Major Diseases

The major diseases affecting children in Pakistan are as follows:

Diarrhoea

Diarrhoea remains a pervasive health concern for children, especially in regions with inadequate access to clean water and sanitation. It is a leading cause of morbidity and mortality in Pakistan, emphasising the importance of public health measures and interventions to address this preventable and treatable condition. In Pakistan, 74 children out of 1000 lose their lives annually due to diarrheal illness. This commentary addresses the contributing factors aggravating this growing dilemma and the effect of a simultaneous rise in COVID‐19 cases in a healthcare system ready to collapse, along with providing recommendations to alleviate the problems causing this spike in diarrheal cases.

In Pakistan, a country of over 225 million, 60% of infant and child deaths are caused by diarrhoea. Children under 5 comprise only 15% of the population, yet make up 50% of the mortality rate. These statistics do not reflect the true situation due to a lack of a functioning disease surveillance system, as well as inadequate data on births and deaths. However, Pakistan has the highest ratio in Asia for infant mortality from diarrhoea. The World Health Organization (WHO) has ranked Pakistan 23 in terms of childhood mortality caused by diarrheal illness, with almost 6.4 million cases of paediatric diarrhoea annually. Recently, diarrheal cases in the paediatric population have been on the rise throughout the country, with over 2000 children being admitted in the city of Lahore in just one month’s time. In the cities of Islamabad and Rawalpindi, hundreds of children are being admitted daily with bouts of acute viral diarrhoea. The situation is mimicked in Karachi, where hospitals are witnessing a surge in diarrheal cases, particularly among children between 3 months and 5 years.

Pneumonia

Pneumonia is a lung affecting inflammatory disease. It is characterised by fluid accumulation in the alveoli, which impedes regular breathing. Pneumonia is primarily but not exclusively caused by bacteria, viruses, and fungus. Streptococcus pneumoniae is the leading cause of bacterial pneumonia in children, whereas Haemophilus influenzae type b (Hib) is the second most common cause. In children, respiratory syncytial virus is the leading cause of viral pneumonia, while Pneumocystis jirovecii is the leading cause of fungus pneumonia. Globally, pneumonia is the leading cause of child mortality, particularly among children under the age of five.

There is an estimation that ten million patients of paediatric pneumonia are appearing every year and it is also a pertinent cause of mortality of under five year patients in our country, Pakistan. Pneumonia is responsible for higher than 920,000 mortality of children under five years in Pakistan making it among top 5 countries which are accountable for ninety nine percent paediatric patients.

Studies conducted earlier, have assessed the outcomes associated with above mentioned factors that demonstrate that, 51% of children in Pakistan were hospitalised for greater than five days, there was need of mechanical ventilation for 20.50% patients and 10.50% patients could not survive.

The number of children affected by Pneumonia in the Punjab region was reportedly 40 children aged between 1 month to 1 year, who died from pneumonia infections in Rawalpindi in 2024. This number surged to 66 within 22 days owing to harsh weather conditions.

Moreover ,younger children are more susceptible to pneumonia. At Benazir Bhutto General Hospital alone, from December 1, 2023, to January 21, 2024, the number of children diagnosed with pneumonia was 950. Of these, 40 lost their lives to the disease.

Malaria

Malaria is the fifth leading cause of mortality worldwide, killing hundreds of thousands of people, especially children under five and pregnant women . According to the WHO, Pakistan has 1.5 million malaria cases each year. Pakistan has been placed in the Eastern Mediterranean Region’s Group 3 countries, accounting for 95% of the overall regional malaria burden . Pakistan reduced case incidence by 40% or more in 2020 compared with 2015, according to the WHO 2021 report. However, Pakistan remained one of the top four countries responsible for the most anticipated malaria cases in the region (56%) in 2020 . In 2018, KP was the most malaria-affected province in Pakistan, followed by Balochistan (17%), the FATA region (19%), and Punjab (0.2%). Malaria cases differ substantially between regions and cannot be correctly analysed due to a lack of data. Because Pakistan experiences all four seasons with harsh climatic conditions, malaria parasitic species have an unequal distribution throughout the country, and their occurrence varies with the seasons . The examination of microscopic slides is routinely used for malaria diagnosis. The rapid diagnostic test is usually used in remote areas among migrant outbreaks and when microscopic detection is impossible. Based on the national malaria treatment guidelines, chloroquine plus primaquine is used as a treatment regimen for P. Vivax. 

Together with sulfadoxine/pyrimethamine, artesunate is recommended as the first-line treatment for P. falciparum after the withdrawal of chloroquine in 2007. However, from 2017 onward, artesunate lumefantrine has been recommended by the WHO as the drug of choice . Malaria control in Pakistan is difficult due to a lack of experienced health personnel, laboratory facilities, and appropriate drugs . Active and passive diagnostics can substantially reduce malaria incidence and prevalence.

Dengue Fever (DF)

 A population of more than 3 billion is at risk of getting this viral infection. Every year, Pakistan reports hundreds of cases of dengue fever. Most of the cases are reported from the southeast of the country. Since 2010, Pakistan has been affected by annual dengue outbreaks, which peak in the post monsoon season. According to the National Institute of Health, about 22 938 DF cases were reported in 2017. More than 3200 in 2018, 24 547 cases in 2019, and 3442 cases were reported in 2020. In 2021, a significant rise in cases was seen in Lahore and the twin cities (Rawalpindi and Islamabad), where the confirmed cases were reported to be 48 906.

Tuberculosis

In 2018, Pakistan recorded 47,804 cases of tuberculosis (TB) among children aged 0-15, marking a 7.7% increase from the previous year and coming close to the UN HLM TB target for children, set at 48,600 for 2018. Sindh, contributing 45% to this rise, reported 13,352 children with TB in 2018, reflecting a 13% surge from 2017. Surprisingly, Punjab, with 60% of Pakistan’s population, was anticipated to be the main contributor to TB notifications but only accounted for 7% of child TB cases in 2018.

Fast forward to 2021, where Pakistan witnessed 81,000 children developing TB, joining the global statistic of 1.1 million children affected by the disease. The factors driving TB in Pakistani children include persistently high levels of chronic and acute malnutrition, affecting over 10 million stunted children. Malnourished children with TB face elevated mortality risks. HIV exacerbates the situation, being a significant contributor, especially in TB endemic settings, where TB stands as the leading cause of death among children living with HIV (CLHIV). Notably, an HIV outbreak in the Larkana district of Sindh in April 2019 resulted from unsafe injection practices.

Despite these alarming figures, nearly 40% of people affected by TB in Pakistan go undiagnosed each year. Guidelines recommend screening household contacts; however, not all index patients or contacts meet the eligibility criteria. Consequently, many potential TB cases among contacts remain uninvestigated. Managing TB in children under 15 remains challenging due to nonspecific symptoms and complicated diagnoses. Despite advancements in TB diagnosis, no diagnostic tool has proven sufficiently sensitive and also related specifically  for childhood TB diagnosis. 

In resource-constrained countries like Pakistan, diagnosis primarily relies on a history of contact with a TB case, alongside clinical and radiological findings, often without microbiological confirmation. Compounding the diagnostic challenges is the underreporting by private healthcare providers (Non-NTP private providers), with estimates suggesting that 78% of childhood TB cases are not reported to the National TB Control Program (NTP) by these providers.

Pakistan’s fight against tuberculosis is not new, but the revelation of paediatric TB’s increasing in­cidence presents a new dimension. Children rep­resent a substantial 10-15% of total TB cases in the country, an estimated 57,000 children, (rang­ing from 51,000 to 63,000), with around 27,232 cases in Punjab. Even more distressing is the fact that children below 5 years of age are particular­ly vulnerable, constituting 8-20% of TB-related deaths.

Insulin/Type 1 Diabetes

Insulin-related issues in children, particularly the autoimmune destruction of beta cells leading to type 1 diabetes, are marked by the presence of autoantibodies against insulin and other pancreatic antigens. The disease often manifests during childhood, necessitating precise insulin dosing and continuous glucose monitoring to maintain glycemic control and prevent complications. Moreover, insulin resistance in children, associated with conditions like obesity, involves impaired cellular response to insulin signalling pathways, contributing to metabolic dysregulation. 

Around 100,000 children are estimated to have type 1 Diabetes in Pakistan who need insulin for the rest of their lives to live a normal and healthy life. Of these children having type 1 Diabetes in Pakistan, many are not diagnosed timely and die within a few days of the onset of the disease. As per a report from the International Diabetic Federation (IDF) ranking the world’s top countries for number of adults (20–79 years) with diabetes in 2021 has put Pakistan in third place with a total of 33 million, after China and India. The IDF ranked Pakistan first place for having the highest comparative diabetes prevalence rate in 2021 at 30.8%, followed by French Polynesia (25.2%) and Kuwait (24.9%)

Measles

Measles is an infectious disease attributed to a viral pathogen, specifically the paramyxovirus family. It is transmitted through both airborne particles and direct personal contact.In Pakistan, there have been 1978 confirmed cases of measles as of the month of November 2019. This number rose to 8500 in 2020 and suddenly spiked to 17,000 in 2021. The estimated number of new cases between November 2022 and April 2023 is 6426. 

Diabetes

Furthermore,  11 million adults in Pakistan have Impaired Glucose Tolerance (IGT), which puts them at higher risk of developing type-2 diabetes.The report noted that more than a quarter (26.9%) of adults living with diabetes in Pakistan are undiagnosed. Moreover,  Pakistan Medical Association (PMA), attributed the country’s decreasing health budget, has forced public hospitals to shut down a wide array of healthcare services, including those for treating diabetes. 

In the past year, diabetes health care and medicine, including insulin, used to be more affordable.  However, costs in  the last four years have skyrocketed, steering away patients.Diabetes medicine and insulin cost between 2,000 rupees ($11) and 7,000 rupees in Pakistan.However, with  the majority live on less than $3 a day, access to  proper treatment becomes increasingly challenging. Only a few hospitals in Sindh province provide free medicine making it further difficult as 22% of Pakistan’s population live below the national poverty line, according to the latest available data from the World Bank.

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