Health care use patterns for diarrhea in children in low-income periurban communities of Karachi, Pakistan

Epidemiology of Human Adenovirus in Pakistani Children Hospitalized with Community-Acquired Gastroenteritis under the Age of Five Years

Acute gastroenteritis is the major cause of morbidity and mortality among infants and children around the globe. Along with other enteropathogens, human adenovirus (HadV) is a major etiological agent associated with diarrhea in young children. However, information about the epidemiology of Adenoviruses in Pakistan is limited or has not been reported. A total of 1082 stool samples were collected from patients with acute gastroenteritis under the age of five years with symptoms of diarrhea, vomiting, nausea, and abdominal cramps who visited Benazir Bhutto Hospital Rawalpindi and Children's hospital in Lahore of Punjab Province in Pakistan. Of this, 384 cases with no blood in their stool, negative for Rotavirus, and under the age of five years were recruited in this study. Human Adenoviruses were isolated in the human epithelial HEp-2 cell line. Furthermore, adenovirus antigen detection was carried out by an enzyme-linked immunosorbent assay (ELISA), and then all positive and negative samples were confirmed by nested PCR. After inoculating a clear stool supernatant on HEp-2 cell lines, we observed a positive cytopathic effect in 65 (16%) cases. Using an enzyme-linked immunosorbent assay, HAdV antigens were detected in 54 (14.06%) of the clear supernatant from gastroenteritis cases. However, HAdV hexon coding regions were amplified in 57 (14.80%) fecal samples, mainly from patients ≤24 months of age. The findings of this study suggest that adenovirus circulates significantly in the children population under the age of five years and may be the potential etiological factor of acute gastroenteritis in the mentioned cities. This study provides baseline data about the possible role of adenovirus in causing viral diarrhea in children. Further large-scale epidemiological surveys are recommended to better understand disease burden, etiological agents, and its clinical impact across the country.

Prescribing Practices of Antibiotics for Acute Diarrhea in Children Aged Less than Five Years Old in Pakistan

Introduction: Childhood diarrhea accounts for 16% of child deaths in Pakistan. Irrational prescribing of antibiotics, prescribing of antibiotics for viral infections, self-medication using antibiotics, prescription sharing, and refilling are very common practices in Pakistan. The aim of this study was to evaluate the prescribing practices of antibiotics for acute diarrhea in children less than five years of age at a Secondary Healthcare Hospital of Pakistan and to assess the compliance of prescribers with authentic clinical guidelines of treatment for childhood acute diarrhea. Method: A cross-sectional study was conducted for a period of one year, from August 2020 to August 2021, at a Secondary Care Hospital of Karachi, Pakistan. It was based on the collection of outpatient clinic prescriptions of children aged less than five years and suffering from acute diarrhea. The regimens or suggested therapies by prescribers for acute diarrhea were assessed as per The National Institute of Care and Health Excellence and World Health Organization guidelines. A brief questionnaire was also distributed among prescribers, pharmacists, and caretakers of children to extract their opinions regarding antibiotic prescribing in acute diarrhea.Results: Antibiotics were inappropriately prescribed for acute diarrhea among children in Pakistan because p-value was less than 0.05 (p<0.05) as calculated by descriptive statistical tools using Z-test. More than 90% prescriptions of acute diarrhea in children less than five years of age failed to comply with the authentic treatment guidelines.Discussion: Due to the limited knowledge of prescribers regarding treatment guidelines and compliance of parents with antibiotic prescribing for diseases in children, irrational prescribing of antibiotics for acute diarrhea in children less than five years of age is frequent in Pakistan. Healthcare professionals must be adequately trained to ensure the proper management of acute diarrhea by following authentic clinical guidelines. Conclusion: Antibiotics are irrationally prescribed for acute diarrhea in children less than five years of age in Pakistan and prescriptions do not comply with authentic clinical guidelines.

Wastewater based environmental surveillance of toxigenic Vibrio cholerae in Pakistan

BACKGROUND

Pakistan has been experiencing intervals of sporadic cases and localized outbreaks in the last two decades. No proper study has been carried out in order to find out the environmental burden of toxigenic V. cholerae as well as how temporal and environmental factors associated in driving cholera across the country.

METHODS

We tested waste water samples from designated national environment surveillance sites in Pakistan with RT-PCR assay. Multistage sampling technique were utilized for samples collection and for effective sample processing Bag-Mediated Filtration system, were employed. Results were analysed by district and month wise to understand the geographic distribution and identify the seasonal pattern of V. cholera detection in Pakistan.

RESULTS

Between May 2019, and February 2020, we obtained and screened 160 samples in 12 districts across Pakistan. Out of 16 sentinel environmental surveillance sites, 15 sites showed positive results against cholera toxigenic gene with mostly lower CT value (mean, 34±2) and have significant difference (p < 0.05). The highest number of positive samples were collected from Sindh in month of November, then in June it is circulating in different districts of Pakistan including four Provinces respectively.

CONCLUSION

V. cholera detection do not follow a clear seasonal pattern. However, the poor sanitation problems or temperature and rainfall may potentially influence the frequency and duration of cholera across the country. Occurrence of toxigenic V. cholerae in the environment samples showed that cholera is endemic, which is an alarming for a potential future cholera outbreaks in the country.

Frequency of Cryptosporidiosis in Children having Persistent Diarrhea

Objective:

Globally childhood diarrheal diseases continue to be the second leading cause of death. Cryptosporidium spp are important intestinal parasites that cause diarrhea in humans and animals particularly in developing countries. This investigation was carried out to find out the frequency of cryptosporidiosis in children presenting with persistent diarrhea.

Methods:

Two hundred stool samples were collected in this descriptive cross-sectional study conducted at Microbiology Department, Combined Military Hospital, Lahore Pakistan between the months of July to Dec 2014. Children aged five years to 12 years who presented with persistent diarrhea were included in the study. Stool specimens were processed using the modified acid-fast staining method, and microscopically examined for Cryptosporidium infection.

Results:

The average age of study participants was 7.95 with a standard deviation of 2.21 years. Among the participants 66% were males whereas 34% were females. Twenty eight percent had presence of oocysts in stool samples.

Conclusions:

The frequency of Cryptosporidiosis among children with persistent diarrhea was 28%. This high frequency indicates that this population is uniquely susceptible to infection. It also highlights the need for education about hygiene, accurate diagnosis, and treatment of Cryptosporidiosis. There is also a need for additional studies regarding the occurrence of this pathogen.

A Community-Based Survey on Health-Care Utilization for Pneumonia in Children in Peri-Urban Slums of Karachi, Pakistan

Pneumonia, as defined by WHO, is a syndromic diagnosis characterized by presence of cough or difficult breathing. Presentation to health-care provider depends on timely identification of signs and symptoms by caretakers. We explored patterns of health-care utilization among caretakers of a randomly selected sample of 1,152 children aged 2-59 months, residing in low-income settlements of Karachi, Pakistan. Information on household demographics, occurrence of pneumonia-specific symptoms, care seeking, air quality, and knowledge regarding preventive measures for pneumonia was collected. Predictors of care seeking were estimated using weighted logistic regression. Prevalence of pneumonia with cough and rapid or difficulty in breathing was found to be 40.8% and 37.1% in infants (2-11 months) and children (12-59 months), respectively. Ninety-five percentage of caretakers sought care, 68.5% privately. Odds ratios (ORs) for independent predictors of care-seeking were as follows: younger age of child (infants compared with children), 3.60 (95% CI = 2.65-4.87); caretaker with primary education compared with none, 3.40 (2.46-4.70); vaccine awareness, 1.65 (1.45-1.87); and breastfeeding awareness, 1.32 (1.13-1.53). Presence of symptoms such as fever OR, 1.51 (1.30-1.76); tachypnea, 1.57 (1.35-1.83); chest indrawing, 2.56 (2.05-3.18); persistent vomiting, 1.69 (1.37-2.09); and recurrent illness, 2.57 (2.23-2.97) were also predictive. There is high health-care utilization for pneumonia with the skewed presentation toward private services. Strategies should be focused on making pneumonia care standardized, efficient and affordable, especially in the private sector.

Healthcare seeking trends in acute respiratory infections among children of Pakistan

AIM

To assess healthcare seeking trends among Pakistani children with acute respiratory infections through comparative analysis between demographic health surveys (DHS) 2006-2007 and 2012-2013.

METHODS

Data of the last born children 0-24 mo of age of the sampled households from both the DHS was analyzed after seeking permission from the DHS open access website. These were children who had suffered from cough and/or breathing difficulty in the past two weeks and sought health care thereafter. The trends of health care seeking were determined separately for the individual, household and community level according to the study parameters. χ² test was applied to compare these trends. A P-value of < 0.05 was considered significant.

RESULTS

Out of 2508 children in 2006-2007 there were 1590 with acute respiratory infections (ARI) according to case definition along with 2142 out of 3419 children in 2012-2013 DHS, whose data was analyzed. During 2006-2007, 69% cases sought healthcare for ARI which improved to 79% in 2012-2013. Additionally, it was revealed that when compared between 2006-2007 and 2012-2013, improvement in care seeking practices was observed among illiterate mothers (64% vs 77%) although there was minimal change in those literate. Similarly, those women working also showed an increase in healthcare seeking from 67% to 79%. Additionally, those belonging to low and middle socioeconomic class showed a marked increase as compared to those in the higher class where there was no significant change. Whereas those living in rural communities also showed an increase from 66% to 78%.

CONCLUSION

Increasing health budget, improving maternal education and strengthening multi-sectoral coordination are among the effective strategies to improve outcomes associated with healthcare seeking in ARI.

Intussusception among children less than 2years of age: Findings from pre-vaccine introduction surveillance in Pakistan

BACKGROUND

Rotavirus vaccination introduction in routine immunization is under consideration in Pakistan. Data on the baseline epidemiology of intussusception will inform surveillance strategies for intussusception after rotavirus vaccine introduction in Pakistan. We describe the epidemiology of intussusception-associated hospitalizations among children <2years of age in Karachi, Pakistan.

METHODS

We conducted a retrospective chart review for July 01, 2012 through June 30, 2015 at the National Institute of Child Health (NICH) and Aga Khan University Hospital (AKUH) Karachi. At AKUH, the International Classification of Disease, ninth revision, code 560.0 for intussusception was used to retrieve intussusception case records. At NICH, daily Operation Theater, Emergency Room, and surgical daycare log sheets and surgical ward census sheets were used to identify cases. Records of children who fulfilled eligibility criteria and the Brighton Collaboration level one case definition of intussusception were selected for data analysis. We used structured case report forms to extract data for the descriptive analysis.

RESULTS

We identified 158 cases of confirmed intussusception; 30 cases (19%) were from AKUH. More than half (53%) of the cases occurred in children aged 6-12months, followed by 35% among those aged <6months. Two-thirds (106/158) of the cases were male. The most common presenting complaints were vomiting and bloody stool. At NICH, almost all (93%) were managed surgically, while at AKUH, ∼57% of the cases were managed with enemas. Three deaths occurred, all from NICH. Cases occurred without any seasonality. At NICH, 4% (128/3618) of surgical admissions among children aged <2years were attributed to intussusception, while that for AKUH was 2% (30/1702).

CONCLUSION

In this chart review, intussusception predominantly affected children 0-6months of age and occurred more commonly in males. This information on the baseline epidemiology of intussusception will inform post-vaccine introduction adverse event monitoring related to intussusception in Pakistan.

Predictors of diarrheal mortality and patterns of caregiver health seeking behavior in in Karachi, Pakistan

Background

Pakistan is unfortunately among the five countries that contributed to the most deaths due to diarrhea and pneumonia in 2010. To explore factors associated with diarrheal deaths we assessed care–seeking behavior and other predictors of diarrhea–related mortality in children in selected low–income peri–urban communities of Karachi, Pakistan.

Methods

A mixed methods study (qualitative and quantitative) using matched case–control design and focus group discussions with parents of children with moderate to severe diarrhea (MSD) was undertaken. Cases were children  <5 years of age who died within 60 days of developing an episode of MSD. Controls were age–matched children who survived after 60 days of an episode of MSD. Demographic, clinical, and care–related behavioral predictors of mortality were assessed. Conditional logistic regression was performed, matched adjusted odds ratios (mOR) are reported.

Results

Parents of 77 cases and 154 controls were interviewed. Cases were less likely to receive appropriate care compared to controls (mOR = 0.2, 95% confidence interval (CI) 0.05–0.91). Refusal for hospital admission (OR = 8.9, 95% CI 2.6–30.8), and delays in reaching the health facility (OR = 3.6, 95% CI 1.0–12.9) were significant independent predictors of mortality. We found strong beliefs in traditional and spiritual healing in the population; use of both modern and traditional/spiritual treatments concurrently was common.

Conclusion

Appropriate care seeking behavior predicts survival in children with diarrhea in Pakistan. There is a complex belief system relating to traditional and standard therapies. Health education for appropriate health care seeking should be implemented in order to achieve a substantial decline in diarrheal disease mortality in Pakistan.

Harmful practices in the management of childhood diarrhea in low- and middle-income countries: a systematic review

BACKGROUND

Harmful practices in the management of childhood diarrhea are associated with negative health outcomes, and conflict with WHO treatment guidelines. These practices include restriction of fluids, breast milk and/or food intake during diarrhea episodes, and incorrect use of modern medicines. We conducted a systematic review of English-language literature published since 1990 to assess the documented prevalence of these four harmful practices, and beliefs, motivations, and contextual factors associated with harmful practices in low- and middle-income countries.

METHODS

We electronically searched PubMed, Embase, Ovid Global Health, and the WHO Global Health Library. Publications reporting the prevalence or substantive findings on beliefs, motivations, or context related to at least one of the four harmful practices were included, regardless of study design or representativeness of the sample population.

RESULTS

Of the 114 articles included in the review, 79 reported the prevalence of at least one harmful practice and 35 studies reported on beliefs, motivations, or context for harmful practices. Most studies relied on sub-national population samples and many were limited to small sample sizes. Study design, study population, and definition of harmful practices varied across studies. Reported prevalence of harmful practices varied greatly across study populations, and we were unable to identify clearly defined patterns across regions, countries, or time periods. Caregivers reported that diarrhea management practices were based on the advice of others (health workers, relatives, community members), as well as their own observations or understanding of the efficacy of certain treatments for diarrhea. Others reported following traditionally held beliefs on the causes and cures for specific diarrheal diseases.

CONCLUSIONS

Available evidence suggests that harmful practices in diarrhea treatment are common in some countries with a high burden of diarrhea-related mortality. These practices can reduce correct management of diarrheal disease in children and result in treatment failure, sustained nutritional deficits, and increased diarrhea mortality. The lack of consistency in sampling, measurement, and reporting identified in this literature review highlights the need to document harmful practices using standard methods of measurement and reporting for the continued reduction of diarrhea mortality.