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In the Name of AllAH The Most Merciful And The Most Beneficient

In the Name of AllAH The Most Merciful And The Most Beneficient. PAKISTAN. CURRENT NATIONAL EID THREATS. 1963.

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In the Name of AllAH The Most Merciful And The Most Beneficient

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  1. In the Name of AllAH The Most Merciful And The Most Beneficient

  2. PAKISTAN CURRENT NATIONAL EID THREATS

  3. 1963 • We can look forward with confidence to a considerable degree of freedom from infectious diseases at a time not too far in the future. Indeed . . . it seems reasonable to anticipate that within some measurable time . . . all the major infections will have disappeared T Adian Cockburn

  4. 1968 • It might be possible with interventions such as antimicrobials and vaccines to “close the book” on infectious diseases and shift public health resources to chronic diseases US Surgeon General

  5. WHO 2004 World Health Report • In 2002 infectious diseases accounted for about 26 % of the 57 m deaths worldwide • Infectious diseases are the 2nd leading cause of death globally • Among young people infections are overwhelmingly the leading cause of death • Approximately 75 percent of emerging pathogens are zoonotic

  6. EMERGING INFECTIOUS DISEASES • Those diseases that have never been recognised before • HIV/AIDS • SARS • Nipah Virus Encephalitis • vCJD

  7. RE-EMERGING INFECTIOUS DISEASES • Those diseases  that have been around for decades or centuries, but have come back in a different form or a different location – Returned with a vengeance • West Nile Virus • Monkey pox • Dengue

  8. Contributing Factors • Economic development • Land use • Human demographics and behavior • International travel • Commerce • Microbial adaptation and change • Breakdown of public health measures

  9. Contributing Factors • Human vulnerability • Climate and weather • Changing ecosystems • Poverty and social inequality • War and famine • Lack of political will • Intent to harm

  10. Pakistan’s Scenario • Low income • To feed a family of 4 for 10 days or to vaccinate? • Population explosion • 180 million • Shrinking resources • GDP – 6.8% (2006) to 2% (2009) • Low expenditure on health • 1.5% of GDP

  11. Pakistan’s Scenario • Urbanization • Crumbling public health • Limited access to potable water • Rudimentary waste disposal • Lack of political will • Drug resistant microbes • Excessive & unregulated antibiotic abuse

  12. The Vicious Circle

  13. Top Ten Causes of Death, all Ages Pakistan, 2002

  14. Fundamental Characteristics of Microbes • Replication • Human generations - every two decades • Microbes - in minutes rapid replication • Microbes also can mutate with each replication cycle • Selectively circumvent human interventions • Antimicrobials • Vaccines • public health measures

  15. Important Emerging & Re-Emerging Infectious Diseases in Pakistan • Community Level • MDR/XDR-TB • Drug Resistant Malaria • Hepatitis B & C • HIV/AIDS • MRST • Dengue Fever • Hospitals • MRSA • MRSE • VRE • O157:H7 • ESBL producing GNRs

  16. Tuberculosis • Incidence of TB per 100,000 population: 181 • National disease burden: 5.1% • Pakistan6thin prevalence worldwide • 96% of Medical Professionals are unaware of the existence of XDR-TB

  17. MDR/XDR-TB • MDR TB • Laboratory-confirmed resistance to the two most potent first-line medications, Isoniazid and Rifampacin • XDR TB • Resistance to both Isoniazid and Rifampacinwith additional resistance to at least one Fluoroquinolone and one injectable agent (Amikacin, Kanamycin or Capreomycin)

  18. MDR/XDR-TB • Gross underreporting • Lack of resources • Unreliable reporting system • Unavailability of quality labs • Lack of trained manpower in public health sector • Lack of political will

  19. Cost Effect of TB

  20. Malaria • Malaria is the 2nd most prevalent and devastating disease in the country (HMIS, 2006)

  21. Eco-epidemiological Zones Pakistan in Group 3: Countries with moderate/ high malaria burden, weak health system and/or complex emergencies

  22. Causal Organism • Plasmodium falciparum is most dangerous (25%) • Plasmodium vivax is most dominant (75%) • High incidence in rural areas (38.65%) than in urban areas (22.39%) • Economic cost • 6 full working days lost due to illness • 12.5 days lost due to partial morbidity

  23. Malaria Epidemiology • Estimated number of annual malaria episodes in Pakistan is 1.5 million. • In 2005, falciparum malaria constituted 33% of reported confirmed malaria cases, this figure decreased to 24% in 2008. • 40% of cases were reported from Baluchistan province.

  24. Roll Back Malaria • If no Malaria control program incidence will double • From 0.69/1000 to 1.39/1000 • 1million new cases every year (Malaria Economic Survey 2002/03) • Total number of malaria cases averted 481,356 (Economic analysis of National Malaria Control Program, 2004)

  25. Hepatitis • Current Estimated Prevalence • Hepatitis B - 3-4 % • Hepatitis C - 5-6 % (Intermediate) • Hepatitis A - 100% exposed by adult age • Hepatitis E • Quality of water and poor sewage disposal leads to pockets of resurgence

  26. Hepatitis B & C • Needles in healthcare settings  • Receipt of blood and blood products • Only 23% screening for HCV • 50% of blood banks regularly utilized paid blood donors • Injection drug users (IDUs)  • 500,000 addicts • 75,000 (15%) are regular IDUs • 150,000 (30%) are occasional IDUs

  27. Hepatitis B & C • Occupational risks  • Higher prevalence in healthcare workers   • HBV 6% • HCV 5.5% • Shaving by barbers  • Awareness in only 13% • 46% reuse of razors • Household contacts/spousal transmission 

  28. HIV/AIDS • Until September 2004 • Full-blown AIDS - 300 cases • HIV infection - 2300 cases • HIV infection - 70,000 to 80,000 persons (0.1 % of the adult population) • Pakistan  • Low-prevalence • With many risk factors

  29. Underreporting HIV/AIDS • Social stigma attached to the infection • Limited surveillance and voluntary counseling • Testing systems • Lack of knowledge • general population • health practitioners

  30. Changing Situation HIV/AIDS • Karachi 2004 • Injecting Drug Users (IDUs) - 20 % infected • Men who have sex with men (MSM) - 4 %  • Eunuchs - 2 % • Significant risk factors • Very low use of condoms among vulnerable populations • Low use of sterile syringes among IDUs • High prevalence of STI among eunuchs • 60 % in Karachi  • 33 % in Lahore

  31. The Tip of Iceberg 70 – 80,000 cases Large susceptible population of, MSM, CSW, IDU Inadequate Blood Transfusion Screening and High Level of Professional Donors Large Numbers of Migrants and Refugees Low Levels of Literacy and Education Unsafe Medical Injection Practices Social and Economic Disadvantages

  32. RISK FACTORS HIV/AIDS • Injecting Drug Users (IDUs) • Drug dependents in Pakistan about 500,000, an estimated 60,000 inject drugs • Men who have Sex with men (MSM) • Lahore estimated 38,000 MSM in 2002 • Unsafe Practices among Commercial Sex Workers (CSW) • 3 large cities population of 100,000

  33. RISK FACTORS HIV/AIDS • Inadequate Blood Transfusion Screening and High Level of Professional Donors  • 1.5 million annual blood transfusions • 40 % not screened for HIV • 1998 study in Karachi • Infection • Hepatitis C 20 % • Hepatitis B 10 % • HIV 1 % • 20 % Professional donors

  34. RISK FACTORS HIV/AIDS • Large Numbers of Migrants and Refugees • Around 4 million are employed overseas • Unsafe Medical Injection Practices • High rate of medical injections - 4.5/capita/year • 94 % injection reuse • Unsafe injections account for • 62 % of Hepatitis B • 84 % of Hepatitis C • 3 % of new HIV

  35. RISK FACTORS HIV/AIDS • Low Levels of Literacy and Education • Illiteracy rate of women over 15 years 71 % • Vulnerability Due to Social and Economic Disadvantages • limited access to information and preventive and support services • Young people are vulnerable • Both men and women from impoverished households may be forced into the sex industry for income

  36. Typhoid • 1987 • 1st Salmonella typhi reported to show In Vitro resistance (AFIP) to • Chloramphenicol • Cotrimaxazole • Amoxicillin • 1991-2 Flouroquinolone • 1997 • Flouroquinolone treatment failure • Today • Multi Resistant Salmonella paratyphi A • Impending therapeutic failure

  37. Typhoid – Current Situation • Defervesence of fever • 1990 48 hrs • Now 5th day • Drug of Choice • 3rd generation Cephalosporins • Costly

  38. Cost Effect • Serious public health problem in Pakistan • Incidence - 800/100,000 in urban populations • Rapid growth of Antibiotic-resistant typhoid • Greater difficulty in treating cases • Prolonged treatment • Rising treatment costs • Heavy economic burden on affected families

  39. Implications of growing antibiotic resistance Average Treatment Costs for Typhoid (US$) Child weighing 20 kg using standard treatment guidelines Source: AKU Pharmindex 2004 & WHO guidelines 2003

  40. Dengue Fever

  41. Dengue Fever • 1st epidemic of DHF in 1953–1954 • Manila, Philippines • Expanded from Southeast Asian countries to Asian countries • Pakistan, India and Sri Lanka •  Before 1989, DHF common in Southeast Asia but rare in the Indian Sub-continent After 1989 regular epidemics were reported from the Indian subcontinent

  42. Dengue Fever • Pakistan absent from the WHO listing for South East Asian countries endemic for dengue until 1993 • The first confirmed outbreak from Pakistan - 1994 • Epidemic outbreaks of DF and DHF in Pakistan since 1994

  43. Dengue Fever • Ill defined types • In 1994DEN-1 & DEN-2 was reported in three of the 10 patients tested • DEN-3 & DEN-4 in Pakistan 1st reported during DHF outbreak in 2005 • 2006 outbreak DEN-2 & DEN-3

  44. Dengue Fever The circulation of two Dengue types classifies Pakistan as hyper-endemic region for dengue

  45. Dengue Fever • AKU (2006) • 250 confirmed cases • Responsible strains - DEN-2 and DEN-3 • The introduction of a new strain (DEN-3) and or a shift of DEN-2 are the probable factors for the recent outbreaks of DHF in this region • AbbasiShaheed Hospital (2007) • Suspect cases 1,200 • Confirmed cases 260 • Died 22

  46. CCHF

  47. Infections in ICU Settings • PRSP • EHEC • MRSA • MRSE • VRE • ESBLs

  48. Acinetobacter baumanii • Globally # 1 problem for ICUs • High mortality and morbidity • Drug resistance • Gentamycin • Tobramycin • Amikacin • Costly • Tigecycline $ 140/day • Minocycline $1/day

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