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Pakistan is among countries with the highest predicted antimicrobial resistance (AMR) bacteria levels in the world, says a global study conducted by international researchers, including Pakistani experts.

Risk Factors

Prescription of antibiotics for self-limited viral infections, availability of antibiotics at pharmacies without prescription, increased consumption of antibiotics in livestock sector, particularly of broad-spectrum antibiotics, are major underlying factors contributing to antibiotic resistance.

Pakistan is currently struggling to deal with several drug-resistant epidemics, (including an outbreak of Extensively Drug-Resistant (XDR) Typhoid which has now gripped the entire country), endemic Multi-Drug Resistant (MDR) Tuberculosis, several strains of drug resistant fungi, and other microorganisms. The comprehensive analysis of sewage collected from 74 cities in 60 countries including Pakistan puts the country at the highest predicted AMR levels.

Solution

Antimicrobial Stewardship Programs (ASP) and Infection Control Programs are the most effective immediate options for combatting AMR. Unfortunately, in Pakistan, such initiatives to address AMR have not been taken until recently. The rise of AMR is threatening the ability of Pakistan to treat common infectious diseases, resulting in people suffering from prolonged illnesses, disability, and even death. Infection Prevention and Control Foundation is going to establish Antimicrobial Stewardship Programs (ASP) and Infection Control Programs throughout the country to counter this challenge which has become a threat to global health.

Dengue is a viral infection transmitted through the bite of infected mosquitoes that feed both indoors and outdoors during the daytime (from dawn to dusk). Dengue can cause mild dengue fever to severe hemorrhagic fever. Hemorrhagic fever results in severe bleeding, sudden drop in blood pressure and if not treated, death. 

Risk Factors

These mosquitoes thrive in areas with standing water, including puddles, water tanks, containers and old tires. Lack of reliable sanitation and regular garbage collection also contribute to the spread of the mosquitoes.

Community awareness can create major hurdle against dengue and can decrease the number of cases. People should be advised to use mosquito repellents, cover their arms and legs, particularly before sunrise and after sunset.

Malaria

Malaria is a life-threatening disease transmitted through the bite of infected mosquitoes.

Pakistan’s monsoon rains and flawed drainage system, coupled with the country’s hot, arid climate, should always keep people on the lookout for malarial infections. Annually 3.5 million cases of malaria appear in the country resulting in 50,000 deaths.

Prevention

Infection Prevention and Control Foundation plans to help institutions in preventing these outbreaks through effective surveillance system. This includes

1. Increasing awareness coverage.
2. Provision of Long Lasting Insecticidal Nets to prevent mosquito bites
3. Better preparedness and early detection of an outbreak.

Hepatitis E virus is transmitted through the same route, principally via contaminated water.

Pakistan’s poor sanitary conditions and lack of hygienic practices lead to 90% of children testing positive for hepatitis A virus. Hepatitis A virus accounts for 50% to 60% of cases of acute viral hepatitis in the pediatric population of Pakistan.

In a recent study of 2,735 confirmed HAV cases, 36.7% of patients died with liver failure.

Hepatitis E

Major urban cities of Pakistan are seeing an epidemic of Hepatitis E for some years. This disease has produced catastrophic effects in pregnant women, resulting in maternal mortality rates and perinatal mortality rate of up to 30 per 1,000 live births.

Prevention

Infection Prevention and Control Foundation is working on war footing basis to control these outbreaks by taking following measures:

1. Close collaboration and technical assistance to public and private sector clean drinking water provision programs.
2. Provision of training and technical assistance to food authorities and food handlers in the country.
3. Awareness drives for food hygiene and hand hygiene in the communities.

People infected with Hepatitis B and C usually have no symptoms.

Pakistan is one of the countries having the highest number of patients with chronic infection of hepatitis B and C. In Pakistan, about 20 million individuals are affected by hepatitis B or C. This makes up about 10% of the population.  It has created a medical emergency situation in the country. The treatment of viral hepatitis is very expensive and poses a great financial burden on the economy of the country.

Risk Areas

Unfortunately, healthcare facilities have become a harbor for spreading Hepatitis B and C. Major risk areas for transmission are as follows:

1. Clinics (reuse of syringes)
2. Dental care facilities
3. Surgical facilities
4. Barbers

Prevention

IPAC Foundation is a partner of a global consortium formed to fight Hepatitis B and C from third world countries including Pakistan. IPAC Foundation is leading the micro-elimination campaign in Pakistan which includes screening, vaccination, treatment referral, and increased awareness coverage in all areas of the country.

Among these, about 27,000 are currently registered as diagnosed cases. Only about 19,000 patients are currently on some form of treatment plan.

Epidemic in Ratodero, Larkana, Sindh

On 25 April 2019, the local administration in Larkana district was alerted by media reports of a surge in human immunodeficiency virus (HIV) cases among children in Ratodero Taluka, Larkana district, Sindh province, Pakistan. Screening for HIV was done on 36,468 individuals from general population in Ratodero. Till now 1,139 (907 children and 232 adults) were found HIV positive during this screening. This is the first time that children have been a major victim of an HIV outbreak.

Risk Factors

The outbreak was found to be caused by backstreet quack clinics and lax doctors spreading the virus by reusing the syringes and needles. Medical waste is not safely disposed of and used syringes are sold again in markets. Unsterilized dentists instruments and barbers’ razors, and poorly regulated blood-transfusions all add to the risks of spreading HIV/AIDS.

Due to lack of awareness and information, people diagnosed with HIV are basically outcast by the society and can no longer live a normal life.

Prevention

IPAC Foundation shall work in following areas to prevent the spread of this deadly virus:

1. Screening of high risk population
2. Treatment referral program
3. Awareness about common risk factors of HIV/AIDS spread and its prevention
4. Medical waste management

According to the Global Alliance for Rabies Control, rabies causes 2000-5000 deaths annually in Pakistan. Since 2012, the number of animal bite cases are increasing in Pakistan each year.

Prevention

Infection Prevention and Control Foundation aligned with World Health Organization “One Health” guidelines plans to reduce the incidence of dog bites through:

1. Vaccination of dogs.
2. Sterilisation of dogs to reduce their

Population.

3. Vaccination of humans at high risk by putting in efforts to create mass awareness on rabies transmission, prevention, and self-protection.

Rabies is 99.9% fatal but is also 100% preventable. Gone are the days when a dog-bite victim had to get 14 injections in the stomach to protect from rabies. Now in the first regimen, 4 doses are given, one on each day, each dose costs around Rs 2,500.

. In 2019, more than 0.1 million cases of typhoid were reported from Punjab province alone.

Outbreak of XDR Typhoid

Pakistani Health Authorities have reported an ongoing outbreak of extensively drug-resistant typhoid fever (XDR Typhoid which is resistant to all recommended antibiotics for typhoid) that began in the Hyderabad district of Sindh province in November 2016. 5274 cases of out of total 8188 XDR typhoid fever cases were reported Sindh province only.

Prevention

Following preventive measures should be taken to prevent from getting infected with typhoid:

1. Typhoid vaccine (One dosage provides immunity for 3 years).
2. Avoid raw fruits and vegetables that cannot be peeled.
3. Avoid food that is raw or undercooked.
4. Drink only bottled water or water that has been boiled.
5. Thoroughly wash your hands each time before eating.
6. Avoiding eating foods and beverages purchased from street vendors.
7. Avoid reusing frozen vegetables and fruits.

Typhoid vaccination campaign

WHO has recommended mass typhoid vaccination campaigns in Pakistan to prevent outbreaks from happening again? IPAC Foundation is going to launch a mass typhoid vaccination campaign in 2020 to help provide herd immunity to high risk urban towns and villages.

Pakistan is also estimated to have the fourth highest prevalence of multidrug-resistant TB (MDR-TB) globally and approximately 15,000 developing drug resistant tuberculosis cases every year. Key reasons for emergence of drug resistance form of TB include: delays in diagnosis, unsupervised, inappropriate and inadequate drug regimens, poor follow-up, and lack of a social support program for high-risk populations.

“MDR TB is the one which grows when the patient stops taking medicines without completion of the course. We register patients and try to ensure that every patient completes the course. Unfortunately, TB is a stigma in the country so patients try to hide the disease and get treatment privately. As a result, many times they miss the medicines. Though the cure rate for TB in over 95pc, around 160,000 cases in the country are not reported at all which means that they either don’t go to hospitals or get treatment privately,” said Dr. Aamer Ikram, National Coordinator for Common Management Unit for TB, AIDS and Malaria.

Dr. Ikram added, “On an average, a person with infectious TB infects 10 to 15 others every year, if not treated well.” It is vital to cease the spreading of TB as soon and possible.

Preventive measures Following measures should be taken by the patient in order to confine the disease to themselves.

1. All the prescribed medicine should be taken unless advised by the doctor otherwise.
2. Appointments with the doctor should not be missed.
3. A patient should always cover their mouths with a tissue when they cough or sneeze. The tissue should sealed in a plastic bag, and thrown away.
4. They should not visit other people.
5. They should use a fan or open windows to move around fresh air.
6. They should not use public transportation.

Infection Prevention And Control Foundation is going to work on:

1. Spreading public awareness about preventive measures
2. Provision of N95 tuberculosis masks to the families and health care providers
3. Advocacy for upgrading the current tuberculosis wards to negative pressure isolation wards in healthcare facilities.