Extending contact screening to 50 metre around tuberculosis patients in urban Pakistan : Follow-up of a large Active Case-finding Project

Tuberkulose pasienter som ikke er diagnostisert er et stort helseproblem i samfunnet i Pakistan. I 2020 var det 52% av det antatte totale nye tilfeller som ikke var registrert i det nasjonale TB programmet (NTP) i Pakistan, selv om det er meldeplikt for sykdommen. Disse pasientene som ikke er diagnostisert er smitteførende og vedlikeholder epidemien. For å finne flere pasienter som har tuberkulose har NTP i Pakistan hatt flere strategier, og en av dem var å systematisk undersøke flere kontakter i nærheten av disse pasientene. Dette ble gjort både i husene der disse pasientene bodde og i nabolaget; prosjektet ble gjort fra 2013 til 2015 i fire distrikter med mye slum: Lahore, Rawalpindi, Faisalabad og Islamabad. De som var naboer og bodde innenfor en radius av 50 meter rundt pasienter som hadde oppspytt-prøver med m.tuberculosis ble identifisert og sporet opp ved hjelp av GIS Geographical Information System. Alle nye identifiserte pasienter ble henvist til behandling. I Paper-I var målet å evaluere effekten av denne strategien i Pakistan. Studien var en før-og-etter intervensjon, basert på pasient register og dokumenter. Før intervensjonen (Juli 2011-juni 2013) var det vanlig diagnostikk med rutinemessig nærkontakt undersøkelser i pasientens hus. Dette ble sammenlignet med intervensjonsperioden (Juli 2013-juni 2015) der personer i nærmiljøet innenfor 50 meter fra pasientene ble undersøkt. Det ble kontaktet 783043 nærkontakter og av dem hadde 23741 symptomer som passet med tuberkulose; av disse ble i alt 4710 (19.8%) diagnostisert med tuberkulose og 4084 (17.2%) hadde prøver som viste m.tuberculosis. Av disse pasientene med påvist bakterier ble 7.6% påvist med Xpert MTB/RIF prøve. Av alle som ble undersøkt var 22.3% i huset til pasienten, 19.1% var i nærmiljøet; 5.1% var blant barn. I løpet av intervensjonen økte antall diagnostiserte med 8% blant alle som ble nærmere undersøkt, og økte med 7% blant de som var bakteriologisk positive. Vi konkluderte med at nærkontakt undersøkelse omkring hus med kjente TB pasienter økte både antallet diagnostiserte pasienter og antallet som ble registrert av tuberkuloseprogrammet. For oppskalering på nasjonalt nivå og evaluering over lengre tid trengs kost-nytte studier. I Paper-II var målet vårt å sammenligne karakteristika på pasienter med lungetuberkulose som ble diagnostisert ved «utvidet» (50m) nærkontakt undersøkelser i 2013-15 med pasientene som ble diagnostisert i rutineprogrammet i 2011-13 i Pakistan. En tverrsnittsstudie ble utført basert på data fra denne intervensjonen og det nasjonale TB programmet med data fra Lahore, Faisalabad, Rawalpindi and Islamabad. I studien registrerte vi 12114 pasienter med lungetuberkulose, av dem ble 4604 (38%) diagnostisert i prosjektet med undersøkelse av nærkontakter og naboer. Blant de som ble diagnostisert i prosjektet var 56.2% (95% konfidens intervall [CI] 54.8–57.6) menn, mens blant de som ble funnet av rutine var 49.7% (95% CI 48.6–50.8) menn. Blant de som ble diagnostisert i prosjektet var 88.0% (95% CI 87.1–88.9) diagnostisert bakteriologisk, mens i rutine programmet var 50.3% (95% CI 49.2–51.4) bakteriologisk. I justerte regresjonsanalyser fant vi høyere sjanse for å bli diagnostisert med tuberkulose blant barn (0-14 år) enn hos unge voskne (15-44 år), og høyere sjanse i Faisalabad enn i Islamabad. Vi konkluderte med at prosjektet identifiserte en høyere andel menn og barn enn rutine programmet, og disse gruppene blir oftere miskjent i det nasjonale programmet. I Paper-III var målet å sammenligne behandlingsutfall mellom de som ble diagnostisert av prosjektet med de i rutineprogrammet i Pakistan i 2013-15. Dette var en oppfølginsstudie i Lahore, Faisalabad, Rawalpindi og Islamabad basert på data fra det nasjonale TB programmet. Vi brukte en log binomial regresjonsmodell for å undersøke om pasientene i prosjektet hadde dårligere behandlingsresultat enn rutine (dårlig behandlingsresultat var et av de følgende: død, tapt for oppfølging, mislykket, ikke evaluert). Av de 79431 lungetuberkulose pasientene som ble diagnostisert var 4604 (5.8%) oppdaget i prosjektet med kontakt og nabo undersøkelser, og 4052 (88%) hadde m.tuberculosis i prøven. Det var ingen forskjell i andelen med dårlig resultat i prosjektet (9.6%) og i rutine (9.9%) bland alle pasientene. Imidlertid, blant de som hadde påvist m.tuberculosis i prøvene var det lavere andel dårlig resultat blant de i prosjektet (9.9%) sammenlignet med rutine (11.6%, p=0.001). I justerte regresjonsanalyser fant vi noe lavere risiko for dårlig behandlingsresultat i prosjektet enn i rutineprogrammet både når vi analyserte alle (aRR 0.90; 95% CI 0.82–0.99), og med subanalyser av pasienter med påvist m.tuberculosis (aRR 0.91; 95%CI 0.82-1.00). Vi konkluderte med at pasienter med lungetuberkulose som ble diagnostisert i prosjektet med undersøkelse av kontakter og naboer ikke hadde dårligere behandlingsresultat.Missing tuberculosis (TB) cases is a major public health issue in Pakistan. In 2020, around 52% of incident TB cases were not notified to the national tuberculosis programme, Pakistan (NTP). These missing cases are the means of transmitting TB and sustain the global TB epidemic. To detect TB patients, NTP, Pakistan implemented several strategies, and one among them was through extended contact screening (ECS). In the ECS, contact investigation was conducted among household and close community in four selected districts with a high concentration of slums; Lahore, Rawalpindi, Faisalabad and Islamabad from July 2013 to June 2015. All the people were screened for tuberculosis who were residing within a radius of 50 metres (using Geographical Information System) from the household of a smear positive TB patient. All the diagnosed TB patients were linked to TB treatment and care. In Paper I, our objective was to evaluate the impact of household and close community contact screening on tuberculosis case detection in Pakistan. This was a before and after intervention study, based on retrospective record review. Routine passive case finding (PCF) and household contact investigation was conducted in the pre-intervention period (July 2011 to June 2013), and it was compared with the intervention period (July 2013 to June 2015) using ECS as addition. A total number of 783,043 contacts were screened for tuberculosis, among them 23,741(3.0%) presumptive TB cases were identified, 4710 (19.8%) were all forms, and 4084 (17.2%) bacteriologically confirmed patients with TB were detected. Xpert MTB/RIF contributed 7.6% to bacteriologically confirmed TB patients. Among investigated, the overall yield of all forms of TB patients was 22.3% in household contacts, 19.1% in close community contacts and 5.1% was among presumptive child TB cases investigated. There was around 8% increase in case detection of all forms and 7% in bacteriologically confirmed patients with TB due to intervention. We concluded that household and close community contact investigation not only increased TB case notification but also identified additional TB patients. However, more long-term assessments and cost effectiveness studies are needed before the national scale-up. In Paper II, our objective was to compare the characteristics of patients with pulmonary tuberculosis who were detected through extended contact screening with those detected by routine passive case finding in Pakistan during 2013-15. A cross-sectional study was conducted based on the data that was collected from ECS and from the routine program (PCF) data from Lahore, Faisalabad, Rawalpindi and Islamabad in 2015. We included 12,114 patients with pulmonary TB in the study where 4,604 (38%) were identified through ECS. The male patients comprised 56.2% (95% confidence interval [CI] 54.8–57.6) were detetected through ECS who were more than 49.7% (95% CI 48.6–50.8) that were identified through PCF. The proportion of bacteriologically confirmed TB patients was 88.0% (95% CI 87.1–88.9) in the ECS group and 50.3% (95% CI 49.2–51.4) in the PCF group. We found through regression analysis, that in comparison with patients who aged 15–44 years, children aged <15 years had higher chances of being detected through ECS (adjusted odds ratio 2.69; 95% CI 2.21–3.28). There was a higher chance of TB cases being detected by ECS in Faisalabad (adjusted odds ratio 2.57; 95% CI 2.01–3.29) in comparison with the cases identified in Islamabad. We concluded that ECS identified a higher proportion of male and child patients with pulmonary TB than routine case finding; both of these groups are more often missed through routine TB control. The objective of Paper III was to compare the treatment outcomes of pulmonary TB patients detected by extended contact screening with those patients detected by routine passive case finding in Pakistan during 2013-15. This was a cohort study conducted in Lahore, Faisalabad, Rawalpindi and Islamabad based on secondary program data in 2013–15. A log binomial regression model was used to assess if ECS was associated with unfavourable treatment outcomes (death, loss-to-follow-up, failure, not evaluated) after adjusting for potential confounders. Of the total 79,431 PTB patients, 4,604 (5.8%) were detected through ECS with 4,052 (88%) bacteriologically confirmation. There was no significant difference between the proportions with unfavourable outcomes in ECS group (9.6%) and the PCF (9.9%) in all PTB patients. However, unfavourable outcomes were significantly lower in ECS (9.9%) than PCF group (11.6%, P = 0.001) among the bacteriologically confirmed patients. ECS was associated with a lower risk of unfavourable outcomes (adjusted relative risk (aRR) 0.90; 95% CI 0.82–0.99) compared to PCF both among all patients with PTB and among bacteriologically confirmed PTB patients (aRR 0.91; 95% CI 0.82–1.00). In conclusion, PTB patients detected by ECS had treatment outcomes that were not inferior to those detected by PCF.Doktorgradsavhandlin

Performance measurement methodology for integrated services networks

With the emergence of advanced integrated services networks, the need for effective performance analysis techniques has become extremely important. Further advancements in these networks can only be possible if the practical performance issues of the existing networks are clearly understood. This thesis is concerned with the design and development of a measurement system which has been implemented on a large experimental network. The measurement system is based on dedicated traffic generators which have been designed and implemented on the Project Unison network. The Unison project is a multisite networking experiment for conducting research into the interconnection and interworking of local area network based multi-media application systems. The traffic generators were first developed for the Cambridge Ring based Unison network. Once their usefulness and effectiveness was proven, high performance traffic generators using transputer technology were built for the Cambridge Fast Ring based Unison network. The measurement system is capable of measuring the conventional performance parameters such as throughput and packet delay, and is able to characterise the operational performance of network bridging components under various loading conditions. In particular, the measurement system has been used in a 'measure and tune' fashion in order to improve the performance of a complex bridging device. Accurate measurement of packet delay in wide area networks is a recognised problem. The problem is associated with the synchronisation of the clocks between the distant machines. A chronological timestamping technique has been introduced in which the clocks are synchronised using a broadcast synchronisation technique. Rugby time clock receivers have been interfaced to each generator for the purpose of synchronisation. In order to design network applications, an accurate knowledge of the expected network performance under different loading conditions is essential. Using the measurement system, this has been achieved by examining the network characteristics at the network/user interface. Also, the generators are capable of emulating a variety of application traffic which can be injected into the network along with the traffic from real applications, thus enabling user oriented performance parameters to be evaluated in a mixed traffic environment. A number of performance measurement experiments have been conducted using the measurement system. Experimental results obtained from the Unison network serve to emphasise the power and effectiveness of the measurement methodology

Patterns of Antibiotic Drug Resistance among Salmonella Typhi Isolates of Enteric Fever in Pediatric Population at a Tertiary Care Hospital

Objective: To determine patterns of antibiotic drug resistance among Salmonella typhi isolates of enteric fever in pediatric population at a tertiary care hospital. Material and methods: Consecutive 161 children with enteric fever were included in this study. This cross – sectional study was done at Department of Pediatric Medicine, Nishtar Medical University and Hospital, Multan from June 2015 to December 2016. Venous blood sample (3-5 ml) was drawn and it was immediately transported to Microbiology laboratory of Pathology Department, Nishtar Hospital Multan for blood culture and sensitivity test. Antibiotic drug resistance was determined after measuring diameter of zone of inhibition of a specific drug on Salmonella isolates on Mueller Hinton agar plates by modified Kirby baur disc diffusion method. Coated tongue, pain abdomen, anorexia and headache was assessed clinically. All the data were entered and analyzed using SPSS-11. Results: Of these 161 study cases, 91 (56.5%) were boys and 70 (43.5%) were girls. Mean age of our study cases was 5.79 ± 2.45 years (with minim age was 2 years while 12 years was maximum age). Previous history of use of antibiotics before 48 hours of the culture and sensitivity test was present in 93 (57.8%) of our study cases. Majority of our study cases having enteric fever presented with abdominal pain 65 (40.4%), headache 28 (17.4%) and diarrhea 17.4 % of our study cases. Chloramphenicol was sensitive in 40 (24.8%) of the Salmonella typhi isolates, Ampicillin was sensitive in 20 (12.4%), Co-trimoxazole in 20 (12.4%), Ciprofloxacin was sensitive in 88 (54.7%) isolates, Ofloxacin was sensitive in 101 (62.7%), Gentamycin was sensitive in 28 (17.4 %), Amoxycillin was sensitive in 36 (22.4 %). Conclusion: Our study results have indicated that S. typhi isolates of enteric fever showed higher degree of antibiotic drug resistance. Multidrug resistant strains were more prevalent in our study which points towards well directed efforts of our health policy makers to adopt certain guidelines regarding use of these drugs in our population. Keywords: Enteric fever, drug resistance, children

On Quasi S-Propermutable Subgroups of Finite Groups

A subgroup H of a finite group G is said to be quasi S-propermutable in G if K⊲¯G such that HK is S-permutable in G and H ∩ K≤HqsG, where HqsG is the subgroup formed by all those subgroups of H which are S-propermutable in G. In this paper, we give some generalizations of finite group G by using the properties and effects of quasi S-propermutable subgroups

Comparison of Teaching by Conventional Method and by using Cognitive Theory of Multimedia to Post Graduate FCPS Radiology Students

Abstract: Objective: Objectives of this study was to teach postgraduate radiology resident physics by both conventional method and by using cognitive theory of multimedia, comparing the results and to see if there was any improvement in their learning and performance. Study Design: Comparative Experimental study Setting and Duration of Study: This study was carried out at B.B.H. and Holy Family Hospital Rawalpindi from Oct to Dec 2019. Methods: Two groups of PG FCPS students of first year and second year comprising of 10 students each were formed. Two groups had similar attributes. First of all Pretest is taken. Group one was taught through didactic lecture and post test was taken. Second group was taught by the use of cognitive theory of multimedia and post test was taken. Cross over was done. Pretest was taken as before. Group one was now taught by the use of cognitive theory of multimedia and post test was taken and group two was taught through didactic lecture and post test was again taken. Results of both groups were compared. Results: Statistically these two groups were similar. At the end of first round mean pretest score in conventionally taught group I was 4.1 and mean post test score was 8.8. In group II taught by cognitive theory of multimedia the mean pretest score was 4.2 and mean post test score was 13.3. After cross over in group II taught conventionally the mean test score was 4.0 and post test score were 8.9. In group I now taught by cognitive theory of multimedia teaching group mean pretest score was 4.1 and mean post test score was 13.6. Conclusion: Postgraduate, first and second year Diagnostic Radiology residents performed better in assessment once they were taught Physics by use of cognitive theory of multimedia as compared when taught by conventional method of teaching. Keywords: Didactic lecture, cognitive theory of multimedia, post graduate residents

Are patients with pulmonary tuberculosis identified by active and by passive case detection different? A cross-sectional study in Pakistan

Objectives Our objective was to compare the characteristics of patients with pulmonary tuberculosis (TB) identified through “extended contact screening” (ECS) with those of patients identified through routine passive case finding (PCF). Methods Active TB case finding by ECS was tested from 2013–2015. This was a cross-sectional study based on data collected from ECS and routine program data from Lahore, Faisalabad, and Rawalpindi districts, and Islamabad in 2015. Characteristics of patients identified through ECS and PCF were compared. Results Of the 12,114 patients with pulmonary TB in the study, 4604 (38%) were identified through ECS, of whom 4052 (88%) had bacteriological confirmation. Male patients comprised 56.2% (95% confidence interval [CI] 54.8–57.6) of patients with pulmonary TB identified through ECS and 49.7% (95% CI 48.6–50.8) of those identified through PCF. The proportion of bacteriologically confirmed cases was 88.0% (95% CI 87.1–88.9) in the ECS group and 50.3% (95% CI 49.2–51.4) in the PCF group. By regression analysis we found that compared with patients aged 15–44 years, children aged <15 years had higher chances of being identified through ECS (adjusted odds ratio 2.69; 95% CI 2.21–3.28). There was a higher chance of cases being detected by ECS in Faisalabad (adjusted odds ratio 2.57; 95% CI 2.01–3.29) than in Islamabad. Conclusion ECS identified a higher proportion of male and child patients with pulmonary TB than routine case finding; both of these groups are more often unidentified through routine TB control.publishedVersio

Extending contact screening within a 50-m radius of an index tuberculosis patient using Xpert MTB/RIF in urban Pakistan: Did it impact treatment outcomes?

Background Pakistan implemented initiatives to detect tuberculosis (TB) patients through extended contact screening (ECS); it improved case detection but treatment outcomes need assessment. Objectives To compare treatment outcomes of pulmonary TB (PTB) patients detected by ECS with those detected by routine passive case finding (PCF). Methods A cohort study using secondary program data conducted in Lahore, Faisalabad and Rawalpindi districts and Islamabad in 2013–15. We used log binomial regression models to assess if ECS was associated with unfavorable treatment outcomes (death, loss-to-follow-up, failure, not evaluated) after adjusting for potential confounders. Results We included 79,431 people with PTB; 4604 (5.8%) were detected by ECS with 4052 (88%) bacteriologically confirmed. In all PTB patients the proportion with unfavorable outcomes was not significantly different in ECS group (9.6%) compared to PCF (9.9%), however, among bacteriologically confirmed patients unfavorable outcomes were significantly lower in ECS (9.9%) than PCF group (11.6%, P = 0.001). ECS was associated with a lower risk of unfavorable outcomes (adjusted relative risk (aRR) 0.90; 95% CI 0.82–0.99) among ‘all PTB’ patients and bacteriologically confirmed PTB patients (aRR 0.91; 95% CI 0.82–1.00). Conclusion In PTB patients detected by ECS the treatment outcomes were not inferior to those detected by PCF

Extending contact screening within a 50-m radius of an index tuberculosis patient using Xpert MTB/RIF in urban Pakistan: Did it impact treatment outcomes?

Background Pakistan implemented initiatives to detect tuberculosis (TB) patients through extended contact screening (ECS); it improved case detection but treatment outcomes need assessment. Objectives To compare treatment outcomes of pulmonary TB (PTB) patients detected by ECS with those detected by routine passive case finding (PCF). Methods A cohort study using secondary program data conducted in Lahore, Faisalabad and Rawalpindi districts and Islamabad in 2013–15. We used log binomial regression models to assess if ECS was associated with unfavorable treatment outcomes (death, loss-to-follow-up, failure, not evaluated) after adjusting for potential confounders. Results We included 79,431 people with PTB; 4604 (5.8%) were detected by ECS with 4052 (88%) bacteriologically confirmed. In all PTB patients the proportion with unfavorable outcomes was not significantly different in ECS group (9.6%) compared to PCF (9.9%), however, among bacteriologically confirmed patients unfavorable outcomes were significantly lower in ECS (9.9%) than PCF group (11.6%, P = 0.001). ECS was associated with a lower risk of unfavorable outcomes (adjusted relative risk (aRR) 0.90; 95% CI 0.82–0.99) among ‘all PTB’ patients and bacteriologically confirmed PTB patients (aRR 0.91; 95% CI 0.82–1.00). Conclusion In PTB patients detected by ECS the treatment outcomes were not inferior to those detected by PCF.publishedVersio