Background Despite large reductions in under-5 lower respiratory infection (LRI) mortality in many locations, the pace of progress for LRIs has generally lagged behind that of other childhood infectious diseases. To better inform programmes and policies focused on preventing and treating LRIs, we assessed the contributions and patterns of risk factor attribution, intervention coverage, and sociodemographic development in 195 countries and territories by drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) LRI estimates. MethodsWe used four strategies to model LRI burden: the mortality due to LRIs was modelled using vital registration data, demographic surveillance data, and verbal autopsy data in a predictive ensemble modelling tool; the incidence of LRIs was modelled using population representative surveys, health-care utilisation data, and scientific literature in a compartmental meta-regression tool; the attribution of risk factors for LRI mortality was modelled in a counterfactual framework; and trends in LRI mortality were analysed applying changes in exposure to risk factors over time. In GBD, infectious disease mortality, including that due to LRI, is among HIV-negative individuals. We categorised locations based on their burden in 1990 to make comparisons in the changing burden between 1990 and 2017 and evaluate the relative percent change in mortality rate, incidence, and risk factor exposure to explain differences in the health loss associated with LRIs among children younger than 5 years.Findings In 2017, LRIs caused 808 920 deaths (95% uncertainty interval 747 286-873 591) in children younger than 5 years. Since 1990, there has been a substantial decrease in the number of deaths (from 2 337 538 to 808 920 deaths; 65·4% decrease, 61·5-68·5) and in mortality rate (from 362·7 deaths [330·1-392·0] per 100 000 children to 118·9 deaths [109·8-128·3] per 100 000 children; 67·2% decrease, 63·5-70·1). LRI incidence declined globally (32·4% decrease, 27·2-37·5). The percent change in under-5 mortality rate and incidence has varied across locations. Among the risk factors assessed in this study, those responsible for the greatest decrease in under-5 LRI mortality between 1990 and 2017 were increased coverage of vaccination against Haemophilus influenza type b (11·4% decrease, 0·0-24·5), increased pneumococcal vaccine coverage (6·3% decrease, 6·1-6·3), and reductions in household air pollution (8·4%, 6·8-9·2).Interpretation Our findings show that there have been substantial but uneven declines in LRI mortality among countries between 1990 and 2017. Although improvements in indicators of sociodemographic development could explain some of these trends, changes in exposure to modifiable risk factors are related to the rates of decline in LRI mortality. No single intervention would universally accelerate reductions in health loss associated with LRIs in all settings, but emphasising the most dominant risk factors, particularly in countries with high case fatality, can contribut...

Summary Background Many countries have shown marked declines in diarrhoeal disease mortality among children younger than 5 years. With this analysis, we provide updated results on diarrhoeal disease mortality among children younger than 5 years from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) and use the study’s comparative risk assessment to quantify trends and effects of risk factors, interventions, and broader sociodemographic development on mortality changes in 195 countries and territories from 1990 to 2017. Methods This analysis for GBD 2017 had three main components. Diarrhoea mortality was modelled using vital registration data, demographic surveillance data, and verbal autopsy data in a predictive, Bayesian, ensemble modelling tool; and the attribution of risk factors and interventions for diarrhoea were modelled in a counterfactual framework that combines modelled population-level prevalence of the exposure to each risk or intervention with the relative risk of diarrhoea given exposure to that factor. We assessed the relative and absolute change in diarrhoea mortality rate between 1990 and 2017, and used the change in risk factor exposure and sociodemographic status to explain differences in the trends of diarrhoea mortality among children younger than 5 years. Findings Diarrhoea was responsible for an estimated 533 768 deaths (95% uncertainty interval 477 162–593 145) among children younger than 5 years globally in 2017, a rate of 78·4 deaths (70·1–87·1) per 100 000 children. The diarrhoea mortality rate ranged between countries by over 685 deaths per 100 000 children. Diarrhoea mortality per 100 000 globally decreased by 69·6% (63·1–74·6) between 1990 and 2017. Among the risk factors considered in this study, those responsible for the largest declines in the diarrhoea mortality rate were reduction in exposure to unsafe sanitation (13·3% decrease, 11·2–15·5), childhood wasting (9·9% decrease, 9·6–10·2), and low use of oral rehydration solution (6·9% decrease, 4·8–8·4). Interpretation Diarrhoea mortality has declined substantially since 1990, although there are variations by country. Improvements in sociodemographic indicators might explain some of these trends, but changes in exposure to risk factors—particularly unsafe sanitation, childhood growth failure, and low use of oral rehydration solution—appear to be related to the relative and absolute rates of decline in diarrhoea mortality. Although the most effective interventions might vary by country or region, identifying and scaling up the interventions aimed at preventing and protecting against diarrhoea that have already reduced diarrhoea mortality could further avert many thousands of deaths due to this illness. Funding Bill & Melinda Gates Foundation.

Background On October 23, 2016, 79 dengue fever cases were reported from the Union Council Tarlai to Federal Disease Surveillance and Response Unit Islamabad. A team was established to investigate the suspected dengue outbreak. Objective The aim of this study was to determine the extent of the outbreak and identify the possible risk factors. Methods Active case finding was performed through a house-to-house survey. A case was defined as an acute onset of fever ≥38℃ in a resident of Tarlai from October 2 to November 11, 2016, with a positive dengue virus (nonstructural protein, NS-1) test and any of the two of following signs and symptoms: retroorbital/ocular pain, headache, rash, myalgia, arthralgia, and hemorrhagic manifestations. A structured questionnaire was used to collect data. Age- and sex-matched controls (1:1) were identified from residents in the same area as cases. Blood samples were taken and sent to the National Institute of Health for genotype identification. Results During the active case search, 145 cases of dengue fever were identified by surveying 928 houses from October 23 to November 11, 2016. The attack rate (AR) was 17.0/10,000. The mean age was 34.4 (SD 14.4) years. More than half of the cases were male (80/145, 55.2%). Among all cases, 29% belonged to the 25-34 years age group and the highest AR was found in the 35-44 years age group (35.6/10,000), followed by the 55-64 years age group (35.5/10,000). All five blood samples tested positive for NS-1 (genotype DENV-2). The most frequent presenting signs/symptoms were fever and headache (both 100%). Stagnant water around houses (odds ratio [OR] 4.86, 95% CI 2.94-8.01; P<.001), presence of flower pots in the home (OR 2.73, 95% CI 1.67-4.45; P<.001), and open water containers (OR 2.24, 95% CI 1.36-3.60; P<.001) showed higher odds among cases. Conversely, use of bed nets (OR 0.44, 95% CI 0.25-0.77; P=.003), insecticidal spray (OR 0.33, 95% CI 0.22-0.55; P<.001), door screens (OR 0.27, 95% CI 0.15-0.46; P<.001), mosquito coil/mat (OR 0.26, 95% CI 0.16-0.44; P<.001), and cleanliness of the house (OR 0.12, 95% CI 0.05-0.26; P<.001) showed significant protective effects. Conclusions Stagnant water acting as breeding grounds for vectors was identified as the probable cause of spread of the dengue outbreak. Establishment of surveillance and an early reporting system along with use of protective measures against the vector are strongly recommended.

Introduction: Serological surveys are valuable tools to evaluate the extent of disease transmission, measuring preventive effectiveness and proportion of asymptomatic individuals. This age-stratified, serological survey was aimed to measure the COVID-19 distribution and determinants in district Islamabad of Pakistan. Methodology: Three-stage cluster sampling, using population proportionate to size technique, starting with a random number was used. A structured, pretested questionnaire was used after taking informed written consent, to gather demographic, risk factor information. Results: Seroprevalence was found 16.5% (AR: 16.5%/100,000). The mean age was 35 (sd:16 Years). The majority were male (64%), self-employed (29%), and had primary level education (33%). The highest seroprevalence was found in the 21-30 years age group (24.8%) while the 41-50 years age group showed the highest attack rate (112.9/100,000 population). The proportion of the population tested that were asymptomatic was 69% (n=711) while the most frequently reported sign/symptom was cough (99%) followed by fever (20%). No known co-morbidity was reported in 86% (n=884) of respondents while hypertension remained the most reported condition (8%). High seroprevalence was observed in urban areas (12.3%) compared to rural union councils (6.4%). Visiting a house where COVID-19 case was isolated (OR 2, CI 1.38-2.84, P< 0.001), history of contact with a known case of COVID-19 (OR 1.42, CI 1.11-1.82, P=0.005), and attending a mass gathering (OR 1.21, CI: 1.02-1.42, p=0.02) were significant risk factors associated with contracting an infection. A Chi-Square test of independence showed significant protection while using regular hand hygiene practices (6.5; p<0.05) and regular usage of face masks (8.6; p<0.05). Conclusion: Seroprevalence gives a direct estimation of population groups exposed to the virus. A remarkable difference in prevalence is found in urban and rural areas, extreme age groups, and socioeconomic statuses, suggesting targeted public health interventions. Sero-studies are affordable counterparts of molecular testing where quick estimation, prevention effectiveness, and data-driven public health policies are priorities.

Introduction: COVID-19, a novel disease, appeared in December 2019 in China and rapidly spread across the world. Till the second week of April 2020, high incidence (2.9/100,000) and cases fatality rates (1.7%) were observed in Pakistan. This study was conducted to determine the temporal and spatial distribution of the first 100 deaths attributed to COVID-19 in Pakistan and their associated demographic factors. Method: We conducted a descriptive epidemiological analysis of the first 100 deaths reported among RT-PCR confirmed COVID-19 cases. Demographic, epidemiological, and risk factors information was obtained associated comorbidities and clinical signs and symptoms were recorded and frequencies were determined. Results: A total of 100 mortalities with overall Case Fatality Rate 1.67% (CFR) were analysed. Median age of patients was 64.5 years (IQR: 54-70) with 75% (n=75) Males. Among all deaths reported, 71 (71%) cases had one or more documented comorbidities at the time of diagnosis. Most frequently reported co-morbidities were; hypertension (67 %), followed by Diabetes Mellitus 945%) and Ischemic Heart Diseases (27%). First death was reported on 18 March 2020 and the most frequent presenting symptoms were shortness of breath (87%) and fever (79%). Median duration of illness was eight days (IQR: 4-11 days), the median delay reaching hospital to seek health care was three days (IQR: 0-6 days) while median duration of hospital stay was also three days (IQR: 1-7 days). Among all reported deaths, 62% were attributed to local transmission as these cases had no history of international travel. The most affected age group was 60-69 years while no death reported in age group below 20 years. Conclusion: High CFR among old age group and its association with co-morbidities (chronic disease) suggests targeted interventions such as social distancing and strict quarantine measure for elderly and morbid people. Comparative studies among deaths and recovered patients are recommended to explore further disease dynamics. Key words: COVID-19, Cases Fatality Rates, Co-morbidities, Epidemiology, Pakistan, Co-morbidities