Hepatitis E virus seroprevalence in pregnant women in Pakistan: maternal and fetal outcomes

Hepatitis E virus [HEV] is endemic in Pakistan. Although otherwise asymptomatic, HEV infection becomes fatal in pregnancy, with considerable maternal and fetal morbidity and mortality. We conducted a descriptive study from April to October 2015 in 10 tertiary care hospitals throughout Pakistan to determine maternal and fetal morbidity and mortality in HEV-positive pregnant women with acute jaundice or raised liver function tests. Twenty-one of 135 women were HEV positive and in 3rd trimester except for 1 in 1st trimester. Overall prevalence of HEV in pregnancy was 0.19%. Ten women were artificially induced, 3 had premature labour, 4 delivered spontaneously [full term], 3 died and there was 1 intrauterine death. One woman had a home abortion before coming to hospital. There were 7 perinatal infant deaths: 4 intrauterine, 3 stillbirths and 1 abortion. Maternal mortality was significantly associated with delivery, as 17 mothers who lived went into labour spontaneously or were artificially induced, whereas 3 women who continued their pregnancy and did not deliver, died. Case fatality rate of HEV infection in pregnancy was 14.2%

Anxiety among the young cardiac patients - a neglected illness

Objective: To explore the prevalence of anxiety among young cardiac patients visiting tertiary care hospital, Rawalpindi

Study Design: Observational cross-sectional study

Place and Duration of Study: Rawalpindi Institute of Cardiology [RIC], from 27[th] Jun to 30[th] Sep 2016

Material and Methods: After ethical clearance and approval of the supervisor of Rawalpindi Institute of Cardiology, data were collected from the OPD patients of Rawalpindi Institute of Cardiology over a period of one month. Patients were briefed about the nature of study and after informed written consent, information was collected through face to face interviews by trained data collectors using General anxiety Disorder [GAD] scale. SPSS-21 was used for data analysis

Results: A total 237 patients were interviewed and male to female ratio was 1.4:1 [140:97]. Age ranged from 20-40 years with mean of 32 +/- 5.2 years. Overall prevalence of anxiety was 25.5%. There was not statistically significant difference observed in anxiety levels between male [23, 9%] and females [25, 11%], [p-value: 1.000]. The participants were divided into 4 age groups and group 4 [36-40 years] was most affected group. However, none of the group showed statistically association with age groups. A statistically significant relationship is found with unemployment and anxiety [OR: 2.8, p-value: <.005]. However there was no relationship between duration of cardiac illness and anxiety [p-value: .588]

Conclusion: Moderate level of anxiety was most prevalent among the 30-40 years age group

Assessment of attitude, an insight from hepatitis patients and their relatives/ attendants of Islamabad, Pakistan

Background: Pakistan is the 2[nd] highest hepatitis C prevalent country while hepatitis B endemnicity is intermediate. Population has poor knowledge and understanding of these diseases therefore they face different types of stigmas. Stigmatization leads to barriers in the access of prevention and care of this disease. This study was conducted to evaluate the feelings and experiences of patients and their attendants [relatives] about hepatitis B and C and identify the gaps to ease access to treatment and care

Study design, settings and duration: Qualitative study conducted in Pakistan Institute of Medical Sciences and Federal Government Services Hospital, Islamabad for 08 months

Patients and Methods: Patients suffering from hepatitis B and C and their relatives who came to the OPDs of PIMS and Polyclinic were selected from the study. After taking consent from these 2 hospitals and consent from participants, the patients and relatives were grouped into 4 groups each comprising of 5-8 participants. Four focus group discussions [FGD's] were conducted for these patients and their attendants separately. Structured FGD guide was developed and special probes were used to stimulate discussion

Results: There were 06 participants in each of patient group and 07 subjects in relative groups. Among patients, majority had negative perceptions about disease and related the disease with fear. They had misconceptions about disease spread. Most of them experienced change in the attitude of family members, relatives and friends especially in sharing clothes, shoes, and utensils. Break up of relationships and discrimination in getting a job due to the disease was also reported resulting in social and financial problems. The attendants also had negative perception about the disease and its mode of transmission. Although they were cautious about the sharing of utensils and during patient care but they had positive feeling for their patient

Conclusion: Due to misconception about disease spread, the attendants/relatives were not sharing items of daily use items like cloths, crockery and bed linen with the patients thus giving them a feeling of dejection. Proper information about disease spread and its prevention along with the counseling of the patients and their attendants/relatives may build a positive relationship between them and thus ease help and care which is required for these patients

Policy message: There is need of public awareness about mode of transmission of hepatitis B and C and its preventive measures

Awareness regarding gestational diabetes mellitus among pregnant women at tertiary care hospital, Rawalpindi, Pakistan

To assess awareness about gestational diabetes mellitus in pregnant cases attending antenatal clinic at Holy Family hospital. Cross sectional study, at antenatal clinic gynae and obstetric department unit II, Holy Family Hospital Rawalpindi, for two months [January-February 2014]. Using convenient sampling, all consecutive pregnant cases visiting antenatal clinics were enrolled and interviewed by trained medical officers. A pretested proforma was used to record the information which included information under three heads i.e. demography, knowledge about diabetes, gestational diabetes and its management. The data was analyzed as frequencies and percentages using spss 17 version. A total of 500 pregnant cases were interviewed, of whom 80% were from urban areas, 32.8% were primi-gravida and 14% were illiterate, 436 [87.2%] knew about the disease however only 170 [30%] could tell the normal blood sugar Level. Majority [77.2%] of the patients knew that diabetes is inherited. Regarding Gestational Diabetes Mellitus [GDM], 302 [60.4%] knew that it develops during pregnancy and 67% considered it is a high risk condition. Almost 49% knew that un- controlled diabetes could cause fetal and maternal complications. Majority 332 [66%] was of opinion that GDM could lead to diabetes in future while 302 [60.4%] thought that it will persist after pregnancy. About treatment, 246 [49.2%] knew about insulin therapy, whereas only 160 [32%] knew the signs and symptoms of hypoglycemia. Exercise and diet were considered important for the control and prevention of diabetes by 440 [88%] and 404 [88%] and 404 [80.8%] thought that obesity had a definitive relation in development of diabetes. Pregnant cases had good knowledge about gestational diabetes, its associated risks, progress of disease, confounding factors and its prevention. However knowledge about disease specific maternal and fetal morbidities was deficient

Retrospective analysis of acute hepatitis e infection in hospitalized pregnant cases

Hepatitis E virus [HEV] is endemic in Pakistan with 16-19% seropositivity of HEV IgG antibodies. The HEV is considered fatal during pregnancy as compared to general population. The objective of the study was to determine the maternal and fetal morbidity and mortality in HEV IgM positive pregnant cases. The study was conducted in four hospitals i.e. Pakistan Institute of Medical Sciences, Islamabad, Isra University Hospital Jamshoro, Sindh, Lady reading Hospital and Hayatabad Medical Complex, Peshawar, Khyber Pakhtoonkhwa. The medical record of pregnant cases from 2008 to 2011 was retrieved who were positive for HEV IgM. Information about age, gestational age, viral markers [HEV IgM, HBsAg, anti HCV], complications during pregnancy and outcome were recorded on pre design questionnaire. Data was analyzed using SPSS version 15. Medical record of 70 HEV positive pregnant cases was retrieved and out of these, 34 were found complete and analyzed further. The median age was 26 years. Twenty six pregnancies [76%] were in 3[rd] trimesters, 05 in 2[nd] trimester and 01 in 1[st] trimester. Pruiritis was the commonest symptom [28 cases], followed by jaundice [27], nausea/ vomiting [25] and encephalopathy [18]. Of 34 cases, 12 were artificially induced, 08 had premature labor, 04 delivered spontaneously [full term], 04 died undelivered and 04 continued till term. One got delivered at home and another had an abortion at home before coming to hospital. A total of 12 mothers along with their undelivered babies died, of these 08 were in 3[rd] trimester and 04 in 2[nd] trimester. Four out of 07 babies who were delivered prematurely also died. Maternal mortality was directly associated with delivery as 24 out of 34 mothers survived who were delivered either naturally or were induced while 12 out of 34 who continued their pregnancy died [p<=0 .004]. Third trimester had the highest maternal death. Acute hepatitis E during pregnancy led to 35% maternal and 47% fetal mortality. Acute hepatitis in pregnancy should always be screened for HEV and if found positive should be vigilantly followed to save mother and child

Child Labour in Pakistan - A tip of an iceberg

To study the basic demographic characteristics of child laborers and to ascertain their working conditions. This cross sectional study was conducted in district Rawalpindi from January to September 2008 and 700 children between 4 - 18 years were enrolled after taking informed consent from both children and their masters. Information on demography and work details was recorded on a structured performa. Total 700 children 4-18 years old with mean age of 13.5 years were enrolled. Male: Female ratio was 5.4:1. Most of the children [401] had a family size of 5-8 members. In 634 cases, 1-4 family members were earning while 05 had 10-12 earning members. Only 479 [68%] children ever attended school, mostly [291, 42%] till primary level. 258 children's families had monthly income of more than PKR 8000, 210PKR 6000-8000, 167 PKR 4000-5000 and 63 families were earning less than PKR 3000/ month. Mostly [270] worked in shops. Reason of work was low family income in 222 and poverty in 207 children. 283 children worked for 7-10 hours per day, 216 for 07 days, 115 for 4-6 hours, 45 for more than 12 hours and 39 for 1-3 hours. Maximum monthly pay was 1000- 2000 rupees in 187 and minimum 500 rupees per month in 106 children. 284 cases sustained injury while at work. Most child labourers are male with a family size of 5-8 members, never attended any school and living in a family whose monthly income is less than 8000 Pakistani Ruppee. The major reason of work was low family income and poverty

assessment of effectiveness of immunotherapy in pollen allergic patients

Background: Allergen-specific immunotherapy[SIT] is a well established treatment option forpatients with allergic rhinitis with or withoutassociated asthma that can modify the allergicdisease process

Aim: To assess clinical efficacy ofimmunotherapy in patients presenting with pollenallergy

Study design: A cross sectional hospitalbased study

Settings and Duration: Conducted atAllergy Center, National Institute of Health [NIH],Islamabad during April - October 2011

Subjectsand Methods: 100 patients visiting the AllergyCenter, NIH with more than two years history ofrhinitis, sneezing, asthma of both genders wereincluded. All patients had positive skin prick test.Selected subjects were explained about the nature ofthe study and informed consent to participate in thestudy was taken from them. Information on commonclinical presentation, duration of allergy, duration ofvaccine use, change in disease attacks after vaccine,and quality of life was recorded on pre developedand pre tested questionnaire

Results: A total of100 patients were enrolled. 57 patients were foundto have allergy against grass, 33 against pollen treeand 53 wereallergic to weed. Common clinical symptoms weresneezing [93%], runny nose [90%] and wheezing[87%] followed by redness in 69% of cases.Majority 66 [65.3%] had positive family history forallergy while 34 [33.7%] did not. Time for whichpatients were on immunotherapy was 1, 2, and 3years where majority being on vaccine for one year.Before vaccine only 12 patients used to have lessacute and frequent attacks compared to 88 patientswho had severe attacks. After starting allergyvaccine 71 patients had complete relief with noacute attacks at all, however 05 patients startinghaving more frequent acute attacks than beforewhereas 24 patients reported having less attacks butnot complete relief. Quality of life in terms of day today activities and freedom to move out withouthaving acute symptoms was improved in 82% ofcases while 18% of the patients did not have suchimprovement

Conclusions: Immunotherapy servesto build up long term resistance against thesensitized allergen. Avoidance to allergen, use ofmedication and immunotherapy are the threeregimes employed to combat the disease

Determination of HBsAg and anti HBs in mothers and their children between 6 months and 3 years of age in Islamabad

To determine the presence of hepatitis B surface antigen and antibodies in mothers and their children aged between 6 months-3 years and assess if vaccination at 6 weeks is preventing maternal to child transmission. Sero-epidemiological cross-sectional community-based study conducted in district Islamabad from Dec. 2008- Dec. 2009 in six clusters [Bani gala, Kuri shehr, Bara kahu, Karachi company, I-sector and Koral town]. About 50 paired samples [Maternal and child] were collected from each cluster making a total of 300 mothers and their children. In each cluster, a door to door survey was done to locate houses that had a child between 6 months to 3 years of age and whose mother was willing to participate in the study. Informed written consent was taken from parents [mother/ father] of the enrolled child. Two ml of blood was taken from mother and child and information regarding the HBV vaccination of child and mother was entered in a questionnaire apart from other risk factors for disease transmission. The sera were stored and later analysed for presence of Hepatitis B surface antibodies [anti HBs], Hepatitis B negative for anti HBs were run for HBsAg and those found positive were run for HBsAg. A total of 227 mothers and their 304 children were enrolled in the study which lasted for 6 months. Out of 277 mothers, 39[14%] were anti HBs positive, 29[11.4%] were positive for HBsAg and out of these three [10.3%] were also HBsAg positive. Out of 304 children who were tested for anti HBs, 239 [77%] showed protective levels. Eight children [2.6%] were positive for HBsAg and 02[25%] were also positive for HBeAg. Out of 261 vaccinated children 89% showed, antibodies while 11% did not have antibodies. Five [2%] children were HBsAg positive despite taking the vaccination. Of the 29 mothers who were HBsAg positive, their 03 children were also positive for the virus. Of the 3 mothers that were HBsAg positive but their mothers were negative for this virus indicating other routes of viral transmission or a paternal transmission. Vertical transmission of HBsAg was seen from HBsAg positive mothers to their newborns. HBV infection is seen in 2% vaccinated children indicating that vaccination at 6 weeks are not protecting these children to this deadly virus. Vaccination of Hepatitis B should be done at birth

To assess the relations between breast feeding and illness in children under two years of age with particular reference to respiratory tract infections

The study was carried out to examine the relation between the breast feeding and morbidity as a result of respiratory illness and infection in the children less than two years of age. This is a prospective analysis of 131 children attending the outdoor peadriatic department of Federal Government Services Hospital, Islamabad during the month of February 2006. A close ended pretested questionnaire was filled after taking informed consent from patient's parents. Out of total 131 enrolled cases [76 male and 55 female] 62 [47%] were breast fed; 56 [43%] bottle fed; while 13 [10%] had mix feeding. Among 38 children, having past history of respiratory tract infections episodes in last one month, only 04 [10%] were breast fed and remaining 34 [90%] were either bottle fed or had partial breast feeding. Out of 62 breast fed children, only 04 [6%] had recurrent episodes of respiratory tract infections, on the other hand out of 56 bottle fed 32 [57%] had previous history of respiratory illness. In our study there is a significant correlation between breast feeding and reduction in number of respiratory tract infections episodes. Predominant breast feeding for at least six months and partial breast feeding for up to one year may reduce the prevalence and subsequent morbidity of respiratory illness and infection in infancy

Access to water quality and functioning sewerage system of internally displaced person's camps in NWFP

Environmental health survey was done on water and sanitation issues, at 43 Internally Displaced Person's Camps [IDP] of the NWFP province after 8[th] October 2005 earthquake in Pakistan. To describe the challenges/situation faced by healthcare providers in providing safe drinking water and sanitation with the objective to restore these in the shortest time. Cross sectional observational survey was done of the IDP camps in NWFP from November, 2005 to April, 2006. A total of 43 camps were visited twice a week. All information was recorded in structured questionnaire, edited and analyzed through SPSS version 10. A total of 43 IDP camps were visited. Using WHO standards for assessment of quality of drinking water, it was found that water quality of 35 camps was satisfactory and of 07 was unsatisfactory while one of them had turbid appearance. Spring water was the main source of water supply in these camps. Twenty-one out of 43 camps had 485 flush latrines and 20 camps had 707 pit latrines. Out of 43 camps, 36 camps had specific latrines for women while others did not have specific latrines for women. Bath facilities were limited