Jalalpur Jattan Case Study
Jalalpur Jattan Case Study
Jalalpur Jattan Case Study
http:// www.elsevier.com/locate/jegh
a
Field Epidemiology and Laboratory Training Programme, NIH, Pakistan
b
Public Health Laboratories Division, National Institute of Health, Islamabad, Pakistan
c
Rawalpindi Medical College, Rawalpindi, Pakistan
d
National Blood Transfusion Programme, Government of Pakistan, Pakistan
e
Bacterial Special Pathogens Branch, Division of High-Consequence Pathogens & Pathology, NCEZID,
Centers for Disease Prevention and Control (CDC), Atlanta, USA
Received 1 April 2013; received in revised form 29 May 2013; accepted 4 June 2013
Available online 8 July 2013
* Corresponding author.
E-mail address: [email protected] (M. Salman).
2210-6006/$ - see front matter ª 2013 Ministry of Health, Saudi Arabia. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jegh.2013.06.001
262 J.A. Ansari et al.
risk factors. Extramarital sex was reported by 4 (9.4%). Only 19 (35.8%) were aware
that HIV can be sexually transmitted and 18 (34%) were aware of HIV transmission by
blood transfusion. Phylogenetic analysis revealed HIV infection in this group was
HIV-1 Subtype A, transmitted over a decade, and the situation is endemic rather
than an outbreak.
Conclusion: The investigation indicates high rates of HIV infection in JPJ. Unlike
other studies from Pakistan, a high proportion of cases in females and children less
than 10 years of age were observed. Socio-cultural norms and stigmatization limited
in-depth investigation of sexual and behavioral practices and history of drug abuse.
A shift of HIV infection from high-risk groups to the general population was seen and
requires vigilant surveillance besides targeted health education, clinical manage-
ment, lab facilities for diagnosis and monitoring, and voluntary counseling and test-
ing services to limit disease spread.
ª 2013 Ministry of Health, Saudi Arabia. Published by Elsevier Ltd. All rights reserved.
3.8. Line listing and GPS mapping 22.64%) and aged 1–10 years (n = 06, 11.32%).
The details are given in Table 1. Twenty eight
A line listing, which included information about (52.8%) females and 25 (47.2%) males were investi-
demographics, clinical and risk factor details was gated. Among those investigated, 27 (51%) were
prepared and reviewed by the investigation team diagnosed by NACP, while the remaining 26 (49%)
on a daily basis. Any missing information was inves- were already confirmed by other sources. Twelve
tigated and updated on a regular basis. Data were (22.6%) were undergoing or had a history of treat-
entered into a specially designed database in ment. As regards marital status, 40 (75.5%) were
Microsoft Access. The statistical analysis was done married, 12 (22.64%) were unmarried and 1
using Epi Info (version 3.5.1) and presented as pro- (1.88%) was widowed.
portions and percentages. A Global Positioning Sys- The GPS mapping of the cases revealed that the
tem (GPS) device (GPS 60, Gramin, USA) was used maximum number of HIV-infected persons investi-
for mapping of sites, including small streets, hospi- gated during the outbreak was clustered around
tals, private clinics and labs, drug shooting spots the Islampura (n = 17) area, New Noshehra
and other places of interest to identify the geo- (n = 11) area and Muwal (n = 6) area.
graphical clustering. Among the signs/symptoms studied, most of the
reactive cases had unexplained fever (n = 42,
4. Results 79.2%), diarrhea (n = 34, 64.15%), recurrent skin
infections (n = 27, 50.9%) and chest infections/RTI
A total of 53 HIV-infected persons were investi- (n = 13, 24.5%). History of co-infection with Hepati-
gated during the outbreak investigation. The distri- tis B and C viruses was reported by 10 HIV-infected
bution of these HIV-infected persons by the month persons (5 each for hepatitis B and C), while tuber-
in which they were tested reactive and their status culosis was present in 13 (24.5%) of the HIV-posi-
reported to the local health authority is shown in tive cases. The details are presented in Table 2.
Fig. 1. Out of the 53 HIV-infected persons investi- The most common risk factor for HIV infection
gated, 47 (88.7%) were alive and available for an was the history of injections (n = 51, 96.2%).
in-person interview, while interviews with family Forty-one cases (77.4%) frequently received injec-
members were conducted for the 6 deceased tions during medical visits while only 12 (22.6%) re-
individuals. ceived injections rarely. Twenty seven (96.4%)
The mean age of the subjects was 34.7 years female patients had a history of ear and nose pierc-
(range: 3–70 years), with a median age of 35 years. ing, out of which 17 (63%) had a history of ear/nose
The highest number of HIV infections was found in piercings carried out at home.
persons between the ages of 31 and 40 years Twenty-one (40%) of the cases interviewed had a
(n = 16; 30.20%) followed by those aged 21– history of dental procedures. Out of these, 12 (57%)
30 years (n = 13; 24.5%), aged 41–50 (n = 12, gave a history of visiting quacks (any medical
30
26
25
20
15 13
11
10
5
1 1 1
0 0 0 0 0
0
Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09
Table 1 Age wise distribution of HIV-reactive cases. Table 3 Frequency of risk factors and practices among
S. No Age group HIV-infected Percentage (%) investigated cases.
in years persons Risk factors/practices Frequency
number (%)
1 1–10 06 11.32
2 11–20 01 1.88 General
3 21–30 13 24.53 Injection in illness 51 (96.2)
4 31–40 16 30.20 Dentists/dental procedures 21 (39.6)
5 41–50 12 22.64 Surgery/surgical procedures 14 (26.4)
6 >50 5 9.43 Blood transfusion 8 (15.1)
Travel abroad 5 (9.5)
Tattoo marking 4 (7.5)
Extramarital sex 4 (7.5)
Table 2 Frequency of signs and symptoms of investi- Sharing of shaving razor 1 (1.9)
gated cases. Used IV drugs 1 (1.9)
S. No Signs/symptoms/co-infections Number (%) Sharing of tooth brush/miswak Nil
of the lack of clinical and demographical informa- matization. Another limitation was difficulty in
tion. Phylogenetic analysis of 10 of the 19 samples recalling events that happened far in the past.
was done using the envelope gene sequences by In 2004, 23% of injecting drug users and 4% of
pairwise distance calculation method using the male sex workers have been found to be positive
Kimura 2-parameter Nucleotide Model for genetic for HIV from Karachi. An outbreak of HIV/AIDS
distance evaluation. The results of the molecular was also reported from Larkana, Sindh, among
studies confirmed the presence of HIV 1 subtype injection drug users in July 2003, which may have
A in the current endemic in JPJ. The pairwise anal- provided a home-base for the virus in Pakistan. A
ysis also reveals that the average distance of the study done by Bokhari et al. predicted that the
tested viruses is 9% with a range of 6–13% with presence of high sero-prevalence of HIV among
an annual variation of 1%. high-risk groups together with unsafe medical
injections could be a source of HIV transmission
5. Discussion into the general population [14].
Even though HIV-infected persons described in
The report presented here describes the epidemio- this outbreak investigation are not representative
logical characteristics of 53 HIV-infected persons of the JPJ population, nearly equal male to female
identified in the outbreak investigation in JPJ, Guj- ratio is different from earlier data reported from
rat district, Pakistan. The investigation indicates Pakistan which showed male predominance [15].
the rise in HIV infections in the JPJ area and the Another important finding of this investigation
probable shift of infection from core (high-risk) was the high HIV positivity among children. Six
groups to the general population, which may re- (11.32%) of the HIV-infected persons in this group
quire further epidemiological studies. This may were children under 10 years of age.
also indicate that there has been a transition in The use of injections for illness by more than
transmission patterns as of the major urban cities 95% of the investigated cases was also a major find-
to the small rural towns of Pakistan which is alarm- ing while a significant proportion of investigated
ing since approximately 66% of the Pakistani popu- persons provided the history of invasive surgical
lation live in rural areas [9]. The virus also seems to and dental procedures in the past. These observa-
have now established a foothold, as evidenced by tions in the presence of poor sterilization practices
the sporadic HIV outbreaks among the injecting could have promoted the spread of HIV and other
drug user community. blood-borne viruses. Use of unsafe injection prac-
Pakistan remained relatively safe from indige- tices both in formal and non-formal health care
nous HIV infections for around two decades, and settings has been documented in Pakistan. Both pa-
most HIV infections were attributed to imported tientÕs and providerÕs preference for injections in
cases among HIV-positive Pakistani workers de- place of oral drugs has become a major public
ported from Middle Eastern countries in the early health concern in Pakistan [16].
1990s with little indication of indigenous transmis- There is also substantial evidence that a commu-
sion limited to high-risk groups. Previous research nity of intravenous drug users exists not only in the
suggests that between 70,000 and 120,000 IDUs affected areas of JPJ, but other areas of town as
and about 200,000 sex workers reside in Pakistan. well. The HIV prevalence remained very low in
Out of these, about 30–50% live in PakistanÕs larg- drug-using populations (0% to 2%) till 2003; however,
est cities [9]. The other factors contributing to among commercial sex workers and prisoners, the
the spread of HIV in Pakistan include the wide- seroprevalence rates have ranged from 0% to 1.8%.
spread presence and interlinking of IDUs and In 2003, however, an outbreak of HIV infection
high-risk sexual networks, mobility of high-risk among injection drug users (IDUs) in a prison located
populations, high volumes of migrant laborers outside of Karachi was reported, in which among 175
within and outside of Pakistan, increasing poverty prisoners tested, 17 (9.7%) were HIV-positive. In
and high illiteracy rates. This is the same pattern 2004, another outbreak of HIV among injection drug
that has been observed in several other Asian users was detected in Karachi, where 23% of IDUs
countries [10–13]. tested were HIV-positive [17]. The HIV prevalence
During the field investigation, intensive efforts rates among drug users in other regions of Pakistan
were undertaken to collect as much clinical, social, have not been studied; however, findings of this
behavioral and epidemiological information as pos- study further emphasize the need for a more fo-
sible; however, interviewed people were reluctant cused approach toward harm reduction in the IDUs.
to provide detailed sexual and drug abuse history In the past, contact investigations have been
because of socio-cultural norms and fears of stig- used as a tool for prevention of HIV and sexually
HIV/AIDS outbreak investigation in Jalalpur Jattan (JPJ), Gujrat, Pakistan 267
transmitted infections (STIs) [18,19]. The investi- therefore not known. There were reports of an-
gation team found this method also applicable to other brothel in the vicinity of the affected area,
this outbreak investigation as it can also be used whose CSWs came from JPJ and other parts of Pun-
to explore the epidemiology of HIV in high-risk pop- jab, and there are at least two known pick-up
ulations and areas, to provide personalized educa- points (commonly known as ‘‘lover points’’) which
tion, and to identify individuals who engage in have been identified as hot spots for promoting
high-risk behaviors [20]. pre- and extra-marital sexual practices, especially
In Pakistan, very limited information is available among young people.
on the prevalence of specific HIV genotypes. Based on the study findings, it was recom-
According to the study by Khan et al. HIV 1 subtype mended that a surveillance center needs to be
A was present in a community of intravenous drug established in the Gujrat district on a priority basis
users in Karachi [21]. The presence of cluster se- with the facilities to screen and offer VCT to screen
quences indicates that the HIV in this area may pregnant women, TB-positive patients, STD pa-
have a common ancestor when compared with tients and to carry-out the surveillance for perina-
other sequences in this analysis. The presence of tal HIV exposure. This area should be included in
a 1% variability rate per year in the env gene region the upcoming round of second generation surveil-
is very significant, and preliminary results indicate lance [23]. The HIV screening of blood before
that the samples tested were not directly linked. transfusion should be made mandatory. The need
This suggests that the introduction of HIV to this was also felt to raise the awareness among the res-
area was not recent and provides evidence of idents of JPJ; therefore it was recommended that
continuing transmission over the years. The same an intensive awareness campaign regarding health
has been seen in the famous Libyan HIV outbreak education and safe injection practices should be
involving foreign medical staff [22]. Although the launched and strengthened and focused on HIV/
analysis does not support the transmission of HIV AIDS. Condom promotion, diagnosis and treatment
among the individuals whose samples were tested of STIs and safer sex activity counseling should be
for phylogenetic testing, only 10 samples from given to HIV/AIDS patients, as well as IDUs should
JPJ were successfully tested for phylogenetic also be taken into consideration to limit the sexual
characteristics. transmission of HIV in JPJ [24]. To understand HIV
This outbreak demonstrates that there is a sig- transmission in the local context, it is recom-
nificant cause for concern regarding the spread of mended that a good cross-sectional study with an
HIV in the JPJ region. The information was col- analytical component to look for risk factors should
lected in 21 days through enhanced contact trac- be conducted.
ing. The spatial clustering of HIV-infected persons
is suggestive of HIV transmission primarily within 6. Conflict of interest
two geographically small areas of JPJ. A conclusive
source of the outbreak was difficult to be traced as None declared.
the transmission spread was over a decade. How-
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