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Pakistan-US Science and Technology Cooperation Program                                                            
Phase 4 (2009 Deadline)

 NIH-KIU Health Interventions Project Street View
Village of Oshikhandass (photo courtesy of Ms. Elizabeth Thomas)

Water, Sanitation, Health, and Hygiene Interventions in a Northern Pakistani Village

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)
Project Overview
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.

Quarterly Update

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.

Progress Reports

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