Clinical and Epidemiological Studies of Oropharyngeal Candidiasis in Various Hospitals of Pakistan

Abstract

Oropharyngeal Candidiasis is one of the most rampant fungal infections in the developing countries, specifically resource lagging areas. In Pakistan about 3.2 million cases are being registered every year. The rate of fungal infections when compared with the aligning countries like India, Sri Lanka and Nepal, resulted in eye opening statistics. Still the exact prevalence of the fungal diseases in the Pakistan is difficult to predict due to various factors including unavailability of epidemiological data, im-presence of clinical laboratories with poor diagnosis of fungal infections, emergence of antibiotic resistance, strained access of public to the health care units. Usually, neonates between the age of 0-4 years are prime victim of the Oropharyngeal Candidiasis. Most of the reports published during the last 20 years, regarding epidemiological clinical investigations and surveys of oral candidiasis, had special emphasis on developed urban units. However, the prevalence of oral candidiasis in the far flunged areas with poor health care facilities has not been reported so far. There are limited studies on Oropharyngeal Candidiasis on neonates in rural localities. These aforesaid problems made a strong rationale for designing of current study. Aim of the study was to collect a epidemiological data of Oropharyngeal Candidiasis infection for neonates of age group up to 4 years belonging to rural localities. Moreover, prevalence of Oropharyngeal Candidiasis assessment along with evaluation of effect of season on the onset of infection, isolation of pathogens causing this fungal infection, enumeration of most prevalent species from clinical isolates, risk factors associated with this disease, and evaluation of those factors acting indirectly and which were related to physicians and or with physical environment at clinical institutes were part of this study. An intervention in this study was included with a hypothesis that patient education, awareness and counselling will reduce the infectious disease burden in the local communities. Therefore, in the first phase of current Oropharyngeal Candidiasis cases were registered for the years 2016 and 2017 from nine Basic Health Units (BHUs) of Punjab, Pakistan. Month wise assessment culminated in the result that the average number of cases were recorded highly in the months of July, August and September of every year taken under consideration i.e. 9.78, 12.64 and 9.37 for the months of July, August and September of 2016 and 10.28, 11.83 and 9.38 for the months of July, August and September of 2017 respectively. Seasonality indexes were also scrutinized to assess any chronobiological cyclicity, it was unearthed that number of cases in summer season were much above than the Oropharyngeal Candidiasis cases recorded during winter season. ix

In the second phase of the study; isolation, identification and characterization of the causative pathogen was carried out. It was found that Candida spp. were among the clinical isolates. Total 1152 clinical cotton swab oral samples from the children of less than 4 years of age were collected. Among the most prevalent species of Candida, Candida albicans 68.6% was the most prevalent species isolated from clinical oral swab samples followed by C. glabrata (12.9%), C. tropicalis (5.6%), C. krusei (8.5%), C. parapsilosis (3.1%), C. dublineiensis (1.1%) and C. lusitaniae (0.4%). Third phase of study circumscribed the assessment of overall contagiousness of Oropharyngeal Candidiasis collectively in all nine BHUs under study. It was found out that in the year 2016, the prevalence of Oropharyngeal Candidiasis was 92.88/1000 which dropped significantly statistics wise (p=0.018332) to half 52.87/1000 in the year 2017. Total three clusters had their respective BHUs. During the ending months of 2016, patient counselling and community awareness programs were carried out to witness the efficacy of patient counselling and community awareness programs in the local outskirts. The focused activity was materialized transpiring in the result that two clusters were characterized with activity whereas one cluster was left undisturbed. It was transpired that there was no inter-cluster statistical significant difference among three clusters in the year 2016, P(T<=t) =-0.84 for Cluster A vs C while the same Cluster comparison for the year 2017 demonstrated a strong statistical significant difference in the year 2017, P(T<=t) 0.029501. This strong dissimilarity exposed the fruitfulness of patient counselling. Similar findings surfaced when the case of cluster B and C was circumnavigated. Effectiveness of our activity of patient counselling and community awareness programs were also demonstrated by the individual cluster assessment between these two years under study. Cluster A (P=0.041291) for year 2016-17, For cluster B, the year 2016-17 comparison resulted in insignificant results due to the transfer of Medical Staff, through which patients counselling was being carried out. These insignificant results highlighted the importance of patient counselling in reduction of infective diseases. The absence of physicians resulted insignificance in reduction of Oropharyngeal Candidiasis cases in the local region (P=0.055402). Same trend was observed for Cluster C, P (>0.05). Next step in the study was to find out the characteristics of the patients with the Oropharyngeal Candidiasis. For this purpose, questionnaire was prepared. Patients were informed and their consent was taken before filling the questionnaire. It was found that 97.8% patients were below less than one year of age from 1152 patients from whom questionnaire was filled while only 2.2% had crossed one year. Maximum patients had 8Kg body weight i.e. 35%, 70.8% were x

female, 89.4% monthly income was 6000-15000 Pak. Rupee/Month. Illiteracy of patient’s family i.e. father (76.6%) mother 93.1%) were found to be significant characteristics. Main reasons behind this high prevalence was absence of awareness among rural residents, no oral hygienic program activity in remote settings, least patient counselling by healthcare professionals and lack of integrated community programs for reduction of infective diseases. Last phase of the study was to assess the perception, knowledge, attitude, referral trends, and satisfaction level of healthcare professionals working in the BHUs under study. It was found that 80.6% were male, 83.9% has good knowledge about Oropharyngeal Candidiasis, 74.2% had very nice clinical knowledge and 87.1% prescribed polyenes for the treatment of the Oropharyngeal Candidiasis. For assessment of satisfaction about service structure, job, working hours, role of Punjab Health Commission (PHC), formulary, staff, number of BHUs, salaries and other parameters, a survey was carried out. For this purpose, a separate questionnaire on Likert scale was prepared and was served to the physicians working in BHUs other than under study BHUs. Principal Component Analysis (PCA) was applied. Only four factors were found out the most critical in determining the dissatisfaction among the healthcare professionals. In addition to above, clinical laboratories facilities for fungal isolation, identification and characterization were assessed also. It was found that no single laboratory had such facility in these rural areas. This is the first study of its type that was focused to acquire epidemiological data regarding the Oral Candidiasis form the remote access area of the Punjab, Pakistan and evaluated the risk factors associated with this fungal infection in neonates between 0 to 4 years of age as well as assessment of isolation, identification and characterization of causative pathogen. Findings of this study are the first picture of Oropharyngeal Candidiasis infection burden in rural localities of Pakistan and in children under 4 years of age. These results can be used for the formulation of policies and executing control programs for reduction of infectious diseases in rural areas in general and Oropharyngeal Candidiasis in special because of its severity and prevalence in rural areas. Moreover, healthcare problems and issues have been highlighted in this study which need immediate remedy for effective role of healthcare professionals in the mitigation of diseases.