Prevalence of risk factors for noncommunicable diseases in adults: key findings from the Pakistan STEPS survey

Background: Pakistan lacks data on the prevalence of risk factors for common noncommunicable diseases [NCDs]. Objectives: This study aimed to determine the prevalence of risk factors for NCDs among a population-based sample in Punjab and Sindh provinces, Pakistan. Methods: This study was conducted in 2013–2014. The NCD risk factors examined were: current daily smoking, eating fewer than 5 servings of fruits/vegetable a day, low physical activity, overweight and obesity. A total of 7 710 households were selected and 1 adult was enrolled from each household. Data were collected using the WHO STEPS instrument [Step 1 and 2], and analysed according to the STEPS statistical plan. Results: The prevalence of tobacco use was 19.7%. The majority of the respondents [96.5%] consumed fewer than 5 servings of fruits/vegetables a day, 41.5% had a low level of physical activity, 26.3% were overweight and 14.9% were obese. The prevalence of stage I and stage II hypertension, including those on medication, was 37% and 15.9% respectively. The prevalence of NCD risk factors differed significantly by sex and occupation [P = 0.0001] but not by age group [P = 0.118], level of education [P = 0.668] and province [P = 0.056]. Only 0.6% of the sample had none of the 5 NCD risk factors while 40% had 3–5. Conclusion: The high prevalence of NCD risk factors in Punjab and Sindh provinces is of concern. Urgent public health interventions are needed to reduce them, especially in youth and young adults

Asymptomatic dengue infection in adults of major cities of Pakistan

OBJECTIVE@#To determine the asymptomatic dengue infection in adults of Pakistani population.@*METHODS@#This study was conducted in five major cities (Islamabad, Karachi, Lahore, Multan, and Peshawar) of Pakistan. A total of 5 230 adults aged 18 years and above without a history of dengue fever at any point in their life were enrolled from participating laboratories. Those who were confirmed for dengue previously were excluded. Of the total, 62.6% (n = 3 276) were male with an average age of 34.6 years. Participants were briefed about the objectives of the study, and written consent was obtained to perform dengue IgG test using enzyme linked immunosorbent assay. The brief information related to age, gender and area was also taken on proforma.@*RESULTS@#Overall 32.3% (n = 1 691) was having asymptomatic dengue infection which was 67.5% (n = 756) in Karachi followed by 39.1% (n = 391) in Islamabad, 29.9% (n = 316) in Lahore and 21% (n = 228) in Peshawar and none from Multan. More males were affected with asymptomatic dengue infection than females. The asymptomatic dengue infection was significantly higher in different cities; however, there was no significant difference with respect to age groups.@*CONCLUSIONS@#The asymptomatic dengue infection is higher in cities i.e. Karachi, Islamabad and Lahore which are at risk of developing secondary dengue infections. There is a need of awareness among the public about secondary dengue infection.

Asymptomatic dengue infection in adults of major cities of Pakistan

Objective To determine the asymptomatic dengue infection in adults of Pakistani population. Methods This study was conducted in five major cities (Islamabad, Karachi, Lahore, Multan, and Peshawar) of Pakistan. A total of 5 230 adults aged 18 years and above without a history of dengue fever at any point in their life were enrolled from participating laboratories. Those who were confirmed for dengue previously were excluded. Of the total, 62.6% (n = 3 276) were male with an average age of 34.6 years. Participants were briefed about the objectives of the study, and written consent was obtained to perform dengue IgG test using enzyme linked immunosorbent assay. The brief information related to age, gender and area was also taken on proforma. Results Overall 32.3% (n = 1 691) was having asymptomatic dengue infection which was 67.5% (n = 756) in Karachi followed by 39.1% (n = 391) in Islamabad, 29.9% (n = 316) in Lahore and 21% (n = 228) in Peshawar and none from Multan. More males were affected with asymptomatic dengue infection than females. The asymptomatic dengue infection was significantly higher in different cities; however, there was no significant difference with respect to age groups. Conclusions The asymptomatic dengue infection is higher in cities i.e. Karachi, Islamabad and Lahore which are at risk of developing secondary dengue infections. There is a need of awareness among the public about secondary dengue infection.

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

Economic burden of dengue in four major cities of Pakistan during 2011

To assess the economic burden of dengue infection by calculating cost per patient and disability adjusted life years lost. The cross-sectional study was conducted in Islamabad, Lahore, Faisalabad and Karachi from July 2012 to March 2013. Residential addresses and telephonic numbers of dengue patients were taken from the records of Pakistan Institute of Medical Sciences, Islamabad, Mayo and Ganga Ram Hospital, Lahore, Civil Hospital, Karachi, and Allied Hospital, Faisalabad. A total of 250 dengue confirmed cases - 50 from each hospital - were randomly selected. Information regarding duration of illness and out-of-pocket expenses were collected to estimate the direct cost, while indirect cost [number of work days missed by the patient] was calculated from disability adjusted life years using Murray's formula. Overall, there were 162[65%] men and 88[35%] with a mean age of 30.4 +/- 13.5years. More than half 138[55%] were below 30 years of age. Socio-economically, 145[58%] belonged to low, 70[28%] middle and 35[14%] to high socioeconomic groups. Of the total, 210[84%] cases had dengue fever followed by 32[12.8%] dengue haemorrhagic fever and 8[3.2%] dengue shock syndrome cases. Average duration of illness was 32 +/- 7.1 days. Overall direct cost per patient was Rs.35, 823 [US$358] and average pre-hospitalisation, hospitalisation and post-hospitalisation was Rs.6154, Rs.21, 242 and Rs.8, 427 respectively. The overall disability adjusted life years per million population was 133.76. Although the government had provided free treatment for dengue in public-sector hospitals, still patients had to pay Rs.21, 242 during hospital stay, resulting in substantial burden which needs to be addressed

Factors influencing the response of interferon therapy in chronic hepatitis C patients

To determine factors influencing response of interferon therapy in chronic hepatitis C patients. Descriptive, analytical study. Pakistan Medical Research Centre, Jinnah Postgraduate Medical Centre, Karachi, from January 1998 to December 2009. Patients of chronic hepatitis C treated with conventional interferon were retrospectively analyzed. End treatment response at 6 months for genotype 2 and 3 and one-year for genotype 1 and 4 was assessed. Sustained virological response was checked after 6 months of cessation of therapy. Non-compliant and incomplete follow-up cases were excluded. Factors influencing the response to therapy were analyzed by univariate and multivariate logistic regression analysis. A total of 932 cases received interferon therapy; 103 were lost to follow-up and were excluded. Treatment was completed in 829 cases; end treatment response was 74% [615 out of 829 cases]. Six months post-treatment follow-up was available in 492 cases. Sustained virological response was seen in 63% [308 out of 492 cases]. Univariate logistic regression analysis showed significantly better response in patients with < 40 years of age, body weight < 70 kg, normal platelet count, serum albumin > 4.0 grams, non diabetic patients and those with a normal alanine aminotransferase [ALT] at 1st month of therapy. Multiple logistic regression analysis showed that only age < 40 years was significantly important for sustained virological response. For conventional interferon therapy, age < 40 years is the best predictor for sustained virological response, however, better response can be achieved in patients with < 70 kg weight, normal platelet count, serum albumin > 4.0 grams, non-diabetics and patients having normal ALT at 1st month of therapy

review of hepatitis viral infections in Pakistan

A review of published literature on viral hepatitis infections in Pakistan is presented. A total of 220 abstracts available in the Pakmedinet and Medline have been searched. All relevant articles were reviewed to determine the prevalence of hepatitis viral infections in Pakistan. Two hundred and three [203] relevant articles/abstracts including twenty nine supporting references are included in this review. Of the articles on prevalence of hepatitis infection, seven were related to Hepatitis A, fifteen to Hepatitis E while the remaining articles were on frequency of hepatitis B and C in different disease and healthy population groups. These included eight studies on healthy children, three on vertical transmission, nineteen on pregnant women, fifteen on healthy individuals, six on army recruits, thirty one on blood donors, thirteen on health care workers, five on unsafe injections, seventeen on high risk groups, five on patients with provisional diagnosis of hepatitis, thirty three on patients with chronic liver disease, four on genotypes of HBV and five on genotypes of HCV. This review highlights the lack of community-based epidemiological work as the number of subjects studied were predominantly patients, high risk groups and healthy blood donors. High level of Hepatitis A seroconversion was found in children and this viral infection accounts for almost 50%-60% of all cases of acute viral hepatitis in children in Pakistan. Hepatitis E is endemic in the country affecting mostly the adult population and epidemic situations have been reported from many parts of the country. The mean results of HBsAg and Anti-HCV prevalence on the basis of data aggregated from several studies was calculated which shows 2.3% and 2.5% prevalence of HBsAg and Anti-HCV in children, 2.5% and 5.2% among pregnant women, 2.6% and 5.3% in general population, 3.5% and 3.1% in army recruits, 2.4% and 3.6% in blood donors, 6.0% and 5.4% in health care workers, 13.0% and 10.3% in high risk groups, 12.3% and 12.0% in patients with provisional diagnosis of hepatitis and 25.7% and 54% in patients with chronic liver disease respectively. This review has illustrated the high endemicity of hepatitis viral infections in Pakistan where hepatitis B and C potentially account for a serious burden of the disease. This review has triggered the launching of a network intervention for the control of hepatitis viral infectious. This review was used as the basis for the launch of hepatitis programme, but putting it into a formal review took time and the hepatitis program was initiated

Frequency of hepatitis C and D super infection in patients with hepatitis B related complex liver disorders

To determine the frequency of super infection of hepatitis C and D in patients with hepatitis B related complex liver disorders and the distribution of HBV genotypes in these patients. Descriptive study. The Gastroenterology Unit of PMRC in JPMC, Karachi, from July 2006 to June 2007. All patients registered for HBV associated infections were selected. Blood was drawn from 180 patients who fulfilled the inclusion criteria. Those with an incomplete test profile were excluded. All clinical conditions were investigated through liver function tests, coagulation profile, and findings at abdominal ultrasonography, upper gastrointestinal endoscopy and liver biopsy. Liver cirrhosis and hepatocellular carcinoma [HCC] were diagnosed either on the basis of histology, or on a combination of radiological, endoscopic and laboratory data. Hepatitis B virus DNA was extracted from serum, and subjected to a nested PCR using the type specific primers for HBV genotype. Descriptive statistics were used for frequency and mean determination. The 129 patients finally selected for statistical analysis included 108 [84%] males and 21 [16%] females. The age ranged from 6- 68 years [mean=31.5 +/- 12.39 years]. There were 70 [54.2%] patients of non-cirrhotic, chronic hepatitis [CLD], 38 [29.4%] carriers, 12 [9.3%] cirrhotics and 9 [6.9%] HCC patients. Among the 129 patients, 45 [34.9%] were positive for double infection with HDV. These included 35 CLD cases, 7 cirrhotic and 3 carriers, 4 [3.1%] patients were positive for double infection with HCV including one with CLD, 2 with cirrhosis and one with HCC. Triple infection with HBV/HDV/HCV was present in 4 [3.1%] patients who had CLD. Approximately 59% [n=76] patients were not coinfected, though 9 had developed HCC. The genotype distribution of HBV was observed as D in 98 [76%] patients, A in 24 [18.6%], and AD mix in 7 [5.4%]. Genotypes B, C, E or F were not found. Accordingly, genotype D strains were the predominant strains among all categories. The frequency of super infection of hepatitis C and D was found to be highest in HBV cirrhosis patients compared to patients having chronic liver disease [non-cirrhotics] and carriers. Genotype D of hepatitis B virus was found dominant in all hepatitis B related complex liver disorders

Risk Factors of hepatitis B and C transmission in patients coming to a hepatology out patients clinic

To see the possible risk factors for the transmission of hepatitis B and C in patients suffering from hepatitis B and C. Hepatitis B and C patients coming to a public sector hepatology centre and a private clinic. All patients suffering from hepatitis B and C of all ages and both gender were included in the questionnaire based study following a verbal consent form all participants. The data was collected over 1 year by 1 doctor at both the OPD and the private clinic. Data on 497 cases was collected, of the total cases 199 were suffering from chronic hepatitis B [HBV] and 298 from hepatitis C [HCV]. Males were more infected with chronic liver disease but hepatitis B was more prevalent in males. Majority of HBV [55.8%] and HCV [49.3%] cases were between 25-44 years age group and 40% HBV and 35% HCV cases were educated up to the secondary level. In 9% HBV and 10% HCV cases the father was also suffering from liver disease and 15% HBV and 13% HCV cases had a death of a family member due to liver disease. Risk factors like injections for various ailments was seen in 189 cases [95%] suffering from HBV and 286 [96%] from HCV, similarly past history of surgery and dental treatment and blood transfusion was significantly more in HCV, when compared with HBV. Though both HBV and HCV are blood born diseases but interfamilial spread of these viruses needs to interpreted with caution as it appears that the virus is coming from the community to the house hold members and the possible sources are treating physicians using a reused syringe, a dentist and barbers

experience of polypectomy in children and adults in Karachi

To see the morphological types of polyps, the acceptability of the procedure and the complications following polypectomy. Out patients department of Gastroenterology at PMRC, Research Centre, Jinnah Postgraduate Medical Centre, Karachi. All patients [children and adults] referred with history of bleeding per rectum underwent flexible sigmoidoscopy or colonoscopy without sedation or analgesia. Bowel cleansing was done using a laxative the night before the procedure and an enema on the morning of the procedure. The site, size and number of polyps were noted and polypectomy performed using Olympus PSD 10 cautry and a snare. Polyp was retrieved with a basket for histological examination. Post polypectomy patients were asked to report if there were any signs of bleed or abdominal distension. Over 3 years, 126 colonic polyps were seen [60 children and 66 adults]. The ages of the patients ranged from 2 - 82 years. The main presenting feature was rectal bleeding and the site of polyp was mostly the recto sigmoid area or the descending colon. Of 60 children, 13 were less than 5 years of age and 47 were between 5 - 15 years. The polyp was mostly single pedunculated cherry red in color. Five children had multiple polyps of whom 3 had polyposis coli. In adults majority had single polyp in the rectum or sigmoid and 11 had multiple polyps with 3 having polyposis coli. In adults most polyps had an ulcerated surface and a short pedicle. Post polypectomy 3 cases had a bleed within 24 hours, [1 child and 2 adults]. Both were admitted and transfused blood. On repeat examination the bleeding was seen from the base of the stalk which was electro coagulated with a hot biopsy forceps. None required surgery. On histology 58 polyps were hyperplasic and 51 hamartomatous including juvenile polyps. Only one adult had a tub-villous adenoma. Biopsy was not done in 9 adults and 7 children. All patients tolerated the procedure well and none required anesthesia or analgesia. Majority of the polyps in children and adults were hyperplasic or hamartomatous with only one adult having tubovillous adenoma. Only 3 [2.4%] had a post polypectomy bleed which was managed by electro coagulation of the stump

Role of ursodeoxycholic acid in lowering ALT in chronic liver disease

The objective was to see the efficacy of ursodeoxycholic acid in improving the ALT levels in patients suffering from chronic liver disease. Thirty patients suffering from chronic liver disease [either B or C] were given oral ursodeoxycholic acid in a dose of 250 mg twice a day for 4 months. Their blood biochemistry and haematology were repeated monthly for 7 months i.e. 4 months of therapy and 3 months post therapy to see the response. The mean ALT levels of 30 patients who completed the study was 101+47 IU/L. During therapy 24 cases [80%] showed lowering of their ALT levels while 6 [20%] either showed no response or worsening of ALT levels. Of 24 cases who showed an improvement in their ALT levels; over 25% drop in ALT levels was seen in 217 cases [70%] and less than 25% drop seen in 7 cases [30%]. The mean ALT values during therapy were 75 IU/L showing an overall 25% reduction from the baseline values. Following cessation of therapy the mean ALT levels showed a rise to 90 IU/L which was almost similar to 101 IU/L value in the pre treatment period. The study showed some role of ursodeoxycholic acid in improving the ALT levels in chronic liver disease

Helicbacter pylori clearance and eradication with triple therapy in duodenal ulcer patients

Triple therapy was given to 49 chronic helicobacter pylori positive chronic duodenal ulcer cases to see its efficacy in H. pylori clearance, eradication and ulcer healing. H. pylori clearance and eradication rates at weeks 5 and 8 were 87.8 percent and 81.5 percent while ulcer healing rates 68.2 percent and 81.5 percent respectively. Seven [18 percent] cases failed to clear H. pylori and were classified as non-responders. Histologically 60 percent showed post-treatment regression of gastritis. Tolerance to drugs was excellent with a good compliance rate

Two weeks triple therapy with lansoprazole, amoxycillin and roxythromycin is better than dual therapy with lansoprazole and amoxycillin for h. pylori infection a randomised, clinical trial

AIMS: To compare the efficacy of 2 weeks of dual therapy of Lansoprazole and Amoxycilline with triple therapy of Lansoprazole, Amoxycilline and Roxythromycin for H. pylori eradication. SUBJECTS: Twenty-five suffering from dyspepsia and found H. pylori positive [CLO] during upper GI endoscopy. METHODS: Patients were divided into 2 groups, one group received Lansoprazole [30 mg] once a day, and amoxycilline [500 mg] three times a day [group I], while the second group received Lansoparazole and amoxycillin in similar dosage with the addition of Roxythromycin [150 mg] twice a day [group II]. H. pylori status was confirmed on endoscopy using CLO test at entry to the protocol and then at 4 weeks. H. pylori eradication was 57% in group I and 86% in group II with healing of lesions in all cases. Better response with triple therapy [group II] indicates enhanced eradication of the pathogens with triple therapy while using roxythromycin [JPMA 50:157, 2000]

Comparison of five different treatment regimens for H. Pylori eradication

AIM: Treatment response to five different H. Pylori eradication regimens were evaluated to see which is the best regimen in our setup. METHODS: Patients presenting with upper GI symptoms of acid peptic disease underwent upper GI endoscopy and an antral CLO test. All those with a positive CLO test were included in the study. The study was carried out over a year and one trial was followed by another. The treatment regimens comprised of [1] Omeprazole 20 mg once a day, colloidal bismuth subcitrate 120 mg three times a day, Metronidazole 200 mg three times a day [18 cases]. [2] Colloidal bismuth subcitrate three times a day, furazolidone 100 mg three times a day, metronidazole 200 mg three times a day [28 cases]. [3] Omeprazole 20 mg once a day, Clarithromycin 500 mg twice a day [21 cases]. [4] Lansoprazole 30 mg once a day, Amoxycillin 500 mg three times a day [21 cases]. [5] Lansoprazole once a day, Amoxycillin 500 mg three times a day and Roxithromycin 150 mg twice a day [14 cases]. Therapy for all 5 groups comprised of 14 days. Endoscopy and CLO test were done prior to the entry in the trial and at 28 days to see the response. Meta analysis was done for all the 5 regimens. For the purpose of analysis patients were divided into 2 groups, i.e., those with peptic ulcer and positive CLO [peptic ulcer disease [PUD] and those without peptic ulcer but positive CLO test [Non ulcer dyspepsia [NUD]. PUD was seen in 14 of 18 cases in group 1, 18 of 28 cases in group 2, 16 of 21 cases in group 3, 6 of 21 cases in group 4 and 3 of 14 cases in group 5. In PUD after 14 days of therapy, lesions healed and CLO became negative in 50% cases each in group 1 and 2, 56% in group 3, 83% in group 4 and all in group 5, while in NUD, 25%, 60%, 80%, 47% and 82% respectively showed H. Pylori eradication. Of the different therapies one proton pump inhibitor with two antibiotics gave best results in ulcer healing and H. pylori eradication in ulcer and non ulcer dyspepsia

Propranolol in bleeding oesophageal varices

Forty seven cases of portal hypertension with bleeding oesophageal varices were given oral propranolol in doses that reduced the resting heart rate by 25%. Patients were fallowed up for 2 years and on each visit pulse, number of bleeds and any side effects were recorded. Eighty three% patients did not bleed till 2 years while they were on propranolol. Titree patients died of gaslro-intestinnal bleeding during the follow up, while one developed bronchospasm, which was controlled on discontinuation of the drug therapy

Endoscopic Re-Evaluation of visick grading

Correlation of Visick grading was done with serial endoscopies in 19 patients operated for duodenal ulceration. Deeper mucosal lesions like ulceration showed good association with Visick grading [100%], while superficial mucosal lesions were mostly asymptomatic and therefore, caused disparity in grading. Moreover, as symptoms and endoscopic findings changed with passage of time, it was concluded that in the light of endoscopic findings the grading needs re-evaluation