1. No category

Vol. 3, No. 2
June 2013
Health Services Academy
H E ALT
H
CADEM
S E RV I C E S A
Y
PAKISTAN JOURNAL OF
PUBLIC HEALTH
ISSN: 2225-0891
E-ISSN: 2226-7018
Pak J Public Health
3
Pakistan Journal of Public Health, 2013 (June)
Vol. 3 No. 2 (June) 2013
Perceptions about measles among mothers living in rural area: A cross-sectional study at Larkana, Sindh
Hussain S, Kumar R, Ali M, Khan EA, Ahmed J, Khan SA, Hussain S.
2
Gaps Analysis in Knowledge, Practices & Control Responses to Combat Cutaneous Leishmaniasis in Bagh AJ&K
Akbar J, Rathor HR, Hassan SA, Bilal H, Khan IA, Idrees M
6
Susceptibility of Salmonella enterica serotype typhi, to the usual line of antimicrobial treatment in Rawalpindi
Abdullah MA, Zahid A, Sattar NY
14
World Health Organization diabetic care guidelines: knowledge and practices of general practitioners in private
Clinics of Rawalpindi, Pakistan
Durrani HM, Kumar R, Durrani SM, Anwar-ul-Haq
19
Bioactivity of botanicals against Aedes aegypti Linnaeus and Anopheles stephensi Liston Larvae
Inam-llah H, Rathor HR, Bilal H, Hassan SA and Khan IA, Faridi TA
23
Morbidity Patterns in Pakistan: Evidence from Pakistan Panel Household Survey 2010
Bari I, Abbas N
28
Socioeconomic and demographic dynamics of Birth Interval in Pakistan
Abbas N, Shaikh I, Bari I
35
Short Communication
A Spot Survey to Investigate an Outbreak of Cutaneous Leishmaniasis at Afghan Refugee Camp at Khairabad
Village in KPK.
Rathor HR, Hassan SA, Bilal H, Khan IA, Fridi TA.
40
Prof. Dr. Hamayun Rashid Rathor,
University of Health Sciences, Lahore
Dr Shahzad Ali Khan,
Dr Inayat Thawar Health Services Academy, Islamabad
Dr Ejaz Ahmed Khan,
Dr Samina Naeem, Health Services Academy Islamabad
Dr Katrina Aminah Ronis, Health Services Academy Islamabad
Cairo
Dr Michael Mecdonald, World Health Organization, Geneva
Prof. Dr. William K. Reisen, University of California, USA
Mr Imtinan Akram Khan, Health Services Academy, Islamabad
Asma Sana Health Services Academy, Islamabad
Dr Saima Iqbal Paracha Health Services Academy, Islamabad
Pakistan Journal of Public Health, 2013 (June)
Pakistan Journal of Public Health, 2013 (June)
Pakistan Journal of Public Health, 2013 (June)
Pakistan Journal of Public Health, 2013 (June)
Correspondence to
Prof. Dr. Hamayun Rashid Rathor
Executive Editor
Pakistan Journal of Public Health
Health Services Academy
Prime Minister National Health Complex
Park Road, Chak Shahzad
Islamabad, 44000, Pakistan
E-mail: [email protected]
Ph: +92-51-9255590-94, Ext 104,106
Fax: +92-51-9255591
Pakistan Journal of Public Health, 2013 (June)
Pak J Public Health Vol. 3, No. 2, 2013
We are pleased to present the volume 3, second issue of the Pakistan Journal of public Health. This journal is gaining its
popularity due to the fact that it provides unique and equal opportunity to young as well as experienced medical and biomedical research workers in Pakistan, to share their research outcomes with national and international researchers.
An innovative feature of this journal is that it responds to the burning issues of public health. In this issue the original articles
present ideas that can form basis for public health planning and policy, especially aimed at more vulnerable groups of the
community and the diseases that have assumed epidemic form in the country. One paper draws attention to paying extra
attention to female section of community because females of age 10 and above, especially 60 and above show higher level
of morbidity compared to males. Another paper deals with the subject of measles that assumed epidemic form this year. It
draws signicant links to mother's level of education to appropriate vaccination of children against measles. Diabetes
mellitus is growing in Pakistan at an alarming rate. An article deals with the ability of General practitioners to deal
appropriately with the Diabetes cases. In view of the prevailing epidemics of dengue and leishmaniasis, papers have been
included, in this issue, on recent indigenous research in the eld of Medical Entomology and Disease Vector Control. A
short communication on quick investigation of leishmaniasis outbreak presents in-depth analysis of factors responsible for
the outbreak and provides comprehensive solutions for present and possible future outbreaks.
We wish to thank our contributors and readers for their overwhelming response and support to PJPH and as reported
earlier, the Pakistan Journal of Public Health has obtained the indexation in WHO EMRO database of Scientic journals
(IMEMR), Index Copernicus and EMBASE, it is in progress with Thomas Reuters, Pakistan Medical and Dental council and
Higher Education Commission of Pakistan.
We wish to acknowledge our gratitude, for the members of editorial board and reviewers for ensuring the quality of
publications and national and international members of Advisory Board for support and advice for continued improvement
of the Journal.
Prof. Dr. Hamayun Rashid Rathor
June 2013. Islamabad
Pakistan Journal of Public Health, 2013 (June)
Pak J Public Health Vol. 3, No. 2, 2013
Perceptions about measles among mothers living in rural area: A cross-sectional
study at Larkana, Sindh
Shahid Hussain1, Ramesh Kumar2, Mansoor Ali1, Ejaz Ahmed Khan2, Jamil Ahmed2, Shahzad Ali Khan2,
1
Sadat Hussain
1
2
Alumni Health Services Academy Islamabad Pakistan, Faculty of Public Health, Health Services Academy
Islamabad Pakistan. (Correspondence to Kumar R:[email protected])
Introduction: Measles is still a public health problem in Pakistan. Despite disease prevention initiatives taken by the
government, the disease is on the increase in rural and remote areas of the country. About 21,000 children die annually due
to measles, which is about 58 children dying daily due to this infection. 63% coverage by vaccination has been reported in
Pakistan, which is below the overall global coverage. This disease is endemic in the country and is considered to be a major
cause of childhood morbidity & mortality.
Methods: A cross-sectional study design with mixed methodological approach was conducted at rural union council of
district Larkana. Total 106 mothers were selected for the study by adapting the multistage sampling technique. A semistructured questionnaire was adapted and focus Group Discussions were carried out with mothers residing outside the
study site.
Results: Study revealed that all the parents somehow had knowledge about vaccination, 85% of the mothers realized
measles vaccination to be benecial, but only 14% had got their children immunized, 41% of the mothers in area of study
did not vaccinate their children because of the fear of bad effects of vaccines. There was signicant relationship between
the literacy of mothers and their knowledge about the total doses recommended for measles (p value 0.06).
Conclusion: The study revealed that knowledge, attitude and practices of mothers about measles are related to their
economic status and better socio-cultural factors, which is signicantly related with mother's level of education. (Pak J
Public Health 2013; 3(2): 2-5)
Keywords: Measles, Practices, Knowledge of mothers, children and vaccination.
Introduction
Pakistan has been reported as highly endemic country for
measles infections due to the low coverage by measles
vaccine (1).Globally, 139,300 deaths, 380 deaths per day
or 15 deaths every single hour resulting from measles have
been reported in year 2010. Most of the cases occur in Low
& Middle Income Countries (LMICs) settings. However, the
vaccination resulted in a 74% drop in number of measles
cases during the past. About 85% of the world's children
received single dose of measles vaccine before reaching
their 1st year of life (2). In 2012 the number of measles
cases decreased through better organized supplementary
immunization campaigns and better Expanded Program on
Immunization (EPI) (3).
Approximately 2.1 million Pakistani people have
been affected by measles, consequently; about 21,000
children die every year. It is endemic in the country and is
considered to be a major cause of childhood morbidity &
mortality. In Pakistan, as per the EPI schedule,
immunization against measles is recommended at 9
months of age, which can be the reason for increased
mortality rate amongst infants who are younger than 9
months, because they had not received the vaccine (4).
The economic, social, and health burden of measles
infection is huge. Measles, a communicable disease,
affects children & transmit as droplets from the nose, throat
or mouth of the infected person. Measles vaccine is
believed to be the most cost effective public health
intervention. Vaccinating a child signicantly reduces costs
of treating diseases, thus providing a healthy childhood and
reducing poverty and suffering. Recently, the immunization
coverage rates have improved sufciently in the developed
countries, thereby conferring herd immunity, whereas most
of the developing countries are still struggling with faltering
rates (5).
In Pakistan, the reported EPI coverage is still far
below the herd immunity threshold (6). Reasons underlying
poor coverage have been studied by researchers globally
and besides other factors, knowledge and beliefs of
parents have been documented to affect immunization
coverage (7). Therefore it is a challenge for immunization
service providers, to offer parents balanced and
comprehensive information about the risks as well as the
benets of vaccination during the counseling sessions. The
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Pakistan Journal of Public Health, 2013 (June)
current study was proposed to decrease morbidity and
mortality in children by early identication of causative
factors of measles and by improving knowledge, attitude
and practices of target population.
Methods
A Cross sectional study was conducted from September to
December 2012. A mixed methodology by including both
qualitative and quantitative approaches was adapted to
collect the data from mothers having at least one under
ve-child living at rural areas of Taulka Ratudero District
Larkana. A semi-structured questionnaire and eld guide
were developed and translated into local language and
used for data collection. Female data collectors were hired
and trained before data collection process. Householders
were considered eligible to participate if they have at least
one under-ve child lived there and those mothers who had
any mental disability were excluded. Following
identication of such a household, the mother of the eligible
child was interviewed after obtaining the written consent.
Sample sizes were calculated by using the proportional
formula. Multistage sampling technique was used in which
at initial stage, convenient sampling technique was used
for the selection of one Union Council out of 11 at Taluka
Ratodero. Afterwards, sub units/sub clusters containing 4
to 5 Lady Health Workers (LHWs) serving areas which
were adjacent to each other were demarked within the
selected Union Council. Further to it, out of all sub units/sub
clusters one sub unit/sub cluster was selected randomly.
After that list of households with eligible mothers were
collected from concerned Lady Health Worker (LHWs) and
entered into SPSS. Finally, 106 eligible households were
selected randomly through SPSS. Further, in case of nonresponse/refusals than already accounted 10%, next
household were to be selected to compensate sample size.
Quantitative survey was the major part of study, for
which a semi-structured questionnaire was utilized to
collect information on basic demographic characteristics,
socio-economic status, parental education, reproductive
history, immunization status of the child (coverage status
was veried by checking EPI card or verbal inquiry) and
mothers' knowledge, attitude and practices about measles
and it's vaccination. For the qualitative part of this study to
explore KAP of mothers about measles, Focus Group
Discussions (FGDs) were carried out with mothers residing
outside the study site. A total of 3 FGDs were conducted,
however the respondents refused to have been audio
recorded hence the written notes were taken. Quantitative
data was entered in SPSS version 17 and descriptive
analysis was carried out. Summary statistics for continuous
variables and frequencies and proportions for categorical
variables were used. Data is presented in tables and
graphs. Chi square test was used to for associations
between knowledge about measles and other variables.
For FGDs, all of the summarized notes were read and
translated in one sitting to look for trends and comments
that elicited emotional response or phrased negatively
were noted. Finally the report was made by keeping in mind
that the results generated would reect the purpose. All the
analysis was done manually. Institutional ethical
considerations were taken from Health Services Academy
Islamabad, Pakistan.
Results
Demographic information shows that, only 36% had some
formal education whereas 64% of mothers were
completely uneducated. For those who were educated
there were drop outs at every level from primary, high
school to college and university; 15 percent had primary
while only 8 percent reached college/university level.
Compared to their spouses, almost 18% of fathers had
sought their Primary education and 41% of them never
went to any school. Majority of mothers 92% were house
wives where as 38% of their husbands were farmers
followed by other 18% who were Government employees.
Information about household characteristics was asked in
relation to type of construction, number of rooms and
number of persons sharing one room, type of facility and
source of drinking water. Information revealed that almost
half of the houses were made up of cement (50%). Majority
of the houses had toilet 77% while very few 19% were using
open area for defecation.
Result shows that all of the parents somehow had
knowledge about government's EPI programme, 85% of
the mothers realized measles vaccination to be benecial,
but only 14% had got their children immunized. 41% of the
mothers in area of study did not vaccinate their children
because of the fear of bad effects of vaccines. This trend
was further followed by fever, staff attitude and long waiting
hours at the facility (37% each) being the main hindering
factors to keep mothers away from vaccinating their
children. According to ndings of this study majority of
studied mothers agreed that measles was a vaccine
preventable disease, but nearly half of them (43%) did not
know even about the total doses of measles vaccine. More
so 6% said that 2nd dose was never required. 82% of the
under-ve children of mothers were partially immunized.
Literacy rate in mothers was very low; almost 64% of the
mothers were illiterate and only 8% of the mothers from 4
villages attained the highest level of college. This highlights
3
Pakistan Journal of Public Health, 2013 (June)
the female restriction to home due to cultural barriers and
non-availability of separate schools for girls. Majority, 92%
of the mothers were house wives. Agriculture is the main
earning source on which villagers depend for most of their
income. Most of the mothers were engaged in agricultural
activities with their men. Fathers education was also low,
41% were reported as illiterate. Only 18% of the fathers
were government employees. More than half (61%) of the
families had joint family system and 50% had cemented
houses.
Table 1 shows that perception about measles as a
vaccine preventable disease highly statistically
signicantly different with respect to their knowledge about
the doses of measles vaccine (p value <0.05). These
results are very important as 46 mothers out of the total
respondents (43%) were those who described that
measles was a vaccine preventable disease however they
did not know about number of doses to be vaccinated for it.
However 13 of selected mothers (12%) were those who did
not know whether measles was a preventable disease, the
question about doses of measles vaccine was skipped
from them.
Table 1: Perception about Measles as a Vaccine
Preventable Disease
Yes Don't know p value*
Knowledge about
doses of measles
vaccine
Total
One
16
0
Two
31
0
Don't
Know
46
0
NA
0
13
93
13
0.000
*Level of signicance p< 0.05; Non signifcance p>0.05
Monthly household income had strong association
with the perception of mothers about measles (p value
<0.05). Whereas age of mother, number of under-ve
children and age of youngest child had no signicance on
the perception of mothers about measles and measles
vaccination (Table-2).
Mothers who were more educated they were more
aware about the total doses of measles vaccine. Although
the p value is 0.06 which shows that the results are
statistically nearly signicant. Hence we can conclude that
there is signicant correlation between the literacy of
mothers and their knowledge about the doses of measles
Table 2: Variables showing Perception of mothers
about measles and measles vaccination
Variables
Yes
No
p value*
Age of mother
29.61
(SD 7.1)
31.85
(SD 7.6)
0.303
Number of under
5 children
1.34
(SD 0.5)
1.31
(SD 0.48)
0.842
Age of the
youngest child
2.42
(SD 1.3)
2.31
(SD 1.3)
0.79
Total monthly
household income
12364
(SD 6982)
2383
(SD 17344)
<0.000
*Level of signicance p< 0.05; Non signicance p>0.05; SD Standard Deviation
vaccine.
Some other factors documented in view of the focus group
discussion were as below:
Knowledge about the measles.
Hygiene is an important in prevention of measles.
Knowledge of sign and symptoms of measles.
Measles can spread from one child to another.
Importance of the vaccination.
Practices on vaccination against measles.
Myths for treatment of measles.
Discussion
Our study shows that the mother's education is very low.
This low literacy level negatively effects on the Knowledge
of mothers regarding measles vaccination in their children
under age of ve years. Study supports these ndings and
suggest that the maternal education is very important factor
in reducing the child mortality in rural areas of sindh (8).
Poverty, low literacy rate, large families, food insecurity,
food safety and women's education are signicant
underlying factors responsible for poor health status of
children from low socioeconomic class (9). Majority of the
rural women are illiterate having poor knowledge of their
health (10). Most of the mothers were aware about the
vaccination but it has been reported that most of their
children were un-vaccinated due to their poor practices
regarding vaccination (11). Our results are nearly matching
with a study conducted by Sultana et al in an urban
population of northern areas of Pakistan which concluded
that there exists a gap between knowledge and practice
(12). One of the interesting nding of this study was that all
the participants knew about immunization and measles as
a disease of children, as many among their previous
generations and they themselves had measles when they
were young. But very few of them knew about the
complications of measles. A matching study about the
status of mother's Knowledge, attitude and practices (KAP)
4
Pakistan Journal of Public Health, 2013 (June)
on child immunization in minorities at Beijing China shows
that besides other factors, knowledge and beliefs of
parents were documented to affect immunization coverage
in the community (7). In another similar study, the most
common primary reason for non-vaccination was found the
lack of knowledge, whereas the most common secondary
reason for non-vaccination was religious taboos. Majority
of the respondents demonstrated poor knowledge of EPI
schedules (13). Low maternal education and routine
vaccination from public EPI facility were signicant
determinants for low coverage (1).
Conclusion
Majority of mothers residing in the rural settings of Sindh do
not have the better opportunities of health and education,
hence their knowledge, attitude and practices regarding
measles are not satisfactory. Our study revealed that
knowledge, attitude and practices of mothers for measles
are more or less related with their economic status and
better socio-cultural factors.
1.
2.
3.
4.
5.
6.
7.
References
Khowaja AR, Sheikh S, Saleem AF, Zaidi AK. Parental
Awareness and Coverage of Mass Measles
Vaccination Drive 2011: Cross-Sectional Survey in the
Metropolitan City of Karachi, Pakistan. Asia-Pacic
journal of public health/Asia-Pacic Academic
Consortium for Public Health. 2012. Epub 2012/11/21.
WHO. Updates on Measels. [5th Sep,2013]; Available
from: http://www.who.int/topics/measles/en/.
Owais A, Khowaja AR, Ali SA, Zaidi AK. Pakistan's
expanded programme on immunization: an overview
in the context of polio eradication and strategies for
improving coverage. Vaccine. 2013;31(33):3313-9.
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International Data Base of Us Census Bureau. [cited
2013 5 September]; Available from:
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Bhutta ZA, Gupta I, de'Silva H, Manandhar D,
Awasthi S, Hossain SM, et al. Maternal and child
health: is South Asia ready for change? BMJ.
2004;328(7443):816-9. Epub 2004/04/09.
Pakistan EotNAaO. Pakistan Health. 2009; Available
from: http://www.nationsencyclopedia.com/Asia-andOceania/Pakistan-HEALTH.html.
Wang YY, Wang Y, Zhang JX, Kang CY, Duan P.
[Status of mother's KAP on child immunization in
minority areas, Guizhou Province]. Beijing da xue xue
bao Yi xue ban = Journal of Peking University Health
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Agha A, Ajmal F, Iqbal A, White F. Father's support and
literacy--factors associated with child mortality in
Gambat, Sindh-Pakistan. JPMA The Journal of the
Pakistan Medical Association. 2010;60(2):81-5. Epub
2010/03/10.
Babar NF, Muzaffar R, Khan MA, Imdad S. Impact of
socioeconomic factors on nutritional status in primary
school children. Journal of Ayub Medical College,
Abbottabad : JAMC. 2010;22(4):15-8. Epub
2010/10/01.
Ali S, Ara N, Ali A, Ali B, Kadir MM. Knowledge and
practices regarding cigarette smoking among adult
women in a rural district of Sindh, Pakistan. JPMA The
Journal of the Pakistan Medical Association.
2008;58(12):664-7. Epub 2009/01/23.
Hasan IJ, Nisar N. Womens' perceptions regarding
obstetric complications and care in a poor shing
community in Karachi. JPMA The Journal of the
Pakistan Medical Association. 2002;52(4):148-52.
Epub 2002/08/15.
Sultana A JS, and Ahmad I. Knowledge, Attitude and
Practice of immunization in an urban population. Pak
Armed Forces Med J. 2010;51:177-81.
Sheikh A, Iqbal B, Ehtamam A, Rahim M, Shaikh HA,
Usmani HA, et al. Reasons for non-vaccination in
pediatric patients visiting tertiary care centers in a
polio-prone country. Archives of public health =
Archives belges de sante publique. 2013;71(1):19.
Epub 2013/07/16.
5
Pakistan Journal of Public Health, 2013 (June)
Pak J Public Health Vol. 3, No. 2, 2013
Gaps Analysis in Knowledge, Practices and Control Responses to Combat Cutaneous
Leishmaniasis in Bagh AJ&K
Javed Akbar1, Hamayun Rashid Rathor1, Soaib Ali Hassan1, Hazrat Bilal1, Imtinan Akram Khan1,
Muhammad Idrees2
1
Health Service Academy, Department of Medical Entomology and Disease vector Control,
Islamabad-Pakistan, 2 AJ&K Health Department (Correspondence to Akbar J: [email protected])
Background: Patients are potential reservoirs and if not responded properly they are playing vital role in transmission,
especially anthroponotic cutaneous Leishmaniasis (CL) transmission.
Method: Cross sectional survey conducted to investigate the gaps and strengths of healthcare providers to respond the
cases of cutaneous Leishmaniasis in primary healthcare facilities.
Results: Most of health facilities (>88%) had no specied staff to respond neglected tropical diseases (NTDs). The
majority of available staff (80%) had inadequate knowledge about treatment and transmission mechanism of cutaneous
Leishmaniasis. Majority of respondents (70%) were neither reporting nor notifying CL cases. Knowledge about rst and
second line responses were signicant (70% know what to do).
Conclusion: Socio-demographic situation of primary health care system favor the existence of human reservoir for further
transmission of cutaneous Leishmaniasis. There is a huge gap in indigenous and technical knowledge and practices
regarding detection and treatment of cases at health sector. (Pak J Public Health 2013; 3(2): 6-13)
Key words: Sand y, Cutaneous Leishmaniasis, healthcare provider, knowledge, tropical disease
Introduction
Tropical diseases are infectious diseases that are found
predominantly in the tropics, where ecological and
socioeconomic conditions facilitate their propagation.
Climatic, social and economic factors create environmental
conditions that facilitate transmission, and the lack of
resources prevents affected populations from obtaining
effective prevention and care (1).
Dengue and Leishmaniasis are serious diseases
that the World Health Organization (WHO) characterizes
as lacking effective control measures. They are transmitted
by insect vectors and can result in epidemic outbreaks. For
dengue neither a specic treatment nor a vaccine is
available, although good supportive treatment of dengue
patient can drastically reduce mortality. Prevention of
dengue through vector mosquito control is the only best
available strategic option. For Leishmaniasis, treatment
relies largely on drugs based on Antimony. Sustained
control of the insect vectors of dengue and Leishmaniasis
may not be easy because their high reproductive potential
that allows quick recovery of vector populations after
intervention wherever adequate breeding conditions exist
(2), however, with motivated community participation,
vector breeding can be prevented and controlled.
Moreover, community education and mobilization can also
prevent vector-man contact and reduce disease
transmission.
Leishmaniasis is an emerging and resurging
tropical disease with an ability to adapt to changing
environments. It is caused by a protozoan “Leshmania”
and transmitted through the bite of the female sand
ies “Phlebotomus” (3). It is amongst the 15 most
neglected disease of the world (4). Old world cutaneous
Leishmaniasis, known as oriental sore , is an ancient
disease dated back to 650 BC. Arab physicians, including
Avicenna described details of oriental sore in 10th century.
Texts from the 15th and 16th centuries mentioned the
risk run by seasonal agricultural workers who returned
from the Andes with skin ulcers (5,6).
The disease has four main forms, depending on
the parasite species and the cellular immune system of the
patient. Clinical symptoms of different parasites are
variable; they include: (a) visceral leishmaniasis,
characterized by weight loss, irregular bouts of fever,
anemia, enlargement of spleen and liver etc. (b)
Mucocutaneous leishmaniasis, leading to partial or total
destruction of mucous membrane of nose, mouth and
throat and (C.) Cutaneous leishmaniasis, producing ulcer
on exposed parts of the body, scarring and on occasion
serious disability (7,8).
The transmission of the disease may be zoonotic
or anthroponotic and even from human to animals
6
Pakistan Journal of Public Health, 2013 (June)
transmission is possible (9). In many geographic areas only
infected animals (such as rodents or dogs) along with sand
ies maintain the disease cycle, called Zoonotic Cutaneous
Leishmaniasis (ZCL). However, in some parts of the world,
infected people generally maintain the cycle; this type is
known as Anthroponotic Cutaneous Leishmaniasis
(ACL) (10). In Asia, Africa, Europe and South America, the
transmission mainly occurs in rain forests, desert areas,
rural, peri urban, sylvatic and domestic habitat areas. The
zoonotic visceral and cutaneous leishmaniasis is caused
by L. infantum while sporadic anthroponotic cutaneous
leishmaniasis caused by L. tropica (11).
It is estimated that 12 million cases of
Leishmaniasis exist worldwide and 2 million new cases are
occurring annually. The geographical distribution of
Leishmaniasis is restricted to tropical and temperate
regions (12).
It is prevalent in four continents and endemic in 88
countries (22 in the New World and 66 in the Old World).
Among these, 16 are developed countries and 72 are
developing countries; 13 of them are among the least
developed countries. More than 90% of the CL cases occur
in countries like Brazil, India, Sudan, Afghanistan, Iran,
Saudi Arabia and Syrian Arab Republic. CL is now
estimated to affect 15,000-20,000 people in Pakistan
yearly (13).
Several factors had been analyzed to determine
the transmission of Leishmaniasis include; biological,
environmental, geopolitical, socio-economic, cultural and
behavioral factors as illustrated in gure 1.
Geo-political factors
Wars and Disasters resulting
migration and displacement
Non immune human population
moves in areas where the disease
and the vector are present
Socio economic Factors
Poor Socio economic systems
Construction of houses with mud
walls and earthen oors
Unscreend rooms
Urbanization
The present survey was limited to determination of
gaps in knowledge and control responses of healthcare
providers which fall under the socio-economic, cultural and
behavioral factors.
In the view of increased numbers of cases and
unavailability of drugs and treatment facilities this study
was planned and conducted to assess the potential gaps in
knowledge and control responses regarding transmission
of CL.
Both clinical and public health interventions
depend on the capacity of a given country's health system
to deliver, noting that some interventions are more
demanding than others in terms of infrastructure and
human resources. In addition, decisions about which
interventions should be given priority will depend on
assessments of the local burden of disease, local health
infrastructure and other social factors as well as on costeffectiveness analysis (14).
Research capacity continues to limit the
successful implementation of those interventions most
needed to improve health in resource-constrained
environments. The number of people trained to carry out
the surveillance and the laboratory and operational
research that are so essential to the successful
implementation of cost-effective interventions remains
woefully inadequate (15).
An estimated 72% of patients are unable to access
medical treatment, mainly because a very few hospitals in
country are providing free treatment and these are specic
to hard access. Most government hospitals do not have any
drugs and skilled staff for Leishmaniasis treatment (16).
Behavioral Factor
Occupation
Daily activity
Sleeping habit
Use of mosquito net
Increased exposure to disease vector
Biological Factor
Hosts; Humans, Animals
Vector; Phlebotomine Sand Flies
Agent; Leshmania species
Reservoirs; Canine, Rodents & man
Availability of blood meal
Outbreaks of Coctancous
Leishmaniasis Transmitted
by Sand y
GAPS in Knowledge & Practices
Inadequate Knowledge and practice of community
about transmission of Leishmaniasis & sand y role
Inadequate responses to CL at healthcare provider level
Lack of community involvement in control strategies
Environmental Factors
Favorable Humidity & temp.
Livestock kept close to human
dwellings
Debris of organic materials &
animal dung
Deforestation & Vegetation near
house
Figure 1: Conceptual framework of Risks factors determining Transmission of Leishmaniasis
7
Pakistan Journal of Public Health, 2013 (June)
Methods
The study was carried out in rural areas of Bagh, Azad
Kashmir: having 3 sub divisions, 19 union councils and 106
villages. Bagh has a hilly topography with mountainous
altitudes, dened snowlines, thick forests with diverse ora
and fauna and streams and Nallahas. It lies between 73º ―
75º and 33º― 36º longitudes and latitudes, respectively.
Altitude varies from 3000 feet to 10,000 feet from sea level.
Climate is temperate with average temperature range 2.6oC to 43.2oC, average annual precipitation is 1500 mm.
The total population is 0.386 million and 770 sq.km area.
Population density 501 person /sq km, household size 7
people per house and growth rate is 2.00% (AJ&K Planning
& Development 2012). Health sector provides primary and
secondary level healthcare. The district health department
comprises: 1 DHQ hospital, 1 THQ-Hospital, 6 RHCs, 17
BHUs and 11 CDs (DHIS Bagh 2012)
A cross-sectional quantitative KAP survey was
conducted, where, structured and semi structured
interviews were carried out to assess the level of
knowledge and control responses to combat resurgence,
emergence and outbreaks of Leishmaniasis. The
questionnaire had designed to analyze strengths,
weaknesses, opportunities to combat Leishmaniasis in the
existing primary healthcare system. The questionnaire
used for collection of data on general and study variables
includes three main parts; sociodemographics of health
units (number of staff, skilled staff to respond NTDs,
availability of anti Leishmaniasis drugs, availability of
insecticides and availability of IEC material regarding CL)
knowledge about disease, vector and reservoirs and
knowledge about treatment and control responses of CL
cases.
Healthcare providers were selected from BHUs,
RHCs and DHQ- Hospital. In-charges of the health units
were approached for responses. At least one healthcare
provider from each health unit preferably in-charge was
selected for interview. Moreover the district health
authorities were also approached to assess their actions
and plans about Leishmaniasis control. Calculations and
statistical analysis
The data was collected and recorded carefully to
make the degree of scientic rigor required for the survey.
Data analysis was followed the objectives, hypothesis and
analysis plan. SPSS 20 package used to analyze the
data. The analysis expressed as condence intervals (CI)
and p-values. 95 % CI and 0.05 p value were used as
signicance levels for results
Results
Stafng Only 6 RHCs (14%) health facilities were
strengthen with more than 15 healthcare providers. While 8
BHUs have (18.6%) 11-15, 5 BHUs (11.6%) with 6-10 and
24 BHUs (55.8) with 2-5 staff members respectively. The
status of technical staff regarding vector borne disease
control and management were investigated and it was
found that most of the health units (>88%) were lacking any
designated healthcare provider to monitor and respond
VBDs, whereas 1 (2.3%) health facility had 1 while 2 (9.3%)
with 4 designated persons to responds VBDs. These are
malaria supervoisers. There was no medical entomologist,
neither epidemiologist but only 01 microbiologist in the
whole District.
Drugs and insecticides The availability of anti
Leishmaniasis dugs was scarce. Only 1 facility responded
positively while 42(97%) had no such drugs. Only 11
(25.6%) have stock sometimes in the year while 29 (67.4%)
had no availability and 3(7%) never ever had.
Notication and Reporting system 13 (30.2%) health
facilities notifying cases of CL, 24 (55.8%) not notifying
while 6(14%) did not know about the mechanism of CL
cases notication (Table: 1).
Knowledge level of Healthcare providers
Types of Leishmaniasis: Majority of the respondents (22;
51.2%) were unaware about the types of Leishmaniasis.
However, 15 (34.9%) have sound knowledge about various
types of Leishmaniasis.
Treatment of CL The treatment protocol of CL was known
to 18.6% while more than 80 did not knowing the standard
treatment protocol.
Anti-Leishmaniasis Drugs More than 60% respondents
were unaware of the drugs used to treat CL cases.
Medicines: 25.6% knew that an injection is used to treat CL
cases. While 11.6 % knew that there are some tablets used
to treat CL cases.
Mode of Disease Transmission 19 out of 43 (44.2%)
respondents knew about the mode of transmission while
about 55% were unaware of the transmission mechanism
of CL.
The respondents had improper knowledge; weather it is a
vector borne disease or otherwise. Only 44% knew it as
VBD while 19 % were unaware that it is a vector bone
disease. Name of Vector: Only 34% PHC workers were
familiar that sand y is the vector of CL while more than
75% were unaware about the name of the insect either it is
sand y or any else insect.
Case conrmation more than 23 % did not responded
properly. 72% responded that laboratory method could be
8
Pakistan Journal of Public Health, 2013 (June)
Table 1: Characteristics of Health Facilities
Items
Category
No. of Respondents
(n=43)
%
a- Manager
4
9.3
b- Planner
1
2.3
c- Clinician
38
88.4
a- 2 to 5
24
55.8
b- 6 to 10
5
11.6
c- 11 to15
8
18.6
d- >15
6
14
a- No (0)
38
88.4
b- 1
1
2.3
c- 2
4
9.3
4- # of Epidemiologists in Health Facilities
a- No
43
100
5- # of Med. entomologists in Health Facilities
a- No
43
100
6- # of microbiologists in Health Facilities
a- No
42
97.7
b- 1
1
2.3
a- No
42
97.7
b- WHO Supply
1
2.3
a- Yes
11
25.6
b- No
29
67.4
c- Don't know
3
7
a- Yes
13
30.2
b- No
24
55.8
c- Don't know
6
14
a- No
16
37.2
b- Don't Know
4
9.3
c- Health
Technician
d- Doctor
10
23.3
2
4.7
e- CDC Worker
11
25.6
a- No
28
65.1
b- CDC Worker
4
9.3
c- Doctor
3
7
d- Health
Technician
e- Media
7
16.3
1
2.3
1- Role &Responsibility of Respondent
2- # of staff in Health Facilities
3- # of CDC ofcials in Health Facilities
7- Availability of anti Leishmaniasis drug
8- Availability of Insecticide
9- Reporting/Notifying CL Cases
10- Who is planning CDC activities
11- Who is reporting /Notifying cases
9
Pakistan Journal of Public Health, 2013 (June)
used to conrm CL cases. More than 4% responded that
symptoms are used to conrm the CL cases.
Trend of Disease 44% said there is no particular trend
while 27 % have knowledge that there are certain localities
where disease occurs and 7% told that the disease is
related to some occupations (farmers, wood cutters).
Knowledge and perceptions about control Responses
for Leishmaniasis Cases
When respondents were asked about the responses upon
the report of CL case; different answers were recorded. The
rst line actions were not known to 30.2% while 70% were
responding to the cases. 68% respondents were referring
CL cases to higher facility. Only 2.3 % of respondents were
treating the cases of CL at the facility. 68% not practicing
and 30% did not know about treatment protocol (Table: 2).
Only 2% prescribing Glucantime as the standard treatment
regime while more than 98% did not knew about these
injections.
Majority (70%) of responds knowing about second line
actions while 24 % did not knew about second line actions.
More than 60% respondents were thinking health
education while 16% thinking vector control by different
means in the areas where CL cases reported.
Discussion
This study was an empirical analysis of strengths,
weaknesses and opportunities in the available primary
healthcare system to responding the cases of CL in the
health facilities and interventions at high risk areas in
community. The available resources, knowledge and
perceptions regarding strategies and control responses of
healthcare providers to combat Leishmaniasis are again
supporting our Hypothesis. The availability of skilled staff is
alarming majority of health facilities (> 50%) had only 2-5
persons while more than 80% of PHC facilities had not a
single person to deal with NTDs. There was neither
entomologist nor epidemiologist in whole District
department. These ndings are differing from the similar
studies conducted in Eastern African countries regarding
gap analysis to combat CL, where designated ofcials has
disease specic duties (17).
The knowledge about the vector and types of
Leishmaniasis was greater (40% and 35% respectively)
than the knowledge about the treatment (18%) and name of
anti-Leishmaniasis drugs (38%). The difference was due to
unavailability anti Leishmaniasis drugs in the facilities.
However the insecticide available at 25% health facilities
indicates some existence of control activities. These
answers were different from the study of Kumar and Singh
2011. In the referred study, level of knowledge in India,
Bangladesh and Nepal were even higher (18). This
difference could be due to existence of effective VL control
program and more strong communication and skilled staff
availability.
The reporting mechanism and notifying the CL
cases was very weak only 20% were notifying CL cases
while 80% have no such practices. This is an indication of
under reporting and under estimation of disease burden in
the study area. This situation did not full the WHO criteria
of notifying cases of NTDs (Global strategic IVM framework
2008-15) to combat NTDs (19).
The knowledge about rst line actions at health
facilities to respond CL cases were referring patients to
higher consultation level (67%) and only 2% knowing and
giving treatment (where, WHO supporting medicines
supply). These perceptions and practices are due to
absence of medicines and improper skills of healthcare
providers in dealing with CL cases (DHO Bagh report
2012). These actions are not matching the ndings of
Zijlstra et al. 2001 to combat disease. It has been
described that patients are potential reservoirs and if not
responded properly they are playing vital role in
transmission, especially anthroponotic transmission. It
had been described that existing cases of Leishmaniasis
are thought to increase transmission of the disease, when
untreated .Skilled human resources could effectively
control and manage the CL by prompt responses. These
responses would be; surveillance of CL, treatment of CL
cases, health education and vector control measures (20).
However, the knowledge and perceptions about
second line actions were satisfactory more than 70% knew
that either health education are vector control while 23%
are not considering any sort of intervention. These
interventions have been supported in a similar study in Iran.
It seems that the best way in prevention and reducing
the related problems of the cutaneous Leishmaniasis,
considering high prices for treatments and scarcity of
medicaments with acceptable safety and efcacy, is to
implement a suitable health education course that leads to
enhanced people's knowledge resulting in early
diagnosis, effective treatment and acceptable follow up.
Based on the results of this study it had been
recommended to prepare and organize a suitable
health educational course to be used not only for
health volunteers, but also for ordinary people as well,
to get better understanding of the cause, main routes
of spread and prevention of the disease, that in turn
leads to a considerable decline in prevalence of the CL
(21).
10
Pakistan Journal of Public Health, 2013 (June)
Table 2: Knowledge and perceptions of Health care Provider regarding control Responses to
combat Cutaneous Leishmaniasis
Variables
1- First line actions at PHC unit
2- Practicing the Treatment of CL Cases
3- Prescribing the injections for CL cases
4- Second line actions of Respondent
5- Types of methods used/advised
The results of existing system and strategies are
different from the Special Programme for Research and
Training in Tropical Diseases (TDR), that dene, best
public health drugs, vaccines and health promotion tools
will be unsuccessful when the health policies and systems
are not responsive to the epidemiological realities and the
social needs of the population (22).
In terms of vector borne diseases, WHO has
developed new strategies for prevention and controls that
emphasis 'integrated vector management' as an approach
that reinforces links between health and environment.
Moreover European Union (EU) also intervening for VBDs
control. By 2013, European Centre for Disease Prevention
and Control (ECDC) had made signicant contributions to
the scientic knowledge of communicable diseases and
their health consequences. To enhance the knowledge of
the health, economic, and social impact of communicable
diseases in the EU this includes all surveillance-related
strategies (23).
Responses
a- No Action
b- Treatment
c- Referring
a- Yes
b- No
c- Don't Know
a- No
b- Glucantime
a- Don't Know
b- Health Education
c- Vector Control
d- No Action
a- No
b- Don't Know
c- Environment
Management
d- Chemical Control
No. of Respondents
(n=43)
%
13
30.2
1
2.3
29
67.4
1
2.3
29
67.4
13
42
1
5
26
7
5
21
13
8
30.2
97.6
2.3
11.6
60.5
16.3
11.6
48.8
30.2
18.6
1
2.3
Conclusion
There is a huge gap in indigenous knowledge and practices
regarding detection and treatment of cases at health
sector. Lack of surveillance of cases and poor
understanding the risk factors could become a disaster.
The reporting mechanism further conrming the
underreporting of CL cases and the situation regarding
disease burden might be worse than the known.
There are certain strengths at health care
providers' level. They had certain aptitude, to respond at
community level as health education and vector control
mechanisms. It seems that the best way in prevention
and reducing the related problems of the cutaneous
Leishmaniasis, considering high prices for treatments
and scarcity of medicaments with acceptable safety and
efcacy, is to implement a suitable health education course
that leads to enhanced people's knowledge resulting in
early diagnosis, effective treatment and acceptable
follow up. These gaps demand special attention in certain
11
Pakistan Journal of Public Health, 2013 (June)
areas under integrated disease management strategy;
which could bring the remarkable change without any big
investments.
Strengthening local health systems to ensure
long-term sustainability, it is therefore a need to strengthen
health care systems, including their capacity for diagnosis,
treatment, case management and surveillance. It will be
important however, that details on the various pathological
forms of Leishmaniasis, the age, sex and geographic origin
of the patient are maintained when data are collected and
collated through the prevailing reporting system. If collation
of surveillance data at national level is currently not
possible, efforts should be made to at least improve
reporting and data analysis in the known highly endemic
areas. Maintaining awareness of the situation in these
locations will allow a faster response when needed. As part
of the process, epidemic thresholds will need to be agreed
upon to differentiate seasonal increases in case loads from
actual outbreaks.
Capacity Building for effective delivery of NTD control
relies on appropriately trained staff. There is a need to
provide support, technical guidance and training to relevant
health personnel especially in the light of global and
national strategic frame work of IVM in this regard.
6.
7.
8.
9.
10.
11.
12.
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13
Pakistan Journal of Public Health, 2013 (June)
Pak J Public Health Vol. 3, No. 2, 2013
Susceptibility of Salmonella enterica serotype typhi, to the usual line of antimicrobial
treatment in Rawalpindi
1
2
Muhammad Ahmed Abdullah , Adnan Zahid , Nargis Yousaf Sattar
3
1
Department of Community and Family Medicine, Shifa College of Medicine (STMU), Islamabad,
3
Department of Medicine, District Headquarters Teaching Hospital, Rawalpindi, Department of Basic Health
Sciences, Shifa College of Medicine (STMU), Islamabad. (Correspondence to Abdullah
MA: [email protected])
2
Introduction: Enteric Fever is a global public health problem, with annual death rates of around 600,000. The bacterial
infection with serious implications largely affects poor populations in the developing world. Modern medicine has
developed an effective arsenal against most infectious diseases during the last century, however the casual use of antimicrobial agents in many developing countries, has rendered them useless. The present study purports to look into the
issue of antimicrobial resistance against S. typhi.
Methods: This study is a Cross-sectional study conducted in a total of 150 consenting participants presenting at DHQ
teaching hospital Rawalpindi, over a period of 6 months (November 2012 to May 2013), through non-random consecutive
sampling technique. Blood cultures were taken from the 96 participants who had tested positive for S. typhi infection. The
results of these blood culture reports have been discussed with a special focus on the various anti-microbial drugs being
currently used.
Results: Out of the 150 study participants 62.5% were men and the remaining were women, mean age of the respondents
was almost 33 years, approximately 40% were uneducated and around half were from urban Rawalpindi. The rst line
agents including Ampicillin, Chloramphenicol and Co-trimoxazole showed resistance in more than 75% of cases, while
strikingly Flouroquinolones including Ciprooxacin, Levooxacin and Ooxacin showed around 80-90% resistance. All the
organisms were sensitive to Ceftriaxone and Cexime.
Conclusion: Anti-microbial resistance is a global health issue with regards to many infectious diseases. Enteric fever has
been treated with various remedial strategies over the years ranging from spiritual healing and water from various shrines
to antibiotics and surgical correction of complications. Owing to various reasons including the prescribing practices of our
physicians, this ticking time bomb of antimicrobial resistance is inuencing the lives of many people. Robust regulatory
strategies and educational interventions are the need of the day, but the most important thing in this regard is the motivation
and good intent of the people responsible for treating and preventing infectious diseases. (Pak J Public Health 2013; 3(2):
14-18)
Key Words: S. typhi, Antimicrobial drugs, Resistance, Rawalpindi
Introduction
With an estimated global burden of over 27 million cases
and 200,000 deaths annually, typhoid fever causes
substantial morbidity and mortality throughout the
developing world. Salmonella enterica subsp. Enterica
serovar typhi (S. Typhi) and Salmonella enterica subsp.
Enterica serovar paratyphi (S. paratyphi) are the causative
agents of typhoid fever (1). The true burden of typhoid fever
in developing countries is difcult to estimate. According to
recent estimates, more than 22 million new cases occur
each year round the world while 90% of the sufferers are
from the South-east Asia. Reported deaths from typhoid
fever accounts to around 2,16,000 per year (2). Asia, with
274 cases per 100,000 persons has the highest incidence
of typhoid fever cases worldwide, especially in Southeast
Asian countries and on the Indian subcontinent, followed
by sub-Saharan Africa and Latin America with 50 cases per
100,000 persons (3). Typhoid fever is among the water
borne infections characteristic of environment with poor
sanitation and hygiene. The causative agent Salmonella
enteric serovar typhi is pathogenic both to man and animals
with associable inammatory reaction in the intestinal tract.
Like other enteric pathogens, S. enteric serovar typhi is
transmitted through food or water that has been
contaminated with faeces from acutely infected person's
persistent excretors (that is constant stooling or diarrhea)
or from chronic asymptomatic carriers (4). In a recent study
conducted in India it was found out that the frequency of
14
Pakistan Journal of Public Health, 2013 (June)
S. typhi infection was 75.3% in Chandigarh India, clearly
pointing out towards the high occurrence of the disease in
the region (5).
The emergence of drug-resistant strains in recent
years, especially multidrug-resistant (MDR) Salmonella
typhi (resistant to ampicillin, chloramphenicol, and
trimethoprim-sulfamethoxazole), has been of major
concern (6). For more than 40 years since its discovery,
chloramphanicol was the drug of choice for the treatment of
typhoid. However, the emergence in the late 1980s of
multidrug-resistant (MDR) serovar typhi (isolates resistant
to ampicillin, chloramphenicol, and cotrimoxazole) in
outbreaks reported in the Indian subcontinent (7), Arabian
Gulf, the Philippines, and South Africa has led to the use of
the uoroquinolones as alternative drugs. In a recent study
conducted in Egypt it was seen that 43% patients with
Typhoid fever had MDR typhoid (8). According to statistics
from a systematic review of data based on the population of
Northern India the following sensitivity patterns were seen
for various anti-microbial agents; 65.3 % to Ampicillin,
93.8% to ciprooxacin, 95.5% to ceftriaxone and 50% to
chloramphenicol (9).
Given the considerable morbidity associated with
MDR typhoid in children, and increased mortality with delay
in treatment (10), it is essential that appropriate antibiotic
therapy be instituted promptly. Oral quinolones have
provided an effective oral form of therapy for MDR typhoid
in adults but are still not licensed for widespread pediatric
use. Where the generic use of quinolones has become
widespread, there are also recent disturbing reports of
emerging quinolone resistance (11). Broad-spectrum
cephalosporins have thus remained an important
therapeutic alternative for the therapy of MDR typhoid in
children, with excellent primary cure rates (12).
Typhoid being an important public health issue
poses new problems in terms of resistance to usual
available treatments. The present study purports to look at
the current sensitivity pattern of most commonly prescribed
drugs for treatment of S. typhi infection and the prevalence
of MDR typhoid fever. As the sensitivity pattern keeps on
changing with time, currently most drugs are prescribed
without obtaining a culture and sensitivity report. Based on
the results of our study, recommendations about the
empirical antimicrobial prescription will be made which will
promote appropriate treatment of these infections, while
utilizing a judicious approach for prescribing antimicrobial
agents.
Methods
The current study is a Cross-sectional study. Information
was collected from patients attending the Outpatient unit of
the Department of Medicine and their blood samples were
collected for culture sensitivity. This was done in order to
see the trends of resistance to the usual line of
antimicrobial treatment being employed at the DHQ
teaching hospital, Rawalpindi in specic and health care
settings in Pakistan in general. The intent of this research is
to generate and disseminate evidence in a local
perspective with much broader long term implications. We
purport to identify the issue of antimicrobial resistance as a
major public health concern for the developing world, and
generate an academic debate and put forth an idea for
further research. For this purpose a total of 150 patients
were selected attending the Out Patient Department of
DHQ Teaching Hospital Rawalpindi, with the suspicion of
having Typhoid Fever, after obtaining written informed
consent. The diagnosis was conrmed by Typhidot test, as
a result of which 96 people were declared of being infected
with S. typhi. Blood samples from these 96 patients were
sent for Culture and Sensitivity. The organisms isolated
from the blood of these individuals were tested for
sensitivity and resistance against relevant antimicrobial
agents (Ampicillin, Chloremphanicol, Nalidixic Acid,
Ciporoxacin, Levooxacin, Ooxacin, Cexime,
Ceftriaxone). The results have been presented in the form
of descriptive statistics.
Ethical approval was taken from the IRB of DHQ
Teaching Hospital Rawalpindi. Technical approval was also
granted by the Research wing of the College of Physicians
and Surgeons of Pakistan. Written informed consent was
taken from all the participants, and the purpose, process,
risks and benets of the study were clearly explained to
them. Keeping in mind the concept of patient condentiality
all participant information was coded using ID numbers
rather than names. No but besides the research team had
access to the information. Treatment was facilitated for the
participants, although the resource and time constraints did
create hurdles in this regard.
Results
A cross-sectional study was conducted, where patients
coming in at the DHQ teaching hospital; suspected of
having Enteric Fever, were enrolled after obtaining written
informed consent. Blood samples were drawn and sent for
a Culture and Sensitivity report. The purpose behind this
exercise was simple; To nd out the resistance/sensitivity
status of the commonly prescribed antimicrobial drugs,
with a special focus on ciprooxacin.
Out of our 150 respondents 62.5% (94) were male
while the remaining 37.5% were females. More than a
15
Pakistan Journal of Public Health, 2013 (June)
quarter females became a part of this study giving our
modest sample selection technique a natural stratication.
The mean age of the respondents was 32.98 years with a
standard deviation of +10.4 years. The age distribution of
the respondents is given in the table 1
Table 1: Table showing age distribution of the
respondents
Table 3: Sensitivity and Resistance patterns of the
drugs
Antimicrobial Agent
Sensitivity Resistance
Ampicillin
26
70
Co-trimoxazole
21
75
Chloramphenicol
37
59
Frequency
Percentage (%)
Ciprooxacin
06
90
18 – 28
60
39.6
Ooxacin
11
85
29-38
42
28.1
Levooxacin
17
79
39-48
40
27.1
Cexime
96
00
49 and above
8
5.2
Ceftriaxone
96
00
Total
150
100
Age distribution (years)
DHQ teaching hospital Rawalpindi, serves a very large and
unclearly dened population. The clientele of this hospital
comes from diverse landscapes and surroundings ranging
from the old city of Rawalpindi to the hill tops of Azad
Kashmir. Our patients belong to different ethnicities and
localities. Because we serve such versatile and widely
dispersed population base, our practice of medicine
demands constant evidence generation in order to
iteratively improve the performance standards.
Based on the operational denition participants
selected for this study were suspected of having Typhoid
fever when two or more of the symptoms given in Table 2
were present. All of these symptoms do not essentially
occur simultaneously; neither do they occur in mutual
exclusion, keeping this in mind the following table gives the
frequency of various symptoms seen in our participants.
The Sensitivity and Resistance patterns of the various
drugs of common use have been given in table 3.
Table 2: Signs and symptoms
Symptoms/signs
Frequency Percentage %
150
100
74
48.9
Constipation
53
35.4
Diarrhea
Relative bradycardia
87
58.3
81
54.2
Rash(Rose spots)
10
7.3
Splenomegaly/Hepatomegaly
36
24
Abdominal pain/tenderness
99
66.7
Vomiting/nausea
109
73.8
Fever
Headache/Neurological
symptoms
The interesting fact to view in these simple details
are the return of the Chloremphanicol, Co-trimoxazole and
Ampicillin sensitive strains, while the high prevalence of
strains resistant to Flouroquinolones is also a matter of
great concern. These statistics would gather even more
strength if they are gleaned simultaneously with a study on
the prescription patterns of our physicians. However it is
quite clear that the drugs most commonly prescribed by
physicians in Public Health care delivery settings have
almost completely lost their efcacy.
Discussion
The ndings of the present study are basically a repetition
of the evidence previously generated by international
scientic literature. What we believe we have done is that
we have generated simple yet pertinent local evidence that
will be very helpful in the operational and strategic planning
in terms of clinical practice. Typhoid fever is a global public
health issue with a disease burden of 27 million cases and
200,000 deaths annually (13). Our clinical practice in public
sector hospitals of a developing country with questionable
trends in terms of evidence based medicine often poses the
conundrum of treating people on the basis of intuition, due
to limited resources. This style of medical practice turns out
to be cost-effective in the short run, but the way it inuences
the micro-organisms that we are ghting against and the
arsenal of antimicrobial drugs, is disastrous. Antimicrobial
resistance is a major public health problem in both S. typhi
and S. paratyphi, and timely treatment with appropriate
antimicrobial agents is important for reducing the mortality
associated with enteric fever (14).
Resistance to the traditional rst-line antimicrobial
agents; ampicillin, chloramphenicol, and trimethoprimsulfamethoxazole denes multidrug resistance (MDR) in S.
enterica. The MDR phenotype has been shown to be
16
Pakistan Journal of Public Health, 2013 (June)
widespread among S. typhi for many years (15) and is
present, although at lower rates, among S. paratyphi (16).
Surveillance studies demonstrate considerable
geographic variation in the proportion of S. typhi isolates
that are MDR in the same region, with sites in India,
Pakistan, and Vietnam having higher rates of MDR isolates
than sites in China and Indonesia (17). Furthermore,
longitudinal studies at the same site showed marked
changes in the proportion of S. typhi and S. paratyphi. A
with MDR over time, including reductions in the proportion
of isolates with MDR (18). Our study has shown the same
results that most participants were resistant to the above
mentioned rst line agents, but did not show 100%
resistance patterns. There were a large proportion of
individuals who showed resistance to all rst line agents
(Multi-drug resistance). Another important aspect to
consider is that around 40% study participants had
organisms sensitive to Chloramphenicol, this statistic is
pointing towards the probable re-emergence of the
Chloramphenicol sensitive strain of S. typhi in our
catchment population.
The wide distribution and high prevalence of MDR
among Salmonella species has led touoroquinolones
assuming a primary role in the therapy forinvasive
salmonellosis. Some investigators have noted increases in
the prevalence of S. typhi and S. paratyphi strains
susceptible to traditional rst-line antimicrobials coinciding
with a switch to uoroquinolones for the management of
enteric fever (19). However, the widespread use of
uoroquinolones has also been associated with decreased
susceptibility and documented resistance to this class of
drugs (20).
Our study has also shown high resistance to three
ourquinolones (Ciprooxacin, Ooxacin and
Levooxacin). This is a very alarming trend as this is the
most commonly used group of anti-microbial agents used
in our setting against S. typhi. This not only raises
questions regarding the changing microbial patterns in our
surroundings but also about the prescription practices of
our physicians. There is a lack of evidence based practice
in our settings and these trends of intuition based medicine
are already having repercussions.
As uoroquinoloneuse continues to expand and as
decreased ciprooxacin susceptibility and uoroquinolone
resistance drives the use of third-generation
cephalosporins and other agents for the management of
enteric fever, new patterns of antimicrobial resistance can
be anticipated.
Literature and recent evidence is also pointing towards the
use of Gatioxacin a recent member of the ouroquinolone
group, to which most strains of S. typhi are still sensitive.
This drug is not in common use in our setting.
Cephalosporins are now the available options
(Ceftriaxone, Cexime) in our region but the threat of
resistance looms over our heads due to their non-judicious
and unchecked use in the present and future.
Conclusion
Although no data regarding prescription practices was
gathered during the course of this study, yet one can say
with experience that the anti-microbial agent prescribing
practices in our settings are awed and have a lot of room
for improvement. Over the years many useful drugs have
lost their potency due to the development of resistance by
various microorganisms, owing to their non-evidence
based used. Most rst line agents against S. typhi have
shown the development of resistance, but the most
alarming aspect is the almost complete resistance of S.
typhi to Quinolones. These drugs were considered to be a
fool proof remedy against typhoid fever, yet over time due
to a multitude of factors and inuences they are now of
limited and in some cases of no use. The study concluded
following recommendations on various levels to curb this
threat of anti-microbial agent resistance.
Policy Level Recommendations
Evidence based policies
Policy development in accordance with International
and regional guidelines
Greater role of motivated technocrats in policy
formulation
Stricter law enforcement and policy implementation
Neutral policy observers and technical audits
Periodic reviews of health policy with room for regular
changes and improvements
Health Systems Level Recommendations
Greater role of infection control committees
Community awareness campaigns regarding safe and
judicious use of antimicrobial drugs
Stricter laws regarding over the counter sale of
antimicrobial agents
Improved availability of resources in terms of
diagnostic and treatment facilities
Regulations for private practice of Medicine
Central data base development
CME (Continuing Medical Education) for all medical
practitioners
Development of local and regional guidelines
17
Pakistan Journal of Public Health, 2013 (June)
Operational recommendations
Use of Culture/Sensitivity instead of non-specic tests
before initiating antimicrobial therapy
Use of evidence based practice of medicine
(International / Local guideline)
Avoidance of empirical anti-microbial therapy
IEC (Information, Education, Communication)
material should be made freely available in hospitals
and health care settings
Use of hospital records data for generating local
evidence
Regular academic sessions for experience sharing
References
Kaashif AA, Khan LH, Roshan B, Bhutta ZA. Factors
associated with typhoid relapse in the era of multiple
drug resistant strains. J Infect Dev Ctries. 2011; 5(10):
727-731.
2. Rahman AKMM, Ahmed M, Begum RS, Hossain MZ,
Hoque SA, Matin A. Typhoid fever in children : An
update. J Dhaka Med Coll. 2010; 19(2) : 135-143.
3. Rajiv K, Nomeeta G, Shalin S. Multi-drug resistant
typhoid fever. Ind. J. Ped. 2007; 74(1): 39-42.
4. Jawetz M, Adelberg S. Medical microbiology, 25th
edition. Prentice Hall International Inc. 2007. pp. 307314.
5. Gupta V, Kaur J, Chander J. An increase in enteric
fever cases due to Salmonella paratyphi A in & around
Chandigarh. Indian J Med Res. 2009; 129: 95-98.
6. Hammad OM, Hifnaway T, Omran D, Tantawi MA,
Gigis NI. Ceftriaxone versus Chloramphenicol for
Treatment of Acute Typhoid Fever. Life Science
Journal, 2011; 8(2): 100-106.
7. Dimitrov T, Udo EE, Albaksami O, Kilani AA, Shehab
el-DM. Ciprooxacin treatment failure in a case of
typhoid fever caused by Salmonella enterica serotype
paratyphi A with reduced susceptibility to
ciprooxacin. J Med Microbiol.2007; 56 (pt. 2): 277279.
8. Zaki SA, Karande S. Multidrug-resistant typhoid fever:
a review. J Infect Dev Ctries 2011; 28(5): 324-337.
9. Kariuki S. Antimicrobial Resistance in Enteric
Pathogens in Developing Countries. Springer, New
York; 2010, pp 177-197
10. Kumar R, Gupta N, Shalini N. Multidrug-resistant
typhoid fever. Indian J Pediatr. 2007; 74(1): 39-42
11. Keddy KH, Smith AM, Sooka A, Ismail H, Oliver S.
Fluoroquinolone-Resistant Typhoid, South Africa.
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1.
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20.
Emerg Infect Dis. 2010; 16(5): 879–880.
Butler T. Treatment of typhoid fever in the 21st century:
promises and shortcomings. ClinMicrobiol Infect.
2011; 17: 959–963
Karkey, A., Thompson, C. N., Thieu, N. T. V., Dongol,
S., Phuong, T. L. T., Vinh, P. V., ... & Baker, S. (2013).
Differential epidemiology of salmonella typhi and
paratyphi a in kathmandu, Nepal: a matched case
control investigation in a highly endemic enteric Fever
setting. PLoS neglected tropical diseases. 7(8),
e2391.
Edelman R, Levine MM. Summary of an international
workshop on typhoid fever. Rev Infect Dis. 1986; 8:
329–349.
Rowe B, Ward LR, Threlfall EJ. Multidrug-resistant
Salmonella Typhi: a worldwide epidemic. Clin Infect
Dis. 1997; 24: S106–109.
Parry CM, Threlfall EJ. Antimicrobial resistance in
typhoidal and nontyphoidal salmonellae. Curr Opin
Infect Dis 2008; 21: 531–538.
Ochiai RL, Acosta CJ, Danovaro-Holliday MC. A study
of typhoid fever in ve Asian countries: disease burden
and implications for control. Bull World Health Organ.
2008; 86: 260–268.
Maskey AP, Basnyat B, Thwaites GE, Campbell JI,
Farrar JJ, Zimmerman MD. Emerging trends in enteric
fever in Nepal: 9124 cases conrmed by blood culture
1993–2003. Trans R Soc Trop Med Hyg. 2008; 102:
91–95.
Sood S, Kapil A, Das B, Jain Y, Kabra SK. Reemergence of chloramphenicol-sensitive Salmonella
Typhi. Lancet. 1999; 353: 1241–1242.
Lynch MF, Blanton EM, Bulens S. Typhoid fever in the
United States, 1999–2006. JAMA. 2009; 302:
859–865.
18
Pakistan Journal of Public Health, 2013 (June)
Pak J Public Health Vol. 3, No. 2, 2013
World Health Organization diabetic care guidelines: knowledge and practices of
general practitioners in private Clinics of Rawalpindi, Pakistan
1
2
3
4
Hameed Mumtaz Durrani ,Ramesh Kumar , Salma Mumtaz Durrani , Anwar-ul-Haq
1
Department of Public Health & Community Medicine, AJK Medical College,
Muzaffarabad, Azad Jammu & Kashmir.2 Department of Health System and Policy, Health Services
3
4
Academy Islamabad-Pakistan. Alumni Rawalpindi Medical College, Rawalpindi, Pakistan. Alumni Health
Services Academy Islamabad, Pakistan. (Correspondence to Kumar R: [email protected])
Introduction: Diabetes mellitus is growing at an alarming rate all over the world particularly in Pakistan.In 1995, Pakistan
had an estimated 4 million diabetics and was eighth in the world in terms of prevalence. It is projected that by 2025,
Pakistan willmove to the fourth highest prevalence with 15 million diabetics. General practitioners (GPs) constitute the
back bone of any health care system and providing healthcare services to the community.The World Health Organization
(WHO)has a standard of care guideline for people with diabetes which is consideredto be the 'Gold Standard'.This study
assesses the Knowledge, Attitude and Practice of GPs theWHO guidelines for the management and care of diabetes
mellitus in Rawalpindi city.
Methods: In the study, a total of 100 medical doctors registered with Pakistan Medical and Dental Council (PM&DC) were
included in the study from four towns of Rawalpindi city for interview through semi-structured questionnaires for their
knowledge and practices regarding diabetics as per WHO guidelines. Data was analyzed by Statistical Package for Social
Sciences (SPSS) version 17.
Results: The mean age of the GPs was 43.3 years ± 5.44 (SD), mean duration of clinical practice amongst the GPs was
14.73years ± 5.48 (SD). The average daily practicing time for the GPs was 8.1 hours ± 2.1 (SD) with an average of 48
patients per GP per day. Twenty one per cent (21%) of the patients had diabetes. Most 85% of the GPs had Knowledge
regarding the complication of Diabetes Mellitus (DM) and 78% had Knowledge about sign and symptoms of DM.
Conclusion: Study concluded that the knowledge of GPs regarding DM was good but they were not following the WHO
guidelines for treatment of DM. (Pak J Public Health 2013; 3(2): 19-22.
Keywords: Diabetes Mellitus, Knowledge, General Practitioners and diabetic care
Introduction
The prevalence of diabetes mellitus worldwide has
increased dramatically during the past few decades.
Diabetes is now one of the most common noncommunicable diseases globally. The incidence of
diabetes is on the incline possibly due to afuence in
certain sections of our community bringing about major
changes in our eating habits and life style (1). The
prevalence of diabetes for all age-groups worldwide was
estimated to be 2.8% in 2000 and 4.4% in 2030 (2). In the
United States, almost 8 percent of the adult population and
19 percent of the population older than the age of 65 years
have diabetes (3).
As a developing country, Pakistan faces many
health challenges amongst which the increasing incidence
& prevalence of DM is one of the most important issues to
be resolved on priority basis. The prevalence of Diabetes in
Pakistan is high and 12% of people above 25 years of age
suffer from the condition and 10% have impaired glucose
tolerance (IGT) (4). The major risk factors identied are
age, positive family history and obesity especially central
obesity (5).Diabetes care centers are limited in number and
are mostly concentrated in urban areas and especially in
the big cities. Rawalpindi is one of the most populated cities
of Pakistan. According to an estimate, there is one doctor
for every 1600 patients (6).General practitioners (GPs)
constitute the back bone of any health care system and
they are one of the main health care providers in most
countries and therefore treat the majority of patients at a
primary level. A survey of GPs working in both rural and
urban areas of Pakistan showed the average time spent
with a person with diabetes was 8.5 minutes (7).GPs are
serving a great number of populations and it was concluded
in one study that GPs in Pakistan under-diagnose and
under-educate patients with diabetes (8).
This study was designed to explore and ascertain
19
Pakistan Journal of Public Health, 2013 (June)
Methods
A cross sectional study was conducted by interviewing 100
general practitioners (GPs) registered with Pakistan
Medical and Dental council (PMDC) practicing in
Rawalpindi city from April to June 2009.The sample size
was calculated by using the proportional formula (add ref).
A multistage sampling technique was adopted according to
the proportion of GP to population ratio (1: 1600). Initially
the GPs were identied in each area through a list of GPs
(with the identication numberobtained from an
international pharmaceutical company)and then a simple
random approach wasustilised toselect the study
participants from all areas.Those GPs who had postgraduation in any medical eld and working as specialist
were excluded from the study. There was no refusal
reported during the data collection process. All the data
collectors were trained by the Principal Investigator before
the data collection. The knowledge of GPs was assessed
by adapting the World Health Organization (WHO)
guidelines on DM questionnaire after taking the written
consent from Gps (9). Data was analyzed by Statistical
Package for Social Sciences (SPSS) version 17.
Institutional ethical approval was taken from ethical
committee of Health Services Academy Pakistan.
Results
The survey was carried on 100 private practicing general
practitioners of Rawalpindi city. Table-1 shows the gender
representations in the study from all four areas. The mean
age of the GPs was 43.3 years ± 5.44 (SD) and range of 31
(28 – 59). Mean duration of clinical practice amongst these
GPs were 14.73years ± 5.48 (SD).The average daily
clinical practicing time of GPs was 8.1 hours ± 2.1 (SD) with
an average of 48 patients seen daily. Of the 48 patients 10
(21%) had diabetes. From the 84 male GPs 19 (22.6%)
were government employees and also having their own
private clinics.. Over three quarters of the GPs 65 (77.4%)
were only practicing at their private clinic.
Table 1: Gender distribution and areas of the study
population.
Areas and Gender of the Respondents
Gender Group
Total
Rawal Pothohar Rawalpindi Chaklala
Town Town
Cantt
Cantt
Male
84
35
26
17
07
Female 16
05
06
04
01
Total
40
31
21
08
100
Figure 1 show that the majority 85% of the GPs had
knowledge regarding complications of DM management
and 78% had knowledge about the signs and symptoms
during the diagnosis of DM. As far as treatment of diabetes
mellitus is concerned 61% GPs were practicing the WHO
guidelines. Few 17% of the Gps could write acceptable
investigations for laboratory diagnosis of diabetes mellitus
as per WHO guidelines. Above one thirds 40% of the GPs
were found to provide the patient education related to life
style modication and care of DM.
90
80
70
Percentage (%)
whether GPs are following the WHO guidelines for
diabetes management and to what extent This is unique in
terms that previous studies have assessed the knowledge
and practice regarding diabetes among diabetic patients
only and not among the GPs. Due to rapid increase in
incidence of diabetes in Pakistan, it is required to identify
the deciencies in the management of diabetes mellitus
and consequently help in improving the diabetes diagnosis
& management skills of the general practitioners. Finally,
the study will help in formulating strategies to combat the
disease in future.
60
50
40
85
78
30
61
20
40
10
17
0
Knowledge on
signs and
symptoms
Knowledge on
laboratory
Diagnosis
Knowledge
about
Treatment
Knowledge
about
complications
Knowledge
on Patient’s
education on DM
Figure 1: Knowledge of GPs regarding Diabetes
Mellitus as per WHO guidelines
Table 2 reveals that 80% of the guidelines had been
followed by 22 GPs, 60% by 33, 40% and 20% by 17 GPs
each. However, 5 out of the totals were not following at all.
Only 6 GPs (5 males and 1 female) were found following
WHO guidelines completely.
Table 2: Proportion of WHO guidelines followed by
the number GPs
Percentage of WHO Guidelines
Number of GPs(N=100)
0% of Guidelines
5
20% of Guidelines
17
40% of Guidelines
17
60% of Guidelines
33
80% of Guidelines
22
100% of Guidelines
6
20
Pakistan Journal of Public Health, 2013 (June)
Source of knowledge update
Regarding knowledge update about diabetes mellitus, all of
the GPs were found to be interested in updating their
knowledge.Just over half (54%) found updated information
through pharmaceutical literature, 21% through the
internet and 25% through medical journals. Only 15% of the
GPs attended refresher courses (g.2).
Pharmaceutical
Literature 54%
Medical
Journals 25%
Internet 21%
laboratory diagnosis of diabetes. In this study, it was found
that one thirds of the GPs were educating their patients
about DM during their patient management. Study
supported our ndings and concluded that the general
practitioners fail to educate the patient about diabetes
mellitus (13).
Conclusions
Study concluded that the knowledge of GPs regarding DM
was good but they were not following the WHO guidelines
for treatment of DM. This low proportion of the GPs leads
much to be desired, as overall understanding of the GPs
regarding this condition is very less. Overall the GPswere
not diagnosing the DM patients and also not giving the
health education to the patients of DM as per WHO
guidelines.
References
1.
Figure 2: Sources of Knowledge in GPs regarding DM
This study reveals that an evenly distributed GP's clinics in
the study area comprising both male and female doctors.
Although having a mean age of 43 years, most of the GPs
gave maximum time both to their practice and patient, with
daily average consultation of 48 patients out of which 10
were diabetics. In this study, knowledge of the GPs about
Diabetes Mellitus was assessed by asking them questions
related to Signs, Symptoms, Laboratory Diagnosis,
Treatment, Complications and education of the patient
about diabetes according to WHO guidelines. It is
interesting to know that a good proportion of the general
practitioners have the knowledge of Signs, Symptoms and
Complications of the disease. A similar study was
conducted among GPs in Pakistan, where they found that
the mean duration of clinical practice was 13.5 years with
an average consultation of 58 patients/day and GPs have
good knowledge (10). Most of the GPs rarely follow any
international guidelines for managing their diabetic
patients. In a study conducted on family physicians of
Pakistan, it has explored and identied the need for
improvement in their practices for treating and educating
diabetics. There are many sources to update their
knowledge but now a day many GPs get updated by the
pharmaceutical literature (11). Studies also supported our
ndings that GPs in Pakistan under-diagnose and undertreat the patients due to their poor knowledge on guidelines
provided for different diseases (12). It is interesting to
observe that the vast majority of the study participants
(GPs) did not haveadequate knowledge regarding
2.
3.
4.
5.
6.
7.
8.
Sarah W, Gojka R, Anders G, Richard S, and Hilary K.
Global Prevalence of Diabetes DiabetesCare. 2004;
27(5):1047-1053.
Wild S, Roglic G, Green A, Sicree R, King H. Global
Prevalence of Diabetes. Diabetes Care. 2004; 27(5):
1047-1053.
Harris MI, Flegal KM, Cowie CC, et al. Prevalence of
diabetes, impaired fasting glucose, andimpaired
glucose tolerance in U.S. adults. Diabetes Care. 1998;
21:518-524.
Shera AS, Raque G, Khwaja IA, etal. Pakistan
National Diabetes Survey: prevalence of
glucose intolerance and associated factors in
Shikarpur, Sindh Province. Diabetic Medicine.1995;
12: 1116-1121.
Shera AS, Jawad F, Maqsood A. Prevalence of
diabetes in Pakistan. Diabetes Res Clin Pract
CRCP: Patient Doctor ratio in Rawalpindi and
Islamabad [online] 18 Jan 2002 [cited 2009 March
29].Available from: URL: http:// www. Patient doctor
ratio in Rawalpindi and Islamabad.
Shera AS, Jawad F, Basit A. Diabetes related
Knowledge, Attitude and Practices of Family
Physicians in Pakistan. J. Pak Med Assoc. 2002; 52:
465-470.
Shahpurwala MM, Sani N, Shah S, Shuja F, Shahid
K, Tariq H, et al. General medical
practitioners in Pakistan fail to educate patients
adequately about complications of diabetes.Practical
Diabetes International. 2006; 23: 57- 61. [electronic]
[cited 2008 Jan02]. Available from: URL: http://: www.
Wiley Inter Science Journal Abstract.htm
21
Pakistan Journal of Public Health, 2013 (June)
9.
10.
11.
12.
13.
World Health Organization 2006. Guidelines for the
prevention, management and care of diabetes
mellitus. EMRO Technical Publication Series 32.
Shera AS, Jawad F, Basit A. Diabetes related
knowledge, attitude and practices of familyphysicians
in Pakistan. J Med Assoc. 2002; 52(10): 465-470.
Shera AS, Jawad F, Basit A. Diabetes related
knowledge, attitude and practices of family physicians
in Pakistan. J Pak Med Assoc. 2002; 52: 465-470.
Tazeen H. J, Saleem J, Fahim H. J, Mohammad I,
Raza O, Sarwar O, Andrew S, Nish C, General
Practitioners' Approach to Hypertension in Urban
Pakistan ; American Heart Association. 2005;111:
1278-1283.
Shahpurwala MM, Sani N, Shah S, Shuja F, Shahid K,
Tariq H, et al. General medical practitioners in
Pakistan fail to educate patients adequately about
complications of diabetes.Practical Diabetes
International 2006; 23: 57-61. [electronic] [cited 2013
Sep 15]. Available from: URL: http://: www. Wiley Inter
Science Journal Abstract htm.
22
Pakistan Journal of Public Health, 2013 (June)
Pak J Public Health Vol. 3, No. 2, 2013
Bioactivity of botanicals against Aedes aegypti Linnaeus and Anopheles stephensi
Liston Larvae
1
1
1
1
1
Haz Inam-llah , Hamayun Rashid Rathor , Hazrat Bilal , Soaib Ali Hassan and Imtinan Akram Khan ,
1
Tallat Anwar Faridi
1
Department of Medical Entomology and Disease vector Control, Health Service Academy, Islamabad.
(Correspondence to Bilal H: [email protected])
Background: Globally plants have been reported to contain certain compounds which have insecticidal properties,
especially on the larval stages of mosquitoes.
Method: Some of the locally grown plants such as Olea vera (Olive), Linum usitatissimum (Linseed), Piper nigrum (Black
pepper), Syzygium aromaticum (Clove) and Calotropis procera (Aak), were selected and evaluated for their larvicidal
activity against dengue vector Aedes aegypti and malaria vector Anopheles stephensi mosquitoes in Pakistan. The
extracts were evaluated according to WHO guidelines for larvae of mosquitoes.
Results: Among the ve plant extracts, linseed had the lowest LC50(2.32%) after 24 hours of exposure while after 48
hours it had 2.32 % LC50 value against Aedes aegypti. Again linseed had the lowest LC50 value (1.1 % and 0.07 %) after
24 hours and 48 hours of exposure against Anopheles stephensi. In terms of % age mortality when population was
exposed to series of concentrations (2%-10%), linseed gave high % mortality against both the tested mosquitoes' species
larvae.
Conclusion: The result revealed that all the 5 plant species have some larvicidal effect but linseed had great potential
against both tested mosquito species. Further small scale eld trials with the extracts of the most promising ones (linseed)
shall be conducted to determine operational feasibility. (Pak J Public Health; 3(2): 23-27.
Key words: Mosquitoes, Plant extracts, Larvicide
Introduction
Malaria, dengue, lariasis, yellow fever and Japanese
encephalitis are the most important diseases spread by
mosquitoes (1). Globally it is estimated that every year 243
million cases and approximately 8, 63, 000 deaths were
occurred due to malaria in 2008 (2), while in EMRO region
there were 5.7 million suspected cases and only one million
cases were conrmed malaria cases parasitologically, 17%
cases were contributed by Pakistan (3)and according to an
estimate by WHO, 50 million cases of dengue occurred
every year (4).
In Pakistan there were an estimated 4.5 million
suspected malaria cases and 59, 284 conrmed cases of
malaria in 2008 (4) and in 2010, suspected cases of malaria
were 3, 00000 due to ood (5). Similarly dengue epidemic
in 2011 is being observed in Pakistanwith more then 22,
778 conrmed cases with 353 deaths (6).
Worldwide mosquito control depends on the
application of synthetic insecticides as a part of Integrated
Vector Control (IVM) Programmes (7) but due to the toxic
effects and resistance to synthetic insecticides, are some
problems in controlling mosquitoes therefore it is
necessary to develop safe alternative insecticides which
required minimum care (8).
Plant extracts may be the best alternative sources
of mosquito control agents as they contain bioactive
compounds that are biodegradable into non-toxic products
and potentially suitable for use in control of mosquito
larvae. In fact, many researchers have reported on the
effectiveness of plant extracts or essential oils against
mosquito larvae (9). Recent studies stimulated the
investigation of insecticidal properties of botanicals and
concluded that they are environmentally safe, degradable
and target specic (10). Muthukrishnan and Puspalatha
(11) evaluated the larvicidal effects of extracts from
Calophyllum inophyllum (Clusiaceae), Rhinacanthus
nasutus (Acanthaceae), Solanum suratense (Solanaceae)
and Samadera indica (Simaroubaceae), Myriophyllum
spicatum (Haloragaceae) against Culex quinquefasciatus,
Aedes aegypti and Anopheles stephensi. A number of other
researchers which have used plant products for the
mosquito control like scientists reported the petroleum
ether extracts of Rhinacanthus nasutus, Trigonostemon
reidioides,Derris elliptica, Stemona tuberose,
Homalomena aromatica, Acorus calamus, Piper nigrum,
Artemisia annua, Sonchus oleraceus, Chenopodium
album, Solanum xanthocarpum and Argemone mexicana
(12-16).
In the view of increased interest in development of
plant based insecticides as an alternative to synthetic
23
Pakistan Journal of Public Health, 2013 (June)
insecticide, this study was planned and conducted to
assess the larvicidal potential of the medicinal plant against
the two medically important vectors Aedes aegypti and
Anopheles stephensi.
Methods
Collection of Plants
Seeds of olive (Olea vera L.Burm. f.), linseed (Linum
usitatissimum L.), black pepper (Piper nigrum L.), clove
(Syzygium aromaticum L. Merrill & Perry syn.) and aak
leaves (Calotropis procera Aiton) were collected from
Rawalpindi (33° 40' N, 40º 30' E) and Islamabad ( 33° 42' N,
73º 10' E).
Extraction of oil
The seeds and leaves were washed, then dried and later
grounded in an electric grinder (Anex Germany). The
grounded material was placed in thimble and kept in
extraction tube of Soxhelt apparatus with extractor ID
38mm, extractor volume 85ml and ask volume 250ml for
the extraction of oil by steam distillation method using ether
as solvent (250 ml/20 g sample). The cycle time for one
sample was 4–5 h. Solvent was evaporated at room
temperature, leaving oil which was then collected (17).
Preparation of Solution
Stock solution was prepared by adding 1 ml of oil from each
plant in 99ml of acetone and considered as 1% stock
solution from which series of concentrations (%) were
prepared (18).
Collection and Rearing of Mosquitoes
The immature Anopheles stephensi were collected from
different areas of Islamabad and Rawalpindi by dipping
with a standard 375ml dipper while adults were collected by
mouth aspirator and CDC sweeper from cattle sheds and
Aedes aegypti were collected from tire shops with standard
pipette. Larvae and adults were reared for mass population
in the insectary of the Department of Medical Entomology
and Disease Vector Control at Health Services Academy,
Islamabad. The rst instar larvae were fed with fat free milk
powder while other instars larvae were fed with chicken
liver powder at 27±2 0C and 75±5% humidity. Adults were
reared in steel cages by providing 10% sucrose solution
while female mosquitoes werealso fed on the blood of
albino rats (19).
Larvicidal Bioassay
The extracted oils were used in four different
concentrations (2%, 4%, 6% and 8%) with three replicates
for each treatment; each replicate containing 200ml of the
oil solution in 250ml Pyrex glass beakers. A batch of
fteen3rd instar larvae of the Aedes aegypti and Anopheles
stephensi were exposed in each beaker containing oil
solution (20], while control was treated with acetone only.
Mortality of larvae was counted after 24 and 48 hours. The
experiment was conducted under lab conditions at 27± 20C
and 75± 5% relative humidity.
Statistical Analysis
Abbot's formula was used for corrected mortality and the
data so obtained was analyzed by probit analysis (21) by
using MANITAB-15 software for dose mortality regression
line and %age mortality graphs were prepared by using
Microsoft Origin software.
Results
The results of plant oils against Aedes aegypti after 24
hours (Table: 1.) revealed that linseed exhibited the lowest
LC50 (5.78%) followed by aak and clove oil (7.59% and
9.71%) respectively. Black pepper and clove oil had the
Table 1: Larvicidal activity of plant extracts against 3rd instar larvae of Aedes aegypti.
Botanical name
Time
LC 50*
**LFL
***ULF
Slope±S.E
X2
Reg. equation
Olive (Olea vera)
24
48
18.0
6.05
10.3
5.1
214.9
7.65
0.73±0.24
1.16±0.21
0.93
0.81
Y=0.73X -2.13
Y=1.16X -2.10
Linseed
(Linum usitatissimum)
24
48
5.78
2.32
4.58
0.79
8.21
3.31
0.82±0.19
0.59±0.18
2.56
2.01
Y=0.82X -1.45
Y=0.59X -0.50
Black Pepper
(Piper nigera)
24
48
17.9
14.1
11.0
8.2
153.4
298.21
1.10±0.36
0.54±0.20
6.9
5.89
Y=1.10X -3.19
Y=0.54X -1.43
Clove
(Syzygium aromaticum)
24
48
9.71
6.31
7.92
4.99
15.17
9.4
1.52±0.34
0.82±0.19
2.29
8.73
Y=1.52X -3.46
Y=0.82X -1.52
Aak
(Calotropis procera)
24
48
7.59
4.3
5.92
2.23
12.71
7.58
0.85±0.21
0.47±0.18
12
2.57
Y=0.85X -1.74
Y=0.47X -0.68
*LC50 i.e., lethal concentration (%age) to kill 50% population of the subjected organism
**LFL = Lower ducial Limit
***UFL = Upper ducial Limit
24
Pakistan Journal of Public Health, 2013 (June)
highest LC50 value (18% and 17.9%) respectively. In terms
of %age mortality linseed and aak oils gave 43% and 34%
mortality respectively, followed by clove, olive and black
pepper gave mortality less than 20% as shown in g # 1.
While after 48 hours (Table # 1.) linseed had the lowest
LC50(2.32%) followed by aak and olive (4.3 % and 6.05%)
respectively. Black pepper and clove oil had the highest
LC50 value (14.1% and 6.31%) respectively. In terms of
%age mortality linseed and aak oils gave 65% and 51%
mortality respectively, followed by clove, olive and black
pepper gave mortality less than 40% as shown in g # 1.
The results of plant oils against Anopheles stephensi after
24 hrs (Table # 2.) showed that linseed had the lowest LC50
value (1.1%) followed by aak and olive (2.18% and 3.62%)
respectively. Black pepper and clove oil had the highest
LC50 value (14.32% and 3.72%) respectively. In terms of
%age mortality linseed and aak oils gave 80% and 70%
mortality respectively, followed by olive, black pepper and
clove gave almost 50% mortality as shown in g # 2.
While after 48 hrs (Table: 2) linseed had the lowest LC50
value (0.07%) followed by aak and olive oil (1.3% and
1.57%). Clove and black pepper oil had the highest LC50
value (6.23% and 1.78%) respectively. In terms of %age
mortality linseed and aak oils gave 94% and 78% mortality
respectively, followed by olive, black pepper and clove
gave almost 70% mortality as shown in gure: 2.
70
24 Hours
48 Hours
65
60
55
50
45
40
35
30
25
20
15
10
5
Piper
Nigera
Linum
Syzygium Calotropis
aromaticum
Procera usitatissium
Olea
Vera
Plant Species
Fig 1: % age mortality of plant extracts against 3rd
instar larvae of Aedes aegypti.
independently contribute to the generation of larvicidal
activities of mosquito (24).
The results of ve different plant species oils are presented
in Tables 1 and 2 obtained were satisfactory and establish
the efcacy. Mortality increases with increase in dose of
plant oil and at higher dose it gave almost complete
mortality without any pupal or adult emergence. While in
control, mortality was less than 5% after 48 h. Many
variations in reaction to oil toxicity between the two tested
mosquito species appeared. The LC50 values were low
and % age mortality of oils were very high in the case of
Anopheles stephensi compared to Aedes aegypti, these
variations are not abnormal. Minijas and Sarda, however,
showed that crude extracts containing saponin from fruit
pods of Swartzia madagascariensis produced higher
mortality in the larvae of Anopheles gambiae than in the
Discussion
Due to the development of resistance to synthetic
insecticide (22), residue problems in the environment and
toxic effect on humans and non-target organism,
investigators now direct their attentions towards the
development of new plant based insecticide.
Various compounds, including phenolics, terpenoids, and
alkaloids, exist in plants (23) and may jointly or
Table 2: Larvicidal activity of plant extracts against 3rd instar larvae of Anopheles stephensi.
Slope±S.E
X2
Reg. equation
4.47
2.57
0.90±0.19
0.54±0.19
3.54
1.94
Y=0.90X -1.16
Y=0.56X -0.24
0.08
0.02
1.95
0.10
0.62±0.20
0.38±0.28
8.1
3.75
Y=0.62X -0.05
Y=0.38X+1
3.72
1.78
2.14
0.91
5.22
2.42
0.58±0.18
0.94±0.21
1.93
3.76
Y=0.58X -0.76
Y=0.94X -0.54
24
48
14.32
6.23
7.81
3.94
4595.4
65.61
0.45±0.19
0.41±0.18
2.83
2.35
Y=0.45X -1.22
Y=0.41X -0.76
24
48
2.18
1.3
1.08
0.15
2.95
2.19
0.77±0.19
0.60±0.19
4.01
4.39
Y=0.77X -0.60
Y=0.60X -0.16
Botanical name
Time
LC 50*
LFL
Olive (Olea vera)
24
48
3.62
1.57
2.71
0.16
Linseed
(Linum usitatissimum)
24
48
1.1
0.07
Black Pepper
(Piper nigera)
24
48
Clove
(Syzygium aromaticum)
Aak
(Calotropis procera)
ULF
*LC50 i.e., lethal concentration (%age) to kill 50% population of the subjected organism
25
Pakistan Journal of Public Health, 2013 (June)
70
other plant extracts should be investigated for the control of
mosquitoes under eld conditions.
24 Hours
48 Hours
65
60
55
References
50
1.
45
40
35
30
2.
25
20
15
10
3.
5
Piper
Nigera
Linum
Syzygium Calotropis
aromaticum
Procera usitatissium
Olea
Vera
Plant Species
Fig 2: % age mortality of plant extracts against 3rd
instar larvae of Anopheles stephensi.
larvae of A. aegypti, and no mortality was induced in the
larvae of Culex quinquefasciatus (25). While our study is
not t with the study of Novak that anophelines were less
sensitive than aedines when assayed to plant extracts (26).
According to our ndings black pepper had some potential
but not so much as linseed does as describe by Nath 2006,
the effectiveness of black pepper against Aedes albopictus
and Culex quinquefasciatus (27).There was less
effectiveness of black pepper when compared with other
tested plant extracts against the adults of Aedes aegypti
(28). Similar studies have been reported that plant extracts
can be highly toxic to mosquitoes like Sarita et al. (2010)
traced out larvicidal potential of three species of
peppercorns against larvae of Ae. aegypti. These extracts
were effective in terms of LC50 and larvae shows abnormal
behavior after its application. In another study, the oil of
menthe, sativa and Melissa against the larvae of Culex
pipens and its constituent piperiten one oxide was the
highly active with LC50 value (29, 30). Patrícia 2010,
reported the 94 plant extracts against Ae. aegypti as
larivicide and six plant species (Coccoloba mollis,
Guettarda grazielae, Merremia aegyptia, Rourea doniana,
Spermacoce verticillata and Triplaris americana) shows
100 % mortality and shown good results against medically
important mosquitoes (31).
4.
5.
6.
7.
8.
9.
10.
11.
12.
Conclusion
13.
Our results indicated that out of the 5 plants linseed oil has
good larvicidal potential against both species but more
effective against larvae of An. Stephensi then Ae. aegypti in
terms of Lc50 and % age mortality as shown in tables and
graphs. So we suggest that Linseed extracts as well as
14.
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G. Isolation and identication of mosquito larvicidal
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Jong-Jin. Potential of citrus seed extracts against
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Atchariya J, Pongsri T, Doungrat R, Benjawan P.
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27
Pakistan Journal of Public Health, 2013 (June)
Review
Pak J Public Health Vol. 3, No. 2, 2013
Morbidity Patterns in Pakistan: Evidence from Pakistan Panel Household Survey 2010
1
Imran Bari , Nayyar Abbas
2
1
MAARK Pharmaceuticals (Pvt) Ltd, 2Alumni Pakistan Institute of Development economics, Islamabad
(Correspondence to Bari I: [email protected])
Introduction: With recent information available on the disease status of population the current study explores the
morbidity patterns among different subgroups of population and observes what type of diseases are common among
children, adults and of the older ages in Pakistan.
Methods: Data source for analyses in this study is taken from Pakistan Panel household survey. This survey was
conducted in year 2010 with a sample size of 4142 households, 1342 in urban and 2800 rural. The current study uses the
sample of population reported ill to be around 8177 in all age groups.
Results: High proportion (27%) reported ill with almost 30% females and 25% males respectively. Age group 60+ is the
most prevalent in disease with high level of morbidity among females ranging from ages 10 and above. Most commonly
reported disease was fever and majority was reported in the younger age groups.
The older segment of the population reported degenerative diseases like diabetes, heart problems and renal/kidney
problems.
Conclusions: Diseases were found to be more prevalent among the age groups of 0-4, 30-59 and 60+, indicating high
levels of morbidity and especially among females. High incidence of illness were reported by males in the younger age
groups of 0-4 and 5-9.These are the only ages where males have shown high morbidity rates than their females counter
parts thus reecting the poor health status of females overall. (Pak J Public Health; 3(2): 28-34.
Key Words: Health, Morbidity Patterns, and Pakistan
Introduction
Health is undoubtedly a basic requirement and an
important factor of human life. Good health reects
reduced morbidity levels as well as decreasing the burden
of diseases in a population. Improved health status has
positive implications for the social and economic well being
of a population. It is a well-established fact that an
enhanced health not only reduces the mortality, morbidity,
fertility levels but also adds to increased productivity, as
fewer workdays are lost due to illness, thus having an
economic uplift (1).In order to achieve efcient and
productive human resource it is of central importance to
invest in health (2).
Pakistan has a fast growing population and has the
highest rates of fertility, infant, child and maternal mortality
when compared with its neighboring countries. This is not
to deny the fact that over the years, Pakistan has shown
considerable improvement in some of the health indicators
but on a whole, it still lags far behind the desired levels (3).
In terms of the total burden of disease, (BOD)
Pakistan is almost in the middle of epidemiological
transition having a double burden of disease (having both
communicable and non-communicable diseases) (4).
Almost 40% of the total burden of disease accounts for the
communicable/ infectious diseases mostly affecting the
children, including respiratory diseases, diarrheal
diseases, tuberculosis, malaria and childhood cluster
(measles, pertussis and polio). Another 12% is due to
reproductive health problems and certain nutritional
deciencies. The remaining major bulk of 40% is of the noncommunicable/degenerative diseases common in old age
population, including cardio-vascular diseases, diabetes,
cancers and other non-communicable diseases (2, 5).
Methods
Data source for analyses in this study was taken from
Pakistan Panel household survey. Pakistan Institute of
Development Economics conducted this survey in year
2010 with a sample size of 4142 households, 1342 in urban
and 2800 rural. Two separate questionnaires were used
male and female, the section of health was included in
female section for the detailed information on disease
status and related behavior of each member (children and
adults) in the household. The logic for asking from females
about the health status of the household members was
that, it is generally the female member of the house who
attends to the sick, as they have a less participation in work
outside the home.
The current study used the sample of population
28
Pakistan Journal of Public Health, 2013 (June)
reported ill to be around 8177 in all age groups. The data
analysis on research is based on bivariate analysis using
percentages for analysis and assessment of the disease
prevalence and patterns by sex/age. These percentages
gave a detailed and useful view into each issue, which is
being examined in the study. SPSS was used for this
research where frequencies cross tabulation and graphs
were run.
Table 1: Percentage of Population Reported ill by Sex
and Age Group
Age Groups
Male
Female
Both Sexes
0-4
35.5
32.1
33.8
5-9
22.7
19.2
21.0
10-19
15.1
16.8
15.9
Results
20-29
15.6
26.6
20.6
About 27.6% of the population reported to be ill during the
past 12 months preceding the survey (results from PPHS,
2010). For males, this proportion is about 25% and for
females 30.6%. This signies that the morbidity rates of
276 per 1000 population, 250 for males and 306 for
females. These ndings and estimates seem to be a bit
higher as these percentages include injuries and
disabilities as well. When compared with other similar
morbidity surveys, the morbidity rates are higher, the
reason lies in the reference period as only two weeks prior
to survey were taken for reporting illness and PSES 2001
did not collect data on injuries and disabilities. A useful view
of illness can be made by observing age/sex patterns.
30-59
29.2
43.2
36.1
60+
58.4
60.0
59.1
All
24.9
30.5
27.6
Total (N)
15488
14230
29718
Patterns of Disease/Injuries by Age and Sex:
A broad view of Morbidity by age group is given in the gure
1, a U-shaped morbidity pattern was be observed among
the different age groups with illness highest in the older
70
Morbidity Pattern
Percentages
60
50
40
30
20
10
0
0-4
5-9
10-19
20-29
30-39
40-49
50-59
60+
Age Groups
Source: Original data of Pakistan Panel Household Survey 2010.
Figure 1: Morbidity by Age Groups
A view of illness by age and sex are given in the
table 1. The age differentials show that the illness is highest
among the age group of 60+ that is almost 59% then age
group of 30-59 and age group of 0-4 in descending order for
percentage of illness.
Pakistan like many developing countries has
shown high incidence of morbidity and mortality among
children between ages 0-4 and the aged population (1),
almost similar results can be observed with the exception of
the morbidity rates of age group 30-59 (36%). The reasons
Source: Original data of Pakistan Panel Household Survey 2010.
can be the type of diseases explored in this survey as many
diseases are of old ages (types of diseases discussed in
the next section of the paper) and the inclusion of injuries as
they also may be endured by population in older ages. It
can be observed in table 4 that the percentages of females
reported ill are higher than males in the ages from 10 above
reective of the poor health status of females. This can also
be due to higher rates of reproductive health problems,
post-menopausal health issues faced by females in these
ages.
Other sources have identied similar scenario, as
reproductive health issues (6) attribute out of the total
burden of diseases in Pakistan is 12%. Maternal issues are
relatively common in Pakistan and disease among 20-59
age groups because of high number of childbirths that
could lead to under nourishment, in turn increasing the
morbidity rates in these ages.
The biological advantage of females over males is
reected in the table-1 especially among children < 10
years of age, as fewer females were reported ill as
compared to male children. The reporting biases cannot be
ruled out particularly the gender preference values in
Pakistan as male sick child is immediately identied
resulting in higher reporting of male children (1,7). In
Pakistan and other countries of South East Asian region
women suffering from illnesses are less frequently reported
for treatment than men are (8). Research suggests that in
older ages males are more venerable to degenerative
diseases thus increasing the morbidity rates (1).
Major illness and their Patterns
The percentage distribution of population reported ill by the
type of diseases among different age groups for both
females and males are given in the table 2. Larger portion
29
Pakistan Journal of Public Health, 2013 (June)
of population suffered from fever (40%) followed by the
group of unspecied diseases (others), which account for
20%. As signicant proportion reported to be ill with fever
this can be due to respondent's perception of fever as
disease with diagnosing as a specic type of disease that
has symptoms of fever. Almost 10% of the population
reported to be suffering from heart diseases including the
problems of blood pressure. It may be observed that fever
is more common among the younger age groups; these
results are expected considering a situation in Pakistan
where there is high morbidity and mortality in children.
The population reported ill by the unspecied
diseases needs to be further probed as information on
these diseases would give important insight into disease
patterns and types. Furthermore, Table 2 does not show
major differentials in illness status between males and
females expect for fever (higher for males), heart problems
and reproductive health problems (affecting females
more).
As expected with other types of illnesses heart
problems, cataract, diabetes and renal/kidney problem are
the diseases of old age and similar results are shown in the
table5. Heart diseases and diabetes account for almost
11% of the total burden of diseases in Pakistan (6), further
women in Pakistan have a greater burden of heart diseases
than men (9).
Interestingly in this data, almost similar results are
displayed as 11.2% females have heart diseases
compared to 9% in males. Tuberculosis is another
important disease as 2% of the population reported to have
TB, in context of developing countries especially in the
South East Asian region TB accounts for 3.5% of total
Disability Adjusted Life Years or DALY's lost (10).
Information of permanent disabilities and their percentage
distribution is given in the table 3.
The nature and severity of disease can be
assessed by the duration of illness (number of days ill with
disease) table 4 shows the percentage distribution of
reported ill by duration of illness. Almost 54% of the
population reported to be ill for more than 15 days. This
indicates that about half of population has serious illnesses
of longer duration, while the rest remain ill for shorter
periods. One reason can be due to the diseases as most of
them are non-communicable, degenerative diseases and
tend to affect the population for longer periods.
Fever is the only disease among other illness
groups where almost 60% of population had that disease
for less than 7 days.
As majority of the diseases affected the ill
Table 3: Percentage Distribution of Population
Reported ill by Disability
Percentage
N
11
Deaf
5.7
2.6
Mute
5.2
10
Loss of limb
8.9
17
Lame
10.0
19
Paralysis
20.0
38
Mental
20.5
39
Other
26.8
51
Total
100
190
Disability
Blind
5
Source: Original data of Pakistan Panel Household Survey 2010.
population for longer periods, it would be worthwhile to
examine these illnesses in detail, especially for younger
segment of the population. Table 5 reports the percentage
distribution of diseases affecting the population for 90 and
more days (chronic illnesses) by age groups. The age
groups of 30-59 has the major bulk of disease (43%)
followed by the age group of 60+ with higher proportions
reporting with diabetes, heart problems, reproductive
health problems and intestinal problems.
Reproductive health problems tend to affect the ill
population for long periods especially in the age groups 2029 and 30-59 with 30% and 54 % respectively. Furthermore
fever majorly affects the age group of 0-4 and 30-59
indicating that it may be caused by chronic or long duration
diseases, calling for a further probe into the matter.
The intensity and severity of these diseases can
also be assessed by the episode of the diseases. Table 6
details into the number of episode of each disease; almost
69% of all diseases had only one episode during the 12
months preceding the survey. As said earlier the diseases
studied in the current study are mainly of old age affecting
the patient permanently and usually have one episode that
is why most of the diseases have one episode. Two and
more episode was reported by relatively small proportion of
population, among the group of four and more episodes
fever has the largest percentage (13%).
The denition of illness, questions on illness and
respondent's perception of illness and the reference
periods can vary from one survey to another, so comparing
the results of these surveys has its limitations. Keeping in
view of limited population based morbidity data these
comparisons were made in the current study.
30
Pakistan Journal of Public Health, 2013 (June)
Table 2: Percentage Distribution of Disease by Age and Sex
Age Groups
Sex
0–4
5–9
10 – 19
20 – 29
30 – 59
60+
All Ages
3.5
2.3
2.9
2.2
2.8
2.4
2.9
2.0
2.5
2.5
3.0
2.8
3.7
3.1
3.4
7.5
4.9
6.5
4.3
3.4
3.9
1.5
1.3
1.4
2.9
2.1
2.5
3.1
2.8
3.0
2.4
1.7
2.1
1.5
1.3
1.4
2.7
2.3
2.5
2.5
2.8
2.6
1.8
1.9
1.8
40.8
37.9
39.4
25.1
23.6
24.4
15.3
12.1
14.2
40.0
39.4
39.7
6.4
6.6
6.5
15.0
17.0
16.2
22.5
27.3
24.2
9.1
11.2
10.2
2.0
0.8
1.4
1.3
1.3
1.3
1.3
1.1
1.2
1.2
1.0
1.1
1.3
0.6
0.9
2.7
3.0
2.8
1.1
0.8
1.0
8.3
12.2
10.2
4.2
6.5
5.5
0.5
0.7
0.5
2.7
4.7
3.7
4.9
6.6
5.7
5.1
6.4
5.8
2.3
2.3
2.3
3.7
4.6
4.2
0.1
-
0.1
0.1
0.1
0.1
0.2
0.1
0.4
0.2
0.3
4.4
4.5
4.5
5.4
4.6
5.0
4.6
4.6
4.6
3.7
3.5
3.6
0.1
0.5
0.3
4.2
5.5
5.3
15.1
9.8
9.0
3.2
3.1
3.1
21.9
19.6
20.8
22.7
22.8
22.9
23.6
22.6
23.2
20.1
20.7
20.4
1.3
1.2
1.2
2.5
2.5
2.5
1.8
1.6
1.7
Injury
Male
Female
Both Sexes
1.3
1.2
1.2
2.9
2.6
2.7
3.8
2.8
1.7
1.8
2.8
2.3
Respiratory Problem
Male
Female
Both Sexes
5.5
3.6
4.5
4.0
4.6
4.3
2.3
2.7
2.5
Male
Female
Both Sexes
1.3
1.3
1.3
2.4
0.8
1.6
2.1
1.3
1.7
Male
Female
Both Sexes
0.3
1.0
0.6
0.8
1.7
1.2
1.1
1.8
1.5
Male
Female
Both Sexes
66.6
67.5
67.0
68.7
71.6
70.1
58.0
54.0
56.0
Male
Female
Both Sexes
0.6
0.6
0.6
0.5
0.5
Male
Female
Both Sexes
0.6
0.6
0.6
1.0
0.2
0.6
Male
Female
Both Sexes
0.3
0.1
0.8
0.5
0.6
Male
Female
Both Sexes
-
-
Male
Female
Both Sexes
2.5
1.5
2.0
2.4
1.1
1.8
3.7
4.5
4.1
Male
Female
Both Sexes
2.0
0.3
1.2
0.5
0.2
0.1
0.8
0.5
Male
Female
Both Sexes
0.5
0.3
0.4
1.3
0.5
0.9
3.3
4.2
3.8
Male
Female
Both Sexes
-
-
0.5
0.1
0.3
Male
Female
Both Sexes
16.9
20.4
18.7
11.8
14.1
12.9
16.7
19.2
17.9
Male
Female
Both Sexes
0.8
1.0
0.9
2.4
1.7
2.0
TB
Intestinal Problem
Fever
Heart problem/BP
2.5
1.7
2.1
Mental illness
0.5
1.3
0.9
Cataract / other sight problem
0.6
0.6
0.6
0.3
1.0
0.6
Reproductive health problem
1.5
3.0
2.2
Jaundice / hepatitis
Measles
Renal / Kidney Problem
Diabetes
Others
Permanent Disability
2.5
2.3
2.4
1.8
2.2
2.0
Source: Original data of Pakistan Panel Household Survey 2010.
31
Pakistan Journal of Public Health, 2013 (June)
Table 4: Percentage Distribution of Disease by Days of illness
LESS THAN 7 DAYS
8-14 DAYS
15 DAYS+
TOTAL
N
Injury
15.1
14.2
70.5
100
204
Respiratory problem
19.2
10.4
70.
100
318
TB
6.5
1.1
92.2
100
161
Intestinal problem
11.5
11.5
76.9
100
154
Fever
59.5
20.8
19.5
100
3239
Heart problem/BP
12.5
3.4
83.9
100
833
Mental illness
3.3
2.2
94.3
100
91
Cataract / other sight problem
23.4
1.2
75.3
100
83
Reproductive health problem
16.5
6.7
76.6
100
312
Jaundice / hepatitis
8.1
4.9
86.8
100
344
Measles
28.0
16.0
56.0
100
25
Renal / Kidney problem
11.6
5.9
82.3
100
300
Diabetes
8.8
1.9
89.1
100
255
Others
21.7
7.6
70.6
100
1668
Permanent Disability
7.2
2.2
90.6
100
190
Total
33.0
12.1
54.8
100
8177
DISEASES
Source: Original data of Pakistan Panel Household Survey 2010.
Table 5: Percentage Distribution of Disease byDays (
DISEASES
90) of Illness (Chronic Diseases)
AGE GROUP
20-29
30-59
0-4
5-9
10-19
60+
Total
Injury
3.7
5.0
15.1
15.1
Respiratory problem
10.3
4.9
8.1
TB
8.3
4.8
Intestinal problem
4.2
Fever
(N)
36.7
24.0
100
79
10.3
32.2
33.8
100
183
13.9
10.4
39.8
22.3
100
143
2.1
8.4
10.5
48.4
26.3
100
95
26.2
9.3
17.2
14.7
22.6
9.7
100
278
Heart problem/BP
1.0
0.3
2.7
7.0
52.0
36.7
100
655
Mental illness
8.6
6.1
9.8
16.0
40.7
18.5
100
81
Cataract / other sight problem
1.9
-
7.6
11.5
21.1
57.6
100
52
Reproductive health problem
-
-
11.2
29.4
53.9
4.3
100
139
Jaundice / hepatitis
6.1
1.9
15.4
18.5
47.4
8.4
100
259
Measles
14.2
14.2
14.2
-
28.5
28.5
100
7
Renal / Kidney problem
1.9
2.8
10.0
14.8
48.3
22.0
100
209
Diabetes
-
-
1.7
1.7
54.6
41.7
100
225
Others
8.2
4.7
11.1
13.6
40.9
21.1
100
922
Permanent Disability
7.2
11.2
19.2
17.6
23.2
21.6
100
125
All
6.7
3.6
9.8
12.5
42.7
24.4
100
3252
Source: Original data of Pakistan Panel Household Survey 2010.
32
Pakistan Journal of Public Health, 2013 (June)
Table 6: Percentage Distribution of Population Reported ill by Number of Episodes of Each Disease Type
DISEASES
1 - Episode 2 - Episodes
3 - Episodes
4 - Episodes
Total
N
Injury
82.8
5.3
4.4
7.3
100
204
Respiratory problem
75.1
7.2
4.7
12.8
100
318
TB
87.5
3.1
0.6
8.6
100
161
Intestinal problem
74.6
9.7
3.8
11.6
100
154
Fever
48.4
22.3
16.0
13.1
100
3239
Heart problem/BP
86.6
2.6
2.4
8.2
100
833
Mental illness
84.6
1.0
3.2
10.9
100
91
Cataract / other sight problem
81.9
6.0
7.2
4.8
100
83
Reproductive health problem
80.1
6.4
5.1
8.3
100
312
Jaundice / hepatitis
88.3
6.1
0.5
4.9
100
344
Measles
82.0
0
12.0
16.0
100
25
Renal / Kidney problem
82.3
4.3
5.6
7.3
100
300
Diabetes
90.1
1.9
1.1
6.6
100
255
Others
78.0
5.0
5.6
11.2
100
1668
Permanent Disability
82.8
2.8
4.2
10.0
100
190
Total
68.46
11.7
8.8
10.9
100
8177
Source: Original data of Pakistan Panel Household Survey 2010.
Conclusions
Based on the data from Pakistan Panel Household Survey
2010, this study explored the incidence of disease among
population by age and sex.
Almost 27 percent of the population reported ill
2010 prior to survey and this percentage is higher for
females around 30 percent with males exhibiting about 25
percent. Disease seems to be more prevalent among the
age group of 60+, indicating high levels of morbidity and
especially among females. High incidence of illness were
reported by males in the younger age groups of 0-4 and 59.These are the only ages where males have shown high
morbidity rates than their females counterparts reecting
the poor health status of females. Most commonly reported
disease was fever and majority was reported in the younger
age groups. As expected, older segment of population
suffered from degenerative diseases like diabetes, heart
problems and renal/kidney problems. Almost 55% of
Surveyed population reported that they fell ill for 15 days
and more.43% of the ill population reported to be still
suffering from illness/diseases, that are almost 13% of the
total survey population indicating a signicant percentage
of burden of diseases.
Health is a neglected sector in Pakistan comprises
of underfunded public health sector, which are
concentrated in urban centers, and an expensive private
health sector, making it out of reach for many. Poverty
coupled with illiteracy, weak health system, poor standards
of sanitation, cultural and social beliefs has lead high
incidence of morbidity among population thus making
Pakistan one of countries with double burden of disease.
Improvement in the morbidity and health status of Pakistan
can be made by promotion of both preventive and curative
health services. Focusing these interventions to the sub
groups of population having high levels of morbidity the
much-needed improvement in health status can be
achieved.
References
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Mehmood N, Ali M.The Disease Pattern and Utilization
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Pakistan Economic survey 2009-10
World Population Data Sheet, Population Reference
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World Bank. Pakistan Poverty Assessment, Poverty in
Pakistan: vulnerabilities, social gaps, and rural
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Pakistan Journal of Public Health, 2013 (June)
dynamics. Poverty Reduction and Economic
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6. Pakistan Economic survey2007 -08
7. Ali M. Gender and Health Care Utilization in Pakistan.
T h e P a k i s t a n D e v e l o p m e n t R e v i e w. 2 0 0 0 ;
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8. Shaikh BT, Hatcher J.Health seeking behavior and
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34
Pakistan Journal of Public Health, 2013 (June)
Review
Pak J Public Health Vol. 3, No. 2, 2013
Socioeconomic and demographic dynamics of Birth Interval in Pakistan
1
2
Nayyar Abbas , Irum Shaikh , Imran Bari
1
3
2
Pakistan Institute of Development Economics, Waseela-e-Sehat, Benazir Income Support Program,
3
MAARK Pharmaceuticals Pvt. Ltd. (Correspondence to Abbas N [email protected])
Introduction: There are many socio-economic and demographic variables such as (education level of parents, age at
marriage, present age of women, parity of women, age differences between spouses, family income, son preference,
gender relations, family planning education, infant mortality, sex of the previous child, survival status of previous child)
which plays a momentous role in birth spacing.
Methods: For this study the Pakistan Demographic and Health Survey 2006-2007 to nd the relationship of these factors
with birth interval. This study uses simple median of months of succeeding (subsequent) birth intervals for analyses and
assessment of birth spacing practices.
Results: We have found that in younger women interval between births are longer than older women, also women with
secondary and higher education and those belong to urban areas tend to space birth more widely. Employed couple get
interval for rst birth between 27-31 mean months. While if the couple is unemployed then interval going to decrease
between 27-29 months. There is no signicant difference between the employed and unemployed women. In this data the
interesting point is to be noted that non-user of more and contraceptives has longer interval then users.
Conclusions: The study found that socio-economic and demographic variables on birth interval are showing almost same
results on all birth order seven by using median (month intervals),do not show any signicant results. This could be
because of data limitations as data in Pakistan Demographic and Health Survey (PDHS) is collected birth-to-birthand not
pregnancy-to-pregnancy so they do not take into account if there were any wastage of pregnancy or miscarriages. (Pak J
Public Health 2013; 3(2): 35-39
Introduction
Birth and pregnancy histories and marriage have been
used by researchers to study fertility behavior of women.
Birth history analysis undoubtedly provides useful
information about reproduction and family formation.
Fertility depends not only on the decisions of couples but
also on many socioeconomic, demographic and healthrelated as well as tradition-related factors (1).These factors
have also effects on child spacing. Thus birth intervals
experienced by women may reveal some insights about
their reproduction patterns. Thegap (in months) between
two consecutive births is birth interval. A detailed analysis
of the sequence of steps in the childbearing process could
provide a more comprehensive picture of the dynamics of
birth intervals (2).Pakistan with its fast growing population,
high rates of fertility, low age at marriage and contraceptive
use, less female education and employment, has poor
socio-economic and demographic indicators compared to
its neighboring countries. Over the years, Pakistan has not
shown any considerable increase in birth spacing
according to different surveys, contrary to the trend found in
the neighboring countries (3).
Methods
The data source for this study is the Pakistan Demographic
and Health Survey, (PDHS) 2006-2007, which was
conducted by the National Institute of Population Sciences
(NIPS). PDHS (2006-07) is the largest household based
survey ever conducted in Pakistan. 972 sample points
were visited across Pakistan and data were collected from
a nationally representative sample of over 95000
households. There were 10023 ever married women in this
s u r v e y. T h e s e w o m e n w e r e a s k e d a b o u t t h e i r
demographic, health and social status. The main
objectives of the survey were to provide state level
estimates on fertility, family planning practices, infant and
child mortality, reproductive health and child health,
nutrition of women and children, and quality of health and
family welfare services.
For this study the section on female birth history
that has the detailed information on fertility status and
related behavior of each female. From female's birth
history the detail information about the fertility related
pattern of females in PDHS. There are various ways of
measuring birth intervals: inter-pregnancy intervals, interbirths, and birth-to-conception intervals. In PDHS can be
obtained, birth interval is calculated by duration between
two births. The type of interval used depends on the issue
being studied. Inter-birth intervals, or the duration between
35
Pakistan Journal of Public Health, 2013 (June)
two succeeding births, using the data from the birth history
was calculated.
This study uses median of months of succeeding
(subsequent) birth interval for analysis and assessment of
birth spacing practices. The present paper gives median
birth intervals to have an insight into fertility behavior of
women in Pakistan. Median is preferred over mean
because medians are less sensitive to extreme scores and
are probably a better indicator. Median is the middle with
50% of values above and 50% below it. When the data is
not symmetrical, this is the form of 'average' that gives a
better idea of any general tendency in the data.
Means are the arithmetic average and are often
used with larger sample sizes. The mean depends on the
actual values in a data set, but the median is dependent
only on the relative position of the values. Changing one
data value does not affect the median, unless the data
value is moved across the middle of the data set. But every
change in a data value affects the mean. Thus, the mean is
affected by a few extremely large or extremely small values
outside the range of the rest of the data, but the median is
not.
Results
The dynamics of fertility performance can be understood
better in term of birth spacing than by the other
conventional indicators. Many economic, social and
demographic factors are deeply related with birth interval.
Table-1 shows some socio demographic variables which
are consider to be related to birth intervals. As the
discussed in table-1, age at marriage has negative impact
on the birth intervals. If a women get married in younger
ages then they have long intervals, but if she gets married
at older age, like thirty or thirty ve, then she tend to
complete her family quickly (4). In Pakistan, majority of
women do not have rst birth until their twentieth birthday
(PDHS, 1990-91) (5)and same is the case according to
(PDHS, 2006-07). The birth of child before the age 15 is
uncommon. There are many reasons of it like age at
marriage in increasing over the time due to increase in
education attainment among males and females, marriage
of both sexes should not be under 18 is restricted by law (4).
Parental educational status has positive impact on
birth intervals, with higher the levels of education longer the
interval (6). Province and type of residence can also affect
birth intervals as the different ethnic groups in Pakistan
have different intervals. Intervals for the birth by the wealth
status generally show that rich women have longer
intervals than poor women but the results in this study show
reverse outcomes. Employment statuses of the parents
have negative impact on the intervals because employed
parents have longer intervals than unemployed parents.
Sex of the last child and last child's survival status can also
affect the next child intervals and this study shows
presence of sex preference.
Table 1, shows Median intervals between births for
the 1st parity to 8th parity. Females are giving 21 median
month's interval at 1st and 24 median month's interval at
2nd birth. There is no difference in median months interval
has observed in remaining birth orders.
As the age at marriage increases the median
interval decreases as aged women have short intervals,
this can be because they are approaching the end of their
reproductive span. Results show that for all age groups
(10-30+) median interval shows some variation only at rst
order births and there is a decreasing trend in median
intervals between births by increasing in the age at
marriage. For all other births almost the same results for all
age groups are found little with a variation seen in the last
age group (30+). For the educational attainment of the
mother was notice that illiterate women have 22 median
months while at the graduate level it is 15 months for the
rst order child in all age groups. Highly educated women
have long intervals for the succeeding births, for second
and third births 24 and 28 median interval respectively,
while the uneducated women giving 25 median intervals at
the rest of all the birth (7).
In the provincial difference, the median interval is
longer in the Baluchistan, which is 24 months than the
Punjab 20, Sindh 22 and KPK that is 20 median intervals for
the rst birth. It was noticed in the province the median birth
interval for the succeeding births are increasing in
provinces. Median interval between the births is showing
almost same trend in next all birth orders. By looking the
urban rural differential, urban women have shorter intervals
19 than rural 22 for the rst birth. At the wealth index, the
poor women have longer interval 23 than the rich 19 as rst
birth but then almost same median interval in other all
births.
There is no signicant difference between the
employed and unemployed women, as they show almost
same interval among all births. In the blood relation with the
husband is concern the women who have no relation with
their husband tend to have shorter interval with those who
had any blood relation with her husband only at rst birth.
Conclusion
This study has presented the association of socio
economic and demographic factors of birth intervals /
spacing in Pakistan. It is mainly concerned with
36
Pakistan Journal of Public Health, 2013 (June)
Table 1: Median Interval between succeeding births with Socio-Economic and Demographic Variables
Background Characteristics
Age At Marriage
Birth Order
1
2
3
4
5
6
7
8
10 – 14
28
25
25
25
24.5
24
25
25
15 – 24
20
24
25
25
25
25
25
26
25 – 29
18
24
26
26
25
24
28
27
30+
16
22
27
25
36
29.5
39
24
No Education
22
24
25
24
25
25
25
25
Primary
20
24
24
25
25
25
25
27
Secondary
17
24
26
26
26
25
26
29
Graduate and Higher
15
24
28
31
29
25
24
21
No Education
22
24
25
24
25
24
25
25
Primary
22
24
24
24
25
25
25
25
Secondary
20
24
25
25
26
25
26
27
Graduate and Higher
17
24
27
27
25
25
23
23
Punjab
20
24
25
25
25
25
25
25
Sindh
22
24
25
25
24
24
24
25
KPK
20
24
26
24
26
25
26
26
Baluchistan
24
25
26
26
25
25
26
25
Urban
19
23
25
24
25
25
25
26
Rural
22
24
25
25
25
25
25
25
Poor
23
25
25
25
25
25
25
25
Middle
22
23
25
25
25
25
26
25
Rich
19
24
25
25
26
25
25
26
Employed
22
24
25
25
25
24
24
25
Unemployed
21
24
25
25
25
25
25
26
Mothers Education
Husbands Education
Region
Type of Residence
Wealth Index
Mother's Occupation
37
Pakistan Journal of Public Health, 2013 (June)
Husband's Occupation
Employed
21
24
25
25
25
25
25
25
Unemployed
21
23
24
22.5
26
25
25
25
Yes
19
23
25
24
25
25
25
25
No
22
24
25
25
25
25
25
26
Yes
-
19
19
18
19
18
19
19
No
-
24
26
25
26
25
25
26
Male
-
24
25
25
25
25
25
25
Female
-
24
25
24
25
25
25
26
No Relation
20
24
25
25
25
25
26
26
Blood Relation
21
25
25
25
25
25
25
26
Other
22
23
24
25
25
25
24
23
Total
21
24
25
25
25
25
25
25
Contraceptive use
Child Last Child alive
Sex of Last Child
Blood Relation with Husband
Source: Calculated from Pakistan Demographic and Health Survey (PDHS 2006-07)
determining the relation of socioeconomic and
demographic factors on birth interval dynamics. It was
found that in younger women interval between births are
longer than older women, also women with secondary and
higher education and those belong to urban areas tend to
space birth more widely. Employed couple get interval for
rst birth between 27-31 mean months. While if the couple
is unemployed then interval going to decrease between 2729 months. There is no signicant difference between the
employed and unemployed women. In this data the
interesting point is to be noted that non user of more and
contraceptives has longer interval then users. In the
provincial difference, the mean interval is longer in the
Baluchistan than the Punjab, Sindh and KPK. In the data it
was noticed that if the rst-born was a boy; women delay
the pregnancy for their 2nd birth, because they might be
wanting invest more on boy.
As we proceed from the third to the seventh birth all
the important factors, residence, occupation, region and
contraception, do not show any signicant impact on the
birth intervals. From the above result it can be concluded
that, education and age at marriage are more signicant
indicators of birth intervals, because as the age at marriage
increase women want to conceive quicker than most
marriages at younger ages. Educational attainment also
impact on birth spacing, as the increase in educational
status wider leads to birth spaces. We have found
insignicant results because of data limitations. Difference
in found only at rst birth in mean and median month's
interval among all females.
The PDHS has very useful information about
fertility related behavior of woman for throughout her
reproductive span; still it has some limitation, which is a
barrier to fully analyze the topic under study. For example
data about pregnancy is not available, making analysis of
inter-pregnancy interval impossible. The results about
birth spacing do not include intervals probably due to
miscarriages or the wastage of pregnancies having place
38
Pakistan Journal of Public Health, 2013 (June)
between two births. That is why probably in Baluchistan,
where miscarriages have the highest rate in Pakistan,
shows long interval between births compared to other
province. Similar confounding results are found for the
wealth index, son preferences, education attainment and
age at marriage when analyzed for birth intervals.
References
1.
2.
3.
4.
5.
6.
7.
Alasdair D. Population Dynamics and Birth Spacing in
Oman. International Journal of Middle East
Studies1999, 5(1): pp136-40.
Pebley A, Millman S. “Birth spacing and child survival”
International Family Planning Perspective. 1986;
12(3): 71-79.
Fertility in Pakistan, A Review of ndings from the
Pakistan Fertility Survey: 1984.
Sathar Z
Birth spacing in Pakistan. Journal of Biosocial Science
Pakistan Institute of Development Economics
Islamabad1988; 20(2): 175-194.
Demographic and Health Survey (PDHS 1990-91).
Suwar J. Socio-cultural dynamics of birth intervals in
Nepal. Nepalese studies. 1996;28(1): 1-33.
Jungho K. Women's Education and Fertility, an
Analysis of the Relationship between Education and
Birth Spacing in Indonesia”Economic Development
and Cultural Change University of Chicago
Press.2010; 58(4): 739-774.
39
Pakistan Journal of Public Health, 2013 (June)
Short Communication
Pak J Public Health Vol. 3, No. 2, 2013
A Spot Survey to Investigate an Outbreak of Cutaneous Leishmaniasis at Afghan
Refugee Camp at Khairabad Village in KPK.
-1
1
1
1
Hamayun Rashid Rathor , Soaib Ali Hassan , Hazrat Bilal , Imtinan Akram Khan ,
1
Tallat Anwar Fridi .
1
Department of Medical Entomology and Disease Vector Control (MEDVC) Health Services Academy
Islamabad (Correspondence to Hassan SA: [email protected])
Summary
Leishmaniasis is caused by infection of protozoan parasite belongs to genus Leishmania. The protozoa transmitted to
human by the bite of infected sand ies of genus phlebotomus in old world. Leishmaniasis is group of diseases the most
common form and wide spread in world is CL causing morbidity (leaving scar after healing) in number of people. In
Pakistan a number of out breaks of CL have been reported from all the provinces including AJK. However, most recently
an outbreak of CL was reported from Khairabad village of district Nowshahera, KPK. All suspected patients visiting Frontier
Primary Health Care (FPHC) of Khairabad were conrmed trough laboratory test and then registered for treatment with
Sodium Stibogluconate injections provided by United Nation High Commissioner for Refugees (UNHCR). A total of 593
patients were registered out of which the percentage of male was 42.32% and 57.67% were female patients. Most the
patients were secondary infected which shows that there is lack of knowledge about disease. So, beside treatment of
cases, community should be educated about the vectors, transmission and symptoms of disease. Also there is an urgent
need to conduct research for seasonal distribution of vector species in the area and to establish insecticide susceptibility /
resistance status of vector species of sand ies, which will help in strategic planning for the control of sand ies and
ultimately the disease burden will reduce. (Pak J Public Health 2013, 3(2): 40-41
Keys words: Cutaneous Leishmaniasis, Outbreak, Sand ies
Outbreak Report
Leishmaniasis is caused by infection of protozoan parasite
belongs to genus Leishmania. The protozoa transmitted to
human by the bite of infected sand ies of genus
Phlebotomus in old world. (1) Leishmaniasis is group of
diseases the most common form and wide spread in world
is CL causing morbidity (leaving scar after healing) in
number of people. Worldwide 1.5 million of CL cases occur
annually (2,3). In Pakistan a number of out breaks of CL
have been reported from all the provinces including AJK.
However, most recently an upsurge of CL was reported
from Khairabad village of district Nowshahera, KPK. A spot
survey of the reported area was conducted by MEDVCHSA team, in December, 2012, to investigate the outbreak.
The village is situated on river side at the border of Punjab
and KPK province. The patients who visited Frontier
Primary Health Care (FPHC) at Khairabad Nowshahera,
KPK during 2012 were recorded.
Discussions were made with medical and paramedical staff of the FPHC. All suspected patients visiting
the (FPHC) of Khairabad were conrmed trough laboratory
test and then registered for treatment with Sodium
Stibogluconate injections provided by United Nation High
Commissioner for Refugees (UNHCR). During the survey it
was observed that a total of 593 patients were registered
out of which the percentage of male was 42.32% and
57.67% were female patients. The age wise distribution of
cases in each month for both male and female patients is
shown in table 1. The lower prevalence of disease in males
is might be because of traveling for jobs outside the
endemic area. The higher prevalence of CL in females is
because they spend most of their times in and around the
houses and working in the animals sheds as shown by
another study in 2009. (4)
It was observed that the majority of community
members lacked knowledge about the disease symptoms
and awareness on how to prevent infective bites by the
vector sand ies, therefore, treatment was started very late
and because of long incubation period and slow process of
healing the patients are acting as a main amplifying host in
further spread of disease. The above explains why most
the patients had secondary infections beside treatment of
cases.
Conclusions
It can be concluded that the inux of infected Afghan
refugees, lack of preventive measures and delayed
treatment of primary infections resulted in outbreak of CL at
Khairabad. In all situations, treatment of infected cases
40
Pakistan Journal of Public Health, 2013 (June)
Table 1: Month wise distribution and total numbers of CL in Khariabad Village (Nowshahera, KPK)
< 5 yeas
5-14 yeas
>15 yeas
Months
M
F
M
F
M
F
Total
January
6
7
14
13
6
19
65
February
11
7
18
23
11
28
98
March
6
2
12
19
14
23
76
April
8
12
18
19
12
28
97
May
10
6
12
10
3
18
59
June
0
1
5
3
6
8
23
July
1
2
1
3
3
4
14
August
0
0
0
0
4
0
4
September
1
4
4
4
3
6
22
October
2
0
8
1
4
8
23
November
3
6
9
11
9
17
55
December
6
6
9
14
12
10
57
Total
54
53
110
120
87
169
593
remains primary need, However, the disease can only be
prevented by mean of vector control activities constituting,
operationalizing sustained sand y control through
Integrated vector management (IVM). Personal protection
measure especially during the dusk to dawn periods; using
insecticide treated bed nets and clothing (5) and minimizing
skin exposure to infective bites of vector sand ies by
applying insect repellents (6). In addition, most importantly
the community should be educated about the vectors,
transmission and symptoms of disease. Also there is an
urgent need to conduct research for seasonal distribution
of vector species in the area and to establish insecticide
susceptibility / resistance status of vector species of sand
ies, which will help in strategic planning for the control of
sand ies and ultimately the existing and future outbreaks.
References
1.
2.
3.
4.
5.
6.
Shakila A, Bilqees FM, Salim A, Mionuddin.
Geographical Distribution of Cutaneous
Leishmaniasis and sandies in Pakistan. Acta
Parasitologica Turcica. 2006; 30(1): 1-6.
World Health Organization. Report of the fth
consultative meeting on leishmaniasis/ HIV
coinfection. Addis Ababa, Ethiopia. 20-22, March
2007.
World Health Organization. Sixtieth World Health
Assembly. Resolution and decision
Annexes. Geneva. 14-23 May, 2007.
Ullah S, Jan AH, Wazir SM, Ali N. Prevalence of
cutaneous leishmaniasis in Lower Dir District
(N.W.F.P), Pakistan. Journal of Pakistan Association
of Dermatologists. 2009; 19: 212-215.
Herwaldt BL. Leishmanaisis. Lancet. 1999; 354:
1191-9.
Desjeux P. Leishmanaisi: Public health aspects and
control. Clin Dermatol. 1996; 14: 417-23.
41
Vol. 3 No. 2 (June) 2013
Perceptions about measles among mothers living in rural area: A cross-sectional study at Larkana, Sindh
Hussain S, Kumar R, Ali M, Khan EA, Ahmed J, Khan SA, Hussain S.
2
Gaps Analysis in Knowledge, Practices & Control Responses to Combat Cutaneous Leishmaniasis in Bagh AJ&K
Akbar J, Rathor HR, Hassan SA, Bilal H, Khan IA, Idrees M
6
Susceptibility of Salmonella enterica serotype typhi, to the usual line of antimicrobial treatment in Rawalpindi
Abdullah MA, Zahid A, Sattar NY
14
World Health Organization diabetic care guidelines: knowledge and practices of general practitioners in private
Clinics of Rawalpindi, Pakistan
Durrani HM, Kumar R, Durrani SM, Anwar-ul-Haq
19
Bioactivity of botanicals against Aedes aegypti Linnaeus and Anopheles stephensi Liston Larvae
Inam-llah H, Rathor HR, Bilal H, Hassan SA and Khan IA, Faridi TA
23
Morbidity Patterns in Pakistan: Evidence from Pakistan Panel Household Survey 2010
Bari I, Abbas N
28
Socioeconomic and demographic dynamics of Birth Interval in Pakistan
Abbas N, Shaikh I, Bari I
35
Short Communication
A Spot Survey to Investigate an Outbreak of Cutaneous Leishmaniasis at Afghan Refugee Camp at Khairabad
Village in KPK.
Rathor HR, Hassan SA, Bilal H, Khan IA, Fridi TA.
40