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PAKISTAN
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
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
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

EMERGING INFECTIOUS
DISEASES

Those diseases that have never been
recognised before
 HIV/AIDS
 SARS
 Nipah Virus Encephalitis
 vCJD
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
Contributing Factors
Economic development
 Land use
 Human demographics and behavior
 International travel
 Commerce
 Microbial adaptation and change
 Breakdown of public health measures

Contributing Factors
Human vulnerability
 Climate and weather
 Changing ecosystems
 Poverty and social inequality
 War and famine
 Lack of political will
 Intent to harm

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
Health
 1.5% of GDP
GDP
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

The Vicious Circle
Low socio
economic
group
Costly
Treatment
Poor
public
health
facilities
Resistant
strains
Infection
Drug
Abuse
Top Ten Causes of Death, all
Ages Pakistan, 2002
Causes
Deaths
Years of
Life Lost
(000)
(%)
(%)
All causes
139
100
100
Lower respiratory infections
164
12
14
Ischemic heart disease
154
11
5
Diarrheal diseases
118
9
12
Perinatal conditions
113
8
13
Cerebro-vascular disease
78
6
2
Tuberculosis
66
5
4
Chronic obstructive pulmonary disease 48
4
1
Measles
36
3
4
Whooping cough
24
2
3
Congenital anomalies
21
2
2
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
Important Emerging &
Re-Emerging Infectious Diseases in
Pakistan

Community Level

Hospitals
 MDR/XDR-TB
 MRSA
 Drug Resistant
 MRSE




Malaria
Hepatitis B & C
HIV/AIDS
MRST
Dengue Fever
 VRE
 O157:H7
 ESBL producing
GNRs
Tuberculosis
Incidence of TB per 100,000 population:
181
 National disease burden:
5.1%
 Pakistan 6th in prevalence worldwide
 96% of Medical Professionals are
unaware of the existence of XDR-TB

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 Rifampacin
with additional resistance to at least one
Fluoroquinolone and one injectable agent
(Amikacin, Kanamycin or Capreomycin)
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

Cost Effect of TB
Type
Duration of
Treatment
Cost
Tuberculosis
6 months
$ 60
MDR
18 – 24 months
$ 6,000
XDR
18 – 36 months
$ 8,000- 12,000
Malaria

Malaria is the 2nd most prevalent and
devastating disease in the country
(HMIS, 2006)
Eco-epidemiological Zones
Pakistan in Group 3:
Countries with moderate/ high malaria burden,
weak health system and/or complex emergencies
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
Malaria Epidemiology
Year
2006
2007
2008
Number of confirmed
cases
124,910
128,570
104,454
• 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.
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)
Hepatitis

Current Estimated Prevalence
 Hepatitis B
 Hepatitis C
 Hepatitis A
-
3-4 %
5-6 % (Intermediate)
100% exposed by adult age
 Hepatitis E
○ Quality of water and poor sewage disposal leads
to pockets of resurgence
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
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
HIV/AIDS

Until September 2004
 Full-blown AIDS
 HIV infection
-
300 cases
2300 cases
HIV infection - 70,000 to 80,000 persons
(0.1 % of the adult population)
 Pakistan

 Low-prevalence
 With many risk factors
Underreporting
HIV/AIDS
Social stigma attached to the infection
 Limited surveillance and voluntary
counseling
 Testing systems
 Lack of knowledge

 general population
 health practitioners
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
The Tip of Iceberg
70 – 80,000 cases
Large susceptible
population of,
MSM, CSW, IDU
Large Numbers of
Migrants and
Refugees
Unsafe Medical
Injection Practices
Inadequate Blood
Transfusion
Screening and
High Level of
Professional
Donors
Low Levels of
Literacy and
Education
Social and
Economic
Disadvantages
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
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
○ Hepatitis B
○ HIV
20 %
10 %
1%
 20 % Professional donors
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
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
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
Typhoid – Current Situation

Defervesence of
fever
 1990
 Now

48 hrs
5th day
Drug of Choice
 3rd generation
Cephalosporins

Costly
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
Implications of growing antibiotic
resistance
Average Treatment Costs for Typhoid (US$)
Child weighing 20 kg using standard treatment guidelines
Course of antibiotics for non-resistant cases
$3-5
Prolonged Fluoroquinolone treatment for Quinolone
or Nalidixic acid resistant cases
$24-30
Azithromycin
$35-42
Oral Cephalosporins (Cefixime)
$37-42
Parenteral Cephalosporins (Ceftriaxone)
$44-104
Source: AKU Pharmindex 2004 & WHO guidelines 2003
Dengue Fever
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

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

Dengue Fever
Ill defined types
 In 1994 DEN-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

Dengue Fever
The circulation of two Dengue types classifies Pakistan as
hyper-endemic region for dengue
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

Abbasi Shaheed Hospital (2007)
 Suspect cases
 Confirmed cases
 Died
1,200
260
22
CCHF
Year
n
Deaths
%
1976
17
3
14%
1978
8
8
100%
1987
2
2
100%
1994
3
0
-
1998
45
20
44%
2004
47
18
37%
2005
20
4
25%
2006
18
6
33%
Infections in ICU Settings
PRSP
 EHEC
 MRSA
 MRSE
 VRE
 ESBLs

Acinetobacter baumanii
Globally # 1 problem for ICUs
 High mortality and morbidity
 Drug resistance

 Gentamycin
 Tobramycin
 Amikacin

Costly
 Tigecycline $ 140/day
 Minocycline $1/day
War Against Microbes
GNR
Sulzone
β Lactamases
3rd generation
Cephalosporins
Penicillin
Cephalosporins
Monobactem
ESBL
Carbepenamase
Cabapenam
ICU
50 cases
Pathogen
Acinetobectar
Pseudomonas
E Coli
n
32
9
7
Resistant to Carbapenam
84%
78%
71%
Misc
2
-
Avian Influenza
Avian Influenza
Low prevalence
 High mortality
 2003 – Feb 2008

 Total cases
 Deaths
 Mortality
359
226
66%
Directly infected from birds
 Little evidence of human to human spread

Swine Flu Epidemic
2009 Flu Pandemic Data
Area
Confirmed deaths
Worldwide (total)
14,286
European Union and EFTA
2,290
Other European countries and Central Asia 457
Mediterranean and Middle East
1,450
Africa
116
North America
3,642
Central America and Caribbean
237
South America
3,190
Northeast Asia and South Asia
2,294
Southeast Asia
393
Australia and Pacific
217
Source: ECDC – January 18, 2010
Virus of the Year:
The Novel H1N1 Influenza

It was supposed to come from Asia
 Instead it came from North America

It was supposed to be a ne strain like Avian Flu
(H5N1)
 It was simply another form of H1N1

It was supposed to be severe with high lethality
 It was severe in some populations, such as children
and pregnant women, but overall mortality only 0.20.4%

It was supposed to cause catastrophe
 Instead it caused confusion
Swine Flu
 High
mortality but limited spread
despite greater scare
 Total cases
63
 Deaths
10
 No cases in Hajjaj
Swine Flu
No effective strategy to stop the spread
 Only 1 Lab in Islamabad
 Virus transport Medium
 Expensive treatment

 10 x Tablets Tamiflu 75mg $125.00
 Vaccine $ 20/dose
Factors in our Armamentarium

Intellect and a Will
 Public health measures
 Biomedical research
 Technological advances

Human species uses its intellect and will
to contain, or at least strike a balance
with, microbial species that rely on
genes, replication and mutation
The Way Forward
Prevention is best as we cannot afford
to fight microbes through treatment
 Improved disease surveillance

 Community
 Hospitals

Increase Public Awareness
 In Schools
 Through Mass Media
 Health professionals
The Way Forward

Improvement in Public Health
 Improve waste management
 Supply of potable water
Institution of Antibiotic Policy
 Effective hospital infection control policy
 Greater Budgetary Allocation for health
 No room for complacency


The future of humanity and microbes
likely will unfold as episodes of a
suspense thriller that could be titled Our
Wits Versus Their Genes
Thank You
?