Interactive Research and Development

Abstract Background The Zindagi Mehfooz Electronic Immunization Registry (ZM-EIR) has improved immunization coverage tracking in Sindh, Pakistan. However, to address missed vaccinations in underserved areas, the government launched the Big Catch-up campaign (BCU). Integrating ZM-EIR data with geospatial techniques allows for assessing and tracking immunization services in these areas. This study evaluates the impact of BCU campaign on immunization coverage, spatial disparities and track vaccinators’ reach by leveraging geospatial techniques. Methods We analyzed Penta-1 and Measles-1 vaccination data of children aged 0-5 years from October 21 to December 16, 2024, categorized into routine immunization (October 21-November 18) and BCU campaign (November 19-December 16) periods. Using geospatial analysis, we identified low coverage areas, compared immunization coverage, and assessed proximity to nearest immunization centers during both periods. Results Comparison showed a significant increase of 49.8% (230,967/464,140) in total coverage, with Penta-1 and Measles-1 coverage increased by 59.1% (129,531/219,033) and 41.4% (101,436/245,107), respectively. Additionally, with implementation of targeted strategies on identified hotspot results showed noticeable coverage improvement. 20 out of 30 districts had coverage below 31%, based on the BCU target, which improved by more than 50% during the BCU campaign. The mean distance from nearest immunization center to immunization event was 0.33 km higher for BCU outreach in contrast to routine outreach, reflecting slight expansion of outreach efforts during BCU campaign. Conclusions This study shows significant impact of BCU campaign's on low coverage areas. The findings reveal significant increases in Penta-1 and Measles-1 vaccinations and highlight spatial disparities in immunization access. Geospatial techniques proved useful in identifying underserved areas and tracking outreach efforts, supporting effective immunization strategies. Key messages • The big Catch-Up campaign increased immunization in Sindh, coverage increased by 59.1% for Penta-1 and 41.4% for Measles-1, showing significant increase in low performing districts. • Geospatial analysis with integrating ZM-EIR data allow to identify underserved areas and track outreach services, aiding more targeted and effective immunization strategies.

Background Child stunting remains a major public health issue in Pakistan, with structural and socioeconomic determinants driving outcomes. While maternal education and empowerment have been widely studied, the role of maternal occupation type (professional vs. non-professional) in shaping child nutritional status remains unclear. Methods This cross-sectional study analyzed data from 420 mother–child pairs (<5 years) attending two hospitals in Karachi. Maternal occupation was categorized as professional/technical/managerial vs. non-professional/unemployed. Child nutritional status was assessed using WHO criteria. Chi-square, t-tests, and logistic regression were employed to examine associations, adjusting for confounders (education, income, family structure, empowerment). Results Overall, 44.2% of children were stunted. Children of professionally employed mothers had significantly lower stunting prevalence (29.4%) compared to non-professional/unemployed mothers (47.1%; χ²=8.12, p=0.004). Adjusted logistic regression confirmed the protective effect of professional maternal occupation against stunting (aOR = 0.52; 95% CI: 0.31–0.87, p=0.012). Subgroup analyses revealed the protective effect was stronger in boys (aOR=0.44, CI: 0.23–0.83) than girls (aOR=0.61, CI: 0.33–1.15). Interaction models suggested maternal education amplified the occupation effect. Conclusions Professional maternal occupation independently reduces child stunting risk, even after adjusting for socioeconomic factors. Policies promoting women’s entry into professional sectors may provide downstream benefits for child nutrition.

Background Child stunting remains a major public health issue in Pakistan, with structural and socioeconomic determinants driving outcomes. While maternal education and empowerment have been widely studied, the role of maternal occupation type (professional vs. non-professional) in shaping child nutritional status remains unclear. Methods This cross-sectional study analyzed data from 420 mother–child pairs (<5 years) attending two hospitals in Karachi. Maternal occupation was categorized as professional/technical/managerial vs. non-professional/unemployed. Child nutritional status was assessed using WHO criteria. Chi-square, t-tests, and logistic regression were employed to examine associations, adjusting for confounders (education, income, family structure, empowerment). Results Overall, 44.2% of children were stunted. Children of professionally employed mothers had significantly lower stunting prevalence (29.4%) compared to non-professional/unemployed mothers (47.1%; χ²=8.12, p=0.004). Adjusted logistic regression confirmed the protective effect of professional maternal occupation against stunting (aOR = 0.52; 95% CI: 0.31–0.87, p=0.012). Subgroup analyses revealed the protective effect was stronger in boys (aOR=0.44, CI: 0.23–0.83) than girls (aOR=0.61, CI: 0.33–1.15). Interaction models suggested maternal education amplified the occupation effect. Conclusions Professional maternal occupation independently reduces child stunting risk, even after adjusting for socioeconomic factors. Policies promoting women’s entry into professional sectors may provide downstream benefits for child nutrition.

The 2022 World Health Organization (WHO) guidelines on multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) recommend 6 months of bedaquiline (Bdq) in the all-oral 9-month shorter regimen and 6 months or longer for Bdq and delamanid (Dlm) in the 18-20-month longer regimen. However, lack of evidence on extended treatment using Bdq or Dlm has limited their use to 6 months. We examine the frequency and incidence of QT prolongation based on duration of Bdq and/or Dlm use in longer regimens. We analyzed a prospective cohort of MDR/RR-TB patients from 16 countries who initiated treatment with Bdq and/or Dlm containing regimens from 1 April 2015 to 30 September 2018. Data were systematically collected using a shared protocol. The outcome of interest was the first clinically relevant prolonged QT interval (grade 3 or above) or a serious adverse event (SAE) involving prolonged QT of any grade. Among 2553 patients, 59% received >6 months of Bdq and/or Dlm. Of these, 579 (20.9%) patients experienced a prolonged QT event, the majority (95.5%) being grade 1 or 2. Sixty-four (2.5%) patients experienced the outcome of interest with only 12 (0.5%) having ≥1 QT prolonging drugs permanently suspended. The incidence rate of the first prolonged QT event was highest in the first six months of treatment and lower in subsequent 6-month periods. We demonstrate that Bdq and/or Dlm use beyond 6 months is safe in longer MDR/RR-TB regimens with most clinically relevant QT prolongation events occurring in the first 6 months. Electrocardiogram (ECG) monitoring for early identification of QT prolongating events is possible in programmatic conditions.

<sec><title>OBJECTIVES</title>The national guidelines recommend contact screening of a subset of patients with the TB index and their household contacts (HHCs). Thus, many contacts with TB remain unscreened.</sec><sec><title>METHODS</title>We collected prospective data under programmatic conditions in Karachi, Pakistan, from January 2018 to December 2019. We screened all HHCs of all patients using the TB index. We disaggregated the data into guideline-eligible or ineligible index patients and contacts. We calculated TB disease yields for different groups of index patients and contacts.</sec><sec><title>RESULTS</title>Of 39,168 HHCs from 6,450 index patients, 21,035 completed clinical assessments for TB, and 416 were diagnosed with all forms of TB. HHCs of patients with clinically diagnosed pulmonary TB (PTB) were as likely to be diagnosed with TB as the HHCs of patients with bacteriologically confirmed PTB (adjusted OR 1.28, 95% CI 0.94-1.75). The yield of TB disease among child contacts (3.4%) was significantly higher than that among adult contacts (0.5%) (P < 0.001).</sec><sec><title>CONCLUSIONS</title>Broadening household contact screening criteria could increase the yield of contact tracing and improve the diagnosis of TB. However, further studies are required to establish the feasibility and cost-effectiveness of this approach, including studies from more diverse settings.</sec>.

Background: The importance of women's empowerment in enhancing child feeding outcomes has been acknowledged. Nevertheless, there is a lack of research on the influence of socioeconomic determinants on women's empowerment and its consequent effect on child nutrition in urban Pakistan. Methods: This research used a cross-sectional design and analyzed data from 420 pairs of mothers and children in Karachi, Pakistan. The assessment of women's empowerment included calculating an aggregate score that took into account decision-making authority, attitudes towards domestic violence, and measures of economic empowerment. The World Health Organization (WHO) growth criteria were used to categorize the nutritional condition of children as stunted, wasted, underweight, or overweight. A multivariate logistic regression analysis was conducted to investigate the correlation between socioeconomic characteristics, women's empowerment, and children's nutritional status. Findings: Women's empowerment showed a favorable correlation with higher levels of maternal education, professional career, and household asset ownership. mothers who were empowered had a far greater likelihood of having well-nourished children (adjusted odds ratio [aOR] = 2.14, 95% confidence interval [CI]: 1.42-3.22) compared to mothers who were not empowered, even after taking into account socioeconomic characteristics. Conclusion: This research emphasizes the significance of socioeconomic variables in shaping the empowerment of women and the resulting effects on child nutrition outcomes in urban Pakistan. Attempts to enhance women's education, economic prospects, and family wealth may lead to an increase in women's empowerment and, as a result, an improvement in child nutrition. Keywords: Women's empowerment, child nutrition, socioeconomic factors, urban Pakistan, decision-making power

We investigated whether deep reinforcement learning (deep RL) is able to synthesize sophisticated and safe movement skills for a low-cost, miniature humanoid robot that can be composed into complex behavioral strategies. We used deep RL to train a humanoid robot to play a simplified one-versus-one soccer game. The resulting agent exhibits robust and dynamic movement skills, such as rapid fall recovery, walking, turning, and kicking, and it transitions between them in a smooth and efficient manner. It also learned to anticipate ball movements and block opponent shots. The agent's tactical behavior adapts to specific game contexts in a way that would be impractical to manually design. Our agent was trained in simulation and transferred to real robots zero-shot. A combination of sufficiently high-frequency control, targeted dynamics randomization, and perturbations during training enabled good-quality transfer. In experiments, the agent walked 181% faster, turned 302% faster, took 63% less time to get up, and kicked a ball 34% faster than a scripted baseline.

Treatment outcomes may be compromised among patients with multidrug- or rifampicin-resistant tuberculosis with additional fluoroquinolone resistance. Evidence is needed to inform optimal treatment for these patients. We compared the effectiveness of longer individualized regimens comprised of bedaquiline for 5 to 8 months, linezolid, and clofazimine to those reinforced with at least 1 third-tier drug and/or longer duration of bedaquiline. We emulated a target trial to compare the effectiveness of initiating and remaining on the core regimen to one of five regimens reinforced with (1) bedaquiline for ≥9 months, (2) bedaquiline for ≥9 months and delamanid, (3) imipenem, (4) a second-line injectable, or (5) delamanid and imipenem. We included patients in whom a fluoroquinolone was unlikely to be effective based on drug susceptibility testing and/or prior exposure. Our analysis consisted of cloning, censoring, and inverse-probability weighting to estimate the probability of successful treatment. Adjusted probabilities of successful treatment were high across regimens, ranging from 0.75 (95%CI:0.61, 0.89) to 0.84 (95%CI:0.76, 0.91). We found no substantial evidence that any of the reinforced regimens improved effectiveness of the core regimen, with ratios of treatment success ranging from 1.01 for regimens reinforced with bedaquiline ≥9 months (95%CI:0.79, 1.28) and bedaquiline ≥9 months plus delamanid (95%CI:0.81, 1.31) to 1.11 for regimens reinforced by a second-line injectable (95%CI:0.92, 1.39) and delamanid and imipenem (95%CI:0.90, 1.41). High treatment success underscores the effectiveness of regimens comprised of bedaquiline, linezolid, and clofazimine, highlighting the need for expanded access to these drugs.