A cross-sectional survey on fruit bat-human interaction in Pakistan; one health perspective.

OBJECTIVE: Several factors, such as residential area topography, population density, and lack of infrastructure, were hypothesized to contribute toward respondents' knowledge, attitude, and practice regarding disease transmission. The present study was designed to investigate the knowledge, attitudes, and perception of human-fruit bat interaction by student respondents located in ten districts within the Punjab and Khyber Pakhtunkhwa provinces in Pakistan. METHOD: A cross-sectional survey was conducted by trained enumerators in academic institutions using a structured questionnaire among student respondents (n = 1466), living in two topographically distinct (Mountainous and Plain) residential regions of the Punjab and Khyber Pakhtunkhwa (KPK) provinces in Pakistan regarding their history of bat encounters. RESULTS: Our study revealed that 71.4% of the 1466 respondents had observed bats in their geographic region. 21% of our survey respondents reported bat bites incidents over their lifetime, but only 40% actively sought medical care for wound management despite reporting they had a close family member that had contracted rabies (27-35%). Our generalized linear models (GLMs) highlighted that a respondent residing in a residential region had a greater association with reporting a suspected bat bite over their lifetime and reported rabies victims in both near and extended family members (OR = -0,85, p-value = 0.03, 95% CI). This appeared to be due to delaying consulting a doctor or medical facility for treatment following a suspected bat bite in the topographic residential group as compared to the respondents in the provincial residential group (OR 1.12, p-value = 0.04, 95% CI). CONCLUSION: Our findings indicate the necessity of a One Health comprehensive surveillance system in Pakistan for emerging and re-emerging zoonotic pathogens in Pteropodidae.

First Report of Aedes vittatus in Islamabad, Pakistan.

Aedes vittatus is distributed throughout Asia, Africa, and Europe and can transmit dengue, chikungunya, yellow fever, and Zika viruses. Like other Aedes species, larvae develop in both natural and artificial containers in urban, suburban, and rural areas. In September 2021, an entomological survey was conducted at the National Institute of Health of Pakistan (NIH) and adjacent housing within the NIH colony. All containers with water were examined for Aedes mosquitoes at 150 locations, including residential properties, a plant nursery, junkyards, and recreational parks and playgrounds. A total of 103 larvae, 37 pupae, 5 female and 2 male Ae. vittatus were collected from a fountain. This was the first detection of Ae. vittatus in urban Islamabad. Additional vector surveillance is needed to better understand the geographical distribution, ecology, and behavior of this invasive species and to understand its possible role in the transmission of dengue and chikungunya viruses in Pakistan.

A comprehensive review on clinical and mechanistic pathophysiological aspects of COVID-19 Malady: How far have we come?

Since its outbreak in 2019, the coronavirus disease (COVID-19) has become a pandemic, affecting more than 52 million people and causing more than 1 million mortalities globally till date. Current research reveals a wide array of disease manifestations and behaviors encompassing multiple organ systems in body and immense systemic inflammation, which have been summarized in this review. Data from a number of scientific reviews, research articles, case series, observational studies, and case reports were retrieved by utilizing online search engines such as Cochrane, PubMed, and Scopus from December 2019 to November 2020. The data for prevalence of signs and symptoms, underlying disease mechanisms and comorbidities were analyzed using SPSS version 25. This review will discuss a wide range of COVID-19 clinical presentations recorded till date, and the current understanding of both the underlying general as well as system specific pathophysiologic, and pathogenetic pathways. These include direct viral penetration into host cells through ACE2 receptors, induction of inflammosomes and immune response through viral proteins, and the initiation of system-wide inflammation and cytokine production. Moreover, peripheral organ damage and underlying comorbid diseases which can lead to short term and long term, reversible and irreversible damage to the body have also been studied. We concluded that underlying comorbidities and their pathological effects on the body contributed immensely and determine the resultant disease severity and mortality of the patients. Presently there is no drug approved for treatment of COVID-19, however multiple vaccines are now in use and research for more is underway.

Use of public health emergency operations center (PH-EOC) and adaptation of incident management system (IMS) for efficient inter-sectoral coordination and collaboration for effective control of Dengue fever outbreak in Pakistan - 2019.

Public Health Emergency Operations Center (PH-EOC) and Incident Management System (IMS) provides a platform for inter-sectoral coordination, and collaboration to enhance efficiency of response activities and help in effective control of disease outbreaks. Dengue fever (DF) is an emerging serious public health threat with a potential to transform into a public health emergency. Pakistan faced a heavy outbreak of Dengue fever (DF) from August to December 2019. National Institute of Health (NIH), Islamabad activated its Public Health Emergency Operations Center (PH-EOC) with an objective to implement principles and practices of IMS for control of the outbreak. The challenges during inter-sectoral collaboration for response activities were also identified. PH-EOC was activated on 16th September 2019, and remained operational for next 81 days till 05th December 2019. Incident management structure, incident action plan (IAP), and risk communication plan was developed and executed during this phase. Daily morning and evening meetings were held during all operational days. Federal and provincial health departments, district health offices (DHO), and government/private hospitals were coordinated for collection of the data pertaining to Dengue confirmed cases and deaths. As of 05th December 2019, a total of 52,877 confirmed Dengue cases were reported from all across Pakistan with maximum cases reported from Rawalpindi and Islamabad collectively i.e. 20,988 (40%), followed by Karachi 14,768 (28%), and Peshawar 2,699 (5%), while AJK reported 1,690 (3%). A total of 92 deaths happened all across Pakistan, out of which 43 (47%) happened in Karachi, 23 (25%) in Rawalpindi, and 22 (24%) in Islamabad. The response was coordinated through NIH based PH-EOC, but was carried out by relevant federal and provincial district health offices, vector surveillance programs, dengue control programs and sanitation departments respectively. As a part of response plan, vector surveillance, larva source management, and insecticidal spraying i.e. both fogging and indoor residual spraying activities were carried out in hotspots or the areas where confirmed cases were reported. Sanitation departments daily reported the removal of additional 80-100 ton of solid waste from hotspot areas. Hospitals were coordinated for reporting of isolation of DF patients and provision of quality clinical management for admitted patients. The International Federation for Red Cross/Crescent conducted community awareness, and covered 28,800 households in affected areas of Islamabad. Conversely, the DF outbreak was controlled 02-03 weeks ahead of previous years trends. All the coordinated activities were incorporated in a daily situation report (SitRep) and this was widely distributed among all the stakeholders through emails. Additionally, the data was displayed on the dashboard in PH-EOC. The data dashboard at PH-EOC served as an information management hub that visually mapped, tracked, analyzed, and displayed clusters of DF cases and hotspots. Accordingly, SitRep substantiated as the main reporting tool to monitor response activities initiated by rapid response teams at the national and subnational level. The inter-sectoral coordinating efforts made among concerned line departments resulted in a timely response leading to effective handling of a national public health threat. The information distilled from this experience was that the early and judicious activation of PH-EOC with adaptation of IMS under decision making leadership resulted in a well-managed and prompt response executed by different departments/stakeholders, and effective control of the outbreak before its transformation into a public health event/emergency of national or international concern.

Impact of environmental factors on COVID-19 cases and mortalities in major cities of Pakistan.

INTRODUCTION: Climate factors play an important role in the transmission of viruses, such as influenza viruses, MERS-CoV, and SARS-CoV-1. This study aimed to determine the relationship between changes in temperature, humidity, rainfall, and SARS-CoV-2 contagion. Five ecologically and climatically distinct regions were considered-Karachi, Lahore, Islamabad, Peshawar, and Gilgit-Baltistan. METHOD: Data on daily COVID-19 cases and deaths were retrieved from government officials, while meteorological information was collected from Pakistan Meteorological Department.. Statistical analysis was performed using SPSS version 20 and the Spearman rank correlation test was used to analyze the correlation between the meteorological factors and COVID-19 cases and deaths. RESULT: Positive correlation of COVID-19 incidence was observed with all the temperature ranges (maximum, minimum and average) and negative correlation was seen with humidity, DTR and rainfall. COVID-19 deaths were positively associated with temperature and were negatively associated only with humidity. Linear regression showed that for every unit increase in humidity, there was a -3.345 daily significant decrease in COVID-19 cases, while in Karachi for every unit increase in humidity, there remained a 10.104 daily significant increase in cases. In Gilgit-Baltistan, for every unit increase in average temperature and rainfall respectively, significant increases of 0.534 and 1.286 in daily cases were found. CONCLUSION: This study signifies the effect of climate factors on COVID-19 incidence and mortality rate, but climate factors are not the only variable and several other interlinked factors enhance the spread of COVID-19. Hence, effective mitigation policies, enhancing testing capacities, and developing public attitudes toward adopting precautionary measures are important to overcome this overwhelming pandemic.

First Report of Aedes albopictus (Diptera: Culicidae) in District Mirpur, Azad Jammu and Kashmir, Pakistan.

Our article documents the presence of Aedes albopictus (Skuse) from urban and rural locations in the lower Himalaya Mountains, northern Pakistan. Larvae were collected from graveyards, junkyards, plant nurseries, parks, and houses. Used tires, bird drinking pots, and water storage containers were the most common containers used by this mosquito. In the absence of Aedes aegypti (L.) (Diptera: Culicidae), Ae. albopictus appears to be the primary vector of recent dengue virus outbreaks.

Infection prevention and control situation in public hospitals of Islamabad.

INTRODUCTION: Healthcare-associated infections represent a global public health challenge and are associated with significant mortality and morbidity. Infection Prevention and Control (IPC) is a neglected area in healthcare facilities across Pakistan. The objective of our study was to elucidate the current state of infection prevention and control practices in public sector hospitals of Islamabad to underscore potential areas for improvement. METHODOLOGY: A cross-sectional survey was conducted between November and December 2019 at five public sector hospitals of Islamabad. The World Health Organization's Infection Prevention and Control Assessment Framework (IPCAF) was used to assess the strengths and weaknesses of hospitals regarding infection prevention and control. Adapted tools derived from Centers for Disease Control and Prevention and Infection Prevention Society were used for detailed assessment of various departments. Data was analyzed using Microsoft Excel 2016. RESULTS: In all five hospitals, the total IPCAF score was less than 200 denoting that infection prevention and control implementation is deficient and significant improvement is needed. The median IPCAF score was 117.5 with an interquartile range of 53.75. With the exception of central sterile services unit at one hospital, departments at all hospitals failed to meet even 50% of required IPC standards. CONCLUSIONS: Significant change is needed to improve the existent situation of infection prevention and control in public sector hospitals of Islamabad. This would involve establishment of functional programs, development and implementation of infection prevention and control guidelines and provision of adequate supplies.

Emergence of Chikungunya Virus, Pakistan, 2016-2017.

During December 2016-May 2017, an outbreak of chikungunya virus infection occurred across Pakistan. The East/Central/South African genotype was predominant. This study provides baseline data on the virus strain and emphasizes the need for active surveillance and implementation of preventive interventions to contain future outbreaks.

Evolutionary analysis of influenza A(H1N1)pdm09 during the pandemic and post-pandemic period in Pakistan.

BACKGROUND: The first case of influenza A(H1N1)pdm09 was detected in Pakistan in June 2009. Since then, it has continued to circulate causing considerable morbidity and mortality. The purpose of this study was to evaluate the evolutionary changes in influenza A(H1N1)pdm09 viruses from 2009 to 2016 and their relevance to the current vaccine viruses. METHODS: Respiratory specimens (throat or nasopharyngeal swabs) were collected from patients with influenza-like illness and severe acute respiratory illness. Samples were processed following the protocol of the US Centers for Disease Control and Prevention. Sequencing and phylogenetic analysis of Haemagglutinin and neuraminidase genes were carried out on representative isolates of Pakistan viruses. RESULTS: Between January 2009 and February 2016, out of 16,024 samples analysed, 1950 (12%) were positive for influenza A. During the pandemic period (2009-2010), influenza A(H1N1)pdm09 was the dominant strain with 366 out of 808 (45%) total influenza positive cases. In the post-pandemic period (2011-2016), a total of 1078 out of 1911 (56%) cases were positive for influenza A(H1N1)pdm09 with co-circulation of different influenza A subtypes. The Pakistan A(H1N1)pdm09 viruses belonged to two genetic clades: clade 7 in the pandemic period, and clade 7 (2011) and clade 6B (2015) in the post-pandemic period. Sequence analysis of genes coding for surface glycoprotein's of Haemagglutinin and neuraminidase had a high degree of sequence similarity with corresponding genes of regional viruses circulating in South-East Asia. CONCLUSION: Influenza A(H1N1)pdm09 viruses from Pakistan clustered into two genetic clades, with co-circulation of some variants. Key substitutions in the receptor binding site and a few changes indicative of virulence were also detected in the post-pandemic strains. Continued monitoring of the viruses is essential for early identification of potential variants of high virulence and their relevance to current vaccine strains.

Molecular characterization of circulating respiratory syncytial virus genotypes in Pakistani children, 2010-2013.

BACKGROUND: Data on the viral etiology of acute lower respiratory infections are scarce in Pakistan. Human respiratory syncytial virus (RSV) is an important cause of morbidity in children but no effective vaccine or antiviral therapy is currently available. As vaccines are expected to become available in the future, it is important to understand the epidemiology of locally prevalent RSV subtypes. This study aimed to define the molecular epidemiology of RSV (A and B) genotypes in Pakistani children under 5 years. METHODS: World Health Organization case definitions for influenza-like illness (ILI) and severe acute respiratory illness (SARI) were used for case selection. Children under 5 years who presented with ILI or SARI at tertiary care hospitals from all provinces/regions, including the eight influenza sentinel sites, during October-April each year between 2010 and 2013 were enrolled. Demographic and clinical data of the children were recorded and nasopharyngeal/throat swabs taken for analysis. All samples were tested for RSV A and B using real-time polymerase chain reaction for non-influenza respiratory viruses. Specific oligonucleotide primers for RSV A and B were used for subtyping and sequencing of the G protein, followed by phylogenetic analysis. RESULTS: A total of 1941 samples were included. RSV was detected in 472 (24%) children, with RSV A detected in 367 (78%) and RSV B in 105 (22%). The G protein of all RSV A strains clustered in the NA1/GA2 genotype while RSV B strains carried the signature 60 nucleotide duplication and were assigned to three BA genotypes: BA-9, BA-10 and the new BA-13 genotype. CONCLUSIONS: This study highlights the importance of RSV as a viral etiologic agent of acute respiratory infections in children in Pakistan, and the diversity of RSV viruses. Continued molecular surveillance for early detection of prevalent and newly emerging genotypes is needed to understand the epidemiology of RSV infections in Pakistan.

HIV/AIDS outbreak investigation in Jalalpur Jattan (JPJ), Gujrat, Pakistan.

BACKGROUND: In June-July 2008 a non-governmental organization (NGO) in Jalalpur Jattan (JPJ), Gujrat, Pakistan arranged two voluntary HIV screening camps after numerous HIV-infected persons reported to their treatment center in Lahore; 88 (35.8%) of 246 persons screened in those camps were positive by rapid test. Intense media coverage made the residents of JPJ hostile to further inquiries. The Pakistan Field Epidemiology Training and Laboratory Training Program (FELTP) was requested by the Provincial AIDS Control Program to carry out an epidemiological investigation. METHODS: HIV-positive persons or family members of patients who died of AIDS and consented to be interviewed during the period 15 December 2008 to 2 January 2009 were investigated. Enhanced contact tracing was done to identify additional cases. A structured questionnaire was used to collect data regarding clinical history, risk factors, and HIV knowledge and practices. The national HIV/STI Referral Laboratory collected blood samples for HIV serology and molecular studies independently following pre- and post-counseling. RESULTS: A total of 53 HIV-infected persons were investigated. Out of these, 47 (88.7%) were alive at the time of investigation and 27 (50.9%) of the cases were female with 6 children aged 10years or less. Median age was 35years (mean 34.7, range 3-70). Most frequent symptoms were unexplained fever 42 (79.2%), diarrhea 34 (64.15%) and skin infections 27 (50.9%); 13 (24.5%) had co-infection with tuberculosis (TB) and 10 (18.9%) with hepatitis (B or C). Use of injections 51 (96.2%), dental procedures 21 (40%) and barber shop visits among males 18 (72%) were common risk factors. Extramarital sex was reported by 4 (9.4%). Only 19 (35.8%) were aware that HIV can be sexually transmitted and 18 (34%) were aware of HIV transmission by blood transfusion. Phylogenetic analysis revealed HIV infection in this group was HIV-1 Subtype A, transmitted over a decade, and the situation is endemic rather than an outbreak. CONCLUSION: The investigation indicates high rates of HIV infection in JPJ. Unlike other studies from Pakistan, a high proportion of cases in females and children less than 10years of age were observed. Socio-cultural norms and stigmatization limited in-depth investigation of sexual and behavioral practices and history of drug abuse. A shift of HIV infection from high-risk groups to the general population was seen and requires vigilant surveillance besides targeted health education, clinical management, lab facilities for diagnosis and monitoring, and voluntary counseling and testing services to limit disease spread.