Therapeutic efficacy and safety of dihydroartemisinin-piperaquine [DP] for the treatment of uncomplicated plasmodium vivax malaria: a single center study

Background: Ninety-five millions of Pakistan's 161 million people, roughly 60% of Pakistan's population live in malaria endemic regions. Despite a well-established malaria control programme, 500,000 malaria infections and 50,000 malaria-attributable deaths occur each year in Pakistan. In Pakistan 15% population lives in high transmission area, 84% in low transmission and 1% in malaria free area, with 64% vivax and 36% Falciparum infections

Objective: The objective of this study was to assess the therapeutic efficacy and safety of Dihydroartemisinin- piperaquine [DP] for the treatment of uncomplicated Plasmodium vivax malaria in subjects

Methods: Its an observational study, conducted at Outpatient Department of Liaquat University Hospital Hyderabad, from December 2012 to December 2013. World Health Organization [WHO] standard protocol for efficacy studies [open-labelled clinical trial] was followed. The subjects with fever or history of fever for 48 hours aged between 6 months to 15 years with microscopically confirmed uncomplicated P. vivax infection were included. Total 109 patients fulfilled the inclusion criteria. Out of 109 patients, 103 had completed the study. Patients were treated with Dihydroartemisinin-piperaquine over three days. Clinical and parasitological parameters were monitored over a 42-days follow-up period to evaluate drug therapeutic efficacy

Results: Adequate clinical and parasitological response of treatment [ACPR] for Dihydroartemisininpiperaquine [DP] was seen in 102/103 [99.02%] patients, no early or late clinical failure was seen while late parasitological failure was seen on 21[st] day in one patient. No adverse events were reported

Conclusion: Dihydroartemisinin-piperaquine is safe and effective treatment option for uncomplicated vivax malaria

Prevalence of pulmonary tuberculosis among household contacts in Hyderabad, Sindh: active contact tracing in children with tuberculosis

Background: Tuberculosis [TB] in children is clearly linked to TB in adults therefore active household contact tracing is an important method of early diagnosis and treatment particularly in high-TB-burden countries

Objectives: To estimate the prevalence of TB among household contacts of children suffering from tuberculosis using active contact tracing and linking them to TB program for treatment

Subjects and Methods: A total of 125 children suffering from active tuberculosis [index cases] aged 12 years or less were randomly selected from the outpatient department of a tertiary care hospital of Hyderabad. Using their home address, all house hold members of the index cases [sharing one kitchen] were identified. The households were visited by a team including a doctor and the supported staff and were screened for TB using history, physical examination, sputum for AFB and X-ray of chest. Clinical suspects were divided in to two populations, equal to or less than 12 years of age and greater than this age. All suspected cases were brought to outpatient's department of the hospital where children were examined and diagnosed by pediatrician and adults were examined by the pulmonologist

Results: There were 125 children and 1365 household members. Prevalence of active TB in adult household contacts was 8.1% and among children was 5.7%. Mother, father, grand parents or siblings were the source of disease spread in children. Family history of TB was present in 95% [pulmonary 78%, extra-pulmonary 22%]

Conclusion: Tuberculosis in children is mostly spreading from household member hence deeply required to undertake active contact tracing in each new case that is diagnosed or being treated

Policy message: National and Provincial TB programs should advocate and undertake active screening of all household contacts of all TB cases

Measles vaccine; risk factors for low antibody titers before and after single dose

To determine the rate of sero-conversion after first dose of measles immunization in children less than one year of age and to find out association between seroconversion with nutritional status, URTI, fever and diarrhea. Descriptive cross sectional study of 6 month duration conducted at outpatient department, EPI center LUH Hyderabad. Total 240 children between 9 to 12 months, who came for measles immunization were enrolled. Pre-vaccination blood samples were obtained along with assessment of nutritional status, and current associated illness like pneumonia, diarrhea and fever of each child. The post vaccination samples were taken after 3 months. Measles antibodies were estimated by using ELISA technique and titers were compared with controls supplied by manufacturers. The effectiveness of measles immunization was 87.5%. Statistical analysis proved that association sero-negativity with clinical condition was insignificant [Chi square test, P value > 0.05]. Regarding the pre-vaccinated status 222 [92.5%] were found negative for anti-measles antibodies and 18 [7.5%] were found to be with persistent maternal anti-measles antibodies. Measles immunization produces adequate immunological responses even among malnourished children however a second dose is necessary to increase the efficacy more than 95%

Impact of an IEC [Information, Education and Communication] intervention on key family practices of mothers related to child health in Jamshoro, Sindh

To determine change in practice of mothers having children less than five years of age in five key areas related to child health, growth and development including immunization, feeding during illness, appropriate home treatment for infections and care seeking behavior. This was a community based interventional study of Information, Education and Communication [/EC] intervention in the UC Jamshoro, Taluka Kotri, district Jamshoro of 15 months duration from March 2011 to June 2012. Ninety five mothers having children less than five years of age were selected by systematic random sampling for house hold based survey by questionnaire designed by EPP evaluation and health section of UNICEF during baseline and post-intervention phases. Base line data was collected from the interventional area then health education messages were given through written and pictorial material by LHWs for 9 months. To measure the impact helath education messages, data was again collected by same questionnaire are from the same union council during post-intervention phase. During baseline survey except immunization all other key family practices were poor. After 9 months of intervention of repeated heath education sessions through LHW during their routine visits all practices were improved with statistically significant difference. Regarding the comparison of the results between baseline and post-intervention surveys we found that except immunization which was already better, all those practices which requires mother's knowledge and practice were improved after our intervention with significant P-values. Improving the mother's education level is very important, to empower the first care provider of child in the community. However, in the mean time, health educational messages reteted to the limited number of key family practices should be disseminated

Role of rapid diagnostic tests for guiding outpatient treatment of febrile illness in Liaquat university hospital

Objectives: To assess the validity /strength of clinical diagnosis of Malaria on the basis of IMNCI algorithm by slide microscopy [gold standard] and to compare the effectiveness of Rapid Diagnostic Test [RDT ]against slide microscopy

Methods: It is a descriptive cross sectional study of 6 month duration conducted at Pediatric Outpatient Department LUH Hyderabad from June-Dec. 2010. Sample of 400[the minimum required sample was 385 with malaria prevalence 5% [0.05] with margin of error of 3% [0.03, frequency vary from 2-8 % among different studies]] febrile children under 5 years classified as Suspected Clinical Malaria according to algorithm of IMNCI were included; The operational definition for Suspected Clinical Malaria was; fever for more than 2 days with no runny nose, no measel rash and no other cause of fever. Hyderabad was considered as low risk area. Rapid diagnostic test [RDT] and slide microscopy were done, and only confirmed cases were treated according to current guidelines given by National Malaria Program/updated IMNCI

Results: Total 2000 patients under 5 years presented with fever and were evaluated. From 2000 cases 20% [400] were diagnosed as suspected clinical Malaria according to IMNCI algorithm; and only 40 cases [10%] have shown positive results for malaria parasite on slide microscopy and 38 cases on RDT. Regarding the plasmodium species 70% were vivax and 30% were falciparum. As regards the effectiveness, RDT has shown 95% sensitivity for the detection of plasmodium antigens in the febrile clinically suspected cases of malaria

Conclusion: Prompt and accurate diagnosis of malaria is needed for implementation of appropriate treatment to reduce unnecessary anti-malarial prescription. RDT is as effective as slide microscopy for the diagnosis of malaria especially in resource poor countries

Effect of prone versus supine position on oxygen saturation in patients with respiratory distress in neonates

To analyze the effect of prone versus supine position on oxygen saturation in neonates with respiratory distress. This comparative study was conducted in the department of paediatric medicine at Liaquat University Hospital Hyderabad during the period of six months. Total numbers of the patients enrolled were one hundred with age ranging three hours to 28 days. All the newborns with respiratory distress [RD] were kept in supine position for three hours after all necessary resuscitation measures and oxygen saturation was recorded with pulse oximeter. Then they were kept in prone position for six hours and oxygen saturation and respiratory rate was measured with two hour interval respectively for six hours. One hundred patients were enrolled in the study with age range 3 hours - 28 days, out of them 87 [87%] term, 9 [9%] preterm and 4 [4%] were post term respectively, male to female ratio was 1.2:1. The oxygen saturation in supine position was 84.84 +/- 4.20. After 2 hour in prone position saturation was 91.05 +/- 3.29, after 4 hour 91.62 +/- 3.89 and after 6 hours it was 92.63 +/- 3.02 respectively with P value of < 0.001 which is statistically highly significant. It shows that Oxygen saturation is increased by about 7%, and maximum oxygen saturation increases in first 2 hours. Similar trend was seen in respiratory rate with reduction of respiratory rate by 6 breaths / min in first two hours. Prone position improves oxygenation saturation and decreases respiratory distress as compared to supine position in neonates with respiratory distress

Assessment of infant feeding practices at a tertiary care hospital

To assess the practice and knowledge of mothers regarding breast feeding, complimentary feeding, and to find out socio-economic correlates of feeding practices. A cross sectional survey conducted at paediatric department of Liaquat University Hospital [LUH] from Jan-Dec 2008. During that period 500 mothers with children less than 24 months were included. Infant feeding patterns were assessed in relation to recommendations and household socio-economic factors by an Interview Technique. Out of 500 mothers, 8.4% started exclusive breast feeding [EBF] while Pre-lacteal use was seen in 31.6%. Regarding the duration 52.2% mothers continued breast feeding for 2 years. Median duration of EBF was 3.5 months. It was seen that 60% of the 0-5 month-old infants breastfed 8 or more times per day. However, exclusiveness of breast feeding decreased from 60% at [0-2 months] to 40% [3-5 months]. Majority 64.2% were poor and 61.5% had no education. There is a statistically significant difference in feeding practices of educated and uneducated [P < 0.0001] and also in poor and middle class mothers [P <0.0003]. Regarding, age of their last born babies, 180 babies were under 6 months, and 320 were 6 to 23 months of age. The knowledge about complimentary feeding [CF] was inadequate. Around 21% of 2-3 months old babies received complementary food and 19% of 6-8 month-olds were only breastfed. In 78% mothers CF was advised by family members while in 23% mothers by doctors. Exclusive breastfeeding was not maintained upto recommended age of 6 months. Knowledge about CF was lacking in the mothers. Regarding, mothers' education and socioeconomic conditions, a positive correlation was noted with feeding practices

Etiological spectrum of pancytopenia based on bone marrow examination in children

To determine the spectrum of pancytopenia with its frequency, common clinical presentation and etiology on the basis of bone marrow examination in children from 2 months to 15 years. Observational study. Department of Paediatrics, Liaquat University of Medical and Health Sciences [LUMHS], Jamshoro, from October 2005 to March 2007. All patients aged 2 months to 15 years having pancytopenia were included. Patients beyond this age limits, already diagnosed cases of aplastic anemia and leukemia, clinical suspicion of genetic or constitutional pancytopenia, history of blood transfusion in recent past, and those not willing for either admission or bone marrow examination were excluded. History, physical and systemic examination and hematological parameters at presentation were recorded. Hematological profile included hemoglobin, total and differential leucocyte count, platelet count, reticulocyte count, peripheral smear and bone marrow aspiration/biopsy. During the study period, out of the 7000 admissions in paediatric ward, 250 patients had pancytopenia on their peripheral blood smear [3.57%]. Out of those, 230 patients were finally studied. Cause of pancytopenia was identified in 220 cases on the basis of bone marrow and other supportive investigations, while 10 cases remained undiagnosed. Most common was aplastic anemia [23.9%], megaloblastic anemia [13.04%], leukemia [13.05%], enteric fever [10.8%], malaria [8.69%] and sepsis [8.69%]. Common clinical presentations were pallor, fever, petechial hemorrhages, visceromegaly and bleeding from nose and gastrointestinal tract. Pancytopenia is a common occurrence in paediatric patients. Though acute leukemia and bone marrow failure were the usual causes of pancytopenia, infections and megaloblastic anemia are easily treatable and reversible

Serum electrolytes changes in malnourished children with diarrhea

To determine the frequency of electrolyte disturbances in malnourished children with and without diarrhea and whether these findings have therapeutic value or not. It is a descriptive study conducted at pediatric Unit-II LUH Hyderabad, from1st August to 31st September 2004. One hundred children of protein-calorie-malnutrition between 6 months to 5 year of age of either sex who were admitted due to diarrhoea, failure to thrive, acute respiratory infection, malaria, anemia, cardiac failure and feeding problems were included in the study. On the basis of history, physical examination and anthropometrics measurement they were divided into Group A patients [n=64] who were malnourished but had diarrhoea and Group B patients [n=36] who were also malnourished and had no diarrhoea. Serum electrolytes were done in patients of both groups and the results were analyzed statistically. Analysis of serum electrolyte in both groups revealed that hypokalemia, hyponatremia and low serum bicarbonate were seen more frequently in patients of group A as compared to group B. In group A hypokalemia was seen in 40 patients[62.5%] while it was observed in 8 patients[22.22%] in group B [p<0.001], hyponatremia was seen in 17 patients [26.56%] in group A and in 5 patients [13.88%] in group B [p<0.001]. In group A 41 patients [64%] had low serum bicarbonate while in group B only 15 patients [41.66%] had low serum bicarbonate value [p<0.001] Electrolyte changes were commonly seen in grade II and III malnourished patients particularly who presented with diarrhoeal episode of variable duration. If these changes are diagnosed in time and treated appropriately the morbidity and mortality could be decreased

Prevalnce of iron defeciency and thalassaemia trait in children at paediatric department of L.U.H.

Aims and To assess the prevalence of Iron deficiency and thalassaemia trait in children attending Paediatric Department of Liaquat University Hospital. Subject and Setting: 50 children from paediatric ward and 50 from paediatric O.P.D were selected by simple randomization. Both males and females from 9 months to 10 years were included during study period of November 2002 to Jan 2003. Study was conducted in Liaquat University Hospital which is a tertiary care referral hospital. All investigations were carried out in new research pathology laboratory of Liaquat University Hospital. Clinical history and examination was done in all cases and 3 investigations including complete blood count, serum iron levels and haemoglobin electrophoresis were conducted in all cases. Iron deficiency with serum iron < 20mcg /dl was seen in 51% of cases with no significant difference between male and females, but was documented to be lowest in < 5 years old compared to 5-10 years age. 74% children were anaemic with severe anaemia [Hb < 6gm/dl] in 7% moderate anaemia [Hb- 6-9gm/dl] in 28% both more commonly documented in admitted cases. Prevalence of thalassaemia trait was 11%, with 2 more cases diagnosed as thalassaemia intermedia. Raised Hb A2 was considered as a normal variant with normal absolute valves in further 7% cases. Both iron deficiency anaemia and thalassaemia trait are common in our paediatric population. We need health education nutritional counselling and iron supplementation to prevent iron deficiency especially in view of recent association of iron deficiency with delayed growth, development and behaviour problems. Thalassaemia also needs proper screening and prevention as yet no effective or easily available curative treatment is possible

Dot Elisa [Typhidot] in early diagnosis of typhoid fever

The study has been carried out on 334 suspected cases of Typhoid fever during the year 2002 on patients either admitted in children emergency Word-11 or seen at out patient department of Liaquat University Hospital Hyderabad - Pakistan. The purpose of study was to evaluate and compare conventional Widal test and qualitative dot enzyme immunoassay "Typhodit" test. The patients were selected below 15 year of age and were categorized in three groups. The overall sensitivity and specificity in "Typhidot" was fund to be 72.4% and 93.3% respectively, as compared to "Widal test" where sensitivity and specificity was found to be only 53.9%. The efficiency of Typhidot comes to be 74.7%. Thus it was concluded that Typhidot - Dot Elisa is a valuable diagnostic tool in early diagnosis of Typhoid fever

Study of malaria in children at Liaquat medical college hospital

The objective of study was to determine chloroquine resistant malaria to children admitted in children ward unit I of Liaquat Medical College Hospital. 210 cases of suspected malaria were admitted in study year Oct 94 to Sep. 95. 80 cases had MP+ve and had no other cause of illness. 60 MP+ve cases were treated with chloroquine out of which 22 cases i.e. 36.6% were resistant Chloroquine resistant cases were treated with iv quinine which showed good response in 84.3% cases. 20 MP+ve cases were given iv quinine as initial treatment and 5% resistance was seen. Overall mortality was 3.7%. The study shows that there is high resistance to chloroquine in the area and IN quinine should be used as fust line antimalarial in severe cases of falciparum malaria

One year study of cases of severe pneumonia treated with chloramphenicol

All cases, aged 2 months to 5 years diagnosed as severe pneumonia according to A.R.I. programme during study year March 1995 to March 1996 were included in the study. The purpose was to determine a] clinical features on presentation, b] correlation between clinical and radiological diagnosis and c] response to treatment with chloramphenicol. Among total admissions of 1623 cases, 24.32% were admitted with respiratory complaints. 71 cases were classified as severe pneumonia according to ARI programme, and treated with chloramphenicol, 3 cases were excluded from the study as they left within 48 hrs. Out of remaining 68 children, 41 [60.29%] were below I year, 15 were 1-3 yrs and 12 cases were 3-5 yrs old. MY ratio was 1.7: I. In 45.6% of cases the duration of complaints was less than 48 hrs, while in 48.6% it was 35 days. Only 25 cases i.e. 36.76% had radiological changes consistent with pneumonia out of which 7 [10.29%] had lobar pneumonia. 61/68 cases i.e. 89.70% responded to treatment with chloramphenicol with clinical response within 48 hrs but 22/61 cases needed treatment for 7 days due to persistent clinical signs. One child expired within 24 hrs, [mortality of 1.47%] and treatment was changed in 6 cases [8.82%] due to lack of response in 48 hrs. This study confirms that chloramphenical is an effective treatment for most cases of severe pneumonia

Six months study of cases of severe pneumonia treated with inl: cefuroxime [zinacef]

All cases of 2 months to 5 years classified as severe pneumonia according to ARI programme were included in the study. 52 cases of severe pneumonia were treated with Inj: cefuroxime during the study period of G months Oct. 96 to March 97. The purpose of study was to 1] determine efficacy of cefurxime [ZINACEF] in the treatment of severe pneumonia and to compare ii] cost of treatment of cefuroxime with chloramphenicol mid third generation cephalosporins, iii] compare clinical efficacy of cefuroxime with chloramphenicol. 41/52 cases i.e. [78.84%] were below 1 year and 11/52 i.e. [21.15%] were between 1-3 yrs old. All cases were treated with inj: cefuroxime 100mg/kg in 3 divided doses. The response to treatment was good in 30/52 i.e. [57,69%] with recovery in 5 days, while slow clinical response was documented in 14/52 i.e. [26.92%] where treatment was continued for 7 days. In 6/52 cases [11.53%] antibiotic was changed due to lack of response within 48 hrs. Mortality rate was 2/52 i.e. [3.84%]. The study concludes that response of severe pneumonia to cefuroxime [84.61%] is comparable to that of chloramphenicol [89.70%] as reported in our previous study. The cost of cefuroxime is 4 time that of chloramphenicol therapy but it may be safer in so far as incidence of aplastie anaemia is concerned