Academic journal article Bulletin of the World Health Organization

Enhanced Disease Surveillance through Private Health Care Sector Cooperation in Karachi, Pakistan: Experience from a Vaccine Trial

Academic journal article Bulletin of the World Health Organization

Enhanced Disease Surveillance through Private Health Care Sector Cooperation in Karachi, Pakistan: Experience from a Vaccine Trial

Article excerpt

Voir page 76 le resume en francais. En la pagina 76 figura un resumen en espanol.


Information about the burden of many infectious diseases in less-developed countries is sparse or not available. In Pakistan, data gathered by the government

underestimate the disease burden because only patients who use public health facilities are captured. The private health sector is the major provider of first-level health care in most of the Indian subcontinent. A study in India showed that 80% of respondents had visited a private health care provider in the previous six months for any ailment. (1)

In less-developed countries where private health care is predominant, (2,3) extension of disease surveillance networks to include private health care providers is essential for success and cost effectiveness. (4,5) The private sector may offer the only functioning public health care system or public clinics may compete with private practitioners for patients. (6) The inclusion of the private health care sector as a sentinel point for disease surveillance is essential but difficult to achieve, although regular contact with private practitioners and continuous feedback has been effective in some surveillance activities. (7)

In preparation for a large trial on a vaccine for typhoid fever, we conducted fever surveillance in two urban squatter settlements of Karachi, Pakistan, starting in January 2002. The study site was chosen because it had a high reported incidence of typhoid fever and no specific typhoid fever control programme had been initiated. Two study health-care centres were established to take blood samples and treat patients with a reported history of fever.

A modified passive surveillance system called "augmented passive surveillance" was adopted for the trial. Cases of reported fever at the household level were identified through weekly household visits by community health workers. Active surveillance was not possible because of the extensive logistic and resource requirements in such a setting. All cases that fulfilled the case definition were encouraged to visit the study centres or the private practitioners of their choice. The process gave the project an estimate of cases of reported fever in the community that was then compared with the number enrolled in the study to assess the surveillance's sensitivity. Household members with reported episodes of fever were encouraged to attend the study centre for treatment and recruitment into the surveillance study.

During the baseline census of the study setting, information on health-care-seeking behaviour for febrile illnesses was collected. About 60% of households stated that they visit a private health-care provider. The private practitioners in the area come from a range of backgrounds. They include dispensers, nurses, health technicians, traditional healers and people who had worked with a healthcare provider in the past. The relatively lower use of study centres by residents who lived far from study centres meant that private practitioners were included systematically in surveillance activities. The participation of private practitioners was useful in establishing sentinel points that were more accessible and did not affect the health-care-seeking behavior of the study population.

We report our experience of engaging private practitioners during the first year of this surveillance, the processes of working with them and their importance in assessing various estimates of disease burden in developing countries.


Surveillance for infection with Salmonella typhi was carried out in two urban squatter settlements (Sultanabad and Hijrat Colony) of Karachi, Pakistan. The study population of 46 273 people lives in about 7000 households and consists mostly of immigrants from elsewhere in Pakistan, especially the north. Domiciliary surveillance was conducted through a team of community health workers. …

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