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

Situational analysis of antimicrobial stewardship program (ASP) among public and private tertiary care hospitals in Karachi : a qualitative case study

Antimicrobial Resistance arises as a substantial threat to the Global Health sanctuary. Unbefitting use of antimicrobials is linked to the growth and spread of drug-resistant microorganisms and is associated with increased mortality, morbidity, length of hospital stay (LOS) and healthcare expenditure. Despite being a natural phenomenon it is promulgated by misuse of antimicrobial medicines, inexistent or inadequate programs for infection prevention and control, weak laboratory capacities, poor quality and counterfeit drugs, ineffective surveillance and regulations for the use of antimicrobial medicines. Antimicrobial Stewardship is the umbrella term for an evidence-based knowledge, translation strategy containing comprehensive quality enhancement activities for optimal use of antimicrobials, improvise patient\u27s clinical outcomes, reduces the progress of antimicrobial resistance and hospital acquired infections such as clostridium difficile and reduce healthcare expenditures. There is scarcity of available literature about antimicrobial stewardship within Pakistan and not much is known about ASP development and implementation. The study aims to assess the current status of implementation of ASP and to identify the barriers and facilitators faced by hospital leadership for its implementation among public and private tertiary care hospitals of Karachi, Pakistan. Moreover, the study also aims to identify the challenges faced by Provincial and National Key Stakeholders for formulation, implementation and monitoring of ASP. Methods: The study employed an exploratory case study design because there is scant knowledge about the development and implementation of the ASP at the organizational level in Karachi and at provincial and national level. For this study, data was collected from 3 public and 4 private tertiary care hospitals in city of Karachi. Twenty Eight in-depth interviews were conducted from the higher and middle management which included Chief Executive Officer, Chief Medical Officer, Medical Superintendent and departmental heads of internal medicine, general surgery and paediatric respectively. Purposive sampling was done to include higher and middle managers whereas the infectious diseases consultant, infectious diseases/clinical pharmacist and clinical microbiologist were interviewed throUgh snow ball sampling methodology at the public and private tertiary care hospitals. Moreover, two key informant interviews were conducted consisting one each from provincial and national stakeholders, again sampling was done purposively. The findings of in-depth and key informant interviews were analyzed via computer-assisted analysis software NVivo. Themes were generated out of the nodes and sub-nodes of the collected data. Information was triangulated between the higher and middle managers and amongst the provincial and federal stakeholders. Results: In this study we found that more than two thirds (n=7, 71%) of tertiary care hospitals in Karachi do not have structured ASP which includes major public sector hospitals (n=3, 43%) and half of private sector hospitals (n=4, 29%). The biggest barrier faced by hospital leadership for the implementation of ASP were related to lack of funding, lack of expertise such as infectious diseases physicians and infectious diseases pharmacist, inadequate information technology resources, non-compliance with infection control and prevention practices, lack of extra benefits and support and prescriber opposition. However, the facilitators were related to acceptance and existence of ASP, dealing of physician antagonism, multidisciplinary team, steward\u27s empowerment and institutional surveillance and reporting mechanism. Moreover, the institutes where ASP is not formulated the resultant emerging themes were; inadequate institutional/hospital based initiatives for antimicrobial control and management, departmental based initiatives for antimicrobial control/management and rationalize use of antimicrobials, improvising means for the formulation and development of ASP and barriers for the formulation of ASP. Moreover, the key findings of the challenges faced by provincial and national key stakeholders for formulation, implementation and monitoring of ASP were related to knowledge and skills, laboratory, accountability, human assets, financial, measures and medications. The three biggest challenges highlighted by provincial and national stakeholder were lack of national policy on surveillance of antimicrobial resistance, weak understanding and limited awareness regarding AMR and ASP, and dearth of expertise. Both stakeholders emphasized that there is a need to establish a coherent vision for antimicrobial stewardship at federal level that need to be executed countrywide. Conclusion: The study identifies the serious dearth of ASP in one of the major city of the country. There are serious barriers and challenges in public sector hospitals as compared to the private sector hospitals. The provincial and federal stakeholders identify AMR as a major public health challenge for the Pakistan. The study even highlights the importance of engaging health ministry in implementing ASP policies at each and all healthcare institutes of the country

Emerging challenges and threats for dental health care sector attributable to COVID-19: Tale of a developing country

Prevention and control of infection in dentistry is an essential matter that has gained immense attention in recent years. There exist a lack of scientific data about the cross-transmission and its associated risk, especially in the dental health care setting of Pakistan. This article will evaluate the emerging challenges and threats for the dental community in Pakistan attributable to the COVID-19 outbreak. Moreover, there exists a significant knowledge gap regarding the state- and institutional-level infection prevention and control (IPC) policies and practices and not much is known about the development, implementation, and monitoring of IPC policies and its challenges

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

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