Epidemics In Pakistan Essay

Pakistan as a developing country is struggling in many fields in which the health system has suffered a lot, resulting in a 122 rank out of 190 countries in a World Health Organization performance report.[1] Pakistan per capita income (PPP current international $, 2013) is 5,041[2] and the total expenditure on health per capita (intl $, 2014) is 129, which is only 2.6% of GDP (2014).[3] The gender inequality in Pakistan is 0.536 and ranks the country 147 out of 188 countries (2004).[4] The total adult literacy rate in Pakistan is 55% (2014) and primary school enrolment is 73%.[5] Life expectancy at birth is 66 years (Male 65, female 67),[6] which is the lowest in comparison to south Asian countries.[7] The proportion of population which has access to improved drinking water and sanitation is 91% (2015) and 64% (15) respectively.[6]

Health infrastructure[edit]

Main article: Healthcare in Pakistan

The health care delivery system includes both state and non-state; and profit and not for profit service provision. The provincial and district health departments, para-statal organizations, social security institutions, non-governmental organizations (NGOs) and private sector finance and provide services mostly through vertically managed disease-specific mechanisms. The country’s health sector is also marked by urban-rural disparities in healthcare delivery and an imbalance in the health workforce, with insufficient health managers, nurses, paramedics and skilled birth attendants in the peripheral areas.[8]

Health status[edit]

Communicable diseases

Communicable diseases have always been the prime cause of mortalities in Pakistan. The reason for the rapid spread of these diseases include overcrowded cities, unsafe drinking water, inadequate sanitation, poor socioeconomic conditions, low health awareness and inadequate vaccination coverage. The epidemic of these diseases is also observed during conflict.

Pakistan is one out of two countries where polio endemic exists (10) and the prevalence of tuberculosis (270 per 100000), malaria and HIV is 12.8 per 1000 and 0.2 per 1000[9]

  • Acute respiratory infection (51%): Among the victims of ARI, most vulnerable are children whose immune systems have been weakened by malnutrition. In 1990, National ARI Control Programme was started in order to reduce the mortality concerned with pneumonia and other respiratory diseases. In following three years, death rates among victims under age of five in Islamabad had been reduced to half.[10] In 2006, there were 16,056,000 reported cases of ARI, out of which 25.6% were children under age of five.
  • Viral hepatitis (7.5%): Viral Hepatitis, particularly that caused by types B and C are major epidemics in Pakistan with nearly 12 million individuals infected with either of the virus. The main cause remains massive overuse of therapeutic injections and reuse of syringes during these injections in the private sector healthcare.
  • Malaria (16%): It is a problem faced by the lower-class people in Pakistan. The unsanitary conditions and stagnant water bodies in the rural areas and city slums provide excellent breeding grounds for mosquitoes. Use of nets and mosquito repellents is becoming more common. A programme initiated by the government aims to bring down malarial incidence below 0.01% by the year 2011. In Pakistan, malarial incidence reaches its peak in September. 1000 million people have died from Malaria since Pakistan came into being till December 2012.[11] In 2006, there were around 4,390,000 new reported cases of fever.
  • Diarrhea (15%): There were around 4,500,000 reported cases in 2006, 14% of which were children under the age of five.
  • Dysentery (8%) and Scabies (7%)
  • Others: goitre, hepatitis and tuberculosis

Noncommunicable diseases

Non-communicable diseases such as cardiovascular problems, diabetes, cancer and coronary heart disease share 20.5% the burden of diseases and 2.5% are disabled. Pakistan has a high prevalence of blindness, with nearly 1% by WHO criteria for visual impairment – mainly due to cataract. Disability from blindness profoundly affects poverty, education and overall quality of life.[12]

Controllable diseases[edit]

  • Cholera: As of 2006, there were a total of 4,610 cases of suspected cholera. However, the floods of 2010 suggested that cholera transmission may be more prevalent than previously understood. Furthermore, research from the Aga Khan University suggests that cholera may account for a quarter of all childhood diarrhea in some parts of rural Sindh.
  • Dengue fever: An outbreak of dengue fever occurred in October 2006 in Pakistan. Several deaths occurred due to misdiagnosis, late treatment and lack of awareness in the local population. But overall, steps were taken to kill vectors for the fever and the disease was controlled later, with minimal casualties.
  • Measles: As of 2008, there were a total of 441 reported cases of measles in Pakistan.
  • Meningococcal meningitis: As of 2006, there were a total of 724 suspected cases of Meningococcal meningitis.

Poliomyelitis[edit]

Main article: Poliomyelitis in Pakistan

Pakistan is one of the few countries in which poliomyelitis has not been eradicated. As of 2008, there were a total of 89 reported cases of polio in Pakistan.[13] Polio cases may be on an increase. The year 2010 saw an increase in the number of cases as well as identification of polio from new locations. Experts from the national program and the WHO felt that the new cases identified from southern Punjab and northern Sindh may have resulted from importation of infections from other locations in Pakistan. Locations in FATA and Khyber Pakhtunkhwa remain hosts for year-round persistence of infection and environmental sampling by the national program, and WHO suggests that polio remains endemic in many other parts of the country.

HIV/AIDS[edit]

Main article: HIV/AIDS in Pakistan

The AIDS epidemic is well established and may even be expanding in Pakistan. Risk factors are high rates of commercial sex and non-marital sex,[14][15] high levels of therapeutic injections (often with non-sterile equipment),[16][17] and low use of condoms [18] The former National AIDS Control Programme (it was devolved with the Health Ministry) and the UNAIDS state that there are an estimated 97,000 HIV positive individuals in Pakistan. However, these figures are based on dated opinions and inaccurate assumptions; and are inconsistent with available national surveillance data which suggest that the overall number may closer to 40,000.[19]

Family planning[edit]

Main article: Family planning in Pakistan

"The government of Pakistan wants to stabilize the population (achieve zero growth rate) by 2020. And maximizing the usage of family planning methods is one of the pillars of the population program".[20] The latest Pakistan Demographic and Health Survey (PDHS) conducted by Macro International with partnership of National Institute of Population Studies (NIPS) registered family planning usage in Pakistan to be 30 percent. While this shows an overall increase from 12 percent in 1990-91 (PDHS 1990-91), 8% of these are users of traditional methods.[21]

Approximately 7 million women use any form of family planning and the number of urban family planning users have remained nearly static between 1990 and 2007. Since many contraception users are sterilized (38%), the actual number of women accessing any family planning services in a given year are closer to 3 million with over half buying either condoms or pills from stores directly. Government programs by either the Health or Population ministries together combine to reach less than 1 million users annually.[21] Thus, fertility remains high, at 4.1 births per woman. Owing to such high fertility levels, Pakistan's overall population growth rate is much higher than elsewhere in South Asia (1.9 percent per year).

Some of the main factors that account for this lack of progress with Family Planning include inadequate programs that don't meet the needs of women who desire family planning or counsel users of family planning about potential side effects, a lack of effective campaign to convince women and their families about the value of smaller families and the overall social mores of a society where women seldom control decisions about their own fertility or families. The single most important factor that has confounded efforts to promote family planning in Pakistan is the lack of consistent supply of commodities and services.[22]

The unmet need for contraception has remained high at around 25% of all married women of reproductive age (higher than the proportion that are using a modern contraceptive and twice as high as the number of women being served with family planning services in any given year[23]) and historically any attempt to supply commodities has been met with extremely rapid rise (over 10% per annum) in contraception users compared with the 0.5% increase in national CPR over the past 50 years.

Currently the government contributes about a third of all FP services and the private sector including NGOs the rest. Within the private sector, franchised clinics offer higher quality health care than unfranchised clinics but there is no discernible difference between costs per client and proportion of poorest clients across franchised and unfranchised private clinics.[24] Government programs are run by both the Ministries of Population Welfare and Health. The most common method used is female sterilization which accounts for over a third of all modern method users. Unfortunately this happens too late for most women as sterilized women are over 30 years of age and have 4 or more children. Condoms are the next most popular method.

Maternal and child health[edit]

The health system in Pakistan is influenced by several factors; communicable, non-communicable diseases, malnutrition in children and women and maternal and child morbidities. Pakistan ranks on no 22 in under 5 mortality rate accounting for 81 U5M (2015) per 1000 live births, whereas infant and neonatal mortalities per 1000 live births were 66 and 46. Maternal mortality ratio is also high at 178 per 100000 live births (2015) and only 52% births were attended by skilled worker.[25]

There is a huge imbalance in these figures. In Balochistan, for instance, the maternal mortality is 785 deaths per 100,000 live births which is nearly triple the national rate. It should be noted here that in rural Pakistan, maternal mortality is nearly twice than that in cities. The sad reality is that 80 per cent of maternal deaths are preventable.[26]

Nutrition[edit]

Nutritionally deprived children not only faces the difficulties in learning but also are at the prime risk of infections, and faces difficulty in combating and recovering from diseases. Whereas extreme nutritional deficiency in can have devastative effect on children such as stunting (45%), wasting (10.5%) and weight gain (4.8%).[25]

Obesity[edit]

Obesity is a health issue that has attracted concern only in the past few years. Urbanisation and an unhealthy, energy-dense diet (the high presence of oil and fats in Pakistani cooking), as well as changing lifestyles, are among the root causes contributing to obesity in the country. According to a list of the world's "fattest countries" published on Forbes, Pakistan is ranked 165 (out of 194 countries) in terms of its overweight population, with 22.2% of individuals over the age of 15 crossing the threshold of obesity.[27] This ratio roughly corresponds with other studies, which state one-in-four Pakistani adults as being overweight.[28][29]

Research indicates that people living in large cities in Pakistan are more exposed to the risks of obesity as compared to those in the rural countryside. Women also naturally have higher rates of obesity as compared to men. Pakistan also has the highest percentage of people with diabetes in South Asia.[30]

According to one study, "fat" is more dangerous for South Asians than for Caucasians because the fat tends to cling to organs like the liver instead of the skin.[31]

References[edit]

Infectious diseases in Pakistan by proportion (2006)
  1. ^"World Health Organization Report"(PDF). 
  2. ^"world bank". 
  3. ^"who". 
  4. ^"- Human Development Reports". 
  5. ^"unicef". 
  6. ^ ab"who". 
  7. ^"Life expectancy in South Asia 2010-2015 - Statistic". 
  8. ^"www.who.int"(PDF). 
  9. ^http://www.who.int/gho/publications/world_health_statistics/2016/en/. 
  10. ^"Pakistan acts to reduce child deaths from pneumonia". who.int. World Health Organization (WHO), International. Archived from the original on 13 April 2001. 
  11. ^"National Malaria Control Programme". Ministry of Health, Pakistan. Retrieved 7 September 2010. 
  12. ^"www.who.int"(PDF). 
  13. ^"Country Profiles (Pakistan)". World Health Organization. Retrieved 7 September 2010. 
  14. ^Migrant men: a priority for HIV control in Pakistan? Faisel A, Cleland J. Sex Transm Infect. 2006;82:307-310
  15. ^National AIDS Control Programme and Population Council of Pakistan. Study of Sexually Transmitted Infections: Survey of the Bridging Population. 2007 "Archived copy"(PDF). Archived from the original(PDF) on 11 November 2008. Retrieved 12 July 2008. 
  16. ^Pasha, O; Luby, SP; Khan, AJ; Shah, SA; McCormick, JB; Fisher-Hoch, SP (1999). "Household members of hepatitis C virus-infected people in Hafizabad, Pakistan: infection by injections from health care providers". Epidemiol Infect. 123: 515–518. doi:10.1017/s0950268899002770. 
  17. ^Khan, AJ; Luby, SP; Fikree, F; et al. (2000). "Unsafe injections and the transmission of hepatitis B and C in a periurban community in Pakistan". Bull World Health Organ. 78: 956–963. 
  18. ^National AIDS Control Programme and HIV/AIDS Surveillance Project. [HIV/AIDS Surveillance Project of Pakistan: Round 3. 2008]http://www.nacp.gov.pk/library/reports/HIV%20Second%20Generation%20Surveillance%20in%20Pakistan%20-%20National%20report%20Round%20III%20%202008.pdf.
  19. ^Burki, T (2008). "New government in Pakistan faces old challenges". Lancet Infect Dis. 8: 217–218. doi:10.1016/s1473-3099(08)70054-9.  and Shah, SA. Tropical Medicine Symposium, The Aga Khan University and the Royal Society of Tropical Medicine, 2008.
  20. ^http://www.mopw.gov.pk/event3.html Population Policy of Government of Pakistan
  21. ^ abhttp://resdev.org/Docs/01fpoverview.pdf Overview of Family Planning in Pakistan
  22. ^http://resdev.org/Docs/01fpservices.pdf Family Planning Services in Pakistan
  23. ^http://resdev.org/Docs/06umn.pdf What unmet need for family planning means in Pakistan
  24. ^Shah, Nirali; et al. (2011). "Comparing Private Sector Family Planning Services To Government And NGO Services In Ethiopia And Pakistan: How Do Social Franchises Compare Across Quality, Equity And Cost?". Health Policy Plan. 26 (Suppl 1): i63–i71. doi:10.1093/heapol/czr027. Retrieved 26 May 2012. 
  25. ^ ab"ww.who.int". 
  26. ^http://www.measuredhs.com/pubs/pub_details.cfm?ID=783&srchTp=advanced Pakistan Demographic and Health Survey 2006-07
  27. ^Streib, Lauren (2 August 2007). "World's Fattest Countries". Forbes. 
  28. ^"One in four adults is overweight or clinically obese". Gulf News. 17 December 2006. 
  29. ^Epidemic of obesity in Pakistan - one in four Pakistanis may be overweight or obese
  30. ^Nanan, D.J. "The Obesity Pandemic - Implications for Pakistan". Journal of Pakistan Medical Association. 
  31. ^"Fat is more dangerous for South Asians: Study - The Express Tribune". 29 July 2011. 

2012•03•13

Kouadio Koffi Isidore, Syed Aljunid, Taro Kamigaki, Karen Hammad and Hitoshi Oshitani

Flooding in Nowshera, Pakistan. Photo: UN Photo/WFP/Amjad Jamal

Beyond damaging and destroying physical infrastructure, natural disasters can lead to outbreaks of infectious disease. In this article, two UNU-IIGH researchers and colleagues review risk factors and potential infectious diseases resulting from the secondary effects of major natural disasters that occurred from 2000 to 2011, classify possible diseases, and give recommendations on prevention, control measures and primary healthcare delivery improvements.

♦ ♦ ♦

Over the past few decades, the incidence and magnitude of natural disasters has grown, resulting in substantial economic damages and affecting or killing millions of people. Recent disasters have shown that even the most developed countries are vulnerable to natural disasters, such as Hurricane Katrina in the United States in 2005 and the Great Eastern Japan Earthquake and tsunami in 2011. Global population growth, poverty, land shortages and urbanization in many countries have increased the number of people living in areas prone to natural disasters and multiplied the public health impacts.

Natural disasters can be split in three categories: hydro-meteorological disasters, geophysical disasters and geomorphologic disasters.

Hydro-meteorological disasters, like floods, are the most common (40 percent) natural disasters worldwide and are widely documented. The public health consequences of flooding are disease outbreaks mostly resulting from the displacement of people into overcrowded camps and cross-contamination of water sources with faecal material and toxic chemicals. Flooding also is usually followed by the proliferation of mosquitoes, resulting in an upsurgence of mosquito-borne diseases such as malaria. Documentation of disease outbreaks and the public health after-effects of tropical cyclones (hurricanes and typhoons) and tornadoes, however, is lacking.

Geophysical disasters are the second-most reported type of natural disaster, and earthquakes are the majority of disasters in this category. Outbreaks of infectious diseases may be reported when earthquake disasters result in substantial population displacement into unplanned and overcrowded shelters, with limited access to food and safe water. Disease outbreaks may also result from the destruction of water/sanitation systems and the degradation of sanitary conditions directly caused by the earthquake. Tsunamis are commonly associated with earthquakes, but can also be caused by powerful volcanic eruptions or underwater landslides. Although classified as geophysical disasters, they have a similar clinical and threat profile (water-related consequences) to that of tropical cyclones (e.g., typhoon or hurricane).

Geomorphologic disasters, such as avalanches and landslides, also are associated with infectious disease transmissions and outbreaks, but documentation is generally lacking.

After a natural disaster

The overwhelming majority of deaths immediately after a natural disaster are directly associated with blunt trauma, crush-related injuries and burn injuries. The risk of infectious disease outbreaks in the aftermath of natural disasters has usually been overemphasized by health officials and the media, leading to panic, confusion and sometimes to unnecessary public health activities.

The prolonged health impact of natural disasters on a community may be the consequence of the collapse of health facilities and healthcare systems, the disruption of surveillance and health programmes (immunization and vector control programmes), the limitation or destruction of farming activities (scarcity of food/food insecurity), or the interruption of ongoing treatments and use of unprescribed medications.

The risk factors for increased infectious diseases transmission and outbreaks are mainly associated with the after-effects of the disasters rather than to the primary disaster itself or to the corpses of those killed.  These after-effects include displacement of populations (internally displaced persons and refugees), environmental changes and increased vector breeding sites. Unplanned and overcrowded shelters, poor water and sanitation conditions, poor nutritional status or insufficient personal hygiene are often the case. Consequently, there are low levels of immunity to vaccine-preventable diseases, or insufficient vaccination coverage and limited access to health care services.

Phases of outbreak and classification of infectious disease

Infectious disease transmission or outbreaks may be seen days, weeks or even months after the onset of the disaster. Three clinical phases of natural disasters summarize the chronological public health effects on injured people and survivors:

  • Phase (1), the impact phase (lasting up to to 4 days), is usually the period when victims are extricated and initial treatment of disaster-related injuries is provided.
  • Phase (2), the post-impact phase (4 days to 4 weeks), is the period when the first waves of infectious diseases (air-borne, food-borne, and/or water-borne infections) might emerge.
  • Phase (3), the recovery phase (after 4 weeks), is the period when symptoms of victims who have contracted infections with long incubation periods or those with latent-type infections may become clinically apparent. During this period, infectious diseases that are already endemic in the area, as well as newly imported ones among the affected community, may grow into an epidemic.

It is common to see the international community, NGOs, volunteers, experts and the media leaving a disaster-affected zone usually within three months, when in reality basic sanitation facilities and access to basic hygiene may still be unavailable or worsen due to the economic burden of the disasters.

Although it is not possible to predict with accuracy which diseases will occur following certain types of disasters, diseases can be distinguished as either water-borne, air-borne/droplet or vector-borne diseases, and contamination from wounded injuries.

Diarrhoeal diseases

The most documented and commonly occurring diseases are water-borne diseases (diarrhoeal diseases and Leptospirosis). Diarrhoeal diseases cause over 40 percent of the deaths in disaster and refugee camp settings. Epidemics among victims are commonly related to polluted water sources (faecal contamination), or contamination of water during transportation and storage. Outbreaks have also been related to shared water containers and cooking pots, scarcity of soap and contaminated food, as well as pre-existing poor sanitary infrastructures, water supply and sewerage systems.

Diarrhoeal epidemics are frequently reported following natural disasters in developing countries. Floods are recurrent in many African countries, such as Mozambique, and usually lead to a significant increase in diarrhoeal disease incidences.

Following the 2005 earthquake in Pakistan, an estimated 42 percent increase in diarrhoeal infections was reported. In Iran, 1.6 percent of the 75,586 persons displaced by the Bam earthquake in 2003 were infected with diarrhoeal diseases. A rapid assessment conducted in Indonesia after the 2004 tsunami showed that 85 percent of the survivors in the town of Calang experienced diarrhoeal illness after drinking from contaminated wells. In Thailand, the 2004 Indian tsunami also contributed to a significant increase in diarrhoeal disease incidences.

An investigation conducted in 100 households after the 2001 earthquake in El Salvador showed that 137 persons out of 594 (22 percent) experienced diarrhoeal infections. An evolving cholera epidemic was reported 9 months after the earthquake in Haiti, with a high fatality rate of 6.4 percent among the victims (of the 4,722 documented affected, 303 died).

Only a small cluster of Norovirus cases was reported in evacuation centres some weeks after the Great Eastern Japanese Earthquake and tsunami, while various pathogens were confirmed among the populations displaced by Hurricanes Allison (2001) and Katrina in the US.

Leptospirosis, the other frequently occurring water-borne disease, can be transmitted through contact with contaminated water or food, or with soil containing contaminated urine (Leptospires) from infected animals (e.g., rodents). Floods facilitate the proliferation of rodents and the spread of Leptospires in a human community. Investigations conducted in populations affected by flood disasters in 2000 in India and Thailand reported Leptospirosis epidemics. Increased risk factors and outbreaks were also reported after Typhoon Nali in China and Taiwan in 2001.

The following table shows a breakdown of the occurrence of communicable diseases. (This is described in detail in the original paper, which is available for downloading in the the right sidebar.)

On the topic of outbreak and classification, one final note regarding the myth of infectious disease transmission from dead bodies: Still controversial and frequently overstated is the assumption that dead bodies pose a significant risk for the transmission of infectious diseases after a natural disaster. Despite the vast number of deaths resulting from major disasters, no outbreaks resulting from corpses have been documented. The environment in which pathogens live in a dead body can no longer sustain them, since the microorganisms involved in putrefaction (decay processes) are not disease causing. There are a few situations, such as deaths from cholera or hemorrhagic fever epidemics, that require specific precautions, but families should not be deprived of appropriate identification and burial ceremonies for their dead relatives from disasters. Survivors of disaster present a much more substantial reservoir for potential infectious diseases.

Prevention and control measures

We recommend re-establishing and improving the delivery of primary health care. Medical supply should be provided, and training of healthcare workers and medical personnel on appropriate case management should be conducted. Public health responders should set up a rapid disease risk assessment within the first week of the disaster in order to identify disaster impacts and health needs. Practically, prompt and adequate prevention and control measures, and appropriate case management and surveillance systems are essential for minimizing infectious disease burdens. The prevention and control checklist provided in our paper shows the measures to be undertaken in order to avoid infectious diseases following natural disasters.

Natural disasters and infectious disease outbreaks represent global challenges towards the achievement of the Millennium Development Goals. It is important for the public, policymakers and health officials to understand the concept that disaster does not transmit infectious diseases; that the primary cause of death in the aftermath of a disaster is non-infectious; that dead bodies (from disasters) are not a source of epidemic; and that infectious disease outbreaks result secondarily from exacerbation of disease risk factors.

National surveillance systems and the establishment of continual practices of protocol for health information management have to be strengthened. In disasters, education on hygiene and hand washing, and provision of an adequate quantity of safe water, sanitation facilities and appropriate shelter are very important for prevention of infectious diseases. The assessment and response activities described above should be properly coordinated.

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