5 % specificity. The primary health-care workers\u27 and physicians\u27 assessments showed fair interobserver agreement (k statistic 0.29). Conclusion: Primary health-care workers identified hyperbilirubinemic neonates with adequate sensitivity. With proper training and supervision, their assessment could improve the referral of hyperbilirubinemic neonates in low-resource settings in the developing world

Incidence and etiology of omphalitis in Pakistan: a community-based cohort study

Introduction: Although omphalitis (umbilical infections) among newborns is common and a major cause of neonatal deaths in developing countries, information on its burden and etiology from community settings is lacking. This study aimed to determine the incidence and etiology of omphalitis in newborns in high neonatal mortality settings in Karachi, Pakistan. Methodology: Trained community health workers surveyed all new births in three low-income areas from September 2004 to August 2007. Pus samples from the umbilical stumps were obtained from babies with pre-defined signs of illness and subjected to culture and antimicrobial susceptibility testing. Results: Among 6904 births, 1501 (21.7%) newborns were diagnosed with omphalitis. Of these, 325 (21.6%) were classified as mild, 1042 (69.4%) as moderate, and 134 (8.9%) as severe, 141 (9.3%) were associated with clinical signs of sepsis. The incidence of omphalitis was 217.4/1000 live births, moderate-severe omphalitis 170.3 per 1000 live births, and associated with sepsis 20.4 per 1000 live births. Of 853 infants with purulent umbilical discharge, 64% yielded 583 isolates. The most common pathogens were Staphylococcus aureus, of which 291 (95.7%) were methicillin-susceptible Staphylococcus aureus (MSSA) and 13 (4.2%) methicillin-resistant S. aureus (MRSA), Streptococcus pyogenes 105 (18%), Group B beta-hemolytic streptococci 59 (10 %), Pseudomonas spp., 52 (8.9 %), Aeromonas spp. 19 (3.2%), and Klebsiella spp. 12 (2%). Conclusions: A high burden of omphalitis can be associated with sepsis among newborns in low-income communities in Pakistan. S. aureus is the most common pathogen isolated from umbilical pus. Appropriate low-cost prevention strategies need to be implemented

RSV associated hospitalizations in children in Karachi, Pakistan: Implications for vaccine prevention strategies

Major progress is being made in vaccines against Respiratory Syncytial Virus (RSV), with multiple vaccine candidates currently in the clinical phase of development. Making an investment case for public sector financing of RSV vaccine will require estimation of burden, cost-effectiveness, and impact. The aim of this study is to determine the proportion, age distribution and clinical spectrum of RSV associated hospitalizations in children in Karachi, Pakistan. A three years prospective study was conducted at the Aga Khan University Hospital in Karachi, a city of 20 million in south Pakistan, from August 2009 to June 2012. Children less than five years old admitted with acute respiratory infections (ARI) were enrolled. Throat swabs were collected and tested for RSV using real-time PCR. Multivariable log binomial regression analysis was performed to identify the associated factors of RSV infection. Out of 1150 children enrolled, RSV was detected among 223 (19%). Highest rate of RSV detection was in young infants less than 3 months of age (48/168, 29%), which accounted for 22% of all RSV detected. Most common diagnosis in RSV positive infants (age) was bronchiolitis followed by pneumonia, while in older children between the ages of one and 5 years of age, pneumonia and asthma were the most common diagnosis. Although identified year-round, RSV was most prevalent from August to October with peak in September, coinciding with the rainy season. This study identified RSV to be independently associated with younger age (P = 0.036), rainy season (P \u3c 0.001), post-tussive emesis (P = 0.008), intubation (P = 0.003), and discharge diagnosis of bronchiolitis (P = 0.004). Vaccines against RSV that target this age group are likely to yield remarkable benefit

Evaluation of vaccine derived poliovirus type 2 outbreak response options: A randomized controlled trial, Karachi, Pakistan

Background: Outbreaks of circulating vaccine derived polioviruses type 2 (cVDPV2) remain a risk to poliovirus eradication in an era without live poliovirus vaccine containing type 2 in routine immunization. We evaluated existing outbreak response strategies recommended by the World Health Organization (WHO) for control of cVDPV2 outbreaks.Methods: Seronegative children for poliovirus type 2 (PV2) at 22 weeks of life were assigned to one of four study groups and received respectively (1) one dose of trivalent oral poliovirus vaccine (tOPV); (2) monovalent OPV 2 (mOPV2); (3) tOPV together with a dose of inactivated poliovirus vaccine (IPV); or (4) mOPV2 with monovalent high-potency IPV type 2. Stool and blood samples were collected and assessed for presence of PV2 (stool) and anti-polio antibodies (sera).Results: We analyzed data from 265 children seronegative for PV2. Seroconversion to PV2 was achieved in 48, 76, 98 and 100% in Groups 1–4 respectively. mOPV2 was more immunogenic than tOPV alone (p \u3c 0.001); and OPV in combination with IPV was more immunogenic than OPV alone (p \u3c 0.001). There were 33%, 67%, 20% and 43% PV2 excretors in Groups 1–4 respectively. mOPV2 resulted in more prevalent shedding of PV2 than when tOPV was used (p \u3c 0.001); and tOPV together with IPV resulted in lower excretion of PV2 than tOPV alone (p = 0.046).Conclusion: mOPV2 was a more potent vaccine than tOPV. Adding IPV to OPV improved immunological response; adding IPV also seemed to have shortened the duration of PV2 shedding. mIPV2 did not provide measurable improvement of immune response when compared to conventional IPV. WHO recommendation to use mOPV2 as a vaccine of first choice in cVDPV2 outbreak response was supported by our findings