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The National Academies
500 5th St NW - KWS 502
Washington, DC 20001
Tel: (202) 334-2800
Fax: (202) 334-2139
Phase 4 (2009 Deadline)
Water, Sanitation, Health, and Hygiene Interventions in a Northern Pakistani Village
Village of Oshikhandass (photo courtesy of Ms. Elizabeth Thomas)
Mark Miller and Zeba Rasmussen, National Institutes of Health, Fogarty International Center (FIC)
Khalil Ahmad, Karakoram International University, Gilgit
Pakistani Funding (HEC): $138,019.90
US Funding (Department of State): $146,372
Project Dates: November 15, 2010 - November 14, 2013 (Extended through March 31, 2014)
Diarrheal disease and pneumonia are major causes of morbidity and mortality in children worldwide. Interventions to decrease these have focused on water and sanitation, vaccines, and handwashing. Interventions for water and sanitation must be specific to local ecological niches and water delivery and source management. In the Pakistani region of Gilgit-Baltitstan, water is primarily obtained from glacier melt, and sanitation facilities include the use of traditional latrines, the contents of which are used as agricultural manure. It is necessary to determine the extent of benefit obtained from specific interventions made to improve water quality and sanitation and whether use of latrine contents is perpetuating a cycle of parasitic infestation and diarrheal disease. A unique opportunity exists to evaluate such interventions in the village of Oshikhandass, where extensive surveillance of more than 1,800 children under age 5 was carried out from 1989-1996. Water treatment plants were introduced in this area in 1996 and 2001 and new latrines in 2003. These circumstances also provide an opportunity to assess how early childhood diarrhea and pneumonia have affected subsequent growth and academic achievement 15-20 years later. This project has the potential to influence and inform policy and program decision making about long-term disease-control investments, and it can be instructive in terms of how health, water, and sanitation interventions can improve quality of life. Working on the project in cooperation with US partners will also improve training and research capabilities at the Karakoram International University (KIU) and will promote linkages with other educational and healthcare institutions, including University of the Punjab and Aga Khan University (AKU). A new cadre of younger women will also be involved in the project, training a new generation in public health work. In addition to capacity building at KIU and the public health force in Gilgit, this effort should also help to enhance the skills of microbiological lab technicians at the District Hospital of Gilgit. The Pakistani principal investigator on this study will continue to serve the local health infrastructure in this regard and train students in the basic skills of outbreak investigation, which should provide excellent preparation in case of future emergency preparedness situations such as disease outbreaks.
Project staff, in the U.S. and in Pakistan, continues their weekly calls to share project updates, discuss potential issues, and discuss next steps on this complicated project. During the past six months, all the IRB renewal documents were submitted and approved by AKU’s Ethical Review Committee on the Pakistani side, and by NIH’s IRB on the US side. A no cost extension request was approved and the project will remain active through March 31, 2014. The project budget was revised for additional personnel (three data collectors and a medical school graduate) to join, to acquire needed field equipment (Sofia analyzer), and to apply the modified field protocols.
In the field, Nasopharyngeal (NP) samples from children with WHO-defined pneumonia are now tested with the new Quidel Sofia® rapid test analyzer, which is more sensitive and specific, and requires fewer NP swabs per child. Field Coordinator, Ms. Assis Jahan, continued to work with Oshikhandass Lady Health Workers (LHWs) and Research Workers (RWs) to treat children and collect data and samples for analysis. From October 2012 through September 2013, there were a total of 503 diarrhea cases among children under 5 in the village. Since July 2013, an attempt has been made to obtain stool samples from children with diarrhea and control children. One hundred and five samples from children with diarrhea have been collected; most mothers are not willing to collect samples from children who do not have diarrhea so only four samples have been obtained from controls. As to following up with young adults in the original 1989-1996 study, field Supervisor, Mr. Wasiat Hasan Shah, and the entire field team have made great progress. To date, 839 (79%) of the 1,060 young adults in Oshikhandass have been interviewed. Data on medical history is collected for all individuals in Oshikhandass. For young adults live in other cities in Pakistan, approximately 78 (42%) of the 185 young adults in Karachi, 68 (44%) of the 154 young adults living in Islamabad and 19 (63%) of the 30 young adults in Lahore have been interviewed. US PI, Dr. Zeba Rasmussen, and Research Associate, Ms. Julia Baker (funded by a separate source), traveled to Gilgit in June to meet and work with the field and data teams.
During the past six months, several database were completed. Data team at KIU made substantial progress with data entry and cleaning. In the meantime, microbiological sampling at the field site is ongoing. M. Phil. students, Mr. Syed Arif and Mr. Imran, collected samples from the contents of latrines and samples from the soil and vegetation on which the latrine contents were used. Additional fund was received from the Department of Health and Human Services' Office of Global Affairs International Influenza Unit to support respiratory disease surveillance in the WSHHI project. Linkages were also formed with the Pakistan National Institutes of Health, located in Islamabad.
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2011 Show summary || Hide summary || Download full report
The leaders of this project have worked very hard to address the many budgetary, logistical, and administrative issues that have arisen in the course of launching such a complex activity, and their efforts are paying off now that the planned field work has begun. The team hired two well-qualified young Pakistanis from Karachi who had recently finished Master’s programs in London. After receiving training at the site of another NIH-supported project based in Sindh Province, they arrived in Gilgit in early July 2011 to begin work as epidemiological and training supervisors on this project. Dr. Zeba Rasmussen began a five-week visit to Pakistan on July 1, and in mid-July she was joined in Gilgit by a research assistant from FIC, Elizabeth Thomas. A major achievement during the visit was securing verbal permission from the Gilgit-Baltistan health authorities for lady health workers (LHWs) under their supervision to participate in the study. A geographer from AKU who carried out the mapping in the previous 1989 study re-mapped Oshikhandass village from July through September 2011, finding that the number of family units had more than doubled in the 22 years since the first study was completed. With the mapping finished and nine LHWs trained, data collection efforts began in November 2011. Additional staff are also being hired and trained.
2012 Show summary || Hide summary || Download full report
The leaders of this project have worked very hard to address the many budgetary, logistical, and administrative issues that have arisen in the course of launching such a complex activity, but despite all the difficulties and challenges the project team has made significant progress. The manual mapping an GPS coordinates of households in the village were completed as of early October 2011, and the results have been entered into a database. Lady Health Workers (LHWs) and their assistants have been trained on survey instruments they would be using and on basic principles from the World Health Organization's procedures on Integrated Management of Neonatal and Childhood Illness, and data collection efforts began in November 2011. Field work, including field testing of forms, surveillance, and the finalization of treatment plans, has been proceeding gradually since then, and as of March 2012 more than 700 children under age 5 had been enrolled in the study.
A new laminar flow cabinet has arrived in Gilgit, and it will be installed once a separate isolated lab is set up at KIU. In addition to its public health aspects, the project is helping to support two master's degree candidates as they pursue their studies at KIU. One student has been collecting weekly water samples since October 2011 as part of research for her thesis on analysis of drinking water near Oshikhandass village. The other student, whose thesis will focus on the impact of traditional pit latrines on the health of village residents, has been collecting samples from latrine sites and analyzing them with regard to various physical and microbiological parameters. The students had papers on their work accepted for presentation at the 32nd Pakistan Congress of Zoology, held in March 2012 at GC College, Lahore, and although they were unable to present their work in person, the papers have been published in the conference proceedings.
FIC research assistant Elizabeth Thomas made another visit to Gilgit in March 2012, during which she worked with AKU co-PI Iqbal Azam and newly hired Gilgit field staff to organize previously collected data and plan for upcoming surveillance work. Although their progress was delayed somewhat by security issues in Gilgit in April, the team is continuing its work.
While in Pakistan in April, FIC team members Elizabeth Thomas and Faran Sikandar met with staff from the National Acute Respiratory Infection (ARI) Research Cell to discuss pneumonia surveillance tools and treatment protocols. Later in the month, Mr. Sikandar visited Karachi to work with project statisticians Mr. Iqbal Azam and Ms. Saba Wasim at AKU and receive training in basic statistical analysis and test administration. Due to sectarian violence in Gilgit in April, working hours were reduced at KIU in April and May, but as conditions permitted field coordinator Assis Jahan continued to enroll children in the study and supervise ongoing data collection. By the end of June, 775 children under age 5 were enrolled in the study. Mr. Sikander received further training when he visited the field site of another project of the Fogarty International Center in Naushero Feroze in early June. Later that month, Dr. Zeba Rasmussen traveled to Pakistan, where she met with Dr. Tabish Hazir of the ARI Research Cell to discuss improvements to the pneumonia component of her project. On June 29, Dr. Rasmussen, Ms. Wasim, and Mr. Sikandar traveled to Gilgit, accompanied by Dr. Aysha Zahidie, Community Medicine Resident at AKU. The visiting team was joined on July 10 by Senior Statistician Iqbal Azam. Together they worked to refine surveillance and data collection procedures and provided training on data entry.
Dr. Rasmussen (second from left in the top row) and Ms. Elizabeth Thomas of FIC (right in the top row) with the LHWs team. (photo courtesy of Ms. Elizabeth Thomas.)
Two new field supervisors, Mr. Ejaz Hussain and Mr. Wasiat Hasan Shah, have been recruited to work on the project beginning in mid-July. Meanwhile, Ms. Saira Baig, the KIU BSc honors student who had been collecting and analyzing water samples on the project, has successfully defended her thesis and graduated. A new student has been identified to work with the water samples, while the student who has been working with microbiological samples is continuing his work. Dr. Ahmed and his colleagues have determined that a pre-fabricated laboratory is badly needed at the KIU campus to safely house the new equipment that is planned for acquisition. Therefore, the team has submitted a plan and a preliminary budget for the lab, and in the coming months they will move forward with construction. The new equipment, primarily including an ELISA machine, will be ordered and installed once the lab space is completed and certified as adequate by the KIU authorities.
Weekly teleconference meetings will continue between FIC, KIU, and AKU project team members as field work continues during the busy summer season. The Socioeconomic and Environmental Survey will be initiated, other data collection will continue, and further training on pneumonia surveillance practices will be conducted for lady health workers and researcher workers. KIU is also recruiting an additional data entry operator to accelerate progress on the project. In addition to their other duties, the two new field supervisors will be helping to translate the project data collection forms into two of the local languages (Burushaski and Shina).
2013 Show summary || Hide summary || Download full report
Project staff, in the U.S. and in Pakistan, continues their weekly calls to share project updates, discuss potential issues, and discuss next steps on this complicated project. Following an NIH IRB approval for a revised protocol to include nasopharyngeal swab sampling from children with influenza-like-illness (ILI) and children without pneumonia/ILI, collection of these samples began in January – March. Research Associate, Mr. Faran Sikandar, has continued following-up on young adults outside of Oshikhandass, the study area. With assistance from a community group in Karachi (TOISWO), he has been able to identify and connect with individuals for follow-up. On January 13, he and Dr. Ayesha Zahidie, of the AKU Department of Community Health Sciences, presented to TOISWO on the WSHHI project. Approximately 150 individuals attended the presentation, including young adults for follow-up and many older adults. In mid-February, data collection on family health status began for households without children under 5 years of age. As of the end of March, over 82% of data collection on socioeconomic and environmental information among households in the village was complete and more than 80% of mothers in the village were surveyed on their knowledge of health and hygiene. Data management is ongoing for other field data collected. On the laboratory side, an ELISA machine was purchased for the KIU lab and delivery is anticipated in the coming weeks. While in early March, a contract was signed at KIU to build a pre-fabricated laboratory.
During this reporting period, the project faced a number of challenges. An equipment used for rapid testing of respiratory samples (Sofia Analyzer) did not initially function properly due to cold winter temperatures and limited electricity required use of batteries which were not readily available in Gilgit. Ultimately, the analyzer was used in homes warmed by fire or in the field office with a heater and large quantities of batteries were purchased in Karachi and sent to the field site. Scheduling interviews of young adult subjects outside of Oshikhandass has been challenging due to reluctance of the subjects and unavailability. In addition the researchers reported that finding children without ARI to serve as controls during the peak pneumonia season has been especially challenging requiring broadening search criteria to include nearby areas. Several abstracts were prepared and submitted to conferences in February-March. Ms. Saira Baig, a BS Honors student at KIU working with PI Dr. Khalil Ahmed, submitted an abstract to APHA describing physical and microbiological analysis of drinking water samples from the village. The team submitted an abstract to APHA describing demographic and basic water/sanitation changes that have occurred in the village from the original study (1989-1996) to the current study period. M.Phil students at KIU, Syed Arif Hussain and Raja Imran, under guidance of the Pakistani PI, submitted two abstracts to the Pakistan Congress of Zoology of results from soil samples and gastrointestinal parasites in pit latrine samples.
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