A randomized comparative study of efficacy and safety of saroglitazar with fenofibrate in diabetic dyslipidemic patients on metformin and glimeperide

Background: This study was conducted to compare the efficacy and safety of saroglitazar with fenofibrate in Indian diabetic dyslipidemic patients who were on Metformin and Glimepiride.Methods: Adults patients with diabetic dyslipidaemia fulfilling the inclusion criteria were randomized in two groups. Group A patients received metformin (1000 mg/ day) + Glimepiride (4 mg/day) with fenofibrate (160 mg/day), while group B patients received metformin (1000 mg/day) + Glimepiride (4 mg/day) with saroglitazar (4 mg/day). Glycosylated haemoglobin (HbA1C), triglyceride (TG), LDL- cholesterol (LDL-C), HDL-cholesterol (HDL-C) levels were measured at baseline and at 12 weeks. Fasting plasma glucose (FPG) and post prandial plasma glucose (PPPG) were measured at baseline and at 4, 8 and 12 weeks.Results: There was a significant reduction in TG and HbA1C levels at 12 weeks from the baseline value (p=0.001) in both groups. However, there was no significant reduction in TG between the groups at 12 weeks but HbA1C levels in group B decreased significantly compared to group A at 12 weeks. Also, there was a significant reduction in FPG and PPPG levels at 4, 8 and 12 weeks in both groups from their baseline values (p=0.001). The reduction in FPG and PPPG levels in group B was statistically significantly compared to group A at every interval. There was statistically significant change in LDL-C and HDL-C at 12 weeks from baseline in both the groups. Also, there was significant rise in HDL-C in group B when compared to group A.Conclusions: Group B patients on saroglitazar with metformin and Glimepiride showed a significant reduction in HbA1C, FPG and PPG levels compared to group A patients on fenofibrate with metformin and Glimepiride

Effect of mobile phone text message reminders on routine immunization uptake in Pakistan: randomized controlled trial

Background: Improved routine immunization (RI) coverage is recommended as the priority public health strategy to decrease vaccine-preventable diseases and eradicate polio in Pakistan and worldwide.Objective: The objective of this study was to ascertain whether customized, automated, one-way text messaging (short message service, SMS) reminders delivered to caregivers via mobile phones when a child is due for an RI visit can improve vaccination uptake and timelines in Pakistan.Methods: This was a randomized controlled trial, conducted in an urban squatter settlement area of Karachi, Pakistan. Infants less than 2 weeks of age with at least one family member who had a valid mobile phone connection and was comfortable receiving and reading SMS text messages were included. Participants were randomized to the intervention (standard care + one-way SMS reminder) or control (standard care) groups. The primary outcome was to compare the proportion of children immunized up to date at 18 weeks of age. Vaccine given at 6, 10, and 14 weeks schedule includes DPT-Hep-B-Hib vaccine (ie, diphtheria, pertussis, and tetanus; hepatitis B; and Haemophilus influenza type b) and oral poliovirus vaccine (OPV). Data were analyzed using chi-square tests of independence and tested for both per protocol (PP) and intention-to-treat (ITT) analyses.Results: Out of those approached, 84.3% (300/356) of the participants were eligible for enrollment and 94.1% (318/338) of the participants had a working mobile phone. Only children in the PP analyses, who received an SMS reminder for vaccine uptake at 6 weeks visit, showed a statistically significant difference (96.0%, 86/90 vs 86.4%, 102/118; P=.03).The immunization coverage was consistently higher in the intervention group according to ITT analyses at the 6 weeks scheduled visit (76.0% vs 71.3%, P=.36). The 10 weeks scheduled visit (58.7% vs 52.7%, P=.30) and the 14 weeks scheduled visit (31.3% vs 26.0%, P=.31), however, were not statistically significant.Conclusions: Automated simple one-way SMS reminders in local languages might be feasible for improving routine vaccination coverage. Whether one-way SMS reminders alone can have a strong impact on parental attitudes and behavior for improvement of RI coverage and timeliness needs to be further evaluated by better-powered studies and by comparing different types and content of text messages in low-and middle-income countries (LMICs)

Operability, acceptability, and usefulness of a mobile app to track routine immunization performance in rural Pakistan: Interview study among vaccinators and key informants

Background: There has been a recent spate of mobile health (mHealth) app use for immunizations and other public health concerns in low- and middle-income countries. However, recent evidence has largely focused on app development or before-and-after effects on awareness or service coverage. There is little evidence on the factors that facilitate adoption of mHealth programs, which is critical to effectively embed digital technology into mainstream health systems. Objective: This study aimed to provide the qualitative experiences of frontline health staff and district managers while engaging with real-time digital technology to improve the coverage of routine childhood immunization in an underserved rural district in Pakistan. Methods: An Android-based app was iteratively developed and used for a 2-year period in 11 union councils of the Tando Muhammad Khan district, an underserved rural district with poor immunization coverage in Pakistan. We used iterative methods to examine the (1) acceptability and operability of the app, (2) validity of the collected data, and (3) use of the collected data. In addition, we collected the barriers and enablers for uptake of the mHealth app. Each of these topics was further explored related to changes in work as well as the enabling factors for and barriers to app use. In-depth interviews were conducted with the 26 vaccinators posted in the 11 union councils and 7 purposively selected key informants (government district managers) involved with the Expanded Program for Immunization. Findings were triangulated in line with the three broad research areas. Results: Digital immunization tracking was considered acceptable by vaccinators and district managers. Real-time immunization data were used to monitor vaccination volume, track children with incomplete vaccinations, develop outreach visit plans, correct existing microplans, and disburse a fuel allowance for outreach sessions. The validity of the app data was perceived to be superior to that of data from manual records. Ease of operability, satisfaction with data, personal recognition, links to field support, and a sense of empowerment served as powerful enablers. Taking twice the time to complete both manual and digital entries and outdated phones over time were considered constraints. An unintended knock-on effect was improved coordination and strengthening of Expanded Program for Immunization review platforms across district stakeholders through digitalized data. Conclusions: Embedding digital technology into mainstream health systems relies on use by both end users and district stakeholders. Ease of operability, satisfaction with data reliability, personal recognition, links to field support, and empowerment are powerful enablers, whereas improved coordination as a result of easy, transparent data access can be an important by-product of digitalization. Findings are relevant not only for wide-scale implementation of immunization tracking apps in Pakistan but also for informing the use of digital technology for results-based delivery by frontline health workers

Geo-spatial reporting for monitoring of household immunization coverage through mobile phones: Findings from a feasibility study

Background: The addition of Global Positioning System (GPS) to a mobile phone makes it a very powerful tool for surveillance and monitoring coverage of health programs. This technology enables transfer of data directly into computer applications and cross-references to Geographic Information Systems (GIS) maps, which enhances assessment of coverage and trends.Objective: Utilization of these systems in low and middle income countries is currently limited, particularly for immunization coverageassessments and polio vaccination campaigns. We piloted the use of this system and discussed its potential to improve the efficiency of field-based health providers and health managers for monitoring of the immunization program.Methods: Using 30×7 WHO sampling technique, a survey of children less than five years of age was conducted in random clusters of Karachi, Pakistan in three high risk towns where a polio case was detected in 2011. Center point of the cluster was calculated by the application on the mobile. Data and location coordinates were collected through a mobile phone. This data was linked with an automated mHealth based monitoring system for monitoring of Supplementary Immunization Activities (SIAs) in Karachi. After each SIA, a visual report was generated according to the coordinates collected from the survey.Result: A total of 3535 participants consented to answer to a baseline survey. We found that the mobile phones incorporated with GIS maps can improve efficiency of health providers through real-time reporting and replacing paper based questionnaire for collection of data at household level. Visual maps generated from the data and geospatial analysis can also give a better assessment of the immunizationcoverage and polio vaccination campaigns.Conclusion: The study supports a model system in resource constrained settings that allows routine capture of individual level data through GPS enabled mobile phone providing actionable information and geospatial maps to local public health managers, policy makers and study staff monitoring immunization coverage

Impact of maternally derived pertussis antibody titers on infant whole-cell pertussis vaccine response in a low income setting

Background: Maternal vaccines against pertussis are not yet recommended in the developing world. Besides unclear burden estimates, another concern is that transplacental transfer of maternal pertussis antibodies could result in attenuation of the immune response to whole cell pertussis (DTwP) primary vaccination series in infants. This study was taken up to determine whether higher levels of maternal pertussis antibodies attenuate immune response of infants to DTwP vaccination series given at 6-10-14 weeks of age.Methodology: A total of 261 pregnant women and their infants from four low-income settlements in Karachi, Pakistan were enrolled in this study. The study endpoints were infant antibody titers for Pertussis toxin (PTx), Filamentous hemagglutinin antigen (FHA), Pertactin (PRN) and Fimbriae type 2/3 (FIM) - from birth through 18 weeks of age. Cord blood or pre-vaccine pertussis antibody titers indicate the concentration of maternal antibodies transferred to infants. Linear regression models were used to determine the association between higher maternal antibody titers and infant immune response to DTwP vaccine. Geometric Mean Ratio (GMR) was calculated as the ratio of infant antibody titers at specified time points against the maternal antibody titers at the time of delivery.Results: At eighteen weeks of age, the adjusted β regression coefficient for PTx was 0.06 (95% CI: -0.49-0.61), FHA 0.02 (95% CI: -0.26 -0.29), PRN 0.02 (95%CI -0.38- 0.43), and FIM 0.17 (95%CI: -0.21-0.54). Among infants who received at least two doses of DTwP vaccine, higher maternal antibody titers did not have any attenuating effect on infant post-immunization antibody titers against all four pertussis antigens.Conclusion: Maternal pertussis antibodies did not attenuate infant\u27s immune response to pertussis antigens in DTwP primary vaccine given at 6-10-14 weeks of age

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

ACORN (A Clinically-Oriented Antimicrobial Resistance Surveillance Network) II: protocol for case based antimicrobial resistance surveillance

Background: Antimicrobial resistance surveillance is essential for empiric antibiotic prescribing, infection prevention and control policies and to drive novel antibiotic discovery. However, most existing surveillance systems are isolate-based without supporting patient-based clinical data, and not widely implemented especially in low- and middle-income countries (LMICs). Methods: A Clinically-Oriented Antimicrobial Resistance Surveillance Network (ACORN) II is a large-scale multicentre protocol which builds on the WHO Global Antimicrobial Resistance and Use Surveillance System to estimate syndromic and pathogen outcomes along with associated health economic costs. ACORN-healthcare associated infection (ACORN-HAI) is an extension study which focuses on healthcare-associated bloodstream infections and ventilator-associated pneumonia. Our main aim is to implement an efficient clinically-oriented antimicrobial resistance surveillance system, which can be incorporated as part of routine workflow in hospitals in LMICs. These surveillance systems include hospitalised patients of any age with clinically compatible acute community-acquired or healthcare-associated bacterial infection syndromes, and who were prescribed parenteral antibiotics. Diagnostic stewardship activities will be implemented to optimise microbiology culture specimen collection practices. Basic patient characteristics, clinician diagnosis, empiric treatment, infection severity and risk factors for HAI are recorded on enrolment and during 28-day follow-up. An R Shiny application can be used offline and online for merging clinical and microbiology data, and generating collated reports to inform local antibiotic stewardship and infection control policies. Discussion: ACORN II is a comprehensive antimicrobial resistance surveillance activity which advocates pragmatic implementation and prioritises improving local diagnostic and antibiotic prescribing practices through patient-centred data collection. These data can be rapidly communicated to local physicians and infection prevention and control teams. Relative ease of data collection promotes sustainability and maximises participation and scalability. With ACORN-HAI as an example, ACORN II has the capacity to accommodate extensions to investigate further specific questions of interest

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Recent advancements in nonwoven bio-degradable facemasks to ameliorate the post-pandemic environmental impact

Plastics have become a severe risk to natural ecosystems and human health globally in the last two decades. The outbreak of the coronavirus pandemic, which led to the manufacturing and use of billions of facemasks made from non-biodegradable and petroleum-derived polymers has aggravated the situation further. There is an urgent need to develop bio-degradable facemasks with excellent filtration efficiency and antimicrobial characteristics using scalable technology. This review article aims to provide the fundamentals of mask technology, its environmental footprint, facemask’s lifecycle assessment, conventional manufacturing routes, and state-of-the-art reports on using bio-degradable polymers for facemask applications. The article also focuses on the current challenges of the conventional facemask and the prospects of an ideal facemask that could significantly reduce the ill effects of petroleum-based polymers. The review includes concise information on the basics of polymer biodegradation and standardized tests to evaluate biodegradability. The use of currently available facemasks has been an effective measure to curb the infection rate, however, is a threat to the environment. Reusing the facemask after decontamination is not a solution from a safety perspective as cloth-based facemasks have lower filtration efficiencies which get further reduced with the washing cycle necessitating a shift towards biodegradable facemask. Systematic information is provided through this article to stimulate research on a bio-degradable facemask with excellent filtration efficiency, antimicrobial properties, and cost-effectiveness for global usage

Effect of mobile phone text messages reminders on uptake of routine immunization among children in Pakistan- Study protocol for a randomized clinical trial

Introduction: Routine Immunization (RI) is considered one of the best public health interventions to decrease child morbidity and mortality. The RI coverage in Pakistan is still well below the desired level, leading to continued polio transmission, large measles outbreaks and thousands of deaths from vaccine-preventable illnesses. Different innovative and cost effective strategies are required to look into for enhancement in vaccination uptake and coverage. We plan to test the effectiveness of reminders to parents/caregivers on cell phones through short messaging system (SMS) in improving vaccine uptake and on-time routine immunization for children in Pakistan.Methods and Analysis: A parallel-randomized controlled trial will be conducted to assess the effectiveness of short messaging service (SMS) text reminders on the mobile phones in improving the uptake and on-time vaccination for routine immunization in children at 6,10 and 14 weeks of age according to the EPI schedule in Pakistan. The trial consists of 300 children with allocation of parallel 1:1 to the SMS reminders or to standard care (control group). The intervention arm in addition to the standard counseling will receive four SMS reminders according to the language preference in the week that the enrolled child is due for routine immunization at 6, 10 and 14-week schedule. The primary outcome is to evaluate whether text reminders can improve uptake and on-time vaccination for routine immunization at 6, 10 and 14 weeks’ schedule. Assumptions used for calculating sample size are increase in coverage rate from 60% to 80%, power at 0.8, alpha error at 0.05 and allowing for 10% dropout.Ethics and Dissemination: Study protocol and associated study instruments, will be submitted to the Aga Khan University’s Ethical Review Committee for approval before commencement of any study activities. Results will be disseminated to pediatric and public health communities in Pakistan through scientific meetings