What influences family planning in rural Pakistan: Franchised service provider and community health worker perspective

Background: Pakistan has a low modern contraceptive prevalence rate, 26%, leading family planning (FP) programmes to explore partnerships with local private providers to improve access to quality FP services. This study aims to understand the socio-cultural and organizational factors that influence delivery of quality family planning services. Methods: This qualitative study was conducted with private service providers and community health workers (CHW) in Marie Stopes Society\u27s (MSS) social franchise network. A total of 31 providers and 28 CHWs from Sindh, Punjab, and Khyber Pakhtunkhwa provinces of Pakistan were purposively selected for in-depth interviews. The study used thematic content analysis to understand providers\u27 and health workers\u27 perspectives of family planning service provision. Results: This study found that normative environment, propagation of myths and misconceptions, and health concerns remain major barriers to service provision in rural communities. Findings showed that CHWs were instrumental in increasing awareness and positive attitudes towards family planning in the catchment areas. Moreover, social franchising was effective in increasing access to high-quality, subsidised family planning services amongst economically marginalised and low-awareness communities. Providers and health workers expressed satisfaction with the franchising approach, and revealed that being part of this network substantially increased their client volume and ability to serve poorer segments of the population. Conclusion: The study found that franchising private service providers in rural areas enhances their ability to serve clients, and when coupled with demand-generation elements, such as vouchers and community health workers, it substantially increases their client volume. Albeit effective, the franchising approach currently lacks the element of long-term service provision at the current scale, and may require further strategizing by the franchisor. Moreover, alternate strategies should be explored to ensure continued provision of FP services without vouchers and CHWs

HIV infection predominantly affecting children in Sindh, Pakistan, 2019: a cross-sectional study of an outbreak.

BACKGROUND: In April 2019, an HIV screening camp for all ages was established in response to a report of an unusually large number of paediatric HIV diagnoses in Larkana, Pakistan. We aimed to understand the clinical profile of the children who registered for HIV care. METHODS: In this cross-sectional study, we review the outbreak response from the government, academia, and UN agencies in Larkana, Sindh, Pakistan. We report age-stratified and sex-stratified HIV prevalence estimated among individuals screened. For children who registered for HIV care, clinical history of previous injections and blood transfusions, HIV disease stage, hepatitis B and hepatitis C status, and CD4 count was abstracted from clinical records from Sindh AIDS Control Program HIV Clinic (Shaikh Zayed Childrens Hospital, Larkana, Pakistan) and analysed using percentages, χ2 tests, and weight-for-age Z scores. We also analysed data for parents who were tested for HIV. FINDINGS: Between April 24, and July 15, 2019, 31 239 individuals underwent HIV testing, of whom 930 (3%) tested positive for HIV. Of these, 763 (82%) were younger than 16 years and 604 (79%) of these were aged 5 years and below. Estimated HIV prevalence was 3% overall; 7% (283 of 3803) in children aged 0-2 years, 6% (321 of 5412) in children aged 3-5 years, and 1% (148 of 11 251) in adults aged 16-49 years. Of the 591 children who registered for HIV care, 478 (81%) were 5 years or younger, 379 (64%) were boys, and 315 (53%) of 590 had a weight-for-age Z score of -3·2. Prevalence of hepatitis B surface antigen was 8% (48 of 574) and hepatitis C antibody positivity was 3% (15 of 574). Of children whose mothers tested for HIV, only 39 (11%) of 371 had HIV-positive mothers. Most children (404 [89%] of 453) reported multiple previous injections and 40 (9%) of 453 reported blood transfusions. INTERPRETATION: This HIV outbreak is unprecedented among children in Pakistan: a 54% increase in paediatric HIV diagnoses over the past 13 years. The outbreak was heavily skewed towards young children younger than 5 years, with a predominance of boys. Epidemiological and molecular studies are needed to understand the full extent of the outbreak and its drivers to guide HIV control strategies. FUNDING: None

EPG5-related Vici syndrome: a paradigm of neurodevelopmental disorders with defective autophagy

Vici syndrome is a progressive neurodevelopmental multisystem disorder due to recessive mutations in the key autophagy gene EPG5. We report genetic, clinical, neuroradiological, and neuropathological features of 50 children from 30 families, as well as the neuronal phenotype of EPG5 knock-down in Drosophila melanogaster. We identified 39 different EPG5 mutations, most of them truncating and predicted to result in reduced EPG5 protein. Most mutations were private, but three recurrent mutations (p.Met2242Cysfs*5, p.Arg417*, and p.Gln336Arg) indicated possible founder effects. Presentation was mainly neonatal, with marked hypotonia and feeding difficulties. In addition to the five principal features (callosal agenesis, cataracts, hypopigmentation, cardiomyopathy, and immune dysfunction), we identified three equally consistent features (profound developmental delay, progressive microcephaly, and failure to thrive). The manifestation of all eight of these features has a specificity of 97%, and a sensitivity of 89% for the presence of an EPG5 mutation and will allow informed decisions about genetic testing. Clinical progression was relentless and many children died in infancy. Survival analysis demonstrated a median survival time of 24 months (95% confidence interval 0–49 months), with only a 10th of patients surviving to 5 years of age. Survival outcomes were significantly better in patients with compound heterozygous mutations (P = 0.046), as well as in patients with the recurrent p.Gln336Arg mutation. Acquired microcephaly and regression of skills in long-term survivors suggests a neurodegenerative component superimposed on the principal neurodevelopmental defect. Two-thirds of patients had a severe seizure disorder, placing EPG5 within the rapidly expanding group of genes associated with early-onset epileptic encephalopathies. Consistent neuroradiological features comprised structural abnormalities, in particular callosal agenesis and pontine hypoplasia, delayed myelination and, less frequently, thalamic signal intensity changes evolving over time. Typical muscle biopsy features included fibre size variability, central/internal nuclei, abnormal glycogen storage, presence of autophagic vacuoles and secondary mitochondrial abnormalities. Nerve biopsy performed in one case revealed subtotal absence of myelinated axons. Post-mortem examinations in three patients confirmed neurodevelopmental and neurodegenerative features and multisystem involvement. Finally, downregulation of epg5 (CG14299) in Drosophila resulted in autophagic abnormalities and progressive neurodegeneration. We conclude that EPG5-related Vici syndrome defines a novel group of neurodevelopmental disorders that should be considered in patients with suggestive features in whom mitochondrial, glycogen, or lysosomal storage disorders have been excluded. Neurological progression over time indicates an intriguing link between neurodevelopment and neurodegeneration, also supported by neurodegenerative features in epg5-deficient Drosophila, and recent implication of other autophagy regulators in late-onset neurodegenerative disease

Determination of intravascular volume status in critically ill patients using portable chest X-rays: Measurement of the vascular pedicle width

Background and Aims: Traditionally, invasive hemodynamic pressure measurements have been used to assess the volume status in critically ill patients. The vascular pedicle, as seen on chest radiographs, is the mediastinal silhouette of the great vessels. It is measured by drawing a perpendicular line from the point at which the left subclavian artery emerges from the aortic arch and measured across to the point at which the superior vena cava crosses the right main stem bronchus. We carried out this study to establish a correlation between the width of the vascular pedicle as seen on chest radiographs and daily fluid balance or pulmonary capillary occlusion pressure in mechanically ventilated, critically ill patients. Materials and Methods: In this prospective clinical study, 50 consecutive adult patients in a tertiary care, multidisciplinary intensive care unit underwent simultaneous measurements of the width of the vascular pedicle as seen on standardized, portable chest radiographs in the supine position and pulmonary capillary occlusion pressure measurements. Twenty-four hour fluid balance calculations were also recorded for each patient. Results: Vascular pedicle width measurements correlated closely with positive fluid balance, r = + 0.88, P 0.000. A Receiver Operating Characteristic curve demonstrated that a vascular pedicle width of 86.5 mm had a 100% sensitivity and an 80% specificity (area under the curve 0.823, 95% confidence intervals 0.714-0.932) for predicting fluid overload equal to and greater than 1200 ml. The correlation between pulmonary capillary occlusion pressures and width of the vascular pedicle was poor, r = 0.41, P 0.02. Conclusions: Our findings suggest that the vascular pedicle width on daily chest radiographs can be used to assess hypervolemia in the intensive care unit. Serial changes in the pedicle width could possibly be used to increase the accuracy of predictions

Government purchasing initiatives involving private providers in the Eastern Mediterranean Region: a systematic review of impact on health service utilisation

Objective This paper provides a systematic review of evidence of government purchase of health services from private providers through stand-alone contracting-out (CO) initiatives and CO insurance schemes (CO-I) on health service utilisation in Eastern Mediterranean Region (EMR) to inform universal health coverage 2030 strategies.Design Systematic review.Data sources Electronic search of published and grey literature on Cochrane Central Register of Controlled Trials, PubMed, CINHAL, Google Scholar and web, including websites of ministries of health from January 2010 to November 2021.Eligibility criteria Randomised controlled trials, quasi-experimental studies, time series, before–after and endline with comparison group reporting quantitative utilisation of data across 16 low-income and middle-income states of EMR. Search was limited to publications in English or English translation.Data extraction and synthesis We planned for meta-analysis, but due to limited data and heterogeneous outcomes, descriptive analysis was performed.Results Several initiatives were identified but only 128 studies were eligible for full-text screening and 17 met the inclusion criteria. These included CO (n=9), CO-I (n=3) and a combination of both (n=5) across seven countries. Eight studies assessed interventions at national level and nine at subnational level. Seven studies reported on purchasing arrangements with non-governmental organisations, 10 on private hospitals and clinics. Impact on outpatient curative care utilisation was seen in both CO and CO-I, positive evidence of improved maternity care service volumes was seen mainly from CO interventions and less reported from CO-I, whereas data on child health service volume was only available for CO and indicated negative impact on service volumes. The studies also suggest pro-poor effect for CO initiatives, whereas there was scarce data for CO-I.Conclusion Purchasing involving stand-alone CO and CO-I interventions in EMR positively impact general curative care utilisation, but lacks conclusive evidence for other services. Policy attention is needed for embedded evaluations within programmes, standardised outcome metrics and disaggregated utilisation data

Comparative Analysis of Microbial Consortiums and Nanoparticles for Rehabilitating Petroleum Waste Contaminated Soils

Nano-bioremediation application is an ecologically and environmentally friendly technique to overcome the catastrophic situation in soil because of petroleum waste contamination. We evaluated the efficiency of oil-degrading bacterial consortium and silver nanoparticles (AgNPs) with or without fertilizer to remediate soils collected from petroleum waste contaminated oil fields. Physicochemical characteristics of control soil and petroleum contaminated soils were assessed. Four oil-degrading strains, namely Bacillus pumilus (KY010576), Exiguobacteriaum aurantiacum (KY010578), Lysinibacillus fusiformis (KY010586), and Pseudomonas putida (KX580766), were selected based on their in vitrohydrocarbon-degrading efficiency. In a lab experiment, contaminated soils were treated alone and with combined amendments of the bacterial consortium, AgNPs, and fertilizers (ammonium nitrate and diammonium phosphate). We detected the degradation rate of total petroleum hydrocarbons (TPHs) of the soil samples with GC-FID at different intervals of the incubation period (0, 5, 20, 60, 240 days). The bacterial population (CFU/g) was also monitored during the entire period of incubation. The results showed that 70% more TPH was degraded with a consortium with their sole application in 20 days of incubation. There was a positive correlation between TPH degradation and the 100-fold increase in bacterial population in contaminated soils. This study revealed that bacterial consortiums alone showed the maximum increase in the degradation of TPHs at 20 days. The application of nanoparticles and fertilizer has non-significant effects on the consortium degradation potential. Moreover, fertilizer alone or in combination with AgNPs and consortium slows the rate of degradation of TPHs over a short period. Still, it subsequently accelerates the rate of degradation of TPHs, and a negligible amount remains at the end of the incubation period

HIV infection predominantly affecting children in Sindh, Pakistan, 2019: A cross-sectional study of an outbreak

Background: In April 2019, an HIV screening camp for all ages was established in response to a report of an unusually large number of paediatric HIV diagnoses in Larkana, Pakistan. We aimed to understand the clinical profile of the children who registered for HIV care.Methods: In this cross-sectional study, we review the outbreak response from the government, academia, and UN agencies in Larkana, Sindh, Pakistan. We report age-stratified and sex-stratified HIV prevalence estimated among individuals screened. For children who registered for HIV care, clinical history of previous injections and blood transfusions, HIV disease stage, hepatitis B and hepatitis C status, and CD4 count was abstracted from clinical records from Sindh AIDS Control Program HIV Clinic (Shaikh Zayed Childrens Hospital, Larkana, Pakistan) and analysed using percentages, χ2 tests, and weight-for-age Z scores. We also analysed data for parents who were tested for HIV.Findings: Between April 24, and July 15, 2019, 31 239 individuals underwent HIV testing, of whom 930 (3%) tested positive for HIV. Of these, 763 (82%) were younger than 16 years and 604 (79%) of these were aged 5 years and below. Estimated HIV prevalence was 3% overall; 7% (283 of 3803) in children aged 0-2 years, 6% (321 of 5412) in children aged 3-5 years, and 1% (148 of 11 251) in adults aged 16-49 years. Of the 591 children who registered for HIV care, 478 (81%) were 5 years or younger, 379 (64%) were boys, and 315 (53%) of 590 had a weight-for-age Z score of -3·2. Prevalence of hepatitis B surface antigen was 8% (48 of 574) and hepatitis C antibody positivity was 3% (15 of 574). Of children whose mothers tested for HIV, only 39 (11%) of 371 had HIV-positive mothers. Most children (404 [89%] of 453) reported multiple previous injections and 40 (9%) of 453 reported blood transfusions.Interpretation: This HIV outbreak is unprecedented among children in Pakistan: a 54% increase in paediatric HIV diagnoses over the past 13 years. The outbreak was heavily skewed towards young children younger than 5 years, with a predominance of boys. Epidemiological and molecular studies are needed to understand the full extent of the outbreak and its drivers to guide HIV control strategies