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Population-based seroepidemiological surveys provide accurate estimates of disease burden. We compare the COVID-19 prevalence estimates from two serial serological surveys and the associated risk factors among women and children in a peri-urban area of Karachi, Pakistan.The AMANHI-COVID-19 study enrolled women and children between November 2020 and March 2021. Blood samples were collected from March to June 2021 (baseline) and September to December 2021 (follow-up) to test for anti-SARS-CoV-2 antibodies using ROCHE Elecsys®. Participants were visited or called weekly during the study for recording symptoms of COVID-19. We report the proportion of participants with anti-SARS-CoV-2 antibodies and symptoms in each survey and describe infection risk factors using step-wise binomial regression analysis.The adjusted seroprevalence among women was 45.3% (95% confidence interval (CI) = 42.6-47.9) and 82.3% (95% CI = 79.9-84.4) at baseline and follow-up survey, respectively. Among children, it was 18.4% (95% CI = 16.1-20.7) and 57.4% (95% CI = 54.3-60.3) at baseline and follow-up, respectively. Of the women who were previously seronegative, 404 (74.4%) tested positive at the follow-up survey, as did 365 (50.4%) previously seronegative children. There was a high proportion of asymptomatic infection. At baseline, being poorest and lacking access to safe drinking water lowered the risk of infection for both women (risk ratio (RR) = 0.8, 95% CI = 0.7-0.9 and RR = 1.2, 95% CI = 1.1-1.4, respectively) and children (RR = 0.7, 95% CI = 0.5-1.0 and RR = 1.4, 95% CI = 1.0-1.8, respectively). At the follow-up survey, the risk of infection was lower for underweight women and children (RR = 0.4, 95% CI = 0.3-0.7 and RR = 0.7, 95% CI = 0.5-0.8, respectively) and for women in the 30-39 years age group and children who were 24-36 months of age (RR = 0.6, 95% CI = 0.4-0.9 and RR = 0.7, 95% CI = 0.5-0.9, respectively). In both surveys, paternal employment was an important predictor of seropositivity among children (RR = 0.7, 95% CI = 0.6-0.9 and RR = 0.8, 95% CI = 0.7-1.0, respectively).There was a high rate of seroconversion among women and children. Infection was generally mild. Parental education plays an important role in protection of children from COVID-19.

In low- and middle-income countries (LMICs), women often use inappropriate materials to manage menstruation, which can threaten their health. Improper practices can also have critical downstream consequences beyond physiologic health, including restricting adolescent girls' access to academic pursuits.We used cross-sectional data collected through a structured questionnaire from the menstruating adolescents and young women 15-23 years of age living in rural Pakistan (n = 25 305). We aimed to describe menstrual hygiene management (MHM) practices and generate a predictive model of the socioeconomic and demographic factors related to the use of MHM materials. Beliefs and barriers around MHM were also summarized. The outcome variable included: those who practiced appropriate and inappropriate MHM practices. Logistic regression was used to generate the predictive model, with results presented as odds ratios (OR) and 95% confidence interval (CI).Inappropriate MHM practices were reported by 75% (n = 19 006) of participants. The majority 61.9% (n = 15 667) reported using old cloths, 12.6% (n = 3191) used nothing, and 0.5% (n = 136) used old cloth with a sanitary pad. One-fourth of participants reported appropriate MHM material use, including 16.2% (n = 4087) sanitary pads, 8.6% (n = 2167) new cloth, and a few reported using sanitary pads with new cloth 0.2% (n = 45). Inappropriate MHM practices were more common in lowest wealth quintile (OR = 4.41; 95% CI = 2.77-7.01, P 0.0001), followed by those with no education (OR = 3.9; 95% CI = 3.36-4.52, P 0.0001).The study indicates the need for multi-sectoral efforts to introduce MHM-specific and MHM-sensitive interventions to improve MHM practices, ranging from the availability of low-cost MHM materials to the inclusion of MHM education in school curriculums and within the community platforms.

Objective To evaluate the sensitivity of the modified Brief Form of Bruininks Oseretsky Test in identifying motor differences secondary to malnutrition and poverty. Methods This longitudinal cohort study was conducted at Nowshero Feroze, Sindh from 2013 to 2014 and comprised data drawn from children who participated in a randomised controlled trial, that assessed responsive stimulation and nutrition interventions in the first two years of life. Outcome measures included motor development assessed using Brief Form of Bruininks Oseretsky Test, child anthropometry and household economic and demographic information. Data was analysed using SPSS 15 and STATA 12. Results Of the 1058 children, 570(53%) were boys. Moderate-severe stunting was reported in 171(16.12%) subjects, while moderate-severe underweight was reported in 117(11.1%). Also, 591(56%) subjects belonged to poor families, 343(32%) had illiterate mothers, and 392(37%) were food-insecure. Malnutrition, socio-economic status and maternal literacy were significantly associated with a 6-item motor composite of the Brief Form of Bruininks Oseretsky Test (p Conclusions The 6-item motor composite of the Brief Form of Bruininks Oseretsky Test was found to be a reliable tool to measure motor performance in Pakistani pre-school children.

Background and aims To assess the psychometric properties of the Fear of COVID-19 (FCV–19S) scale and to determine its associated factors among the Pakistani patients with diabetes. Methods This observational study was conducted in 24-h helpline service, a department of Baqai Institute of Diabetology and Endocrinology (BIDE). Study duration was from August to September 2020. The target population was registered adult patients with type 2 diabetes aged >16 years. Baseline demographic details were obtained from hospital management system of BIDE. Forward-backward translation method was used to translate the existing Fear scale (FCV–19S). Symptoms of depressive disorder were assessed through Patient Health Questionnaire (PHQ9). Results Total of 380 participants with mean age 51.93 ± 12.03 years contributed in the study. Three factors loading and item correlation of fear COVID-19 explained 96% of total variance having unidimensional Cronbach’s alpha of 0.881. All demographic indicators that showed significance in univariate model were included in multivariate model. Females had more fear for COVID-19 compared to males (OR = 1.73, 95% CI (1.15–2.6)), whereas current smokers had also showed 4 times more fear than non-smokers (OR = 4.19, 95% CI (1.18–14.83). Depression assessed by PHQ9 showed maximum fear of COVID-19 in participants with moderate depression. Conclusion FCV-19S had adequate psychometric properties for assessing effects of pandemic in people with diabetes attending tertiary care center.

Culture-independent diagnostics have revealed a larger burden of Shigella among children in low-resource settings than previously recognized. We further characterized the epidemiology of Shigella in the first two years of life in a multisite birth cohort. We tested 41,405 diarrheal and monthly non-diarrheal stools from 1,715 children for Shigella by quantitative PCR. To assess risk factors, clinical factors related to age and culture positivity, and associations with inflammatory biomarkers, we used log-binomial regression with generalized estimating equations. The prevalence of Shigella varied from 4.9%-17.8% in non-diarrheal stools across sites, and the incidence of Shigella-attributable diarrhea was 31.8 cases (95% CI: 29.6, 34.2) per 100 child-years. The sensitivity of culture compared to qPCR was 6.6% and increased to 27.8% in Shigella-attributable dysentery. Shigella diarrhea episodes were more likely to be severe and less likely to be culture positive in younger children. Older age (RR: 1.75, 95% CI: 1.70, 1.81 per 6-month increase in age), unimproved sanitation (RR: 1.15, 95% CI: 1.03, 1.29), low maternal education (, Author summary Shigella is the second leading cause of diarrhea morbidity and mortality among children in low and middle-income countries. We characterized the epidemiology of Shigella using highly sensitive diagnostic methods in 41,405 diarrheal and monthly non-diarrheal stools from the first two years of life in a multisite birth cohort. The prevalence of Shigella varied from 4.9%-17.8% across sites, and the incidence of Shigella-attributable diarrhea was 31.8 cases (95% CI: 29.6, 34.2) per 100 child-years. Shigella diarrhea episodes were more likely to be severe and less likely to be culture positive in younger children. Older age, unimproved sanitation, low maternal education, initiating complementary foods before 3 months, and malnutrition were risk factors for Shigella. There was a linear dose-response between Shigella quantity and myeloperoxidase, a marker of intestinal inflammation, which suggests a potential mechanism for the impact of Shigella on child growth. Because culture missed most clinically relevant cases of severe diarrhea and dysentery, molecular diagnostics may be important tools in upcoming Shigella vaccine trials.

Tuberculosis (TB) in children represents a missed opportunity for diagnosis and preventive therapy. The magnitude or burden of disease in children is not fully understood due to our limitations with respect to exploring sensitive diagnostic algorithms. In a setting of TB endemicity in Pakistan, we carried out a proof-of-concept study to evaluate for the first time the performance of B cell analyses by the use of well-defined diagnostic criteria and NIH consensus guidelines as “culture-confirmed,” “probable,” and “possible” TB groups. In contrast to detection of serum antibody, we focused on mycobacterial-antibody-secreting cell (MASC) detection as a marker of active disease in children with a strong suspicion of TB. Further work exploring a larger panel of inflammatory biomarkers and enrichment of B cells with the objective of increasing the sensitivity of the current MASC assay would lead to the development of a field-friendly assay for timely diagnosis of childhood TB., Reliance on microbiologic methods to diagnose Mycobacterium tuberculosis infection is a suboptimal approach for children due in part to the paucibacillary nature of the disease. A blood-based biomarker assay, such as the mycobacterial-antibody-secreting cell (MASC) assay, could be a major advance for the field of study of pediatric tuberculosis (TB). Children

Low birthweight (LBW) remains a significant public health problem in Pakistan and further understanding of factors associated with LBW is required. We conducted a hospital-based matched case control study to identify risk factors associated with LBW in a rural district of Pakistan. We found that illiteracy (AOR: 2.68; 95% CI: 1.59 - 4.38), nulliparity (AOR: 1.82; 95% CI: 1.26-2.44), having a previous miscarriage/abortion (AOR: 1.22; 95% CI: 1.06-2.35), having2 antenatal care (ANC) visits during last pregnancy (AOR: 2.43; 95% CI: 1.34-2.88), seeking ANC in third trimester (AOR: 3.62; 95% CI : 2.14-5.03), non-use of iron folic acid during last pregnancy (AOR: 2.72; 95% CI: 1.75-3.17), having hypertension during last pregnancy (AOR: 1.42; 95% CI: 1.13-2.20), being anemic (AOR: 2.67; 95% CI: 1.65-5.24) and having postpartum weight of45 kg (AOR: 3.30; 95% CI : 1.97-4.52) were significantly associated with an increased odds of having a LBW baby. Our study identifies modifiable risk factors requiring immediate commitment from the health authorities.العوامل المرتبطة بانخفاض وزن المواليد في الحمل المكتمل: دراسة حالة ضابطة مقارنة من المناطق الريفية في باكستان.محمد عاطف حبيب، كميل رينز كرينوو، شبينة عارف، ساجد صوفي،عابد حسين، قمر جونجو، أمجد حسين، فريحه شاهين، كرستن بلاك.لا يزال انخفاض الوزن عند الولادة مشكلة صحية عامة كبرة في باكستان، ويلزم التوصل إلى فهم أعمق للعوامل المرتبطة بانخفاض الوزن عند الولادة. وقد أجرينا دراسة حالة ضابطة مقارنة في المستشفيات لتحديد عوامل الخطر المرتبطة بانخفاض الوزن عند الولادة في منطقة ريفية في باكستان. وتبنّ لنا أن الإلمام بالقراءة والكتابة (4.38–AOR: 2.68, %95 CI: 1.59)، وانعدام الحمل (2.44–AOR: 1.82, %95 CI: 1.26)، والتعرض لسقوط الحمل/الإجهاض في السابق (2.35 – AOR: 1.22, %95 CI: 1.06)، وإجراء أكثر من زيارتن لرعاية ما قبل الوضع خال الحمل الأخر (2.88 – AOR: 2.43, %95 CI: 1.34)، والسعي للحصول عى الرعاية ما قبل الوضع خال الثلث الثالث من الحمل (5.03 – AOR: 3.62, %95 CI: 2.14)، وعدم استخدام حمض الفوليك الحديدي خال الحمل الأخر (3.17 – AOR: 2.72, %95 CI: 1.75)، والإصابة بارتفاع ضغط الدم خال الحمل الأخر (2.20 – AOR: 1.42, %95 CI: 1.13)، والإصابة بفقر الدم (1.65 – AOR: 2.67, %95 CI: 5.24) ووصول الوزن بعد الولادة إلى أقل من 45 كغم (4.52 – AOR: 3.30, %95 CI: 1.97)، يرتبط ارتباطاً ذا دلالة بتزايد احتالات إنجاب طفل وزنه منخفض عند الولادة. وتحدِّد دراستنا عوامل الخطر القابلة للتعديل والتي تتطلب التزاماً فورياً من السلطات الصحية.Facteurs associés à une insuffisance pondérale à la naissance dans les cas de grossesses à terme : étude castémoins appariés au Pakistan rural.L’insuffisance pondérale à la naissance demeure un problème de santé publique significatif au Pakistan, et une compréhension approfondie des facteurs associés à ce problème est requise. Nous avons conduit une étude cas-témoins appariés en hôpital afin d’identifier les facteurs de risque associés à l’insuffisance pondérale à la naissance dans un district rural du Pakistan. Il est apparu que l'analphabétisme (OR ajusté : 2,68 ; IC de 95 % : 1,59-4,38), la nulliparité (OR ajusté : 1,82 ; IC de 95 % : 1,26-2,44), les antécédents de fausse couche ou d’avortement (OR ajusté : 1,22; IC de 95 % : 1,06-2,35), le fait d’avoir eu moins de deux visites de soins prénatals au cours de la dernière grossesse, (OR ajusté : 2,43 ; IC de 95 % : 1,34-2,88), de n’avoir recherché des soins prénatals qu’au troisième trimestre (OR ajusté : 3,62 ; IC de 95 % : 2,14-5,03), de ne pas avoir bénéficié d’une supplémentation en fer et en acide folique pendant la dernière grossesse (OR ajusté : 2,72 ; IC de 95 % : 1,75-3,17), d’avoir souffert d’hypertension durant la dernière grossesse (OR ajusté : 1,42 ; IC de 95 % : 1,13-2,20), d’anémie (OR ajusté : 2,67; IC de 95 % : 1,65-5,24) et d’avoir un poids post-partum de moins de 45 kg (OR ajusté : 3,30 ; IC de 95 % : 1,97-4,52) étaient significativement associés à des risques accrus d’avoir un bébé souffrant d'une insuffisance pondérale à la naisance. La présente étude a identifié les facteurs de risque modifiables nécessitant un engagement immédiat des autorités sanitaires.

Background The United Nation’s Sustainable Development Goals encompass lifelong learning from birth to youth to adulthood (Goal 4) and economic opportunities for young people (Goal 8). The targets include improving access to quality early childhood care and education (ECCE) as well as learning and training opportunities for adolescents and youth. Cross-generational models for young children and youth may offer opportunities to address the interconnections between goals and targets for the next generation. We investigated whether an ECCE programme for young children (3.5–6.5 years) delivered by female youth (18–24 years) in rural Pakistan would be effective on children’s school readiness. Methods In partnership with the National Commission for Human Development in Pakistan, we implemented the ‘Youth Leaders for Early Childhood Assuring Children are Prepared for School’ (LEAPS) programme to train female youth to deliver ECCE. The effectiveness of the LEAPS programme on children’s school readiness was evaluated in a cluster-randomised controlled trial. We randomly allocated five clusters (villages) to receive the intervention (n = 170 children) and five clusters to control (n = 170 children). Children’s school readiness was assessed after nine months of intervention exposure using the International Development and Early Learning Assessment tool. Analyses was by intention-to-treat. The trial is registered with ClinicalTrials.gov, number NCT02645162. Findings At endline, the intervention group had significantly higher school readiness scores (n = 166, mean percentage score 59.4, 95% CI 52.7 to 66.2) compared with the control group (n = 168, mean percentage score 45.5, 95% CI 38.8 to 52.3). The effect size (Cohen’s d) was 0.3. Conclusion Trained female youth delivered an ECCE programme that was effective in benefitting young children’s school readiness. The cross-generational model is a promising approach to support early child development; however, further evaluation of the model is needed to assess the specific benefits to youth including their skills and economic development.

Background Most congenital hypothyroidism (CH) is not avertable; however, the adverse effects of CH are preventable with early detection and treatment. It is a common congenital endocrine disorder that affects 1 in 2000-4000 newborns globally. The true incidence in Pakistan is unknown. Data from hospital studies quote an incidence of 1 in 1600-2000. The aim of this study was to uncover existing knowledge of CH and screening for the condition and to assess the impact of health education on mothers' knowledge and attitudes towards having their newborns screened. Methods The study was conducted from January 2012 to August 2013 at a local hospital in Karachi, Pakistan. This was a prospective, interventional cohort study implemented through a pre- and post-cross-sectional knowledge, attitudes and practices (KAP) survey. Interviews were conducted using structured questionnaires on CH. Results At baseline (pre-intervention survey), 400 participants consented and 355 (88.9%) completed the study. There was a significant increase in awareness among participating women following the intervention (20% to approximately 98%). Similarly, 78.9% agreed to opt for a screening test for their newborns following delivery as compared with 57.7% in the pre-intervention KAP survey (relative risk 1.38, p-value

a b s t r a c t Objective: To develop and evaluate a risk score to predict people at high risk of developing type 2 diabetes in Pakistan. Methodology: Cross sectional data regarding primary prevention of diabetes in Pakistan. Diabetes risk score was developed by using simple parameters namely age, waist circumference, and family history of diabetes. Odds ratios of the model were used to assign a score value for each variable and the diabetes risk score was calculated as the sum of those scores. Results: We externally validated the score using two data from 1264 subjects and 856 subjects aged 25 years and above from two separate studies respectively. Validating this score using the first data from the second screening study gave an area under the receive operator characteristics curve [AROC] of 0.758. A cut point of 4 had a sensitivity of 47.0% and specificity of 88% and in the second data AROC is 0.7 with 44% sensitivity and 89% specificity. Conclusions: A simple diabetes risk score, based on a set of variables can be used for the identification of high risk individuals for early intervention to delay or prevent type 2 diabetes in Pakistani population.

Aims To determine the diagnostic accuracy of direct ophthalmoscopy for the presence and severity of diabetic retinopathy (DR) using fundus photographs as a reference standard. Methods Patients with type 2 diabetes attending the outpatient department (OPD) of a tertiary care diabetes center, from October 2009 to March 2010 were recruited in the study after obtaining signed informed consent. Patients with type 1 diabetes and gestational diabetes or having eye problems were excluded. After checking visual acuity, direct ophthalmoscopy of each eye was done by diabetologist, followed by photography of two fields of retina by fundus camera. DR was graded by a retinal specialist, according to International Diabetic Retinopathy Disease Severity Scale. According to severity, patients with DR were grouped into non-sight threatening diabetic retinopathy (NSTDR) and sight threatening diabetic retinopathy (STDR). Sensitivity and specificity of direct ophthalmoscopy for detection of any retinopathy, NSTDR and STDR was calculated. Results A total of 728 eyes were examined by direct ophthalmoscopy as well as fundus photography. Sensitivity (95% CI) of direct ophthalmoscopy for any retinopathy, NSTDR and STDR was found to be 55.67% (50.58–60.78), 37.63% (32.67–42.59) and 68.25% (63.48–73.02) respectively. Whereas, specificity of direct ophthalmoscopy was found to be 76.78% (72.45–81.11), 71.27% (CI: 66.63–75.91) and 90.0% (86.93–93.07) for any retinopathy, NSTDR and STDR respectively. Conclusion The sensitivity and specificity of direct ophthalmoscopy performed by the diabetologist for the presence and severity of DR was lower compared to the recommended level of sensitivity and specificity of a screening test of DR.