Mid-upper arm circumference assessment and comparison with weight for length Z-score in infants ≤6 months as an indicator of severe acute malnutrition

Objective: To assess the frequency of severe acute malnutrition (SAM) and to determine the validity of mid-upper arm circumference (MUAC) as compared to weight for length z-score (WLZ-score) as an indicator of the nutritional status in this age group.Methods: A cross-sectional study, with a purposive sampling was conducted from March 2018 to November 2018 to enroll 540 infants ≤6 months of age from three different sites in Karachi, Pakistan. The anthropometric measurements (MUAC, length and weight) were taken by experienced community health workers. The data were analyzed using SPSS. MUAC was compared with WLZ-score for sensitivity and specificity to observe the concordant among the two diagnostic measures. The Youden Index was used to determine the ideal cut-off for infants less than 6 months of age in this population and the Kappa coefficient was also calculated to assess the agreement between MUAC and WLZ-score.Results: The study findings revealed that SAM was found in 13.6% (n=74) of the children. MUAC cut-off ≤11.5 cm yielded the Youden Index of 0.31 with 59.5% sensitivity and 71.4% specificity. The total area under receiver operating characteristic curve was 0.70 (95% CI: 0.63, 0.77; P \u3c 0.001). The degree of agreement between mid-upper arm circumference and weight for length z-score to diagnose SAM ranged from 0.2 to 0.3.Conclusion: The Youden index implied that a MUAC cut-off of ≤11.5 cm can be used as an indicator with acceptable validity for diagnosing SAM in children ≤6 months of age in a low middle income developing country like Pakistan

Poliovirus excretion among children with primary immune deficiency in Pakistan: A pilot surveillance study protocol

Introduction: Children with primary immunodeficiency disorders (PID) are more susceptible to developing viral infections and are at a substantially increased risk of developing paralytic poliomyelitis. Such children, if given oral polio vaccines tend to excrete poliovirus chronically that may lead to the propagation of highly divergent vaccine-derived poliovirus (VDPV). Consequently, they may act as a reservoir for the community by introducing an altered virus potentially imposing a risk to global polio eradication. However, the risks of chronic and prolonged excretion are not well characterised in the study context. This study seeks to establish a pilot surveillance system for successful identification and monitoring of VDPV excretion among children with PID. It will assess whether the Jeffrey Modell warning signs of PID can be used as an appropriate screening tool for PID in Pakistan.Methods and analysis: In this pilot surveillance, recruitment of PID cases is currently done at participating hospitals in Pakistan. Potential children are screened and tested against the Jeffrey Modell Foundation (JMF) warning signs for immunodeficiency and their stool is collected to test for poliovirus excretion. Cases excreting poliovirus are followed until the two consecutive negative stool samples are obtained over a period of 6 months. The data will be analysed to calculate hospital-based proportions of total Immunodeficiency-related vaccine-derived poliovirus (iVDPV) cases over a 2-year period and to determine the sensitivity and specificity of the JMF signs.Ethics and dissemination: This protocol was reviewed and approved by the WHO (WHO Reference-2018/811124-0), Aga Khan University (AKU ERC-2018-0380-1029) and National Bioethics Committee (Ref No. 4-87 NBC-308-Y2). The results will be published in an open access peer-reviewed scientific journal and presented to the iVDPV Working Group members, policy-makers, paediatric consultants and fellow researchers with the same domain interest. It may be presented in scientific conferences and seminars in the form of oral or poster presentations

A mixed method multi-Country assessment of barriers to implementing pediatric inpatient care guidelines

Introduction: Accelerating progress in reducing child deaths is needed in order to achieve the Sustainable Development Goal child mortality target. This will require a focus on vulnerable children-including young children, those who are undernourished or with acute illnesses requiring hospitalization. Improving adherence to inpatient guidelines may be an important strategy to reduce child mortality, including among the most vulnerable. The aim of our assessment of nine sub-Saharan African and South Asian hospitals was to determine adherence to pediatric inpatient care recommendations, in addition to capacity for and barriers to implementation of guideline-adherent care prior to commencing the Childhood Acute Illness and Nutrition (CHAIN) Cohort study. The CHAIN Cohort study aims to identify modifiable risk factors for poor inpatient and post discharge outcomes above and beyond implementation of guidelines.Methods: Hospital infrastructure, staffing, durable equipment, and consumable supplies such as medicines and laboratory reagents, were evaluated through observation and key informant interviews. Inpatient medical records of 2-23 month old children were assessed for adherence to national and international guidelines. The records of children with severe acute malnutrition (SAM) were oversampled to reflect the CHAIN study population. Seven core adherence indicators were examined: oximetry and oxygen therapy, fluids, anemia diagnosis and transfusion, antibiotics, malaria testing and antimalarials, nutritional assessment and management, and HIV testing.Results: All sites had facilities and equipment necessary to implement care consistent with World Health Organization and national guidelines. However, stockouts of essential medicines and laboratory reagents were reported to be common at some sites, even though they were mostly present during the assessment visits. Doctor and nurse to patient ratios varied widely. We reviewed the notes of 261 children with admission diagnoses of sepsis (17), malaria (47), pneumonia (70), diarrhea (106), and SAM (119); 115 had multiple diagnoses. Adherence to oxygen therapy, antimalarial, and malnutrition refeeding guidelines was \u3e75%. Appropriate antimicrobials were prescribed for 75% of antibiotic-indicative conditions. However, 20/23 (87%) diarrhea and 20/27 (74%) malaria cases without a documented indication were prescribed antibiotics. Only 23/122 (19%) with hemoglobin levels meeting anemia criteria had recorded anemia diagnoses. HIV test results were infrequently documented even at hospitals with universal screening policies (66/173, 38%). Informants at all sites attributed inconsistent guideline implementation to inadequate staffing.Conclusion: Assessed hospitals had the infrastructure and equipment to implement guideline-consistent care. While fluids, appropriate antimalarials and antibiotics, and malnutrition refeeding adherence was comparable to published estimates from low- and high-resource settings, there were inconsistencies in implementation of some other recommendations. Stockouts of essential therapeutics and laboratory reagents were a noted barrier, but facility staff perceived inadequate human resources as the primary constraint to consistent guideline implementation

Enteric Permeability, Systemic Inflammation, and Post-Discharge Growth among a Cohort of Hospitalized Children in Kenya and Pakistan

Funding Information: Sources of Funding: The CHAIN Network is supported by the Bill & Melinda Gates Foundation [OPP1131320]. For the purpose of Open Access, the authors have applied a CC-BY public copyright license to any author accepted manuscript version arising from this submission. The lactulose-rhamnose testing was funded by an Early Career Award from the Thrasher Research Foundation. The funders had no role in conduct of the study, interpretation, writing the manuscript or decision to submit. No authors were paid to write this article by any company, organization or agency. Publisher Copyright: © 2022 Lippincott Williams and Wilkins. All rights reserved.Objectives: To determine whether gut permeability is associated with post-discharge growth and systemic inflammation among hospitalized children in low- and middle-income countries. Methods: Children aged 2-23 months being discharged from Civil Hospital Karachi (Pakistan) and Migori County Referral Hospital (Kenya) underwent lactulose-rhamnose ratio (LRR) permeability testing and were compared to age-matched children from their home communities. Linear mixed effect models estimated the associations between LRR among discharged children with change in length-for-age (LAZ) and weight-for-age z score (WAZ) at 45, 90, and 180 days after discharge. Linear regression tested if relationships between LRR, systemic inflammation [C-reative protein (CRP), Cluster of Differentiation 14 (CD14), Tumour Necrosis Factor Alpha (TNFα), Interleukin-6 (IL-6)], and enterocyte damage [Intestinal Fatty-Acid Binding protein (I-FABP)] differed between the hospitalized and community groups. Results: One hundred thirty-seven hospitalized and 84 community participants were included. The hospitalized group had higher log-LRR [0.43, 95% confidence interval (CI): 0.15-0.71, P = 0.003] than the community children. Adjustment for weight-for-length z score at discharge attenuated this association (0.31, 95% CI: 0.00-0.62, P = 0.049). LRR was not associated with changes in WAZ or LAZ in the post-discharge period. Associations between LRR and CRP (interaction P = 0.036), TNFα (P = 0.017), CD14 (P = 0.078), and IL-6 (P = 0.243) differed between community and hospitalized groups. LRR was associated with TNFα (P = 0.004) and approached significance with CD14 (P = 0.078) and IL-6 (P = 0.062) in community children, but there was no evidence of these associations among hospitalized children. Conclusions: Although increased enteric permeability is more prevalent among children being discharged from hospital compared to children in the community, it does not appear to be an important determinant of systemic inflammation or post-discharge growth among hospitalized children.Peer reviewe

The Effects of dental scaling on adverse birth outcome : a randomized trial in Karachi, Pakistan

Approximately two-thirds of pregnant Pakistani women suffer from periodontal disease which is a common inflammatory disease of the soft tissues surrounding the tooth. Offenbacher in 1996 demonstrated that periodontitis among pregnant women is significantly associated with preterm birth and low birth weight. Pakistan has a high prevalence of these adverse birth outcomes therefore; identifying an intervention is of prime importance and may have social and economic benefits. Methods: One hundred and forty two women were recruited from two private obstetric clinics in Karachi. They were randomized to receive dental scaling and oral hygiene instructions by 28 weeks of gestation (intervention) and oral hygiene instructions only (control). All the controls received scaling after cessation of pregnancy. A qualified and trained dentist conducted the oral examination for the plaque index, gingival bleeding index and the periodontal pocketing. A blinded observer recorded the measures at the time of birth for a composite outcome comprising of either preterm birth (\u3c37weeks of gestation), low birth weight (\u3c2500g birth weight) or still birth. Results: During the interim analysis there were a total of 8 (22.22%) adverse outcomes recorded in the intervention group and 10 (24.39%) adverse outcomes recorded in the control group. The mean gestational age in intervention group was 37.68 (SD 2.23) weeks and in the control group was 37.19 (SD 2.38) weeks. The mean birth weight in the intervention arm was 2893.61 (556.71) grams and the control arm was 2712.5 (487.89) grams. The difference between the two groups was statistically insignificant at p=0.823. Conclusion: There was a reduction in the number of adverse birth events in the intervention group receiving dental scaling and oral hygiene instructions by 28 weeks of gestation as compared to the group which received oral hygiene instructions only. The results were similar to what have been observed in similar trials in developing countries

Epidemiological, Clinical, and Radiological comparison of adult and Pediatric features in COVID-19: A Scoping Review

Objective: To assess epidemiological, clinical, and radiological characteristics of the coronavirus disease in children and adults. Method: The scoping review comprised search on PubMed, Scopus Cochrane, and Google Scholar databases from January 2020 to April 2021 for English-language articles dealing with clinical and radiological manifestations amongst children and adults affected by coronavirus disease.  Two reviewers independently screened the titles and abstracts. Results: Of the 389 studies initially identified, 39(10%) were reviewed in detail. Data suggested that children were less frequently affected by the coronavirus disease. The affected children showed milder disease with low case fatalities compared to the adults. Conclusions: There exists significant gaps in knowledge of clinical and radiological aspects of coronavirus disease, but the available scientific data showed that the disease seems to be unusual in children. Key Words: Children, COVID-19, SARS-CoV2, Epidemiology, Clinical, Radiological. Continuous..

Mucosal immunity to poliovirus in children 0-15 years of age: A community-based study in Karachi, Pakistan in 2019

This study assesses poliovirus type 1 (PV1) immunity in children to inform the contribution of mucosal immunity in and preventing poliovirus circulation. A community-based study was conducted in peri-urban Karachi, Pakistan. Randomly selected children (0-15 years) received oral poliovirus vaccine (OPV) challenge dose. Blood and stool samples were collected at several time points and evaluated for polio-neutralizing antibodies and serotype-specific poliovirus, respectively. 81/589 (14%) children excreted PV1 7 days post-OPV-challenge; 70/81 (86%) were seropositive at baseline. 12/610 (2%) were asymptomatic Wild Poliovirus Type 1 (WPV1) excretors. Most poliovirus excretors had humoral immunity, suggesting mucosal immunity in these children likely waned or never developed. Without mucosal immunity, they are susceptible to poliovirus infection, shedding, and transmission. Asymptomatic WPV1 excretion suggests undetected poliovirus circulation within the community

Impact of COVID-19 on feto-maternal and neonatal health in Karachi, Pakistan, A retrospective cohort study

Scientific literature suggests that pregnant women are at greater risk of acquiring a more severe form of COVID-19 exposing both mother and child to a higher risk of obstetric and neonatal complications. These include increased hospitalization rates, ICU admissions, or ventilatory support among pregnant women when compared to COVID-19 negative pregnant womenA case-control study was conducted at the Aga Khan University Hospital, Karachi, Pakistan with the objective of evaluating the clinical presentation of COVID-19 in pregnancy and its effect on maternal and neonatal outcomes. Data was retrospectively collected from April 2020 till January 2022 of obstetric patients with COVID-19 positive cases and were compared with COVID-19 negative cases from the same time. A total of 491 women were included in the study, 244 cases and 247 controls. The most common complication amongst cases was gestational diabetes mellitus (n = 59, 24%), followed by gestational hypertension (n = 16, 31.7%), pre-eclampsia (n = 13, 5%) Pre-rupture of membrane (85.7%). Amongst the COVID positive mothers the most common presenting complaints were fever followed by dry cough, headache, and shortness of breath. It was observed that COVID-19 did not result in increased adverse maternal or neonatal outcomes compared to COVID-19 negative mother

One-year decline of poliovirus antibodies following fractional-dose inactivated poliovirus vaccine

Background: Fractional dose (1/5th of full intramuscular dose) of inactivated poliovirus-vaccine administered intradermally (fIPV) is used as IPV dose-sparing strategy. We compared the rate of decline of poliovirus antibodies (PVA) in recipients of either two doses of fIPV or IPV.Methods: Community-based randomized controlled trial was conducted in Karachi, Pakistan. Children aged 14 weeks were randomized into fIPV or full IPV study arms (A, B) and received one vaccine doses at 14 weeks and one at 9 months of age. PVA were measured at 14, 18 weeks and 10, 21 months of age.Results: Seroprevalence of poliovirus-type 2 antibodies of 170/250 (68%) enrolled children after two IPV or fIPV doses at 10 months of age in arms-A and B reached 100% vs 99% (p=0.339); and at 21 months it was 86% vs 67% (p=0.004). Between 10 and 21 months of age, the antibody-titers in log2 scale dropped from \u3e=10.5 to 6.8 in arm-A; and from 9.2 to 3.7 in arm B.Interpretation: A significant decline in antibody titers12 months following second IPV dose. The slope of decline is similar for both full IPV and fIPV recipients. The results provide further evidence that fIPV is a viable option for IPV dose-sparing

Two-year duration of immunity of inactivated poliovirus vaccine: A follow-up study in Pakistan in 2020

This was a follow-up study conducted in 2020 assessing changes in levels of type 2 poliovirus-neutralizing antibodies two years post-immunization in children who received inactivated poliovirus vaccine (IPV) in Karachi, Pakistan. Unexpectedly, the findings revealed an increase in seroprevalence of type 2 antibodies from 73.1% to 81.6% one and two years after IPV, respectively. The increase in type 2 immunity could result from the intensive transmission of circulating vaccine-derived poliovirus type 2 (cVDPV2) in Karachi during the second year of IPV administration. This study suggests that the cVDPV2 outbreak detected in Pakistan infected large proportions of children in Karachi. Clinical Trial Registration NCT03286803